The Young Mother's Club | to pdf >>
by Kathryn Keller Biddle, NP, RN, MS

Introduction
The 38-year-old woman sat to my right, weeping openly. Her daughter sat to my left, looking uncomfortable, one tear sliding silently down her cheek. She was only 14 years of age.

The young girl's menstrual period was now three months late. Finally, she had come into the Kaiser Permanente (KP) laboratory after school for a pregnancy test. Still, she was shocked when the advice nurse had informed her the test was positive: She was pregnant. She was offered an appointment with me, the Young Mother's Clinic nurse practitioner, for the next afternoon.

This scene is a frequent one for me yet each time I am sad for both mother and daughter. Neither were prepared for this moment. Neither had expected this news. Neither could begin to realize how much their lives would change from this time on.

I quietly questioned how the young girl felt. Had she told her boyfriend the news? Did she understand her choices? Had she already come to a decision?

The problem of teen pregnancy is well documented. Statistics show that >1 million U.S. teenagers per year become pregnant. According to data released by Planned Parenthood Foundation of America, Inc, 11% of all teens aged 15 to 19 years old become pregnant each year, a rate twice that of other industrialized countries.¹ The March of Dimes reported that 40% of pregnant teenagers will subsequently become pregnant within two years.²

Two of the earliest studies to document the benefits of Specialized Prenatal Adolescent Programs on maternal and infant outcomes were published in the 1980s. In 1983, Neeson et al³ at the University of California, San Francisco found that the outcome of teen pregnancy when managed in specialized antenatal programs more closely resembled the pattern of young adults rather than the outcome of teens cared for in a general clinic. Three factors; early prenatal care, adequate emphasis on nutrition, and nursing management in primary care were cited as contributing to these results. Infant weight and gestational scoring as well as Apgar scores were significantly better than those in a general clinic.

Slager-Earnest et al⁴ also documented improved outcomes with their 1987 study of 100 pregnant adolescents. Fifty attended the specialized program, and 50 did not. Mother and infant pairs in the program had fewer complications than those who did not participate in the program.

The Young Mother's Club
Eight years ago, the Young Mothers Club (YMC) was designed in the KP South San Francisco obstetrics and gynecology department to meet the needs of our pregnant adolescent population. We hoped that our young clients would experience the benefits of a specialized program. YMC had six specific goals: 1) to provide easy access to early prenatal care; 2) to ensure improved self-esteem, parenting skills, and higher rates of breastfeeding; 3) to improve nutritional status, and reduce anemia; 4) to encourage continued formal education; 5) to reduce the rate of complications associated with teen pregnancy (eg, low birthweight, preterm labor); and 6) to prevent teen pregnancy. Our clinic consists of a physician, two nurse practitioners, a dietitian, and a social worker.

The YMC meets each Thursday afternoon. The young women meet in our departmental conference room, where a light, nutritious snack, videos about pregnancy and parenting, and a table of free written information have been set up. Donated baby clothes and other related items are displayed for the teens to take home. Periodically, drawings for large donated items such as high chairs, car seats, or strollers are held. A 30-minute class is given at each clinic session. Taught by experts from our own department or from the pediatrics department, classes feature such topics as: Breast/Bottle-feeding, Infant care/Bath, Parenting, Relationships, Drug and Alcohol Use, Sexually Transmitted Diseases, Birth Control Planning, and Hospital Routines/Early Labor. In addition, our medical center provides a 6-week childbirth preparation course at no cost.

Since its beginning the YMC staff has cared for >1000 young women aged 12 to 19 (excluding teenagers who chose to terminate their pregnancies after receiving initial counseling) who were KP members. Clients are referred either from the pediatrics clinic or directly by the obsteterics and gynecology advice nurse when clients receive positive results of a pregnancy test. In a session conducted by one of two nurse practitioners, clients are offered initial counseling to discuss their options. This session is often very emotional and may include the client's parents, the father of the baby, or a combination of these. Clients who decide to continue the pregnancy are then enrolled into the YMC program.

After being enrolled in YMC, adolescents are given a "pregnancy confirmation" visit. This visit is conducted by the YMC nurse practitioner who provided initial counseling and, if possible, is scheduled within the first 6 to 7 weeks of pregnancy. Teenagers who are tested late in pregnancy are seen within a few days of being given the positive result. This visit is usually about 60 minutes and includes a complete medical history, family history, social situation evaluation, and complete physical examination. The pelvic examination is the first for many girls, and special care is given to explain all aspects of this examination. Routine prenatal blood testing is done; testing for sexually transmitted disease (STD) is done and HIV counseling and testing is encouraged. Use of drugs, alcohol, and cigarettes is evaluated by using a written questionnaire. Routine urinary drug screening is done after obtaining written consent. Pregnancy-related information on diet, exercise, body changes and fetal development is discussed, and each client is given a pregnancy journal in which to record her own progress and feelings.

The client then meets with the YMC social worker to identify the client's specific emotional needs, family situation, status in school, and financial needs and concerns. Any substance use or abuse identified is evaluated and, if appropriate, referral is made to the drug and alcohol treatment center based in the psychiatry department.

Within one month after the first examination (sooner if high-risk factors are identified), clients will return for their second visit. This visit is conducted by our YMC doctor, who reviews the client's progress, reevaluates her needs, and performs a routine prenatal examination. At this time the client also meets with our YMC dietitian for evaluation and design of a nutritional plan to meet her specific needs. Follow-up appointments with the YMC social worker are arranged as needed.

Routine prenatal visits are continued every 4 weeks until 30 weeks of gestation; every 2 weeks from 30 to 36 weeks of gestation; and weekly until the 40th week. Care is provided on a rotating basis by either a YMC nurse practitioner or by the YMC physician. Consultation during and after YMC hours between all the YMC staff occurs. Staffing needs may vary according to size of clinic, number of clients, or both.

Family and Community Involvement in YMC
For many young women, formal education ends when they discover they are pregnant. One of our highest priorities is therefore, to help our young clients return to school or to work toward passing a high school equivalency test. From its beginning, YMC has had a close relationship with the local high schools' School Age Mothers Program (SAMP). This program provides continuing education for any pregnant teenager who resides within the geographic boundaries of the local school districts. The program provides a full-time teacher as well as a public health nurse. Regular classwork is supplemented with instruction in nutrition, pregnancy, and infant care. To further motivate our clients, we have agreed with the local school districts that they will give high school credit for classes attended in our YMC program.

To further link YMC with the community and to advance YMC's goals, the YMC physician and a YMC nurse practitioner give 40 class sessions per year at the local high school. These classes teach about male and female anatomy, sexual responsibility, STDs, "safe sex," and birth control. About 50% of these high school students are members of our health plan.

We encourage the father of the baby (or the person who is otherwise the client's partner) to attend her prenatal visits and classes. Many clients bring a friend or parent. Family involvement is encouraged by the YMC providers to give the young women a sense of security at an extremely vulnerable time in their lives. The family will often assume childcare to enable their daughter to complete her education. Acceptance by her family is especially important if the young woman has no emotional or financial support from the father of the baby. Our social worker is adept at evaluating family dynamics and at helping the family find solutions together.

YMC Client Survey Results
Statistics were compiled during YMC's first five years (1990-1994). During this time, YMC served 540 teenagers. Attrition was attributed to spontaneous abortions (8 clients) or to elective termination of pregnancy before 17th week of gestation (20 clients) after enrolling in YMC. Mean age of our clients was 17 years, the youngest was 12 years. YMC clients were Hispanic (33%), white non-Hispanic (23%), Filipino (24%), black (15%), or other ethnic groups (5%).

Rate of drug use as reported by YMC clients was 22%, rate of smoking was 21%, and rate of alcohol use was 16%. Nearly all (98%) of YMC clients reported discontinuing all use of these substances after entering the YMC program.

Cultures for STDs were positive in 21% of YMC clients. Chlamydia was the most frequently reported sexually transmitted infection: 38 cases treated (included many which had been discovered during the initial physical examination.)

Clinical Statistics Supported YMC Goals:

Each year since our original statistics were compiled, the number of clients enrolled in the YMC has increased; in 1996, 150 teenagers participated in the YMC program. In the same year, in a joint effort with our pediatrics department, we began inviting all adolescent girls (usually aged 14 to 15 years) for a "personal talk" with one of the YMC nurse practitioners. These visits give us a chance not only to answer their questions but to provide information about their changing bodies, emotions, sexuality, and the serious issues surrounding sex at an early age. Abstinence, birth control, and safe sex are discussed. Girls who are already sexually active are given a pelvic examination, STD testing, and contraceptives.

In collaboration with the pediatrics department, our social services department was recently awarded a KP Innovation Program grant which will enable us to continue observing YMC participants after their babies are born. This program will include support groups and continuity of care.

Conclusion
Teenage pregnancy is a serious issue. Providing specialized services to meet the identified needs of our young clients will help them face the future and its responsibilities. Providing information and open discussion through easy and confidential clinic access, as well as contributing community service to our schools, may help reduce the number of teenagers who later need our services for prenatal care or pregnancy termination.

For health care providers involved in the Young Mothers Club, the rewards are many. One particular couple comes to mind: after the girl became pregnant (at 15 years), they worked together, attended all her prenatal visits, and finished school. A letter and picture of their young family arrive every Christmas. At 22 years of age, the parents are now married, employed, and happy. The young woman writes every year to thank us for the difference our clinic made in her family's lives. "Best practices" are those which make a difference.

References

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