Why is CAMP?
The proportion of American teenagers who are sexually active increased
dramatically during the 1970s, 1980s, and early 1990s (1-3). The reasons for
the soaring number and plummeting age of sexually experienced American
teenagers remain a matter of speculation. Biologic and psychosocial
explanations have been proposed (3). The latest vital statistics and national
survey data are both sobering and encouraging.
At least 25% of 9th graders and 75% of 12th graders have had sexual
intercourse on one or more occasions. However, American teenagers have been having less sex and using
more birth control since 1996 (1-3). As a result, teenagers in the United States (US) are less
likely to become pregnant and have babies now
than a decade ago (1-3). However, there
is no reason for complacency or diminished concern. American teenagers are
still more likely to conceive than teenagers in most other western developed
countries (4). This is not because they
are more sexually active, but because they use contraceptives less effectively
(1-4).
The general trend toward decreased teen sexual activity in the
More than 1 out of 10 infants born in
Since the annual cost is nearly 6 billion dollars
in welfare payments, medical and food subsidies,
and foster care and prison expenditures, prevention is a national priority
(10).
It has been difficult to determine why
adolescent parents and their children are at such high risk for medical and
social problems (5-9). This is because in most studies young maternal age is
associated with characteristics such as poverty and under-education that
predispose individuals of all ages to adverse pregnancy and parenting outcomes.
For most adolescents, the risks associated with childbearing are due primarily
to social factors such as poor health habits, poverty, and stress. But among
the very young, biologic factors, such as, incomplete maternal growth and
maternal reproductive immaturity may also be important (9). Nonetheless, the consensus is that the
majority of the medical complications associated with childbearing at this age
can be reduced (if not eliminated) by early, consistent, adolescent-oriented,
prenatal care (5, 6, 9, 11, 12). Unfortunately
adolescents rarely obtain an adequate quantity of prenatal care. For example,
in
Clearly, something must be done to improve access
to high-quality adolescent-oriented, prenatal care in
However, this can only be considered a
first step.
Simply improving the quantity and
quality of prenatal care adolescents receive will not solve the problems these
untimely conceptions create. Programs
that only target the index pregnant or parenting teenager and those that end at
delivery have little or no effect on the attitudes and problems within
families, communities, and social networks that foster teen pregnancy or the
long-term sequelae of adolescent childbearing (5, 6,
13, 14). For example, studies of the pattern of teen pregnancy indicate that
the younger sisters and daughters of teen mothers are 2-to-3 times more likely
to conceive during adolescence than their peers (14-19). Moreover, without
intensive postpartum intervention the repeat teen pregnancy rate averages
20-to-25% during the first and 30-to-40% during the second postpartum year (5,6,20).
Preventing second and higher order teen pregnancies is a highly sought
after public health objective. This is
because all of the outcomes of adolescent childbearing are influenced by the
number of additional children teenage parents have during adolescence (5-7,20). Teenagers who are able to postpone further
childbearing for as little as 2 years reap numerous health, psychological, and
economic benefits for themselves and their children (5-7,20).
By contrast, the risk of preterm delivery and the likelihood of completing high
school, having a job, and being self-supporting, decreases with each additional
teen pregnancy (5-7,9,20). Finally, the amount of time
and resources that can be spent on the first child diminishes with each
successive pregnancy at this age (5, 7, 13). Thus, the risk of developmental delay, school
failure, accidental and non-accidental trauma, delinquency, and teen pregnancy
in the next generation increases in tandem with family size.
Clearly, something must be done to prevent rapid
additional teen pregnancies
if these families are ever going to escape the intergenerational cycle of
poverty.
Helping families who have experienced one teen pregnancy prevent others
ought to be an easy task
(13, 14, 21-25). Most
teenage mothers and their younger sisters and daughters insist that they and
their boyfriends do not want to become pregnant "anytime soon". Most also have aspirations for their futures and their children’s
futures that are as incompatible with early childbearing as those of their
never-pregnant peers. Finally, almost all of these you women receive contraceptive counseling and supplies on
repeated occasions. Consequently, most
teenagers try to use contraception when they first become sexually active and
right after they have babies (21-27). Indeed, teenagers who have just begun to
have sex and those who have just given birth are more likely to report that they
are using contraception than their more sexually experienced and parenting peers (21, 25, 27).
The problem is not convincing teenagers to use
contraception. Rather, what we need to
do
is help them understand and believe that the consistent use of contraceptives
can increase their chances of achieving what they want most for themselves in
life.
How to do so is one of the most perplexing diagnostic and therapeutic dilemmas
American health care and social service providers
face. Most of these young women clearly have the means and express the
motivation to remain non-pregnant during adolescence. However, absent interventions that increase
the real life opportunity costs of early childbearing and/or the tangible
benefits of delaying childbearing beyond adolescence, the heightened
contraceptive vigilance initial sexual experiences and pregnancy motivate wanes
rapidly in daily living environments that are conducive to adolescent
childbearing (22-29). Because so many of the teenagers who reside in these
communities quickly find that pregnancy and parenthood have significant
rewards, even in health care settings that guarantee confidentiality and
eliminate common barriers to care, they typically become inconsistent
contraceptive users at best (7, 22-29). Extending comprehensive,
adolescent-oriented, maternity programs beyond the immediate postpartum period
and providing aggressive postpartum follow up, with a strong emphasis on
family, career, and lifestyle planning appears to be one of the most effective
ways to eliminate the unsafe sexual risk-taking that persist among adolescent
mothers who are cared for in traditional adult-oriented reproductive health
care settings (5,13, 20, 25). In particular it has been found that young
mothers who are cared for along with their infants receive more regular care,
are more compliant with contraceptive prescriptions, and postpone second
pregnancies for longer periods of time than do young mothers who receive
medical care in other settings.
Improving the efficacy of contraceptive use among teenage mothers and
preventing second and higher order teen pregnancies
are important public health goals.
However, simply improving the
quantity and quality of postpartum care
adolescent mothers receive will not solve the problem of unintended pregnancy
in their families.
The younger sisters and daughters of teenage mothers are at higher risk
for teen pregnancy than most other groups of girls in the
Intervention is imperative, because most middle
school students are still too cognitively and psychosocially immature
to protect themselves from the untoward
consequences of the unprotected sexual activity.
Families who have experienced one teen pregnancy are easy to
identify. However, the younger sisters
and daughters of teen mothers are notoriously difficult to reach within the
confines of the traditional educational and reproductive health care systems
(14). Sex education classes and family planning clinics that cater to
teenagers' special needs give them the capacity to prevent conception. However, these programs have had little
impact on the teen pregnancy rate in poor, urban communities where the problem
is endemic (29). The opportunity costs
of childbearing are simply too low and the rewards too high to be countered by
talk alone (22, 28). Engaging young teenagers in structured volunteer community
service that fosters strong attachments to family, school, and community and
gives them an opportunity to work and interact with adults who can be positive
role models is a promising approach.
Moreover, these programs offer teenagers an alternative to the risky
sexual practices they develop when motherhood is disproportionately modeled as
means of attaining adult status (30-35).
In particular it has been found that strategies ranging from one-on-one
mentoring to structured, voluntary, community service job placements increase the
likelihood that teenagers will grow-up with the optimistic, future-oriented
outlook, resources, and reasons they need to remain non-pregnant during
adolescence, graduate from high school, and become happy, productive adult
members of their communities (30-36).
When family planning is promoted as a means of
attaining a desirable lifestyle, rather than an end in itself,
the benefits of intervention go far beyond the immediate goal of preventing
teen pregnancies.
The literature strongly suggests that among adolescents pre- and postnatal care
are most effective when they are provided within the context of a
comprehensive, multidisciplinary program designed to meet their unique medical,
nutritional, psychosocial, transportation, and educational needs. However, it is more expensive to provide this
type of care. Hence, it is important to demonstrate that the benefits attributed
to programs like CAMP reflect unique aspects of the care they provide. Based on
this review of the literature and over 25 years of clinical experience with
this population, we have identified several tangible differences between
adolescent- and adult-oriented maternity care (11-14,36-40).
These are summarized in the section entitled “Why
is CAMP different”.
Taken
together the data support our hope that CAMP will serve as a national model.
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