Context: Even in intensive, adolescent-oriented programs, in which access to highly effective contraceptives is guaranteed, repeat adolescent pregnancies commonly occur.
Methods: To assess whether adoption of the contraceptive implant would lower the rate of repeat pregnancy, contraceptive use and pregnancy outcomes were tracked among 309 adolescent mothers-171 "early""implant users who began use within six months of delivery and 138 who either adopted another method or had used no method. Participants were interviewed at delivery and at six-month intervals through the second year postpartum. Multivariate logistic regression analyses were conducted to ascertain the likelihood of a repeat pregnancy within the first and second year postpartum.
Results: During the first year postpartum, although 7% of the early implant users had their implants removed, pregnancy rates were significantly (p
Conclusions: Although early implant insertion significantly decreased the rate of rapid, repeat adolescent pregnancies, the rates of removal and of pregnancy by the end of the second year postpartum were high. Thus, health care providers need to address the motivational components of adolescent pregnancy even among those who accept ostensibly long-term methods. Family Planning Perspectives, 1999, 31(2):88-93
Repeat adolescent pregnancies commonly occur even in special post.partum programs that promote contraceptive use and ensure access to highly effective methods.l This problem is perplexing, because although the majority of adolescent mothers enrolled in such programs insist that they do not want to become pregnant again "any time soon," most become inconsistent contraceptive users, at best? Factors associated with inconsistent contraceptive use and with an increased risk of repeat adolescent pregnancy include a range of demographic, psychosocial, pregnancy-related and reproductive intentions-related factors.3
None of these characteristics or environmental factors, however, include an inherent mechanism that necessarily leads to inconsistent contraceptive use or to repeat adolescent pregnancy. Thus, such traits are probably associated with repeat pregnancy because, collectively, they create an atmosphere that favors positive attitudes about adolescent pregnancy or fosters ambivalence about postponing further childbearing beyond adolescence.
Indeed, the finding that the number of risk factors, rather than the presence of any single risk factor, is the best predictor of rapid, repeat conception during adolescence4 implies an underlying etiologic mechanism similar to that explaining other adolescent risk behaviors.5
The literature suggests that extending multidisciplinary, adolescent-oriented maternity programs beyond the immediate postpartum period and providing care for both parents and their children reduces the complexity of providing contraceptive care and promotes more consistent method use.6 However, given the frequency and rapidity with which repeat pregnancies occur, even in these intensive reproductive health care settings, it is unlikely that further efforts to increase availability of contraceptives will eliminate the risk of unintended pregnancy among adolescent mothers. New types of interventions are critical, because the incidence of adverse pregnancy-related, educational and vocational outcomes increases with each additional pregnancy during adolescence.7
Adolescents' use of the subdermal hormonal implant (marketed under the name Norplant) could alleviate this problem by preventing unintended conceptions and by providing constant protection during temporary lapses in the need for contraception that arise when teenagers briefly consider sexual abstinence or having another baby as a way of coping with other aspects of their lives.8 Indeed, several recent studies indicate that adolescent mothers who use the implant experience only a fraction of the anticipated number of repeat pregnancies.9
These data are particularly encouraging because they do not appear to reflect background differences between implant users and users of other methods following delivery.lo However, small sample sizes,ll short, variable or unspecified follow-up periods,12 and unacceptably high attrition rates 13 raise concern about the validity and generalizability of these findings. Furthermore, to date, no studies have been conducted in settings that specifically guarantee access to developmentally appropriate contraceptive counseling and to reliable contraceptives throughout the observation period.
This article presents the results of a study designed to determine the impact of implant use on the repeat pregnancy rate in a comprehensive adolescent-oriented maternity program. We hypothesized that even in this intensive reproductive health care setting, in which access to highly effective contraceptive alternatives is guaranteed, early postpartum insertion of the implant would significantly decrease the rate of repeat adolescent pregnancies.
Data and Methods Studi Population
We examined data from adolescents who delivered during calendar years 1992 and 1993. We chose these particular years because the implant was extremely popular at that time, which antedated major concerns about side effects and the removal process. All study participants had obtained care through the Colorado Adolescent Maternity Program, a comprehensive, multidisciplinary adolescent-oriented program that provides prenatal, delivery, postpartum and infant care in Denver, Colorado.l4 The study was approved by the Institutional Review Board at the University of Colorado Health Sciences Center.
The original study sample consisted of 354 predominantly poor and primiparous 13-18-year-olds. Our analyses are based on 87% of the sample whose contraceptive and reproductive behavior was tracked for at least 12 months following delivery (309 teenagers). We lost contact with 13% of the adolescent mothers (N-45), mostly because they had moved out of the region and left no address or contact person. Additionally, 285 (92%) of the 309 teenagers were followed through the end of the second year postpartum.
Among the 309 study participants tracked for at least one year, 55% (171) had had the contraceptive implant inserted early in the postpartum period (within six months of delivery, mean of 11.1 weeks postpartum, standard deviation of 9.9 weeks). The remaining 45% had chosen another method (84 teenagers), did not practice contraception at all during that interval (52) or did not supply data on their postpartum contraceptive use (two).
An attrition analysis indicated that the young mothers who were lost to follow-up did not differ significantly from those who completed the study in their race, socioeconomic status or prior contraceptive or pregnancy experience. They did, however, differ in age, as those lost to follow-up were older than those who remained in the sample (mean age of 17.3 vs.16.9 years, p=.05). Thus, since young maternal age is a risk factor for repeat adolescent pregnancy, our study could slightly overestimate the repeat pregnancy rate in this population.l5
Data Collection
The study participants were interviewed following delivery but prior to discharge from the postpartum ward at the University Hospital in Denver. Interviews were conducted by a female research assistant who was not involved in the prenatal contraceptive counseling and who was unaware of the study hypothesis. A precoded, multiple-choice questionnaire was used to collect information on the teenagers' sexual and reproductive histories, on the social context of their pregnancies and on 21 factors that have been widely demonstrated to affect the consistency of contraceptive use and the rate of repeat adolescent pregnancy. These factors fall into the following four broad domains.
Two background social and demographic factors.l6 These were: belonging to a minority race or ethnicity (i.e., being black or Hispanic), and living in poverty and being welfare-dependent (i.e., qualifying for Medicaid).
Thirteen psychosocial variables.l7 These were: young maternal age (i.e., age 16 or younger); being behind or doing poorly in school; having dropped out of school; having no immediate plans to return to school following delivery; having no future career plans or goals; having three or more siblings; living alone or with a boyfriend or relatives rather than with a biological parent; remaining married after a first birth rather than divorcing or being unmarried; living in an environment where adolescent pregnancy is the norm; being unable to make child care arrangements; feeling depressed; having a new boyfriend (who is not the baby's father); and having a nonadolescent boyfriend or husband.
