- Email: [email protected]
Contraceptive use among adolescent mothers at 6 months postpartum
Contraceptive Use Among at 6 Months Postpartum ABBEY B. BEXENSON,
MD, AND CONSTANCE
Objective: To assess patterns and predictors of reliable and unreliable contraceptive use among adolescent mothers in the first 6 months following delivery. Methods: We surveyed 462 women, 18 years of age or younger, at delivery and again at 6 months postpartum. Contraceptive behaviors were evaluated among the 359 adolescents who stated they were sexually active and not trying to conceive. Results: Method discontinuation and switching were common during the 6-month interval. Only 100 of 189 adolescents (53%) initially prescribed oral contraceptives were still using this method 6 months after delivery; ten of these 100 stated that they had missed at least three pills in the last cycle. Twelve (10%) of the 115 adolescents who initiated depot-medroxyprogesterone acetate failed to obtain a second injection within 4 months of the initial injection or use an alternative method. In contrast, nine of the ten women who received levonorgestrel implants were still using this method 6 months after delivery. Overall, 76% of the sample reported using reliable contraception at last intercourse. Multivariate analyses identified seven factors as predictive of reliable contraceptive use: school enrollment, not having failed a grade in school, adequate support, belief that pregnancy is likely without birth control, attendance at postpartum visit, prior abortion, and the adolescent’s desire to wait at least 2 years before having another child. Conclusion: Interventions designed to reduce rapid repeat pregnancy during the adolescent years should address emotional, financial, and educational, as well as contraceptive, needs. (Obstet Gynecol 1997;89:999-1005. 0 1997 by The American College of Obstetricians and Gynecologists.)
According to the National Longitudinal Survey of Youth (1988), approximately 24-31% of adolescent From the Division of Pediatric and Adolescent Gynecology, Deyartmerit of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas. Presented at the 44th Annual Chical Meeting of the American College of Obstetricians and Gynecologists, Dmver, Colorado, April 27-May 1, 1996. This research was supported by grants awarded to CMWfrom the National Institutes ofHealth fR03-DA084041 and the Hogg Foundation for Mental Health.
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Adolescent M. WIEMANN,
Mothers
PhD
mothers experience a second birth within 24 months of delivery.’ Rapid repeat pregnancy has been demonstrated to result in a number of adverse consequences for the mother including school discontinuation, unemployment, and welfare dependence.* Despite these consequences,few studies have attempted to identify factors associated with unreliable use of birth control among adolescent mothers. One recent study,3 which did investigate contraceptive use among adolescents, observed that over one-half failed to use reliable birth control even after delivering a child. Hispanic adolescents, as compared with African-American adolescents, and those who had a reading level below the sixth grade or who grew up in a household that received welfare one-half or more of the time, were lesslikely to use effective contraception following their delivery. In a separate study, Jekel et al4 observed that adolescent mothers who were enrolled in school were lesslikely to become pregnant within 15 months of delivery than those who discontinued their education. Unfortunately, both of these investigations are limited in their application as neither included users of the newest form of hormonal contraception approved for use in the United States-depot-medroxyprogesterone acetate. Because this method provides extended protection against pregnancy, it has the potential to affect dramatically adolescent use of birth control and subsequent rates of repeat pregnancy. The purpose of this study was to assess patterns and predictors of reliable and unreliable contraceptive use, including use of depot-medroxyprogesterone acetate, among adolescent mothers in the first 6 months following delivery.
Materials and Methods Subjects enrolled in this study were recruited from the postpartum unit of the University of Texas Medical Branch. This facility serves primarily indigent patients who reside in Galveston and surrounding counties. All patients 18 years of age or younger, who delivered
OOZY-7844/97/$17.00 PII SOO29-7844(97)00123-3
999
between December 8, 1993, and May 31, 1995, planned to retain custody of their baby, could read and write at a fifth-grade level, were free of major psychiatric disorders, gave birth to a relatively healthy infant weighing at least 1500 g, and were of white, African-American, or Mexican-American race / ethnicity, were eligible to participate in this study (n = 657). As part of an ongoing investigation of adolescent mothers, subjects were interviewed on the postpartum unit and were mailed surveys to complete 6 months after delivery. Five hundred ninety-two (90%) of the 657 who met eligibility criteria agreed to participate and were interviewed within 48 hours of delivery. With Institutional Review Board approval, each subject was approached within 48 hours of delivery by an English- or Spanish-speaking interviewer. Written consent to participate was obtained from each patient and from a parent or legal guardian for those under 18 years who currently lived with their parent or guardian and were not legally married. Subjects then completed a baseline interview designed to elicit information on demographic and reproductive characteristics. To determine contraceptive practices, depressive symptoms, and social and economic support over the first 6 months postpartum, all subjects were mailed a structured survey to complete approximately 6 months after delivery. This survey asked subjects if they had been sexually active in the previous 3 months, the type of birth control, if any, used at last intercourse, frequency of condom use, their assessment of the likelihood they would become pregnant if they used no method of contraception, and whether they had initiated levonorgestrel implants, depot-medroxyprogesterone acetate injections, or oral contraceptives since their babies were born. Subjects receiving oral contraceptives were also asked the number of times they had missed taking the pills during the previous 30 days. Those who received depot-medroxyprogesterone acetate were prompted to record the dates of all shots received and the location (hospital, or clinic or doctor’s office) of their first injection. Levonorgestrel implant recipients were queried as to their dates of insertion and removal, if applicable. All patients were also asked to indicate when in the future they, their partner, and their mother wanted another pregnancy. To maximize survey return, subjects were contacted by phone to verify survey receipt and to encourage survey completion. All patients who completed the 6-month survey by mail or phone received $10 compensation. Returned surveys were reviewed so that incomplete or inconsistent reporting could be followed up by contact with specific respondents. Completed 6-month surveys were electronically scanned while baseline data
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were automated using SPSS (Statistical Package for the Social Sciences; SPSS, Inc., Chicago, IL) data-entry programming and verified to ensure 100% accuracy. Baseline and 6-month follow-up surveys were pilot tested on 35 adolescent mothers who delivered at our institution in the month before the start of subject recruitment. Content validity for measures of social support was established by the consensus of two professionals who reviewed the survey items independently. Reliable contraceptive use was defined as use of levonorgestrel implants, depot-medroxyprogesterone acetate, an intrauterine device (IUD), a condom at last intercourse, or oral contraceptives if the patient did not miss three or more pills in the previous cycle. Financial resources were assessed by asking patients how often they went hungry or had to make diapers stretch because they could not afford to purchase more. The head of the household was considered employed fulltime if he or she worked 35 or more hours per week. For ease of interpretation in the multivariate analyses, categories for the time line in which the patient, her mother, and partner wanted a subsequent pregnancy were dichotomized as up to 2 years or more than 2 years. Depressive symptoms were measured using the 13-item Beck Depression Inventory” with a score of 11 or more indicating moderate to severe depression. Emotional support was evaluated by asking patients who in their support network told them they were an important person or a good mother. Patients were also asked to indicate the ways in which their families helped them (positive family support) and whether they felt they received enough total (tangible, emotional, and informational) support (adequate total support). Four hundred sixty-two (78%) of the 592 6-month surveys mailed to study participants were completed successfully. Comparison of demographic characteristics (gravidity, prior abortion, parity, age at delivery, education level, school enrollment at delivery, number of grades repeated, race/ethnicity, planned nature of baseline pregnancy, and religion) between those who did and did not return 6-month surveys revealed no significant differences between groups. Of those who completed the survey, 95 patients reported that they had not been sexually active since delivery. These patients were removed from subsequent analyses as it was unknown whether this behavior was chosen for contraceptive reasons or due to lack of a partner. One sexually active adolescent reported that she was trying to conceive, three reported planned conceptions, and four additional subjects had missing or inconsistent data; these subjects were also removed from subsequent analyses. Contraceptive behaviors were then evaluated
Ot7sfctYzCS 0 Gyrwology
at 6 months postpartum among the remaining 359 adolescents who were sexually active and not attempting to conceive. To identify demographic and economic differences among patients who selected different methods of birth control, patients were divided into groups based on the first type of contraceptive initiated following delivery. Comparisons were made among patients who initiated oral contraceptives, depot-medroxyprogesterone acetate, and those who failed to initiate any prescription method of birth control. One IUD and ten levonorgestrel implant users were excluded from these analyses because of their low numbers. In order to identify correlates of reliable and unreliable contraceptive use at 6 months postpartum, patients were then assigned to one of two groups based on the aforementioned criteria. All group comparisons were made using 2 Fisher exact test, Kruskal-Wallis, or Student t tests, depending on the level of measurement and the extent to which parametric assumptions were satisfied. Bivariate correlates of unreliable contraceptive use (P 5 .lO) were then considered for entry in stepwise logistic regression analyses to identify factors independently associated with the outcome. Multicolinearity was evaluated by examining correlations among independent variables. The individual contributions of highly correlated variables to the logistic regression model were examined separately by adding and removing each in subsequent analyses. Variables with correlation coefficients at or below 0.40 were included in the final model to avoid statistical problems encountered when two or more predictor variables are highly correlated.6
Results The most common prescription methods of birth control first initiated following delivery were the pill (53%) and depot-medroxyprogesterone acetate (32%). Ten women had levonorgestrel implants inserted and one chose an IUD. No prescription method of contraception was used by 12% of the sample. Eighty-seven percent of patients obtained their prescription method of contraception immediately postpartum or at the first postpartum visit. When subjects were compared by method of contraception selected, few differences were noted between those subjects who initially selected the birth control pill, those who chose medroxyprogesterone acetate injections, and those who failed to initiate any prescription method (Table 1). Adolescents with two or more children were more likely than those with only one child to select injections or no method rather than the pill (P = .02). Differences were also observed by race: African-Americans were more likely to choose depot-
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medroxyprogesterone acetate; whites usually selected pills; and Mexican-Americans demonstrated no strong method preference. No significant differences were observed in age, religion, educational status, living arrangements, employment, or socioeconomic status between those who chose injections, those who selected birth control pills, and those who failed to initiate any hormonal method. When surveyed at 6 months postpartum, 283 (79%) of the 359 adolescents reported using birth control at last intercourse (Table 2). Nine of the ten patients who had selected levonorgestrel implants still were using this method as well as the one patient who had selected an IUD. In contrast, method discontinuation and switching were common among those adolescents who had initially selected depot-medroxyprogesterone acetate and the pill. Of those who had selected depot-medroxyprogesterone acetate initially, 72% were still using this method, 10% failed to use any method, and 16% had switched to pills or condoms. Of the 189 patients who had been prescribed the pill, 20% were no longer using any method, and 28% had selected another method. Condoms were used as the primary method of contraception by 39% of patients who had never received a prescription for birth control following delivery. However, 31 (49%) of the 63 who used condoms for birth control reported that they did not use condoms every time. Twenty-seven of the 359 patients interviewed never obtained birth control and consequently did not use any method at last intercourse. In addition, 12 patients who had received depot-medroxyprogesterone acetate postpartum failed to receive their second shot within 4 months of the first injection and thus were unprotected. Thirty-seven of the women who initiated pills discontinued this method by 6 months and failed to use an alternative method while ten additional patients were classified as unreliable because they had missed three or more pills in the last cycle. Thus, 86 (24%) subjects interviewed at 6 months postpartum reported a failure to use contraception or inadequate use at last intercourse and were classified as unreliable. After classifying subjects as reliable or unreliable users, bivariate and multivariate analyses were conducted to develop a profile of the reliable contraceptive user. Bivariate analyses demonstrated that reliable USers of birth control had better financial resources, were more likely to be enrolled in school 6 months after delivery, and were more likely to have experienced a prior abortion (Table 3). Adolescents who had failed a grade in school, reported depressive symptoms, or were living with a new partner were significantly less likely to use contraception reliably (Table 4). A lack of social support also correlated with unreliable use; those who
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Table
1. Selected Demographic
Characteristics
by First Prescription
16.9 58 30 27
Gravidity > 1 Parity > 1 Abortion > 0 Race / Ethnicity white Mexican-American African-American Religion Protestant Catholic Other Education level (y) In school Repeated 21 grade Living with:” Mom Father of baby Boyfriend or husband Self Other Employed last 3 mo of pregnancy Head of household works full-time Mother < 12 y education Father < 12 y education
2 1.1 (31%) (16%) (14%)
16.8 42 32 21
Method
Current method None oc Depot-Medroxyprogesterone acetate Implants IUD Condoms
P
NS NS
17.0 2 1.0 15 (34%) 13 (30%) 3 (7%)
.02 NS .Ol
28 (24%) 38 (33%) 49 (43%)
17 (39%) 19 (43%) 8 (18%)
82 67 39 9.8 89 78
(44%) (36%) (21%) k 1.7 (47%) (42%)
56 35 23 9.8 52 51
(49%) (31%) (20%) k 1.5 (45%) (44%)
15 17 12 9.7 18 21
(34%) (39%) (27%) k 1.5 (41%) (49%)
NS NS NS
88 (47%) 76 (40%) 21 (11%) 3 (2%) 22 (12%) 34 (18%) 124 (70%) 79 (48%) 60 (43%)
54 34 11 3 23 18 80 48 28
(47%) (30%) (10%) (3%) (20%) (16%) (71%) (48%) (35%)
21 18 4 0 8 7 32 18 18
(48%) (41%) (9%) (0%) (18%) (16%) (74%) (53%) (55%)
NS NS NS NS NS NS NS NS NS
NS
did not have at least two people in their lives verbalize their importance as a person or confirm their skills as a parent were lesslikely to use birth control consistently. Similarly, adolescents who reported inadequate family support were more likely to use contraception unreliably. Furthermore, adolescents who felt that they were not likely or only slightly likely to become pregnant if they used no birth control used reliable contraception
2. First Prescription
2 1.1 (37%) (28%) (18%)
None (n = 44)
73 (39%) 64 (34%) 52 (28%)
NS = not significant. Data are presented as n (%) or mean 2 standard deviation; due to rounding, percentages varies across variables due to missing information. * Categories are not mutually exclusive.
Table
Method
Depot-medroxyprogesterone acetate (n = 115)
Pill (n = 189)
Age(Y)
Contraceptive
of Birth Control Postpartum
None (n = 44)
(n ?89)
27 (61%) 0 0
37 (20%) 100 (53%) 15 (8%)
0 0 17 (39%)
3 (2%) 1 (1%) 33 (17%)
percentages
may not total 100. Denominator
term used to calculate
less often. Finally, subjects who reported that they wished to become pregnant within the next 2 years, or that their partner or mother desired another child within this time frame, were more likely to report unreliable use of birth control than those who did not desire pregnancy for at least 2 years. Age, gravidity, parity, race, and employment were unrelated to contraceptive use. Compared
to 6 Months
First method initiated postpartum Depot-medroxyprogesterone acetate (n = 115)
Implants (n = 10)
IUD (n = 1)
12 (10%) 7 (6%) 83 (72%)
0 0 0
0 0 0
1 (1%) 0 12 (10%)
9 (90%) 0 1 (10%)
0 1 (100%) 0
OC = oral contraceptive; IUD = intrauterine device. Data are presented as n (%); percentages may not total 100 due to rounding.
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3. Demographicand EconomicIndicators of Reliable and UnreliableContraceptiveUseat Last
Table
Table
4. Socialand EmotionalIndicatorsof Reliableand
UnreliableContraceptiveUse
Intercourse Reliable (n = 273)
Age (Y) Gravidity > 1 Parity > 1 Abortion > 0 Race / ethnicity White Mexican-American African-American In school at delivery In school at 6 mo postpartum Repeated 2 1 grade Unemployed Mother < 12 y education Father < 12 y education Head of household works full-time Financial resources Makes diapers stretch Patient reports hunger
Unreliable (n = 86)
16.9 91 53 47
2 1.1 (33%) (19%) (17%)
16.9 2 1.1 29 (34%) 25 (29%) 6 (7%)
90 97 86 132 123 106 72 113 79 185
(33%) (36%) (32%) (48%) (45%) (39%) (26%) (48%) (41%) (68%)
32 (37%) 28 (33%) 26 (30%) 33 (38%) 28 (33%) 49 (59%) 16 (19%) 36 (52%) 31(48%) 51 (61%)
81 (30%) 37 (14%)
38 (45%) 18 (21%)
Reliable Unreliable (n = 273) (n = 86) P NS NS .06 .02” NS
.lO .04 .OOl NS NS NS NS
.Ol .09
NS = not significant. Data are presented as n (%) or mean + standard deviation; percentages may not total 100 due to rounding; denominator term used to calculate percentages varies across variables due to missing information. *Fisher exact test was used for analyses with fewer than ten observations in a cell.
Multivariate analyses identified seven factors to be predictive of reliable contraceptive use (Table 5). School enrollment, not having failed a grade in school, adequate support, compliance with their postpartum visit, history of a prior abortion, belief that pregnancy would likely occur if contraception was not used, and a desire to wait at least 2 years before having another child were all associated with reliable use.
Living with* Subject’s mother Father of baby Boyfriend or husband Self Other Moderate-severe depression One person or less tells her She is important She is a good mom Positive family support Insufficient total support Subject wants next pregnancy 52y >2Y Partner 52y ‘2Y Patient’s 52y
wants
mother
105 (39%) 121 (44%) 7 (3%) 12 (4%) 47(17%) 53 (19%)
35 (41%) 44(51%) 4(5%) 1 (1%) 10 (12%) 27(31%)
NS NS NS+ NS+ NS .02
55 (20%) 57(21%) 112 (41%) 102 (37%)
29(34%) 27(31%) 46 (55%) 42 (49%)
.Ol .04 .03 .06 .02
19 (7%) 254 (93%)
13 (15%) 73 (85%)
37 (14%) 233 (86%)
21(25%) 64 (75%)
6 (2%) 262 (98%)
6 (7%) 79 (93%)
.02
next pregnancy
wants
‘2Y Belief that pregnancy birth control used Unlikely Likely
.04+
next pregnancy
is likely
P
.01+
if no 66 (24%) 207 (76%)
35 (41%) 51(59%)
Data are presented as n (%). Denominator term used to calculate percentages varies across variables due to missing information. * Categories are not mutually exclusive. *Fisher exact test was used for analyses with fewer than ten observations in a cell.
ued the pill failed to use any method of contraception at last intercourse, placing themselves at risk for an unintended pregnancy. Becauseit appears that oral contraceptives are effectively used by only a small portion of adolescents over an extended time period, their use as first-line contraception for adolescents may require reevaluation.
Discussion Similar to previous studies on adolescent mothers, the majority of patients in this sample were prescribed the birth control pill for contraception following delivery.7 This method remains popular among physicians and patients despite numerous reports of its poor effectiveness (due to inconsistent use) among young mothers. Polaneczky et al8observed that two-thirds of adolescent mothers studied discontinued this method within 15 months of delivery resulting in a 38% rapid repeatpregnancy rate among those who initiated this method postpartum. In our study, we observed that 47% of those who selected the pill discontinued it within 6 months while an additional 5% missed multiple pills each cycle. Thirty-seven (42%) of the 89 who discontin-
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Table
5. LogisticRegressionModel of Reliable ContraceptiveUseat 6 Months Postpartum Adjusted odds ratio
Abortion > 0 Wants next pregnancy > 2y No grades repeated In school at 6 mo Belief that pregnancy is likely without birth control Attendance at postpartum visit Adequate total support The final sample consisted cluded due to missing data.
Berenson
and Wiemann
95% confidence interval
P
3.1 2.7 2.2 2.2 2.2
1.2,7.9 1.2, 6.1 1.3,3.9 1.2, 3.9 1.2,3.8
.02 .02 ,003 .Ol .Ol
1.9
1.0,3.7
.04
1.7
1.0, 2.9
of 349 subjects;
Contraceptives
ten subjects
and Adolescents
.05 were
ex-
1003
Unfortunately, two methods of contraception that are largely user-independent, levonorgestrel implants and the IUD, were rarely selected by the adolescent mothers in this sample. When implants were initially introduced in the United States, young mothers frequently selected this method and expressed satisfaction with its use.9Z10 Furthermore, its use resulted in significantly lower numbers of unintended pregnancies in comparison with other methods8-lo Its popularity, however, has decreased markedly in recent years due to adverse publicity regarding side effects. Although use of the IUD has increased slightly in the last few years as a result of its improved design, it has never regained the popularity it enjoyed before 1980. In contrast, depot-medroxyprogesterone, which provides protection for up to 14 weeks, is a popular method among young patients” and was selected by 32% of mothers included in this sample. Due to its long range of action, this method should result in lower rates of unintended pregnancy. However, it is important to note that even with this extended range, effective use still depends largely on patient compliance. Ten percent of patients in this study who initiated this method failed to receive their second injection on schedule or to use an alternative method. This practice resulted in four positive pregnancy tests by 6 months postpartum. It is likely that a longer follow-up period would have identified even more pregnancies resulting from unreliable use of this method. Additional research, therefore, must continue to focus on ways to increase compliance with all methods of contraception, rather than relying on depotmedroxyprogesterone acetate as though it were the panacea for adolescent pregnancy. Method switching was common, with 46 adolescents switching from a hormonal type of contraception to a nonprescription method (condoms) during the 6-month interval. Hirsch et all2 demonstrated that adolescents are most likely to switch methods following a month of sexual inactivity. This tendency places the adolescent at great risk of an unintended pregnancy as she is often not adequately protected when sexual activity resumes. Therefore, appropriate contraceptive counseling should advise adolescents of the need to continue contraception even during brief periods of abstinence. Reliable contraception was observed to occur more frequently among adolescents who had performed well in school and who were enrolled in school 6 months following delivery. It is probable that this group wished to complete their education and thus were more motivated to avoid a rapid repeat pregnancy. In contrast, those who were not in school at 6 months or those who had failed prior grades were less reliable contraceptors. Once the adolescent has discontinued school, a repeat pregnancy does not threaten her future educational
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plans and she may be less motivated to use reliable contraception. This consideration supports observations by Ryan and SweeneyI as well as those of Kleini that for an adolescent to be a good contraceptor, she must have hope for her future and desirable alternatives to becoming pregnant. Emotional support also strongly predicted contraceptive compliance. Adolescents who had more than one person tell them they were important or tell them they were a good mother and those who reported adequate support from others were more likely to use reliable contraception. This association between support and contraceptive use has been noted by other investigators. Gispert et al’s observed that adolescents who had good relationships with their mothers were less likely to have a repeat pregnancy during the teenage years. Additionally, Jekel et al4 noted that adolescents who moved away from their families shortly after delivery were more likely to become pregnant again within 15 months. These studies underscore the importance of contact between the adolescent and other key people in her life who can provide assistance, guidance, and confirmation of her self-worth. Two limitations of this study should be noted. First, follow-up data were available on only 78% of adolescents who were interviewed at delivery. Although we did not observe any demographic differences between those who were and were not included, it is possible that reliable users were more likely to return their 6-month survey. This may have led to overestimation of continuation and satisfaction rates. Second, we relied on patient reports to obtain all data. Confirmation by chart review was not possible due to the large number of clinics in our area from which adolescents could receive contraceptive services. Similar to others,“*i7 we found that prevention of rapid repeat pregnancy during the teenage years requires more than distribution of birth control pills. Providers should be certain that adolescents comprehend the strong likelihood of pregnancy should they fail to use reliable contraception. Family planning clinics should train their nurses and physicians to offer emotional support to young patients and confirm parenting skills observed during the visit. School continuance should be emphasized. Long-term goals should be discussed and a plan for the future outlined. Finally, clinics should help adolescents enroll in the Special Supplemental Nutrition Program for Women, Infants, and Children or other programs that can provide financial assistance. By providing for the adolescent’s emotional, financial, and educational, as well as contraceptive, needs, rapid repeat pregnancy is more likely to be avoided.
Obstetrics
B Gynecology
References 1. Kalmuss DS, Namerow PB. Subsequent childbearing among teenage mothers: The determinants of a closely spaced second birth. Fam Plann Perspect 1994;26:149-53, 159. 2. Polit DF, Kahn JR. Early subsequent pregnancy among economically disadvantaged teenage mothers. Am J Public Health 1986;76: 167-71. 3. Maynard R, Rangarajan A. Contraceptive use and repeat pregnancies among welfare-dependent teenage mothers. Fam l’lann Perspect 1994;26:198-205. 4. Jekel JF, Klerman LV, Bancroft RE. Factors associated with rapid subsequent pregnancies among school-age mothers. Am J Public Health 1973;63:769-73. 5. Seligman ME, Abramson LY, Semmel A, von Baeyer C. Depressive attributional style. J Abnorm Psycho1 1979;88:242-7. 6. Hosmer DW, Lemenshow S. Model-building strategies and methods for logistic regression. In: Barnett V, Bradley R, Hunter J, Kadane J, Kendall G, Smith A, et al, eds. Applied logistic regression. New York (NY): John Wiley and Sons, 1989:131-3. 7. Ford K. Second pregnancies among teenage mothers. Fam Plann Perspect 1983;15:268-72. 8. l’olaneczky M, Slap G, Forke C, Rappaport A, Sondheimer S. The use of levonorgestrel implants (Norplant) for contraception in adolescent mothers. N Engl J Med 1994;331:1201-6. 9. Dinerman LM, Wilson MD, Duggan AK, Joffe A. Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods. Arch Pediatr Adolesc Med 1995;149: 967-72. 10. Berenson AB, Wiemann CM. Use of levonorgestrel implants versus oral contraceptives in adolescence: A case-control study. Am J Obstet Gynecol 1995;172:1128-35. 11. Cromer BA, Smith RD, Blair JM, Dwyer J, Brown RT. A prospective study of adolescents who choose among levonorgestrel implant (Norplant), medroxyprogesterone acetate (Depo-Provera), or the combined oral contraceptive pill as contraception, Pediatrics 1994; 94:687-94.
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12. Hirsch MB, Zabin LS, Streett R, Hoffman-Goldwasser E, Fitzgerald C, Vines E, et al. The effect of sexual behavior and a pregnancy on contraceptive method switching among black female teens. J Adolesc Health Care 1989;10:289-94. 13. Ryan GM, Sweeney PJ. Attitudes of adolescents toward pregnancy and contraception. Am J Obstet Gynecol 1980;137:358-66. 14. Klein L. Antecedents of teenage pregnancy. Clin Obstet Gynecol 1978;21:1151-9. 15. Gispert M, Brinich I’, Wheeler K, Krieger L. Predictors of repeat pregnancies among low-income adolescents. Hosp Community Psychiatry 1984;35:719-23. 16. Rubenstein E, Panzarine S, Lanning P. Peer counseling with adolescent mothers: A pilot program. Fam Sot J Contemp Hum Serv 1990;71:136-41. 17. Meyers AB, Rhodes JE. Oral contraceptive use among African American adolescents: Individual and community influences. Am J Community Psycho1 1995;23:99-115.
Address
reprint
requests
to:
Abbey B. Berenson, MD Departmentof Obsfefricsand Gynecology University of TexasMedical Branch 301 University Boulevard Galveston, TX 77555-0587
Received November 14, 1996. Received in revised form February Accepted February 21, 1997.
10, 1997
Copyright 0 1997 by The American College of Obstetricians Gynecologists. Published by Elsevier Science Inc.
Berenson
and
Wiemann
Contraceptives
and Adolescents
and
1005
MD, AND CONSTANCE
Objective: To assess patterns and predictors of reliable and unreliable contraceptive use among adolescent mothers in the first 6 months following delivery. Methods: We surveyed 462 women, 18 years of age or younger, at delivery and again at 6 months postpartum. Contraceptive behaviors were evaluated among the 359 adolescents who stated they were sexually active and not trying to conceive. Results: Method discontinuation and switching were common during the 6-month interval. Only 100 of 189 adolescents (53%) initially prescribed oral contraceptives were still using this method 6 months after delivery; ten of these 100 stated that they had missed at least three pills in the last cycle. Twelve (10%) of the 115 adolescents who initiated depot-medroxyprogesterone acetate failed to obtain a second injection within 4 months of the initial injection or use an alternative method. In contrast, nine of the ten women who received levonorgestrel implants were still using this method 6 months after delivery. Overall, 76% of the sample reported using reliable contraception at last intercourse. Multivariate analyses identified seven factors as predictive of reliable contraceptive use: school enrollment, not having failed a grade in school, adequate support, belief that pregnancy is likely without birth control, attendance at postpartum visit, prior abortion, and the adolescent’s desire to wait at least 2 years before having another child. Conclusion: Interventions designed to reduce rapid repeat pregnancy during the adolescent years should address emotional, financial, and educational, as well as contraceptive, needs. (Obstet Gynecol 1997;89:999-1005. 0 1997 by The American College of Obstetricians and Gynecologists.)
According to the National Longitudinal Survey of Youth (1988), approximately 24-31% of adolescent From the Division of Pediatric and Adolescent Gynecology, Deyartmerit of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas. Presented at the 44th Annual Chical Meeting of the American College of Obstetricians and Gynecologists, Dmver, Colorado, April 27-May 1, 1996. This research was supported by grants awarded to CMWfrom the National Institutes ofHealth fR03-DA084041 and the Hogg Foundation for Mental Health.
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Adolescent M. WIEMANN,
Mothers
PhD
mothers experience a second birth within 24 months of delivery.’ Rapid repeat pregnancy has been demonstrated to result in a number of adverse consequences for the mother including school discontinuation, unemployment, and welfare dependence.* Despite these consequences,few studies have attempted to identify factors associated with unreliable use of birth control among adolescent mothers. One recent study,3 which did investigate contraceptive use among adolescents, observed that over one-half failed to use reliable birth control even after delivering a child. Hispanic adolescents, as compared with African-American adolescents, and those who had a reading level below the sixth grade or who grew up in a household that received welfare one-half or more of the time, were lesslikely to use effective contraception following their delivery. In a separate study, Jekel et al4 observed that adolescent mothers who were enrolled in school were lesslikely to become pregnant within 15 months of delivery than those who discontinued their education. Unfortunately, both of these investigations are limited in their application as neither included users of the newest form of hormonal contraception approved for use in the United States-depot-medroxyprogesterone acetate. Because this method provides extended protection against pregnancy, it has the potential to affect dramatically adolescent use of birth control and subsequent rates of repeat pregnancy. The purpose of this study was to assess patterns and predictors of reliable and unreliable contraceptive use, including use of depot-medroxyprogesterone acetate, among adolescent mothers in the first 6 months following delivery.
Materials and Methods Subjects enrolled in this study were recruited from the postpartum unit of the University of Texas Medical Branch. This facility serves primarily indigent patients who reside in Galveston and surrounding counties. All patients 18 years of age or younger, who delivered
OOZY-7844/97/$17.00 PII SOO29-7844(97)00123-3
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between December 8, 1993, and May 31, 1995, planned to retain custody of their baby, could read and write at a fifth-grade level, were free of major psychiatric disorders, gave birth to a relatively healthy infant weighing at least 1500 g, and were of white, African-American, or Mexican-American race / ethnicity, were eligible to participate in this study (n = 657). As part of an ongoing investigation of adolescent mothers, subjects were interviewed on the postpartum unit and were mailed surveys to complete 6 months after delivery. Five hundred ninety-two (90%) of the 657 who met eligibility criteria agreed to participate and were interviewed within 48 hours of delivery. With Institutional Review Board approval, each subject was approached within 48 hours of delivery by an English- or Spanish-speaking interviewer. Written consent to participate was obtained from each patient and from a parent or legal guardian for those under 18 years who currently lived with their parent or guardian and were not legally married. Subjects then completed a baseline interview designed to elicit information on demographic and reproductive characteristics. To determine contraceptive practices, depressive symptoms, and social and economic support over the first 6 months postpartum, all subjects were mailed a structured survey to complete approximately 6 months after delivery. This survey asked subjects if they had been sexually active in the previous 3 months, the type of birth control, if any, used at last intercourse, frequency of condom use, their assessment of the likelihood they would become pregnant if they used no method of contraception, and whether they had initiated levonorgestrel implants, depot-medroxyprogesterone acetate injections, or oral contraceptives since their babies were born. Subjects receiving oral contraceptives were also asked the number of times they had missed taking the pills during the previous 30 days. Those who received depot-medroxyprogesterone acetate were prompted to record the dates of all shots received and the location (hospital, or clinic or doctor’s office) of their first injection. Levonorgestrel implant recipients were queried as to their dates of insertion and removal, if applicable. All patients were also asked to indicate when in the future they, their partner, and their mother wanted another pregnancy. To maximize survey return, subjects were contacted by phone to verify survey receipt and to encourage survey completion. All patients who completed the 6-month survey by mail or phone received $10 compensation. Returned surveys were reviewed so that incomplete or inconsistent reporting could be followed up by contact with specific respondents. Completed 6-month surveys were electronically scanned while baseline data
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were automated using SPSS (Statistical Package for the Social Sciences; SPSS, Inc., Chicago, IL) data-entry programming and verified to ensure 100% accuracy. Baseline and 6-month follow-up surveys were pilot tested on 35 adolescent mothers who delivered at our institution in the month before the start of subject recruitment. Content validity for measures of social support was established by the consensus of two professionals who reviewed the survey items independently. Reliable contraceptive use was defined as use of levonorgestrel implants, depot-medroxyprogesterone acetate, an intrauterine device (IUD), a condom at last intercourse, or oral contraceptives if the patient did not miss three or more pills in the previous cycle. Financial resources were assessed by asking patients how often they went hungry or had to make diapers stretch because they could not afford to purchase more. The head of the household was considered employed fulltime if he or she worked 35 or more hours per week. For ease of interpretation in the multivariate analyses, categories for the time line in which the patient, her mother, and partner wanted a subsequent pregnancy were dichotomized as up to 2 years or more than 2 years. Depressive symptoms were measured using the 13-item Beck Depression Inventory” with a score of 11 or more indicating moderate to severe depression. Emotional support was evaluated by asking patients who in their support network told them they were an important person or a good mother. Patients were also asked to indicate the ways in which their families helped them (positive family support) and whether they felt they received enough total (tangible, emotional, and informational) support (adequate total support). Four hundred sixty-two (78%) of the 592 6-month surveys mailed to study participants were completed successfully. Comparison of demographic characteristics (gravidity, prior abortion, parity, age at delivery, education level, school enrollment at delivery, number of grades repeated, race/ethnicity, planned nature of baseline pregnancy, and religion) between those who did and did not return 6-month surveys revealed no significant differences between groups. Of those who completed the survey, 95 patients reported that they had not been sexually active since delivery. These patients were removed from subsequent analyses as it was unknown whether this behavior was chosen for contraceptive reasons or due to lack of a partner. One sexually active adolescent reported that she was trying to conceive, three reported planned conceptions, and four additional subjects had missing or inconsistent data; these subjects were also removed from subsequent analyses. Contraceptive behaviors were then evaluated
Ot7sfctYzCS 0 Gyrwology
at 6 months postpartum among the remaining 359 adolescents who were sexually active and not attempting to conceive. To identify demographic and economic differences among patients who selected different methods of birth control, patients were divided into groups based on the first type of contraceptive initiated following delivery. Comparisons were made among patients who initiated oral contraceptives, depot-medroxyprogesterone acetate, and those who failed to initiate any prescription method of birth control. One IUD and ten levonorgestrel implant users were excluded from these analyses because of their low numbers. In order to identify correlates of reliable and unreliable contraceptive use at 6 months postpartum, patients were then assigned to one of two groups based on the aforementioned criteria. All group comparisons were made using 2 Fisher exact test, Kruskal-Wallis, or Student t tests, depending on the level of measurement and the extent to which parametric assumptions were satisfied. Bivariate correlates of unreliable contraceptive use (P 5 .lO) were then considered for entry in stepwise logistic regression analyses to identify factors independently associated with the outcome. Multicolinearity was evaluated by examining correlations among independent variables. The individual contributions of highly correlated variables to the logistic regression model were examined separately by adding and removing each in subsequent analyses. Variables with correlation coefficients at or below 0.40 were included in the final model to avoid statistical problems encountered when two or more predictor variables are highly correlated.6
Results The most common prescription methods of birth control first initiated following delivery were the pill (53%) and depot-medroxyprogesterone acetate (32%). Ten women had levonorgestrel implants inserted and one chose an IUD. No prescription method of contraception was used by 12% of the sample. Eighty-seven percent of patients obtained their prescription method of contraception immediately postpartum or at the first postpartum visit. When subjects were compared by method of contraception selected, few differences were noted between those subjects who initially selected the birth control pill, those who chose medroxyprogesterone acetate injections, and those who failed to initiate any prescription method (Table 1). Adolescents with two or more children were more likely than those with only one child to select injections or no method rather than the pill (P = .02). Differences were also observed by race: African-Americans were more likely to choose depot-
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medroxyprogesterone acetate; whites usually selected pills; and Mexican-Americans demonstrated no strong method preference. No significant differences were observed in age, religion, educational status, living arrangements, employment, or socioeconomic status between those who chose injections, those who selected birth control pills, and those who failed to initiate any hormonal method. When surveyed at 6 months postpartum, 283 (79%) of the 359 adolescents reported using birth control at last intercourse (Table 2). Nine of the ten patients who had selected levonorgestrel implants still were using this method as well as the one patient who had selected an IUD. In contrast, method discontinuation and switching were common among those adolescents who had initially selected depot-medroxyprogesterone acetate and the pill. Of those who had selected depot-medroxyprogesterone acetate initially, 72% were still using this method, 10% failed to use any method, and 16% had switched to pills or condoms. Of the 189 patients who had been prescribed the pill, 20% were no longer using any method, and 28% had selected another method. Condoms were used as the primary method of contraception by 39% of patients who had never received a prescription for birth control following delivery. However, 31 (49%) of the 63 who used condoms for birth control reported that they did not use condoms every time. Twenty-seven of the 359 patients interviewed never obtained birth control and consequently did not use any method at last intercourse. In addition, 12 patients who had received depot-medroxyprogesterone acetate postpartum failed to receive their second shot within 4 months of the first injection and thus were unprotected. Thirty-seven of the women who initiated pills discontinued this method by 6 months and failed to use an alternative method while ten additional patients were classified as unreliable because they had missed three or more pills in the last cycle. Thus, 86 (24%) subjects interviewed at 6 months postpartum reported a failure to use contraception or inadequate use at last intercourse and were classified as unreliable. After classifying subjects as reliable or unreliable users, bivariate and multivariate analyses were conducted to develop a profile of the reliable contraceptive user. Bivariate analyses demonstrated that reliable USers of birth control had better financial resources, were more likely to be enrolled in school 6 months after delivery, and were more likely to have experienced a prior abortion (Table 3). Adolescents who had failed a grade in school, reported depressive symptoms, or were living with a new partner were significantly less likely to use contraception reliably (Table 4). A lack of social support also correlated with unreliable use; those who
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Table
1. Selected Demographic
Characteristics
by First Prescription
16.9 58 30 27
Gravidity > 1 Parity > 1 Abortion > 0 Race / Ethnicity white Mexican-American African-American Religion Protestant Catholic Other Education level (y) In school Repeated 21 grade Living with:” Mom Father of baby Boyfriend or husband Self Other Employed last 3 mo of pregnancy Head of household works full-time Mother < 12 y education Father < 12 y education
2 1.1 (31%) (16%) (14%)
16.8 42 32 21
Method
Current method None oc Depot-Medroxyprogesterone acetate Implants IUD Condoms
P
NS NS
17.0 2 1.0 15 (34%) 13 (30%) 3 (7%)
.02 NS .Ol
28 (24%) 38 (33%) 49 (43%)
17 (39%) 19 (43%) 8 (18%)
82 67 39 9.8 89 78
(44%) (36%) (21%) k 1.7 (47%) (42%)
56 35 23 9.8 52 51
(49%) (31%) (20%) k 1.5 (45%) (44%)
15 17 12 9.7 18 21
(34%) (39%) (27%) k 1.5 (41%) (49%)
NS NS NS
88 (47%) 76 (40%) 21 (11%) 3 (2%) 22 (12%) 34 (18%) 124 (70%) 79 (48%) 60 (43%)
54 34 11 3 23 18 80 48 28
(47%) (30%) (10%) (3%) (20%) (16%) (71%) (48%) (35%)
21 18 4 0 8 7 32 18 18
(48%) (41%) (9%) (0%) (18%) (16%) (74%) (53%) (55%)
NS NS NS NS NS NS NS NS NS
NS
did not have at least two people in their lives verbalize their importance as a person or confirm their skills as a parent were lesslikely to use birth control consistently. Similarly, adolescents who reported inadequate family support were more likely to use contraception unreliably. Furthermore, adolescents who felt that they were not likely or only slightly likely to become pregnant if they used no birth control used reliable contraception
2. First Prescription
2 1.1 (37%) (28%) (18%)
None (n = 44)
73 (39%) 64 (34%) 52 (28%)
NS = not significant. Data are presented as n (%) or mean 2 standard deviation; due to rounding, percentages varies across variables due to missing information. * Categories are not mutually exclusive.
Table
Method
Depot-medroxyprogesterone acetate (n = 115)
Pill (n = 189)
Age(Y)
Contraceptive
of Birth Control Postpartum
None (n = 44)
(n ?89)
27 (61%) 0 0
37 (20%) 100 (53%) 15 (8%)
0 0 17 (39%)
3 (2%) 1 (1%) 33 (17%)
percentages
may not total 100. Denominator
term used to calculate
less often. Finally, subjects who reported that they wished to become pregnant within the next 2 years, or that their partner or mother desired another child within this time frame, were more likely to report unreliable use of birth control than those who did not desire pregnancy for at least 2 years. Age, gravidity, parity, race, and employment were unrelated to contraceptive use. Compared
to 6 Months
First method initiated postpartum Depot-medroxyprogesterone acetate (n = 115)
Implants (n = 10)
IUD (n = 1)
12 (10%) 7 (6%) 83 (72%)
0 0 0
0 0 0
1 (1%) 0 12 (10%)
9 (90%) 0 1 (10%)
0 1 (100%) 0
OC = oral contraceptive; IUD = intrauterine device. Data are presented as n (%); percentages may not total 100 due to rounding.
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3. Demographicand EconomicIndicators of Reliable and UnreliableContraceptiveUseat Last
Table
Table
4. Socialand EmotionalIndicatorsof Reliableand
UnreliableContraceptiveUse
Intercourse Reliable (n = 273)
Age (Y) Gravidity > 1 Parity > 1 Abortion > 0 Race / ethnicity White Mexican-American African-American In school at delivery In school at 6 mo postpartum Repeated 2 1 grade Unemployed Mother < 12 y education Father < 12 y education Head of household works full-time Financial resources Makes diapers stretch Patient reports hunger
Unreliable (n = 86)
16.9 91 53 47
2 1.1 (33%) (19%) (17%)
16.9 2 1.1 29 (34%) 25 (29%) 6 (7%)
90 97 86 132 123 106 72 113 79 185
(33%) (36%) (32%) (48%) (45%) (39%) (26%) (48%) (41%) (68%)
32 (37%) 28 (33%) 26 (30%) 33 (38%) 28 (33%) 49 (59%) 16 (19%) 36 (52%) 31(48%) 51 (61%)
81 (30%) 37 (14%)
38 (45%) 18 (21%)
Reliable Unreliable (n = 273) (n = 86) P NS NS .06 .02” NS
.lO .04 .OOl NS NS NS NS
.Ol .09
NS = not significant. Data are presented as n (%) or mean + standard deviation; percentages may not total 100 due to rounding; denominator term used to calculate percentages varies across variables due to missing information. *Fisher exact test was used for analyses with fewer than ten observations in a cell.
Multivariate analyses identified seven factors to be predictive of reliable contraceptive use (Table 5). School enrollment, not having failed a grade in school, adequate support, compliance with their postpartum visit, history of a prior abortion, belief that pregnancy would likely occur if contraception was not used, and a desire to wait at least 2 years before having another child were all associated with reliable use.
Living with* Subject’s mother Father of baby Boyfriend or husband Self Other Moderate-severe depression One person or less tells her She is important She is a good mom Positive family support Insufficient total support Subject wants next pregnancy 52y >2Y Partner 52y ‘2Y Patient’s 52y
wants
mother
105 (39%) 121 (44%) 7 (3%) 12 (4%) 47(17%) 53 (19%)
35 (41%) 44(51%) 4(5%) 1 (1%) 10 (12%) 27(31%)
NS NS NS+ NS+ NS .02
55 (20%) 57(21%) 112 (41%) 102 (37%)
29(34%) 27(31%) 46 (55%) 42 (49%)
.Ol .04 .03 .06 .02
19 (7%) 254 (93%)
13 (15%) 73 (85%)
37 (14%) 233 (86%)
21(25%) 64 (75%)
6 (2%) 262 (98%)
6 (7%) 79 (93%)
.02
next pregnancy
wants
‘2Y Belief that pregnancy birth control used Unlikely Likely
.04+
next pregnancy
is likely
P
.01+
if no 66 (24%) 207 (76%)
35 (41%) 51(59%)
Data are presented as n (%). Denominator term used to calculate percentages varies across variables due to missing information. * Categories are not mutually exclusive. *Fisher exact test was used for analyses with fewer than ten observations in a cell.
ued the pill failed to use any method of contraception at last intercourse, placing themselves at risk for an unintended pregnancy. Becauseit appears that oral contraceptives are effectively used by only a small portion of adolescents over an extended time period, their use as first-line contraception for adolescents may require reevaluation.
Discussion Similar to previous studies on adolescent mothers, the majority of patients in this sample were prescribed the birth control pill for contraception following delivery.7 This method remains popular among physicians and patients despite numerous reports of its poor effectiveness (due to inconsistent use) among young mothers. Polaneczky et al8observed that two-thirds of adolescent mothers studied discontinued this method within 15 months of delivery resulting in a 38% rapid repeatpregnancy rate among those who initiated this method postpartum. In our study, we observed that 47% of those who selected the pill discontinued it within 6 months while an additional 5% missed multiple pills each cycle. Thirty-seven (42%) of the 89 who discontin-
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Table
5. LogisticRegressionModel of Reliable ContraceptiveUseat 6 Months Postpartum Adjusted odds ratio
Abortion > 0 Wants next pregnancy > 2y No grades repeated In school at 6 mo Belief that pregnancy is likely without birth control Attendance at postpartum visit Adequate total support The final sample consisted cluded due to missing data.
Berenson
and Wiemann
95% confidence interval
P
3.1 2.7 2.2 2.2 2.2
1.2,7.9 1.2, 6.1 1.3,3.9 1.2, 3.9 1.2,3.8
.02 .02 ,003 .Ol .Ol
1.9
1.0,3.7
.04
1.7
1.0, 2.9
of 349 subjects;
Contraceptives
ten subjects
and Adolescents
.05 were
ex-
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Unfortunately, two methods of contraception that are largely user-independent, levonorgestrel implants and the IUD, were rarely selected by the adolescent mothers in this sample. When implants were initially introduced in the United States, young mothers frequently selected this method and expressed satisfaction with its use.9Z10 Furthermore, its use resulted in significantly lower numbers of unintended pregnancies in comparison with other methods8-lo Its popularity, however, has decreased markedly in recent years due to adverse publicity regarding side effects. Although use of the IUD has increased slightly in the last few years as a result of its improved design, it has never regained the popularity it enjoyed before 1980. In contrast, depot-medroxyprogesterone, which provides protection for up to 14 weeks, is a popular method among young patients” and was selected by 32% of mothers included in this sample. Due to its long range of action, this method should result in lower rates of unintended pregnancy. However, it is important to note that even with this extended range, effective use still depends largely on patient compliance. Ten percent of patients in this study who initiated this method failed to receive their second injection on schedule or to use an alternative method. This practice resulted in four positive pregnancy tests by 6 months postpartum. It is likely that a longer follow-up period would have identified even more pregnancies resulting from unreliable use of this method. Additional research, therefore, must continue to focus on ways to increase compliance with all methods of contraception, rather than relying on depotmedroxyprogesterone acetate as though it were the panacea for adolescent pregnancy. Method switching was common, with 46 adolescents switching from a hormonal type of contraception to a nonprescription method (condoms) during the 6-month interval. Hirsch et all2 demonstrated that adolescents are most likely to switch methods following a month of sexual inactivity. This tendency places the adolescent at great risk of an unintended pregnancy as she is often not adequately protected when sexual activity resumes. Therefore, appropriate contraceptive counseling should advise adolescents of the need to continue contraception even during brief periods of abstinence. Reliable contraception was observed to occur more frequently among adolescents who had performed well in school and who were enrolled in school 6 months following delivery. It is probable that this group wished to complete their education and thus were more motivated to avoid a rapid repeat pregnancy. In contrast, those who were not in school at 6 months or those who had failed prior grades were less reliable contraceptors. Once the adolescent has discontinued school, a repeat pregnancy does not threaten her future educational
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plans and she may be less motivated to use reliable contraception. This consideration supports observations by Ryan and SweeneyI as well as those of Kleini that for an adolescent to be a good contraceptor, she must have hope for her future and desirable alternatives to becoming pregnant. Emotional support also strongly predicted contraceptive compliance. Adolescents who had more than one person tell them they were important or tell them they were a good mother and those who reported adequate support from others were more likely to use reliable contraception. This association between support and contraceptive use has been noted by other investigators. Gispert et al’s observed that adolescents who had good relationships with their mothers were less likely to have a repeat pregnancy during the teenage years. Additionally, Jekel et al4 noted that adolescents who moved away from their families shortly after delivery were more likely to become pregnant again within 15 months. These studies underscore the importance of contact between the adolescent and other key people in her life who can provide assistance, guidance, and confirmation of her self-worth. Two limitations of this study should be noted. First, follow-up data were available on only 78% of adolescents who were interviewed at delivery. Although we did not observe any demographic differences between those who were and were not included, it is possible that reliable users were more likely to return their 6-month survey. This may have led to overestimation of continuation and satisfaction rates. Second, we relied on patient reports to obtain all data. Confirmation by chart review was not possible due to the large number of clinics in our area from which adolescents could receive contraceptive services. Similar to others,“*i7 we found that prevention of rapid repeat pregnancy during the teenage years requires more than distribution of birth control pills. Providers should be certain that adolescents comprehend the strong likelihood of pregnancy should they fail to use reliable contraception. Family planning clinics should train their nurses and physicians to offer emotional support to young patients and confirm parenting skills observed during the visit. School continuance should be emphasized. Long-term goals should be discussed and a plan for the future outlined. Finally, clinics should help adolescents enroll in the Special Supplemental Nutrition Program for Women, Infants, and Children or other programs that can provide financial assistance. By providing for the adolescent’s emotional, financial, and educational, as well as contraceptive, needs, rapid repeat pregnancy is more likely to be avoided.
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B Gynecology
References 1. Kalmuss DS, Namerow PB. Subsequent childbearing among teenage mothers: The determinants of a closely spaced second birth. Fam Plann Perspect 1994;26:149-53, 159. 2. Polit DF, Kahn JR. Early subsequent pregnancy among economically disadvantaged teenage mothers. Am J Public Health 1986;76: 167-71. 3. Maynard R, Rangarajan A. Contraceptive use and repeat pregnancies among welfare-dependent teenage mothers. Fam l’lann Perspect 1994;26:198-205. 4. Jekel JF, Klerman LV, Bancroft RE. Factors associated with rapid subsequent pregnancies among school-age mothers. Am J Public Health 1973;63:769-73. 5. Seligman ME, Abramson LY, Semmel A, von Baeyer C. Depressive attributional style. J Abnorm Psycho1 1979;88:242-7. 6. Hosmer DW, Lemenshow S. Model-building strategies and methods for logistic regression. In: Barnett V, Bradley R, Hunter J, Kadane J, Kendall G, Smith A, et al, eds. Applied logistic regression. New York (NY): John Wiley and Sons, 1989:131-3. 7. Ford K. Second pregnancies among teenage mothers. Fam Plann Perspect 1983;15:268-72. 8. l’olaneczky M, Slap G, Forke C, Rappaport A, Sondheimer S. The use of levonorgestrel implants (Norplant) for contraception in adolescent mothers. N Engl J Med 1994;331:1201-6. 9. Dinerman LM, Wilson MD, Duggan AK, Joffe A. Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods. Arch Pediatr Adolesc Med 1995;149: 967-72. 10. Berenson AB, Wiemann CM. Use of levonorgestrel implants versus oral contraceptives in adolescence: A case-control study. Am J Obstet Gynecol 1995;172:1128-35. 11. Cromer BA, Smith RD, Blair JM, Dwyer J, Brown RT. A prospective study of adolescents who choose among levonorgestrel implant (Norplant), medroxyprogesterone acetate (Depo-Provera), or the combined oral contraceptive pill as contraception, Pediatrics 1994; 94:687-94.
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12. Hirsch MB, Zabin LS, Streett R, Hoffman-Goldwasser E, Fitzgerald C, Vines E, et al. The effect of sexual behavior and a pregnancy on contraceptive method switching among black female teens. J Adolesc Health Care 1989;10:289-94. 13. Ryan GM, Sweeney PJ. Attitudes of adolescents toward pregnancy and contraception. Am J Obstet Gynecol 1980;137:358-66. 14. Klein L. Antecedents of teenage pregnancy. Clin Obstet Gynecol 1978;21:1151-9. 15. Gispert M, Brinich I’, Wheeler K, Krieger L. Predictors of repeat pregnancies among low-income adolescents. Hosp Community Psychiatry 1984;35:719-23. 16. Rubenstein E, Panzarine S, Lanning P. Peer counseling with adolescent mothers: A pilot program. Fam Sot J Contemp Hum Serv 1990;71:136-41. 17. Meyers AB, Rhodes JE. Oral contraceptive use among African American adolescents: Individual and community influences. Am J Community Psycho1 1995;23:99-115.
Address
reprint
requests
to:
Abbey B. Berenson, MD Departmentof Obsfefricsand Gynecology University of TexasMedical Branch 301 University Boulevard Galveston, TX 77555-0587
Received November 14, 1996. Received in revised form February Accepted February 21, 1997.
10, 1997
Copyright 0 1997 by The American College of Obstetricians Gynecologists. Published by Elsevier Science Inc.
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