Screening positive urine pregnancy tests for sexually transmitted diseases expedites the treatment of infected adolescent gravidas.

OBJECTIVE: To test the utility of screening the urine samples used to diagnose pregnancies at urban teen clinics for Chlamydia trachomatis and Neisseria gonorrhoeae by polymerase chain reaction (PCR). We hypothesized that urine screening would increase the proportion of teenagers treated for these two sexually transmitted diseases (STDs) before they initiated pregnancy-related care. DESIGN: A randomly selected subset of the urine samples used to diagnose 212 teen pregnancies were tested for C. trachomatis and N. gonorrhoeae by PCR. Endocervical testing was at the providers' discretion. Bivariate analyses were used to compare the teenagers randomized to the urine screening group (n = 102) and the non-screening group (n = 110). RESULTS: Of the 102 urine PCR tests, 14 (13.7%) were positive. Endocervical swabs were obtained in 31 (14.6%) of the 212 teenagers and five (16.1%) were positive. Since pelvic examinations were performed so infrequently, the net endocervical swab detection rate was significantly lower than the urine-based detection rate (1.8% compared to 13.7%; p = 0.001). Only one infected teenager was untreated when she initiated pregnancy-related care. Thus, the treatment rate was more than six times higher when urine samples were screened (12.7% compared to 1.8%; p = 0.003). CONCLUSIONS: Screening the urine samples used to diagnose teen pregnancies for two common STDs is a simple, non-invasive procedure that is acceptable to providers and patients, and significantly increases the number of teenagers who are treated for genital infection before they initiate pregnancy-related care.

To be rather than not to be--that is the problem with the questions we ask adolescents about their childbearing intentions.

OBJECTIVE: To demonstrate that rephrasing the questions used to assess childbearing intentions to quantify the strength of the intent to remain nonpregnant, rather than the strength of the intent to become pregnant, would make teenagers' responses more useful to health care providers, family planning counselors, and health policy makers. METHODS: Examples from the teen pregnancy prevention literature are used to support the recommendations for change. RESULTS: Teenagers rarely plan their pregnancies. However, because those who are having sexual intercourse must actively try not to become pregnant or they will likely conceive, teenagers often become pregnant because they lack a firm commitment not to do so. Thus, to accurately profile the antecedents of adolescent pregnancy, (1) the questions used to assess childbearing intentions must be rephrased so that teenagers who intend to remain nonpregnant can be distinguished from those who do not and (2) separate differential diagnoses must be developed for inconsistent contraceptive use within these 2 groups of teenagers who are at risk for unintended pregnancy. CONCLUSION: Asking sexually active teenagers about the strength of their intent to remain nonpregnant will make the results of office interviews and national surveys more useful because the responses such questions elicit will enable health care providers and policy makers to target common, modifiable antecedents of inconsistent contraceptive use for interventions.

A comparison of the psychological resources of adolescents at low and high risk of mistreating their children.

OBJECTIVE: Our objective was to compare the psychological resources of pregnant teenagers who are at low and high risk for mistreating their children. METHOD: We studied 71 participants in a comprehensive, adolescent-oriented maternity program. During the prenatal period, the Family Stress Checklist was used to quantify child abuse potential, with scores > or =25 defining high risk. Information about the social context of the pregnancy and maternal psychological resources was obtained with self-administered questionnaires. A composite psychological resource variable was computed by summing the z scores for intelligence, mental health, and mastery, with scores < or =0 defining the low-resource group. RESULTS: Of the 71 teenagers, 26 (36.6%) were classified as high risk for child abuse and neglect. Compared with low-risk teens, high-risk teens had more behavioral problems, lower psychological resource scores (mean +/- SD of z score: -0.98 +/- 2.02 compared with 0.39 +/- 1.79; P =.004), and were more likely to have low psychological resources (69.2% compared with 44.4%; P =.04). CONCLUSIONS: Pregnant teenagers who are at risk for child abuse and neglect exhibit fewer psychological resources than their low-risk peers do, and may therefore benefit preferentially from intensive, in-home intervention.

Skinfold caliper and ultrasound assessments of change in the distribution of subcutaneous fat during adolescent pregnancy.

OBJECTIVE: This study compares skinfold caliper and sonographic measurements of the amount and distribution of subcutaneous adipose tissue teenagers gain during pregnancy to test three hypotheses: (1) skinfold caliper and sonographic measurements of subcutaneous adiposity are highly correlated in pregnancy; (2) the extent to which the skinfold caliper heads compact the tissues increases during gestation; and (3) skinfold caliper measurements yield a smaller estimate of the amount of subcutaneous adipose tissue gained during gestation than do sonographic measurements. METHODS: We studied 28 primiparous teenagers at 10.7+/-2.8 and 29.6+/-1.8 weeks gestation. At both study visits subcutaneous adipose tissue thickness was measured at six body sites, first by skinfold caliper and then by ultrasound. Taking the nearly compression-free sonographic measurements as the standard, we quantified the extent to which the skinfold caliper heads compacted the tissues at each measurement site by computing the percentage compression: (mean adipose tissue thickness by ultrasound-(0.5xmean adipose tissue thickness by caliper)/mean adipose tissue thickness by ultrasound)x100. Pearson correlations and paired t-tests were used to compare the skinfold caliper and sonographic measurements. RESULTS: Hypothesis 1 was supported; the skinfold caliper and sonographic measurements were highly correlated at both study visits. Hypothesis 2 was not supported; between study visits caliper-related tissue compression decreased at measurement sites on the trunk and remained the same at measurement sites on the extremities. Hypothesis 3 was also refuted; the skinfold caliper-derived estimate of the amount of subcutaneous adipose tissue gained on the trunk exceeded the corresponding sonographic determination. As anticipated, the skinfold caliper measurements indicated that adipose tissue was stored more rapidly on the trunk than the extremities, but the opposite pattern emerged when the sonographic measurement technique was used. CONCLUSIONS: The results of this study challenge the notion that pregnant women store adipose tissue preferentially on the trunk and suggest that pregnancy-related changes in the regional distribution of maternal body fat based on skinfold caliper measurements should be interpreted cautiously.

Adolescents at risk for mistreating their children. Part I: Prenatal identification.

OBJECTIVE: To determine if the Family Stress Checklist helps prenatal care providers identify adolescents who are at risk for mistreating their children. METHODS: We studied 262 participants in a comprehensive, adolescent-oriented maternity program. During the prenatal period, the Family Stress Checklist was used to quantify abuse potential, with scores >25 defining high risk. Information about the social context of the pregnancy and the pattern of health care utilization was obtained with a self-administered questionnaire, and by reviewing the medical records. Major disruption of primary care giving by the adolescent mother was classified hierarchically as abuse, neglect, and abandonment. RESULTS: Family Stress Checklist scores ranged from 0 to 65 (mean + SD = 20.1 + 1.4); 113 (43%) of the 262 teenagers were classified as high risk. High and low risk adolescent mothers made an equivalent number of health maintenance and Emergency Department visits, but the high risk group initiated significantly more acute care visits (6.0 + 4.1 compared to 3.9 + 3.3; p < .0001). After controlling for pre-existing sociodemographic differences, high risk 1-year-olds were 8.41 (95% CI: 1.77-40.01) times and high risk 2-year-olds 5.19 (95% CI: 1.99-13.60) times more likely to have been mistreated than their low risk counterparts. CONCLUSIONS: Prenatal care providers can use the Family Stress Checklist to systematically identify a subgroup of adolescent mother whose excessive use of the acute medical care services and propensity for mistreating their children suggests the need for additional support services.

Adolescents at risk for mistreating their children. Part II: A home- and clinic-based prevention program.

OBJECTIVE: To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect. METHODS: We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment. RESULTS: Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p < .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mother's custody. CONCLUSIONS: Prediction efforts were effective in identifying at-risk infants, but this intensive home- and clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children.

A comparison of four techniques for measuring central adiposity in postpartum adolescents.

OBJECTIVE: To develop a reliable office technique for measuring central body fat in postpartum adolescents, we compared: first, a direct sonographic measurement of visceral adiposity to measurements of visceral and subcutaneous abdominal adiposity by computed tomography (CT); and second, skinfold caliper and sonographic measurements of subcutaneous adipose tissue distribution to CT measurements of visceral and subcutaneous abdominal adiposity. METHODS: Postpartum adipose tissue distribution was assessed in 15 teenagers by measuring the thickness of the subcutaneous fat at six body sites with skinfold calipers and ultrasound. Visceral adiposity was measured directly by ultrasound and CT. Taking the CT measurements as the standards, Pearson correlations and regression analyses were used to compare ultrasound measurement of visceral adiposity and the skinfold caliper and sonographic measurements of subcutaneous adipose tissue distribution. RESULTS: All of the adiposity measurements correlated significantly with the two CT measurements. The correlations between the ultrasound and the two CT measurements of abdominal adiposity were weaker than the correlations between the skinfold caliper and the sonographic determinations of subcutaneous adiposity and the two CT measurements of abdominal adiposity. Multivariate analyses identified the sonographic determination of subcutaneous adiposity at the costal site as the best independent predictor of central adiposity. CONCLUSIONS: The results of this study do not support the validity of ultrasound measurement of visceral adiposity as a measure of central adiposity in postpartum teenagers, but do suggest that sonographic determinations of subcutaneous adiposity could be useful for conducting epidemiological studies of the metabolic sequelae of gestational weight gain in this high-risk population of young women.

A village would be nice but...it takes a long-acting contraceptive to prevent repeat adolescent pregnancies.

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.

The prevalence of genital human papillomavirus infections in abused and nonabused preadolescent girls.

OBJECTIVE: To compare the prevalence of genital human papillomavirus (HPV) infections in sexually abused and nonabused preadolescent girls and assess the feasibility of conducting a longitudinal study of the natural history of HPV infection in this population. METHOD: Consecutively referred, 5- to 12-year-old girls who were evaluated for sexual abuse by a Child Advocacy and Protection Team were invited to participate in the study. During a standard forensic medical examination, 2 specimens for HPV testing were obtained (one by rubbing a Dacron swab over the perineum and the other by lavaging the vagina with phosphate-buffered saline). The specimens were evaluated for HPV DNA by polymerase chain reaction using MY09/11 consensus primers and high-risk (16,18,31,33,35,39,45,51,52, 56,58) and low-risk (6,11,42,43,44) types were detected with a solution hybridization assay, the SHARP Signal System (Digene Diagnostics). The genital area was examined for warts and subclinical, colposcopic evidence of HPV. Participants were invited to return for longitudinal evaluation at 4-month intervals for 2 years. RESULTS: Sexual abuse was confirmed in 29 (72.5%) of the 40 study participants, suspected in 2 (5%), and ruled out in 9 (22.5%). None of the girls had genital warts or abnormal colposcopic findings. HPV DNA was detected in 5 (16%) of the 31 girls with confirmed or suspected sexual abuse (1 with high-risk and 4 with low-risk types) and none of the nonabused girls (Fisher's exact test). Girls who tested positive and negative for HPV did not differ significantly in age or type of abuse. Despite close telephone follow-up and numerous attempts to schedule appointments, none of the participants returned for follow-up. CONCLUSIONS: Genital HPV infection is more common among sexually abused than nonsexually abused girls, with the majority of infections not clinically apparent. Because it is so difficult to study the natural history of these infections in abused children, it may be necessary to draw inferences about the long-term sequelae of pediatric HPV infections from longitudinal studies of girls who voluntarily initiate sexual activity soon after menarche.

The timing of norplant insertion and postpartum depression in teenagers.

BACKGROUND: This study tested the hypothesis that teenagers who have Norplant inserted during the puerperium report more depressive symptoms during the first postpartum year than their peers who do not receive Norplant. METHODS: We studied the prevalence of depressive symptoms in a group of 212 mothers aged 19 years less, in relation to the timing of Norplant insertion. The participants were divided into 3 groups: 100 (47%) had Norplant inserted during the puerperium (early Norplant users); 72 (34%) had Norplant inserted during the next 10 months (late Norplant users); and 40 (19%) used other contraceptives (40% oral contraceptives; 17% condoms; 43% nothing). Depressive symptoms were measured with the Center for Epidemiologic Studies - Depression Scale. Postpartum depression was defined as a scale score >/=16, 6-12 months after Norplant insertion or delivery. Variables examined as potential confounders were identified a priori from a review of the literature and controlled for in analysis of variance. RESULTS: At delivery, members of the 3 contraceptive groups did not differ significantly with regard to age, race, parity, educational, marital, or socioeconomic status. Late Norplant users were, however, more apt to have new boyfriends (p =. 03), to rate the support they received from the baby's father as poor (p =.004), and experience depression prior to Norplant insertion (p =.02). Contrary to the study hypothesis, late rather than early Norplant insertion was associated with postpartum depression. Multivariate analyses identified 3 independent predictors of the severity of depressive symptoms at follow-up (depression prior to Norplant insertion, a new boyfriend at delivery, and late Norplant insertion); R(2) = 41.3%. CONCLUSIONS: Contrary to the study hypothesis, puerperal Norplant insertion did not exacerbate postpartum depression. Delaying Norplant insertion may increase the risk of depression during the first postpartum year, particularly in teenagers with other psychosocial risk factors.

Does mothering a doll change teens' thoughts about pregnancy?

OBJECTIVE: To determine the effect of age on the efficacy of the computerized, infant simulator doll Baby Think It Over (BTIO) for increasing middle school girls' knowledge about the responsibilities of parenthood and discouraging plans for teen childbearing. We hypothesized: 1) 8th grade students would be less apt than 6th grade students to equate BTIO care with mothering because they would rationalize that their infant would be easier to care for than BTIO; and 2) BTIO would be a more effective teen pregnancy prevention program with 6th grade students than with 8th grade students. METHODS: Nulliparous 6th (n = 68) and 8th (n = 41) grade girls attending an urban middle school in a predominantly lower socioeconomic, Hispanic, neighborhood were asked to care for BTIO for 3 days and 2 nights. Responses to a self-administered questionnaire were used to assess the girls' understanding of the responsibilities and difficulties associated with parenting, their feelings about the similarity of BTIO care and real infant care, and their childbearing intentions before and after caring for BTIO. RESULTS: Only 32 (29%) of the 109 girls thought that real infant care would be like BTIO care. Although 8th grade students were less apt than 6th grade students to equate BTIO care with real infant care (17% vs 37%), 6th grade students were more likely than 8th grade students to endorse statements suggesting that real infant care would be easier than BTIO care (37% vs 24%). Multivariate analyses revealed that this was largely because 6th grade students found BTIO care more difficult than did 8th grade students. Also, regardless of age or grade, the more difficult a girl found it to care for BTIO than anticipated, the more likely she was to endorse statements indicating that it would be easier to care for her own infant than it had been for her to care for BTIO. Little learning about the difficulties of parenting took place during the study. On average, the 6th grade students did not find BTIO care more difficult than anticipated and the 8th grade students actually found it easier than anticipated. Finally, caring for BTIO had no affect on the intent of students to become teen parents; 13 (12%) of the 109 students wanted to be teen parents before they cared for BTIO and 16 (15%) wanted to be teen parents after they cared for the doll. CONCLUSION: The results of this study demonstrate that the propensity of people this age for rationalizing their own immunity to the nocuous aspects of potentially desirable situations (the personal fable of omnipotence) allows those who perceive parenthood to be attractive to overlook the negative aspects of any parenting experience they have.

Participation in a program that helps families with one teen pregnancy prevent others.

STUDY OBJECTIVE: To define the optimal target population for a home- and clinic-based mentoring program designed to help one teen pregnancy-families prevent others, by prospectively determining who might be willing to participate in an intervention of this type. DESIGN/SETTING/PARTICIPANTS: Pregnant 13-to-19 year olds in a comprehensive, adolescent-oriented maternity program and their younger, nulliparous, 10-to-16 year old sisters were asked to participate in the intervention. RESULTS: Only 27 (61%) of the 44 eligible families agreed to participate and 9 (33%) of these 27 families withdrew within 6 months. Older sisters from nonparticipating families were significantly more likely to be over 16 years of age at conception (53% compared to 15%; P =.01), and younger sisters from families that withdrew were significantly more likely to be over 14 years of age or under 12 years of age at enrollment (63% vs 22%; P =.03). Ultimately, 75% of the families in which the older sister was less than 17 years of age at conception joined the program and only 16% of the families in which the younger sister was 12-to-14 years of age at enrollment withdrew within 6 months. CONCLUSIONS: Investigators testing the efficacy of programs for preventing pregnancies among teen mothers and their nulliparous, younger sisters could minimize selection bias by prospectively targeting families in which the older sister became pregnant before she was 17 years old and the younger sister is 12 to 14 years old.

Short cervix: a cause of preterm delivery in young adolescents?

OBJECTIVE: To test the hypothesis that at midgestation younger adolescents (<16 years of age at conception) have shorter cervices than older adolescents (16-19 years of age at conception). METHODS: At midgestation (22.9 +/- 2.4 weeks) we measured cervical length by transvaginal ultrasound in a group of 46 13-19-year-old participants in an intensive, adolescent-oriented, antenatal program. Subjects were also comprehensively screened and treated for other recognized physiologic, microbiologic, obstetric, behavioral, and psychosocial factors associated with preterm delivery. Univariate, bivariate, and logistic regression analyses were used. RESULTS: The 18 younger adolescents had significantly shorter cervices than the 28 older adolescents (30 +/- 11 mm vs. 39 +/- 8 mm; P = 0.002). The younger adolescents' cervices were also more likely to be < or =25 mm long (33% and 4%, respectively; P = 0.02) and to exhibit funneling (39% vs. 4%; P = 0.01). Teenagers with cervices < or =25 mm long were younger, thinner, more apt to report vaginal bleeding and substance abuse, and to be treated for preterm labor (71% vs. 21%; P = 0.005). Logistic regression analyses revealed that age <16 years at conception (odds ratio = 13.7; 95% CI: 1.3-151.4) and substance abuse (odds ratio = 8.5; 95% CI: 1.2-62.8) were associated with cervical length < or =25 mm. Cervical length < or =25 mm was the only significant predictor of preterm delivery (odds ratio = 26.2; 95% CI: 2.1-333.6; P = 0.01) in this population of adolescents who were routinely treated for other recognized causes of preterm delivery. CONCLUSIONS: Cervical length < or =25 mm and cervical funneling may be complications of conception prior to 16 years of age. Randomized trials are needed to determine if younger adolescents benefit preferentially from ultrasound screening for short cervix at midgestation.

Comparing endocervical curettage and endocervical brush at colposcopy.

OBJECTIVE: To determine the sensitivity and specificity of the cytologic diagnosis obtained from the endocervical brushings (ECB) compared to the histologic information obtained from endocervical curettage (ECC). MATERIALS AND METHODS: Of 369 patients referred for colposcopy, 105 nonpregnant women underwent conization and/or hysterectomy allowing analysis of tissue samples. The racially diverse, sociodemographically homogeneous population was 15 through 71 years old. Participants had repeat Papnicolaou smears, ECB, colposcopy (with/without directed biopsy), and ECC. The sensitivity, specificity, and positive and negative predictive values of ECB and ECC for diagnosing endocervical disease were compared. RESULTS: No invasive cancers were missed by either ECB or ECC. The sensitivity of ECB was 93%, which exceeded that of ECC (62%) for detection of endocervical pathology. However, the negative predictive value of both ECB and ECC was excellent. The specificity of ECC (63%) exceeded that of ECB (25%) for detection of endocervical pathology. However, the positive predictive value of both ECC and ECB was poor. CONCLUSION: This study suggests that ECB can replace ECC during colposcopic evaluation of an abnormal Papnicolaou smear.▪.

Should gynecologic maturity change the management of cervical cytologic atypia during adolescence?

STUDY OBJECTIVE: To test the hypothesis that atypical cytology (ASCUS) portends ominous histologic diagnoses during adolescence. METHODS: The prevalence of squamous intraepithelial lesions (SILs) was determined in a racially diverse group of thirty-six 14- to 21-year-olds who were undergoing colposcopic evaluation of ASCUS cytology. The prevalence of 10 widely accepted risk factors for SIL was also qualified. RESULTS: SILs were detected in biopsies obtained from 20 (56%) of the 36 study subjects. There were 15 (39%) low-grade SILs and 5 (17%) high-grade SILs. No single risk factor or combination of risk factors distinguished subjects with SIL histology from those with more benign diagnoses. CONCLUSION: The hypothesis was supported. More than half (56%) of the adolescents we studied with ASCUS cytology had SIL histology. The findings suggest that immediate colposcopic evaluation may be prudent for adolescents with ASCUS cytology that cannot be attributed to concurrent lower genital tract infections.

Preventing repeat adolescent pregnancies with early adoption of the contraceptive implant.

CONTEXT: Even in intensive, adolescent-oriented programs, in which access to highly effective contraceptives is guaranteed, repeat adolescent pregnancies commonly occur. METHODS: To assess whether adoption of the contraceptive implant would lower the rate of repeat pregnancy, contraceptive use and pregnancy outcomes were tracked among 309 adolescent mothers--171 "early" implant users who began use within six months of delivery and 138 who either adopted another method or had used no method. Participants were interviewed at delivery and at six-month intervals through the second year postpartum. Multivariate logistic regression analyses were conducted to ascertain the likelihood of a repeat pregnancy within the first and second year postpartum. RESULTS: During the first year postpartum, although 7% of the early implant users had their implants removed, pregnancy rates were significantly (p < .0001) lower among early implant users (less than 1%) than among the other adolescent mothers in the sample (20%). By the end of the second year postpartum, 37% of early implant users had discontinued use. Nevertheless, their two-year pregnancy rate (12%) remained significantly lower (p < .0001) than that of the other adolescent mothers (46%). The multivariate analysis showed that early implant use was the only independent predictor of a repeat pregnancy within the first year postpartum, while early use, parity and number of risk factors for repeat pregnancy were independently associated with the likelihood of another pregnancy in the second year postpartum. CONCLUSIONS: Although early implant insertion significantly decreased the rate of rapid, repeat adolescent pregnancies, the rates of removal and of pregnancy by the end of the second year postpartum were high. Thus, health care providers need to address the motivational components of adolescent pregnancy even among those who accept ostensibly long-term methods.

PIP: More widespread use by US adolescents of contraceptive implants could reduce the number of repeat adolescent pregnancies--a common problem even when adolescent mothers participate in comprehensive, multidisciplinary programs aimed at eliminating barriers to contraceptive use. The impact of such a strategy was assessed in a 2-year prospective study of 309 adolescent mothers enrolled in the Colorado (US) Adolescent Maternity Program in 1992-93. 171 of these young mothers began implant use within 6 months of delivery; the remaining 138 adopted another method or used no method. Implant acceptors were significantly more likely than women in the second group to have experienced side effects with past methods (63% vs. 51%) and significantly less likely to be Black (23% vs. 33%), to be giving birth for the first time (79% vs. 91%), or to want another child within 2 years (1% vs. 6%). During the first postpartum year, 12 of the implant users (7%) discontinued the method. There was only 1 pregnancy (0.6%) in this group (a discontinuer) compared with 26 pregnancies (20%) among users of other methods or nonusers. During the second postpartum year, an additional 48 (30%) of the 161 early implant users for whom data were available discontinued method use. Nonetheless, the 2-year pregnancy rate remained significantly lower among implant users (20 women, 12%) than in the other group (57 women, 46%) (p 0.001). In the multivariate analysis, early implant use was the only independent predictor of repeat pregnancy in the first postpartum year, while implant use, parity, and number of psychosocial and demographic risk factors were significant in the second postpartum year. These findings point to the importance of addressing the motivational components of repeat adolescent pregnancy, even among acceptors of ostensibly long-term methods.

Low-birthweight prevention programs: the enigma of failure.

BACKGROUND: Low birthweight is the primary cause of neonatal morbidity and mortality in the United States. The purpose of our study was to identify factors associated with the effectiveness and apparent ineffectiveness of comprehensive, multicomponent, prenatal care programs for preventing low birthweight. METHODS: We reviewed obstetric, pediatric, and public health program evaluations, research reports, and commentaries, published in the English language literature, over the last four decades that pertained to the efficacy of prenatal care for preventing low birthweight. RESULTS: The heterogeneous nature of the services delivered and the lack of consistency in the definition of variables made it impossible to use rigorous, quantitative techniques to summarize this evaluation of the literature. Two general limitations of research design that emerged from our reviews were the focus on clusters of commonly associated risk factors, which has blurred the causal pathways linking specific risk factors to low birthweight, and the failure to examine process variables. These two methodologic problems have led investigators to erroneous conclusions that overstate the significance of negative intervention outcomes. The success and failure of low-birthweight prevention programs has rarely been examined in relation to evidence that the intervention actually modified the targeted risk factors. CONCLUSIONS: Few rigorous evaluations of well-designed programs have been conducted. Without an improvement in intervention designs and evaluation studies, recommendations to support or curtail the funding of comprehensive, multicomponent prenatal care services are inappropriate. Rigorously obtained evidence of the costs and benefits of approaches to the prevention of low birthweight are sorely needed.