The teen—Tot clinic

JOURNAL OE ADOLESCENT HEALTH CARE 3:19-23, 1982

The Teen-Tot Clinic: An Alternative to Traditional Care for Infants of Teenaged Mothers K A T H L E E N G. N E L S O N , M.D., DIANE KEY, R.N,, P.N.P., JANICE K. FLETCHER, M.S.W., ELLEN KIRKPATRICK, R.D., A N D R O N A L D FEINSTEIN, M.D.

A comprehensive interdisciplinary clinic was established to provide health care for teenaged mothers ~ 16 years old and their infants. Thirty-five mother-infants pair s using this clinic were matcl~ed with 70 mother-infant pairs who used "traditional" health care facilities. Significant differences in infant outcomes of immunization status at 6 months (91% versus 46% completed), and weight (97% versus 83% within "normal" range) and maternal outcomes of contraceptive use (91% versus 63%), enrollment in educational programs (86% versus 66%), and repea t pregnancy rate (16% versus 38%) were found between Teen-Tot Clinic particiLpants and the control group. Coordination and consolidation of services for teenaged mothers and their infants appears to favorably influence their short-term outcomes. KEY WORDS:

Comprehensive care Adolescent pregnancy Well-child care Adolescent parenting Parenthood places psychological, social, economic, educational and physical stresses on the teenaged parent and may place the child of the teenager atrisk for psychosocial handicaps (1). Comprehensive programs offering service,; to sexually active, pregnant adolescents, and teenaged parents have proliferated in response to the increased recognition of the needs of this population (2-12). Evaluations of From the Department of Pediatrics, University of Alabama in Birmingham, Birmingham, Alabama. Address correspondence to: Kathleen G. Nelson, The Children's Hospital, 1601 Sixth Avenue, South, Birmingham, AL 35233. Manuscript accepted 16 February 1982.

these programs are necessary to measure the effectiveness of the interventions and to justify continuation or expansion during times of economic restraint. This paper describes an interdisciplinary clinic, the Teen-Tot Clinic, at our institution. The outcomes of infants and mothers receiving care in this program are compared to the "traditional" s y s t e m for the care of infants of teenaged mothers.

Methods The Teen-Tot Clinic, of the University of Alabama in Birmingham Medical Center began accepting infants of teenage mothers in 1978. The Clinic is interdisciplinary and the staff includes a pediatrician, pediatri c nurse-practitioner, social worker, arid nutritionist. Primary health care services for infants of teenaged mothers are Provided during the infant's first 18 months of life. Efforts are made to promote the infant's physical, emotional, and social growth: The teenaged mothers receive services designed to increase their functioning in the parent role, to encourage future family planning, and to support and facilitate completion of their education. The services offered to the teenaged mother and her infant are accomplished through individual and group encounters between participants and health care team members. Traditionally, health care for most infants of teenage mothers is based in the local public health department's Well Baby Clinic and may involve other categorical programs within the public health department (i.e., WIC, EPSDT). If an infant becomes ill, sick care is usually provided in an emergency

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NELSONET AL.

room staffed with different personnel than the Well Baby Clinics. Thus, there is no access to the infant's past medical record. In this system, there is no effort to identify the infant of young teenaged mothers who are at higher risk for morbidity than infants of nonteenaged mothers. These infants and their parents receive no additional services and there is no attempt to address their needs differently from that of other health department clients. The Teen-Tot Clinic attempts to coordinate and consolidate health care services to these infants and mothers. The infants receive comprehensive care, including periodic health supervision visits at 2, 6, 12, and 18 weeks, 6, 9, 12, !5, and 18 months old. Developmental assessments, nutrition counseling, and WIC and EPSDT screening for chronic or handicapping conditions are also performed. Liaison services to other community agencies and programs are provided. The Teen-Tot Clinic offers the opportunity for teenaged parents to interact in group sessions preceding the infant assessments. The group sessions are semistructured and facilitated by team members. Topics range from economic concerns to differences in child development. The group sessions are designed to train adolescents in interpersonal and pa r enting skills. The techniques of modeling behaviors, practicing behaviors, reinforcing behaviors, and feedback by the team members and peers are used. Financial, educational, social, and emotional adjustments of the mothers and fathers are assessed. Contraceptive counseling and services are provided. Parents are given encouragement and assistance with their decisions regarding education, employment, living arrangements, personal goals, and relationships. Participation in the Teen-Tot Clinic is offered to mothers 16 years old or less who have delivered infants at the two major city hospitals since May 1978. Thirty-five out of the first 50 eligible teen-tot pairs elected to participate in the program and form the study population. Seventy control mothers who delivered infants one year previously and used the "traditional" public health clinics were matched for maternal age, race, parity, marital status, site of prenatal care, and infant's sex and birfhweight. Outcomes of infant's immunization status and weight at 6 months old an d maternal outcomes of contraceptive use, enrollment in education programs, and repeat pregnancies were obtained by retrospective chart review and interviews of all clinic patients and controls. Immunization status was assessed as being up to

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date if the infant had received all "recommended" immunizations by the end of the sixth month of life (i.e. 3 diphtheria, pertussis, tetanus, 2 oral polio vaccine). In the event of illness preventing the completion of the immunization series, additional time to receive immunizations was granted, if this reason was so stated. Nutritional status was considered adequate if the infant's weight was between the 5th and 95th percentile at age 6 months according to the National Center for Health Statistics growth charts. The maternal outcome of participating in a family planning program was assessed and judged to be positive if the mother reported using contraceptive pills, intrauterine device, or a diaphram and this report was validated by the mother's family planning clinic record. Maternal reports of the use of condoms and/or foam for contraception (one of 35 Teen-Tot pairs, 3 of 70 controls) were accepted as true. Maternal enrollment in education programs was assessed by interview. This was judged to be positive if the mother reported that she was participating in an academic, vocational, or GED (high school equivalency) program at the time the infant was 6 months of age. Repeat pregnancy was assessed by interview of both populations 18-24 months after the index pregnancy. If the mother reported that she was pregnant or had delivered a child within 18 months of the delivery of the index pregnancy or had had an abortion or miscarriage during this time, this outcome was tabulated. Statistical analysis was performed utilizing chi square.

Results The demographic characteristics of the study, control and eligible but nonparticipating clinic populations are shown in Table 1. The 15 eligible mothers who elected not to participate in the Teen-Tot Clinic differed significantly from the study population in their marital status, race, site of prenatal care, and hom e community, which was often more than !5 miles from the Teen-Tot Clinic. Lack of transportation was most often cited as the reason for nonparticipation by these 15 mothers. In addition, all of these patients had the opportunity to attend the TeenTot Clinic, but some elected not to. There may also be differences in motivation between the two groups that could account for differences in their outcomes. To avoid these biases, therefore, a control group who did not have the opportunity to participate in the Teen-Tot Clinic but was closely matched for demographic characteristics with the participating TeenTot patients was selected. There are no statistically

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CARE OF INFANTS OF TEENAGED MOTHERS

T a b l e 1. D e m o g r a p h i c Characteristics of the Study Populations Teen-tot participants (N = 35) Age Race Black White Marital status Married Single Parity Infant's sex Male Female Birthweight (g) Years education

Control (N = 70)

Eligible non-participants (N = 15)

15:7

15.8

15.9

32 3

64 6

3 32 1.2

6 64 1.3

5 10 1.4

16 19 2960 10.7

32 38 2910 10.5

7 8 2930 10.3

9 6

significant differences between the study and control populations, even for variables not included in the matching process (i.e., household size, educational level, involvement of fathers in the care of infants, and use of contraceptives prior to the index pregnancy). The outcomes assessed were chosen because of their importance to the overall physical and psychosocial health of teenaged parents and their children. Each outcome was readily obtainable and verifiable by medical records review. Significant differences in all outcomes were found between the Teen-Tot Clinic patients and the control patients. These results are displayed in Table 2. Ninety-one percent of the Teen-Tot Clinic infants had completed their immunizations by 6 months old as compared to only 46% of ,control infants (P < .01). Immunizations in either clinic setting were admin-

Table 2. Maternal and Infant ,Outcomes in Teen-Tot Clinic vs. "Traditional Care''a Infants Completed immunizations Normal weight Mothers Actively family planning Attending school Subsequent unplanned pregnancy "Chi Square Analysis bp < 0.01 cp < 0.05

N

Teen-tot

N

Traditional

35

91%

70

46% b

35

97%

70

83% c

35

91%

70

63% c

35 32

86% 16%

70 66

66% c 38% c

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istered during a health supervision visit, which includes physical and developmental examinations and anticipatory guidance. The control children who were deficient in their immunizations were also not receiving regular well-child care during this time. The child's weight was chosen as a measure of overall nutritional status, recognizing that it may not be a "true" assessment. Height, head circumference, and skin-fold thickness were not uniformly available and were therefore not used. Ninety-seven percent of the Teen-Tot Clinic infants had weights within the range of normal as compared With 83% of the control infants (P < .05). Possible explanationS for these differences include an increased awareness of nutritional at-risk status by the Teen-Tot Clinic staff with directed education and early intervention for suspected nutritional problems. The Teen-Tot Clinic participants also had improved access to WIC referral which was performed within the context of the Teen-Tot Clinic visit. In contrast, public health department patients need to be seen in an additional WIC Clinic. The maternal outcome of return to school was particularly important. Ultimate employment opportunities and financial security is influenced by educational achievements. By 6 months postpartum, 86% of the Teen-Tot mothers were enrolled in education programs as compared with 66% of control patients (P < .05), Postpartum school attendance correlates well with the likelihood of fewer repeat pregnancies (3;6,7). Ou r study confirms this for our Teen-Tot population. Eight Teen-Tot mothers had repeat pregnancies, 6 of them were not enrolled in education programs at the time of the pregnancy. Of those patients who were attending school, only 7.5% had a repeat pregnancy within 18 months of the index pregnancy. Six months postpartum, 91% of the Teen-Tot mothers were participating in family planning by their report. Of the control population, only 63% were using contraceptives (P < .05). Despite this, by 18 months after the index pregnancy, there were 8 repeat pregnancies in the 35 Teen-Tot patients, 5 of which were n o t planned, o f the 5 patients with unplanned pregnancies, none were correctly using contraceptives at the time of conception. Two of these pregnancies were terminated by first trimester abortions and one by the delivery of a premature infant. Two were carried to term. Three repeat pregnancies in the Teen-Tot population were planned by married patients. Two patients had been married during the index pregnancy and the other married following the birth of her index child. The repeat un-

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planned pregnancy rate in the control population was 38% (P K .05) compared with 16% in the TeenTot Clinic population.

Discussion Comprehensive programs aimed at the pregnant and postpartum adolescent have shown results similar to those of the Teen-Tot Clinic. The Rochester Adolescent Maternity Project (RAMP), which has existed since i969, had 24% repeat pregnancies at 2year follow-up in the mothers who had received their services (2). The Inter-Conceptional Care Clinic (ICC) for teenagers in Atlanta reported an 84% utilization of contraceptives among its patients at 6 months postpartum (7). This group of patients also had only 4.8% repeat pregnancies as compared to 16.6% in a similar age group who did not attend the ICC. The Young Mother's Educational Development (YMED) program (8) in Syracuse, New York offers services during pregnancy and for 1 year postpartum and is based in a school which enables the teenager to continue her education with a day-care service available on site. Of participants in this program, 87% continued in school and unwanted pregnancies were reduced by about 2/3 at 3 years after the index pregnancy. The Young Mother's Program (YMP) at Yale (3) compared the outcomes of their clinic patients with a group of similar aged patients who previously received care in the General Obstetric Clinic of the same hospital. This comparison group is similar to the "traditional" care control group used in our study. The improved outcomes in the YMP were felt to be in part due to the separation of the school-age patient from older pregnant women and that contraceptive use and school attendance could be more effectively encouraged within a peer group. The Teen-Tot Clinic team promotes responsible family planning and encourages return to school at every group session and at each individual patient encounter. Every patient who misses a Teen-Tot Clinic appointment is contacted and their return to the clinic is urged. The Teen-Tot Clinic staff is also in contact with the schools attended by the young mothers and is able to arrange for time off from school to attend the clinic. If transportation is difficult, access is facilitated by providing transportation money or by arranging car pool services. These approaches are not frequent in the public health department system and may explain the differences in some outcomes.

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 1

Because the Teen-Tot Clinic is hospital based, the cost is relatively high as compared to costs in the public health department's ambulatory facilities. The hospital's centralized location may have been a limiting factor for some potential clients who did not have transportation to the hospital and/or found the local health department clinics more convenient. The overall cost of delivering comprehensive care must take into consideration the long-term cost of an additional pregnancy in an already high-risk population. It is estimated that each infant of a teenage mother costs the U.S. Government $18,000 until he/ she reaches age 18 years (13). In this study repeat pregnancy was reduced by 59%. This savings would potentially cover the cost of a similar comprehensive program. With a few modifications, this model could be applied in the "traditional" setting by directing the services and personnel available specifically toward the teenaged mother and her child. Individual, categorical programs in the "traditional" system cover most of the services offered by the Teen-Tot Clinic. With coordination and development of a core team, these services could be combined into a comprehensive program targetted for teenagers. Health-department-based programs would have the potential advantage of being located nearer to the patient's home and having a lower cost because the overhead cost of a hospital-based setting could be reduced. Comprehensive programs designed to serve the teenaged parent and her child seem to offer some distinct advantages for improving short-term outcomes in this high-risk group. Continued development and evaluation of new programs and reassessment of existing services is necessary to design the most effective method for decreasing morbidity associated with adolescent child bearing.

References 1. Alan Guttmacher Institute: 11 Million Teenagers--What can be done about the epidemic of adolescent pregnancies in the United States. New York, Planned Parenthood Federation of America, 1976 2. McAnarney ER, Roghmann KJ, Adams BN, et al.: Obstetric, neonatal, and psychosocial outcome of pregnant adolescents. Pediatrics 61:199-205, 1978 3. Klerman LV, Jekel FJ. School Age Mothers. Problems, Progress and Policy. Hamden, CT, Shoe String Press, 1973 4. Furstenberg FF: Unplanned Parenthood. New York, The Free Press, 1976 5. Gutelius MF, Krisch AD, McDonald S, et al.: Controlled study of child health supervision: Behavioral results. Pediatrics 60:294-304, 1977

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6. Dempsey JJ: Recidivism and post-delivery school withdrawal: Implications for a follow up study for planning preventive services. J School Health 42:291-297, 1972 7. Klein L: Early teenage pregnancy, contraception and repeat pregnancy. Am J Obstet Gynecol 120:249-255, 1974 8. Osofsky HJ, Osofsky JD: Adolescents as mothers, results of a program for low income pregnant teenagers with some emphasis on infant's development. Amer J Orthopsych 40:825834, 1970 9. Youngs, DD, Niebyl JR, Blake DA, et al.: Experience with an adolescent pregnancy program. Obstet Gynecol 50:212-216, 1977

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10. Perkins RP, Nakashima II, Mullin M, et al.: Intensive care in adolescent pregnancy. Obstet Gynecol 52:179-187, 1978 11. Sherline DM, A-Davidson R: Adolescent pregnancy: The Jackson, Mississippi experience. Am J Obstet Gynecol 132:245255, 1978 12. Edwards LE, Steinman ME, Arnold KA, et al.: Adolescent pregnancy preventive services in high school clinic. Fam Plan Persp 12:6-14, 1980 13. Population Resource Center: An analysis of Government expenditure as a consequence of teenaged childbirth. Menlo Park, CA, S.R.I. International, 1979