Teenage Pregnancy and the Black Community Francis L. Hutchins, Jr., MD, FACOG Philadelphia, Pennsylvania
There has been a dramatic increase in teenage pregnancy in the United States which is most marked and persistent in those under 18 years of age. A disproportionate number of these pregnancies occur among black teenagers. Intercourse among teenagers is likewise on the increase; but, whereas the greatest increases in general have occurred among whites, the actual percentage of sexually active teenagers is greatest among blacks. Teenagers are poor users of contraception and repeat pregnancy is a persistent trend. Teenage pregnancy is marked by a high maternal mortality rate in the younger age groups (less than 15 years) and a high incidence of toxemia of pregnancy (10-29 percent in most reports). Infants of teenage mothers have a high incidence of prematurity as well as increased perinatal mortality. Teenagers in general seem to make poor parents and are more likely to be involved in child abuse than are older parents. As a result of the above noted factors, as well as others, the IQs of infants born to teenagers tend to be lower than those of infants born to more mature mothers. It is concluded that teenage pregnancy has special significance for the black community requiring immediate and dramatic action. From 1950 through 1960, there was a significant increase in the number of live births in the United States. All age groups contributed to this increase. However, the most pronounced increase in live births occurred among teenagers, as evidenced by the 39 percent increase in births to women ages 18 to 19, the 44 percent increase in births to women ages 16 to 17, and the 37 percent increase to those age 16 or less. Since 1960, there has been a significant drop in the overall number of live births in this country; however, births to teenagers (especially younger teenagers) have continued to increase. Thus, there has been a 25 percent increase in births to women aged 16 to 17 and an 80 percent increase in births to women aged 16 years or less from 1960 through 1973.1 Despite the fact that over 70 percent of these pregnancies
Requests for reprints should be addressed to: Dr. Francis L. Hutchins, Jr., Department of Obstetrics and Gynecology, Lankenau Hospital, Philadelphia, PA 19151.
occur in white teenagers, there is a disproportionate number of pregnancies among black teenagers.2
Characteristics of the Sexually Active Teenager Zelnick and Kantner recently published a review of sexual and contraceptive experiences among teenagers in the United States between 1971 and 1976.3 In this study, it was noted that appoximately 34.9 percent of unmarried women, aged 15 to 19, had had intercourse at least once. This represented a 30 percent increase for the 15 to 19-year-old age group and a 17.9 percent increase for the 19-year-olds since 1971. When examined by race, significant differences were noted. Whereas in 1976, 30.8 percent of all white teenagers aged 15 to 19 had had intercourse, for blacks the equivalent figure was 62.7 percent. While both groups showed significant increases between 1971 and 1976, the increase was far greater for whites (43.9 percent) than for blacks (22.5 percent) with the exception of the 15-year-old age group in
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 11, 1978
which both whites and blacks experienced approximately a 26-percent increase in intercourse. In all other age groups through the age of 19, the increase in intercourse was approximately two to three times greater for whites than for blacks. Nevertheless, the percentage of sexually active teenagers in all age groups, 15 to 19, was greater for blacks than for whites. For example, in 1976, 13.8 percent of white 15-year-olds were sexually active as compared to 38.4 percent of black 15year-olds. Although the incidence of intercourse among teenagers appears to have increased, the actual frequency of intercourse appears to be unchanged. Thus, in 1971 and 1976, it was noted by the investigators that teenagers tended to have intercourse sporadically. An additional factor to be noted is that although teenagers have increased their use of contraception, there has been a consistent lag between the time of first intercourse and initiation of contraception. There is also a tendency for teenagers to use contraception less often and less effectively; and there is a significant percentage who never use it at all, particularly in the younger age
groups.3'4 A final disturbing characteristic in sexually active teenagers is the phenomenon of repeat pregnancy. Stickle and Ma in their national survey noted that in 1973, essentially all births to mothers under age 16 were first births, but for mothers aged 16 and 17, 11 percent were second and one percent were third or subsequent births. Of births to women aged 18 and 19 in that year, 22 percent were second and four percent were third or subsequent births.' A dramatic demonstration of this characteristic among an urban nonwhite population can be seen in Figure 1. This represents gravidity data drawn from a retrospective analysis of 4,221 infants delivered to teenagers from July 1970 through December 1975, at Temple University Hospital. These data were derived from an urban population 857
11001000-
BIRTHS TO TEENAGERS BY GRAVIDITY toll
10 9.3%
8.5% B90
900-
47
67%
-~ ~
5
500-
3.2
of 1 0 - 1fi4
7 O lB 6 AGE GROUP
which was 75 percent black and 16 percent Puerto Rican. The overwhelming majority of this population qualified for either medical assistance or welfare. It was found that 35 percent of these teenagers were experiencing repeat pregnancies. While all deliveries to 12 and 13-year-olds represented first pregnancies, by age 14, five percent of the deliveries represented second pregnancies; by age 17, 27 percent were second and five percent were third or subsequent pregnancies. Finally, by age 19, only 45 percent were first pregnancies while 33 percent were second, 17 percent were third, and approximately four percent were fourth or subsequent pregnancies with one delivery representing the eighth for a 19year-old mother.
Pregnancy Characteristics and Outcome Of the three pregnancy options available, teenagers tend to choose either to abort or to have their babies and raise them as opposed to placing them for adoption.5 Tietze6 showed that although the abortion rate (number of abortions per 1,000 women) was higher for nonwhites than for whites under age 20, the abortion ratios (number of abortions per 1,000 live births) were essentially the same, suggesting that the option of abortion is chosen with the same frequency by both white and nonwhite pregnant teenagers. In this writer's experience at Temple University, approximately 50 percent of pregnant teenagers opt for abortion with few, if any, choosing adoption. Of those who elect to carry their pregnancies, poor prenatal care is a
(16
17-19
40+
Figure 2. Percentage of patients developing preeclampsia in each age group.
characteristic. This is related to poor attendance in prenatal clinics because of fear of discovery, ambivalence over the pregnancy, ignorance of the suggestive signs and symptoms of early pregnancy, etc.7 Poor use of prenatal care, particularly among urban teenagers, such as those served at Temple University, may be reflective of the casual attitude of the overall population towards prenatal care. For example, among our patients, 30 percent of those aged 16 years and under, 22 percent of those aged 17 to 19, and 18 percent of those 20 to 34 years of age failed to register for prenatal care prior to the third trimester of pregnancy. Furthermore, 25 percent of teenagers and 21 percent of adults 20 to 34 years of age made five or less clinic visits with 4.1 percent and 4.5 percent of these groups, respectively, receiving no prenatal care prior to delivery. The major medical consequences for the teenage mother are an increase in mortality rate and toxemia of pregnancy. Maternal mortality rate tends to rise as maternal age decreases. '5 This is especially marked in women under age 15 where the rate is the highest of any age group under 40 years old, and is approximately three to four times the mortality rate for women in their twenties.' Figure 2 shows that at Temple, teenagers had the highest incidence of preeclampsia with the exception of women over 40. This has been noted frequently by other authors and appears to be especially marked in predominately black populations where most authors report a 10-29 percent in-
cidence.7'8
20-34 35-39 AGE ArouP
19
Figure 1. Births to teenagers by age and gravidity of mothers (4,221 infants).
858
5
39%
IL4
800
The most serious medical consequences of teenage pregnancy affect the infant as indicated by elevated rates of prematurity and perinatal mortality.1'7'8 As noted by Stickle and Ma,1 prematurity as determined by weight (less than 2,500 gm) has its highest incidence among babies of nonwhite teenage mothers, where it may reach 20 percent. At Temple, a 17 percent incidence of prematurity has been noted in teenage pregnancies. This increased risk of mortality persists through the first year of life during which time the infant mortality for infants born of teenagers is consistently higher than that for infants born to women in their twenties. As was pointed out by Nye,9 it is likely that much of this excess mortality, as well as birth injuries, particularly neurologic injuries, can be traced to prematurity and its causes.
Socioeconomic Consequences For the black teenager, pregnancy produces numerous negative consequences. Furstenbergt0 pointed out that the teenager who experiences a pregnancy shares similar life goals with her nonpregnant peers; however, she is much less likely to achieve her goals as a consequence of her ill-timed pregnancy. Indeed, one of the more striking characteristics of pregnancy in the teen years is the significant gap which ultimately exists between articulated as opposed to realized goals. Having experienced a pregnancy, a teenager is less likely to finish high school, less likely to ultimately become socioeconomically independent, less likely to marry, and should she marry at the time of her pregnancy, that marriage
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70,
NO. 11, 1978
would be subject to one of the highest divorce rates in this country. Child neglect and abuse is another aspect of this problem. As might be expected, teenagers are ill prepared for the demands of parenthood, and because of their lack of skills and understanding, they are likely to neglect their infants which results in an increase in failure-to-thrive syndrome. Child abuse appears to be an increasingly frequent problem. Among other causes given for this have been the dual observations that teenage parents tend to have unrealistic expectations for their children as well as a low tolerance for crying.9 The final concern to be noted is with the intellectual and emotional development of the products of these pregnancies. Roberts and Angil,11 as well as Opel and Royston,12 have noted lower IQs among infants born to teenage mothers and, in fact, the IQ tends to diminish as the age of the mother decreases. It is probable that the causes here are multiple and would include the
increased likelihood of prematurity, the well-documented poor nutrition of adolescent mothers, as well as poor parenting and child abuse. The implications of these findings for the infant, its family, and its community-particularly in attaining upward mobility-are obvious.
Conclusion It is obvious that teenage pregnancy is fraught with numerous problems. It is further apparent that in a community attempting to overcome the ravages of generations of inequality and oppression, this problem may have an even more devastating impact than usual. This is a very unpleasant problem and a disconcerting one for the black community to recognize. The natural reaction would be to suppress this kind of negative issue and replace it with something more positive. Unfortunately, that is an unaffordable luxury. The future of any people is vested in its children, and teenage pregnancy poses a major threat to black youth today.
Literature Cited 1. Stickle G, Ma P: Pregnancy in adolescents: Scope of the problem. Contemp Obstet Gynecol 5:85-91, 1975 2. Tietze C: Legal abortions in the United States: Rates and ratios by race and age 19721974. Fam Plann Perspect 9:(1)12-15, 1977 3. Zelnick M, Kanner JF: Sexual and contraceptive experiences of young unmarried women in the United States, 1976 and 1971. Fam Plann Perspect 9:(2)55-71, 1977 4. Aktom CA, Akpomkl DM: Prior sexual behavior attending rap session for the first time. Fam Plann Perspect 8:(4)203-206, 1976 5. Guttmacher A: Eleven Million Teenagers. New York, Planned Parenthood Federation of America, 1976 6. Tietze C: Legal abortions in the United States: Rates and ratios by race and age 19721974. Fam Plann Perspect 9:(1)12-15, 1977 7. Dott AB, Fort AT: Medical and social factors affecting early teenage pregnancy. Am Jour Obstet Gynecol 125:(4)532-536, 1976 8. Dickens HO, Mudd EH, Garcia CR, et al: One hundred pregnant adolescents: Treatment approaches in a university hospital. Am J Public Health 63:(9)794-800, 1973 9. Nye Fl: School-age parenthood: Consequences for babies, mothers, fathers, grandparents and others. Wash State Univ Ext Serv Bull, 667, July 1977 10. Furstenberg FF: Unplanned pregnancy: The social consequences of teenage childbearing. New York, The Free Press, 1976 11. Roberts J, Engel A: Family background, early development and intelligence of children 6-11 years. In National Center for Health Statistics (Rockville, Md): National Health Survey, Series 11, No. 142. 12. Opel WC, Royston AB: Teenage births: Some social, psychological and physical sequelae. Am J Public Health 61:4, 1971
1979 NMA Convention
Medical Association
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 11, 1978
The 84th annual convention and scientific assembly of the National Medical Association will be held in Detroit, Michigan from July 29-August 2, 1979. The scientific program will include Aerospace and Military Medicine, Anesthesiology, Basic Science, Community Medicine, Dermatology, Family Practice, Internal Medicine, Neurology and Psychiatry, Obstetrics and Gynecology, Ophthalmology, Orthopedics, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Radiology, Surgery, and Urology.
859
There has been a dramatic increase in teenage pregnancy in the United States which is most marked and persistent in those under 18 years of age. A disproportionate number of these pregnancies occur among black teenagers. Intercourse among teenagers is likewise on the increase; but, whereas the greatest increases in general have occurred among whites, the actual percentage of sexually active teenagers is greatest among blacks. Teenagers are poor users of contraception and repeat pregnancy is a persistent trend. Teenage pregnancy is marked by a high maternal mortality rate in the younger age groups (less than 15 years) and a high incidence of toxemia of pregnancy (10-29 percent in most reports). Infants of teenage mothers have a high incidence of prematurity as well as increased perinatal mortality. Teenagers in general seem to make poor parents and are more likely to be involved in child abuse than are older parents. As a result of the above noted factors, as well as others, the IQs of infants born to teenagers tend to be lower than those of infants born to more mature mothers. It is concluded that teenage pregnancy has special significance for the black community requiring immediate and dramatic action. From 1950 through 1960, there was a significant increase in the number of live births in the United States. All age groups contributed to this increase. However, the most pronounced increase in live births occurred among teenagers, as evidenced by the 39 percent increase in births to women ages 18 to 19, the 44 percent increase in births to women ages 16 to 17, and the 37 percent increase to those age 16 or less. Since 1960, there has been a significant drop in the overall number of live births in this country; however, births to teenagers (especially younger teenagers) have continued to increase. Thus, there has been a 25 percent increase in births to women aged 16 to 17 and an 80 percent increase in births to women aged 16 years or less from 1960 through 1973.1 Despite the fact that over 70 percent of these pregnancies
Requests for reprints should be addressed to: Dr. Francis L. Hutchins, Jr., Department of Obstetrics and Gynecology, Lankenau Hospital, Philadelphia, PA 19151.
occur in white teenagers, there is a disproportionate number of pregnancies among black teenagers.2
Characteristics of the Sexually Active Teenager Zelnick and Kantner recently published a review of sexual and contraceptive experiences among teenagers in the United States between 1971 and 1976.3 In this study, it was noted that appoximately 34.9 percent of unmarried women, aged 15 to 19, had had intercourse at least once. This represented a 30 percent increase for the 15 to 19-year-old age group and a 17.9 percent increase for the 19-year-olds since 1971. When examined by race, significant differences were noted. Whereas in 1976, 30.8 percent of all white teenagers aged 15 to 19 had had intercourse, for blacks the equivalent figure was 62.7 percent. While both groups showed significant increases between 1971 and 1976, the increase was far greater for whites (43.9 percent) than for blacks (22.5 percent) with the exception of the 15-year-old age group in
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 11, 1978
which both whites and blacks experienced approximately a 26-percent increase in intercourse. In all other age groups through the age of 19, the increase in intercourse was approximately two to three times greater for whites than for blacks. Nevertheless, the percentage of sexually active teenagers in all age groups, 15 to 19, was greater for blacks than for whites. For example, in 1976, 13.8 percent of white 15-year-olds were sexually active as compared to 38.4 percent of black 15year-olds. Although the incidence of intercourse among teenagers appears to have increased, the actual frequency of intercourse appears to be unchanged. Thus, in 1971 and 1976, it was noted by the investigators that teenagers tended to have intercourse sporadically. An additional factor to be noted is that although teenagers have increased their use of contraception, there has been a consistent lag between the time of first intercourse and initiation of contraception. There is also a tendency for teenagers to use contraception less often and less effectively; and there is a significant percentage who never use it at all, particularly in the younger age
groups.3'4 A final disturbing characteristic in sexually active teenagers is the phenomenon of repeat pregnancy. Stickle and Ma in their national survey noted that in 1973, essentially all births to mothers under age 16 were first births, but for mothers aged 16 and 17, 11 percent were second and one percent were third or subsequent births. Of births to women aged 18 and 19 in that year, 22 percent were second and four percent were third or subsequent births.' A dramatic demonstration of this characteristic among an urban nonwhite population can be seen in Figure 1. This represents gravidity data drawn from a retrospective analysis of 4,221 infants delivered to teenagers from July 1970 through December 1975, at Temple University Hospital. These data were derived from an urban population 857
11001000-
BIRTHS TO TEENAGERS BY GRAVIDITY toll
10 9.3%
8.5% B90
900-
47
67%
-~ ~
5
500-
3.2
of 1 0 - 1fi4
7 O lB 6 AGE GROUP
which was 75 percent black and 16 percent Puerto Rican. The overwhelming majority of this population qualified for either medical assistance or welfare. It was found that 35 percent of these teenagers were experiencing repeat pregnancies. While all deliveries to 12 and 13-year-olds represented first pregnancies, by age 14, five percent of the deliveries represented second pregnancies; by age 17, 27 percent were second and five percent were third or subsequent pregnancies. Finally, by age 19, only 45 percent were first pregnancies while 33 percent were second, 17 percent were third, and approximately four percent were fourth or subsequent pregnancies with one delivery representing the eighth for a 19year-old mother.
Pregnancy Characteristics and Outcome Of the three pregnancy options available, teenagers tend to choose either to abort or to have their babies and raise them as opposed to placing them for adoption.5 Tietze6 showed that although the abortion rate (number of abortions per 1,000 women) was higher for nonwhites than for whites under age 20, the abortion ratios (number of abortions per 1,000 live births) were essentially the same, suggesting that the option of abortion is chosen with the same frequency by both white and nonwhite pregnant teenagers. In this writer's experience at Temple University, approximately 50 percent of pregnant teenagers opt for abortion with few, if any, choosing adoption. Of those who elect to carry their pregnancies, poor prenatal care is a
(16
17-19
40+
Figure 2. Percentage of patients developing preeclampsia in each age group.
characteristic. This is related to poor attendance in prenatal clinics because of fear of discovery, ambivalence over the pregnancy, ignorance of the suggestive signs and symptoms of early pregnancy, etc.7 Poor use of prenatal care, particularly among urban teenagers, such as those served at Temple University, may be reflective of the casual attitude of the overall population towards prenatal care. For example, among our patients, 30 percent of those aged 16 years and under, 22 percent of those aged 17 to 19, and 18 percent of those 20 to 34 years of age failed to register for prenatal care prior to the third trimester of pregnancy. Furthermore, 25 percent of teenagers and 21 percent of adults 20 to 34 years of age made five or less clinic visits with 4.1 percent and 4.5 percent of these groups, respectively, receiving no prenatal care prior to delivery. The major medical consequences for the teenage mother are an increase in mortality rate and toxemia of pregnancy. Maternal mortality rate tends to rise as maternal age decreases. '5 This is especially marked in women under age 15 where the rate is the highest of any age group under 40 years old, and is approximately three to four times the mortality rate for women in their twenties.' Figure 2 shows that at Temple, teenagers had the highest incidence of preeclampsia with the exception of women over 40. This has been noted frequently by other authors and appears to be especially marked in predominately black populations where most authors report a 10-29 percent in-
cidence.7'8
20-34 35-39 AGE ArouP
19
Figure 1. Births to teenagers by age and gravidity of mothers (4,221 infants).
858
5
39%
IL4
800
The most serious medical consequences of teenage pregnancy affect the infant as indicated by elevated rates of prematurity and perinatal mortality.1'7'8 As noted by Stickle and Ma,1 prematurity as determined by weight (less than 2,500 gm) has its highest incidence among babies of nonwhite teenage mothers, where it may reach 20 percent. At Temple, a 17 percent incidence of prematurity has been noted in teenage pregnancies. This increased risk of mortality persists through the first year of life during which time the infant mortality for infants born of teenagers is consistently higher than that for infants born to women in their twenties. As was pointed out by Nye,9 it is likely that much of this excess mortality, as well as birth injuries, particularly neurologic injuries, can be traced to prematurity and its causes.
Socioeconomic Consequences For the black teenager, pregnancy produces numerous negative consequences. Furstenbergt0 pointed out that the teenager who experiences a pregnancy shares similar life goals with her nonpregnant peers; however, she is much less likely to achieve her goals as a consequence of her ill-timed pregnancy. Indeed, one of the more striking characteristics of pregnancy in the teen years is the significant gap which ultimately exists between articulated as opposed to realized goals. Having experienced a pregnancy, a teenager is less likely to finish high school, less likely to ultimately become socioeconomically independent, less likely to marry, and should she marry at the time of her pregnancy, that marriage
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70,
NO. 11, 1978
would be subject to one of the highest divorce rates in this country. Child neglect and abuse is another aspect of this problem. As might be expected, teenagers are ill prepared for the demands of parenthood, and because of their lack of skills and understanding, they are likely to neglect their infants which results in an increase in failure-to-thrive syndrome. Child abuse appears to be an increasingly frequent problem. Among other causes given for this have been the dual observations that teenage parents tend to have unrealistic expectations for their children as well as a low tolerance for crying.9 The final concern to be noted is with the intellectual and emotional development of the products of these pregnancies. Roberts and Angil,11 as well as Opel and Royston,12 have noted lower IQs among infants born to teenage mothers and, in fact, the IQ tends to diminish as the age of the mother decreases. It is probable that the causes here are multiple and would include the
increased likelihood of prematurity, the well-documented poor nutrition of adolescent mothers, as well as poor parenting and child abuse. The implications of these findings for the infant, its family, and its community-particularly in attaining upward mobility-are obvious.
Conclusion It is obvious that teenage pregnancy is fraught with numerous problems. It is further apparent that in a community attempting to overcome the ravages of generations of inequality and oppression, this problem may have an even more devastating impact than usual. This is a very unpleasant problem and a disconcerting one for the black community to recognize. The natural reaction would be to suppress this kind of negative issue and replace it with something more positive. Unfortunately, that is an unaffordable luxury. The future of any people is vested in its children, and teenage pregnancy poses a major threat to black youth today.
Literature Cited 1. Stickle G, Ma P: Pregnancy in adolescents: Scope of the problem. Contemp Obstet Gynecol 5:85-91, 1975 2. Tietze C: Legal abortions in the United States: Rates and ratios by race and age 19721974. Fam Plann Perspect 9:(1)12-15, 1977 3. Zelnick M, Kanner JF: Sexual and contraceptive experiences of young unmarried women in the United States, 1976 and 1971. Fam Plann Perspect 9:(2)55-71, 1977 4. Aktom CA, Akpomkl DM: Prior sexual behavior attending rap session for the first time. Fam Plann Perspect 8:(4)203-206, 1976 5. Guttmacher A: Eleven Million Teenagers. New York, Planned Parenthood Federation of America, 1976 6. Tietze C: Legal abortions in the United States: Rates and ratios by race and age 19721974. Fam Plann Perspect 9:(1)12-15, 1977 7. Dott AB, Fort AT: Medical and social factors affecting early teenage pregnancy. Am Jour Obstet Gynecol 125:(4)532-536, 1976 8. Dickens HO, Mudd EH, Garcia CR, et al: One hundred pregnant adolescents: Treatment approaches in a university hospital. Am J Public Health 63:(9)794-800, 1973 9. Nye Fl: School-age parenthood: Consequences for babies, mothers, fathers, grandparents and others. Wash State Univ Ext Serv Bull, 667, July 1977 10. Furstenberg FF: Unplanned pregnancy: The social consequences of teenage childbearing. New York, The Free Press, 1976 11. Roberts J, Engel A: Family background, early development and intelligence of children 6-11 years. In National Center for Health Statistics (Rockville, Md): National Health Survey, Series 11, No. 142. 12. Opel WC, Royston AB: Teenage births: Some social, psychological and physical sequelae. Am J Public Health 61:4, 1971
1979 NMA Convention
Medical Association
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 11, 1978
The 84th annual convention and scientific assembly of the National Medical Association will be held in Detroit, Michigan from July 29-August 2, 1979. The scientific program will include Aerospace and Military Medicine, Anesthesiology, Basic Science, Community Medicine, Dermatology, Family Practice, Internal Medicine, Neurology and Psychiatry, Obstetrics and Gynecology, Ophthalmology, Orthopedics, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Radiology, Surgery, and Urology.
859
