Research articleA village would be nice but …: It takes a long-acting contraceptive to prevent repeat adolescent pregnancies
Introduction
The consequences of closely spaced adolescent childbearing and when teenage mothers should have more children remains controversial.1, 2, 3, 4, 5, 6 However, achieving an interpregnancy interval of 2 years has become a national priority because this interval motivates further childbearing delays and personal achievements that enable teenagers to break out of poverty.1, 2, 5, 6
It should be easy to prevent second adolescent pregnancies because most teenage mothers insist that they and their boyfriends do not want more children “anytime soon,” receive contraceptive counseling and supplies repeatedly, and try to use contraception between pregnancies.6, 7, 8, 9, 10, 11, 12, 13, 14, 15 However, teenage mothers are at higher risk for conception than their never-pregnant peers because even those who do not want more children experience fluctuations in the motivation to remain nonpregnant, stop using contraception briefly, and (because from a physiologic standpoint, their natural state will eventually be pregnant) become pregnant by default.2, 8, 15, 16
The frequency and rapidity with which teenagers who have the means and who exhibit the motivation to delay further childbearing become pregnant have fostered numerous attempts to modify those aspects of their lives that predispose them to conception (Table 1). 1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 However, because most of those characteristics are not necessarily causally related to unprotected sexual activity,17, 18, 31, 32, 33 interventions designed to mitigate them rarely keep teens from becoming pregnant.1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 Rather, programs that integrate adolescent mothers back into the educational system often have a paradoxically negative effect on their reproductive behavior, and intensive mother–baby care rarely convinces family-oriented teens that the costs of repeat childbearing outweigh the benefits.2, 7, 8, 11, 14, 32 Indeed, after more than 4 decades of study, it remains to be demonstrated that interventions to promote return to school postpartum and consistent contraceptive use produce the same enduring effects on fertility as has been associated with the natural pursuit of these activities. This enigma challenges one of the key assumptions in the conceptual model underlying most teen pregnancy prevention programs: Namely, that it is possible to modify those aspects of a teenage mother’s life that predispose her to rapid repeat conception by supporting her efforts to use contraception and to pursue a career in addition to motherhood.
This conundrum of failure motivated us to examine the implementation and effect of the Colorado Adolescent Maternity Program (CAMP). The goal was to determine which of the many components of this comprehensive, multidisciplinary, adolescent-oriented maternity program are associated with childbearing delays (and therefore might be expected to help teenagers delay subsequent pregnancies) and which are underused or not associated with positive changes in reproductive behavior.
Section snippets
Subjects
The study sample consisted of a racially and ethnically diverse (41% white, 33% black, 24% Hispanic, and 2% other) group of 373 poor (93% Medicaid recipients), predominantly unmarried (94%), primiparous (91%), 13- through 19-year-olds (mean±SD, 17.4±1.4 years) who identified CAMP as their and their infant’s primary healthcare provider 2 months after delivery. As shown in Table 2, 280 (75%) of the 373 study participants were recruited consecutively at delivery from the CAMP prenatal clinic; the
Program implementation
As shown in Table 2, the attrition rate was high from both CAMP and the evaluation. The 254 teenagers who remained in CAMP at the end of the first postpartum year and the 119 who withdrew exhibited a similar number of risk factors from Table 1 (7.5±2.5 and 7.8±2.4, respectively). However, during the second postpartum year, selective loss of 182 program participants left a CAMP clinic population (n=191) that exhibited significantly (p=0.04) fewer repeat pregnancy risk factors (7.3±2.5).
Discussion
Most American programs to prevent teen pregnancy are based on a conceptual framework that posits that the risk of conception rises during adolescence in tandem with the number of risk factors listed in Table 1 because those characteristics collectively create an environment in which the consequences of conception seem no more onerous than those of contraceptive use.2, 3, 8, 15, 19, 20, 31 However, even teenagers who exhibit multiple high-risk characteristics can remain nonpregnant if other
Acknowledgements
We thank the CAMP staff members and patients for their help with implementing the intervention and data collection and Judy Kralewski, RN, MSN, CPNP, for her review of the manuscript.
This research was supported by the National Institutes of Health, National Center for Research Resources, General Clinical Research Centers Program Grant 5 MO1 RR00069.
This article was presented in part at the annual meeting of the Society for Pediatric Research, Boston, MA, May 2000.
References (45)
- et al.
Pregnant again? Psychosocial predictors of short-interval repeat pregnancy among adolescent mothers in Mexico City
J Adolesc Health
(1992) - et al.
Risk factors for rapid repeat pregnancy among adolescent mothersa review of the literature
J Pediatr Adolesc Gynecol
(1998) Risk behavior in adolescencea psychosocial framework for understanding and action
J Adolesc Health
(1991)- et al.
Change in depressive symptoms during pregnancyrelationship to birth outcome
J Pediatr Adolesc Gynecol
(1995) - et al.
The teen-tot clinican alternative to traditional care for infants of teenaged mothers
J Adolesc Health Care
(1982) - et al.
The best intentions
(1995) - et al.
Is teenage childbearing an adaptive strategy for the socioeconomically disadvantaged or a strategy for adapting to socioeconomic disadvantage?
Arch Pediatr Adolesc Med
(1995) Dubious conceptionsthe politics of teenage pregnancy
(1996)Teenage childbearing and social and reproductive disadvantagethe evolution of complex questions and the demise of simple answers
Fam Relation
(1991)- et al.
Adolescent mothers and their children in later life
Fam Plann Perspect
(1987)
Adolescent mothers and repeat childbearingeffects of a school-based intervention program
Am J Orthopsychiatry
Effects of a comprehensive program for teenage parentsfive years after Project Redirection
Fam Plann Perspect
Reasons for first teen pregnancies predict the rate of subsequent teen conceptions
Pediatrics
Subsequent pregnancy among adolescent mothers
Adolescence
New chancefinal report on a comprehensive program for young mothers in poverty and their children
A randomized trial of a health care program for first-time adolescent mothers and their infants
Nurs Res
Medical and psychosocial impact of comprehensive care on adolescent pregnancy and parenthood
JAMA
Contraceptive use and repeat pregnancies among welfare-dependent teenage mothers
Fam Plann Perspect
Why some women fail to use their contraceptive methoda psychological investigation
Fam Plann Perspect
Subsequent childbearing among teenage mothersthe determinants of a closely spaced second birth
Fam Plann Perspect
Protecting adolescents from harm
JAMA
Cited by (136)
Adolescent Contraception Use after Pregnancy, an Opportunity for Improvement
2018, Journal of Pediatric and Adolescent GynecologyFactors influencing repeated teenage pregnancy: a review and meta-analysis
2017, American Journal of Obstetrics and GynecologyEtonogestrel-Releasing Contraceptive Implant for Postpartum Adolescents: A Randomized Controlled Trial
2017, Journal of Pediatric and Adolescent GynecologyMotivational Interviewing to Promote Long-Acting Reversible Contraception in Postpartum Teenagers
2017, Journal of Pediatric and Adolescent GynecologyCitation Excerpt :However, research is suggestive that a repeat birth to a teenage mother is just as likely to be unintended as the first,4 making developing models of care to prevent these repeat teen births of great interest to adolescent health care providers. Adolescent-focused prenatal health clinics seem an obvious solution but results have been disappointing.7,8 Multiple studies have shown that even multidisciplinary, adolescent-focused care is not as effective as postpartum long-acting reversible contraception (LARC) at preventing rapid repeat teen pregnancy (RRP), defined as pregnancies less than 2 years apart.7–10