Pregnancy intentions, long-acting contraceptive use, and rapid subsequent pregnancies among adolescent and adult first-time mothers.

PROBLEM: Greater understanding is needed related to qualitatively assess pregnancy intentions and rapid subsequent pregnancies among adolescent and adult mothers. METHODS: Four-site prospective study of 227 adolescent and adult mothers. Data were analyzed to understand the relationship between pregnancy intentions, adolescent status, and use of long-acting contraceptives and rapid subsequent pregnancy. FINDINGS: The findings from this study provide evidence of the importance of goal-oriented pregnancy intentions, long-acting contraceptive use, and older age in delaying a second pregnancy. CONCLUSION: Findings reveal the need for clinician awareness of the qualitative pregnancy intentions of young women and potential desired use of long-acting contraceptives.

What mothers don't know and doctors don't say: Detecting early developmental delays.

The present study examined the detection of early developmental delays of high-risk infants by first-time mothers in a community sample of families (N = 451). About half of the mothers were adolescents at time of childbirth, and two thirds reported household incomes below $20,000 annually. Children were assessed at 12 and 24 months of age on standardized measures of cognitive, language, adaptive, and socioemotional development. According to the Individuals with Disabilities Education Act (PL101-476) guidelines, about 1 in 4 children was eligible for intervention services at 12 months, and about 1 in 3 children was eligible at 24 months. Despite receiving regular medical services, mothers reported that very few eligible children (2% at 12 months and 9% at 24 months) were identified by medical professionals as having any problems that could interfere with development. Much like medical professionals, few mothers were appropriately worried about development, and the likelihood of expressing concerns was related to mothers' knowledge about infant development. These findings highlight the need for medical providers to frequently screen high-risk children and for parents to become more knowledgeable about infant development.

The clinical content of preconception care: care of psychosocial stressors.

In the period before conceiving, many women are under considerable psychosocial stress, which may affect their ability to conceive and to carry a pregnancy successfully to term. Thus, health care providers who interact with women in the preconception and interconception period should ask their patients about possible psychosocial risks. It is no longer sufficient to wait until the woman mentions a problem or seeks advice; the provider must be proactive, because many women do not realize the potential impact of stressors on their pregnancy outcomes nor are they always aware that their provider is interested in their psychosocial as well as their physical health. An income that puts women below or near the federal poverty level is one such stress. If a woman's economic situation can be improved before the pregnancy, she is more likely to be healthy after conception, because increased income can reduce financial stress, improve food security, and improve well-being in other ways. Therefore, all women should be asked about their economic status and those who appear to be struggling financially should be referred to an agency that can check their eligibility for various types of financial assistance. Many women of childbearing age have difficulty accessing the primary care services needed for preconception care. Usually this is due to lack of insurance, but it may also be caused by living in an area with an insufficient number of providers. Certainly all women who are uninsured, and possible many who are on Medicaid and have difficulty finding providers who will accept Medicaid, have access problems. All women should be asked about their health insurance coverage and their usual source of care. If they do not have health insurance, they should be referred to an agency that can determine their eligibility. If they do not have a usual source of care, one should be established that will accept their insurance coverage or provide care free of charge or on a sliding fee basis. Intimate partner violence, sexual violence outside of an intimate relationship (usually rape), and maltreatment (abuse or neglect) as a child or adolescent place a woman at elevated risk during a pregnancy, as well as having possible adverse impacts on the fetus, the infant, and the child. Studies show that women believe it is appropriate for health care providers to ask about interpersonal violence, but that they will not report it spontaneously. Therefore, screening for ongoing and historical interpersonal violence, sexual violence, and child maltreatment should be incorporated into routine care by all health care providers.

Geographic access to family planning facilities and the risk of unintended and teenage pregnancy.

OBJECTIVES: This study tested the hypotheses that greater geographic access to family planning facilities is associated with lower rates of unintended and teenage pregnancies. METHODS: State Pregnancy Risk Assessment Monitoring System (PRAMS) and natality files in four states were used to locate unintended and teenage births, respectively. Geographic availability was measured by cohort travel time to the nearest family planning facility, the presence of a family planning facility in a ZIP area, and the supply of primary care physicians and obstetric-gynecologists. RESULTS: 83% of the PRAMS cohort and 80% of teenagers lived within 15 min or less of a facility and virtually none lived more than 30 min. Adjusted odds ratios did not demonstrate a statistically significant trend to a higher risk of unintended pregnancies with longer travel time. Similarly there was no association with unintended pregnancy and the presence of a family planning facility within the ZIP area of maternal residence, or with the supply of physicians capable of providing family planning services. Both crude and adjusted relative rates of teenage pregnancies were significantly lower with further distance from family planning sites and with the absence of a facility in the ZIP area of residence. In adjusted models, the supply of obstetricians-gynecologists and primary care physicians was not significantly associated with decreased teen pregnancies. CONCLUSIONS: This study found no relationship between greater geographic availability of family planning facilities and a risk of unintended pregnancies. Greater geographic availability of family planning services was associated with a higher risk of teenage pregnancy, although these results may be confounded by facilities locating in areas with greater family planning needs.

Accessibility of family planning services: impact of structural and organizational factors.

OBJECTIVES: This study sought to determine whether selected structural and organizational characteristics of publicly available family planning facilities are associated with greater availability. METHODS: A survey was sent to 726 publicly available family planning facilities in four states. These included local health departments, federally qualified health centers (FQHC), Planned Parenthood sites, hospital outpatient departments, and freestanding women's health centers. Usable responses were obtained from 526 sites for a response rate of 72.5%. Availability variables included the provision of primary care services; the contraceptives offered; professional staffing; scheduling, waiting time, and transportation; and cultural congruence and competency. The structural and organizational variables were state, type of organization, and funding source. RESULTS: Some states were more likely to offer emergency contraception while others were more likely to have weekend hours. FQHCs were most likely to provide primary care and Planned Parenthood sites most likely to offer emergency contraception. Title X funding was associated with increased likelihood of providing emergency contraception and staffing by midlevel practitioners and registered nurses. CONCLUSIONS: This study found that availability varied by structural and organizational variables, many of which are determined by federal and state policies. Revising some of these policies might increase utilization of family planning facilities.

Family planning services: an essential component of preconception care.

Family planning services are necessary for the widespread adoption of preconception care for two reasons. First, preconception care is more likely if pregnancies are planned, and family planning services encourage pregnancy planning. Second, family planning services usually include counseling, and counseling provides an opportunity to discuss the advantages of preconception care. However, the potential of family planning services to promote preconception care is limited by underutilization of these services and inadequate attention to preconception care during family planning visits. This article suggests ways to reduce these problems.

Preconception care between pregnancies: the content of internatal care.

For more than two decades, prenatal care has been a cornerstone of our nation's strategy for improving pregnancy outcomes. In recent years, however, a growing recognition of the limits of prenatal care and the importance of maternal health before pregnancy has drawn increasing attention to preconception and internatal care. Internatal care refers to a package of healthcare and ancillary services provided to a woman and her family from the birth of one child to the birth of her next child. For healthy mothers, internatal care offers an opportunity for wellness promotion between pregnancies. For high-risk mothers, internatal care provides strategies for risk reduction before their next pregnancy. In this paper we begin to define the contents of internatal care. The core components of internatal care consist of risk assessment, health promotion, clinical and psychosocial interventions. We identified several priority areas, such as FINDS (family violence, infections, nutrition, depression, and stress) for risk assessment or BBEEFF (breastfeeding, back-to-sleep, exercise, exposures, family planning and folate) for health promotion. Women with chronic health conditions such as hypertension, diabetes, or weight problems should receive on-going care per clinical guidelines for their evaluation, treatment, and follow-up during the internatal period. For women with prior adverse outcomes such as preterm delivery, we propose an internatal care model based on known etiologic pathways, with the goal of preventing recurrence by addressing these biobehavioral pathways prior to the next pregnancy. We suggest enhancing service integration for women and families, including possibly care coordination and home visitation for selected high-risk women. The primary aim of this paper is to start a dialogue on the content of internatal care.

Risk of poor pregnancy outcomes: is it higher among multiparous teenage mothers?

It is commonly believed that pregnancy outcomes for multiparous teenage mothers are worse than those for teenage women experiencing a first birth. This article, based on a review of the literature, finds that when teenage mothers having a second birth are compared with those having a first birth, the second births often have worse outcomes. However, when the first and second birth to the same mother are compared, teenagers follow the pattern of older women, i.e., the second births usually have better outcomes than the first. This difference is probably due to selection bias.

Selecting, implementing, and evaluating teen pregnancy prevention interventions: lessons from the CDC's Community Coalition Partnership Programs for the Prevention of Teen Pregnancy.

PURPOSE: To summarize 13 communities' experiences with selecting, implementing, and evaluating teen pregnancy prevention interventions within the CDC Community Coalition Partnership Programs for the Prevention of Teen Pregnancy. The study focuses on decision-making processes and barriers encountered in five categories of interventions: reproductive health services, reproductive health education, parent-child communication, male involvement, and programs for pregnant and parenting teens. METHODS: Telephone interviews were conducted with program directors, lead evaluators, and community coalition chairpersons in each of the 13 communities. The descriptive analysis explored factors that influenced community decisions to develop or not to develop interventions. These factors were analyzed by type of intervention. RESULTS: Each community implemented an average of six interventions and operated them with a variety of funding sources. Interventions were selected on the basis of need, and the community needs and assets assessment process was "very important" for most reported interventions. Decision-making was influenced most often by project staff, the coalition, or related work groups. Teens were infrequently viewed as primary decision-makers in the selection of interventions. Communities with family planning services as hub agencies were more likely to address reproductive services and reproductive health education. Communities with child advocacy or youth-serving agencies were more likely to focus on other intervention categories. About two-thirds of the interventions were evaluated by either process or outcome measures, or by both. CONCLUSIONS: This study highlights important lessons learned that should be considered in examinations of the overall effectiveness of this community coalition approach to the prevention of teen pregnancy.

Challenges in data collection, analysis, and distribution of information in community coalition demonstration projects.

PURPOSE: This article summarizes the experiences of 13 grantees funded by the Centers for Disease Control and Prevention under the Community Coalition Partnership for the Prevention of Teenage Pregnancy in collecting, analyzing, and disseminating data as required under the requirements of this community-based demonstration project. While describing the challenges associated with these activities, this article suggests how future demonstration projects can better support both centralized and locally based data collection and analysis and enhance their usefulness for various audiences. METHODS: A multi-method data collection approach was employed that included: (a) a systematic review of semiannual progress reports submitted by the grantees to CDC between 1998 and 2002, (b) telephone interviews with program directors and evaluators and (c) site visits to four of the 13 grantee locations. In all, 46 individuals were interviewed, for an average of 3.5 respondents per grantee site. Data collected for this article focused on three data collection/analysis activities required as part of the Partnership: needs assessments conducted during the planning phase of the project, the collection of cross-site indicator data and project-specific studies. RESULTS: Grantees from the 13 Partnership communities indicated that two of the data collection/analysis requirements (the needs and assets assessments and project-specific studies) were useful and should be included in future demonstration projects. The collection of cross-site indicator data was found to be more challenging. Across all areas of data collection/analysis, the grantees' efforts were complicated by data collection challenges, difficulties conducting studies of local programs, and uncertainties about how local efforts fit with national goals for the demonstration projects. CONCLUSION: The data collection/analysis activities within the Partnership were viewed by the grantees as being both supportive of project efforts, but also challenging. On the positive side, the presence of community-based evaluators helped the grantees to profile community needs, identify program interventions, provide participant feedback, and track community mobilization efforts. Collection of the cross-site indicator data was difficult for many of the grantees and not always connected to locally determined objectives. The value of these activities can be enhanced in the future if greater attention is given to creating more clearly defined goals at the demonstration project level and to providing guidance on scientifically valid data collection and analysis techniques to maximize the usefulness of local efforts.

Smoking-related activities in prenatal care programs.

BACKGROUND: Convincing pregnant women who smoke to give up this behavior is one of the few universally agreed upon methods for improving pregnancy outcomes. An exploratory study was conducted to determine what public and quasi-public facilities serving pregnant women were doing to assist pregnant smokers in quitting, the reasons why more was not being done, and what could be done to increase smoking-cessation services. METHODS: Questionnaires eliciting information about pregnancy-related smoking prevention activities were mailed to home visitation projects, federally funded Healthy Start programs, CityMatCH members, and maternal and child health units in state health departments with a subsample of local health units. Responses were obtained from 354 programs. RESULTS: Only about a quarter of the respondents thought they were doing enough to help pregnant smokers stop or reduce smoking, and most thought that the inadequacy was due to insufficient funds. Only about a quarter offered smoking-cessation classes or clinics. Almost all programs had policies restricting smoking in their offices. The nationally sponsored activity that the respondents felt might be most helpful in increasing their efforts was the provision of materials. Among the 313 programs that included home visits, 86% required the home visitors to conduct a needs assessment, and 97% of those expected the woman's smoking status to be recorded. Smoking status prior to pregnancy or by other household members was required less often. Less than half of the programs provided training on smoking-cessation/reduction methods to home visitors. Only 28% said smoking-cessation/reduction had a very high priority in comparison to other home visit objectives. CONCLUSIONS; Programs for pregnant women, including those with a home visit component, do not pay sufficient attention to the problem of smoking among their clients. Programs should make greater use of the evidence-based interventions now available.

Second births among teenage mothers: program results and statistical methods.

This paper uses survival analysis to examine three large-scale, multi-site, randomized, controlled programs that attempted to prevent or delay second births to teenagers. Statistically significant differences in the hypothesized direction were found between the intervention and the control groups in the Elmira and Memphis Home Visitation sites. No statistically significant differences in the hypothesized direction were found in the Teen Parent Welfare Demonstration overall or in any of its three sites or in all New Chance sites combined. Delaying second pregnancies among teenagers requires intensive efforts. Survival analysis is a more accurate and useful way of presenting program results than simple analysis of the proportion of women with a second birth.

Adolescent pregnancy in the United States.

The rates of adolescent pregnancies and births in the United States are higher than those in most industrialized nations. Fortunately, the rates of sexual activity, pregnancies, and births have declined in the last few years. Contraceptive use has increased and the induced abortion rate and ratio have also declined. The decrease in sexual activity and the increase in contraceptive use are usually attributed, at least in part, to fear of contracting HIV/AIDS. Other contributing factors may be health education programs, a changing moral climate, new contraceptives, and the improved economy. The decrease in sexual activity and increase in contraceptive use have led to the decline in the pregnancy and birth rates. The decline in induced abortions is probably due to legislation restricting access to abortion for minors, harassment of abortion facilities, and violence against abortion providers. Programs to prevent adolescent pregnancies and births have traditionally focused on health education and provision of contraceptive services. Recently there has been increased emphasis, supported by federal funds, on teaching about the value of abstinence. Another new approach has been youth development programs that provide adolescents with opportunities to interact with caring adults outside of their families and to build self-esteem, a sense of self-worth, and skills.

Association of early childbearing and low cognitive ability.

CONTEXT: Teenage pregnancy remains a pressing social issue and public health problem in the United States. Low cognitive ability is seldom studied as a risk factor for adolescent childbearing. METHODS: Data from the National Longitudinal Survey of Youth were used in a matched-pairs nested case-control study comparing women who had a first birth before age 18 with those who did not. Significant differences in Armed Forces Qualifications Test scores and in reproductive and social intervening variables were determined using chi-square analyses and t-tests. Multiple logistic regression models determined the independent effects of specific factors on early childbearing. RESULTS: Women who had their first birth before age 18 had significantly lower cognitive scores than others; women with a second birth before age 20 had significantly lower scores than those with one teenage birth. On average, women with the lowest cognitive scores initiated sexual activity 1.4 years earlier than those with the highest cognitive scores. Among those who had had a sexuality education course, a smaller proportion of women had scores in the first quartile for the overall sample than in the fourth quartile (20% vs. 28%); an even greater difference was seen among women who correctly answered a question about pregnancy risk (14% vs. 43%). Both poverty and low cognitive ability increased the odds of early childbearing. CONCLUSIONS: Young women with low cognitive ability are at increased risk for early initiation of sexual activity and early pregnancy. Further research is needed to design interventions that consider this population's specific information and support needs.

The extent of pregnancy mistiming and its association with maternal characteristics and behaviors and pregnancy outcomes.

CONTEXT: The National Survey of Family Growth (NSFG) classifies pregnancies as intended, mistimed or unwanted. However, these categories could be too broad, as a woman's feelings about a pregnancy, her health behaviors during pregnancy and thus her pregnancy outcomes may vary according to whether her pregnancy is moderately or seriously mistimed. These relationships have not yet been explored. METHODS: Data from the 1995 NSFG were examined to assess associations between pregnancy mistiming and maternal characteristics. Descriptive and multivariate analyses were conducted of the extent of mistiming for each maternal characteristic. Chi-square and F-tests were used to examine the associations between a pregnancy's intendedness--according to a four-category classification--and maternal characteristics, maternal happiness ratings, maternal behaviors and pregnancy outcomes. RESULTS: Fifty-five percent of mistimed pregnancies were mistimed by 24 months or less, 32% were mistimed by 25-60 months and 13% were mistimed by more than 60 months. According to multivariate analyses, pregnancies among younger women, never-married women and black women were mistimed by significantly more months than those among other women. The distribution of moderately mistimed pregnancies differed significantly from those of both seriously mistimed and unwanted pregnancies according to most maternal characteristics; there were few differences between intended and moderately mistimed pregnancies, and between seriously mistimed and unwanted pregnancies. CONCLUSIONS: Mistiming is not a unitary construct. Its extent is associated with maternal characteristics and behaviors. Future research on pregnancy intention should examine the extent of mistiming and consider alternatives to traditional definitions of intendedness.

Demographic and educational characteristics of inner city middle school problem absence students.

Results of a study of characteristics of middle school students revealed highly significant differences between problem absence students and non-problem absence students on all study variables except sex. Characteristics such as increasing grade, being behind appropriate grade, busing and special education status, and the particular school attended were highly correlated with this behavior, as were race and increasing age.

Teenage parenting and child abuse: are they related?

The relationship between teenage parenting and child abuse is examined in terms of three methodological problems that must be considered in assessing this relationship. Four data sets illustrative of the methodological difficulties are described. Results suggest that the hypothesized association between teenage pregnancy and child abuse may be confounded by the association of each variable with social class.

Coping with pregnancy resolution among never-married women.

The Janis-Mann model of decision-making provides the theoretical orientation for empirical analyses of decisions to deliver or abort in matched samples of never-married women. Results focus on four variables: happiness about pregnancy; initial acceptance of delivery or abortion; ease of decision-making; and satisfaction with final choice. Path analyses summarize findings, which are discussed in terms of conflict resolution strategies.

PIP: To examine in detail their decision-making process, 249 never-married owomen delivering and 249 women aborting a pregnancy were matched for age, race, parity, and welfare status; they completed questionnaires covering sociodemographic information, personality, previous pregnancy history, circumstances surrounding conception, reaction to pregnancy, influence of significant others, perception of decision process, attitudes toward abortion, and role models. The results are analyzed in terms of 1) happiness about being pregnant, 2) initial acceptance or rejection of the eventual decision to deliver or abort, 3) ease of the decision-making process, and 4) happiness about the eventual choice. In general, all pregnancies were greeted with sadness, but women delivering were relatively happier about the pregnancy, were more likely to initially accept delivery, received more support for their decision from others, had an easier decision process, and were happier with their eventual choice than women aborting. All women received more support than opposition to their choice from significant others. Path analysis of the 4 components of the decision process showed that sadness about the eventual decision was a function of (in rank order) a more difficult decision process, initial rejection of the choice made, and deciding to abort rather than deliver. The questionnaire findings are discussed in terms of the strategies the women used to cope with the stress of making a decision, including 1) the use of ego defense mechechanisms to avoid the reality of unwanted pregnancy, 2) management of interpersonal relationships with significant others as they impinge on the decision process, 3) the use of authority figures and societal expectations to arrive at a decision, 4) attitude and cognitive restructuring to avoid cognitive dissonance, 5) searching for new knowledge relevant to the decision, and 6) techniques to maintain self-esteem through the whole process.