Research article
A village would be nice but …: It takes a long-acting contraceptive to prevent repeat adolescent pregnancies

https://doi.org/10.1016/S0749-3797(01)00316-6Get rights and content

Abstract

Objective: To determine which components of a comprehensive, multidisciplinary, adolescent-oriented maternity program help teenage mothers delay subsequent pregnancies.

Design/ Setting/ Patients: A cohort of 373 participants in a comprehensive, multidisciplinary, adolescent-oriented maternity program was studied.

Intervention: The program was designed to prevent rapid subsequent pregnancies directly by simplifying access to contraceptives and indirectly by discouraging school drop-out and encouraging the pursuit of careers incompatible with closely spaced childbearing. Parents and children were seen together; nine visits were scheduled during the first postpartum year and four visits during the second year.

Main Outcome Measure: Repeat adolescent pregnancy.

Results: The repeat pregnancy rate was 14% at 1 year and 35% at 2 years. Teenage mothers who became pregnant exhibited significantly more repeat pregnancy risk factors but were as compliant with clinic visits as their nonpregnant peers. The contraceptive choices the teenagers made during the puerperium had the most profound effect on their subsequent fertility. A logistic regression analysis identified failure to use Norplant during the puerperium as the strongest predictor of repeat pregnancy during the first 2 postpartum years (relative risk [RR]=8.89; 95% confidence interval [CI]=2.80–28.50). Exhibiting nine or more repeat pregnancy risk factors (RR=2.37; 95% CI=1.38–4.06) and not using Depo-Provera during the puerperium (RR=2.30; 95% CI=1.60–3.29) also predicted repeat conception, but clinic visits and return to school postpartum did not.

Conclusions: Using a long-acting hormonal contraceptive during the puerperium was associated with pregnancy prevention during the first 2 postpartum years, but frequent clinic visits, contact with supportive healthcare and social service providers, and return to school were not.

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.

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