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Pregnancy in the adolescent
Pregnancy in the adolescent I. Preliminary
summary
WILLIAM
J.
HARRY ANN
M.
Galveston,
CALHOUN, B.
status
M.D M.D.
M.P.H.
JENNINGS,
EVELYN EARL
McGANITY, LITTLE,
FOGELMAN,
LEQUIDA
of health
DAWSON,
R.N. M.S.W. PH.D.
Texas
Basic descriptiue data concerning the obstetric, socioeconomic, educational, nutritional, and biochemical information have been obtained from over 800 adolescent pregnant women who sought prenatal care at the University of Texas Medical Branch Hospitals. The mean nutrient intake with the exception of calcium and iron met or exceeded the Recommended Dietary Allowances of the National Research Council (1964). Biochemical assessment revealed significant deprivation of iron, vitamins A and C, and riboflavin. Clear differences between nonwhite and white segments of the population were found in the hematologic levels. Implications are discussed for the educational, social, health, and related nutritional preparation of these young mothers in our community.
After a flurry of reports beginning in the late 1930’s and carrying through the mid 1950’s our American literature has not reflected a great deal of interest in human nutrition during pregnancy. The current status of this literature is reviewed and a position paper published in the World Health
P R E G N A N c Y occurring in the years before a young woman’s twentieth birthday has become one of our most studied population problems. From an initial article by Harris,l in 1922, our literature has expanded by leaps and bounds. Eight reports were published during the 1950’s and at least 19 related papers have appeared so far this decade. These represent only the obstetric and fetal implications of the problem. To this must be added the demographic, social, medical, and nutritional considerations. All of this material is summarized and abstracted by Savitz, McCann, and Stitt.2
From the Department Gynecology, University Branch. ‘This work in&a-agency Department Texas.
Organizations
Technical
Report
No.
302-
1965. The nutritional health of adolescent girls has interested several investigator? during the past 5 years. They reflect primary concern in the problems of the obese and the bizarre eating patterns of these young women. Only a few groups4 have attempted to describe their population groups utilizing all the tools available to the physician-nutritionist-clinical, biochemical, and dietary assessment. Only two groups, ours in Galveston and Unglaub’s group5 at Tulane, have focused particular attention on the comprehensive nutritional health status of the pregnant adolescent. Our study of over 800 pregnant teenagers was initiated as a base-line evaluation
of Obstetrics and of Texas Medical
was supported in part by an contract with Texas State of Public Health, Austin,
Presented at the Seventy-ninth Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot Springs, Virginia, Sept. 5-7, 1968.
773
774
McGanity
et al.
of our population in Galveston, Texas. From these findings we planned to develop and initiate programs in our rommunity and institutions to correct deficits as they were found. Material
and
methods
For a 2 year period from January, 1964, through calendar 1966, a prospective survey was made of 861 pregnant teen-aged “highrisk” patients who entered prenatal care at the University of Texas Medical Branch Hospitals, Galveston. This represents over 90 per cent of all pregnant teen-agers delivered in our county during this period. In addition to the nutritional evaluation, a comprehensive study of the social, educational, and environmental background of our patients was conducted by a team of health-related specialists-a public health nurse (L. J.) , a social worker (E. C.) , a nutritionist (A. F.), a biochemist (E. B. D.), and an obstetrician (H. M. L.). This report presents the data on 550 “high-risk” patients (64 per cent of total) on whom we have the triad of information: ( 1) prenatal care and obstetric and fetal outcome, (2) nutrient intake data at time of entry into antenatal care, and (3) nutritional biochemical assessment on admission to antenatal care. Questionnaires were developed and used by three interviewers. Considerable effort was devoted to brief explanations to each patient to introduce the purposes and elicit the cooperation of our patients. The nutritionist interviewed each teen-ager at the first antenatal visit prior to any physician contact. At this visit a random 20 ml. aliquot of whole blood plus a 60 ml. sample of voided urine was obtained. Other team members interviewed the patients on their second and third follow-up visits. The public health nurse also interviewed the patients following delivery while the young mother was still in the hospital and at her postpartum visit. All questionnaire data were graded as to reliability by the interviewer, and only data that could
be considered valid have been included in computation and analysis. Rather than attempt the traditional but limited methods of dietary interview based on individual dietary recall of 1, 3, or 7 days, one of us (A. F.) developed a comprehensive food frequency format involving 160 food items. A computer analysis format was developed. All dietary intake frequency data were calculated in number of senings eaten per month, per week, or per day, and the percentage of our patients Tvho \VPN: eating and not eating a given food itcrn. Individual food items lucre then grouped into appropriate food groups and sources of major specific nutrients, such as protein, minerals, and vitamins. Full details and critique of this methodology tl-ill be pulilished separately. We believe this format when supported by nutritional biochemistry provides a more realistic evaluation of usual dietary intake and food practices. It hns its limitations, since it does not permit a critical evaluation of questionable data: as obta.ined by traditional recall means, and \ve are unable to calculate the distribution of intake of individual nutrient items. Our nutritional interview included questions designed to gather data on famil) shopping and eating practices, cost of family food, attitudes, customs, and the like that might influence food selection and usage. Many questions were open ended so we lsere able to obtain data about type of changes that our patients thought should be made (as compared to what the!; actually did make) during pregnancy, lactation, and menses. We attempted to ascertain their sources of health and nutritional inforrnation as well as their reasons for food prcferrnccs and making dietary modifications. The biochemical assessment was measured by standard procedures as modified and published in the “Manual for Nutritional Surveys.” Appropriate mean or median values of individual items \t:ere calculated. Distribution of values into the “lo\v” range were based on the suggested interpretive guide for blood and urinary values of individual nutri-
Volume Number
Pregnancy
103 6
Table I. Suggested
guide
to interpretation
serum
protein
data in pregnant
Trimester
Constituent Total
of blood
(Gm./lOO
ml.)
Low
in
adolescent
775
women” Acceptable
High
1 2 3
< 6.4 < 5.9 < 5.9
6.5-6.9 6.0-6.9 6.0-6.9
> 7.0 > 7.0 > 7.0
Serum
albumin
(Gm./lOO
ml.)
1 2 3
< 3.9 < 3.4 < 3.4
4.0-4.9 3.5-4.4 3.5-4.4
> 5.0 > 4.5 > 4.5
Serum
globulin
(Gm./lOO
ml.)
1 2 3
< 1.3 < 1.9 < 2.1
2.0-2.9 2.0-2.9 2.2-2.9
> 3.0 > 3.0 > 3.0
1 2 3
< 10.9 < 10.4 < 10.4
11.0-14.4 10.5-12.9 10.5-12.9
> 14.5 > 13.0 > 13.0
1 2 3
2:: -c 32
Hemoglobin
(Gm./lOO
Hematocrit
(PCV)
Mean corpuscular tration (%) Plasma Plasma
ascorbic vitamin
Plasma
carotene
ml.)
( %)
hemoglobin
concen-
acid A
1 2 3 > All All
(Pg/lOO
ml.)
Riboflavin
(pg/Gm.
(Pg/Gm.
creatinine) <
N’-methyl atinine)
nicotinamide
(mg./Gm.
cre-
*Based on observations in the Vanderbilt Cooperative Study physical findings in 2,129 delivered pregnancies (J. Nutrition trimester do not differ appreciably from those of nonpregnant
ents as adjusted for gestational trends during pregnancy and published6 on pages 236 and 246 of the “Manual for Nutritional Surveys, 1963” (Table I). As all urinary aliquots were obtained on a random time basis they were calculated in relation to grams of creatinine excreted. The following nutritional biochemical measurements were determined : hemoglobin, hematocrit, mean corpuscular hemoglobin concentration (MCHC) , plasma vitamins A and C, plasma carotene, and the urinary excretion of thiamine, riboflavin, and methyl nicotinamide. Plasma macro-
1 2 3
> 35.0
30.5-34.9
< 0.20 < 20
0.20-0.39 20-49
2 0.4 > 50
:z
40-99 80-199 80-249
> 100 > 200 > 250
< 65 < 54 < 49
66-129 55-109 50-99
> > >
< 79 119 < 89
80-269 120-399 go-299
> 270 > 4.00 > 300
1.6-4.29 2.0-4.99 2.5-6.49
> > >
< 39
creatinine)
> 43 > 38 > 35
< 30.4
2 Thiamine
38-42 35-37 33-34
< 1.59 < 1.99 < 2.49 of Maternal and Infant Nutrition. 51:565-598, 1953). Values for women in the same age group.
130 110 100
4.3 5.0 6.5
IV. Dietary, laboratory pregnant women in the
and first
and microminerals were measured by atomic absorption spectrophotometry in 60 per cent of the subjects. These included iron, calcium, lead, copper, zinc, magnesium, cadmium, sodium, and potassium, Only the plasma iron values will be presented here. The remaining trace mineral data have been accepted for publicatiom7 Analysis
of
data
In order to set the stage for the more detailed consideration of our mothers nutritional status as they entered our prenatal
776
McGanity
hiarch
et al.
Am. J. Obd.
Table II. Time patients
of onset of menarche
Table VI. Fetal birth among 550 patients Weight
Age (years) < < < < < < <
in 539
%
10 11
2 8 27 56 83 94 98
12 13 14 15 16
w-z----
(grams)
< 500 500999 l,OOO-1,499 1,500-1,999 2,000-2,499 > 2,500
weight
15. 1969 & &ICC-.
at delivery
1
%
_
-.
1 1 1 L! 12 -__----84.7
.._.. _
Table VII. Time of maternal entry into prenatal care among 550 patients Table III. Maternal 550 patients Age
age at delivery
%
13 14 15 16 17 18 19 20
0 1 4 11 27 49 75 100
Table IV. Maternal “biologic” delivery among 541 patients Postmenarche (years)
age at
2: <3 25”
27 19 56 37
<6 <7
76 88 97
Table V. Gestational patients (weeks) < 2% 20 32 34 36 38 40 42
age at delivery
I
% : 5 8 19 38 78 95
(weeks) < 12 16 20 24 28 32 36 39
%
<8
Age
Time
(years) < < < < < < < <
among
in 547
-_
% 2 8 18 34 49 67 88 .._____ 100
.---.-
care system a short summation of pertinent related social, economic, educational, and health practices of these 550 “high-risk” young women is necessary. Chronological, biologic, and prior reproductive characteristics. The mean age of onset of menses was 12.3 years. The per cent distribution of our patients by age at time of onset of menarche is presented in Table II. In 10 per cent, menarche had occurred prior to the eleventh year and 6 per cent after their fifteenth year. The mother’s age at tl~ time of delivery ranged from 13 through 19 years of age (Table III). Approximately equal quartiles were delivered prior to the seventeenth birthday, and during each of the seventeenth, eighteenth, and nineteenth years. Actual delivery occurred an average of 5.8 years after the menarche. In 19 per cent the termination of pregnancy was less than 3 years following menarche (Table IV). Our teen-age patients were 71 per cent Negro and 29 per cent white (comparable figures for our over-all staff service were 57 per cent Negro and 43 per cent white). All received their prenatal, intrapartum, and
Vrhme
103
Number
6
Pregnancy
Table VIII. Number of prenatal visits patient among 550 patients No. of visits % :i > 8 > 10 > 12 > 14
59 36 19 8 2 1
Table IX. Family income eligibility dependents among 550 patients Income
< < < < < < <
per
year
$1,500
$1,800 $2,100 $2,400 $2,700 $3,000 $4,200
per
for 3 70 19 56 69 80 87 92 99
postpartum care on the staff service of the University of Texas Medical Branch Hospitals. At the time of delivery 45 per cent were single. Fifty-six per cent were single at the time of conception. Two-thirds were in their first pregnancy. The remaining third had had 150 prior pregnancies yielding 168 living children. Maternal and fetal complications and outcome. Termination of pregnancy occurred prior to 36 weeks’ gestation in 19 per cent of our patients (Table V). Low birth weight infants were delivered of 15.3 per cent of the mothers; only 3.3 per cent weighed less than 2,000 grams at birth (Table VI). Of the live-born neonates 81 per cent had a 1 minute Apgar score of 7 or above; 4 per cent had an initial score of less than 3; 13 per cent had an initial score between 4 and 7 ; 31 per cent had an initial score of 7 or 8; and the remaining 50 per cent had an initial score of 9 or 10. There were 4 abortions, no stillbirths, and 10 neonatal deaths, of which one-half occurred after the infant was discharged from the newborn nursery. The absolute perinatal and postneonatal mortality
in adolescent
777
was 18.3 per 1,000 live births and the 7 day perinatal mortality was 9.2 per 1,000 live births. The neonates were 54 per cent male. Only in the increased prevalence of major and minor congenital anomalies (9 per cent) were the fetal characteristics different from those of our general newborn population. Maternal medical complications were fewer in this group than our general obstetric population, except for a higher prevalence of anemia, bacteriuria, and venereal disease. The following obstetric problems were higher among these young “high-risk” mothers than in our private patients: acute toxemia, antepartum and postpartum anemia, premature rupture of the membranes, third-trimester bleeding, abnormal presentations and position, operative vaginal and abdominal deliveries, and postpartum complications. However, the occurrence rate of these problems was not different in our teenagers than the over-all rate for our older staff obstetric patients. Health practices. All patients acknowledged the need for and importance of prenatal care; 70 per cent stated it should begin in the first trimester, as shown in Table VII yet only 2 per cent entered our care system prior to the twelfth week of pregnancy, while one-half entered prenatal care prior to the twenty-eighth week of gestation. The average number of prenatal visits was 5.7 throughout the whole period of gestation; 41 per cent had fewer than four visits with our physicians (TabIe VIII). The patients attributed their delay in entering into care and frequency of missed appointments and medications to lack of funds for health services and nonavailability of transportation to and from the clinic. The majority of our patients (60 per cent) had not seen a physician during their teens other than when they were acutely ill or pregnant. Of those with prior living children, only 12 per cent took them to available neighborhood well-baby clinics. Four out of 5 of the present pregnancies were unplanned. Only 1 out of 5 had ever used any means of family planning methods. When specifically offered family planning services
778
McGanity
et al.
during antenatal and hospital postpartum supervision, 80 per cent indicated their desire to have such help post partum. However, only 44 per cent returned for such assistance within the first 3 months after delivery. Of those (56 per cent) who returned for postpartum care within 6 weeks after delivery, 1 out of 4 acknowledged they had had coitus prior to the scheduled appointment. Educational background and preparation for motherhood. The educational attainment of these young women was somewhat more than we had anticipated. The mothers had completed an average of nine grades of formal education, 35 per cent had graduated from high school (Grade 12). The fathers had completed an average o.f the tenth grade. Over a third (35) of our patients Lverc enrolled in school at the onset of the pregnancy. Very simple testing on male and female reproductive anatomy and physiology revealed a glaring lack of knowledge of both aspects. What meager information they had was gained from their peers-not parental, church, or educational sources. As illustrations of this: 50 per cent were unaware of the body changes which occur during pregnancy; ol’er 60 per cent could not identify the structure or function of thr uterus: between a third and a quarter were unable to identify the structure or function of the penis. Social, economic, and environmental characteristics. Of the mothers who were not attending school, over two-thirds were not employed. One in 8 of the putative fathers of the infants of the single women was married to another woman, while 1 in 16 of the mothers had had prior pregnancies by other men. One half of 550 others received some financial assistance from one or both sets of parents. We were surprised to learn that less than 5 per cent of those interxiewed received individual aid from any local, state, or federal source. Yet 80 per cent of our “high-risk” patients fell into the lower four segments of 0111‘ economic classification, which is based on family unit with 3 dependents (if less than 3, $300 per dependent per annum is deducted) (Table IX). Under
March 15, 1969 Am. .I. Obst. & Gym.
usual circumstances this group would be eligible for receipt of surplus food commodities, but, in fact, only 1 in 10 acknowledged receipt of these and in most instances through their parents’ eligibility. Almost two-thirds were living with parents and/‘or other relatives. In contrast to the usual pattern, only 2 per cent of the unmarried mothers wcrc planning to place the nelvlxxn infant for adoption. Food patterns and dietary intake. The calculated mean dietary intake of these mothers at time of admission into prenatal care met or exceeded the 1964 and 1968 Keconimended Dietary Allowances oi the Food and Nutrition Board of the National Research Council for protein, vitamin ( :. thiamine, riboflavin, and niacin. The 5nboptimal arras of nutrient intake involve <.Llicium, iron, and vitamin A and its precursors. In contrast to other data we have, on older pregnant and nonpregnant worrlrn, thrrc were not significant differences in food intake pattern among the various cultural and ethnic segments of our 550 adolescent pregnant women. Our mothers’ means of h&&t and weight at the onset of their pregnancy xvert: ti=l inches and 119 pounds. The mean wcigllt ,qain during pregnancy was almost 24 pounds in our voun,g mothers. Wright gain ranged from 5 ;o as much as 60 !pounds (Table X‘I. Over 90 per cent of our mothers had a11 of the necessary facilities to store, prepare and cook their food. Almost all (95 per c&j made the vast majority of their food purchasrs in neighborhood supermarkets at averace weekly intervals. Their families’ food costs ranged from $11.00 per \cer,k to $13.00 prr tveek over the 2 )car period of our study. One in 4 received regular pcriodic food contributions from various mcmbers of their family. \Yhile only 5 out of 8 of our patients ace breakfast regularly when nonpregnant or pregnant, they managed an average of 4.5 feedings per day during their pregnancy. Tbvo of 3 increased their food consumption during pregnancy. Four out of 5 altered thrir food intake pattern during pregnancy, partic-
Volume Number
103 6
Pregnancy
Table X. Maternal pregnancy among
weight gain during 501 patients
Weight gain (pounds) < 10 < 15 < < < < <
Table
XI.
25 30 35 40
Pattern
of food intake
1. Bread/cereals, etc. White bread 2.
10
Milk
4.8 2.1 2.4 1.3 2.5 0.2 0.2 0.5 0.3 1.0 0.8 2.4 0.3 4.8
products
Whole milk 3. Meat/legumes Chicken Hamburger Lunch meat Pinto beans
5-42 5 5
18 12
4. 5. 6. 7. 8.
12 38 20-40 15-20 2
%
% 12 23 38 56 72 81 90
20
O-30 0 10-34
Table
(
XII. Not
11 34 23 5
Water
Intake
eating 30 37
Eggs Citrus Fruits/vegetables Fats/oils
on nonessential Miscellaneous food items
1. Potato chips 2. Saltines 3. Soda pop 4. Kool-Aid 5. Candy 6. Su,qar
foods Servings/day (No.) 0.2 0.2
0.7 0.5 0.4 1.3
ularly with respect to decreased amounts of sweets, starch, fats, and salt. It was of some interest to learn that 33 per cent of our patients also changed their food intake pattern during their menstrual periods. Fried food preparation was the preferred method with 66 per cent of our mothers. Pica in the form of starch, clay, dirt soil, and refrigerator frost, was ingested by 28
in adolescent
779
per cent of our mothers. In 3 out of 4 instances this was simply because they liked it; the remaining mothers stated it was for cultural or other reasons. The average pattern of food intake and per cent of mothers not eating various food groups or items are summarized in Table XI. It reveals a respectable picture over-all. However, it does suggest possible limitation of intake of citrus fruits, dark green leafy and yellow vegetables, and other fruits. One might predict a number of “low” blood levels of vitamin A and vitamin C. An abbreviated list of “nonessential” food items is presented in Table XII. Most of these contributed only to high calories, low nutrient, plus sodium intake. The mean dietary intakes of calories, protein, minerals, and vitamins are presented in Fig. 1. The 100 per cent line represents the National Research Council’s Food and Nutrition Boards Allowances 1964 for 15- to 18-year-old women and includes the upward adjustment recommended for pregnancy. The mean intakes of calcium, iron, vitamin A, and niacin were less than 90 per cent of this standard. The two groups represent the separation of data collected during 1964, 1965, and 1966. Sixty-two of the 73 grams of protein came from animal and dairy sources-25 per cent from dairy products and 60 per cent from meat sources. Two thirds of the 780 mg. of calcium was provided by the milk and dairy products. Iron sources were contributed by meat (60 per cent) and cereals (25 per cent). Four fifths of the vitamin A and its precursors originated from green and colored vegetables, citrus fruits, and margarine. Seventy-five per cent of the vitamin C was provided from the citrus fruits and juices. Dairy and meat products, in almost equal portions, contributed 80 per cent of the riboflavin. Nutritional biochemical assessment. Figs. 2 to 11 summarize the mean and per cent “low” values. Comparative data from the Vanderbilt Cooperative Study* are used for the blood levels. The Galveston data reflect values for our mothers as they entered pre-
780
McGanity
et al. h.
Percent
Adequacy
Nutrient
Intake
% 120
.g
.d
110
3
$
5 ‘U B
100 90
s _L
<
”
E
E ,z
;
, /
e z z +
lMWCb 15, 1969 J. Obst. & Gyrrec.
%
z
u
!’ TD::
80 70 60
Intake 2155Cd
Fig.
1. Mean
dietary
73GM
intakes
URINARY
mcg/gm
780MG.
of ralories,
127MG
protein,
5070
IU.
9eMG
minerals,
12MG
ZOMG
15MG
and vitamins.
THIAMINE
Cf$llg$‘NE
I3 0
E 3 24
l50-
,.,d ****-1*~~*lu,,,,,, ~,..,, I *,11-.****g, 49
HIGH m--m----
9
I L--------,, L
IOO-
m-
y-24
01 4
8
12
I6
WEEKS
Fig.
2. Mean
urinary
4a -36
L
LOW
0
-------
excretion
2 . 20
24
26
32
2 . 36
-12 4o” .~
B 3 s g -I
z
GESTATION
of thiamine.
natal care. The bars and/or shaded areas along the horizontal axis indicate the percentage of “low” values as determined from the suggested interpretative guide of the Manual for Nutrition Surveys, 1963. The limits of the “acceptable” and “high” range are indicated with appropriate variation for the physiologic alterations of pregnancy. Except for the hematologic data no ethnic or cultural differences were demonstrated in the nutritional biochemical data. Figs. 2 and 3 reveal that the mean urinary excretion of thiamine and N’-methyl nico-
tinamide feli within the “high” range. ‘The percentage of “low” values was minimal. Urinary riboflavin data are presented in Fig. 4. The mean level is in the “acceptable” range. However, the individual levels were skewed. Thirty-three per cent of the second trimester and 27 per cent of the third trimester levels were “low.” Vitamin A activity was measured in two form-the precursor beta carotene and vitamin A. Mean plasma carotene levels (Fig. 5) were in the “acceptable” range. Our Galveston data do not follow the pattern of in-
Volume Number
Pregnancy
103 6
-46
4--------a
2-
I
I LOW
7
0
16
12
WEEKS
Fig.
3. Mean
urinary
excretion
mcg /gm CREATININE 500
URINARY
of N’-methyl
I 24
20
-36
in LLI 2
-24
’
-12g-I
9
y
0-l 4
781
j
r---------
HIGH
in adolescent
4 20
32
OS 36
40
GESTATION
nicotinamide.
RIBOFLAVIN
1
300
HIGH -------a
-m-w----
:
4
8
12
16
WEEKS
Fig.
4. Urinary
riboflavin
20
24
if3
32
36
40
GESTATION
data.
crease with advancing gestation that was reported from the Vanderbilt Study of 2,200 white pregnant women.* In the Nashville study mean carotene values were found to be lower in the patients under 20 years of age. Of our Galveston mothers at the time of their entry into our prenatal care system, 1 in 6 during the second and 1 in 8 during the third trimester had “low” carotene values. Mean plasma vitamin A levels were consistently higher than those found in the Vanderbilt study (Fig. 6). One possible nutritional explanation may be the result of the use of fortified oleomargarine by our moth-
ers in Galveston. At the time of the Nashville study, this food item was not available in their local markets. The Texas mean plasma vitamin A was along the border of the “high” and “acceptable” ranges. Twelve per cent of the mothers who entered prenatal care in the first and second trimesters and 23 per cent in the third trimester had vitamin A levels in “low” range. The mean plasma vitamin C levels in patients from Galveston and Nashville are very similar (Fig. 7). Both means fall along the edge of “high” and “acceptable” limits. Mothers entering care in the second and third trimesters had 15 and 27 per cent, re-
PLASMA
m-3
CAROTENE
-48 -36 a z
40LOW
8
a
, 12
carotene
levels.
07 4
plasma
mcg % 120
PLASMA
VITAMIN
60-
/
40.
24
28
,...’
.+,,
Fj”‘.,,,,,
‘.,,
81
.,,-VANDERBILT
129
12
16
vitamin
PLASMA
v) w 3 3
-12 -Ig
I
plasma
-36 -24
t-n
8
s
97 -48
I2
WEEKS
6. Mean
,,...**’ ‘~,,,..I.~
23 I2
4
,o 40
08 96 +l,.l*--*“*%,*
‘,,, ‘,,
zo-.
0
9
‘G, *-,,,,TEXAS
_._,_,_._.-.-.-.-.-.-.-
LOW
j;
-12
GESTATION
,-.-.-.-.-.-.-.-.-,-,-,-,-
Fig.
1 36
32
-24
A
*...--
HIGH ------~~------u~,~,~.~---~--~~~~
I 20
16
WEEKS
5. Mean
12
16
3
20
24
28
32
;6
.\”
40’
GESTATION
A levels. ASCORBIC
ACID
mg % O.B1
d a 2
15
LOW
27
02-7 OT 0
4
8
I2
I6
WEEKS
Fig.
7. Mean
plasma
vitamin
C levels.
20
GESTATION
24
28
32
36
-24 -12 ,o 40
; 8
Volume 103 Number 6
Pregnancy
in adolescent
patients. Mean hemoglobin (Fig. 8) values decreased with advancing gestation and fell along the lower edge of the “acceptable” range for our white population. Over-all mean Negro levels were almost 1.0 Gm. per cent lower than white values. However, at this time the effects of parity and other factors have not been examined and excluded. At time of entry into prenatal care, 18.5 per cent of all our patients were found to have
spectively, of the ascorbic acid levels fall in the “low” range. The hematologic data from our “highrisk” population revealed a significant problem of “anemia” among our mothers at the time they entered prenatal care. All three parameters-hemoglobin, hematocrit, mean corpuscular h e m o g 1 o b i n concentration (MCHC) -revealed a similar pattern of significantly lower mean values in our Negro
HEMOGLOBIN --VANDERBILT TEXAS Negro -- White S %-IO gm
24 18 E’ I2 0”
9.0
u 6s 0
0 L 0
4
0
I2
16 WEEKS
Fig. 8. Mean hemoglobin
units
20
24
28
32
36
40
GESTATION
values.
-=-
%
34
VANDERBILT TEXAS Negro -- White yi %Low
Values
33.5
g
32.5
0’ 3
24 ‘2 I8 3 s I2 6 : -I
32
0s
0 0
4
8
12
16 WEEKS
Fig. 9. Mean
hematocrit
levels.
783
20
24
GESTATION
28
32
36
40
784
McGanity
March 15, 1969 4111. I. Obst. & Gynrc.
et al.
A similar picture is evident in the mc’an hematocrit (Fig. 9) and MCHC (Fig. 101 data. Mean hematocrit levels were 1 .(I to I .5 per cent lower in our Negro patients. Over-all only 6 per cent of MCHC levels fell into the “low” range I kss than 30.5 units). However, four times as many Negro and Latin American patients entered prcnatal care with “low” MCHC values when compared to our other mothers.
hemoglobin levels less than 10.0 Gm. per 100 ml.; 41.3 per cent entered with a hemoglobin level less than 11.0 Gm. per cent. When examined separately, 19 per cent of the Negro mothers had hemoglobin levels under 10 Gm. as compared to 9.9 per cent in our white mothers. With the 11 Gm. level, 46 per cent of our Negro and 30 per cent of our white mothers entered prenatal care with levels under that value.
units 40
%
HEMATOCRIT
1
-m-VANDERBILT TEXAS
38
-
Negro
-w
White %<33
Hct
K34 3 g 32 $
36
I 30 24
2
18
;
12
” a9
6
0
4
8
12
18
20
WEEKS
Fig. 10. Mean corpuscular
hemoglobin
24
28
32
36
40
GESTATION
concentration.
170 150 130
Y3 I10 SJ 90 p
70
3a
50
6
15
\
k/‘-g 16
$
50
7
30
1
0
1 0
Fig. 11. Mean plasma iron levels.
‘0 28
20
24
WEEKS
GESTATION
36
i 0 40
z P s v s
Volume Number
103 6
Mean plasma iron levels (Fig. 11) fell with advancing gestation in both Negro and Lvhite mothers from 150 pg in the first trimester to 100 kl,g per 100 ml. at term. No significant difference was found between the mean Negro and white iron data. The per cent of patients with plasma iron values less than 60 pg per cent gradually increased throughout pregnancy from 15 per cent in those who entered in the first trimester to almost 30 per cent in entrants late in the third trimester. Comment
There were approximately 13 million females between 13 and 20 years of age in the United States in 1967. Only 5 per cent of these (600,000) have been delivered of infants during any of the past 3 or 4 years. Marriage among our young females has been occurring earlier and more frequently for several years both nationally and locally. Over one half of all females in our community are married by the age of 19 yearsor within 18 months of completion of formal secondary school education. On a national basis, approximately 2 per cent of teen-age pregnancies are completed prior to the mother’s fifteenth birthday, 31 per cent during the fifteenth and sixteenth years, and 66 per cent during the seventeenth, eighteenth, and nineteenth years. Comparable figures for our Galveston study were 3.3, 22.5, and 74.2 per cent, respectively. In the United States, Texas, and Galveston County, 4 out of 10 of all first pregnancies and 2 out of 10 of all second babies are delivered of y-oung women under 20 years of age. Our study population rate was somewhat higher-6 out of 10 of first babies and 3 out of 10 of all second babies. Over-all, one quarter of all our deliveries were of mothers less than 20 years in comparison to 1 in 6 nationally and statewide. Over the past decade the teen-age segment of our obstetric population has become an important high-risk part of our responsibility. Many authors as well as the National Vital Statistics have reported that this group has contributed more than their share of
Pregnancy
in adolescent
785
maternal and fetal complications, such as prematurity and perinatal and neonatal mortality. Our study group does not support this contention. When our high-risk teen-agers are compared to the over-all staff patients, prematurity was 15.3 per cent in the former group versus 15.5 per cent in the latter group; the 7 day neonatal mortality was 7.2 versus 6.9 per 1,000 live births for infants weighing over 1,000 grams at time of their delivery, and pre-eclampsia was 13.8 versus 13.6 per cent. During the young girl’s adolescent growth spurt, from years 11 through 16, she contributes 8 per cent to her total physical development. By the age of 17 years whether she be an early or late bloomer she will have completed her sexual, biologic, physiologic, and skeletal maturation. During this adolescent period she has the greatest quantitative nutritional demands for any female age group. Based on the best available information which is incorporated in the NRC Recommended Dietary Allowances 1964 and 1968,91 lo these young women, exclusive of pregnancy demands, have calorie requirements which equal those of an adult male engaging in moderate activity, i.e., 40 to 50 calories per kilogram of body weight. Protein is needed at the level of 1.2 to 1.5 mg. per kilogram of body weight. Both calcium and iron are at the highest level of requirement of any time for the female except during pregnancy and lactation. The increased demands for the vitamins are related primarily to the enhanced caloric needs. Others’l have characterized this young woman as having the poorest dietary habits and food intake of any member of the family at any age. There has been reported a frequent pattern of no breakfast and missed meals plus the ingestion of large amounts of “junk” food. Our nutritional data do not wholly support this thesis as we have determined it at the time she entered prenatal care at our institution. The majority of our young matrons have reported an adequate and satisfactory pattern of food intake and nutrient content. Except for calcium, iron, and to a lesser extent vitamin A and niacin their
786
McGanity
mean
intake
tory.
of
nutrients
Biochemical was only
nificant
the with
hematologic
values,
mineral
was
not
and
cent
our
acid
was
lvere
in
the
not
rate
of
low
evidence in
our
being
into
added midst
of
folate
by
McGanityl?
at the Our
per
cent
less than
3 ng.
Based tional,
on social,
per
hematonic
Alperin, International
We
Folic
other
tions
and
grounds.
Congress
2.
3.
4.
5.
6.
Texas. At a very me that nutrition pregnancy. When
social,
that
are wit11
arr
(health?
attemptins;
educational,
pregnancy
country
cultural,
psycho-
and
throughout
to describe
and/or
ethnic,
Hopefully
tional
sul-Leys
a
United
States
life,
the
popu-
the
different
dietary
series
underway will
having
and
of
at present
provide
each
back-
10
nutri-
in the
section
of
findings--educa-
country with information on the present status of nutritional health of the lowe socioeconomic segment of our population.
as well
including
folate
levels
as nutri-
Discussion CHARLES
those
we
attempted
of has
Harris, J. W.: Bull. Johns Hopkins Hosp. 23: 12, 1922. Savitz, R. A., McCann, M., and Stitt, P. G.: Childbearing, monograph, Washington, D. C., 1966, Children’s Bureau, United States Department of Health, Education and Welfare, pp. 10-15. Savitz. R. A., McCann, M., and Stitt, P. G.: Childbearing; monograph, Washington, D. C., 1966. Children’s Bureau. United States Departient of Health, E&cation and Welfare, pp. 21-22. Savitz, R. A., McCann, M., and Stitt, P. G.: Childbearing, monograph, Washington, D. C., 1966, Children’s Bureau, United States Department of Health, Education and Welfart, pp. 22-23. Lyon, R., Langham, R. A., Metzinger, A. B., and Unglaub, W. G.: Personal communication, 1968. Interdepartmental Committee on Nutrition for
DR.
in have
of our
social,
our
REFERENCES
1.
OUI
lation in Galveston, Texas. Without similar and confirmatory data for the adolescent pregnant females of other areas it would be unwarranted to extrapolate o11r findings to similar obstetric patients living in other SIY-
are
100 ml. over-all
of
to
resources
welfare)
the
series
In cooperation
community
and
improve
including of age.
a srrvict:
adventure
data
population
of serum
health-related
to
of
the
arrest
Haggard,
our
provision
logical? emotional, and nutritional preparation of these young women for their 9 month
as we
These
obstetric
as
a frequency and
of
implemented
the
our
augmen-
maturation
incidence our
C,
care.
concentration population.
reported
many
45 per
iron
this
megaloblastic
obstetric
20 years
from
prenatal
to
patients,
less than
in
education,
of
example,
of ascertaining
Hematology. 2.1
an
received
entry
obstetric
pre-
and
period
indicated
As
patients
after
exsig-
supplementation
unless
findings.
of
tation
the
vitamin
prescribed
biochemical
A
During
have
changes
“acceptable”
vitamins
as riboflavin.
study,
entered
than
tional-we
in-
one
However,
patients
less
satisfacthese
when
values.
of our
care
well
very of
obtained mean
numbers
natal
was
confirmation
terpretations amined
March IS, 1969 Am. J. Obst. Sr Gynec.
et al.
E. FLOWERS, JR., Houston, early age it became clear to was extremely important in I was 13 years old, my father
7. 8. 9.
10.
11.
12.
this
high-risk
obstetric
,group.
National Defense: Manual for Nutrition Surveys, Bethesda, Maryland, 1963, National Center for Chronic Disease Control. Dawson, E. B., Clark, R. R., and McGanity, W. J.: AM. J. OBST. & GTNEC. In press. Darby, W. J., et al.: J. Nutrition 51: 56.5, 1953. National Research Council, Food and Nutrition Board: Dietary Allowances, Washington, D. C., 1964, National Academy of Sciences, Publication No. 1146. National Research Council, Food and Nutrition Board: Dietary Allowances, Washington, D. C., 1968. National Academy of Scierlcr\: Publication No. 1694. Nutritional Status Morgan, A. F., editor: US.4, Berkeley, 1959, California Agricultural Experimental Station, Bulletin No. 769. Alperin, J. B., Haggard, M. E., and McGanity, W. J.: Abstract XII Congress of the International Society of Hematology, New York, 1968, p. 96.
felt that I money. He was to take rabbits oats, to grow and
should begin making my spending bought me a hutch of rabbits that I care of and sell for profit. I fed my cracked corn, and hay. They seemed thrive, but I had almost a 50 per
summary
WILLIAM
J.
HARRY ANN
M.
Galveston,
CALHOUN, B.
status
M.D M.D.
M.P.H.
JENNINGS,
EVELYN EARL
McGANITY, LITTLE,
FOGELMAN,
LEQUIDA
of health
DAWSON,
R.N. M.S.W. PH.D.
Texas
Basic descriptiue data concerning the obstetric, socioeconomic, educational, nutritional, and biochemical information have been obtained from over 800 adolescent pregnant women who sought prenatal care at the University of Texas Medical Branch Hospitals. The mean nutrient intake with the exception of calcium and iron met or exceeded the Recommended Dietary Allowances of the National Research Council (1964). Biochemical assessment revealed significant deprivation of iron, vitamins A and C, and riboflavin. Clear differences between nonwhite and white segments of the population were found in the hematologic levels. Implications are discussed for the educational, social, health, and related nutritional preparation of these young mothers in our community.
After a flurry of reports beginning in the late 1930’s and carrying through the mid 1950’s our American literature has not reflected a great deal of interest in human nutrition during pregnancy. The current status of this literature is reviewed and a position paper published in the World Health
P R E G N A N c Y occurring in the years before a young woman’s twentieth birthday has become one of our most studied population problems. From an initial article by Harris,l in 1922, our literature has expanded by leaps and bounds. Eight reports were published during the 1950’s and at least 19 related papers have appeared so far this decade. These represent only the obstetric and fetal implications of the problem. To this must be added the demographic, social, medical, and nutritional considerations. All of this material is summarized and abstracted by Savitz, McCann, and Stitt.2
From the Department Gynecology, University Branch. ‘This work in&a-agency Department Texas.
Organizations
Technical
Report
No.
302-
1965. The nutritional health of adolescent girls has interested several investigator? during the past 5 years. They reflect primary concern in the problems of the obese and the bizarre eating patterns of these young women. Only a few groups4 have attempted to describe their population groups utilizing all the tools available to the physician-nutritionist-clinical, biochemical, and dietary assessment. Only two groups, ours in Galveston and Unglaub’s group5 at Tulane, have focused particular attention on the comprehensive nutritional health status of the pregnant adolescent. Our study of over 800 pregnant teenagers was initiated as a base-line evaluation
of Obstetrics and of Texas Medical
was supported in part by an contract with Texas State of Public Health, Austin,
Presented at the Seventy-ninth Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot Springs, Virginia, Sept. 5-7, 1968.
773
774
McGanity
et al.
of our population in Galveston, Texas. From these findings we planned to develop and initiate programs in our rommunity and institutions to correct deficits as they were found. Material
and
methods
For a 2 year period from January, 1964, through calendar 1966, a prospective survey was made of 861 pregnant teen-aged “highrisk” patients who entered prenatal care at the University of Texas Medical Branch Hospitals, Galveston. This represents over 90 per cent of all pregnant teen-agers delivered in our county during this period. In addition to the nutritional evaluation, a comprehensive study of the social, educational, and environmental background of our patients was conducted by a team of health-related specialists-a public health nurse (L. J.) , a social worker (E. C.) , a nutritionist (A. F.), a biochemist (E. B. D.), and an obstetrician (H. M. L.). This report presents the data on 550 “high-risk” patients (64 per cent of total) on whom we have the triad of information: ( 1) prenatal care and obstetric and fetal outcome, (2) nutrient intake data at time of entry into antenatal care, and (3) nutritional biochemical assessment on admission to antenatal care. Questionnaires were developed and used by three interviewers. Considerable effort was devoted to brief explanations to each patient to introduce the purposes and elicit the cooperation of our patients. The nutritionist interviewed each teen-ager at the first antenatal visit prior to any physician contact. At this visit a random 20 ml. aliquot of whole blood plus a 60 ml. sample of voided urine was obtained. Other team members interviewed the patients on their second and third follow-up visits. The public health nurse also interviewed the patients following delivery while the young mother was still in the hospital and at her postpartum visit. All questionnaire data were graded as to reliability by the interviewer, and only data that could
be considered valid have been included in computation and analysis. Rather than attempt the traditional but limited methods of dietary interview based on individual dietary recall of 1, 3, or 7 days, one of us (A. F.) developed a comprehensive food frequency format involving 160 food items. A computer analysis format was developed. All dietary intake frequency data were calculated in number of senings eaten per month, per week, or per day, and the percentage of our patients Tvho \VPN: eating and not eating a given food itcrn. Individual food items lucre then grouped into appropriate food groups and sources of major specific nutrients, such as protein, minerals, and vitamins. Full details and critique of this methodology tl-ill be pulilished separately. We believe this format when supported by nutritional biochemistry provides a more realistic evaluation of usual dietary intake and food practices. It hns its limitations, since it does not permit a critical evaluation of questionable data: as obta.ined by traditional recall means, and \ve are unable to calculate the distribution of intake of individual nutrient items. Our nutritional interview included questions designed to gather data on famil) shopping and eating practices, cost of family food, attitudes, customs, and the like that might influence food selection and usage. Many questions were open ended so we lsere able to obtain data about type of changes that our patients thought should be made (as compared to what the!; actually did make) during pregnancy, lactation, and menses. We attempted to ascertain their sources of health and nutritional inforrnation as well as their reasons for food prcferrnccs and making dietary modifications. The biochemical assessment was measured by standard procedures as modified and published in the “Manual for Nutritional Surveys.” Appropriate mean or median values of individual items \t:ere calculated. Distribution of values into the “lo\v” range were based on the suggested interpretive guide for blood and urinary values of individual nutri-
Volume Number
Pregnancy
103 6
Table I. Suggested
guide
to interpretation
serum
protein
data in pregnant
Trimester
Constituent Total
of blood
(Gm./lOO
ml.)
Low
in
adolescent
775
women” Acceptable
High
1 2 3
< 6.4 < 5.9 < 5.9
6.5-6.9 6.0-6.9 6.0-6.9
> 7.0 > 7.0 > 7.0
Serum
albumin
(Gm./lOO
ml.)
1 2 3
< 3.9 < 3.4 < 3.4
4.0-4.9 3.5-4.4 3.5-4.4
> 5.0 > 4.5 > 4.5
Serum
globulin
(Gm./lOO
ml.)
1 2 3
< 1.3 < 1.9 < 2.1
2.0-2.9 2.0-2.9 2.2-2.9
> 3.0 > 3.0 > 3.0
1 2 3
< 10.9 < 10.4 < 10.4
11.0-14.4 10.5-12.9 10.5-12.9
> 14.5 > 13.0 > 13.0
1 2 3
2:: -c 32
Hemoglobin
(Gm./lOO
Hematocrit
(PCV)
Mean corpuscular tration (%) Plasma Plasma
ascorbic vitamin
Plasma
carotene
ml.)
( %)
hemoglobin
concen-
acid A
1 2 3 > All All
(Pg/lOO
ml.)
Riboflavin
(pg/Gm.
(Pg/Gm.
creatinine) <
N’-methyl atinine)
nicotinamide
(mg./Gm.
cre-
*Based on observations in the Vanderbilt Cooperative Study physical findings in 2,129 delivered pregnancies (J. Nutrition trimester do not differ appreciably from those of nonpregnant
ents as adjusted for gestational trends during pregnancy and published6 on pages 236 and 246 of the “Manual for Nutritional Surveys, 1963” (Table I). As all urinary aliquots were obtained on a random time basis they were calculated in relation to grams of creatinine excreted. The following nutritional biochemical measurements were determined : hemoglobin, hematocrit, mean corpuscular hemoglobin concentration (MCHC) , plasma vitamins A and C, plasma carotene, and the urinary excretion of thiamine, riboflavin, and methyl nicotinamide. Plasma macro-
1 2 3
> 35.0
30.5-34.9
< 0.20 < 20
0.20-0.39 20-49
2 0.4 > 50
:z
40-99 80-199 80-249
> 100 > 200 > 250
< 65 < 54 < 49
66-129 55-109 50-99
> > >
< 79 119 < 89
80-269 120-399 go-299
> 270 > 4.00 > 300
1.6-4.29 2.0-4.99 2.5-6.49
> > >
< 39
creatinine)
> 43 > 38 > 35
< 30.4
2 Thiamine
38-42 35-37 33-34
< 1.59 < 1.99 < 2.49 of Maternal and Infant Nutrition. 51:565-598, 1953). Values for women in the same age group.
130 110 100
4.3 5.0 6.5
IV. Dietary, laboratory pregnant women in the
and first
and microminerals were measured by atomic absorption spectrophotometry in 60 per cent of the subjects. These included iron, calcium, lead, copper, zinc, magnesium, cadmium, sodium, and potassium, Only the plasma iron values will be presented here. The remaining trace mineral data have been accepted for publicatiom7 Analysis
of
data
In order to set the stage for the more detailed consideration of our mothers nutritional status as they entered our prenatal
776
McGanity
hiarch
et al.
Am. J. Obd.
Table II. Time patients
of onset of menarche
Table VI. Fetal birth among 550 patients Weight
Age (years) < < < < < < <
in 539
%
10 11
2 8 27 56 83 94 98
12 13 14 15 16
w-z----
(grams)
< 500 500999 l,OOO-1,499 1,500-1,999 2,000-2,499 > 2,500
weight
15. 1969 & &ICC-.
at delivery
1
%
_
-.
1 1 1 L! 12 -__----84.7
.._.. _
Table VII. Time of maternal entry into prenatal care among 550 patients Table III. Maternal 550 patients Age
age at delivery
%
13 14 15 16 17 18 19 20
0 1 4 11 27 49 75 100
Table IV. Maternal “biologic” delivery among 541 patients Postmenarche (years)
age at
2: <3 25”
27 19 56 37
<6 <7
76 88 97
Table V. Gestational patients (weeks) < 2% 20 32 34 36 38 40 42
age at delivery
I
% : 5 8 19 38 78 95
(weeks) < 12 16 20 24 28 32 36 39
%
<8
Age
Time
(years) < < < < < < < <
among
in 547
-_
% 2 8 18 34 49 67 88 .._____ 100
.---.-
care system a short summation of pertinent related social, economic, educational, and health practices of these 550 “high-risk” young women is necessary. Chronological, biologic, and prior reproductive characteristics. The mean age of onset of menses was 12.3 years. The per cent distribution of our patients by age at time of onset of menarche is presented in Table II. In 10 per cent, menarche had occurred prior to the eleventh year and 6 per cent after their fifteenth year. The mother’s age at tl~ time of delivery ranged from 13 through 19 years of age (Table III). Approximately equal quartiles were delivered prior to the seventeenth birthday, and during each of the seventeenth, eighteenth, and nineteenth years. Actual delivery occurred an average of 5.8 years after the menarche. In 19 per cent the termination of pregnancy was less than 3 years following menarche (Table IV). Our teen-age patients were 71 per cent Negro and 29 per cent white (comparable figures for our over-all staff service were 57 per cent Negro and 43 per cent white). All received their prenatal, intrapartum, and
Vrhme
103
Number
6
Pregnancy
Table VIII. Number of prenatal visits patient among 550 patients No. of visits % :i > 8 > 10 > 12 > 14
59 36 19 8 2 1
Table IX. Family income eligibility dependents among 550 patients Income
< < < < < < <
per
year
$1,500
$1,800 $2,100 $2,400 $2,700 $3,000 $4,200
per
for 3 70 19 56 69 80 87 92 99
postpartum care on the staff service of the University of Texas Medical Branch Hospitals. At the time of delivery 45 per cent were single. Fifty-six per cent were single at the time of conception. Two-thirds were in their first pregnancy. The remaining third had had 150 prior pregnancies yielding 168 living children. Maternal and fetal complications and outcome. Termination of pregnancy occurred prior to 36 weeks’ gestation in 19 per cent of our patients (Table V). Low birth weight infants were delivered of 15.3 per cent of the mothers; only 3.3 per cent weighed less than 2,000 grams at birth (Table VI). Of the live-born neonates 81 per cent had a 1 minute Apgar score of 7 or above; 4 per cent had an initial score of less than 3; 13 per cent had an initial score between 4 and 7 ; 31 per cent had an initial score of 7 or 8; and the remaining 50 per cent had an initial score of 9 or 10. There were 4 abortions, no stillbirths, and 10 neonatal deaths, of which one-half occurred after the infant was discharged from the newborn nursery. The absolute perinatal and postneonatal mortality
in adolescent
777
was 18.3 per 1,000 live births and the 7 day perinatal mortality was 9.2 per 1,000 live births. The neonates were 54 per cent male. Only in the increased prevalence of major and minor congenital anomalies (9 per cent) were the fetal characteristics different from those of our general newborn population. Maternal medical complications were fewer in this group than our general obstetric population, except for a higher prevalence of anemia, bacteriuria, and venereal disease. The following obstetric problems were higher among these young “high-risk” mothers than in our private patients: acute toxemia, antepartum and postpartum anemia, premature rupture of the membranes, third-trimester bleeding, abnormal presentations and position, operative vaginal and abdominal deliveries, and postpartum complications. However, the occurrence rate of these problems was not different in our teenagers than the over-all rate for our older staff obstetric patients. Health practices. All patients acknowledged the need for and importance of prenatal care; 70 per cent stated it should begin in the first trimester, as shown in Table VII yet only 2 per cent entered our care system prior to the twelfth week of pregnancy, while one-half entered prenatal care prior to the twenty-eighth week of gestation. The average number of prenatal visits was 5.7 throughout the whole period of gestation; 41 per cent had fewer than four visits with our physicians (TabIe VIII). The patients attributed their delay in entering into care and frequency of missed appointments and medications to lack of funds for health services and nonavailability of transportation to and from the clinic. The majority of our patients (60 per cent) had not seen a physician during their teens other than when they were acutely ill or pregnant. Of those with prior living children, only 12 per cent took them to available neighborhood well-baby clinics. Four out of 5 of the present pregnancies were unplanned. Only 1 out of 5 had ever used any means of family planning methods. When specifically offered family planning services
778
McGanity
et al.
during antenatal and hospital postpartum supervision, 80 per cent indicated their desire to have such help post partum. However, only 44 per cent returned for such assistance within the first 3 months after delivery. Of those (56 per cent) who returned for postpartum care within 6 weeks after delivery, 1 out of 4 acknowledged they had had coitus prior to the scheduled appointment. Educational background and preparation for motherhood. The educational attainment of these young women was somewhat more than we had anticipated. The mothers had completed an average of nine grades of formal education, 35 per cent had graduated from high school (Grade 12). The fathers had completed an average o.f the tenth grade. Over a third (35) of our patients Lverc enrolled in school at the onset of the pregnancy. Very simple testing on male and female reproductive anatomy and physiology revealed a glaring lack of knowledge of both aspects. What meager information they had was gained from their peers-not parental, church, or educational sources. As illustrations of this: 50 per cent were unaware of the body changes which occur during pregnancy; ol’er 60 per cent could not identify the structure or function of thr uterus: between a third and a quarter were unable to identify the structure or function of the penis. Social, economic, and environmental characteristics. Of the mothers who were not attending school, over two-thirds were not employed. One in 8 of the putative fathers of the infants of the single women was married to another woman, while 1 in 16 of the mothers had had prior pregnancies by other men. One half of 550 others received some financial assistance from one or both sets of parents. We were surprised to learn that less than 5 per cent of those interxiewed received individual aid from any local, state, or federal source. Yet 80 per cent of our “high-risk” patients fell into the lower four segments of 0111‘ economic classification, which is based on family unit with 3 dependents (if less than 3, $300 per dependent per annum is deducted) (Table IX). Under
March 15, 1969 Am. .I. Obst. & Gym.
usual circumstances this group would be eligible for receipt of surplus food commodities, but, in fact, only 1 in 10 acknowledged receipt of these and in most instances through their parents’ eligibility. Almost two-thirds were living with parents and/‘or other relatives. In contrast to the usual pattern, only 2 per cent of the unmarried mothers wcrc planning to place the nelvlxxn infant for adoption. Food patterns and dietary intake. The calculated mean dietary intake of these mothers at time of admission into prenatal care met or exceeded the 1964 and 1968 Keconimended Dietary Allowances oi the Food and Nutrition Board of the National Research Council for protein, vitamin ( :. thiamine, riboflavin, and niacin. The 5nboptimal arras of nutrient intake involve <.Llicium, iron, and vitamin A and its precursors. In contrast to other data we have, on older pregnant and nonpregnant worrlrn, thrrc were not significant differences in food intake pattern among the various cultural and ethnic segments of our 550 adolescent pregnant women. Our mothers’ means of h&&t and weight at the onset of their pregnancy xvert: ti=l inches and 119 pounds. The mean wcigllt ,qain during pregnancy was almost 24 pounds in our voun,g mothers. Wright gain ranged from 5 ;o as much as 60 !pounds (Table X‘I. Over 90 per cent of our mothers had a11 of the necessary facilities to store, prepare and cook their food. Almost all (95 per c&j made the vast majority of their food purchasrs in neighborhood supermarkets at averace weekly intervals. Their families’ food costs ranged from $11.00 per \cer,k to $13.00 prr tveek over the 2 )car period of our study. One in 4 received regular pcriodic food contributions from various mcmbers of their family. \Yhile only 5 out of 8 of our patients ace breakfast regularly when nonpregnant or pregnant, they managed an average of 4.5 feedings per day during their pregnancy. Tbvo of 3 increased their food consumption during pregnancy. Four out of 5 altered thrir food intake pattern during pregnancy, partic-
Volume Number
103 6
Pregnancy
Table X. Maternal pregnancy among
weight gain during 501 patients
Weight gain (pounds) < 10 < 15 < < < < <
Table
XI.
25 30 35 40
Pattern
of food intake
1. Bread/cereals, etc. White bread 2.
10
Milk
4.8 2.1 2.4 1.3 2.5 0.2 0.2 0.5 0.3 1.0 0.8 2.4 0.3 4.8
products
Whole milk 3. Meat/legumes Chicken Hamburger Lunch meat Pinto beans
5-42 5 5
18 12
4. 5. 6. 7. 8.
12 38 20-40 15-20 2
%
% 12 23 38 56 72 81 90
20
O-30 0 10-34
Table
(
XII. Not
11 34 23 5
Water
Intake
eating 30 37
Eggs Citrus Fruits/vegetables Fats/oils
on nonessential Miscellaneous food items
1. Potato chips 2. Saltines 3. Soda pop 4. Kool-Aid 5. Candy 6. Su,qar
foods Servings/day (No.) 0.2 0.2
0.7 0.5 0.4 1.3
ularly with respect to decreased amounts of sweets, starch, fats, and salt. It was of some interest to learn that 33 per cent of our patients also changed their food intake pattern during their menstrual periods. Fried food preparation was the preferred method with 66 per cent of our mothers. Pica in the form of starch, clay, dirt soil, and refrigerator frost, was ingested by 28
in adolescent
779
per cent of our mothers. In 3 out of 4 instances this was simply because they liked it; the remaining mothers stated it was for cultural or other reasons. The average pattern of food intake and per cent of mothers not eating various food groups or items are summarized in Table XI. It reveals a respectable picture over-all. However, it does suggest possible limitation of intake of citrus fruits, dark green leafy and yellow vegetables, and other fruits. One might predict a number of “low” blood levels of vitamin A and vitamin C. An abbreviated list of “nonessential” food items is presented in Table XII. Most of these contributed only to high calories, low nutrient, plus sodium intake. The mean dietary intakes of calories, protein, minerals, and vitamins are presented in Fig. 1. The 100 per cent line represents the National Research Council’s Food and Nutrition Boards Allowances 1964 for 15- to 18-year-old women and includes the upward adjustment recommended for pregnancy. The mean intakes of calcium, iron, vitamin A, and niacin were less than 90 per cent of this standard. The two groups represent the separation of data collected during 1964, 1965, and 1966. Sixty-two of the 73 grams of protein came from animal and dairy sources-25 per cent from dairy products and 60 per cent from meat sources. Two thirds of the 780 mg. of calcium was provided by the milk and dairy products. Iron sources were contributed by meat (60 per cent) and cereals (25 per cent). Four fifths of the vitamin A and its precursors originated from green and colored vegetables, citrus fruits, and margarine. Seventy-five per cent of the vitamin C was provided from the citrus fruits and juices. Dairy and meat products, in almost equal portions, contributed 80 per cent of the riboflavin. Nutritional biochemical assessment. Figs. 2 to 11 summarize the mean and per cent “low” values. Comparative data from the Vanderbilt Cooperative Study* are used for the blood levels. The Galveston data reflect values for our mothers as they entered pre-
780
McGanity
et al. h.
Percent
Adequacy
Nutrient
Intake
% 120
.g
.d
110
3
$
5 ‘U B
100 90
s _L
<
”
E
E ,z
;
, /
e z z +
lMWCb 15, 1969 J. Obst. & Gyrrec.
%
z
u
!’ TD::
80 70 60
Intake 2155Cd
Fig.
1. Mean
dietary
73GM
intakes
URINARY
mcg/gm
780MG.
of ralories,
127MG
protein,
5070
IU.
9eMG
minerals,
12MG
ZOMG
15MG
and vitamins.
THIAMINE
Cf$llg$‘NE
I3 0
E 3 24
l50-
,.,d ****-1*~~*lu,,,,,, ~,..,, I *,11-.****g, 49
HIGH m--m----
9
I L--------,, L
IOO-
m-
y-24
01 4
8
12
I6
WEEKS
Fig.
2. Mean
urinary
4a -36
L
LOW
0
-------
excretion
2 . 20
24
26
32
2 . 36
-12 4o” .~
B 3 s g -I
z
GESTATION
of thiamine.
natal care. The bars and/or shaded areas along the horizontal axis indicate the percentage of “low” values as determined from the suggested interpretative guide of the Manual for Nutrition Surveys, 1963. The limits of the “acceptable” and “high” range are indicated with appropriate variation for the physiologic alterations of pregnancy. Except for the hematologic data no ethnic or cultural differences were demonstrated in the nutritional biochemical data. Figs. 2 and 3 reveal that the mean urinary excretion of thiamine and N’-methyl nico-
tinamide feli within the “high” range. ‘The percentage of “low” values was minimal. Urinary riboflavin data are presented in Fig. 4. The mean level is in the “acceptable” range. However, the individual levels were skewed. Thirty-three per cent of the second trimester and 27 per cent of the third trimester levels were “low.” Vitamin A activity was measured in two form-the precursor beta carotene and vitamin A. Mean plasma carotene levels (Fig. 5) were in the “acceptable” range. Our Galveston data do not follow the pattern of in-
Volume Number
Pregnancy
103 6
-46
4--------a
2-
I
I LOW
7
0
16
12
WEEKS
Fig.
3. Mean
urinary
excretion
mcg /gm CREATININE 500
URINARY
of N’-methyl
I 24
20
-36
in LLI 2
-24
’
-12g-I
9
y
0-l 4
781
j
r---------
HIGH
in adolescent
4 20
32
OS 36
40
GESTATION
nicotinamide.
RIBOFLAVIN
1
300
HIGH -------a
-m-w----
:
4
8
12
16
WEEKS
Fig.
4. Urinary
riboflavin
20
24
if3
32
36
40
GESTATION
data.
crease with advancing gestation that was reported from the Vanderbilt Study of 2,200 white pregnant women.* In the Nashville study mean carotene values were found to be lower in the patients under 20 years of age. Of our Galveston mothers at the time of their entry into our prenatal care system, 1 in 6 during the second and 1 in 8 during the third trimester had “low” carotene values. Mean plasma vitamin A levels were consistently higher than those found in the Vanderbilt study (Fig. 6). One possible nutritional explanation may be the result of the use of fortified oleomargarine by our moth-
ers in Galveston. At the time of the Nashville study, this food item was not available in their local markets. The Texas mean plasma vitamin A was along the border of the “high” and “acceptable” ranges. Twelve per cent of the mothers who entered prenatal care in the first and second trimesters and 23 per cent in the third trimester had vitamin A levels in “low” range. The mean plasma vitamin C levels in patients from Galveston and Nashville are very similar (Fig. 7). Both means fall along the edge of “high” and “acceptable” limits. Mothers entering care in the second and third trimesters had 15 and 27 per cent, re-
PLASMA
m-3
CAROTENE
-48 -36 a z
40LOW
8
a
, 12
carotene
levels.
07 4
plasma
mcg % 120
PLASMA
VITAMIN
60-
/
40.
24
28
,...’
.+,,
Fj”‘.,,,,,
‘.,,
81
.,,-VANDERBILT
129
12
16
vitamin
PLASMA
v) w 3 3
-12 -Ig
I
plasma
-36 -24
t-n
8
s
97 -48
I2
WEEKS
6. Mean
,,...**’ ‘~,,,..I.~
23 I2
4
,o 40
08 96 +l,.l*--*“*%,*
‘,,, ‘,,
zo-.
0
9
‘G, *-,,,,TEXAS
_._,_,_._.-.-.-.-.-.-.-
LOW
j;
-12
GESTATION
,-.-.-.-.-.-.-.-.-,-,-,-,-
Fig.
1 36
32
-24
A
*...--
HIGH ------~~------u~,~,~.~---~--~~~~
I 20
16
WEEKS
5. Mean
12
16
3
20
24
28
32
;6
.\”
40’
GESTATION
A levels. ASCORBIC
ACID
mg % O.B1
d a 2
15
LOW
27
02-7 OT 0
4
8
I2
I6
WEEKS
Fig.
7. Mean
plasma
vitamin
C levels.
20
GESTATION
24
28
32
36
-24 -12 ,o 40
; 8
Volume 103 Number 6
Pregnancy
in adolescent
patients. Mean hemoglobin (Fig. 8) values decreased with advancing gestation and fell along the lower edge of the “acceptable” range for our white population. Over-all mean Negro levels were almost 1.0 Gm. per cent lower than white values. However, at this time the effects of parity and other factors have not been examined and excluded. At time of entry into prenatal care, 18.5 per cent of all our patients were found to have
spectively, of the ascorbic acid levels fall in the “low” range. The hematologic data from our “highrisk” population revealed a significant problem of “anemia” among our mothers at the time they entered prenatal care. All three parameters-hemoglobin, hematocrit, mean corpuscular h e m o g 1 o b i n concentration (MCHC) -revealed a similar pattern of significantly lower mean values in our Negro
HEMOGLOBIN --VANDERBILT TEXAS Negro -- White S %-IO gm
24 18 E’ I2 0”
9.0
u 6s 0
0 L 0
4
0
I2
16 WEEKS
Fig. 8. Mean hemoglobin
units
20
24
28
32
36
40
GESTATION
values.
-=-
%
34
VANDERBILT TEXAS Negro -- White yi %Low
Values
33.5
g
32.5
0’ 3
24 ‘2 I8 3 s I2 6 : -I
32
0s
0 0
4
8
12
16 WEEKS
Fig. 9. Mean
hematocrit
levels.
783
20
24
GESTATION
28
32
36
40
784
McGanity
March 15, 1969 4111. I. Obst. & Gynrc.
et al.
A similar picture is evident in the mc’an hematocrit (Fig. 9) and MCHC (Fig. 101 data. Mean hematocrit levels were 1 .(I to I .5 per cent lower in our Negro patients. Over-all only 6 per cent of MCHC levels fell into the “low” range I kss than 30.5 units). However, four times as many Negro and Latin American patients entered prcnatal care with “low” MCHC values when compared to our other mothers.
hemoglobin levels less than 10.0 Gm. per 100 ml.; 41.3 per cent entered with a hemoglobin level less than 11.0 Gm. per cent. When examined separately, 19 per cent of the Negro mothers had hemoglobin levels under 10 Gm. as compared to 9.9 per cent in our white mothers. With the 11 Gm. level, 46 per cent of our Negro and 30 per cent of our white mothers entered prenatal care with levels under that value.
units 40
%
HEMATOCRIT
1
-m-VANDERBILT TEXAS
38
-
Negro
-w
White %<33
Hct
K34 3 g 32 $
36
I 30 24
2
18
;
12
” a9
6
0
4
8
12
18
20
WEEKS
Fig. 10. Mean corpuscular
hemoglobin
24
28
32
36
40
GESTATION
concentration.
170 150 130
Y3 I10 SJ 90 p
70
3a
50
6
15
\
k/‘-g 16
$
50
7
30
1
0
1 0
Fig. 11. Mean plasma iron levels.
‘0 28
20
24
WEEKS
GESTATION
36
i 0 40
z P s v s
Volume Number
103 6
Mean plasma iron levels (Fig. 11) fell with advancing gestation in both Negro and Lvhite mothers from 150 pg in the first trimester to 100 kl,g per 100 ml. at term. No significant difference was found between the mean Negro and white iron data. The per cent of patients with plasma iron values less than 60 pg per cent gradually increased throughout pregnancy from 15 per cent in those who entered in the first trimester to almost 30 per cent in entrants late in the third trimester. Comment
There were approximately 13 million females between 13 and 20 years of age in the United States in 1967. Only 5 per cent of these (600,000) have been delivered of infants during any of the past 3 or 4 years. Marriage among our young females has been occurring earlier and more frequently for several years both nationally and locally. Over one half of all females in our community are married by the age of 19 yearsor within 18 months of completion of formal secondary school education. On a national basis, approximately 2 per cent of teen-age pregnancies are completed prior to the mother’s fifteenth birthday, 31 per cent during the fifteenth and sixteenth years, and 66 per cent during the seventeenth, eighteenth, and nineteenth years. Comparable figures for our Galveston study were 3.3, 22.5, and 74.2 per cent, respectively. In the United States, Texas, and Galveston County, 4 out of 10 of all first pregnancies and 2 out of 10 of all second babies are delivered of y-oung women under 20 years of age. Our study population rate was somewhat higher-6 out of 10 of first babies and 3 out of 10 of all second babies. Over-all, one quarter of all our deliveries were of mothers less than 20 years in comparison to 1 in 6 nationally and statewide. Over the past decade the teen-age segment of our obstetric population has become an important high-risk part of our responsibility. Many authors as well as the National Vital Statistics have reported that this group has contributed more than their share of
Pregnancy
in adolescent
785
maternal and fetal complications, such as prematurity and perinatal and neonatal mortality. Our study group does not support this contention. When our high-risk teen-agers are compared to the over-all staff patients, prematurity was 15.3 per cent in the former group versus 15.5 per cent in the latter group; the 7 day neonatal mortality was 7.2 versus 6.9 per 1,000 live births for infants weighing over 1,000 grams at time of their delivery, and pre-eclampsia was 13.8 versus 13.6 per cent. During the young girl’s adolescent growth spurt, from years 11 through 16, she contributes 8 per cent to her total physical development. By the age of 17 years whether she be an early or late bloomer she will have completed her sexual, biologic, physiologic, and skeletal maturation. During this adolescent period she has the greatest quantitative nutritional demands for any female age group. Based on the best available information which is incorporated in the NRC Recommended Dietary Allowances 1964 and 1968,91 lo these young women, exclusive of pregnancy demands, have calorie requirements which equal those of an adult male engaging in moderate activity, i.e., 40 to 50 calories per kilogram of body weight. Protein is needed at the level of 1.2 to 1.5 mg. per kilogram of body weight. Both calcium and iron are at the highest level of requirement of any time for the female except during pregnancy and lactation. The increased demands for the vitamins are related primarily to the enhanced caloric needs. Others’l have characterized this young woman as having the poorest dietary habits and food intake of any member of the family at any age. There has been reported a frequent pattern of no breakfast and missed meals plus the ingestion of large amounts of “junk” food. Our nutritional data do not wholly support this thesis as we have determined it at the time she entered prenatal care at our institution. The majority of our young matrons have reported an adequate and satisfactory pattern of food intake and nutrient content. Except for calcium, iron, and to a lesser extent vitamin A and niacin their
786
McGanity
mean
intake
tory.
of
nutrients
Biochemical was only
nificant
the with
hematologic
values,
mineral
was
not
and
cent
our
acid
was
lvere
in
the
not
rate
of
low
evidence in
our
being
into
added midst
of
folate
by
McGanityl?
at the Our
per
cent
less than
3 ng.
Based tional,
on social,
per
hematonic
Alperin, International
We
Folic
other
tions
and
grounds.
Congress
2.
3.
4.
5.
6.
Texas. At a very me that nutrition pregnancy. When
social,
that
are wit11
arr
(health?
attemptins;
educational,
pregnancy
country
cultural,
psycho-
and
throughout
to describe
and/or
ethnic,
Hopefully
tional
sul-Leys
a
United
States
life,
the
popu-
the
different
dietary
series
underway will
having
and
of
at present
provide
each
back-
10
nutri-
in the
section
of
findings--educa-
country with information on the present status of nutritional health of the lowe socioeconomic segment of our population.
as well
including
folate
levels
as nutri-
Discussion CHARLES
those
we
attempted
of has
Harris, J. W.: Bull. Johns Hopkins Hosp. 23: 12, 1922. Savitz, R. A., McCann, M., and Stitt, P. G.: Childbearing, monograph, Washington, D. C., 1966, Children’s Bureau, United States Department of Health, Education and Welfare, pp. 10-15. Savitz. R. A., McCann, M., and Stitt, P. G.: Childbearing; monograph, Washington, D. C., 1966. Children’s Bureau. United States Departient of Health, E&cation and Welfare, pp. 21-22. Savitz, R. A., McCann, M., and Stitt, P. G.: Childbearing, monograph, Washington, D. C., 1966, Children’s Bureau, United States Department of Health, Education and Welfart, pp. 22-23. Lyon, R., Langham, R. A., Metzinger, A. B., and Unglaub, W. G.: Personal communication, 1968. Interdepartmental Committee on Nutrition for
DR.
in have
of our
social,
our
REFERENCES
1.
OUI
lation in Galveston, Texas. Without similar and confirmatory data for the adolescent pregnant females of other areas it would be unwarranted to extrapolate o11r findings to similar obstetric patients living in other SIY-
are
100 ml. over-all
of
to
resources
welfare)
the
series
In cooperation
community
and
improve
including of age.
a srrvict:
adventure
data
population
of serum
health-related
to
of
the
arrest
Haggard,
our
provision
logical? emotional, and nutritional preparation of these young women for their 9 month
as we
These
obstetric
as
a frequency and
of
implemented
the
our
augmen-
maturation
incidence our
C,
care.
concentration population.
reported
many
45 per
iron
this
megaloblastic
obstetric
20 years
from
prenatal
to
patients,
less than
in
education,
of
example,
of ascertaining
Hematology. 2.1
an
received
entry
obstetric
pre-
and
period
indicated
As
patients
after
exsig-
supplementation
unless
findings.
of
tation
the
vitamin
prescribed
biochemical
A
During
have
changes
“acceptable”
vitamins
as riboflavin.
study,
entered
than
tional-we
in-
one
However,
patients
less
satisfacthese
when
values.
of our
care
well
very of
obtained mean
numbers
natal
was
confirmation
terpretations amined
March IS, 1969 Am. J. Obst. Sr Gynec.
et al.
E. FLOWERS, JR., Houston, early age it became clear to was extremely important in I was 13 years old, my father
7. 8. 9.
10.
11.
12.
this
high-risk
obstetric
,group.
National Defense: Manual for Nutrition Surveys, Bethesda, Maryland, 1963, National Center for Chronic Disease Control. Dawson, E. B., Clark, R. R., and McGanity, W. J.: AM. J. OBST. & GTNEC. In press. Darby, W. J., et al.: J. Nutrition 51: 56.5, 1953. National Research Council, Food and Nutrition Board: Dietary Allowances, Washington, D. C., 1964, National Academy of Sciences, Publication No. 1146. National Research Council, Food and Nutrition Board: Dietary Allowances, Washington, D. C., 1968. National Academy of Scierlcr\: Publication No. 1694. Nutritional Status Morgan, A. F., editor: US.4, Berkeley, 1959, California Agricultural Experimental Station, Bulletin No. 769. Alperin, J. B., Haggard, M. E., and McGanity, W. J.: Abstract XII Congress of the International Society of Hematology, New York, 1968, p. 96.
felt that I money. He was to take rabbits oats, to grow and
should begin making my spending bought me a hutch of rabbits that I care of and sell for profit. I fed my cracked corn, and hay. They seemed thrive, but I had almost a 50 per