Options Counseling for the Pregnant Adolescent Patient

Once the diagnosis of pregnancy is made, supportive individuals for the patient can be identified to the best of the pediatrician’s ability and, with the patient’s approval, brought into a discussion of pregnancy options. Depending on the estimated gestational age of the pregnancy, the adolescent usually has the following options available:

• carrying her pregnancy to delivery and raising the infant;

• carrying her pregnancy to delivery and making an adoption or kinship care plan; and

• terminating her pregnancy.

It is advisable that the pediatrician present all options in a factually accurate and nonjudgmental manner while respecting the patient’s personal, family, and spiritual beliefs and cultural practices. The patient’s psychosocial development and any limitations for abstract and future thinking need to be appreciated, especially in the case of a younger adolescent.

Continuing the pregnancy is the most common choice made by pregnant adolescents, although the medical risks associated with it remain unclear. Identifying obstetric risks associated with adolescent pregnancy has been challenging because of confounding factors such as socioeconomic status, maternal weight gain, and adequacy of prenatal care. Although the authors of several recent studies have found that adolescents are at a higher risk of complications, such as preterm delivery, small-for-gestational-age infants, and neonatal death, than mothers in their twenties,^8,–11 other study authors have indicated similar obstetric risks between the 2 groups.^12,–14 Pregnant adolescents are less likely than older women to receive early and adequate prenatal care,^15,16 so efforts should be made to facilitate a prompt referral to a prenatal care provider should the adolescent decide to continue her pregnancy.

In contrast to the obstetric risks, the psychosocial risks associated with adolescent parenting are well-established. Although, with ambition and support, many adolescent mothers achieve their personal aspirations and raise healthy, successful children, they face significant challenges. Less than 40% of adolescent girls who have a child before 18 years of age receive a high school diploma by age 22. Nearly two-thirds of adolescent mothers receive public assistance, and as they proceed into adulthood, their chances of living in poverty increase. Most adolescent mothers receive no child support from their child’s father. Generally, the children of adolescent mothers perform worse academically and are more likely to repeat a grade or drop out of high school. The daughters of adolescent mothers are more likely to repeat the cycle and become adolescent mothers themselves.^17,–19 The challenges unique to teen-aged parents and their children, along with suggestions for support by pediatricians, are outlined in the AAP clinical report “Care of Adolescent Parents and Their Children.”²⁰ 

Although many adolescents will choose to parent, some may not be in a position to do so and may consider kinship care, whereby a grandparent or other relative serves as parent to the infant. This may be through an informal, private arrangement or through the child welfare system, varying state by state.²¹ Kinship care may allow the adolescent to continue to be involved with her child as well as the opportunity to take on the responsibilities of parenthood in the future.

Adoption is an important option for the pediatrician to discuss with the adolescent.²² Today, making an adoption plan for a newborn infant is relatively uncommon. The number of never-married women younger than 45 years who made adoption plans for their newborn infants declined from nearly 9% before 1973 to <1% in the mid-1990s.²³ More recent and adolescent-specific data are difficult to obtain.²⁴ It is believed that nearly half of infants whose birth mother voluntarily made an adoption plan are adopted by someone who knew the mother before the adoption, including relatives.²⁵ Most birth mothers who make an adoption plan for their child are adult women; only one-quarter of birth mothers who make an adoption plan for their child are younger than 20 years. Most women who make this choice have completed high school, and many have completed some college or vocational training. Many have given birth previously. Pregnant teenagers choosing to make an adoption plan for their child are often more mature in their thinking, have personal goals, and recognize limitations in their ability to parent well at this point in their lives.²⁶ 

Grief, thoughts about the relinquished child, guilt and shame, and effects on other relationships are common among birth parents who make an adoption plan for their child.^27,28 Under the right circumstances, open adoptions, in which birth and adoptive families have some form of contact, may be possible and can be beneficial in this regard.^29,–31 Pediatricians should be familiar with reputable adoption services in their area that can offer further information about adoption.

Many pregnant adolescents will consider abortion and should be offered accurate information about it.³² It is important for pediatricians to be knowledgeable about both medical and surgical procedures that may be used to terminate a pregnancy³³ and of their availability in the community or region. Medical and surgical abortions are safe when performed by licensed and experienced physicians. The mortality associated with childbirth is many times higher than that associated with legal abortion.³⁰ Although they can occur with both types of abortions, rates of complications are low.^34,–36 Concerns about possible late effects of induced abortion, including infertility, increased cancer risks, or mental health issues, are not supported by current evidence.^37,–40 Feelings of grief and loss can follow an abortion, and the pediatrician should be prepared to offer resources for emotional support after the procedure. Adolescents who are considering pregnancy termination should be referred to a trained abortion provider for more detailed information and counseling.

The pediatrician should be cognizant of local laws affecting the availability of pregnancy termination services, requirements for parental notification or consent, and the cost for such services.^41,42 Out-of-pocket costs for abortion services can be substantial for patients and families. Lack of funds can cause delays, which potentially lead to the need for more complicated and more costly procedures.⁴³ The pediatrician should be familiar with sources of financial assistance that may be available in his or her community or state.

The topics of premarital sex, teen-aged pregnancy and parenting, adoption, and abortion can evoke strong personal feelings. Some pediatricians may feel limited in their ability to present and discuss all legal pregnancy options with a pregnant adolescent because of claims of conscience. Pediatricians generally can refuse to perform procedures they consider medically inappropriate. However, refusal may constitute an imposition of the pediatrician’s moral beliefs on the patient.⁴⁴ The pediatrician must respect the pregnant adolescent’s right to choose the course that best suits her and must not impose barriers to receiving the health information and services she desires. Should a pediatrician realize that he or she cannot counsel the adolescent patient about all pregnancy options, the patient should be referred promptly to another capable and willing professional.⁴⁴ 

The adolescent with an unplanned pregnancy faces a difficult decision, one that likely will have lifelong impact. The AAP reaffirms its position that pregnant adolescents have the right to be informed and counseled on all legal pregnancy options. Pediatricians should take the following steps:

1. Inform the pregnant adolescent of the options, which include carrying the pregnancy to delivery and raising the infant, carrying the pregnancy to delivery and making an adoption or kinship care plan, or terminating the pregnancy;

2. Be prepared to provide a pregnant adolescent with basic, accurate information about each of these options in a developmentally appropriate manner, support her in the decision-making process, and assist in making connections with community resources that will provide her with quality services during and after her pregnancy; and

3. Examine their own beliefs and values to determine if they can provide nonjudgmental, factual pregnancy options counseling. If they cannot, they should facilitate a prompt referral for counseling by another knowledgeable professional in their practice setting or community who is willing to have such discussions with adolescent patients.

AAP

American Academy of Pediatrics

Laurie L. Hornberger, MD, MPH, FAAP

Cora C. Breuner, MD, MPH, FAAP, Chairperson

Elizabeth M. Alderman, MD, FSAHM, FAAP

Robert Garofalo, MD, FAAP

Laura K. Grubb, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Krishna Kumari Upadhya, MD, FAAP

Stephenie B. Wallace, MD, FAAP

Paula K. Braverman, MD, FAAP, Immediate Past Chairperson

William P. Adelman, MD, FAAP

Arik V. Marcell, MD, MPH, FAAP

Laurie L. Hornberger, MD, MPH, FAAP – Section on Adolescent Health

Liwei L. Hua MD, PhD – American Academy of Child and Adolescent Psychiatry

Margo Lane, MD, FRCPC – Canadian Pediatric Society

Seema Menon, MD – North American Society for Pediatric and Adolescent Gynecology

Meredith Loveless, MD – American College of Obstetricians and Gynecologists

Lauren Zapata, MD – Centers for Disease Control and Prevention

Karen Smith

James Baumberger, MPP