A teenage pregnancy, and even more so when the girl is very young, is often discovered late for many reasons: ignorance, fear of talking about it, absence of an interlocutor, anxiety concerning the medical follow-up, fear of being forced to abort and, for some, denial of an initially desired reality that is subsequently dreaded once it is fulfilled. All coincide to delay the official declaration to the national health insurance program and thus the monitoring of the pregnancy. Indeed, certain extreme cases can go to term without being noticed or even suspected by the girl’s entourage and therefore end in an unexpected delivery at home or, even worse, in a public site or school. This clandestinity is a major problem because it prevents all medical surveillance, thereby rendering the pregnancy more vulnerable, and puts the future mother in a state of isolation that is detrimental from all points of view.
The diagnosis of this pregnancy is also made difficult by the high number of long and irregular menstrual cycles during this period and the reported dates of the last menstruation are pure fantasy. Indeed, such a date, when vague, should never a fortiori be considered as being etched in stone.
Very often, the adolescent will consult her doctor without causal relationship with her condition and, when unclear symptoms are described, the question of a possible pregnancy must simply be asked. At the time of the first medical visit, the chief complaint (or presenting problems) may vary from vague and nonspecific symptoms, such as a sore throat, abdominal pain or urinary tract symptoms, to more specific signs and symptoms characteristic of pregnancy.
Ultrasonography remains the best examination to determine the time of gestation during the first trimester with the aim of leaving enough time to allow the choice of termination. After this legal time limit, all the obligatory examinations will be performed to complete the physical examination and interview, so as to determine the specific risk factors of each adolescent.
In our study, only 13% of the pregnancies were seen during the first trimester, respectively 31 and 41% consulted as of the second and third trimesters, and 17% were first seen at the time of delivery. Analysis of the teenager’s family situation showed that 42% were married or living with their partner and 58% were single but two-thirds knew who the father of their child was.
Teenage pregnancy is reputed to be at-risk, primarily because of the higher number of low-birth-weight infants. The rate of premature deliveries, around 10% in all studies, is probably more responsible for these low birth weights because true intrauterine growth retardation at the 10th percentile is approximately 13%, barely more common than in the general population.
Nutritional disorders are often the most common risk factor, as the protein needs are not always met because of the more frequent vomiting early during pregnancy and later because of the low socioeconomic level. In contrast, for 1 out of 5 cases, too much weight is gained because of the too high intake of glucides and it can result in definitive obesity.
Iron-deficiency anemia is common and must systematically be treated as of the second half of the pregnancy.
The two principal complications are directly associated with the late onset of prenatal care and behavior to ‘erase’ the pregnancy, combined with the failure to take any physical or dietary precautions and the continuation or even aggravation of addictive behaviors. It should be recalled that, in France, declaring the pregnancy to the national health insurance system during the first trimester opens the door to free prenatal monitoring with one consultation per month (more often for pathological pregnancies), including all the complementary examinations and delivery.
The pregnant teenager is allocated a monthly allowance as a single parent of 600 euros and, as soon as the baby is born and for 3 years thereafter, this amount rises to 750 euros per month.
It is clear that in industrialized countries, unlike underdeveloped nations, pregnancy should not be considered an exclusively medical problem. Other than very young adolescents, under 15 years old, more clearly exposed to preeclampsia and their fetuses to intrauterine growth retardation, the problem is not so much associated with age as it is with social context: poor social and economic conditions, lack of affective support and, frequently, the absence of prenatal monitoring. This situation explains the importance we accord to the psychosocial support given to these pregnancies to achieve the best possible welcome for the newborn.
A certain number of factors are only slightly or not modifiable: very young age, financial precariousness, a low level of education, and deficient social or familial support. Others are amenable to change: clandestinity and insufficient prenatal care, nutritional deficiencies, habits poorly or not at all adapted to pregnancy (smoking and use of toxic substances), the stress or risk of inappropriate activities, and sexually transmitted genital infections.
In practice, an all-encompassing strategy is applied that can be adapted to respond to the different facets – medical, obstetrical, lifestyle and psychosocial – of the teenager’s situation. This approach is best handled by a trained, pluridisciplinary team, in conjunction with the girl’s partner and/or parents or parental authority, when possible, with the goal of evaluating the context in which the infant can be welcomed.
For the most disadvantaged adolescents, with no hope of immediately procuring decent resources, particularly those marginalized, estranged or rejected by their families or in a violent environment, etc., entry into a home for unwed mothers is highly desirable. Such a facility reserved for very young mothers would be the best adapted. The few existing institutions are small units with an educational staff and child-care facilities. These structures allow the young woman, before and after the baby’s birth, to partake in outside activities (school, professional training), while still benefiting from being ‘accompanied’ and by personnel trained in child welfare. Unfortunately, these facilities are too rare, well below current needs.
According to all studies, delivery, strictly speaking, has a reputation of being without risk, as long as the pregnancy has been recognized, so that some notions of parenting can be taught before the arrival of the infant. Our study generated results similar to those already published: a large majority (94%) of natural births, 22.5% of which required forceps, and only 5.9% cesareans (while the rate for the general population is around 18%). The old idea, according to which delivery through an immature pelvis can expose the young woman to disproportionate risk and need for a cesarean, has not been confirmed by practice.
In the context of the extreme economic precariousness of these girls, 3% of these ‘unexpected’ births occurred at home, 10% of the infants were transferred to neonatal units, 1% required neonatal intensive care, 1% of the fetuses died in utero, 1% of the pregnancies followed sexual aggression and 1% of the newborns were abandoned at birth.
Disproportionately high rates of maternal and neonatal mortality are associated with adolescent childbearing, especially for non-white adolescents under 15 years.
Revision date: July 7, 2011
Last revised: by Jorge P. Ribeiro, MD