- Email: [email protected]
The Enigma of Rapid Repeat Pregnancy: A Qualitative Study of Teen Mothers
Original Study The Enigma of Rapid Repeat Pregnancy: A Qualitative Study of Teen Mothers K.N. Conroy MD, MS 1, T.G. Engelhart MHS 1,*, Y. Martins PhD 2, N.L. Huntington PhD 1, A.F. Snyder BA 3, K.D. Coletti MD 4, J.E. Cox MD 1 1
Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts Dana Farber Cancer Institute, Boston, Massachusetts 3 Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida 4 Department of Pediatrics, Johns Hopkins University Hospital, Baltimore, Maryland 2
a b s t r a c t Study Objective: Rapid repeat pregnancy accounts for 18% of teen pregnancies and leads to adverse health, economic, and developmental outcomes for teen mothers and their children. Few interventions have been successful in reducing rapid repeat pregnancy. In this qualitative study we examined adolescent mothers' perceptions of their decision-making and behaviors that helped prevent or promote a rapid repeat pregnancy. Design, Setting, Participants, Interventions, and Main Outcome Measures: Semistructured interviews were conducted with 31 adolescent mothers, aged 16-21 years; 15 of these subjects experienced a repeat pregnancy within a year of their first child's birth and 16 had not. Two researchers used a grounded, inductive technique to identify emergent themes; interviews were subsequently coded accordingly. Counts were tabulated of the number of times themes were endorsed among those with or without a repeat pregnancy. Results: Four overarching themes emerged from the interviews: intentionality regarding pregnancy planning, patients' degree of independence in making contraceptive choices, sense of control over life experience, and barriers to follow-through on contraceptive planning. Teens who had not experienced a rapid repeat pregnancy more often endorsed themes of intentionality in preventing or promoting a pregnancy, independence in decision-making, and feelings of control over their experience. Ambivalence and lack of decision-making about seeking another pregnancy were frequently endorsed by mothers who had experienced a second pregnancy. Conclusion: Decision-making regarding seeking or preventing a rapid repeat pregnancy is complex for teen mothers; techniques to help support decision-making or to delay pregnancy until decision-repeat making is complete might be important in reducing rapid pregnancy. Key Words: Pregnancy in adolescence, Sexual behavior, Unplanned pregnancy, Rapid repeat pregnancy
Introduction
Despite a progressive decline in teen pregnancy rates since 1991, the United States has the highest rate of teenage pregnancies and births among industrialized nations.1,2 Repeat teen births, although decreased in number over the past 2 decades,3,4 continue to account for 18.3% of total births to teen mothers.3 A disproportionate number of these repeat births are experienced by low-income nonwhite teenagers.5,6 Teen childbearing is associated with adverse health, educational, economic, and developmental outcomes for mother and child.7 Each additional child is thought to compound these negative implications.8,9 Having multiple children might reduce educational achievement for the mother and children and decrease the mothers' economic self-sufficiency.9e11 Adolescents who experience a repeat birth within 2 years of the index child are more likely to exhibit parenting stress and neglectful behavior12; children
The authors indicate no conflicts of interest. * Address correspondence to: T.G. Engelhart, MHS, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Hunnewell Ground, Boston, MA 02115; Phone: (617) 355-0570 E-mail address: [email protected] (T.G. Engelhart).
of repeat pregnancies face increased risk of prematurity and behavior problems.9 There is no shortage of research on risk factors for and strategies to prevent repeat teen pregnancy. Inconsistent contraceptive use and high-risk sexual activity are known predictors of repeat pregnancy,6,12e15 whereas long-acting reversible contraception (LARC) has demonstrated efficacy in preventing repeat pregnancies.10,13e17 However, uptake of LARC among teen mothers is limited, and, despite extensive clinic and community-based research,12,18e22 gaps remain in understanding how adolescents approach contraceptive and pregnancy decision-making in the postpartum period. With no recent qualitative data on rapid repeat pregnancy (RRP), we returned to the experience and voices of adolescent mothers to identify untapped strategies for reducing repeat teen pregnancy. We designed a qualitative study on adolescent mothers' perceptions of their own intentions and behaviors that might have helped prevent or facilitate a repeat pregnancy in the year after the birth of their first child. Materials and Methods
This was a retrospective qualitative study in which teen mothers completed semistructured interviews about their
1083-3188/$ - see front matter Ó 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2015.12.003
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social, sexual, behavioral, and environmental experiences and decision-making in the year after the birth of their first child. The study setting was an urban, hospital-based teentot clinic, which provides primary care and access to free Title X-funded contraceptives. Study participants were identified from an existing database of 152 teen mothers who were patients in the teen-tot clinic and participants in a previous randomized controlled trial. All mothers in the database whose first child was born between 2006 and 2010, who had experienced an RRP (defined as becoming pregnant within 1 year of the birth of the index child, regardless of the outcome of that pregnancy), and who continued to live in the community were recruited. Potential comparison subjectsdwho had not experienced RRPdwere identified from the same database, and were matched to those in the RRP group according to race and age at time of birth of index child (Fig. 1). Informed consent was obtained; the hospital institutional review board approved all study procedures. Each participant was paid $40. For each participant, time between the birth of the index child and the interview varied from 12 to 48 months; median interval time in the RRP and non-RRP (NRRP) groups was 28 and 22 months, respectively. Development of Interviews
On the basis of a review of the literature and previous clinical observations, 9 topics were identified for exploration (see Interview Topics). A preliminary interview guide with open-ended questions and follow-up prompts was developed by a 9-person team comprised of experts in survey methodology and adolescent clinical care and research. We conducted pilot interviews with 3 RRP mothers and 2 NRRP mothers and questions were revised on the basis of feedback. On all questions, participants were directed to focus on the 12-month period after the birth of the index child. Interview Topics
1. General demographic information; 2. Experience receiving health care in teen-tot clinic;
Fig. 1. Study enrollment. NRRP, nonrapid repeat pregnancy; RRP, rapid repeat pregnancy.Ă
3. 4. 5. 6. 7. 8. 9.
Planning for next pregnancy; Effect of another pregnancy; Partner influence on pregnancy decision; Social influence on pregnancy decision-making; Contraception; You and your family; Mental health and risk behaviors.
Interview Procedure
Two trained interviewers who had no clinical contact with potential participants (T.G.E., A.F.S.) each conducted half of the interviews for the RRP and NRRP groups. All interviews were conducted in a private space, taped, and transcribed. Interviews lasted 4075 minutes. Statistical Analyses
We used a 3-Sstep approach to synthesize data: (1) develop a coding scheme; (2) code the data; and (3) examine similarities and differences in emergent themes between mothers in the RRP and NNRP group. The coding scheme was developed by 2 independent coders using a grounded, inductive coding technique (Y.M., K.V.P.).23,24 Data were not precoded. Instead, unique categories within each response were identified until no unique categories or themes appeared. Each coder independently developed a coding scheme; fewer than 5% of the categories or themes identified by the coders differed. The coders met to discuss the discrepant categories until 100% agreement was reached. As the list of categories increased, abstract themes emerged of which 4 became the focus of this analysis. For the second step, using the final coding scheme, 2 independent people, who had not been involved in creating the coding scheme, coded the interviews (L.B.G., K.D.C.). A third reviewer resolved any coding discrepancies (K.N.C.). Simple counts were used to compare how often these emergent themes were endorsed in the 2 groups.
K.N. Conroy et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e6 Table 1 Self-Reported Demographic Characteristics of Teen Mothers Characteristic
RRP (n 5 15)
NRRP (n 5 16)
Mean age at birth of index child, years (SD) Race Black White Other Two or more races Ethnicity Hispanic/Latina Annual household income Below $20,000 $20,001-$40,000 $40,001-$60,000 Health insurance Medicaid/Mass Health Total pregnancies at time of interview (range), n Abortion ever Lived with parents during index period Lived with partner during index period Family history of teen pregnancy None Current and/or previous generation School during index period Did not mention Pursued GED High school/college Not in school or GED program
17.57 (1.22)
17.81 (1.27)
7 1 6 1
(46) (7) (40) (7)
6 2 8 0
(38) (12) (50) (0)
8 (53)
10 (62)
12 (75) 2 (13) 1 (7)
15 (94) 1 (6) 0 (0)
15 (100) 2-6
16 (100) 1-5
7 (46) 12 (80) 1 (6)
1 (6) 10 (62) 1 (6)
5 (33) 10 (66)
1 (6) 15 (93)
2 1 11 1
2 1 13 0
(13) (6) (73) (6)
(12) (6) (81) (0)
GED, General Education Diploma; NRRP, nonrapid repeat pregnancy; RRP, rapid repeat pregnancy. Data are presented as n (% or SD) except where otherwise stated.
Results
In Table 1 demographic information on the participants categorized according to pregnancy outcomes are summarized. The 2 groups did not differ in age, race, ethnicity, or household income, but differences were noted in history of abortion and family history of teen pregnancy. Researchers identified 4 major themes: (1) intentionality regarding repeat pregnancy; (2) sense of control over one's life experience; (3) decision-making around contraception; and (4) logistic barriers to obtaining contraception.
Intentionality Regarding Repeat Pregnancy
Participants varied in their degree of described intentionality about avoiding a second pregnancy within 1 year of the index child's birth. Some women endorsed a clear intention to become pregnant: “Like, I wanted 2 children regardless, because it's more love for me. So my daughter could always have someone beside her. If something ever happened to me, they have each other.” (RRP 7); “I thought it [experience of having first child] made me stronger as a person. So I figured, I could do it again, because doing it again would just make me even more stronger.” (RRP 4); In contrast, many patients expressed a clear intention to avoid a second pregnancy. Often this desire was described in context of personal goals, with clear parameters to be met before the birth of another child: “My plan was to go to school, to not have another baby so soon, and, just figure out what I want to do with myself and
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get my life together.” (NRRP 1); “No! Oh my goodness! No! Again no! Again? No! I don't want!. I'm just, I'm letting the tape recorder know that this is a serious no. No more children until I finish college. So. No!” (NRRP 9); “Well my new goal is I can't have a new child., until I'm done with school., I have to have a decent job. And I have to have a car ‘cause there's no way I'm gonna have 2 kids on the bus.” (NRRP 13). Still others expressed ambivalence about another pregnancy. Some felt stuck between 2 choices, and others described a lack of intentionality: “I don't know how to explain it. I was trying to get pregnant. But then in my head I didn't want to get pregnant. That's what I'm saying, I don't know, I, I'm in the middle.” (NRRP 1); “I really didn't care if I had another kid at the time.” (RRP 4); “Well, we wasn't using protection so, I knew it was going to happen. We didn't plan to have a second kid.” (RRP 15); “We go with the flow. Like, if it happens, it happens. We have to deal with it. If it doesn't, then we don't have to deal with it.” (NRRP 7). Sense of Control over Her Life Experience
Participants voiced a range of perspectives regarding their sense of control over their life and decisions. Among women who endorsed a sense of control over their own experience, some voiced this in a prospective way, with the speaker describing a need to take responsibility for her own actions: “I believe that if I'm big enough to lay there and do this, then I'm big enough to take care of my responsibility.” (RRP 9). Other mothers noted that successful attention to motherhood and other life concerns had left them feeling empowered, or “proud” of their own actions: “I felt good because I was like well she's already 1., I did it.. You know? Some parents, they can't do it. I was still in school and I didn't drop out like, I just, I got daycare for her and everything. I felt good.” (NRRP 4); “I'm proud of the way I am now. I got my son. That's the only man in my life right there.” (NRRP 8). Other women described feeling little control over their choices or actions in the first year after the index child's birth. They described a cycle of feeling discouraged by the situation, which hindered them from taking control over their actions, further perpetuating their negative feelings: “I was always tired all the time. I didn't feel like waking up in the morning. I wouldn't go to school. I wouldn't send him to daycare. And like eventually all my absences just caused me to fail my sophomore year, and then my junior year, and then my senior year.” (RRP 6); “So I would smoke, or I would drink trying to just. To make myself feel like I'm still me.” (RRP 3). Decision-Making Regarding Contraception
Participants were asked who in their partnership made decisions about contraceptive use. Some young women made contraceptive decisions independent of their partner, often denying their partner a voice:
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“Well to me he really doesn't have a choice cause this is my body. So. He be, he's fine with it. He didn't like it at first .but I didn't really care because this is my body.” (NRRP 5). “[My partner] doesn't have no say so ‘cause I'm the one that's going to be carrying the baby. So. he's just got to listen.” (NRRP 14). In contrast, other participants described a collaborative approach to contraceptive decision-making: “My partner. No matter what it is. Even though we have our problems, I always value his opinion. Always.” (RRP 8); “We, we're joint in the efforts. So, we both are pretty firm on and agree what to do.” (RRP 14). Barriers
While discussing the themes of sense of control and intention, many participants mentioned barriers to carrying out their intended plans regarding contraception. The barriers were largely logistical, including insurance struggles, or challenges with keeping appointments for LARC or picking up a prescription. Notably, all participants were receiving medical care at a clinic where depo medroxyprogesterone acetate and oral contraceptive pills were free on-site through Title X funding. The hormone patch was available at a local pharmacy by prescription, and intrauterine devices or hormonal implants were available to be inserted at an affiliated medical site. All participants were fully eligible for insurance throughout the index period; any insurance lapse was due to missing paperwork rather than a true denial. Financial counseling was available to resolve insurance issues. “I was scheduled a few times to go do the IUD. But . when you're a mom and trying to work and go to school, or even trying to get a job, it's really hard. And I missed the appointment.” (NRRP 7); “I never had a time. There was always something in my way. I always used to be like, um I have to pick up this [the patch].But I never could.” (RRP 10); “.there was birth control that we never picked up because of multiple things with school and baby and all that. stuff. Then when I went to um, the pharmacy to pick it up they said something was wrong with my insurance. Table 2 Pregnancy and Contraceptive Intentions and Behaviors During the Index Period Behavior Intention regarding repeat pregnancy Intend to become pregnant Intend to avoid pregnancy Ambivalent Sense of control Endorsed sense of control Endorsed lack of control Decision-making regarding contraception Independent decision-making Collaborative decision-making Logistic barriers Mentioned LARC Used LARC during study period
RRP (n 5 15)
NRRP (n 5 16)
1 1 9
0 14 1
1 10
11 2
3 6
14 1
6
4
1
7
LARC, long-acting reversible contraception; NRRP, nonrapid repeat pregnancy; RRP, rapid repeat pregnancy. Data are presented as n; counts do not equal the total n, because participants might not have fallen into either category.
And that was even more discouraging. And then it just never got dealt with. And, I got pregnant.” (RRP 14). Comparing Responses of the RRP and NRRP Groups
In Table 2 a comparison the counts of the emergent themes among the RRP group and the NRRP group are shown. Notably, most women in the NRRP group expressed a clear intention to avoid pregnancy, and more women in the RRP group expressed ambivalence about a second pregnancy. Feeling little control over life experiences was more frequently endorsed in the RRP group. Almost all women in the NRRP group noted that they made independent decisions regarding contraception. Logistical barriers to obtaining contraception were endorsed in each group. Eight participants used LARC during the study interval, most of whom were in the NRRP group. Notably, 2 of the women who used LARC did not endorse a strong intention to prevent pregnancy (data not shown). Discussion
Our study suggests that among low-income, urban, teen mothers, intentionality regarding repeat pregnancy, a sense of control over life experiences, and ability to make independent decisions about contraception might be key factors in the experience of women who avoid an RRP, and might also serve as drivers for those who experience a repeat pregnancy. Our finding that intention to prevent repeat pregnancy was often endorsed in the NRRP group echoes earlier studies that associated strong intention to prevent pregnancy with increased contraception compliance.25 Furthermore, our finding that ambivalence regarding repeat pregnancy was widely articulated among those who experienced RRP supports research that suggests that all teens not actively seeking to prevent pregnancy are “susceptible to pregnancy” or “pregnancy receptive,” and that those who do not strongly endorse intention to prevent pregnancy should be considered high-risk.26,27 Indeed, previous studies identify ambivalence about pregnancy as a risk factor for inconsistent contraception use28 and for primary pregnancy in adolescents.29,30 Our participants' descriptions of ambivalence was heterogeneous, ranging from those who had mixed feelings or were vacillating, to those who “did not care” about the outcome. Mothers in the NRRP group frequently described their contraceptive decision-making as independent, in contrast to women with RRP who endorsed that they worked collaboratively with their partner to make these decisions. This trend is notable because it contradicts current policy and funding strategies, which encourage teen parenting programs to involve fathers.31e33 Recent research has been conducted to explore the variable role partner attitudes play in decreasing unwanted pregnancies, and suggested that not all partner involvement reduces the rate of pregnancies.34,35 Furthermore, research on teen parenting consistently shows that relationships between young parents are unstable with frequent break-ups and declining father involvement over time.10,17 Domestic violence also
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increases risk of unplanned pregnancy.36 Therefore, the observation in our study of a trend toward avoidance of repeat pregnancy through independent decision-making warrants further study. Not surprisingly, with the robust evidence for the effectiveness of LARC16,37e40 most LARC users in our study did not experience a repeat pregnancy. More interestingly, however, some teens received LARC but did not describe themselves as strongly intending to prevent pregnancy. Perhaps at some point they did intend to prevent pregnancy, but intention might be dynamic over time. In these cases, receipt of LARC might have buffered these women against future moments of ambivalence. Our study has a number of key limitations. Because of our retrospective design, participants' descriptions of their feelings or actions during the study period might suffer from recall bias. Furthermore, the time interval since birth of the index child varied between participants. Although the major demographic factors of age, race, ethnicity, and household income did not appear to differ between the groups, there were other notable differences in abortion history and family history of teen pregnancy that could directly affect repeat pregnancy, or one of the identified themes, thus acting as a confounder. However, because of the qualitative nature of this study, we did not directly investigate this. Some of our researchers close clinical connection with this population might have biased our recognition of certain themes in this writing. However, the coding scheme and the coding of the interviews were performed by researchers not on the clinical team. Finally, although counts reflected whether or not a teen “mentioned” a theme or experience, teens might have responded differently had they been asked about certain experiences directly. Our findings have several implications. First, intention about preventing an RRP should not be assumed. Acknowledgement of some adolescents' desire to have a repeat pregnancy might help to optimize planning for a healthy repeat pregnancy. Furthermore, honest recognition of ambivalence and techniques to help teens formulate clear plans could be a key technique to curb undesired RRP. Office-based techniques such as motivational interviewing that help adolescents identify and work through ambivalence are promising.18 Our finding that young women who made contraceptive choices without their partner had greater success in avoiding pregnancy merits further exploration because it contrasts current philosophy regarding programming for teen pregnancy. Finally, encouraging receipt of LARC might not only protect those who have intention to avoid a repeat pregnancy, but might provide time for young women with ambivalence to find their intention. Acknowledgments
This research was supported in part by the Office of Adolescent Pregnancy Programs, Grant # APHPA002003308-01. The authors thank the staff and patients of the Young Parents Program at Boston Children's Hospital. The authors
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also thank Laura Baldaji-Garcia and Kelly Perez-Vergara, for their careful and diligent assistance in the early stages of this study, and Dr Jean Emans for her thoughtful guidance and review. References 1. The National Campaign to Prevent Teen and Unplanned Pregnancy. Fast Facts: How Does the United States Compare? Available: http://thenationalcampaign. org/resource/fast-facts-how-does-united-states-compare. Accessed January 5, 2016. 2. Martin JA, Hamilton BE, Osterman MJ, et al: Births: final data for 2012. Natl Vital Stat Rep 2015; 64:1 3. Vital Signs: Repeat Births Among Teens - United States, 2007-2010. Atlanta, GA, Center for Disease Control and Prevention, 2013 4. Schelar E, Franzetta K, Manlove J: Repeat Teen Childbearing: Differences Across States and by Race and Ethnicity, Child Trends, Washington, DC, 2008. 5. Stevens-Simon C, Lowy R: Teenage childbearing. An adaptive strategy for the socioeconomically disadvantaged or a strategy for adapting to socioeconomic disadvantage? Arch Pediatr Adolesc Med 1995; 149:912 6. Rigsby DC, Macones GA, Driscoll DA: Risk factors for rapid repeat pregnancy among adolescent mothers: a review of the literature. J Pediatr Adolesc Gynecol 1998; 11:115 7. Ruedinger E, Cox JE: Adolescent childbearing: consequences and interventions. Curr Opin Pediatr 2012; 24:446 8. Barnet B, Rapp T, DeVoe M, et al: Cost-effectiveness of a motivational intervention to reduce rapid repeated childbearing in high-risk adolescent mothers: a rebirth of economic and policy considerations. Arch Pediatr Adolesc Med 2010; 164:370 9. The National Campaign to Prevent Teen and Unplanned Pregnancy: Klerman LV: Another Chance: Preventing Additional Births to Teen Mothers. Available: https://thenationalcampaign.org/sites/default/files/resource-primary-downloa d/anotherchance_final.pdf. Accessed January 5, 2016. 10. Savio Beers LA, Hollo RE: Approaching the adolescent-headed family: a review of teen parenting. Curr Probl Pediatr Adolesc Health Care 2009; 39:216 11. Pogarsky G, Thornberry TP, Lizotte AJ: Developmental outcomes for children of young mothers. J Marriage Fam 2006; 68:332 12. El-Kamary SS, Higman SM, Fuddy L, et al: Hawaii’s healthy start home visiting program: determinants and impact of rapid repeat birth. Pediatrics 2004; 114: e317 13. Stevens-Simon C, Kelly L, Kulick R: A village would be nice but.it takes a long-acting contraceptive to prevent repeat adolescent pregnancies. Am J Prev Med 2001; 21:60 14. Stevens-Simon C, Kelly L, Singer D: Preventing repeat adolescent pregnancies with early adoption of the contraceptive implant. Fam Plann Perspect 1999; 31:88 15. Meade CS, Ickovics JR: Systematic review of sexual risk among pregnant and mothering teens in the USA: pregnancy as an opportunity for integrated prevention of STD and repeat pregnancy. Soc Sci Med 2005; 60:661 16. Tocce KM, Sheeder JL, Teal SB: Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012; 206:481 17. Cox JE, Buman MP, Woods ER, et al: Evaluation of raising adolescent families together: a medical home for teen mothers and their children. Am J Public Health 2012; 102:1879 18. Barnet B, Liu J, DeVoe M, et al: Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial. Ann Fam Med 2009; 7:436 19. Katz KS, Rodan M, Milligan R, et al: Efficacy of a randomized cell phone-based counseling intervention in postponing subsequent pregnancy among teen mothers. Matern Child Health J 2011; 15(Suppl 1):S42 20. Salihu HM, August EM, Jeffers DF, et al: Effectiveness of a Federal Healthy Start program in reducing primary and repeat teen pregnancies: our experience over the decade. J Pediatr Adolesc Gynecol 2011; 24:153 21. Sims K, Luster T: Factors related to early subsequent pregnancies and second births among adolescent mothers in a Family Support Program. J Fam Issues 2002; 23:1006 22. Omar HA, Fowler A, McClanahan KK: Significant reduction of repeat teen pregnancy in a comprehensive young parent program. J Pediatr Adolesc Gynecol 2008; 21:283 23. Strauss A, Corbin JM: Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications, Los Angeles, 1998 24. Jones J, Hunter D: Qualitative research: consensus methods for medical and health services research. BMJ 1995; 311:376 25. Bartz D, Shew M, Ofner S, et al: Pregnancy intentions and contraceptive behaviors among adolescent women: a coital event level analysis. J Adolesc Health 2007; 41:271 26. Stevens-Simon C, Beach RK, Klerman LV: To be rather than not to beethat is the problem with the questions we ask adolescents about their childbearing intentions. Arch Pediatr Adolesc Med 2001; 155:1298 27. Watnick D, Silver EJ, Leu CS, and Bauman LJ: When teens want pregnancy: examining poverty and teen relationships. In: Proceedings of the Pediatric Academic Societies Annual Meeting, May 4-7, 2013. Washington, DC.
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28. Crosby RA, Diclemente RJ, Wingood GM, et al: Adolescents’ ambivalence about becoming pregnant predicts infrequent contraceptive use: a prospective analysis of nonpregnant African American females. Am J Obstet Gynecol 2002; 186:251 29. Jaccard J, Dodge T, Dittus P: Do adolescents want to avoid pregnancy? Attitudes toward pregnancy as predictors of pregnancy. J Adolesc Health 2003; 33:79 30. Sheeder J, Teal SB, Crane LA, et al: Adolescent childbearing ambivalence: is it the sum of its parts? J Pediatr Adolesc Gynecol 2010; 23:86 31. Grady WR, Klepinger DH, Billy JO, et al: The role of relationship power in couple decisions about contraception in the US. J Biosoc Sci 2010; 42:307 32. Urban Institute: Sonenstein F, Punja S, Scarcella C: Future directions for family planning research: a framework for Title X family planning service delivery improvement research. Available: http://www.urban.org/research/publication/ future-directions-family-planning-research. Accessed January 5, 2016. 33. Cox S, Posner SF, Sangi-Haghpeykar H: Who's responsible? Correlates of partner involvement in contraceptive decision making. Womens Health Issues 2010; 20:254
34. Forste R, Morgan J: How relationships of U.S. men affect contraceptive use and efforts to prevent sexually transmitted diseases. Fam Plann Perspect 1998; 30:56 35. Kavanaugh ML, Lindberg LD, Frost J: Factors influencing partners’ involvement in women’s contraceptive services. Contraception 2012; 85:83 36. Sarkar NN: The impact of intimate partner violence on women's reproductive health and pregnancy outcome. J Obstet Gynecol 2008; 28:266 37. Davis AJ: Intrauterine devices in adolescents. Curr Opin Pediatr 2011; 23: 557 38. McNicholas C, Peipert JF: Long-acting reversible contraception for adolescents. Curr Opin Obstet Gynecol 2012; 24:293 39. Winner B, Peipert JF, Zhao Q, et al: Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366:1998 40. Baldwin MK, Edelman AB: The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: a review. J Adolesc Health 2013; 52(4 Suppl):S47
Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts Dana Farber Cancer Institute, Boston, Massachusetts 3 Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida 4 Department of Pediatrics, Johns Hopkins University Hospital, Baltimore, Maryland 2
a b s t r a c t Study Objective: Rapid repeat pregnancy accounts for 18% of teen pregnancies and leads to adverse health, economic, and developmental outcomes for teen mothers and their children. Few interventions have been successful in reducing rapid repeat pregnancy. In this qualitative study we examined adolescent mothers' perceptions of their decision-making and behaviors that helped prevent or promote a rapid repeat pregnancy. Design, Setting, Participants, Interventions, and Main Outcome Measures: Semistructured interviews were conducted with 31 adolescent mothers, aged 16-21 years; 15 of these subjects experienced a repeat pregnancy within a year of their first child's birth and 16 had not. Two researchers used a grounded, inductive technique to identify emergent themes; interviews were subsequently coded accordingly. Counts were tabulated of the number of times themes were endorsed among those with or without a repeat pregnancy. Results: Four overarching themes emerged from the interviews: intentionality regarding pregnancy planning, patients' degree of independence in making contraceptive choices, sense of control over life experience, and barriers to follow-through on contraceptive planning. Teens who had not experienced a rapid repeat pregnancy more often endorsed themes of intentionality in preventing or promoting a pregnancy, independence in decision-making, and feelings of control over their experience. Ambivalence and lack of decision-making about seeking another pregnancy were frequently endorsed by mothers who had experienced a second pregnancy. Conclusion: Decision-making regarding seeking or preventing a rapid repeat pregnancy is complex for teen mothers; techniques to help support decision-making or to delay pregnancy until decision-repeat making is complete might be important in reducing rapid pregnancy. Key Words: Pregnancy in adolescence, Sexual behavior, Unplanned pregnancy, Rapid repeat pregnancy
Introduction
Despite a progressive decline in teen pregnancy rates since 1991, the United States has the highest rate of teenage pregnancies and births among industrialized nations.1,2 Repeat teen births, although decreased in number over the past 2 decades,3,4 continue to account for 18.3% of total births to teen mothers.3 A disproportionate number of these repeat births are experienced by low-income nonwhite teenagers.5,6 Teen childbearing is associated with adverse health, educational, economic, and developmental outcomes for mother and child.7 Each additional child is thought to compound these negative implications.8,9 Having multiple children might reduce educational achievement for the mother and children and decrease the mothers' economic self-sufficiency.9e11 Adolescents who experience a repeat birth within 2 years of the index child are more likely to exhibit parenting stress and neglectful behavior12; children
The authors indicate no conflicts of interest. * Address correspondence to: T.G. Engelhart, MHS, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Hunnewell Ground, Boston, MA 02115; Phone: (617) 355-0570 E-mail address: [email protected] (T.G. Engelhart).
of repeat pregnancies face increased risk of prematurity and behavior problems.9 There is no shortage of research on risk factors for and strategies to prevent repeat teen pregnancy. Inconsistent contraceptive use and high-risk sexual activity are known predictors of repeat pregnancy,6,12e15 whereas long-acting reversible contraception (LARC) has demonstrated efficacy in preventing repeat pregnancies.10,13e17 However, uptake of LARC among teen mothers is limited, and, despite extensive clinic and community-based research,12,18e22 gaps remain in understanding how adolescents approach contraceptive and pregnancy decision-making in the postpartum period. With no recent qualitative data on rapid repeat pregnancy (RRP), we returned to the experience and voices of adolescent mothers to identify untapped strategies for reducing repeat teen pregnancy. We designed a qualitative study on adolescent mothers' perceptions of their own intentions and behaviors that might have helped prevent or facilitate a repeat pregnancy in the year after the birth of their first child. Materials and Methods
This was a retrospective qualitative study in which teen mothers completed semistructured interviews about their
1083-3188/$ - see front matter Ó 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2015.12.003
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social, sexual, behavioral, and environmental experiences and decision-making in the year after the birth of their first child. The study setting was an urban, hospital-based teentot clinic, which provides primary care and access to free Title X-funded contraceptives. Study participants were identified from an existing database of 152 teen mothers who were patients in the teen-tot clinic and participants in a previous randomized controlled trial. All mothers in the database whose first child was born between 2006 and 2010, who had experienced an RRP (defined as becoming pregnant within 1 year of the birth of the index child, regardless of the outcome of that pregnancy), and who continued to live in the community were recruited. Potential comparison subjectsdwho had not experienced RRPdwere identified from the same database, and were matched to those in the RRP group according to race and age at time of birth of index child (Fig. 1). Informed consent was obtained; the hospital institutional review board approved all study procedures. Each participant was paid $40. For each participant, time between the birth of the index child and the interview varied from 12 to 48 months; median interval time in the RRP and non-RRP (NRRP) groups was 28 and 22 months, respectively. Development of Interviews
On the basis of a review of the literature and previous clinical observations, 9 topics were identified for exploration (see Interview Topics). A preliminary interview guide with open-ended questions and follow-up prompts was developed by a 9-person team comprised of experts in survey methodology and adolescent clinical care and research. We conducted pilot interviews with 3 RRP mothers and 2 NRRP mothers and questions were revised on the basis of feedback. On all questions, participants were directed to focus on the 12-month period after the birth of the index child. Interview Topics
1. General demographic information; 2. Experience receiving health care in teen-tot clinic;
Fig. 1. Study enrollment. NRRP, nonrapid repeat pregnancy; RRP, rapid repeat pregnancy.Ă
3. 4. 5. 6. 7. 8. 9.
Planning for next pregnancy; Effect of another pregnancy; Partner influence on pregnancy decision; Social influence on pregnancy decision-making; Contraception; You and your family; Mental health and risk behaviors.
Interview Procedure
Two trained interviewers who had no clinical contact with potential participants (T.G.E., A.F.S.) each conducted half of the interviews for the RRP and NRRP groups. All interviews were conducted in a private space, taped, and transcribed. Interviews lasted 4075 minutes. Statistical Analyses
We used a 3-Sstep approach to synthesize data: (1) develop a coding scheme; (2) code the data; and (3) examine similarities and differences in emergent themes between mothers in the RRP and NNRP group. The coding scheme was developed by 2 independent coders using a grounded, inductive coding technique (Y.M., K.V.P.).23,24 Data were not precoded. Instead, unique categories within each response were identified until no unique categories or themes appeared. Each coder independently developed a coding scheme; fewer than 5% of the categories or themes identified by the coders differed. The coders met to discuss the discrepant categories until 100% agreement was reached. As the list of categories increased, abstract themes emerged of which 4 became the focus of this analysis. For the second step, using the final coding scheme, 2 independent people, who had not been involved in creating the coding scheme, coded the interviews (L.B.G., K.D.C.). A third reviewer resolved any coding discrepancies (K.N.C.). Simple counts were used to compare how often these emergent themes were endorsed in the 2 groups.
K.N. Conroy et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e6 Table 1 Self-Reported Demographic Characteristics of Teen Mothers Characteristic
RRP (n 5 15)
NRRP (n 5 16)
Mean age at birth of index child, years (SD) Race Black White Other Two or more races Ethnicity Hispanic/Latina Annual household income Below $20,000 $20,001-$40,000 $40,001-$60,000 Health insurance Medicaid/Mass Health Total pregnancies at time of interview (range), n Abortion ever Lived with parents during index period Lived with partner during index period Family history of teen pregnancy None Current and/or previous generation School during index period Did not mention Pursued GED High school/college Not in school or GED program
17.57 (1.22)
17.81 (1.27)
7 1 6 1
(46) (7) (40) (7)
6 2 8 0
(38) (12) (50) (0)
8 (53)
10 (62)
12 (75) 2 (13) 1 (7)
15 (94) 1 (6) 0 (0)
15 (100) 2-6
16 (100) 1-5
7 (46) 12 (80) 1 (6)
1 (6) 10 (62) 1 (6)
5 (33) 10 (66)
1 (6) 15 (93)
2 1 11 1
2 1 13 0
(13) (6) (73) (6)
(12) (6) (81) (0)
GED, General Education Diploma; NRRP, nonrapid repeat pregnancy; RRP, rapid repeat pregnancy. Data are presented as n (% or SD) except where otherwise stated.
Results
In Table 1 demographic information on the participants categorized according to pregnancy outcomes are summarized. The 2 groups did not differ in age, race, ethnicity, or household income, but differences were noted in history of abortion and family history of teen pregnancy. Researchers identified 4 major themes: (1) intentionality regarding repeat pregnancy; (2) sense of control over one's life experience; (3) decision-making around contraception; and (4) logistic barriers to obtaining contraception.
Intentionality Regarding Repeat Pregnancy
Participants varied in their degree of described intentionality about avoiding a second pregnancy within 1 year of the index child's birth. Some women endorsed a clear intention to become pregnant: “Like, I wanted 2 children regardless, because it's more love for me. So my daughter could always have someone beside her. If something ever happened to me, they have each other.” (RRP 7); “I thought it [experience of having first child] made me stronger as a person. So I figured, I could do it again, because doing it again would just make me even more stronger.” (RRP 4); In contrast, many patients expressed a clear intention to avoid a second pregnancy. Often this desire was described in context of personal goals, with clear parameters to be met before the birth of another child: “My plan was to go to school, to not have another baby so soon, and, just figure out what I want to do with myself and
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get my life together.” (NRRP 1); “No! Oh my goodness! No! Again no! Again? No! I don't want!. I'm just, I'm letting the tape recorder know that this is a serious no. No more children until I finish college. So. No!” (NRRP 9); “Well my new goal is I can't have a new child., until I'm done with school., I have to have a decent job. And I have to have a car ‘cause there's no way I'm gonna have 2 kids on the bus.” (NRRP 13). Still others expressed ambivalence about another pregnancy. Some felt stuck between 2 choices, and others described a lack of intentionality: “I don't know how to explain it. I was trying to get pregnant. But then in my head I didn't want to get pregnant. That's what I'm saying, I don't know, I, I'm in the middle.” (NRRP 1); “I really didn't care if I had another kid at the time.” (RRP 4); “Well, we wasn't using protection so, I knew it was going to happen. We didn't plan to have a second kid.” (RRP 15); “We go with the flow. Like, if it happens, it happens. We have to deal with it. If it doesn't, then we don't have to deal with it.” (NRRP 7). Sense of Control over Her Life Experience
Participants voiced a range of perspectives regarding their sense of control over their life and decisions. Among women who endorsed a sense of control over their own experience, some voiced this in a prospective way, with the speaker describing a need to take responsibility for her own actions: “I believe that if I'm big enough to lay there and do this, then I'm big enough to take care of my responsibility.” (RRP 9). Other mothers noted that successful attention to motherhood and other life concerns had left them feeling empowered, or “proud” of their own actions: “I felt good because I was like well she's already 1., I did it.. You know? Some parents, they can't do it. I was still in school and I didn't drop out like, I just, I got daycare for her and everything. I felt good.” (NRRP 4); “I'm proud of the way I am now. I got my son. That's the only man in my life right there.” (NRRP 8). Other women described feeling little control over their choices or actions in the first year after the index child's birth. They described a cycle of feeling discouraged by the situation, which hindered them from taking control over their actions, further perpetuating their negative feelings: “I was always tired all the time. I didn't feel like waking up in the morning. I wouldn't go to school. I wouldn't send him to daycare. And like eventually all my absences just caused me to fail my sophomore year, and then my junior year, and then my senior year.” (RRP 6); “So I would smoke, or I would drink trying to just. To make myself feel like I'm still me.” (RRP 3). Decision-Making Regarding Contraception
Participants were asked who in their partnership made decisions about contraceptive use. Some young women made contraceptive decisions independent of their partner, often denying their partner a voice:
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“Well to me he really doesn't have a choice cause this is my body. So. He be, he's fine with it. He didn't like it at first .but I didn't really care because this is my body.” (NRRP 5). “[My partner] doesn't have no say so ‘cause I'm the one that's going to be carrying the baby. So. he's just got to listen.” (NRRP 14). In contrast, other participants described a collaborative approach to contraceptive decision-making: “My partner. No matter what it is. Even though we have our problems, I always value his opinion. Always.” (RRP 8); “We, we're joint in the efforts. So, we both are pretty firm on and agree what to do.” (RRP 14). Barriers
While discussing the themes of sense of control and intention, many participants mentioned barriers to carrying out their intended plans regarding contraception. The barriers were largely logistical, including insurance struggles, or challenges with keeping appointments for LARC or picking up a prescription. Notably, all participants were receiving medical care at a clinic where depo medroxyprogesterone acetate and oral contraceptive pills were free on-site through Title X funding. The hormone patch was available at a local pharmacy by prescription, and intrauterine devices or hormonal implants were available to be inserted at an affiliated medical site. All participants were fully eligible for insurance throughout the index period; any insurance lapse was due to missing paperwork rather than a true denial. Financial counseling was available to resolve insurance issues. “I was scheduled a few times to go do the IUD. But . when you're a mom and trying to work and go to school, or even trying to get a job, it's really hard. And I missed the appointment.” (NRRP 7); “I never had a time. There was always something in my way. I always used to be like, um I have to pick up this [the patch].But I never could.” (RRP 10); “.there was birth control that we never picked up because of multiple things with school and baby and all that. stuff. Then when I went to um, the pharmacy to pick it up they said something was wrong with my insurance. Table 2 Pregnancy and Contraceptive Intentions and Behaviors During the Index Period Behavior Intention regarding repeat pregnancy Intend to become pregnant Intend to avoid pregnancy Ambivalent Sense of control Endorsed sense of control Endorsed lack of control Decision-making regarding contraception Independent decision-making Collaborative decision-making Logistic barriers Mentioned LARC Used LARC during study period
RRP (n 5 15)
NRRP (n 5 16)
1 1 9
0 14 1
1 10
11 2
3 6
14 1
6
4
1
7
LARC, long-acting reversible contraception; NRRP, nonrapid repeat pregnancy; RRP, rapid repeat pregnancy. Data are presented as n; counts do not equal the total n, because participants might not have fallen into either category.
And that was even more discouraging. And then it just never got dealt with. And, I got pregnant.” (RRP 14). Comparing Responses of the RRP and NRRP Groups
In Table 2 a comparison the counts of the emergent themes among the RRP group and the NRRP group are shown. Notably, most women in the NRRP group expressed a clear intention to avoid pregnancy, and more women in the RRP group expressed ambivalence about a second pregnancy. Feeling little control over life experiences was more frequently endorsed in the RRP group. Almost all women in the NRRP group noted that they made independent decisions regarding contraception. Logistical barriers to obtaining contraception were endorsed in each group. Eight participants used LARC during the study interval, most of whom were in the NRRP group. Notably, 2 of the women who used LARC did not endorse a strong intention to prevent pregnancy (data not shown). Discussion
Our study suggests that among low-income, urban, teen mothers, intentionality regarding repeat pregnancy, a sense of control over life experiences, and ability to make independent decisions about contraception might be key factors in the experience of women who avoid an RRP, and might also serve as drivers for those who experience a repeat pregnancy. Our finding that intention to prevent repeat pregnancy was often endorsed in the NRRP group echoes earlier studies that associated strong intention to prevent pregnancy with increased contraception compliance.25 Furthermore, our finding that ambivalence regarding repeat pregnancy was widely articulated among those who experienced RRP supports research that suggests that all teens not actively seeking to prevent pregnancy are “susceptible to pregnancy” or “pregnancy receptive,” and that those who do not strongly endorse intention to prevent pregnancy should be considered high-risk.26,27 Indeed, previous studies identify ambivalence about pregnancy as a risk factor for inconsistent contraception use28 and for primary pregnancy in adolescents.29,30 Our participants' descriptions of ambivalence was heterogeneous, ranging from those who had mixed feelings or were vacillating, to those who “did not care” about the outcome. Mothers in the NRRP group frequently described their contraceptive decision-making as independent, in contrast to women with RRP who endorsed that they worked collaboratively with their partner to make these decisions. This trend is notable because it contradicts current policy and funding strategies, which encourage teen parenting programs to involve fathers.31e33 Recent research has been conducted to explore the variable role partner attitudes play in decreasing unwanted pregnancies, and suggested that not all partner involvement reduces the rate of pregnancies.34,35 Furthermore, research on teen parenting consistently shows that relationships between young parents are unstable with frequent break-ups and declining father involvement over time.10,17 Domestic violence also
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increases risk of unplanned pregnancy.36 Therefore, the observation in our study of a trend toward avoidance of repeat pregnancy through independent decision-making warrants further study. Not surprisingly, with the robust evidence for the effectiveness of LARC16,37e40 most LARC users in our study did not experience a repeat pregnancy. More interestingly, however, some teens received LARC but did not describe themselves as strongly intending to prevent pregnancy. Perhaps at some point they did intend to prevent pregnancy, but intention might be dynamic over time. In these cases, receipt of LARC might have buffered these women against future moments of ambivalence. Our study has a number of key limitations. Because of our retrospective design, participants' descriptions of their feelings or actions during the study period might suffer from recall bias. Furthermore, the time interval since birth of the index child varied between participants. Although the major demographic factors of age, race, ethnicity, and household income did not appear to differ between the groups, there were other notable differences in abortion history and family history of teen pregnancy that could directly affect repeat pregnancy, or one of the identified themes, thus acting as a confounder. However, because of the qualitative nature of this study, we did not directly investigate this. Some of our researchers close clinical connection with this population might have biased our recognition of certain themes in this writing. However, the coding scheme and the coding of the interviews were performed by researchers not on the clinical team. Finally, although counts reflected whether or not a teen “mentioned” a theme or experience, teens might have responded differently had they been asked about certain experiences directly. Our findings have several implications. First, intention about preventing an RRP should not be assumed. Acknowledgement of some adolescents' desire to have a repeat pregnancy might help to optimize planning for a healthy repeat pregnancy. Furthermore, honest recognition of ambivalence and techniques to help teens formulate clear plans could be a key technique to curb undesired RRP. Office-based techniques such as motivational interviewing that help adolescents identify and work through ambivalence are promising.18 Our finding that young women who made contraceptive choices without their partner had greater success in avoiding pregnancy merits further exploration because it contrasts current philosophy regarding programming for teen pregnancy. Finally, encouraging receipt of LARC might not only protect those who have intention to avoid a repeat pregnancy, but might provide time for young women with ambivalence to find their intention. Acknowledgments
This research was supported in part by the Office of Adolescent Pregnancy Programs, Grant # APHPA002003308-01. The authors thank the staff and patients of the Young Parents Program at Boston Children's Hospital. The authors
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also thank Laura Baldaji-Garcia and Kelly Perez-Vergara, for their careful and diligent assistance in the early stages of this study, and Dr Jean Emans for her thoughtful guidance and review. References 1. The National Campaign to Prevent Teen and Unplanned Pregnancy. Fast Facts: How Does the United States Compare? Available: http://thenationalcampaign. org/resource/fast-facts-how-does-united-states-compare. Accessed January 5, 2016. 2. Martin JA, Hamilton BE, Osterman MJ, et al: Births: final data for 2012. Natl Vital Stat Rep 2015; 64:1 3. Vital Signs: Repeat Births Among Teens - United States, 2007-2010. Atlanta, GA, Center for Disease Control and Prevention, 2013 4. Schelar E, Franzetta K, Manlove J: Repeat Teen Childbearing: Differences Across States and by Race and Ethnicity, Child Trends, Washington, DC, 2008. 5. Stevens-Simon C, Lowy R: Teenage childbearing. An adaptive strategy for the socioeconomically disadvantaged or a strategy for adapting to socioeconomic disadvantage? Arch Pediatr Adolesc Med 1995; 149:912 6. Rigsby DC, Macones GA, Driscoll DA: Risk factors for rapid repeat pregnancy among adolescent mothers: a review of the literature. J Pediatr Adolesc Gynecol 1998; 11:115 7. Ruedinger E, Cox JE: Adolescent childbearing: consequences and interventions. Curr Opin Pediatr 2012; 24:446 8. Barnet B, Rapp T, DeVoe M, et al: Cost-effectiveness of a motivational intervention to reduce rapid repeated childbearing in high-risk adolescent mothers: a rebirth of economic and policy considerations. Arch Pediatr Adolesc Med 2010; 164:370 9. The National Campaign to Prevent Teen and Unplanned Pregnancy: Klerman LV: Another Chance: Preventing Additional Births to Teen Mothers. Available: https://thenationalcampaign.org/sites/default/files/resource-primary-downloa d/anotherchance_final.pdf. Accessed January 5, 2016. 10. Savio Beers LA, Hollo RE: Approaching the adolescent-headed family: a review of teen parenting. Curr Probl Pediatr Adolesc Health Care 2009; 39:216 11. Pogarsky G, Thornberry TP, Lizotte AJ: Developmental outcomes for children of young mothers. J Marriage Fam 2006; 68:332 12. El-Kamary SS, Higman SM, Fuddy L, et al: Hawaii’s healthy start home visiting program: determinants and impact of rapid repeat birth. Pediatrics 2004; 114: e317 13. Stevens-Simon C, Kelly L, Kulick R: A village would be nice but.it takes a long-acting contraceptive to prevent repeat adolescent pregnancies. Am J Prev Med 2001; 21:60 14. Stevens-Simon C, Kelly L, Singer D: Preventing repeat adolescent pregnancies with early adoption of the contraceptive implant. Fam Plann Perspect 1999; 31:88 15. Meade CS, Ickovics JR: Systematic review of sexual risk among pregnant and mothering teens in the USA: pregnancy as an opportunity for integrated prevention of STD and repeat pregnancy. Soc Sci Med 2005; 60:661 16. Tocce KM, Sheeder JL, Teal SB: Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012; 206:481 17. Cox JE, Buman MP, Woods ER, et al: Evaluation of raising adolescent families together: a medical home for teen mothers and their children. Am J Public Health 2012; 102:1879 18. Barnet B, Liu J, DeVoe M, et al: Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial. Ann Fam Med 2009; 7:436 19. Katz KS, Rodan M, Milligan R, et al: Efficacy of a randomized cell phone-based counseling intervention in postponing subsequent pregnancy among teen mothers. Matern Child Health J 2011; 15(Suppl 1):S42 20. Salihu HM, August EM, Jeffers DF, et al: Effectiveness of a Federal Healthy Start program in reducing primary and repeat teen pregnancies: our experience over the decade. J Pediatr Adolesc Gynecol 2011; 24:153 21. Sims K, Luster T: Factors related to early subsequent pregnancies and second births among adolescent mothers in a Family Support Program. J Fam Issues 2002; 23:1006 22. Omar HA, Fowler A, McClanahan KK: Significant reduction of repeat teen pregnancy in a comprehensive young parent program. J Pediatr Adolesc Gynecol 2008; 21:283 23. Strauss A, Corbin JM: Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications, Los Angeles, 1998 24. Jones J, Hunter D: Qualitative research: consensus methods for medical and health services research. BMJ 1995; 311:376 25. Bartz D, Shew M, Ofner S, et al: Pregnancy intentions and contraceptive behaviors among adolescent women: a coital event level analysis. J Adolesc Health 2007; 41:271 26. Stevens-Simon C, Beach RK, Klerman LV: To be rather than not to beethat is the problem with the questions we ask adolescents about their childbearing intentions. Arch Pediatr Adolesc Med 2001; 155:1298 27. Watnick D, Silver EJ, Leu CS, and Bauman LJ: When teens want pregnancy: examining poverty and teen relationships. In: Proceedings of the Pediatric Academic Societies Annual Meeting, May 4-7, 2013. Washington, DC.
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