Delay in Obstetrical Care
in
Newly Diagnosed Teenage Pregnancy
Albert J. Pomeranz, MD*; Steve C. Matson, MD*; David B. Nelson, MD, MSc**
retrospective study of 42 adolescent patients diagnosed as being pregnant between June February 1990 at the Downtown Health Center (DHC), an inner city pediatric primary care clinic, was conducted to determine whether patients referred to a hospital-based Teen Pregnancy Clinic (TPC) were seen within a reasonable period of time. The frequency of sexually transmitted diseases (STDs) was also determined when these women were initially seen at TPC. Only 5 of the 42 patients seen at DHC had a pelvic exam prior to referral. Of the 40 patients seen at TPC, 20% were not seen until four weeks or more after initial diagnosis. Fifty percent had A
1987 and
STD. Pediatricians should recognize that pregnant teenagers may have a significant delay between diagnosis of pregnancy and entry into obstetrical care. Pelvic exam including cultures for STDs is recommended prior to referral. a
Introduction The United States has significantly higher rates of teenage pregnancy, abortion and live births than most other developed countries.’ In 1987, there were 1,014,620 teenage pregnancies of which 50% resulted in a live birth, 36% in abortion and an estimated 14% in miscarriage.2 The risk of maternal death from complications of pregnancy is 60% higher in women 15 years of age and younger.’ Infants bom to mothers less than 15 years old are more than twice as likely to weight less than 2500 grams at birth’ and are almost three times more likely to die in the first 28 days of life.’ Among the complicating factors of teenage pregnancy, young pregnant women with bacterial vaginosis and those infected with Chlamydia trachomatis or Neisseria gonorrhea are at increased risk for pre-term labor. 6-1 C. trachomatis and N. gonorrhea infections during pregnancy may also cause low infant birth weight, 10,&dquo; and the transmission of either agent to the infant ,an result in conjunctivitis and pneumonia. 12,13 Prevention of teenage pregnancy should be the ultimate goal of iealth care workers interacting with sexually active adolescents. however, once pregnancy occurs, timely pre-natal care is essenial to the health and well being of both the teenage mother and her etus. A Johns Hopkins study of one hospital-based adolescent
pregnancy program demonstrated that improved prenatal care resulted in improved neonatal outcomes.’4 Often the pregnancy is diagnosed by the primary care physician and no further exam or evaluation is performed because the patient is referred to an obstetric clinic for prenatal care. A delay between diagnosis and the first visit to the obstetric clinic could place the teenage mother and fetus at increased risk. By not documenting an intrauterine pregnancy at the time of diagnosis, the mother may be placed at risk for missed ectopic pregnancy. Also, by not dating the pregnancy by uterine size, the date of conception may be incorrectly estimated leading the patient to
delay prenatal care. Pelvic exams were not routinely done at the Downtown Health Center (DHC) because it was assumed that one would be done at the Teen Pregnancy Clinic (TPC). We were concerned that delays between the initial diagnosis of pregnancy and the date the teenager was actually seen in the TPC may place the teenager and her fetus at risk for obstetrical problems associated with untreated sexually transmitted diseases (STDs). The purpose of our study was to determine the length of delay and the frequency of STDs at the first prenatal visit.
Methods
*Assistant Professor, Department of Pediatrics, Medical College of Wisonsin; **Professor of Pediatrics, Georgetown University, Washington, D.C. Presented in part at Annual Meeting of Regions V & VI of Ambulatory ediatric Association on October 19, 1990 in Milwaukee, WI.
The DHC is a primary care clinic located in the Milwaukee inner city operated by the Medical College of Wisconsin and the Children’s Hospital of Wisconsin. There are approximately fourteen thousand patient visits per year to the DHC. It serves a population that is 75% black, 14% caucasian, 8% hispanic, and 3% &dquo;other.&dquo; Eighty-five percent of the patients receive public assistance. The medical records of forty-two adolescents (ages 661
Downloaded from cpj.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on March 11, 2015
years) with the diagnosis of pregnancy between June February 1990 at DHC were reviewed. All the patients were Medicaid assigned HMO patients. Patients were seen by pediatric housestaff and one of six attending physicians. All patients were referred immediately to a comprehensive, hospital-based teen pregnancy clinic (TPC) for prenatal 12-19
1987 and
and postpartum care. Both DHC and TPC charts were reviewed for the following information: age, race, previous pregnancies, and birth control method. All of the TPC charts were reviewed by one of the authors (A.J.P.) and all of the DHC charts were reviewed by a study nurse and one of the authors (A.J.P.). The patient’s chief complaint and whether a pelvic exam was performed was obtained from DHC charts. All patients had positive urine pregnancy tests (Tandom Icon II-Hybritech, Inc.). Gestational age at presentation was obtained from TPC charts by ultrasonic or physical exam and date of the last menstrual period. All patients seen at TPC had pelvic examinations and were assessed for the presence of Chlamydia trachomatis, Neisseria gonorrhea, Trichomonas vaginalis, and condyloma acuminatum. Cervical samples were assessed for chlamydia by an enzyme-linked immunosorbent assay (Chlamydiazyme, Syva) and for gonorrhea by culture on Thayer-Martin media. All patients were tested for syphilis utilizing the RPR (rapid protein reagin) blood test. Viral cultures for Herpes simplex were collected only if clinically suspected. the presence of venereal warts was based on physical examination, which admittedly is not the most sensitive screening test. The interval between initial diagnosis of pregnancy at the DHC and the first TPC visit were based on the dates of these two visits recorded in the chart.
Table 2 · Interval between diagnosis of pregnancy and initial visit at Teen Pregnancy Clinic (n=40)*
*
Two
patients did
not appear at Teen
Pregnancy Clinic.
Fifty percent of our patients were found to have at least one presentation to the TPC. Chlamydia was the most commonly seen, with 37.5% of our patients having evidence of STD at
infection either alone or in combination with other STDs (Table 3). Gonorrhea was seen in 20% of our patients, either alone or in
Table 3o
Frequency of sexually transmitted disease at first visit to Teen Pregnancy Clinic (n=40)*
Results The mean age of our patients was fifteen years, with a range of 12-19 years. All but one were black (97.6%). The most common chief complaint at presentation to the DHC was suspected pregnancy (73%) followed by non-specific gastrointestinal complaints (20%) (Table 1). Twenty-five percent of our patients had been pregnant before, and the majority (64.3%) used no form of birth control. Twenty-five percent presented to us during the second trimester, and ten percent during the third. Only 5 ( 12%) of the 42 patients seen at the DHC had pelvic exams performed. The interval between diagnosis of regnancy at DHC and the first visit at TPC are presented in Table 2. Of the 40 patients seen at TPC, 8 (20%) were not seen until four weeks or more after diagnosis. Two patients who were referred to TPC did not receive follow-up care there, and no follow-up could be determined.
Table 1· Chief
complaints of patients on initial presentation to the DHC (n=41 )*
*
No
complaint documented for one patient
*
Two
patients
did not appear at Teen
combination with
having syphilis ent. There
Pregnancy Clinic.
chlamydia. No patients were documented as Herpes simplex lesions clinically apparno significant differences in infection rate in
nor were
were
early or late at the TPC. The infection rate was approximately 50% at each time interval between diagnosis and TPC visit (Table 2). This implies that the infection rate if cervical and vaginal samples had been assessed at the initial visit would have been approximately 50%. teens seen
Discussion
Optimal prenatal care is important to insure good perinatalmaternal outcomes regardless of the age of the pregnant woman. However, pregnant teens generally receive prenatal care less frequently than older women. 15 We were concerned that pregnant teens seen in our clinic had problems that were not being addressed in a timely fashion because a pelvic exam was not being done at the time of evaluation for pregnancy. When a diagnosis of pregnancy was made at our health center (DHC), a referral was made to a hospital-based teen pregnancy clinic. The phone number of the clinic was given to the patient and she was told to call and arrange an appointment as soon as
662
Downloaded from cpj.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on March 11, 2015
possible. Usually a pelvic was not done unless the patient’s main complaint involved vaginal discharge. Our review of 42 pregnant teens diagnosed at DHC revealed a substantial delay from the time of diagnosis of pregnancy until they were seen at the TPC. In 20% of our patients, four weeks or more passed before prenatal care was begun. Whether this delay is a result of lack of available appointments or poor patient compliance is not known. This delay is important because of the deleterious effects of STDs on the health of the mother and her newborn. Fifty percent of our patients were found to have a STD
(Table 3). Some of these STDs may acquired after being seen in the DHC, but because the
at presentation to the TPC
have been
proportion of patients with STDs was so high and consistent at all it is likely a significant number may have been infected at the time of their initial DHC visit. A delay in diagnosing STDs in pregnant teens may result in further transmission of STDs and poorer pregnancy outcomes. 16,11 If pelvic exams and search for STDs had been routinely performed on our patients at the time of diagnosis, prompt treatment could have been instituted. We suspect that many practitioners refer their pregnant teenagers without routinely completing a pelvic exam and evaluating the patient for STDs. It is also likely that many do not realize how much time may pass before these patients are seen by an obstetrical service. The delays seen in our population possibly reflect an overburdened obstetrical program and do not necessarily pertain to all prenatal clinics. The prevalence of STDs is also higher in our population than in the teenage population as a whole. However, in populations similar to ours, the delay to the first prenatal visit may be prolonged and the prevalence of STDs high. Therefore, we recommend that all newly diagnosed pregnant teenagers receive a pelvic exam with appropriate evaluation for STDs. If the physician is unable to do this, then a referral appointment should be personally scheduled with careful follow up to insure that the appointment was kept.
delay intervals,
7.
Alger LS, Lovchik JC, Hebel JR, et al. The association of Chlamydia trachomatis, Neisseria gonorrhea, and group B streptococci with preterm rupture of the membranes and pregnancy outcome. Am J Obstet Gynecol
1988; 159:397-404. Martius J, Eschenbach DA. The role of bacterial vaginosis as a cause of amniotic fluid infection, chorioamnionitis and prematurity a review. Arch Gynecol Obstet 1990; 247:1-13. 9. Eschenbach DA. Relationships of vaginal Lactobacillus species, cervical Chlamydia trachomatis, and bacterial vaginosis to preterm birth. Obstet Gynecol 1988; 71:89-95. 10. Berman SM, Harrison HR, Boyce WT, et al. Low birth weight prematurity, and postpartum endometritis. Association with prenatal cervical Mycoplasma hominis and Chlamydia trachomatis infections. JAMA 1987; 257:1189-94. 11. Elliott B, Brunham RC, Laga M, et al. Maternal gonococcal infection as a preventable risk factor for low birth. J Infect Dis 1990; 161:531-6. 12. Alexander ER. Gonorrhea in the newborn. Ann NY Academy Science 8.
—
1988; 549:180-6. 13. Preece PM, Ades A, Thompson RG, Brooks JH. Chlamydia trachomatis infection in late pregnancy: a prospective study. Pediatr Perinatal Epidemiol 1989; 3:268-77. 14. Hardy JB, King TM, Repke JT. The Johns Hopkins’ Adolescent Pregnancy Program: an evaluation. Obstet Gynecol 1987; 69:300. 15. Vital Statistics of the United States-1987. Volume I-Natality. Hyattsville, Maryland: National Centre for Health Statistics, 1989. Table 1-44 pg. 74-76. DHHS publication no. (PHS)89-1100. 16. Dodson MG, Fortunato SJ. Microorganisms and premature labor. Reproduct Med 1988; 33 (Suppl):87-96. 17. Cohen I, Veille JC, Calkins BM. Improved pregnancy outcome following successful treatment of chlaymydial infection. JAMA 1990; 263:31607.
Acknowledgement I wish to thank Judy Adams and Gloria McGrath for their help with the data collection and Gail Kreklow for her help with the manuscript preparation. I would like to acknowledge Michael J. Chusid, M.D. for his critical review of this paper.
References 1.
2. 3.
4. 5.
5.
Teenage pregnancy in industrialized countries. Yale University Press, New Haven, CT, 1986. Facts in Brief, Teenage Sexual and Reproductive Behavior in the United Jones EF, et al.
States. The Alan Guttmacher Institute, June 1, 1991. Testa M, Wulczyn F. The State of the Child, Vol. 1. Children’s Policy Research Project, University of Chicago, 1980. Advance report of final natality statistics, 1985. Monthly Vital Statistical Report 1987; 36 (Suppl):1-43. Lee KS, Corpvz M. Teenage pregnancy: trend and impact on rates of low birth weight and fetal, maternal and neonatal mortality in the United States. Clin Perinatol 1987; 15:929-42. The Johns Hopkins Study of Cervicitis and Adverse Pregnancy Outcome. Association of Chlamydia trachomatis and Mycoplasma hominis with intrauterine growth retardation and preterm delivery. Am J Epidemiol
1989; 129:1247-57.
663
Downloaded from cpj.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on March 11, 2015
in
Newly Diagnosed Teenage Pregnancy
Albert J. Pomeranz, MD*; Steve C. Matson, MD*; David B. Nelson, MD, MSc**
retrospective study of 42 adolescent patients diagnosed as being pregnant between June February 1990 at the Downtown Health Center (DHC), an inner city pediatric primary care clinic, was conducted to determine whether patients referred to a hospital-based Teen Pregnancy Clinic (TPC) were seen within a reasonable period of time. The frequency of sexually transmitted diseases (STDs) was also determined when these women were initially seen at TPC. Only 5 of the 42 patients seen at DHC had a pelvic exam prior to referral. Of the 40 patients seen at TPC, 20% were not seen until four weeks or more after initial diagnosis. Fifty percent had A
1987 and
STD. Pediatricians should recognize that pregnant teenagers may have a significant delay between diagnosis of pregnancy and entry into obstetrical care. Pelvic exam including cultures for STDs is recommended prior to referral. a
Introduction The United States has significantly higher rates of teenage pregnancy, abortion and live births than most other developed countries.’ In 1987, there were 1,014,620 teenage pregnancies of which 50% resulted in a live birth, 36% in abortion and an estimated 14% in miscarriage.2 The risk of maternal death from complications of pregnancy is 60% higher in women 15 years of age and younger.’ Infants bom to mothers less than 15 years old are more than twice as likely to weight less than 2500 grams at birth’ and are almost three times more likely to die in the first 28 days of life.’ Among the complicating factors of teenage pregnancy, young pregnant women with bacterial vaginosis and those infected with Chlamydia trachomatis or Neisseria gonorrhea are at increased risk for pre-term labor. 6-1 C. trachomatis and N. gonorrhea infections during pregnancy may also cause low infant birth weight, 10,&dquo; and the transmission of either agent to the infant ,an result in conjunctivitis and pneumonia. 12,13 Prevention of teenage pregnancy should be the ultimate goal of iealth care workers interacting with sexually active adolescents. however, once pregnancy occurs, timely pre-natal care is essenial to the health and well being of both the teenage mother and her etus. A Johns Hopkins study of one hospital-based adolescent
pregnancy program demonstrated that improved prenatal care resulted in improved neonatal outcomes.’4 Often the pregnancy is diagnosed by the primary care physician and no further exam or evaluation is performed because the patient is referred to an obstetric clinic for prenatal care. A delay between diagnosis and the first visit to the obstetric clinic could place the teenage mother and fetus at increased risk. By not documenting an intrauterine pregnancy at the time of diagnosis, the mother may be placed at risk for missed ectopic pregnancy. Also, by not dating the pregnancy by uterine size, the date of conception may be incorrectly estimated leading the patient to
delay prenatal care. Pelvic exams were not routinely done at the Downtown Health Center (DHC) because it was assumed that one would be done at the Teen Pregnancy Clinic (TPC). We were concerned that delays between the initial diagnosis of pregnancy and the date the teenager was actually seen in the TPC may place the teenager and her fetus at risk for obstetrical problems associated with untreated sexually transmitted diseases (STDs). The purpose of our study was to determine the length of delay and the frequency of STDs at the first prenatal visit.
Methods
*Assistant Professor, Department of Pediatrics, Medical College of Wisonsin; **Professor of Pediatrics, Georgetown University, Washington, D.C. Presented in part at Annual Meeting of Regions V & VI of Ambulatory ediatric Association on October 19, 1990 in Milwaukee, WI.
The DHC is a primary care clinic located in the Milwaukee inner city operated by the Medical College of Wisconsin and the Children’s Hospital of Wisconsin. There are approximately fourteen thousand patient visits per year to the DHC. It serves a population that is 75% black, 14% caucasian, 8% hispanic, and 3% &dquo;other.&dquo; Eighty-five percent of the patients receive public assistance. The medical records of forty-two adolescents (ages 661
Downloaded from cpj.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on March 11, 2015
years) with the diagnosis of pregnancy between June February 1990 at DHC were reviewed. All the patients were Medicaid assigned HMO patients. Patients were seen by pediatric housestaff and one of six attending physicians. All patients were referred immediately to a comprehensive, hospital-based teen pregnancy clinic (TPC) for prenatal 12-19
1987 and
and postpartum care. Both DHC and TPC charts were reviewed for the following information: age, race, previous pregnancies, and birth control method. All of the TPC charts were reviewed by one of the authors (A.J.P.) and all of the DHC charts were reviewed by a study nurse and one of the authors (A.J.P.). The patient’s chief complaint and whether a pelvic exam was performed was obtained from DHC charts. All patients had positive urine pregnancy tests (Tandom Icon II-Hybritech, Inc.). Gestational age at presentation was obtained from TPC charts by ultrasonic or physical exam and date of the last menstrual period. All patients seen at TPC had pelvic examinations and were assessed for the presence of Chlamydia trachomatis, Neisseria gonorrhea, Trichomonas vaginalis, and condyloma acuminatum. Cervical samples were assessed for chlamydia by an enzyme-linked immunosorbent assay (Chlamydiazyme, Syva) and for gonorrhea by culture on Thayer-Martin media. All patients were tested for syphilis utilizing the RPR (rapid protein reagin) blood test. Viral cultures for Herpes simplex were collected only if clinically suspected. the presence of venereal warts was based on physical examination, which admittedly is not the most sensitive screening test. The interval between initial diagnosis of pregnancy at the DHC and the first TPC visit were based on the dates of these two visits recorded in the chart.
Table 2 · Interval between diagnosis of pregnancy and initial visit at Teen Pregnancy Clinic (n=40)*
*
Two
patients did
not appear at Teen
Pregnancy Clinic.
Fifty percent of our patients were found to have at least one presentation to the TPC. Chlamydia was the most commonly seen, with 37.5% of our patients having evidence of STD at
infection either alone or in combination with other STDs (Table 3). Gonorrhea was seen in 20% of our patients, either alone or in
Table 3o
Frequency of sexually transmitted disease at first visit to Teen Pregnancy Clinic (n=40)*
Results The mean age of our patients was fifteen years, with a range of 12-19 years. All but one were black (97.6%). The most common chief complaint at presentation to the DHC was suspected pregnancy (73%) followed by non-specific gastrointestinal complaints (20%) (Table 1). Twenty-five percent of our patients had been pregnant before, and the majority (64.3%) used no form of birth control. Twenty-five percent presented to us during the second trimester, and ten percent during the third. Only 5 ( 12%) of the 42 patients seen at the DHC had pelvic exams performed. The interval between diagnosis of regnancy at DHC and the first visit at TPC are presented in Table 2. Of the 40 patients seen at TPC, 8 (20%) were not seen until four weeks or more after diagnosis. Two patients who were referred to TPC did not receive follow-up care there, and no follow-up could be determined.
Table 1· Chief
complaints of patients on initial presentation to the DHC (n=41 )*
*
No
complaint documented for one patient
*
Two
patients
did not appear at Teen
combination with
having syphilis ent. There
Pregnancy Clinic.
chlamydia. No patients were documented as Herpes simplex lesions clinically apparno significant differences in infection rate in
nor were
were
early or late at the TPC. The infection rate was approximately 50% at each time interval between diagnosis and TPC visit (Table 2). This implies that the infection rate if cervical and vaginal samples had been assessed at the initial visit would have been approximately 50%. teens seen
Discussion
Optimal prenatal care is important to insure good perinatalmaternal outcomes regardless of the age of the pregnant woman. However, pregnant teens generally receive prenatal care less frequently than older women. 15 We were concerned that pregnant teens seen in our clinic had problems that were not being addressed in a timely fashion because a pelvic exam was not being done at the time of evaluation for pregnancy. When a diagnosis of pregnancy was made at our health center (DHC), a referral was made to a hospital-based teen pregnancy clinic. The phone number of the clinic was given to the patient and she was told to call and arrange an appointment as soon as
662
Downloaded from cpj.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on March 11, 2015
possible. Usually a pelvic was not done unless the patient’s main complaint involved vaginal discharge. Our review of 42 pregnant teens diagnosed at DHC revealed a substantial delay from the time of diagnosis of pregnancy until they were seen at the TPC. In 20% of our patients, four weeks or more passed before prenatal care was begun. Whether this delay is a result of lack of available appointments or poor patient compliance is not known. This delay is important because of the deleterious effects of STDs on the health of the mother and her newborn. Fifty percent of our patients were found to have a STD
(Table 3). Some of these STDs may acquired after being seen in the DHC, but because the
at presentation to the TPC
have been
proportion of patients with STDs was so high and consistent at all it is likely a significant number may have been infected at the time of their initial DHC visit. A delay in diagnosing STDs in pregnant teens may result in further transmission of STDs and poorer pregnancy outcomes. 16,11 If pelvic exams and search for STDs had been routinely performed on our patients at the time of diagnosis, prompt treatment could have been instituted. We suspect that many practitioners refer their pregnant teenagers without routinely completing a pelvic exam and evaluating the patient for STDs. It is also likely that many do not realize how much time may pass before these patients are seen by an obstetrical service. The delays seen in our population possibly reflect an overburdened obstetrical program and do not necessarily pertain to all prenatal clinics. The prevalence of STDs is also higher in our population than in the teenage population as a whole. However, in populations similar to ours, the delay to the first prenatal visit may be prolonged and the prevalence of STDs high. Therefore, we recommend that all newly diagnosed pregnant teenagers receive a pelvic exam with appropriate evaluation for STDs. If the physician is unable to do this, then a referral appointment should be personally scheduled with careful follow up to insure that the appointment was kept.
delay intervals,
7.
Alger LS, Lovchik JC, Hebel JR, et al. The association of Chlamydia trachomatis, Neisseria gonorrhea, and group B streptococci with preterm rupture of the membranes and pregnancy outcome. Am J Obstet Gynecol
1988; 159:397-404. Martius J, Eschenbach DA. The role of bacterial vaginosis as a cause of amniotic fluid infection, chorioamnionitis and prematurity a review. Arch Gynecol Obstet 1990; 247:1-13. 9. Eschenbach DA. Relationships of vaginal Lactobacillus species, cervical Chlamydia trachomatis, and bacterial vaginosis to preterm birth. Obstet Gynecol 1988; 71:89-95. 10. Berman SM, Harrison HR, Boyce WT, et al. Low birth weight prematurity, and postpartum endometritis. Association with prenatal cervical Mycoplasma hominis and Chlamydia trachomatis infections. JAMA 1987; 257:1189-94. 11. Elliott B, Brunham RC, Laga M, et al. Maternal gonococcal infection as a preventable risk factor for low birth. J Infect Dis 1990; 161:531-6. 12. Alexander ER. Gonorrhea in the newborn. Ann NY Academy Science 8.
—
1988; 549:180-6. 13. Preece PM, Ades A, Thompson RG, Brooks JH. Chlamydia trachomatis infection in late pregnancy: a prospective study. Pediatr Perinatal Epidemiol 1989; 3:268-77. 14. Hardy JB, King TM, Repke JT. The Johns Hopkins’ Adolescent Pregnancy Program: an evaluation. Obstet Gynecol 1987; 69:300. 15. Vital Statistics of the United States-1987. Volume I-Natality. Hyattsville, Maryland: National Centre for Health Statistics, 1989. Table 1-44 pg. 74-76. DHHS publication no. (PHS)89-1100. 16. Dodson MG, Fortunato SJ. Microorganisms and premature labor. Reproduct Med 1988; 33 (Suppl):87-96. 17. Cohen I, Veille JC, Calkins BM. Improved pregnancy outcome following successful treatment of chlaymydial infection. JAMA 1990; 263:31607.
Acknowledgement I wish to thank Judy Adams and Gloria McGrath for their help with the data collection and Gail Kreklow for her help with the manuscript preparation. I would like to acknowledge Michael J. Chusid, M.D. for his critical review of this paper.
References 1.
2. 3.
4. 5.
5.
Teenage pregnancy in industrialized countries. Yale University Press, New Haven, CT, 1986. Facts in Brief, Teenage Sexual and Reproductive Behavior in the United Jones EF, et al.
States. The Alan Guttmacher Institute, June 1, 1991. Testa M, Wulczyn F. The State of the Child, Vol. 1. Children’s Policy Research Project, University of Chicago, 1980. Advance report of final natality statistics, 1985. Monthly Vital Statistical Report 1987; 36 (Suppl):1-43. Lee KS, Corpvz M. Teenage pregnancy: trend and impact on rates of low birth weight and fetal, maternal and neonatal mortality in the United States. Clin Perinatol 1987; 15:929-42. The Johns Hopkins Study of Cervicitis and Adverse Pregnancy Outcome. Association of Chlamydia trachomatis and Mycoplasma hominis with intrauterine growth retardation and preterm delivery. Am J Epidemiol
1989; 129:1247-57.
663
Downloaded from cpj.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on March 11, 2015
