Abstract
Teenage pregnancy usually results from an unstable relationship, is often unplanned and results in the adolescent becoming a parent before becoming an adult [1]. Social disadvantage and dependency on government benefits mean that many are required to survive on or below the poverty line [2]. In particular, it is the younger group of adolescent mothers who experience problems. In 1997, Western Australia alone recorded 465 births to women aged less than 18 years [3]. Failure to identify and treat social and psychiatric problems in this group can result in poor mothercraft skills and infant development [4].
In addition, community concern over the level of non-prescription drug use in adolescents is rising. Many teenagers of both sexes continue to abuse alcohol, tobacco, marijuana and other drugs despite major public health campaigns [5,6]. While it remains unclear what proportion of drug experimenters will develop significant long-term problems, the harmful effects of drug abuse in pregnancy are well documented and include foetal growth retardation, prematurity, infection, stillbirth and newborn withdrawal syndromes [7].
Few data exist that audit the incidence of social problems and drug abuse in this population in an Australian setting. We, therefore, first set out to evaluate in a Western Australian adolescent antenatal population the level of social and psychological problems. Second, we aimed to establish the incidence of smoking, drinking and the use of illegal drugs. Third, we aimed to evaluate how often these issues were routinely addressed by caregivers in general antenatal clinics. Failure to discover significant psychosocial and drug abuse problems in the antenatal period may deprive patients of the opportunity to receive intervention to help resolve adverse lifestyle factors prior to the birth of their infant.
Method
From 1 January, 1997 to 1 January, 1998, a prospective cohort study was undertaken on 160 adolescent antenatal patients aged 17 years or less, who planned to continue with their pregnancy, and did not intend to relinquish their infant.
One subgroup of the cohort was formally assessed by interview for psychosocial issues. This assessed group consisted of 100 consecutive adolescent antenatal patients booked to deliver at the adolescent pregnancy clinic at King Edward Memorial Hospital for Women. At their booking visit, a midwife, obstetric doctor and social worker interviewed each patient. In view of potential problems with literacy in this population (currently the subject of further investigation), patients were at no time asked to complete written questions. All information gained was through verbal discourse. At the end of each clinic, a team meeting was held to discuss new patients, with input from an adolescent psychiatrist. Social and psychological problems were defined, and the use of non-prescription drugs recorded. After defining issues unique to each patient, a management plan was devised. These plans included the decision to offer referral for additional support services in social work, parent education, obstetric care or psychiatry. In some cases, a decision was made to offer acute hospital admission. At subsequent appointments, the care plan was implemented, and the accuracy of original information verified with the patient.
The control group consisted of 60 adolescent patients who attended general antenatal clinics at the Joondalup Health Campus, Osborne Park and King Edward Memorial Hospitals. Their records were reviewed after delivery to ascertain whether any psychosocial history was obtained by caregivers.
Data were analysed by applying Chi-squared tests, and Fishers Exact test where appropriate, to discrete data and the Student t-test to continuous data.
These patients constituted the preliminary data group of the ‘What Happens To Adolescent Mothers’ study (multi-institutional ethics committee approval), which is a prospective randomised trial of adolescent mother outcomes.
Results
The demographics of the two study groups were representative of those from the total Western Australian population of younger adolescent mothers. Specifically, the mean age of all adolescent mothers aged 17 years or less who delivered in Western Australia during the study period was 16.43 years; this is not significantly different to the mean age in the control groups of 16.45 years (p = 0.85), but it is significantly different to the mean age in the assessed group of 16.21 years (p = 0.0074) [3]. The latter difference of 0.24 years is, however, sufficiently small to be of doubtful clinical significance. Aboriginal patients constituted 37% of all births in Western Australia to women aged less than 18 years during the study period [3]. They constituted 35% of the births in both the assessed and control groups. These differences were not significant (p = 0.67 and p = 0.75, respectively).
In the assessed group (n = 100), social isolation was self-reported by 46% of patients who felt that they lacked support from family and friends. This was supported by the fact that 47% of patients stated that their relationship with the father of the baby had ended and that he would not be involved further with their pregnancy or the care of the infant. In addition, 16% of patients were noted to be officially homeless, where this was defined as failure to identify a place of residence other than a refuge or emergency accommodation. It also included patients who could not give a permanent address and had in excess of four temporary residences with a variety of friends and relatives during the course of their pregnancy. A factor contributing to homelessness was the presence of domestic violence, which was reported by 22% of patients. Domestic violence was usually instigated by a step-parent, past or present partner, and resulted in the teenager leaving home or expressing reluctance to remain in their current living environment after the birth of the infant.
Sixty percent of patients who received formal assessment through the adolescent pregnancy clinic (assessed group) were ultimately identified as having a major social or psychological problem that interfered with their ability to carry out acts of daily living. Based upon the team meetings, management plans were offered to these individual patients. All patients who had an identifiable problem were referred for ongoing social work support. In addition, 20 patients (20%) were formally referred to an adolescent psychiatrist for ongoing management, six were acutely admitted to hospital in order to address pressing social and psychiatric problems, three were ultimately commenced on antidepressant medications and one on a drug withdrawal program. In some cases, and with patient consent, liaison with the Department of Family and Children's Services was initiated when the patient had an existing case worker.
In the control group (n = 60), the majority of patients did not have these issues addressed during the course of their pregnancy. Social supports and the question of ongoing involvement by the father of the infant were not addressed in 50% and 47% of cases, respectively. Important issues of homelessness and the presence of domestic violence were not addressed in 48% and 53% of control patients. No assessment of the patient's overall psychosocial status was made in 42% of cases and, consequently, no antenatal interventions were initiated for this group.
However, the incidence of psychosocial problems in the control patients from whom an adequate history was obtained was not significantly different from those levels documented for the assessed group (social isolation, 53%, p = 0.65; father of infant no longer involved, 47%, p = 0.85; homeless, 10%, p = 0.56; domestic violence, 14%, p = 0.43; major psychosocial problem identified, 49%, p = 0.39).
In the assessed group, nearly half of the pregnant adolescent patients was still smoking at their first antenatal visit (44%), and 23% of these smoked in excess of 20 cigarettes a day. Twenty-one percent drank alcohol, and of these, 24% admitted to binge-drinking. Binge-drinking was defined as drinking alcoholic beverages until the subject either passed out or lacked memory of subsequent events, and this occurred at least once a fortnight.
Thirty-eight percent of patients admitted to illegal drug use during the pregnancy. Marijuana was used by 74% of these, and was the most commonly used drug in this group. Of concern, 21% of the drug takers abused solvents, and 16% used heroin. Benzodiazepines, amphetamines and LSD were only used in combination with a second agent and were the least frequently abused drugs in this study.
In the control group, an adequate drug history was not taken in some cases. Cigarette-smoking, alcohol consumption, and drug abuse was not asked of 7%, 12%, and 28% of patients, respectively. However, the incidence of smoking, alcohol consumption, and non-prescription drug use in the control patients from whom an adequate history was obtained, was not significantly different from those levels documented for the assessed group (cigarette-smoking, 50%, p = 0.58; alcohol consumption, 13%, p = 0.33; non-prescription drug use, 33%, p = 0.67).
Discussion
The findings of this study indicate that pregnant adolescent women have high levels of social and psychological problems. Many lack sufficient support networks from family, friends or a partner to help them adequately deal with daily affairs. In addition, many continue to smoke cigarettes, drink alcohol and abuse illegal drugs during their pregnancy.
Unfortunately, failure to perform an adequate psychosocial history is often the rule rather than the exception in antenatal care. Care of adolescent patients in the control group was undertaken by a combination of general practitioner, midwifery and specialist obstetric staff. Adolescent patients may not have been identified as being at increased risk compared to their older counterparts. This may translate into a failure on the part of the caregiver to explore for underlying social pathology when faced by the time constraints of a busy clinic which is largely designed to manage low risk older patients.
However, social pathology is often clearly present. The findings in the present study that 22% of assessed patients had experienced domestic violence is not surprising. A recent survey of women attending emergency departments found that 26% had experienced domestic violence at some time [8], and the Public Policy Research Centre estimates that nearly one-third of women will be victims of domestic violence in their lifetime [9]. The findings on homelessness are also supported by recent Australian data [10]. Domestic violence and unstable living arrangements can negatively impact upon the ability of any mother to parent a newborn. If these issues are identified in the antenatal period, then an opportunity exists to provide the patient with independent or alternative accommodation which removes her from risk and provides domestic security. Otherwise, she may be forced to raise her newborn in a hostile or dangerous environment. This can lead to child abuse and crisis care with reactive rather than pro-active management.
The levels of social and psychological disorders identified in the study group are higher than those reported for the general adolescent population. The 1-year prevalence of psychiatric disorder in teenagers is estimated at 10–15%, increasing up to 21% in some inner city areas [11,12]. However, we identified 60% of our patients with a major social or psychological problem.
The majority of disorders in teenagers referred to psychiatric clinics tend to fall into the clinical categories of emotional, conduct and mixed emotional conduct disorders. Family and social influences are often important in this group of disorders, and the case for individual illness is less clear [13]. Family pathology played a large role in our adolescent antenatal patients. Social isolation, relationship breakdown with the father of the infant, homelessness and domestic violence provide a poor model from which the teenager can construct positive mothercrafting strategies. Evidence would suggest that these life experiences, if not resolved, could impact on the relationship with the newborn infant, and lead to an ongoing cycle of deprivation [2,4].
Pregnancy is a time when many teenagers hope for a change in their fortunes, with optimism and high ideals. Positive intervention at this time is often welcome, before the rigours of unplanned and unsupported motherhood intervene. We found that patients were usually happy to receive additional support and accepted the benefits of acute hospitalisation at times of crisis.
Although many teenagers are known to experiment with drugs, pregnancy is traditionally a time during which women are thought to be more inclined to adopt a healthier lifestyle and give up cigarettes and other harmful substances. Several American studies support this premise. Zuckerman et al. [14] reported that primigravida Boston teenagers aged from 13 to 18 years of age used less psychoactive drugs, smoked or used alcohol compared to mature women giving birth at the same hospital, and similar findings have been reported in young Camden nulliparas [15].
In contrast, a study from Malta reported that pregnant teenagers were significantly more likely to be cigarette smokers than mothers aged 20–29 years of age [16], and this supports our findings where the level of use of cigarettes, alcohol and illegal drugs was equal to or higher than that reported for the general Australian adolescent population [5].
The most recent Australian figures on smoking found that 31% of women aged 16–19 years of age were smokers and 12% were ex-smokers [5]. However, the figures in the present study were considerably higher with 44% of patients admitting to smoking, and 10% smoking in excess of 20 cigarettes a day.
A self-report survey of over 3000 London schoolchildren found that 10% of 11–16 years olds were using alcohol once a week or more [6]. Our study found that 21% of patients were drinking alcohol, and of note, 5% admitted to binge-drinking.
The 1993 Australian National Campaign Against Drug Abuse household survey reported that up to 32% of 14–19 years olds had ever tried cannabis, but only 20% had tried in the past year, and only 3% within a week of the survey [17]. We found that 38% of patients in our study had used an illegal drug or solvents during their pregnancy. Cannabis was the illegal drug most commonly taken by the pregnant adolescents, with 28% admitting to its use. These findings are of concern as cannabis use in pregnancy is associated with low birthweight and a possible rise in the risk of birth defects [18]. Cannabis use in adolescents is associated with increased levels of discontinuation of high school education and job instability [18]. These are poor companions to adolescent motherhood.
Solvent abuse has marked neuropsychological effects [19] and is particularly harmful in pregnancy, yet 8% of subjects in this study continued to sniff a variety of solvents. This agrees with studies that estimate 3–11% of secondary school children experiment with solvents [6,19]. Use of heroin and cocaine is estimated at less than 1% in general school-based surveys, but rises up to 2% in some high risk localities [6,19]. However, its use in our study was considerably higher, with 6% of patients admitting to its regular use in pregnancy.
It is possible that many Australian drug prevention programs are simply failing to reach this high risk audience. The antenatal clinic provides an ideal setting in which to address issues of smoking, excessive alcohol consumption and use of non-prescription drugs on a one-to-one basis. Although many adolescents are reluctant to attend medical services, pregnancy is often an exception. However, problems need to be identified in order to be addressed, and sufficient time must be available to ensure that adequate assessments are undertaken.
Aboriginal patients are disproportionately represented in adolescent pregnancy statistics. This highlights the importance of utilising culturally specific interventions to detect and address problems in this group. Aboriginal liaison officers are of particular use in providing a link between care givers and some patients and their families, but care has to be taken to preserve patient confidentiality. Otherwise social workers, psychologists and psychiatrists with expertise in adolescent pregnancy can play a vital role.
For many reasons, adolescent pregnancy impacts the community. These teenagers, and their newborn infants, are at increased risk compared to the general population of adolescents in both their levels of social and psychological problems and in their use of non-prescribed drugs. Although our sample is small, both assessed and control groups were representative of the wider population of adolescents delivering in Western Australia during the study period. Antenatal intervention may offer these women an alternative foundation upon which to base their mothercrafting and parenting strategies, in order to prevent the ongoing cycle of social disadvantage. These interventions can then be continued into the postpartum period and provide the opportunity for pro-active management.
Footnotes
Acknowledgement
We would like to acknowledge the ‘Innovative Funding for Homeless Youth Support Scheme’ Commonwealth Department of Health.