abortion, p. 771
adoption, p. 773
birth control, p. 770
coercive sex, p. 773
gynecological age, p. 778
intimate partner violence, p. 777
long-acting contraceptive, p. 770
low birth weight, p. 779
non-genital sexual behavior, p. 771
paternity, p. 775
peer pressure, p. 773
prematurity, p. 779
prenatal care, p. 776
repeat pregnancy, p. 780
sexual debut, p. 772
sexual victimization, p. 773
statutory rape, p. 773
weight gain, p. 778
—See Glossary for definitions
Dyan A. Aretakis, RN, FNP, MSN
Dyan A. Aretakis began her nursing practice in pediatrics at the University of Connecticut and at a regional residential facility for the mentally retarded. She went on to co-develop a model teen health center at the University of Virginia Health System in 1990 and currently practices in and directs its daily and long-term programs. This program is unique because it provides a range of adolescent primary health care services as well as community and professional outreach programs.
Teen pregnancy is an area of public concern because of its significant effect on communities. Resources to support the special needs of pregnant teenagers are decreasing, and the costs of sustaining young families are prohibitive. Many teenagers who become pregnant are caught in a cycle of poverty, school failure, and limited life options. Even under the ideal circumstances of adequate finances, loving and supportive families, and good birth outcomes, a teen mother must circumvent her own necessary developmental tasks to raise her child.
There is neither a uniform reason that teens become pregnant nor a universally acceptable solution. The causes of teen pregnancy are diverse and affected by changing moral attitudes, sexual codes, and economic circumstances. Teen pregnancy places an enormous strain on the health care and social service systems. Social concern is also raised about the lost potential for young parents when pregnancy occurs, and the academic and economic disadvantages that their children will experience. Nurses are in a key position to understand how teen pregnancy affects both the individual and the community. This chapter presents a variety of issues associated with teen pregnancy and proposes nursing interventions to promote healthy outcomes for individuals and communities.
Adolescent Health Care in the United States
Adolescents are generally healthy, and when they seek health care it is for reasons different from those of adults or young children. The main causes of teen mortality are high-risk behaviors: motor vehicle accidents (usually including alcohol), homicide, suicide, and accidental injuries (such as falls, fires, or drowning). Teens often engage in behaviors that put them at risk for life-threatening diseases. For example, each year, one fourth of both new human immunodeficiency virus (HIV) infections and newly identified sexually transmitted diseases (STDs) occur among adolescents. During the teen years, other behaviors are initiated (e.g., smoking, decreased activity, and poor nutrition) that can ultimately lead to poor health as well as influence behavior change that can significantly alter a young person’s life.
National surveys highlight the health issues facing adolescents. There have been some improvements in risk behaviors as well as a worsening of others. Among ninth to twelfth graders participating in the 2007 Youth Risk Behavior Surveillance System, fewer teens reported riding in a car with a driver who had been drinking, currently smoking cigarettes or marijuana, trying methamphetamines, or attempting suicide. However, these and other significant risk behaviors continued at high rates. Of ninth to twelfth graders, 44.7% reported current alcohol use (26% reported episodic heavy drinking); 20% of teens were current cigarette smokers; and 38% had tried marijuana (19% were current users and 8% tried it before the age of 13). Mental health issues are also strongly associated with the adolescent years: 28.5% of students reported feeling sad or hopeless for more than 2 weeks; 35% of females and 21% of males reported these symptoms. Suicidal thoughts with a plan existed for 11.3% of students nationwide, and suicide was attempted by 9% of girls and 4% of boys (CDC, 2008).
Adolescents may not seek care for these problems for the following reasons: (1) access to health care may be hindered due to a limited number of professionals with expertise in dealing with teenagers, (2) costs of care or availability of insurance may limit services, (3) adolescents need to believe that their visits are confidential before they will honestly reveal information, and (4) health care professionals must be able to discuss sensitive topics in a non-judgmental and supportive manner and demonstrate a desire to work with youths. Nurses who want to promote the health of adolescents by providing anticipatory guidance about peer pressure, assertiveness, and future planning need to understand adolescent behaviors, health risks, and the social context in which they live. Involvement and education of the parents about youth culture and development can promote positive and supportive parenting of teens.
The Adolescent Client
Adolescents have limited experience in independently seeking health care. When they do seek care, it is often to discuss concerns about a possible pregnancy or to find a birth control method. These teens may also need assistance negotiating complex health care systems. Special approaches in both client interview and subsequent client education are often warranted. The behavior of adolescents toward the nurse can range from mature and competent during one visit to hostile, rude, or distant at other times because behavior often reflects intense anxiety over what the teen is experiencing.
Because client interviews usually begin with evaluation of a chief complaint, teens need to know that their concerns are heard. Health care providers may have their own opinions about what teenagers need and may fail to take the chief complaint seriously. For example, when a teen expresses ambivalence about or a desire to become pregnant, this should be discussed in depth even though the nurse may feel uncomfortable when asked to provide information to a teen about how to conceive. During this interview, the nurse can provide preconception counseling and emphasize the need to achieve good health and to establish a health-promoting lifestyle before pregnancy. Health risks to the mother, as well as to fetal development, can be discussed. The nurse can encourage a young person to consider lifetime goals and discuss how parenthood might affect them. Not only does information presented this way demonstrate that the nurse has heard what the teen is saying, but it also allows the nurse to provide useful health information that may encourage the teen to examine her plans carefully, seriously, and maturely.
It is also important to pay attention to what the teen fails to verbalize. Knowledge of adolescent health care issues is valuable so that the nurse can anticipate other health concerns and provide an environment in which the adolescent feels safe about discussing other issues. By creating a caring and understanding atmosphere, the nurse can encourage the young person to discuss concerns about family violence, drugs, alcohol, or dating.
Discussing reproductive health care is a sensitive matter for both teens and many adults. Teens may have difficulty expressing themselves because of a limited sexual vocabulary or embarrassment resulting from their lack of knowledge. The nurse must recognize this potential deficit and embarrassment and assist teens by anticipating concerns. It is also important to allow teens to express themselves in their own language, which may include crude or offensive words. Nurses must learn about common slang expressions and common misconceptions so they do not miss important concerns that a teenager might have. The nurse can offer more appropriate terms once trust is established.
Teens may have difficulty discussing topics that provoke a judgmental reaction, such as discussing STDs (Box 35-1). The nurse can choose neutral words to evaluate symptoms (e.g., “Has there been a change in your typical vaginal discharge?”). This approach also gives the nurse a chance to educate the young client about normal anatomy and physiology.
Considerable debate exists over whether adolescents should make reproductive health care decisions without their parents’ knowledge. As seen in Box 35-2, the adolescent’s right for access to contraceptive treatment is established by federal law. Obstacles to services do exist, however, and this may result in a teen not receiving contraceptive information and treatment. Obstacles can include lack of transportation to a health care facility, insufficient money to pay for services, or permission to leave school early to attend an appointment.
Although most minor teens can consent to birth control services in the United States, there is great variability in who may access and release their medical records. In recognition of the importance of confidentiality in reproductive health care, federal privacy rules were established in 2002 as follow up to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This rule, the HIPAA Privacy Rule (or more correctly, the Standards for Privacy of Individually Identifiable Health Information), established that if a minor consented to care, then only that individual could access and release those medical records. However, the Privacy Rule also deferred to existing state law. In many states the laws specify that parents can legally access all the medical records of their minor children (English, 2007; English and Kenney, 2010), which limits the confidentiality assurances offered to a teen seeking reproductive health care. It is incumbent on nurses working with teens to be knowledgeable about state and federal laws so they can accurately inform teenagers of their rights and limitations in seeking reproductive health care.
Abortion services for adolescents are not clearly defined. No federal protection is extended to adolescents requesting abortion services, and the adolescent’s right to privacy and ability to give consent varies by state (Box 35-3). Confidential care to teenagers may mean the difference in preventing an unwanted pregnancy, an abortion, and a birth. This care can influence whether prenatal visits begin in the first trimester or in the second or third trimester. Teens have various reasons for pursuing confidential care, including seeking independence as well as serious and well-founded concerns about a parent’s potential reaction (e.g., abuse of the teen). Once nurses recognize the reason for confidential care, they can work with teens to discuss reproductive health care needs with the family. To do so, first clarify family values about sexuality and family communication styles with the teen. In a non-healthy family, referral to community agencies (e.g., child protective services, Al-Anon) may be necessary. However, the nurse may need to honor the adolescent’s need for confidentiality for an unknown period and proceed with the usual interventions, such as pregnancy testing, options counseling, and referral for clinical care.
Trends in Adolescent Sexual Behavior, Pregnancy, and Childbearing
In 2009, there were 414,870 births to women under age 20. These numbers represent a 2-year increase in birth rates. The birth rate in the United States remains higher than in any other developed nation (Ikramullah, Barry, Manlove, and Moore, 2011). The numbers of teens who become pregnant are generally identified in the following way: by age group (e.g., younger than 15, ages 15-17, ages 18-19, and under age 20); by states, by marital status; by rates (e.g., number of pregnancies, births, and abortions per 1000 young women); and by race/ethnicity (e.g., African American, white, Hispanic/Latino). Births to teenagers make up 11% of all births in the United States (Ikramullah et al, 2011). Teen birth rates increase by age, with the highest rates occurring among 19-year-olds. Pregnancy and birthrates increased steadily among teens of all ages from 1986 to 1991 and declined among teens of all ages and ethnicities from 1991 to 2005. Decreases from 25% to 19% were also noted in the teen repeat birth rate from 1991 to 2005 and increased in 2006 and 2007 (Ikramullah et al, 2009, 2011). Decreases in pregnancy among teens ages 15 to 17 have been attributed to reduced sexual activity (one fourth of the reduction) and the rest resulting from improved contraceptive use. For teens ages 18 to 19 the reduction is entirely attributed to increased contraceptive use (Kost, Henshaw, and Carlin, 2010).
In 2006 the teen birth rate began to rise for the first time since 1991. That year it rose by 5% and then another 1% in 2007. This increase was the greatest among white teens, followed by African-American teens. The Hispanic teen birth rate decreased between 2006 and 2007; however, the declines in the years previous were not as dramatic as with white and African-American teens. Even with these increases, the birth rate today is still less than half of the birth rate from 1960 for 15- to 17-year-olds and 18- to 19-year-olds. In addition, more than 86% of teens are unmarried at the time of their child’s birth (Ikramullah et al, 2009).
The 2009 rate of 39.1 births per 1000 females age 15-19 was 6% lower than in 2008 (41.5) (Ikramullah et al, 2011).
In 2006, 27% of pregnancies of teenagers were ended by elective abortion, a decrease from 46% of teen pregnancies in 1986 (Guttmacher Institute, 2010). Elective abortion rates for teenagers increased from the time of legalization in 1973 until 1988 and then began to decline. This decrease was caused in part by decreases in the pregnancy rate, but may also have resulted from laws that required parental notification or consent for minors requesting abortion services in some states. An adolescent might cite lack of maturity, an inability to afford a baby, and concerns about how a child would change his or her life as reasons for terminating a pregnancy by abortion (Guttmacher Institute, 2010).
Many adults have difficulty understanding why young people would jeopardize their careers and personal potential by becoming pregnant during the teen years. Adolescents, however, do not view the world in the same way as adults. Teens often feel invincible and therefore do not recognize any risk related to their behaviors or anticipate the consequences. That is, they may not believe that sexual activity will lead to pregnancy. When teens become pregnant, they do not believe that the negative outcomes they are advised of could come true. Many teens believe that they are unique and different and that everything will work out fine. The developmental circumstances of adolescence, coupled with potential background disadvantages, can magnify the problems facing the pregnant and parenting teen. Pregnant teens often express the unrealistic attitude that they can do it all: school, work, parenting, and socializing.
Babies born to teenage mothers in the United States are at-risk for many of the same problems as their young mothers. These risks include school failure, poverty, and physical or mental illness (American Academy of Child & Adolecent Psychiatry, 2004).
Specifically, a disproportionate number of teens who give birth are poor (more than 75%), have limited educational achievements, and see few advantages in delaying pregnancy since they do not expect that their circumstances will improve at a later time (Kirby, 2002). Most teens report that their pregnancy was unplanned. They typically think that a pregnancy should be delayed until people are older, have completed their education, and are employed and married. Their behaviors, however, do not support the opinions they express. In fact, some teens actually seem ambitious about becoming pregnant. Several factors that often contribute to pregnancy are discussed next.
Sexual Activity and Use of Birth Control
The sexual debut, or first experience with intercourse, for a teen will have a significant impact on pregnancy risk. Although the percentage of sexually active teens today is much greater than it was in the 1970s, decreases between 1991 and 2007 have been noted. A reported 7.1% of students first had sex before the age of 13; in the ninth grade, approximately 33% of students are sexually active, 44% by tenth grade, 55% by the eleventh grade, and 65% by the twelfth grade. For each grade the percentage of males is greater than females in each racial group. Almost 15% of students have had sexual intercourse with four or more persons during their life. Male students and African-American students were more likely than white, Hispanic/Latino, or female students to initiate sexual activity before age 13. African-American students (67%) are more likely to report a history of sexual activity, followed by Hispanic/Latino (52%) and white students (44%) (CDC, 2008).
The Healthy People 2020 goal is to increase the proportion of adolescents who have never engaged in sexual intercourse by age 17 (USDHHS, 2010).
Although more teens have begun using birth control in the past 10 years, there is still progress to be made. Healthy People 2020 addresses this with goals to increase the proportion of 15- to 19-year-olds who use condoms and a hormonal contraceptive and increase the proportion of teens who receive reproductive health information through formal instruction as well as from their parents or guardians (USDHHS, 2010). Condoms are the most commonly used method of birth control, with 66% of adolescent females and 71% of adolescent males (Guttmacher, 2010) reporting their use at first voluntary coitus. Male teens use condoms with more frequency than female teens; ninth-grade males use condoms more than tenth-, eleventh-, or twelfth-grade males; and African-American males use condoms more often than any other group, male or female. Overall, 61% of teen couples reported that the male partner used condoms the last time they had intercourse, with the greatest use at last intercourse reported by African-American male teens (74%) and the lowest use reported by Hispanic/Latino female teens (52%) (CDC, 2008). Half of all first-time pregnancies occur within 6 months of initiating intercourse, and teens using a hormonal birth control method report sexual activity for up to 1 year before they see a health care provider to obtain a prescription (Klein and the Committee on Adolescence, 2005). Teens harbor many myths that contribute to poor use of birth control, such as believing women cannot get pregnant the first time, and some teens have erroneous knowledge about a woman’s fertile time. Failure to use birth control can also reflect teens’ embarrassment in discussing this practice with partners, friends, parents, and health care providers and the obstacles they encounter finding facilities that provide confidential and affordable birth control.
The earlier the sexual debut, the less likely a birth control method will be used, since younger teens have less knowledge and skill related to sexuality and birth control. School-based sex education can come too late or not at all. Birth control is usually discussed in the secondary-school curriculum, but this could be eighth grade in one school district and tenth in another; school curricula are not standardized. Younger teens may falsely believe that they are too young to purchase birth control methods such as condoms. Confidential reproductive health care services may be available for teens, but problems are still associated with transportation, school absences, and costs of care that ultimately restrict access to these services.
Inconsistent use of birth control can reflect teens’ willingness to take risks, their dissatisfactions with available birth control methods, and their ambivalence about becoming pregnant. Real and perceived side effects of birth control methods can discourage use. Hormonal methods such as Mirena (an intrauterine device every 5 years), Implanon (a contraceptive implant every 3 years), Depo-Provera (an intramuscular injection every 3 months), NuvaRing (a monthly vaginal ring), and the Ortho Evra patch appeal to some women because the method is less directly tied to coitus. These methods may have nuisance-type effects (e.g., irregular bleeding or insertion into the vagina) that require the nurse to provide anticipatory guidance and management instructions to young women. Table 35-1 describes hormonal birth control methods that would be appropriate for the adolescent to consider.
|METHOD||FAILURE RATE WITH TYPICAL USE (%/YEAR)||PATTERN OF USE||NON-CONTRACEPTIVE BENEFITS|
|Mirena IUD||0.2||Placed in the uterus; effective continuously for 5 years||Less menstrual bleeding, often with amenorrhea after initial few months|
|Implanon||0.5||Placed subdermally in the upper arm; effective continuously for 3 years||Less menstrual bleeding|
|Depo Provera||3||IM injection into either the deltoid or the gluteal muscle every 3 months||Decreases sickle cell crisis|
Decreases the seizure threshold
May become amenorrheic
|NuvaRing||8||Vaginal ring inserted for 21 to 32 days; contains estrogen and progestin||For all estrogen/progestin combinations:|
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