Key points

Overview

Adolescent pregnancy, typically defined as a pregnancy in a female between the ages of 13 and 19, occurs in approximately 13% of the United States population and approximately 25% of women worldwide. Although high, this rate has been steadily declining over the last 15 years, owing to support of education, contraception, and other pregnancy prevention strategies. When looking at teens between 15 and 19 years of age, the birth rate was 24.2 per 1000 in 2014, down 9% from 2013. Even with the decrease, in 2008, approximately 7% of teenage girls in the United States became pregnant. Approximately 80% of pregnancies conceived during adolescence are unintended. Teen births are highest in those cohabiting, married, and in lower income groups. Those aged 18 to 19 years make up the vast majority of teen pregnancies, between 64% and 76%. This high rate of unintended pregnancy correlates to a high rate of abortions in this population, with 1 study reporting that up to 50% of teen pregnancies lead to abortions. Not only specific to the United States, adolescent pregnancy is a global health problem, with complications during pregnancy and childbirth serving as the second leading cause of mortality in the 15- to 19-year-old age group worldwide. In the United States, preventing unintended adolescent pregnancies is part of the Healthy People 2020 campaign. Promoting safe sex and having access to contraception for these individuals continues to be part of this objective.

Adolescent pregnancy contributes highly to the financial, emotional, and social well-being of the pregnant teen. Many of these factors are compounded by the fact that teenagers have greater risk of poor nutrition, delayed pregnancy diagnosis, and delayed access to prenatal care. They are often plagued by poor social support and emotional well-being, compared with adult women. Pregnant teens have higher use of tobacco (36% vs 7%) and alcohol and recreational drugs (1.1% vs 0.2%), as well as higher levels of emotional stress, partner violence and abandonment, and unstable and/or unsafe home environments. Having a child while in school significantly decreases the chance of completion of high school, with as many as 30,000 citing pregnancy or childbirth as reasons of dropout each year. However, those pregnant adolescents who remain in school after childbirth are less likely to have a short-interval repeat pregnancy, making continued encouragement of the adolescent to complete her schooling even more important. Pediatricians and other primary care providers can have such an important role in this counseling, especially before pregnancy diagnosis. Additionally, pediatricians care for many potential teenage fathers and thus can also impact adolescent pregnancy rates through counseling regarding safe sex practices to all youth. By their 19th birthday, 7 of 10 teens in the United States have had sexual intercourse.

Adolescent well visits are a perfect time to discuss delaying parenthood until after adolescence. Contraceptive counseling and safe sex practices, when addressed in the pediatric or family practice office, can be a tool to help the adolescent make healthy decisions regarding their reproductive desires. Many adolescents feel immune to the possibility of pregnancy and therefore do not consider contraception until a health care provider initiates the discussion. Social stressors of adolescent pregnancy should be addressed immediately with a collaborative, nonjudgmental environment of support through social work, and community resources, including Planned Parenthood, psychiatry if appropriate, as well as any local advocacy groups.

Overview

Adolescent pregnancy, typically defined as a pregnancy in a female between the ages of 13 and 19, occurs in approximately 13% of the United States population and approximately 25% of women worldwide. Although high, this rate has been steadily declining over the last 15 years, owing to support of education, contraception, and other pregnancy prevention strategies. When looking at teens between 15 and 19 years of age, the birth rate was 24.2 per 1000 in 2014, down 9% from 2013. Even with the decrease, in 2008, approximately 7% of teenage girls in the United States became pregnant. Approximately 80% of pregnancies conceived during adolescence are unintended. Teen births are highest in those cohabiting, married, and in lower income groups. Those aged 18 to 19 years make up the vast majority of teen pregnancies, between 64% and 76%. This high rate of unintended pregnancy correlates to a high rate of abortions in this population, with 1 study reporting that up to 50% of teen pregnancies lead to abortions. Not only specific to the United States, adolescent pregnancy is a global health problem, with complications during pregnancy and childbirth serving as the second leading cause of mortality in the 15- to 19-year-old age group worldwide. In the United States, preventing unintended adolescent pregnancies is part of the Healthy People 2020 campaign. Promoting safe sex and having access to contraception for these individuals continues to be part of this objective.

Adolescent pregnancy contributes highly to the financial, emotional, and social well-being of the pregnant teen. Many of these factors are compounded by the fact that teenagers have greater risk of poor nutrition, delayed pregnancy diagnosis, and delayed access to prenatal care. They are often plagued by poor social support and emotional well-being, compared with adult women. Pregnant teens have higher use of tobacco (36% vs 7%) and alcohol and recreational drugs (1.1% vs 0.2%), as well as higher levels of emotional stress, partner violence and abandonment, and unstable and/or unsafe home environments. Having a child while in school significantly decreases the chance of completion of high school, with as many as 30,000 citing pregnancy or childbirth as reasons of dropout each year. However, those pregnant adolescents who remain in school after childbirth are less likely to have a short-interval repeat pregnancy, making continued encouragement of the adolescent to complete her schooling even more important. Pediatricians and other primary care providers can have such an important role in this counseling, especially before pregnancy diagnosis. Additionally, pediatricians care for many potential teenage fathers and thus can also impact adolescent pregnancy rates through counseling regarding safe sex practices to all youth. By their 19th birthday, 7 of 10 teens in the United States have had sexual intercourse.

Adolescent well visits are a perfect time to discuss delaying parenthood until after adolescence. Contraceptive counseling and safe sex practices, when addressed in the pediatric or family practice office, can be a tool to help the adolescent make healthy decisions regarding their reproductive desires. Many adolescents feel immune to the possibility of pregnancy and therefore do not consider contraception until a health care provider initiates the discussion. Social stressors of adolescent pregnancy should be addressed immediately with a collaborative, nonjudgmental environment of support through social work, and community resources, including Planned Parenthood, psychiatry if appropriate, as well as any local advocacy groups.

Early diagnosis of pregnancy

Because early detection and therefore early referral of a pregnant adolescent can help to decrease perinatal risks, it is imperative to not miss a diagnosis of pregnancy in an adolescent who presents to the office for vague complaints. Although some teens may present with more classic symptoms of amenorrhea, nausea, vomiting, breast tenderness, and/or weight gain, others may be more subtle, with complaints of fatigue, abdominal pain, dizziness, or overall “not feeling well.” Additionally, the menstrual cycle of an adolescent is often irregular and may give a false reassurance that a pregnancy does not need to be considered, thus causing a delay in diagnosis and prenatal care. Teens often feel they are not at risk for pregnancy, regardless of unprotected intercourse. Denial often plays a role in the patient’s late presentation for medical care and ultimate diagnosis of pregnancy. However, this is why it is important to check a pregnancy test with menstrual irregularities, regardless of reported sexual history, because some patients are not forthcoming with regard to their sexual history. Alternatively, some adolescents will present to their pediatrician or family medicine physician with vague complaints, already knowing they are pregnant, to establish medical care. Urine qualitative human chorionic gonadotropin tests are the gold standard for initial evaluation and may be repeated if negative in 1 to 2 weeks if suspicion is high. Adolescent mothers are at greater risk for late or no prenatal care, with 9.1% of adolescents aged 15 to 16 years and 15.8% of those 10 to 14 years in 2003 having either no prenatal care or care starting after the second trimester. In general, it is wise to consider the diagnosis of pregnancy frequently in the adolescent population.

Adverse perinatal outcomes

Several adverse perinatal outcomes have been associated with adolescent pregnancies, specifically, preeclampsia, preterm birth, low birth weight babies, and an increase in stillbirths, intrapartum deaths, and miscarriages. One study reports more than 4 times the risk of intrapartum stillbirth in the youngest teens (<15 years old) and 50% higher in teens 15 to 19 years old compared with women aged 20 to 24. The highest risk of poor perinatal outcomes occurs in pregnancies taking place within 2 years of menarche. A higher incidence of intrapartum stillbirth in this group has been postulated to be owing to increase in shoulder dystocia or intrapartum asphyxia owing to the immaturity of the young teenage body and bony pelvic structures, but this direct correlation has not been made. Additionally, the younger the patient, the greater the risk, with rates of infant mortality, very low birth weight and preterm delivery significantly greater if pregnancy is diagnosed before 15 years old compared with older teens. Lack of early prenatal care has been cited as one of the leading contributors to this problem, though not the only cause of these adverse outcomes in this patient population, and therefore serves as a focus of much research as to how to improve the outcomes in this high risk population. Fraser and colleagues, while studying a mainly homogenous population in Utah, demonstrated that younger maternal age was an independent risk factor for adverse pregnancy outcomes of important confounding sociodemographic factors, although did still note that inadequate prenatal care was mostly strongly correlating to adverse perinatal outcomes. Interestingly, although there are concerns with incomplete growth and biologic immaturity of the adolescent causing some of these poor outcomes, there is a decrease in the cesarean delivery rate in this population, suggesting that pelvic structure may in fact be sufficiently developed in most adolescents. Preventable risks include late prenatal care initiation, poor nutrition, substance abuse and genital infections. Primary care physicians who diagnose pregnancy in adolescent patients can be of great assistance in preventing poor outcomes and optimizing care for the mother and fetus.