Adolescent Pregnancy and Associated Risks: Not Just a Result of Maternal Age
Am Fam Physician. 2007 May 1;75(9):1310-1311.
Adolescent pregnancy (i.e., in females 13 to 19 years of age) is associated with an increased risk of maternal complications during pregnancy and delivery, as well as increased risk to the fetus and neonate. Complications associated with adolescent pregnancy include preterm delivery, low birth weight, and infant mortality.1 However, age-related biologic factors alone are not associated with an increased risk of fetal death.2 In infants of teenage mothers, much of the risk of low birth weight is related to behavioral and psychosocial factors.3 Thus, psychosocial risk factors should be a major focus of care.
One risk factor for poor outcomes in adolescent pregnancy is a maternal history of adverse childhood experiences (e.g., emotional, physical, or sexual abuse; intimate partner violence; living with someone who has substance abuse or mental illness, or is involved in criminal activity; having parents who are divorced or separated). These experiences are associated with subsequent sexual risk behaviors, smoking, alcohol consumption, and mental health problems such as depression.2 A history of remote maternal exposure to adverse childhood experiences is associated with an increased risk of fetal death.2 However, not all children exposed to these conditions have adverse outcomes. Protective factors such as good parenting, feelings of self-worth and achievement, and strong connections to family, school, and community can modulate the effects of negative experiences.
Intimate partner violence is most often directed toward women. It is more common in women younger than 24 years and in women who have not completed high school or whose partner has not completed high school.4 Even though screening for intimate partner violence in health care settings has been endorsed by many organizations, screening rates remain low.
Children born to women with psychiatric disorders have a higher risk of psychological problems, which can lead to a multigenerational sequence of mental health disability. One half of women with mental health disabilities experienced physical or sexual abuse as children.5 Children whose mothers report poor interpersonal relationships or low self-esteem are twice as likely to be neglected or physically or sexually abused.6 Early recognition and treatment of psychiatric disorders in children and in adolescent mothers (especially perinatal depression and anxiety) are essential to interrupt this pattern. However, perinatal depression often goes undetected, and physicians often do not recognize maternal depression when seeing children for well-child care or acute illness. Unfortunately, evidence of improved outcomes from screening for perinatal and postpartum depression is inconsistent.7
In men, a history of adverse childhood events is associated with an increased risk of fathering a child with an adolescent mother.8 In partners of adolescent women, older age and lower education are associated with higher risk of pregnancy; 60 percent of mothers 15 to 17 years of age and one half of mothers 18 to 19 years of age have a partner at least three years older than themselves.9
Because family physicians care for patients of all ages and both sexes and often care for multiple members of a family, they are uniquely suited to address the full range of risks associated with adolescent pregnancy. Interventional programs to reduce rates of adolescent pregnancy and to modulate adverse health effects should be based on risk factors, including very young maternal age, exposure to adverse childhood experiences, maternal psychiatric morbidity, and paternal age and education level. Physicians should consider routinely questioning women about adverse childhood experiences. Similarly, more intensive clinical services and support may be appropriate for pregnant women who experienced abuse or other adverse conditions in childhood.10 More attention should be devoted to screening and treatment for depression in pregnant patients, especially adolescents.11 Physicians also should be alert to the risk of age disparities and educational deficits in sex partners of adolescents.
Although evidence exists for the benefit of identifying some of these risk factors, evidence is lacking for the effectiveness of integrated intervention programs. Family physicians should lead comprehensive program development and evaluation to reduce the likelihood and adverse effects of adolescent pregnancy.
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2. Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004;113:320–7.
3. Reichman NE, Pagnini DL. Maternal age and birth outcomes: data from New Jersey [Published correction appears in Fam Plann Perspect 1998;30:127]. Fam Plann Perspect. 1997;29:268–72,295.
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5. Tonmyr L, Jamieson E, Mery LS, MacMillan HL. The relation between childhood adverse experiences and disability due to mental health problems in a community sample of women. Can J Psychiatry. 2005;50:778–83.
6. Bifulco A, Moran PM, Ball C, Jacobs C, Baines R, Bunn A, et al. Childhood adversity, parental vulnerability and disorder: examining inter-generational transmission of risk. J Child Psychol Psychiatry. 2002;43:1075–86.
7. Gaynes BN. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence report/technology assessment no. 119. Rockville, Md.: Agency for Healthcare Research and Quality, 2005.
8. Anda RF, Chapman DP, Felitti VJ, Edwards V, Williamson DF, Croft JB, et al. Adverse childhood experiences and risk of paternity in teen pregnancy. Obstet Gynecol. 2002;100:37–45.
9. Landry DJ, Forrest JD. How old are U.S. fathers? Fam Plann Perspect. 1995;27:159–61,165.
10. Mezey G, Bacchus L, Bewley S, White S. Domestic violence, lifetime trauma and psychological health of childbearing women. BJOG. 2005;112:197–204.
11. American College of Obstetricians and Gynecologists Committee on Healthcare for Underserved Women.. ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention. Obstet Gynecol. 2006;108:469–77.
Copyright © 2007 by the American Academy of Family Physicians.
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