FeaturesPregnancy outcomes of adolescents enrolled in a CenteringPregnancy program
Introduction
Although there has been a steady decline in the adolescent pregnancy rate since the early 1990s, 896,000 young women under the age of 20 became pregnant in the United States in 1997. The birth rate for adolescents aged 15 to 19 dropped by 13% from 1990 through 1997 (from 59.9 to 52.3 per 1000 adolescents per year). Over the same time period, the abortion rate declined by almost one-third from 40.3 to 27.5 per 1000 pregnancies,1 more than twice the drop in the birth rate for adolescents. This disparity between dropping birth rates and dropping abortion rates may reflect an increased number of unplanned births among adolescents.2 It may also reflect the steady increase in education regarding responsible sexual behavior as well as an increase in the number of adolescents using contraception during that same time period, a trend that continues through 2001.3, 4 Despite encouraging trends, the reported birth rate of 45.8 births per 1000 adolescents in 20014 remains a significant social, economic, and health concern.
Adolescence is the transition between childhood and adulthood, a period of biological maturity and a time to prepare for participation in society. It is a developmental phase of rapid and intense physical growth and profound emotional changes, a time of daily struggle with changing bodies, emotions, intellect, social and family relations, and values.5 The psychosocial developmental tasks of adolescence include developing self-esteem, acceptance of physical and emotional changes, independence, increasing relationships with peers, and the establishment of love and work relationships.6, 7
Adolescent thought is egocentric, with two major characteristics: the imaginary audience and the personal fable.8 The imaginary audience is the adolescent’s belief that others are as preoccupied with her as she herself is. This is reflected in the attention-getting behaviors so common in this age group. The personal fable is the adolescent’s sense of personal uniqueness and indestructibility. Adolescents are generally self-centered and may believe that they are not bound by the rules of nature that govern others. It is this feeling of invincibility, the inability of the adolescent to anticipate or believe in the possible consequences of behavior, that often precipitates adolescent pregnancy.
Adolescent pregnancy represents a developmental threat. As the adolescent is struggling to grow physically and emotionally and develop during the pubertal years, the pregnant adolescent must also adjust to the physical and emotional changes that accompany pregnancy, build a relationship with the fetus, and develop an identity as a mother. Pregnancy may actually inhibit the growth of individual identity and personality and interfere with the completion of the developmental tasks of adolescence.9 Although adolescents who become pregnant come from all socioeconomic classes, races, faiths, and geographic locations, they usually fit into all four of the most widely accepted categories of risk: bearing children at an early age; having low socioeconomic status, being poorly educated, and being unmarried.10
Many adolescents enter pregnancy with poor health habits, and many do not make the necessary adjustments in lifestyle that are necessary to promote a healthy pregnancy. Teens often receive limited or no prenatal care.11 Adolescents are generally thought to be at greater risk for gestational morbidity, especially excessive weight gain, preeclampsia, eclampsia, cephalopelvic disproportion, premature labor dystocia, operative delivery, and complications at birth. Research over the past decade, however, is inconsistent; it appears that many of these complications are, in fact, not increased when factors such as prenatal care and coexisting illness are taken into account.12, 13, 14, 15, 16 It is clear that the incidence of low birth weight (LBW) and preterm births are disproportionately higher among adolescents than among their older counterparts.17 This is an important consideration because LBW is the leading cause of neonatal and infant morbidity and mortality today.18
Social support for the pregnant and parenting adolescent comes primarily from her mother and from the father of the baby.16 This is in contrast to the normative development of strong peer social support relationships. For the pregnant adolescent, peer support, if present, may be unhelpful at its best and stressful at its worst.19, 20 Adolescent mothers often experience negative social pressure, social isolation from their friends, and alienation from their families. There is a significant relationship between the amount and quality of the social support a pregnant or parenting adolescent receives and her health, her general life circumstances, and the health and well-being of her child.20, 21 These correlations hold true regardless of the source of the social support.
The unique developmental needs of pregnant adolescents require prenatal care services focused on assessment, health promotion, preventive clinical services, social support, continuity of care, and education. There are two other issues concerning health services for adolescents: accessibility and affordability. Locating these services in programs specifically designed to serve pregnant and parenting teenagers may increase adolescents’ use of health care services. Programs that include psychosocial as well as medical support have had demonstrable effects in lowering risks associated with poor pregnancy weight gain, preterm delivery, and LBW.22, 23
The CenteringPregnancy model, with its emphasis on assessment, education, and support, was deemed to be the ideal model for this endeavor. The CenteringPregnancy model is a comprehensive prenatal program in which small groups of pregnant women come together for 90-minute sessions throughout their pregnancies with one postpartum session.24 Care is provided within the group context through facilitative leadership and focuses on assessment, education, and group support directed toward self-care responsibility. The model, although not developed specifically for adolescents, seems optimally suited for use with teens because the care, education, and support components can easily be based on their developmental needs. It seems to be acceptable to adolescents because the original pilot data indicated 92% compliance in the teen groups.24
The purpose of this article is to describe the implementation and evaluation of a CenteringPregnancy program specifically designed to facilitate positive outcomes in an adolescent population that traditionally has more adverse outcomes.
Section snippets
Application of CenteringPregnancy in St. Louis for an adolescent population
The Teen Pregnancy Center, an urban, hospital-based clinic at Barnes Jewish Hospital, was established in collaboration with Washington University School of Medicine in February 1999 as the only multidisciplinary program in the St. Louis metropolitan area to provide specialized prenatal care for adolescents 17 years of age and younger. The Teen Pregnancy Center team includes three certified nurse-midwives, a social worker, a nutritionist, a registered nurse, an education coordinator, a
Research questions
The Teen Pregnancy Center developed an evaluation program prior to the implementation of CenteringPregnancy in March 2001 to address the following research questions:
What are the health visit attendance rates for adolescents in CenteringPregnancy groups?
What are the perinatal outcomes for adolescents in CenteringPregnancy groups?
What is the level of satisfaction for teens in Centering groups?
The Human Studies Committee at Washington University School of Medicine approved this research study.
Data collection
Comparison groups
For descriptive purposes, perinatal outcomes of the adolescents in the CenteringPregnancy were compared with two groups of adolescents. The first comparison group (2001 group) consists of adolescents 17 years of age or younger who gave birth at Barnes Jewish Hospital in 2001 excluding adolescents receiving no prenatal care and teens participating in Centering groups through the Teen Pregnancy Center. Birth weight, gestational age, and delivery type data were collected from the delivery logbook
Discussion and implications
The CenteringPregnancy model provides support for young women in an active, developmentally appropriate environment and has demonstrated excellent health care compliance, high levels of client satisfaction, and good pregnancy outcomes at the Teen Pregnancy Center of Barnes Jewish Hospital.
The adolescents in Centering groups at the Teen Pregnancy Center, at-risk for LBW and preterm infants because of their age, educational level, race, and socioeconomic status, had a 50% lower rate of LBW and
Limitations
Limitations of this project include the self-selection of adolescents into either CenteringPregnancy or traditional prenatal care. Adolescents choosing the Teen Pregnancy Center and CenteringPregnancy may be a more motivated group of adolescents, and this may influence birth outcomes and prenatal visit attendance. The 2001 comparison group excluded adolescents receiving care at the Teen Pregnancy Center in 2001 and could influence comparisons between Centering and the 2001 comparison group.
Future plans
For adolescents, pregnancy is a life-changing event, an important time of transition, and the beginning of life as a new parent. Pregnancy, however, is just the beginning. Although CenteringPregnancy is an ideal model of care for adolescents, their needs for education, peer support, and ongoing assessment do not end with delivery. The first year of life for the infant and the adolescent mother is a time of attachment, adjustment, and development. The Teen Pregnancy Center staff has recently
Conclusion
The CenteringPregnancy model worked well in this population of adolescents. The model appears to be valuable in terms of consistency in and satisfaction with prenatal care. CenteringPregnancy allows adolescents to explore their feelings and concerns about pregnancy and parenting in a safe and supportive environment. Adolescents often realize that they can change health behaviors and gain support from other young women in the group. The fact that we were able to demonstrate differences in LBW
Acknowledgements
Program support for this demonstration project was received from the Episcopal-Presbyterian Charitable Health and Medical Trust, Copeland/Citigroup, First Book-St. Louis, and Ronald McDonald House Charities of Greater St. Louis. Thank you to the Teen Pregnancy Center Team including Maureen Foster, CNM, MSN, Debbie Hollander, CNM, MSN, Linda Amsden, RN, Lorien Carter, MSW, Terri Madison, Tina Pruitt, Granada Walker, LCSW, Amber Wamhoff, RD, and our peer assistants.
Mary Alice Grady, CNM, MS, is in clinical practice at the Teen Pregnancy Center at Barnes Jewish Hospital. She is adjunct faculty at Washington University School of Medicine.
References (36)
Addressing developmental needs of pregnant adolescents
J Obstet Gynecol Neonat Nurs
(1996)- et al.
Obstetric risks of pregnancy in women less than 18 years old
Obstet Gynecol
(2000) - et al.
Social support, relationship quality, and well-being among pregnant adolescents
J Adolesc
(1999) Effective prenatal care for adolescent girls
Nurs Clin North Am
(2002)Centering pregnancyAn interdisciplinary model of empowerment
J Nurse Midwifery
(1998)- et al.
Adolescent mothers and child abuse potentialAn evaluation of risk factors
Child Abuse Negl
(1996) - et al.
Young maternal age associated with increased risk of postneonatal death
Obstet Gynecol
(2002) Centering pregnancyA model for pregnant adolescents
J Midwifery Womens Health
(2003)- et al.
Trends in pregnancy rates for the United States, 1976–97An update
Natl Vital Stat Rep
(2001) Unintended pregnancy in the United States
Fam Plann Perspect
(1998)
Family planning annual report2001 Summary
BirthsFinal data for 2001
Natl Vital Stat Rep
Adolescent development
Annu Rev Psychol
Human development and education
IdentityYouth and crisis
Egocentrism in adolescence
Child Dev
High risk pregnancyA team approach
Teen sex and pregnancy
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Mary Alice Grady, CNM, MS, is in clinical practice at the Teen Pregnancy Center at Barnes Jewish Hospital. She is adjunct faculty at Washington University School of Medicine.
Kathaleen C. Bloom, CNM, PhD, is an Associate Professor in the School of Nursing at the University of North Florida in Jacksonville, Florida. She is in clinical practice at the West Jacksonville Family Health Center.