Young Moms’ Clinic: A Multidisciplinary Approach to Pregnancy Education in Teens and in Young Single Women

J Pediatr Adolesc Gynecol (1997) 10:28-33

Young Moms' Clinic: A Multidisciplinary Approach to Pregnancy Education in Teens and in Young Single Women J.T. Van Winter, M.D. , l M.e. Harmon , R.N. 人E.J. Atkinson , M.S. ,3 P.S. Sin1ffions , M.D. ,4 and P.L. Ogburn , Jf. , M.D. l lDepartment of Obstetrics and Gynecology , 2Section of Patient and Health Education , 3Section of Biostatistics , and 4Section of Community Pediatric and Adolescent Medicine , Mayo Clinic and Mayo Foundation , Rochester , Minnesota

Abstract. Study Objective: To study outcome of pregnant adolescents and single young women who attended and those who chose not to attend a nonurban , developmentally appropriate , pilot antenatal clinic called the ' 'Young Moms' Clinic." To study "perceived" outcome anl0ng the Young Moms' Clinic partIcIpants. Methods: A multidisciplinary clinic was established to provide education about pregnancy , childbirth , infant care , contraception , and healthy lifestyles to young mothers with similar backgrounds. Over a 2-year period , all adolescents and single young mothers aged 13-23 years were invited to attend the Young Moms' Clinic after the first trimester. The Clinic group consisted of the first 101 young women who were invited and chose to attend. The nonclinic group consisted of the first 95 young wonlen who were invited but declined to attend. Both groups had the same obstetric care givers , had a similar number of prenatal visits (median number , 12), and delivered in the same hospital. Univariate and multivariate analyses were performed to determine whether participation in the clinic was an independent factor in outcome. Results: Maternal weight gain and infant birth weight were significantly higher in the Clinic group. Pregnancy complications (preterm labor , intrauterine growth retardation , anemia) were significantly higher in the nonclinic group. Participants in the nonclinic group were almost three times as likely to have cesarean section delivery as those in the Clinic group. Neonatal intensive care unit transfer occurred only in infants of the control group. Conclusions: Participation of pregnant adolescent and young adult women from a nonurban community in a developmentally targeted pilot , prenatal program resulted in fewer pregnancy complications and improved outcome in comparison with those who chose not to participate in the program. The results may be subject to bias because of self-selection among partIcIpants.

Address reprint requests to: Jo T. Van Winter, M.D. , Department of

Obstetrics and Gynecology , Mayo Clinic , 200 First Street SW, Rochester, Minnesota 55905. 1083-3188 © 1997 Chapman & Hall

Key Words. Antenatal clinic-Pregnancy complications-Neonatal care-Pregnancy outcome-Teenage pregnancy Introduction Adolescent pregnancy is a national concen1 that 甘an­ scends all racial and social boundaries. Of the 1,000,000 pregnancies among adolescents in the United States each year , about 522 ,000 result in live births. Eighty-five percent of adolescent pregnancies are unintentional , and 97% of adolescent mothers keep their infants. The annual cost to society is $25.1 billion. l --4 These pregnancies are at high risk for adverse outcome such as preterm delivery , low birth weight , increased fetal/maternal morbidity and mortality , and long-term financial dependence on society. However , pregnancy outcome appears to be amenable to developmentally appropriate intervention. Medical , social , and economic risks for the adolescent mother and her infant should be decreased substantially by early and comprehensive prenatal care targeted to their intellectual and emotional maturity. The provision of adequate prenatal care (together with a comprehensive educational program) and improven1ent in socioeconomic status have been shown to markedly reduce the risks associated with adolescent pregnancy in urban settings. 5 - 12 There is a paucity of information on the outcome of adolescent pregnancy in nonurban areas. Preliminary studies in this population indicate an improved outcome for pregnant adolescents enrolled in a developmentally appropriate prenatal education program. 13 Before the establishment of our "Young Moms' Clinic ," no multidisciplinary community program existed to serve junior high- , high school- , and collegeaged pregnant women. Therefore , the pu叩ose of the retrospective study reported herein was to determine the effect that participation in a pilot program designed for young pregnant women had on pregnancy outcome.

Van Winter et al. : Young Moms' Clinic Materials and Methods In 1990 , a task force was developed in response to the unmet needs of pregnant adolescent and single young adult women at the Mayo Medical Center (Rochester , Minnesota). The goal of the task force was to design an accessible and developmentally appropriate program integrating all components of patient care. The result was a patient-focused multidisciplinary clinic involving obstetricians , pediatricians , social workers , and nurse educators. The clinic addressed the physical , psychosocial , educational , and financial needs of young mothers in a developmentally appropriate manner throughout pregnancy and the neonatal period. It was designed to meet the needs of a population that the task force identified as being underserved in our community , that is , pregnant women aged 23 years or younger. The goals of this program were to 1) teach participants about pregnancy , child birth , early parenting , healthy lifestyles , and contraception , 2) facilitate open communication , trust , and cooperative interaction between young mothers and their health care providers , 3) provide information about and access to appropriate supportive services in the community , 4) increase compliance in adolescent patients by coordinating their prenatal classes with obstetric clinic appointments , 5) provide a confidential and supportive atmosphere for peer interaction , and 6) assess medical , educational , and affective outcomes. The format of the labor and birth classes of the Young Moms' Clinic consisted of an ongoing series of seven weekly afternoon sessions (Appendix A) team-taught by two nurse childbirth educators. Health care professionals fron1 other disciplines regularly contributed as guest speakers throughout each series. Eligible young women were identified and offered participation in this clinic during their initial prenatal visi t. Over a 2-year period , all adolescents (13-21 years old , single or married) and single young mothers (21-23 years old) were invited to attend the Young Moms' Clinic along with their companions , labor coaches , or an interested family member. Of the 196 adolescents and single young women who were invited to attend the clinic , 101 chose to attend (the , 'Clinic group") and 95 declined (the “ nonclinic group' 了 . Of the 101 young won1en in the Clinic group , 53 attended with the baby's father , 17 with their n10thers, 3 with their sisters , and 7 with friends; 26 a

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Caucasian of north European descent; 2% were Asian; 1.5% were Hispanic; 1% were Black; and 0.5% were North American Indian. Although enrollment in the Young Moms' Clinic was offered at any time during pregnancy , most participants entered labor and birth classes between 26 and 28 weeks of gestation. Continuous variables comparing the Clinic and the nonclinic groups were examined univariately with the two-sided Wilcoxon rank sum tes t. Discrete variables were examined univariately with the two-sided Chi square tes t. The main study endpoints were infant birth weight , gestational age at delivery , weight for gestational age , cesarean section rates , neonatal intensive care unit stay , and neonatal complications. Linear and logistic regression analyses were used to test whether there was a difference between the groups after adjusting for various demographic variables. Stepwise model selection was used to select baseline variables related to the endpoint , and then an indicator variable for the Young Moms' Clinic was added. Because information about cigarette smoking and/or alcohol consumption was often missing , these models were built including and excluding these variables. Although the following additional variables were not examined with multivariate models , they were of interes t: maternal weight gain , change in number of cigarettes per day during pregnancy , change in number of alcoholic drinks per week during pregnancy , number of prenatal visits , pregnancy complications , and 6-week postpartum con仕aceptlve use.

Results Tables 1, 2 , and 3 compare socioden10graphic and maternal health factors between the Clinic and nonclinic groups. No significant differences between the two groups were found in terms of marital status , psychiatric or chronic disease history , use of street drugs , sexually transmitted diseases , age , or educational background. There were significant differences between the two groups with regard to race , gravidity , and cigarette and alcohol use. There also was a significant difference between the groups for those providing smoking-use information. At the time of the initial visit (mean gestational age , 14 weeks) , current smokers in both groups smoked the same mean number of cigarettes per day , but current drinkers in the Clinic group consumed more alcohol per day. However , as shown in Table 4 , it appears that significantly more smokers (p < 0.001) and drinkers (p 0.005) in the Clinic group decreased or stopped smoking and drinking during pregnancy than those in the nonclinic group. Antenatal complications of the two groups are compared in Table 5. Among those in the clinic group , 7.9% had premature onset of labor (before 37 weeks of gesta-

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Van Winter et a l. :

Young Moms' Clinic

Table 1. Demographic Data Other Than Smoking/Drinking History for the Clinic and Nonclinic Groups: Discrete Variables Clinic Group

Nonclinic Group

Variable

No.

%

No.

%

pa

Single , no. (%) Previous pregnancy White Psychiatric history History of chronic disease b Previous use of street drugs Previous episode of sexually transmitted disease Use of street drugs at initial VISIt

85/101 24/101 99 /101 41 /100 18/101 37/100

84.2 23.8 98.0 4 1.0 17.8 37.0

74/95 42/95 85/95 30/94 26/94 36/95

77.9 44 .2 89.5 3 1.9 27.7 37.9

0 .263 0.002 0.013 0.189 0.101 0.897

17/98

17.3

23/91

25.3

0.182

4.0

4/95

4.2

0.930

4/100

aBased on two-sided chi square test (some variables have an occasional missing value). bThe chronic diseases identified included asthma in 17, mild thalassemia-related anemia in 4 , insulin-dependent diabetes mellitus in 3, recurrent urinary tract infection in 5 , iron deficiency anemia in 10, and chronic hepatitis in 3.

Table 2. Demographic Data Other Than Smoking/Drinking History for the Clinic and Nonclinic Groups: Continuous Variables Variable Age , yr Clinic (n = 10 1) Nonclinic (n = 95) No. of years education Clinic (n = 10 1) Nonclinic (n = 95)

Mean

Median

SD a

Minimum

Maximum

pb

19.2 19.7

18.9 19.8

2.2 2.2

13.7 14.4

23.7 23.6

0.100

1 1.4 1 1.6

12.0 12.0

1.6 1.4

6.0 9.0

16.0 15.0

0.315

aSD-standard deviation. bBased on two-sided rank sum tes t.

Table 3. Smoking/Drinking History for the Clinic and Nonclinic Groups: Discrete Variables a Clinic Group

Nonclinic Group

Variable

No.

%

No.

%

pb

Ever smoked Current smoker Ever drank alcohol Current drinker

56/93 46/93 50/92 10/92

60.2 49.5 54 .3 10.9

54/64 52/64 47/51 29/51

84 .4 8 1.3 92.2 56.9

o仇0υ0 1 < 0.001 < 0.001 < 0.001

aFor those women with the information available in their medical history. bBased on two-sided chi square tes t.

tion) , as compared with 19% among those in the nonclinic group. Also , 14.9% of the Clinic group and 36.8% of the nonclinic group were anen1ic (hemoglobin < 11.0 g/dl). Three percent of the Clinic group had intrauterine growth retardation (fetuses were either at or below the 10th percentile for gestational age-adjusted birth weight on ultrasonography) in comparison with 14.7% of the nonclinic group. Comparisons between the Clinic and nonclinic groups during labor and delivery are shown in Tables 6 , 7, and 8. The length of active labor and use of epidural pain medication were similar in both groups. Although the rates of normal spontaneous vaginal delivery and opera-

tive delivery other than cesarean section were also similar in both groups , the rate of cesarean section delivery was significantly less in the Clinic group (6.9% versus 0.019). Even after 17.9% for the nonclinic group , p adjusting for maternal weight , which was associated with the method of delivery , participants in the nonclinic group were still aln10st three times as likely to have a cesarean section delivery. The most frequent reason for operative deliveries in both groups was a nonreassuring fetal heart tracing. Gestational age at delivery ranged from 35 to 42 weeks in the Clinic group and 25 to 42 weeks in the nonclinic group. Infant birth weight was significantly greater among those in the Clinic group;

Van Winter et al. : Young Moms' Clinic

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Table 4. Smoking /Drinking History for the Clinic and Nonclinic Groups: Continuous Variables Median

Mean

Variable

Current smokers , change in no. of cigarettes/dayc ,d 一4 . 6 Clinic group (n = 45) -0.2 Nonclinic group (n = 43) 。 Current drinkers , change in drinks/week c, 一2 . 6 Clinic group (n = 10) O Nonclinic group (n = 22) 一0 . 5

SDa

Minimum

Maximum

pb

5.9 2.8

-21

4 10

< 0.001

3.3 2 .1

一9

O 3

0.005

一10

一7

aSD, standard deviation. bBased on two-sided rank sum test. C(First visit) 一(last visit). dAt time of initial visit , current smokers in both groups smoked the same mean number of cigarettes per day. e At time of initial visit , current drinkers in the Clinic group consumed nlore alcohol daily: mean (median) number of drinks/week at initial visit for the Clinic group (n = 10) was 3.8 (2) 組d 0.7 (0) for the nonclinic group (n = 22) (p = 0.002). Table 5. Comparison of Antenatal Complications in the Clinic and Nonclinic Groups Nonclinic Group (n = 95)

Clinic Group (n = 101) Variable

%

No.

%

8

7.9

18

19.0

0.023

1.0

3

3.2

0.283

15

14.9

35

36.8

< 0.001

3

3

14

14.7

0.003

Premature onset of labor b Pregnancy -induced hypertension c Anemia , hemoglobin < 11.0 g/dl Intrauterine growth retardation d

pa

No.

aBased on two-sided chi square test , and results confirmed with Fisher' s exact test. bLabor before 37 weeks of gestational age. CAmerican College of Obstetricians and Gynecologists definition. dGrowth less than the 10th percentile for gestational age on ultrasonography. Table 6. Comparison of the Clinic and Nonclinic Groups During Labor and Delivery: Continuous Variables Variable Length of active labor , hC Clinic group (n = 97) Nonclinic group (n = 78) Gestational age at delivery , wk Clinic group (n = 10 1) 95) Nonclinic group (n Infant birth weight , g Clinic group (n = 101) Nonclinic group (n = 95) Maternal weight gain , kg Clinic group (n = 10 1) Nonclinic group (n 95)

Mean

Median

SDa

Minimum

Maximum

pb

6.6 6.2

6 6

4 .4 2.5

。2

38 12

0.770

39.5 38.8

40 39

1.5 2.6

35 25

42 42

0.094

3,393.5 3,156.5

3,400 3,200

481.3 601.2

2,290 535

4 ,620 4 ,600

0.007

14.1 11.7

14 11

6.2 5.7

33 25

0.005

。

aSD, standard deviation. bBased on two-sided rank sum test. CFour centimeters to delivery.

infants of mothers in this group weighed an average of 200 g more than infants of mothers in the nonclinic group. This difference was still significant (p = 0.01) after adjusting for differences in race and maternal weight. Neonatal complications of the Clinic and nonclinic

groups are compared in Table 9. Infants that were small for gestational age (l ess than the 10th percentile for gestational age-adjusted birth weight) were born to 2% of mothers in the Clinic group , as compared with 11.6% of 0.007). Prematurity those in the nonclinic group (p

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Van Winter et a l. :

Young Moms' Clinic

Table 7. Comparison of the Clinic and Nonclinic Groups With Respect to Size for Gestational Age Small for Gestational Age a

Appropriate for Gestational Age

Large for Gestational Age b

Total

2 11

91 77

8 7

101 95

Clinic group (n) Nonclinic group (n)

aWeight less than the 10th percentile for gestational age-adjusted weigh t. bWeight greater than the 90th percentile for gestational age-adjusted weigh t. Table 8. Comp訂ison of the Clinic and Nonclinic Groups During Labor and Delivery: Continuous Variables Variable Length of active labor , hC Clinic group (n = 97) Nonclinic group (n = 78) Gestational age at delivery , wk Clinic group (n = 10 1) 95) Nonclinic group (n Infant birth weight , g Clinic group (n = 101) Nonclinic group (n = 95)

Median

SD a

6.6 6.2

6 6

4 .4 2.5

O

2

38 12

0.770

39.5 38.8

40 39

1.5 2.6

35 25

42 42

0.094

3,393.5 3,156.5

3 ,400 3 ,200

481.3 601.2

2 ,290 535

4 ,620 4 ,600

0.007

Mean

Minimum

Maximum

pb

aSD, standard deviation. bBased on two-sided rank sum tes t. CFour centimeters to delivery. Table 9. Comparison of Neonatal Complications in the Clinic and Nonclinic Groups Clinic Group (n = 10 1) Variable Level 3 nursery transfer b (neonatal intensive care unit) Small for gestational ageC Meconium spillage Hyperbilirubinemia Sepsis Prematurity Respiratory distress syndrome Congenital anomaly Overall neonatal complications d

Nonclinic Group (n = 95)

No.

%

No.

%

pa

。2

O

6 11 14 2 11 10

6 .4 1 1.6 14.7 2.1 11.6 10.5

0.010 0.007 0.302 0.701 0.090 0.013

10 3 5 2

2.0 9.9 3.0 5.0 2.0

O

O

2

2.0

3 4

3.2 4.2

0.072 0.365

22

2 1.8

32

33.7

0.062

aBased on two-sided chi square test and confirmed with Fisher's exact tes t. bCost of hospitalization for neonates of mothers in the nonclinic group was more than $685 ,000. CWeight less than the 10th percentile for gestational age (Dubowitz criteria). dNot including level 3 nursery transfer or small for gestational age.

was also significantly more common among infants in the nonclinic group (p == 0.013). Neonatal intensive care unit admission occurred only in the nonclinic group , at a cost of more than $685 ,000. It was not possible to adjust for potential confounders (such as smoking or alcohol use) , because there were only six transfers to the neonatal intensive care uni t. Therefore , it is possible that the difference may not be due to participation in the Clinic group.

The Clinic and nonclinic groups did not differ significantly with regard to postpartum contraception. The common contraceptive choices for both groups were oral contraceptives (n 93) , levonorgestrel implant (Norplant , n 45) , condoms and 8) , medroxyprogesterone (Depo-Provera , foam (n n - 6) , and "others ," which included the "mini-pill" (progesterone only, n == 3) and diaphragm (n == 1). Eighty percent of the participants in the Clinic group

Van Winter et al. : Young Moms' Clinic returned for a postpartum visit and filled out a questionnaire directed at a 6th-grade reading leve l. All of these participants acknowledged that the Young Moms' Clinic had helped them to understand healthy antenatal lifestyles , the delivery process , and the characteristics of the newborn.

Discussion Pregnancy among adolescents and single young adult won1en is potentially a high-risk condition for mother and infant. Improving these outcon1es is an important challenge. The results of our retrospective pilot study suggest that a prenatal education program specifically aimed at the developmental level of young pregnant won1en has a positive impact on pregnancy outcome , both from self-perception and medical-outcome perspectives. In part , the positive response to our program may have been the result of 1) an enthusiastic , professional team , 2) a patient-focused program that addressed the educational , psychosocial , and obstetrical needs of young pregnant women on a weekly basis at a single site , and 3) a trusting , nonjudgmental environment where each participant was afforded dignity and respec t. Several limitations must be considered when interpreting our study results. These groups were selfselected. Also , our nonurban groups consisted largely of white females in their late teens (in general , this age group has developed abstract reasoning capabilities). Therefore , comparison with the outcome of other groups consisting mainly of younger adolescents and those from minority groups and urban backgrounds may not be appropriate. It is interesting to note , however , that the 25 adolescents who were 16 years old or younger had similar outcomes and appeared to benefit from the same educational approach as older adolescents and single young women in their early 20s. Information about tobacco and alcohol use was not equally reported between the two groups (e.g. , data about a smoking history were missing for 8% of the Clinic group and 32.6% of the nonclinic group). Because of these missing data , it is difficult to adjust for these variabIes. Also , a large number of variables have been analyzed , and purely by chance , some of these variables may be statistically significant at the 0.05 leve l. An impressive aspect of our study was the savings generated by the absence of neonatal intensive care unit admission from the Clinic group. The cost of more than $685 ,000 for the hospitalized infants of the nonclinic group was substantially greater than the cost of $107 per mother in the Clinic group for a 7-week course ($10 ,800). The savings to society was more than $675 ,000. However , some of this difference may be due to self-selection by Clinic participants. A prospective randomized study is necess

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pregnancy and outcome improvement attributable to the Young Moms' Clinic. Appendix A. Young Moms' Clinic Labor and Birth Classes-You're Invited to Learn About Labor and the Birth of Your Baby Class 1 Class 2 Class 3 Class 4 Class 5 Class 6 Class 7

Body changes in pregnancy. Overview of labor. Birth n10vie, "Comfort Measures for Labor and How a Labor Companion Can Help." What we do about pain. What to expect in the hospital? What happens after the baby is born? Taking care of yourself after birth. Tour; labor review; graduation party.

References 1. Goldman EL: Teen contraception: nonjudgmental advice crucial. Obstet Gynecol News 1994; Jan 1:10 2. Jaskiewicz JA, McAnarney ER: Pregnancy during adolescence. Pediatr Rev 1994; 15:32-38 3. Van Winter JT, Simmons PS: A proposal for obstetric and pediatric management of adolescentpregnancy. Mayo Clin Proc 1990; 65:1061-1066 4. Burnhill MS: Adolescent pregnancy rates in the US. Contemp Obstet Gynecol 1994; Feb:26-30 5. Hardy JB: Premature sexual activity, pregnancy, and sexually transmitted diseases: the pediatrician's role as a counselor. Pediatr Rev 1988; 10:69-76 6. Johnson F, Lay P, Wilbrandt M: Teenage pregnancy: sues, interventions, and direction. J Nat! Med Assoc 1988; 80:145-152 7. Lee KS, Corpuz M: Teenage pregnancy: trend and impact on rates of low birth weight and fetal, maternal, and neonatal mortality in the United States. Clin Perinatol 1988; 15:929-942 8. Hardy JB, King TM, Repke JT: The Johns Hopkins Adolescent Pregnancy Program: an evaluation. Obstet Gynecol 1987; 69:300-306 9. Scholl TO, Miller LK, Salmon R\\九et al: Prenatal care adequacy and the outcome of adolescent pregnancy: effects on weight gain, preterm delivery, and birth weight. Obstet Gynecol 1987; 69:312-316 10. Slager-Earnest SE, Hoffman 剖， Beckmann CJ: Effects of a specialized prenatal adolescent program on maternal and infant outcomes. J Obstet Gynecol Neonatal Nurs 1987; 16:422-429 11. Silva MO, Cabral H, Zuckerman B: Adolescent pregnancy in Portugal: effectiveness of continuity of care by an obstetrician. Obstet Gynecol 1993; 81:142-146 12. Rabin JM, Seltzer V, Pollack S: The long term benefits of a comprehensive teenage pregnancy program. Clin Pediatr 1991; 30:305-309 13. Mikanowicz CK, Nicholson ME, Olsen LK, et al: Adolescent pregnancy outcomes from a rural Pennsylvania program. Health Values 1992; 16:23-30

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