Adolescent pregnancy

Adolescent Health Committee, Canadian Paediatric Society (CPS)

Paediatr Child Health 2006;11(4):243-6
Reference No. AH06-02 (Formerly AM94-02)

Index of position statements from the Adolescent Health Committee

Contents

• Introduction
• Table 1
• Diagnosis
• Management of the pregnant adolescent
  • Options
  • Counselling the adolescent who plans to continue the pregnancy
  • Counselling the adolescent who plans to terminate the pregnancy
• Pregnancy prevention
• Summary and recommendations
• References

The objectives of this statement are to:

• provide health care practitioners with information about the diagnosis of pregnancy in adolescents;
• review the important aspects for options counselling with the pregnant adolescent; and
• present an approach to the care of adolescents who choose to continue with a pregnancy (with or without choosing to parent) and those who choose to terminate a pregnancy.

Introduction

Pregnancy among Canadian adolescents has been decreasing in recent decades. In 2003, there were 33,553 pregnancies to women younger than 20 years (includes live births and fetal losses [from database of hospital-reported stillbirths, miscarriages and abortions]). This represents an overall rate of 27.1 per 1000 population, which has been falling since 1994 when it was 48.8 per 1000. The pregnancy rate is highest among 18- to 19-year-olds (Table 1), many of whom have planned pregnancies. The rate among 15- to 17-year-olds, while considerably lower, likely includes a higher proportion of unplanned adolescent pregnancies (1). Pregnancies among girls younger than 15 years represent a small proportion of overall pregnancies in the adolescent population.

Pregnancy rates and outcomes of adolescent pregnancy vary widely across provinces and regions. Overall, just over 50% of adolescent pregnancies end in induced abortion, which includes abortions performed in hospitals and clinics in Canada , as well as those performed in selected American states (1).

Diagnosis

The early detection of pregnancy is essential to allow the adolescent as many options as possible and to initiate prenatal care for young women who choose to continue the pregnancy. Poor prenatal care is the major cause of the increased rate of complications in 15- to 19-year-olds (2).

Early detection is often difficult, however, because many adolescents deny the possibility of pregnancy even to themselves. In addition, complex social situations may make it difficult for the adolescent to openly address the prospect of pregnancy. The normal menstrual irregularities of early adolescence can also mask a pregnancy. Adolescents who present with menstrual irregularities, nausea, vomiting, fatigue or abdominal pain (which may indicate ectopic pregnancy) should be questioned about the possibility of pregnancy and screened accordingly.

Laboratory testing can detect pregnancy before a physical examination. Sensitive radioimmunoassays are able to detect human chorionic gonadotropin (hCG) in serum as early as six days postconception. Urine tests used at home and in offices or clinics use monoclonal antibodies to detect hCG and can show positive results as early as 10 to 14 days after ovulation. However, these may not detect a pregnancy until one week after the missed period (3). False-negative results may occur with urine pregnancy testing; if pregnancy is still suspected, a serum hCG should be ordered. A bimanual pelvic examination can be performed to attempt to establish gestational age. The uterus may be palpable above the pubic bone after approximately nine to 12 weeks’ gestation. Ultrasound may also be useful in confirming the gestation of the pregnancy, particularly if the young woman is unsure of the date of her last normal menstrual period and in the case of suspected ectopic pregnancy.

Management of the pregnant adolescent

In taking a history of the pregnant adolescent, the health care practitioner should:

• inquire about the physical and emotional effects of her pregnancy;
• determine her knowledge of the options and her feelings about these options;
• explore any family, cultural or community issues that may play a role in her situation;
• when appropriate, explore her partner’s opinion about the options and discuss his role in the young woman’s decision-making process;
• establish the extent of her support system (for example: Who has she told about the pregnancy? How have they reacted? Who may provide support during the decision-making process?);
• assess for any underlying health issues and for any complications;
• assess for current substance use and other high-risk health behaviours; and
• review housing and school status, as well as the adolescent’s personal and academic goals.

A health care practitioner who is unable to counsel and follow up with a pregnant adolescent about her options has a responsibility to refer her (and her partner, if involved) to appropriate professionals and resources. Information about the services available in the community – and, if necessary, outside the area – is essential.

Options

Although time is an important factor because some options are not available after the first trimester, the adolescent must not be forced to make a hasty decision. Any confusion, hesitation and pressure from others must be addressed. Few adolescents choose to give up their babies for adoption and of those who do, a significant number change their minds when the baby is born. To foster acceptance of her decision, a mother who gives up her baby should be given the opportunity to have contact with the baby.

Health care practitioners should also remember that a pregnant adolescent wants to make the ‘right’ choice. Health professionals can help reassure the adolescent by saying something such as, “When you have an unplanned pregnancy, there is no perfect choice. All you can do is think about what is best for you at this time. No matter what option you choose, it is unlikely that you will feel it is 100% right.”

The options available to the pregnant adolescent carry different medical risks. ‘Medical’ abortion using methotrexate and misoprostol is currently available in Canada for early termination of pregnancy. A recent Cochrane review (4) found that it is an effective and safe option for termination of first trimester pregnancy. Some studies examining its use have included adolescent subjects; however, there is limited evidence about its use in the adolescent population (5,6). In addition, medical abortion requires several office visits and the ability to have close follow-up and monitoring, which may not best suit most adolescent patients. The various surgical methods (including manual vacuum aspiration, dilatation and curettage, and vacuum extraction) are performed, depending on gestation, from early in the first trimester to early in the second trimester. The risks associated with abortion increase with gestation, but are low overall (these risks include uterine perforation, hemorrhage and infection) (7,8). Pregnancy and its associated complications present the highest risk to an adolescent. Maternal mortality rates in this age group are higher than the risk from surgical abortion (9).

Counselling the adolescent who plans to continue the pregnancy

Prenatal care should be initiated as early as possible to optimize maternal and fetal health and well-being. A counselling health care practitioner who will not be providing obstetrical care can discuss with the adolescent how to choose a practice or clinic that can best meet her physical and emotional needs. The patient should look for a practitioner who is comfortable addressing social and health issues, such as relationships, smoking, alcohol and other substance use, sexually transmitted infections, nutrition and breastfeeding, and who will provide anticipatory guidance. Access to adolescent-focused prenatal, postnatal and paediatric services may improve outcomes for both the adolescent and her infant (10,11).

The health care practitioner should also:

• refer the adolescent to appropriate resources: maternity homes, drop-in centres and support groups;
• encourage her to continue her education to enhance the potential for positive maternal and child outcomes, and decrease social isolation and depression;
• encourage, if appropriate, the presence of the baby’s father and/or her current partner in the follow-up and discussions about future parenting roles and responsibilities;
• in the case of young women who choose adoption, refer them to an adoption service that provides counselling and support;
• stay in contact with mothers who keep their babies, as well as those who do not;
• provide contraceptive counselling to help delay future pregnancies (35% of adolescents who deliver will have another pregnancy within the following two years) (12); and
• advocate for high-quality subsidized child care and for school programs that are flexible in meeting the needs of adolescent parents.

Counselling the adolescent who plans to terminate the pregnancy

The adolescent who has decided to terminate the pregnancy needs:

• information about the specific details of the procedures available;
• anticipatory guidance about common emotional responses, such as grief, relief and anger;
• referral to appropriate medical and surgical services; and
• appointments for follow-up that include a review of any complications, such as excessive bleeding, fever, cramps after the first 48 h, abnormal discharge, physical and emotional concerns, and contraceptive follow-up.

Pregnancy prevention

Health care practitioners have an important role in preventing unplanned adolescent pregnancies. While there is currently no gold standard to prevent pregnancy in adolescents, several reviews in the recent literature have summarized the characteristics of more effective programs (13,14). These characteristics include longitudinal follow-up, provision of a continuum of options from abstinence to contraceptive information, and life-skills training. Practitioners should discuss decision-making with their adolescent patients from a young age and apply this to the issues of sexuality, individual choice, peer pressure, safe sex and contraception in a manner appropriate to the adolescent’s development. This is particularly important for adolescents with a developmental delay, disability or chronic condition. Adolescents of both sexes who are likely to engage in early sexual activity should be counselled in methods of contraception. The discussion should include information about the emergency contraceptive pill (15). Adolescents at risk of unprotected intercourse include those:

• experiencing social and family difficulties;
• whose mothers were adolescent mothers;
• undergoing early puberty;
• who have been sexually abused;
• with frequent school absenteeism or lacking vocational goals;
• with siblings who were pregnant during adolescence;
• who use tobacco, alcohol and other substances; and
• who live in group homes, detention centres or are street-involved.

It is important to ask questions about intentionality for pregnancy because there is evidence to suggest that some adolescents may have the intention of becoming pregnant and, thus, require more than simply contraception counselling (16,17).

Summary and recommendations

Pregnancy carries significant physical and psychosocial risks for adolescents. Through counselling and treatment, health care practitioners caring for adolescents should aim to prevent unplanned adolescent pregnancy. When pregnancies occur, the risks can be reduced through early diagnosis, by offering a complete range of therapeutic options and by fully supporting the decisions made by these young people. The health care practitioner’s role includes medical care and counselling, referral to appropriate services and advocacy.

The Canadian Paediatric Society acknowledges the complex social, ethical and religious issues involved and recognizes the right of health care practitioners not to participate in all aspects of counselling related to contraception and pregnancy. However, health care practitioners have a responsibility to ensure that comprehensive services are accessible and offered to all pregnant adolescents.

To minimize risks to the pregnant adolescent, the Canadian Paediatric Society recommends that health care practitioners:

• counsel pregnant adolescents in a nonjudgmental way about their pregnancy options. If they are unable to do so, they should refer to others who can provide this service;
• attempt to protect adolescents from being coerced into any option against their will;
• help the adolescent develop a supportive network that may include family members, her partner, trusted friends and other health care providers;
• provide people in that support network with guidance as to how they can best help the pregnant adolescent;
• make follow-up appointments;
• ensure that adolescents referred to another practitioner or service have made and kept their appointment; and
• respect the adolescent’s right to privacy and medical confidentiality.

References

1. Statistics Canada Data. Pregnancy outcomes by age group. http://www40.statcan.ca/l01/cst01/hlth65a.htm (Version current at March 30, 2006).
2. Koniak-Griffin D, Turner-Pluta C. Health risks and psychosocial outcomes of early childbearing: A review of the literature. J Perinat Neonatal Nurs 2001;15:1-17.
3. Wilcox AJ, Baird DD, Dunson D, McChesney R, Weinberg CR. Natural limits of pregnancy testing in relation to the expected menstrual period. JAMA 2001;286:1759-61. (Erratum in 2002;287:192)
4. Kulier R, Gulmezoglu AM, Hofmeyr GJ, Cheng LN, Campana A. Medical methods for first trimester abortion. Cochrane Database Syst Rev 2005;(2):AB002855.
5. Creinin MD, Wiebe E, Gold M. Methotrexate and misoprostol for early abortion in adolescent women. J Pediatr Adolesc Gynecol 1999;12:71-7.
6. Wiebe ER. Abortion induced with methotrexate and misoprostol. CMAJ 1996;154:165-70.
7. Kulier R, Fekih A, Hofmeyr GJ, Campana A. Surgical methods for first trimester termination of pregnancy. Cochrane Database Syst Rev 2001;(4):CD002900.
8. Public Health Agency of Canada. Induced Abortion. In: Canadian Perinatal Surveillance System. Ottawa: Public Health Agency of Canada, 2005.
9. Public Health Agency of Canada. Special Report on Maternal Mortality and Severe Morbidity in Canada. Enhanced Surveillance: The Path to Prevention. Ottawa: Public Health Agency of Canada, 2004:13. http://www.phac-aspc.gc.ca/rhs-ssg/srmm-rsmm (Version current at March 16, 2006 ).
10. Bensussen-Walls W, Saewyc EM. Teen-focused care versus adult-focused care for the high-risk pregnant adolescent: An outcomes evaluation. Public Health Nurs 2001;18:424-35.
11. Leslie K, Dibden L. Adolescent parents and their children – The paediatrician’s role. Paediatr Child Health 2004;9:561-4.
12. East PL, Felice ME. Adolescent Pregnancy and Parenting: Findings from a Racially Diverse Sample. Mahwah: Lawrence Erlbaum Associates, 1996:29-39.
13. Nicoletti A. Teen pregnancy prevention issues. J Pediatr Adolesc Gynecol 2004;17:155-6.
14. Card JJ. Teen pregnancy prevention: Do any programs work? Annu Rev Public Health 1999;20:257-85.
15. Canadian Paediatric Society, Adolescent Health Committee. Emergency contraception. http://www.cps.ca/english/statements/AM/ah03-01.htm (Version current at April 6, 2006).
16. Rosengard C, Phipps MG, Adler NE, Ellen JM. Adolescent pregnancy intentions and pregnancy outcomes: A longitudinal examination. J Adolesc Health 2004;35:453-61.
17. Stevens-Simon C, Beach RK, Klerman LV. To be rather than not to be – that is the problem with the questions we ask adolescents about their childbearing intentions. Arch Pediatr Adolesc Med 2001;155:1298-300.

Adolescent health committee (2004-2005)

Members: Drs Sheri M Findlay, McMaster Children’s Hospital – Hamilton HSC, Hamilton, Ontario; Jean-Yves Frappier, Sainte-Justine UHC, Montreal, Quebec (chair); Eudice Goldberg, The Hospital for Sick Children, Toronto, Ontario; Jorge Pinzon, BC’s Children’s Hospital, Vancouver, British Columbia; Koravangattu Sankaran, Royal University Hospital, Saskatoon, Saskatchewan (board representative); Danielle Taddeo, Sainte-Justine UHC, Montreal, Quebec
Liaison: Dr Karen Mary Leslie, The Hospital for Sick Children, Toronto, Ontario (Adolescent Health Section, Canadian Paediatric Society)
Principal author: Dr Karen Mary Leslie, The Hospital for Sick Children, Toronto, Ontario

Posted April 2006