Symposium on Adolescent Medicine
Adolescent Pregnancy and Abortion David D. Youngs, M.D.*, and Jennifer R. Niebyl, M.D.**
DIMENSIONS OF THE PROBLEM During the past decade, there has been a startling increase in the number -of adolescent pregnancies. In 1972, lout of every 10 girls became pregnant while still of junior or senior high school age. Coupled with the falling birthrate in the United States, their numbers have become even more conspicuous. Until recently, teenage pregnancy was thought to be a problem confined primarily to the nonwhite, lower income inner city population. Recent information indicates that teenage pregnancy is involving more and more middle class youngsters in both rural and suburban settings. For example, in Arizona, during 1971, 18.9 per cent of all births were to teenagers 16 years or under, of whom 63 per cent were white. 13 Klein reports that illegitimacy rates for middle class whites is rising while the rates for blacks continue to fall. 11 For many of these youngsters, marriage is no longer a prerequisite to parenthood; nor is adoption the only alternative. Currently no more than 18 per cent of unwed mothers give up their newborn infants for adoption. 20 Earlier reports by Battaglia and Coates suggest that adolescents fare less well obstetrically, and that those 14 years and under are at particular risk for major complications such as toxemia, anemia, prematurity, prolonged labor, and postpartum complications.2 • 4 More recent studies by Dwyer and Webb fail to show significant differences in obstetric complications or outcome for adolescents when "more comprehensive" obstetric care was provided.5 • 17 While pregnant adolescents continue to represent a special group at risk, differences in access to quality care, social class, and racial background are probably more significant factors than age alone in influencing obstetric outcome. An additional consideration is that adolescents are a heterogeneous group even when social class and ethnic background are similar. For example, the pregnant 12
*Director, Center for Social Studies in Human Reproduction, and Assistant Professor of Gynecology and Obstetrics and Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland '"Assistant Professor of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland Medical Clinics of North America- Vol. 59, No. 6, November 1975
1419
1420
DAVID D. YOUNGS AND JENNIFER
R. NIEBYL
year old, who is dependently attached to her mother and inexperienced in social relationships, represents a very different management problem from the sophisticated 17 year old, who is sexually experienced, and emotionally emancipated, and comes shortly after a missed menstrual period for a therapeutic abortion. Probably in no other area of medicine are stereotyped ideas and conventional therapeutic practices less applicable. In practical terms, then, physicians who provide care for pregnant adolescents must acquire a degree of sophistication about adolescents in general, a flexibility of approach, and a willingness to deploy a variety of therapeutic strategies in dealing with this often difficult age group. In communities that lack physicians who are interested in the problem, attendance for prenatal care will usually be poor, obstetric complications excessively high, and repeat pregnancy the rule rather than the exception. Furthermore these adolescents may (1) lack financial resources or be ignorant of available community assistance, (2) be embarrassed or ambivalent over being pregnant and (3) lack emotional support from understanding adults who are sympathetic to their problems. All too often these young patients fail to receive adequate prenatal care and appear only after medical complications have developed. In addition these new mothers often complete their pregnancy with few mothering skills and a negative view of the child who has caused them so many problems.
ETIOLOGIC FACTORS The successful management of the pregnant adolescent depends upon some working knowledge of the social and psychological forces as well as the family dynamics that set the stage for the teenager's pregnancy. For middle class adolescents, pregnancy is commonly the result of maladaptive attempts to solve psychological conflicts specific to their particular stage of adolescent development.9 For example, loosening of a dependent relationship with a clinging mother, "acting out" an erotic attachment with a seductive father, or manipulating a reluctant boyfriend into a more committed relationship are common dynamics. When serious psychological or social pathology is responsible for teenage pregnancy it is more often associated with other maladaptive patterns such as drug abuse, delinquency, abandonment by the family or truancy from school. Intrafamily dynamics may be the motivating force in a significant number of such teenage pregnancies. Using a comparison group of nonpregnant teenagers, Abernethy has demonstrated that adolescents who become pregnant are more likely to be dissatisfied with their mother as a role model, express a preference for their father even to an exclusive degree, or report hostility within the parents' marriage.! In contradistinction, parents who are affectionate and close are more likely to foster their daughter's identity as a woman and enhance her self esteem, thus diminishing the probability of promiscuous sexual behavior and possible conception.! Ignorance about sexual functions and superstitions or fears concerning the use of contraception also contribute to the problem of
PREGNANCY AND ABORTION
1421
unwanted pregnancy. A small proportion of adolescents actively desire pregnancy and probably an equal number are indifferent about the possibility of pregnancy following coitus. For some of these youngsters, pregnancy may represent a constructive attempt to negotiate the developmental problems of adolescence. Unfortunately, the odds are very much against the development of a stable marriage for such teenagers or the creation of a healthy environment for the newborn infant, although some young mothers do succeed. Factors which appear to be central in those who succeed include (1) the presence of a caretaking person who will provide the necessary emotional and financial security until the adolescent is self sufficient, (2) a realistic view of the maternal role as well as the needs of the infants, and (3) the motivation for pregnancy being for positive and healthy reasons rather than self-destructive or neurotic ones. An appreciation of the personal, family and social factors impinging on the pregnant adolescent is helpful in orienting the physician to the alternatives available in managing the pregnancy and to the opportunities for "planning" future pregnancies. For the inner city adolescent, pregnancy is further complicated by poverty, social and community disruption, and the lack of suitable role models. Successful care, then, will depend on understanding the various etiologic factors involved, the specific needs of the adolescent, and the availability of various community resources.
GOALS FOR THE CARE OF PREGNANT ADOLESCENTS The question of quality obstetrical care for the pregnant adolescent must address itself to considerations that go beyond the narrow definition of traditional medical services. The increased rates of fetal and maternal morbidity previously alluded to have not been shown to be significantlyaltered merely by the provision of traditional obstetrical services; therefore, any successful effort must embrace a broader range of personal and health care needs for this group. With this in mind the realistic goals for quality care are (1) early diagnosis and intervention, (2) early and active participation in a suitable health care program, (3) an opportunity for therapeutic abortion as an alternative, (4) attention to the social and personal needs of the adolescent, (5) health education, particularly in the areas of human sexuality, reproduction and contraception, (6) preparation for mothering activities and introduction to child development and child care, (7) coordinated follow up care as well as family planning services, and (8) reintegration of the adolescent mother back into her community through such assistance as day care, vocational or special educational services.
MODEL PROGRAMS: ELEMENTS OF SUCCESS Osofsky and Sarrel were the first to report on a successful interdisciplinary approach to adolescent pregnancy. Focusing predominantly on low income nonwhite adolescents, they were able to achieve a remark-
1422
DAVID D. YOUNGS AND JENNIFER
R.
NIEBYL
able reduction in obstetrical morbidity, prematurity, and antenatal complications as well as lowering the incidence of repeat pregnancy and increasing school attendance}5, 16 Subsequent reports from a more diverse population including white middle class youngsters show similarly good resultsP Drawing from our own experience with an interdisciplinary approach to teenage pregnancy19 and those reports in the literature;O,15,17 the common attributes of such programs that seem to be major contributors to success are: (1) improved communication between community, school, and medical services leading to early diagnosis and referral and complementary rather than competitive care, (2) the selection of nonjudgmental professional and staff members who are interested and skilled in relating to pregnant teenagers as people rather than as problems, (3) the inclusion of psychological and social work services as an integral part of obstetrical care rather than following the traditional patterns of referral that imply "there is something wrong with you, therefore you must see the psychiatrist or social worker," (4) providing continuity of medical care by an interested obstetrician, nurse midwife, nurse, or other experienced staff member who offers a more permanent relationship throughout the antepartum period, labor and delivery, and postpartum experience, (5) follow-up care for the new mother and infant that combines vocational, educational, and social work services in addition to inter-conceptional medical care for the mother and well baby care for the infant, (6) providing easy access to a nonjudgmental professional who is available to coordinate ongoing care, assist in handling common adjustment problems, provide advice about child care, or make necessary alterations in the contraceptive program.
MANAGEMENT CONSIDERATIONS: THE CONSULTANT VERSUS THE PRIMARY CARE ROLE Prompt and accurate diagnosis is a prerequisite to the successful management of adolescent pregnancy. Awareness of the increasing frequency of pregnancy among teenagers, particularly in the middle class, should alert the physician to the possibility of pregnancy among his young female patients. Vague symptoms such as nausea, fatigue, abdominal cramps, or syncope should not be dismissed until the question of pregnancy is explored. Establishing the date of the last menstrual period will frequently be helpful in suggesting the diagnosis. The necessity for a "high index of suspicion" should not be confused with an intrusive or probing manner. In spite of most adolescents' anxiety and apprehension during the first office visit, usually sufficient "clues" are provided to suggest the possibility of pregnancy. The initial encounter of the adolescent with the physician and the office staff is of critical importance. A sense of security and confidence is slow to develop among adolescents, even in the best of circumstances. In the face of an embarrassing problem (pregnancy) and on unfamiliar territory (the physician's office) the initial encounter may determine whether the patient will return for regular care or abandon the physi-
PREGNANCY AND ABORTION
1423
cian for less adequate services. Several visits may be required before the patient feels sufficiently secure and trusting of the physician to provide an accurate history and allow a complete and informative pelvic examination. The initial office visit, then, for the young female adolescent is of major importance. It may be her first pelvic examination. Along with the usual mixed feelings of anxiety and fear, the uncertainty of possible pregnancy commonly makes her more sensitive to minor slights, thoughtless criticism, or unsympathetic handling. Advising abortion or adoption before a comfortable and honest rapport with the physician has developed may seriously strain the doctor-patient relationship or more likely result in failure of the patient to return. A skilled office staff may ease the adolescent's anxiety, obtain a more complete history or serve as an accessible friend during this difficult period. Guidance and advice concerning contraceptive information, abortion, or adoption may be more easily accepted from office staff members of the patient's own sex or someone closer to her age. When the physician also cares for the adolescent's mother, issues of confidentiality and trust are more difficult to deal with and referral to a sympathetic colleague may be preferable. When the patient is accompanied by her mother in the initial visit, a useful approach is to meet briefly with both to collect relevant information from the mother and observe firsthand the mother and daughter interaction. In addition, it is helpful to get some sense of the father's reaction to his daughter's pregnancy. Fathers that accompany their daughters for the first interview can be handled in much the same manner as the mother. The majority of the interview time should be spent with the adolescent, obtaining her history, gaining her confidence, and establishing a secure relationship. Only when the adolescent is markedly immature, retarded, or severely disturbed should the primary relationship be developed with the mother. The initial history and physical examination, including the pelvic examination, should establish the presence of pregnancy or make it a strong possibility. Waiting for uterine enlargement or a positive pregnancy test only delays an open discussion of possible pregnancy and unnecessarily postpones a review of such options as abortion. Several visits may be required to satisfactorily explore the patient's feelings about abortion versus continued pregnancy or to rally the support of the family. Common complaints of pregnant adolescents seen in the office include feeling hurried, embarrassed, being treated like children, or being advised that "abortion is the only solution." For many adolescents, particularly those 16 years of age or older, pregnancy is not associated with serious social or psychological pathology. However, in younger patients who are separated from their families, truant from school, or demonstrate evidence of delinquent behavior, psychiatric disturbances or major adolescent adjustment problems should be suspected and referral for appropriate mental health counseling is indicated. Physicians who are sufficiently experienced and interested may elect to provide the majority of the adolescent's health services including informal counseling, patient education, and routine antenatal care. Other physicians may elect to refer the patient to a colleague, a teen clinic or other community
1424
DAVID D. YOUNGS AND JENNIFER
R.
NIEBYL
based program that has particular expertise with this problem. In either case, the physician who has a comfortable and familiar relationship with school personnel and relevant social agencies will improve the adolescent's chances of successfully resolving her pregnancy. PREVENTATIVE HEALTH MEASURES Pregnant adolescents can be viewed as a group at particular risk for repeated pregnancy; as well as future social, vocational, academic, and health care problems. Infants who are the product of adolescent pregnancies are likewise at risk for a wide range of developmental problems including child abuse, child neglect, retarded physical and emotional development, poor school performance, and serious delinquent behavior.B No single approach has been efficacious in dealing with the entire range of problems presented by the pregnant adolescent. Success for the majority of patients appears to be related to the degree to which quality obstetrical, pediatric, social, psychological and educational services are provided. Health education during pregnancy which focuses on the issues of sex education, emotional and attitudinal preparation for pregnancy, family planning, nutrition, drug effects on pregnancy, preparation for delivery, planning for the baby, infant care, and family life can be extremely valuable in helping the adolescent to integrate her many experiences. Educational programs that offer psychological assistance as well may promote more responsible and mature behavior. The adolescent's contacts with the professional staff during pregnancy may be her only good source of information concerning sexuality, venereal disease, and/or contraception. Her future willingness or ability to use contraception or seek care for suspected medical problems will depend to a large degree on her experiences with the medical staff during pregnancy and the availability of sympathetic professional people afterwards. When family planning and contraceptive services are provided in the more traditional fashion, the adolescent's continued participation in such programs has been discouraging,12 More promising results of continued contraceptive usage are found when the broader emotional and health care needs of these young mothers are provided. 10 Clearly, the success of the "storefront" health clinics with pregnant adolescents suggests the need for establishing more comfortable and informal milieus in caring for teenagers. In more traditional institutions separate teen clinics run by selected staff personnel have also been very popular. For example, a program for some 400 pregnant adolescents at Johns Hopkins Hospital was able to enroll the majority (60 per cent) of patients by the twelfth week of pregnancy with excellent continued participation. In addition, 95 per cent of the patients have returned for postpartum care. 19 CONTRACEPTION AND ABORTION Contraceptive counselling and services are important for the adolescent. It is currently estimated that 1.4 to 2.3 million single female
PREGNANCY AND ABORTION
1425
teenagers in the United States need contraception. 14 Whether the young woman is sexually active or not, there is opportunity for education about her reproductive organs, ovulation, and menstruation. A discussion about how women can prevent unwanted pregnancy can follow naturally from such a conversation. Unfortunately, no contraceptive has proven clearly superior for any population, including teenagers. The risks of birth control methods must be compared with the alternative of an unwanted pregnancy. Selection of the most appropriate contraceptive continues to be a difficult issue. Most teenagers, however, can make an appropriate decision after they have been informed about the various methods, their risks, side effects and failure rates. Oral contraceptives are the most effective form of birth control if the patient has sufficient motivation to take a daily pill. In addition they offer the teenager with dysmenorrhea the advantage of pain relief. A small risk of pituitary suppression exists, but the more common clinical problem is the teenager who misses a few pills and presents with an unwanted pregnancy. The newly designed smaller intrauterine devices are often well tolerated by nulliparous as well as parous teenagers. The patient must be cooperative, however, to allow accurate insertion and avoid the risk of uterine perforation. The most frequent side effects are increased menstrual flow, inter-menstrual bleeding, and cramps; consequently, they are not usually recommended for patients who already have significant dysmenorrhea. Most problems with the intrauterine devices occur in the first few months. For patients who retain the device the pregnancy rate is in the 2 per cent range. Thus, the IUD removes the potential for patient failures inherent in the use of oral contraceptives, but introduces a small percentage of method failures. A mature teenager may be educated to use a diaphragm and use it reliably, but failure to regularly use the device threatens the success of most teenagers to use a diaphragm or condom contraception. Missed periods are common in adolescents in whom regular ovulatory menses have not become established. It is important, however, to perform a pelvic examination and a pregnancy test in such cases since many a pregnant adolescent has concealed her pregnancy from her parents and physician. Despite the availability of contraceptives, many teenagers first present to the physician with an unwanted pregnancy. Significant numbers of pregnant adolescents will select abortion if offered. In the Baltimore inner city adolescent population, therapeutic abortion is selected by approximately 30 per cent of the patients when this alternative is readily accessible to them. The significant medical and emotional advantages of suction abortion over a mid-trimester technique make early diagnosis of pregnancy important. Therapeutic abortion is performed by suction dilatation and curettage up to 12 weeks from the patient's last menstrual period. In most abortion facilities this is an outpatient procedure done under local anesthesia with sedation, and requires a stay of 4 to 6 hours. An intrauterine device can be inserted easily at the time of suction abortion. After 12 to 14 weeks from the patient's last menstrual period the
1426
DAVID D. YOUNGS AND JENNIFER
R.
NIEBYL
abortion must be done by a mid-trimester technique. These include intra-amniotic injection of hyperosmolar saline or urea, and intra-amniotic or intravenous infusions of prostaglandins. The patient then goes through a period of labor to abort the fetus and placenta. These procedures usually require a hospitalization of 24 to 48 hours. The most frequent complications of abortion are hemorrhage, infection, and uterine perforation. Suction abortion is associated with a low overall morbidity. Morbidity is somewhat higher with mid trimester pregnancy termination including coagulation disturbances}s.19 Mid trimester abortion is a more emotionally stressful experience, and adolescents are particularly prone to adverse psychological reactions. As it is often the younger, more immature adolescents who delay in seeking professional help, supportive counselling is indicated during and after the procedure.
CONCLUSION Adolescence for most young people represents a time of considerable change and uncertainty. When this developmental period is compounded by unwanted pregnancy, the experience may be particularly trying to the patient as well as her family and physician. Psychological struggles are frequently intensified by family instability, the lack of appropriate adult role models, or inadequate information about human reproduction, sexuality, and/or contraception. All too often adolescents are left to fend for themselves among peers who are equally uninformed about sexual function and reproductive matters. For many youngsters, the family physician continues to be the only visible source of reliable and confidential help. Coordinated interdisciplinary services are probably the most effective approach and can more economically meet the multiple needs of this group. When such services are not available, adequate care can be provided by the interested physician who is willing to set aside the necessary time, provide a sympathetic ear, and develop some expertise in dealing with this challenging problem.
REFERENCES 1. Abernethy, V.: Illegitimate conception among teenagers. Amer. J. Publ. Health., 64:662, 1974. 2. Battaglia, F. C., et al.: Obstetric and pediatric complications of juvenile pregnancy. Pediatrics, 32:902, 1963. 3. Burnett, L. S., Wentz, A. C., and King, T. M.: Techniques of pregnancy termination. (Part II) Obstet. Gynec. Surveys, 29:6,1974. 4. Coates, J. B.: Obstetrics in the very young adolescent. Amer. J. Obstet. Gynec., 108:68, 1970. 5. Dempsey, J. J.: Illegitimacy in early adolescence. Amer. J. Ob stet. Gynec., 106:260, 1970. 6. Dwyer, J. F.: Teenage pregnancy. Amer. J. Obstet. Gynec., 118:373,1974. 7. Furstenberg, F. F., et al.: How can family planning programs delay repeat teenage pregnancies? Family Planning Perspectives, 4(No. 3) July, 1972. 8. Hardy, J.: Johns Hopkins Child Development Study. Unpublished data. 9. Hatcher, S. M.: The adolescent experience of pregnancy and abortion: A developmental analysis. J. Youth Adolescence, 2(No. 1) 1973.
PREGNANCY AND ABORTION
1427
10. Jorgensen, V.: One-year contraceptive follow-up of adolescent patients. Amer. J. Obstet. Gynec., 115 :484, 1973. 11. Klein, C.: The Single Parent Experience. Avon, New York, 1973, p. 20. 12. Klein, L.: Early teenage pregnancy, contraception and repeat pregnancy. Amer. J. Obstet. Gynec., 120:249, 1974. 13. MCHD Bureau of Systems and Statistics, March 1973. 14. Morris, L.: Estimating the need for family planning services among unwed teenagers. Family Planning Perspectives, 6:91, 1974. 15. Osofsky, J., et al.: An interdisciplinary program for low income pregnant schoolgirls: A progress report. J. Reprod. Med., 5:18,1970. 16. Sarrel, P. M., et al.: The young unwed mother. Ob stet. Gynec., 32:741,1968. 17. Webb, G., et al.: A comprehensive adolescent maternity program in a community hospital. Amer. J. Obstet. Gynec., 113:511, 1972. 18. Wentz, A. C., Burnett, L. S., and King, T. M.: Methodology: Premature pregnancy termination. Obstet. Gynec. Surveys, 28:2, 1973. 19. Youngs, D. D., et al.: The Johns Hopkins Adolescent Pregnancy Program. Urban Health- The Journal of Health Care in the Cities, 1975, p. 40. 20. Zelnik, M., and Kantner, J F.: The resolution of teenage first pregnancies. Family Planning Perspectives, 6:74,1974. The Johns Hopkins Hospital Baltimore, Maryland 21205
Adolescent Pregnancy and Abortion David D. Youngs, M.D.*, and Jennifer R. Niebyl, M.D.**
DIMENSIONS OF THE PROBLEM During the past decade, there has been a startling increase in the number -of adolescent pregnancies. In 1972, lout of every 10 girls became pregnant while still of junior or senior high school age. Coupled with the falling birthrate in the United States, their numbers have become even more conspicuous. Until recently, teenage pregnancy was thought to be a problem confined primarily to the nonwhite, lower income inner city population. Recent information indicates that teenage pregnancy is involving more and more middle class youngsters in both rural and suburban settings. For example, in Arizona, during 1971, 18.9 per cent of all births were to teenagers 16 years or under, of whom 63 per cent were white. 13 Klein reports that illegitimacy rates for middle class whites is rising while the rates for blacks continue to fall. 11 For many of these youngsters, marriage is no longer a prerequisite to parenthood; nor is adoption the only alternative. Currently no more than 18 per cent of unwed mothers give up their newborn infants for adoption. 20 Earlier reports by Battaglia and Coates suggest that adolescents fare less well obstetrically, and that those 14 years and under are at particular risk for major complications such as toxemia, anemia, prematurity, prolonged labor, and postpartum complications.2 • 4 More recent studies by Dwyer and Webb fail to show significant differences in obstetric complications or outcome for adolescents when "more comprehensive" obstetric care was provided.5 • 17 While pregnant adolescents continue to represent a special group at risk, differences in access to quality care, social class, and racial background are probably more significant factors than age alone in influencing obstetric outcome. An additional consideration is that adolescents are a heterogeneous group even when social class and ethnic background are similar. For example, the pregnant 12
*Director, Center for Social Studies in Human Reproduction, and Assistant Professor of Gynecology and Obstetrics and Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland '"Assistant Professor of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland Medical Clinics of North America- Vol. 59, No. 6, November 1975
1419
1420
DAVID D. YOUNGS AND JENNIFER
R. NIEBYL
year old, who is dependently attached to her mother and inexperienced in social relationships, represents a very different management problem from the sophisticated 17 year old, who is sexually experienced, and emotionally emancipated, and comes shortly after a missed menstrual period for a therapeutic abortion. Probably in no other area of medicine are stereotyped ideas and conventional therapeutic practices less applicable. In practical terms, then, physicians who provide care for pregnant adolescents must acquire a degree of sophistication about adolescents in general, a flexibility of approach, and a willingness to deploy a variety of therapeutic strategies in dealing with this often difficult age group. In communities that lack physicians who are interested in the problem, attendance for prenatal care will usually be poor, obstetric complications excessively high, and repeat pregnancy the rule rather than the exception. Furthermore these adolescents may (1) lack financial resources or be ignorant of available community assistance, (2) be embarrassed or ambivalent over being pregnant and (3) lack emotional support from understanding adults who are sympathetic to their problems. All too often these young patients fail to receive adequate prenatal care and appear only after medical complications have developed. In addition these new mothers often complete their pregnancy with few mothering skills and a negative view of the child who has caused them so many problems.
ETIOLOGIC FACTORS The successful management of the pregnant adolescent depends upon some working knowledge of the social and psychological forces as well as the family dynamics that set the stage for the teenager's pregnancy. For middle class adolescents, pregnancy is commonly the result of maladaptive attempts to solve psychological conflicts specific to their particular stage of adolescent development.9 For example, loosening of a dependent relationship with a clinging mother, "acting out" an erotic attachment with a seductive father, or manipulating a reluctant boyfriend into a more committed relationship are common dynamics. When serious psychological or social pathology is responsible for teenage pregnancy it is more often associated with other maladaptive patterns such as drug abuse, delinquency, abandonment by the family or truancy from school. Intrafamily dynamics may be the motivating force in a significant number of such teenage pregnancies. Using a comparison group of nonpregnant teenagers, Abernethy has demonstrated that adolescents who become pregnant are more likely to be dissatisfied with their mother as a role model, express a preference for their father even to an exclusive degree, or report hostility within the parents' marriage.! In contradistinction, parents who are affectionate and close are more likely to foster their daughter's identity as a woman and enhance her self esteem, thus diminishing the probability of promiscuous sexual behavior and possible conception.! Ignorance about sexual functions and superstitions or fears concerning the use of contraception also contribute to the problem of
PREGNANCY AND ABORTION
1421
unwanted pregnancy. A small proportion of adolescents actively desire pregnancy and probably an equal number are indifferent about the possibility of pregnancy following coitus. For some of these youngsters, pregnancy may represent a constructive attempt to negotiate the developmental problems of adolescence. Unfortunately, the odds are very much against the development of a stable marriage for such teenagers or the creation of a healthy environment for the newborn infant, although some young mothers do succeed. Factors which appear to be central in those who succeed include (1) the presence of a caretaking person who will provide the necessary emotional and financial security until the adolescent is self sufficient, (2) a realistic view of the maternal role as well as the needs of the infants, and (3) the motivation for pregnancy being for positive and healthy reasons rather than self-destructive or neurotic ones. An appreciation of the personal, family and social factors impinging on the pregnant adolescent is helpful in orienting the physician to the alternatives available in managing the pregnancy and to the opportunities for "planning" future pregnancies. For the inner city adolescent, pregnancy is further complicated by poverty, social and community disruption, and the lack of suitable role models. Successful care, then, will depend on understanding the various etiologic factors involved, the specific needs of the adolescent, and the availability of various community resources.
GOALS FOR THE CARE OF PREGNANT ADOLESCENTS The question of quality obstetrical care for the pregnant adolescent must address itself to considerations that go beyond the narrow definition of traditional medical services. The increased rates of fetal and maternal morbidity previously alluded to have not been shown to be significantlyaltered merely by the provision of traditional obstetrical services; therefore, any successful effort must embrace a broader range of personal and health care needs for this group. With this in mind the realistic goals for quality care are (1) early diagnosis and intervention, (2) early and active participation in a suitable health care program, (3) an opportunity for therapeutic abortion as an alternative, (4) attention to the social and personal needs of the adolescent, (5) health education, particularly in the areas of human sexuality, reproduction and contraception, (6) preparation for mothering activities and introduction to child development and child care, (7) coordinated follow up care as well as family planning services, and (8) reintegration of the adolescent mother back into her community through such assistance as day care, vocational or special educational services.
MODEL PROGRAMS: ELEMENTS OF SUCCESS Osofsky and Sarrel were the first to report on a successful interdisciplinary approach to adolescent pregnancy. Focusing predominantly on low income nonwhite adolescents, they were able to achieve a remark-
1422
DAVID D. YOUNGS AND JENNIFER
R.
NIEBYL
able reduction in obstetrical morbidity, prematurity, and antenatal complications as well as lowering the incidence of repeat pregnancy and increasing school attendance}5, 16 Subsequent reports from a more diverse population including white middle class youngsters show similarly good resultsP Drawing from our own experience with an interdisciplinary approach to teenage pregnancy19 and those reports in the literature;O,15,17 the common attributes of such programs that seem to be major contributors to success are: (1) improved communication between community, school, and medical services leading to early diagnosis and referral and complementary rather than competitive care, (2) the selection of nonjudgmental professional and staff members who are interested and skilled in relating to pregnant teenagers as people rather than as problems, (3) the inclusion of psychological and social work services as an integral part of obstetrical care rather than following the traditional patterns of referral that imply "there is something wrong with you, therefore you must see the psychiatrist or social worker," (4) providing continuity of medical care by an interested obstetrician, nurse midwife, nurse, or other experienced staff member who offers a more permanent relationship throughout the antepartum period, labor and delivery, and postpartum experience, (5) follow-up care for the new mother and infant that combines vocational, educational, and social work services in addition to inter-conceptional medical care for the mother and well baby care for the infant, (6) providing easy access to a nonjudgmental professional who is available to coordinate ongoing care, assist in handling common adjustment problems, provide advice about child care, or make necessary alterations in the contraceptive program.
MANAGEMENT CONSIDERATIONS: THE CONSULTANT VERSUS THE PRIMARY CARE ROLE Prompt and accurate diagnosis is a prerequisite to the successful management of adolescent pregnancy. Awareness of the increasing frequency of pregnancy among teenagers, particularly in the middle class, should alert the physician to the possibility of pregnancy among his young female patients. Vague symptoms such as nausea, fatigue, abdominal cramps, or syncope should not be dismissed until the question of pregnancy is explored. Establishing the date of the last menstrual period will frequently be helpful in suggesting the diagnosis. The necessity for a "high index of suspicion" should not be confused with an intrusive or probing manner. In spite of most adolescents' anxiety and apprehension during the first office visit, usually sufficient "clues" are provided to suggest the possibility of pregnancy. The initial encounter of the adolescent with the physician and the office staff is of critical importance. A sense of security and confidence is slow to develop among adolescents, even in the best of circumstances. In the face of an embarrassing problem (pregnancy) and on unfamiliar territory (the physician's office) the initial encounter may determine whether the patient will return for regular care or abandon the physi-
PREGNANCY AND ABORTION
1423
cian for less adequate services. Several visits may be required before the patient feels sufficiently secure and trusting of the physician to provide an accurate history and allow a complete and informative pelvic examination. The initial office visit, then, for the young female adolescent is of major importance. It may be her first pelvic examination. Along with the usual mixed feelings of anxiety and fear, the uncertainty of possible pregnancy commonly makes her more sensitive to minor slights, thoughtless criticism, or unsympathetic handling. Advising abortion or adoption before a comfortable and honest rapport with the physician has developed may seriously strain the doctor-patient relationship or more likely result in failure of the patient to return. A skilled office staff may ease the adolescent's anxiety, obtain a more complete history or serve as an accessible friend during this difficult period. Guidance and advice concerning contraceptive information, abortion, or adoption may be more easily accepted from office staff members of the patient's own sex or someone closer to her age. When the physician also cares for the adolescent's mother, issues of confidentiality and trust are more difficult to deal with and referral to a sympathetic colleague may be preferable. When the patient is accompanied by her mother in the initial visit, a useful approach is to meet briefly with both to collect relevant information from the mother and observe firsthand the mother and daughter interaction. In addition, it is helpful to get some sense of the father's reaction to his daughter's pregnancy. Fathers that accompany their daughters for the first interview can be handled in much the same manner as the mother. The majority of the interview time should be spent with the adolescent, obtaining her history, gaining her confidence, and establishing a secure relationship. Only when the adolescent is markedly immature, retarded, or severely disturbed should the primary relationship be developed with the mother. The initial history and physical examination, including the pelvic examination, should establish the presence of pregnancy or make it a strong possibility. Waiting for uterine enlargement or a positive pregnancy test only delays an open discussion of possible pregnancy and unnecessarily postpones a review of such options as abortion. Several visits may be required to satisfactorily explore the patient's feelings about abortion versus continued pregnancy or to rally the support of the family. Common complaints of pregnant adolescents seen in the office include feeling hurried, embarrassed, being treated like children, or being advised that "abortion is the only solution." For many adolescents, particularly those 16 years of age or older, pregnancy is not associated with serious social or psychological pathology. However, in younger patients who are separated from their families, truant from school, or demonstrate evidence of delinquent behavior, psychiatric disturbances or major adolescent adjustment problems should be suspected and referral for appropriate mental health counseling is indicated. Physicians who are sufficiently experienced and interested may elect to provide the majority of the adolescent's health services including informal counseling, patient education, and routine antenatal care. Other physicians may elect to refer the patient to a colleague, a teen clinic or other community
1424
DAVID D. YOUNGS AND JENNIFER
R.
NIEBYL
based program that has particular expertise with this problem. In either case, the physician who has a comfortable and familiar relationship with school personnel and relevant social agencies will improve the adolescent's chances of successfully resolving her pregnancy. PREVENTATIVE HEALTH MEASURES Pregnant adolescents can be viewed as a group at particular risk for repeated pregnancy; as well as future social, vocational, academic, and health care problems. Infants who are the product of adolescent pregnancies are likewise at risk for a wide range of developmental problems including child abuse, child neglect, retarded physical and emotional development, poor school performance, and serious delinquent behavior.B No single approach has been efficacious in dealing with the entire range of problems presented by the pregnant adolescent. Success for the majority of patients appears to be related to the degree to which quality obstetrical, pediatric, social, psychological and educational services are provided. Health education during pregnancy which focuses on the issues of sex education, emotional and attitudinal preparation for pregnancy, family planning, nutrition, drug effects on pregnancy, preparation for delivery, planning for the baby, infant care, and family life can be extremely valuable in helping the adolescent to integrate her many experiences. Educational programs that offer psychological assistance as well may promote more responsible and mature behavior. The adolescent's contacts with the professional staff during pregnancy may be her only good source of information concerning sexuality, venereal disease, and/or contraception. Her future willingness or ability to use contraception or seek care for suspected medical problems will depend to a large degree on her experiences with the medical staff during pregnancy and the availability of sympathetic professional people afterwards. When family planning and contraceptive services are provided in the more traditional fashion, the adolescent's continued participation in such programs has been discouraging,12 More promising results of continued contraceptive usage are found when the broader emotional and health care needs of these young mothers are provided. 10 Clearly, the success of the "storefront" health clinics with pregnant adolescents suggests the need for establishing more comfortable and informal milieus in caring for teenagers. In more traditional institutions separate teen clinics run by selected staff personnel have also been very popular. For example, a program for some 400 pregnant adolescents at Johns Hopkins Hospital was able to enroll the majority (60 per cent) of patients by the twelfth week of pregnancy with excellent continued participation. In addition, 95 per cent of the patients have returned for postpartum care. 19 CONTRACEPTION AND ABORTION Contraceptive counselling and services are important for the adolescent. It is currently estimated that 1.4 to 2.3 million single female
PREGNANCY AND ABORTION
1425
teenagers in the United States need contraception. 14 Whether the young woman is sexually active or not, there is opportunity for education about her reproductive organs, ovulation, and menstruation. A discussion about how women can prevent unwanted pregnancy can follow naturally from such a conversation. Unfortunately, no contraceptive has proven clearly superior for any population, including teenagers. The risks of birth control methods must be compared with the alternative of an unwanted pregnancy. Selection of the most appropriate contraceptive continues to be a difficult issue. Most teenagers, however, can make an appropriate decision after they have been informed about the various methods, their risks, side effects and failure rates. Oral contraceptives are the most effective form of birth control if the patient has sufficient motivation to take a daily pill. In addition they offer the teenager with dysmenorrhea the advantage of pain relief. A small risk of pituitary suppression exists, but the more common clinical problem is the teenager who misses a few pills and presents with an unwanted pregnancy. The newly designed smaller intrauterine devices are often well tolerated by nulliparous as well as parous teenagers. The patient must be cooperative, however, to allow accurate insertion and avoid the risk of uterine perforation. The most frequent side effects are increased menstrual flow, inter-menstrual bleeding, and cramps; consequently, they are not usually recommended for patients who already have significant dysmenorrhea. Most problems with the intrauterine devices occur in the first few months. For patients who retain the device the pregnancy rate is in the 2 per cent range. Thus, the IUD removes the potential for patient failures inherent in the use of oral contraceptives, but introduces a small percentage of method failures. A mature teenager may be educated to use a diaphragm and use it reliably, but failure to regularly use the device threatens the success of most teenagers to use a diaphragm or condom contraception. Missed periods are common in adolescents in whom regular ovulatory menses have not become established. It is important, however, to perform a pelvic examination and a pregnancy test in such cases since many a pregnant adolescent has concealed her pregnancy from her parents and physician. Despite the availability of contraceptives, many teenagers first present to the physician with an unwanted pregnancy. Significant numbers of pregnant adolescents will select abortion if offered. In the Baltimore inner city adolescent population, therapeutic abortion is selected by approximately 30 per cent of the patients when this alternative is readily accessible to them. The significant medical and emotional advantages of suction abortion over a mid-trimester technique make early diagnosis of pregnancy important. Therapeutic abortion is performed by suction dilatation and curettage up to 12 weeks from the patient's last menstrual period. In most abortion facilities this is an outpatient procedure done under local anesthesia with sedation, and requires a stay of 4 to 6 hours. An intrauterine device can be inserted easily at the time of suction abortion. After 12 to 14 weeks from the patient's last menstrual period the
1426
DAVID D. YOUNGS AND JENNIFER
R.
NIEBYL
abortion must be done by a mid-trimester technique. These include intra-amniotic injection of hyperosmolar saline or urea, and intra-amniotic or intravenous infusions of prostaglandins. The patient then goes through a period of labor to abort the fetus and placenta. These procedures usually require a hospitalization of 24 to 48 hours. The most frequent complications of abortion are hemorrhage, infection, and uterine perforation. Suction abortion is associated with a low overall morbidity. Morbidity is somewhat higher with mid trimester pregnancy termination including coagulation disturbances}s.19 Mid trimester abortion is a more emotionally stressful experience, and adolescents are particularly prone to adverse psychological reactions. As it is often the younger, more immature adolescents who delay in seeking professional help, supportive counselling is indicated during and after the procedure.
CONCLUSION Adolescence for most young people represents a time of considerable change and uncertainty. When this developmental period is compounded by unwanted pregnancy, the experience may be particularly trying to the patient as well as her family and physician. Psychological struggles are frequently intensified by family instability, the lack of appropriate adult role models, or inadequate information about human reproduction, sexuality, and/or contraception. All too often adolescents are left to fend for themselves among peers who are equally uninformed about sexual function and reproductive matters. For many youngsters, the family physician continues to be the only visible source of reliable and confidential help. Coordinated interdisciplinary services are probably the most effective approach and can more economically meet the multiple needs of this group. When such services are not available, adequate care can be provided by the interested physician who is willing to set aside the necessary time, provide a sympathetic ear, and develop some expertise in dealing with this challenging problem.
REFERENCES 1. Abernethy, V.: Illegitimate conception among teenagers. Amer. J. Publ. Health., 64:662, 1974. 2. Battaglia, F. C., et al.: Obstetric and pediatric complications of juvenile pregnancy. Pediatrics, 32:902, 1963. 3. Burnett, L. S., Wentz, A. C., and King, T. M.: Techniques of pregnancy termination. (Part II) Obstet. Gynec. Surveys, 29:6,1974. 4. Coates, J. B.: Obstetrics in the very young adolescent. Amer. J. Obstet. Gynec., 108:68, 1970. 5. Dempsey, J. J.: Illegitimacy in early adolescence. Amer. J. Ob stet. Gynec., 106:260, 1970. 6. Dwyer, J. F.: Teenage pregnancy. Amer. J. Obstet. Gynec., 118:373,1974. 7. Furstenberg, F. F., et al.: How can family planning programs delay repeat teenage pregnancies? Family Planning Perspectives, 4(No. 3) July, 1972. 8. Hardy, J.: Johns Hopkins Child Development Study. Unpublished data. 9. Hatcher, S. M.: The adolescent experience of pregnancy and abortion: A developmental analysis. J. Youth Adolescence, 2(No. 1) 1973.
PREGNANCY AND ABORTION
1427
10. Jorgensen, V.: One-year contraceptive follow-up of adolescent patients. Amer. J. Obstet. Gynec., 115 :484, 1973. 11. Klein, C.: The Single Parent Experience. Avon, New York, 1973, p. 20. 12. Klein, L.: Early teenage pregnancy, contraception and repeat pregnancy. Amer. J. Obstet. Gynec., 120:249, 1974. 13. MCHD Bureau of Systems and Statistics, March 1973. 14. Morris, L.: Estimating the need for family planning services among unwed teenagers. Family Planning Perspectives, 6:91, 1974. 15. Osofsky, J., et al.: An interdisciplinary program for low income pregnant schoolgirls: A progress report. J. Reprod. Med., 5:18,1970. 16. Sarrel, P. M., et al.: The young unwed mother. Ob stet. Gynec., 32:741,1968. 17. Webb, G., et al.: A comprehensive adolescent maternity program in a community hospital. Amer. J. Obstet. Gynec., 113:511, 1972. 18. Wentz, A. C., Burnett, L. S., and King, T. M.: Methodology: Premature pregnancy termination. Obstet. Gynec. Surveys, 28:2, 1973. 19. Youngs, D. D., et al.: The Johns Hopkins Adolescent Pregnancy Program. Urban Health- The Journal of Health Care in the Cities, 1975, p. 40. 20. Zelnik, M., and Kantner, J F.: The resolution of teenage first pregnancies. Family Planning Perspectives, 6:74,1974. The Johns Hopkins Hospital Baltimore, Maryland 21205
