Options Counseling for the Pregnant Adolescent Patient

With a pregnancy diagnosis, the pediatrician and the adolescent may engage in dialogue to identify supportive individuals who, with the patient’s approval, may be included in the discussion of pregnancy options. The principals of reproductive justice call for every person’s right to decide whether to have children, to decide the number and spacing of children, and to have the information, education, and access to health services to make these decisions.⁸  Depending on the estimated gestational age of the pregnancy, the adolescent usually has the following options available:

• Continuing the pregnancy to delivery and raising a child.

• Continuing the pregnancy to delivery and making an adoption, kinship care, or foster care plan.

• Terminating the 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 pediatrician needs to consider and document the patient’s psychosocial development and any limitations for abstract and future thinking, especially for younger adolescents. In addition, it is good practice to document discussions about involving (or not involving) parents/guardians and the rationale for those decisions and referrals to other providers (or informed refusal for patients who decline that option). Excellent documentation of medically appropriate care may better legally protect physicians and help defend their decisions in tort or licensure cases.

Most pregnant adolescents choose to continue the pregnancy.¹  Adolescents, especially younger adolescents, are at increased risks of adverse obstetric and neonatal outcomes, including preterm birth, small-for-gestational-age infants, low birth weight, and infant death compared with women in their twenties.^9–15  Biological and social factors contribute to these outcomes, with the receipt of adequate prenatal care being associated with improved outcomes.^9,16  Given that pregnant adolescents are less likely than older women to receive early and adequate prenatal care,^10,17  pediatricians should facilitate a prompt referral to a prenatal care provider, ideally one skilled in caring for adolescents, should the adolescent decide to continue the pregnancy.

Although many adolescent parents achieve their personal aspirations and raise healthy children, they often face significant challenges. The AAP clinical report, “Care of Adolescent Parents and Their Children” outlines unique challenges to adolescent parents and their children, along with suggestions for support by pediatricians.¹⁸  In the United States, there are disparities in educational attainment between adolescent mothers and young women who delay parenting with consequent economic disadvantages¹⁹ ; however, the negative outcomes associated with teenage pregnancy may be consequences of poverty and systemic inequalities, and young parents should not be further stigmatized.²⁰ 

Although many adolescents will choose to parent, some may not be able to do so and may consider kinship care, whereby a grandparent or other relative parents 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 be involved with the child and the opportunity to take on the responsibilities of parenthood in the future. Some adolescents may choose foster care for their infant when kinship care is unavailable or not suitable.

Adoption is an important option for the pediatrician to discuss with the adolescent.²² 

Adoption planning 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 less than 1% in the mid-1990s.²³  More recent and adolescent-specific data are not available.²⁴  Birth parents who make an adoption plan for their child may experience grief, thoughts about the relinquished child, guilt, and shame.^25,26  Open adoptions, in which birth and adoptive families have some form of contact, are common and may be beneficial in this regard.^27–29  Pediatricians are encouraged to assist a patient interested in finding information about adoption.

Many pregnant adolescents will consider abortion, and health care providers should offer accurate information.³⁰  It is important for pediatricians to be knowledgeable about medication and procedural options for abortion and of their availability in the community or region (see Box).³¹  Moreover, abortion provision is within the scope of practice of pediatrics, and training is available for pediatricians to provide abortion care.^32,33  Legal abortion in the United States is safer than childbirth, and rates of complications are low.^31,34  The majority of available evidence does not support concerns about possible late effects of induced abortion including infertility, increased cancer risks, or mental health issues.^35–38  In contrast, denying women abortion services provokes anxiety and stress.³⁹  Being able to control the timing of pregnancies has a positive impact on women achieving their life plans as well as bonding with future children and the economic security of those children.^40,41  In contrast, not being able to obtain a wanted or needed abortion leads to economic insecurity for women and their families and negatively impacts existing children’s economic and emotional well-being.^42,43 

It is recommended that adolescents who are considering abortion be referred to a clinician who provides abortion care for more detailed information and counseling. Certain populations face inequities accessing abortion care, including adolescents, people living in or near poverty; Black, Indigenous and other people of color; transgender, nonbinary, and gender-nonconforming people; people with disabilities; people living in rural areas; immigrants; and people who are incarcerated.^8,44–54  It is important that pediatricians support equitable access to abortion care and provide facilitated abortion referrals to patients in need or at their request. At a minimum, the referral should provide information about abortion services, including a list of local or regional abortion providers.⁵⁵  More facilitative abortion referral behaviors include assistance in scheduling abortion; assistance in accessing supportive services, such as transportation, legal resources, and abortion funding; and following up on outcomes with continual updating of referral resources.⁵⁵  Given the barriers that many adolescents experience when obtaining abortion care, such as parental involvement requirements, limited telehealth services, travel logistics, and financial challenges, it is important that pediatricians provide as much referral support as possible for adolescents considering abortion.^{44–46,56,57} 

It is ethically and medically necessary to provide pregnancy options counseling about the full range of options and facilitate abortion referral if the pediatrician cannot provide an abortion. Reliable online and telephone hotline resources are available to locate abortion providers, including those who provide procedural and/or medication abortion (see Box); these often incorporate a person’s age, location, and date of last menstrual period and search for medication and procedural abortion providers according to the person’s information. Pediatricians may access these together with their patients to assist in determining the patient’s next point of contact for more information about obtaining an abortion. Caution is needed when accessing unfamiliar abortion locator websites.⁵⁸  Similarly, it is important to be aware of crisis pregnancy centers⁵⁹  whose mission it is to convince people considering abortion to continue their pregnancies and provide misleading information about abortion as an option.^60–62 

Knowledge of regional laws affecting the availability or criminalization of abortion, the criminalization of or other restrictions on providing abortion referrals, requirements for parental notification or consent, and insurance coverage for abortion care is essential.^63–65  The Hyde Amendment, which affects people in 34 states and the District of Columbia, prohibits the use of federal funds to pay for abortion services, except in the case of rape, incest, or life endangerment.⁶⁶  Coverage for abortion services is highly regulated by states, with some private health insurance plans covering abortion.⁶⁷  There is variation in how “medically necessary” or “medically indicated,” which is interpreted by insurance companies. Medicaid in 16 states covers all or most medically necessary abortions.⁶⁸  Out-of-pocket costs for abortion services can be substantial for patients and families and disproportionately impact adolescents, persons of color, immigrants, and people of low socioeconomic status.⁶⁹  Not being able to afford abortion care can cause delays, which potentially lead to the need for more complicated, costly, and potentially dangerous procedures.⁷⁰  Abortion access funds are private sources of financial assistance for abortion for which young people may be eligible (see Box). The National Abortion Federation Hotline provides confidential consultation and case management support, including information about judicial bypass and financial assistance for abortion care.

It is critical that pediatricians be aware of laws that rely on private citizens to bring civil suits against anyone who “abets” an abortion, such as Texas Senate Bill 8, and other laws that may penalize or criminalize health care professionals providing counseling about pregnancy options and referrals for abortion care.⁷¹  Any legislation aimed to limit the ability of pediatricians to counsel on all pregnancy options violates patient autonomy and is anathema to the practice of medicine. Such laws threaten to undermine the fundamental ethical and clinical practices of providing accurate and unbiased medical information to patients and conflict with the policy of the AAP.^6,72  The AAP acknowledges the tension that pediatricians may face between their ethical duty to the patient and their duty to observe the law, and that pediatricians may choose not to follow these AAP recommendations when it is illegal to do so. Pediatricians should advocate against legislation that restricts the ability of health care professionals to provide pregnant adolescents with unbiased counseling that includes the full range of pregnancy options.

The topics of sexuality, adolescent pregnancy and parenting, adoption, and abortion may evoke strong and complicated personal feelings. Some pediatricians may feel limited in their ability to present and discuss 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.⁷³  The pediatrician should respect the pregnant adolescent’s right to choose the course that best suits them and not impose barriers to receiving the health information and services they desire and need. If a pediatrician realizes that they cannot counsel the adolescent patient about all pregnancy options, the patient should be referred promptly to another capable and willing professional.⁷³  When referral is not possible or feasible, the pediatrician has an ethical obligation to provide this counseling.

The AAP reaffirms its position that pregnant adolescents have the right to be informed and counseled on their pregnancy options. Pediatricians should:

1. Inform the pregnant adolescent of all their options, which include continuing the pregnancy and raising the child; continuing the pregnancy and making an adoption, kinship care, or foster care plan; or terminating the pregnancy.

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

3. Be familiar with laws and policies impacting access to abortion care, especially for minor adolescents, as well as laws that seek to limit health care professionals’ provision of unbiased pregnancy options counseling and referrals for abortion care. Pediatricians should oppose efforts by state governments to interfere in the patient-physician relationship or to levy criminal sanctions on physicians for the provision of care.

4. Examine their own beliefs and values to determine whether they can provide nonjudgmental, factual pregnancy options counseling that includes the full range of pregnancy options. If they cannot fulfill this role, 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. The impact on the patient should be minimized and the patient should not know the reasons a referral to another provider is needed. When referral is not possible or feasible, the pediatrician has an ethical obligation to provide this counseling. The AAP acknowledges the tension that pediatricians may face between their ethical duty to the patient and their duty to observe the law, and that pediatricians may choose not to follow these AAP recommendations when it is illegal to do so.

Elise D. Berlan, MD, MPH, FAAP Seema Menon, MD

Elizabeth M. Alderman, MD, FSAHM, FAAP, Chairperson Elise D. Berlan, MD, MPH, FAAP Richard J. Chung, MD, FAAP Michael D. Colburn, MD, MEd, FAAP Laura K. Grubb, MD MPH, FAAP Janet Lee, MD, FAAP Stephenie B. Wallace, MD, MSPH, FAAP

Anne-Marie Amies, MD, American College of Obstetricians and Gynecologists Liwei L. Hua MD, PhD, American Academy of Child and Adolescent Psychiatry Seema Menon, MD, North American Society for Pediatric and Adolescent Gynecology Maria H. Rahmandar, MD, FAAP, Section on Adolescent Health Ellie Vyver, MD, Canadian Paediatric Society Lauren Zapata, PhD, MSPH, Centers for Disease Control and Prevention

Karen S. Smith James Baumberger, MPP