Pregnancy Outcomes of Adolescents Enrolled in a CenteringPregnancy Program

Mary Alice Grady, CNM, MS, and Kathaleen C. Bloom, CNM, PhD
Adolescent pregnancy remains a signicant social, economic, and health issue in the United States. The unique developmental needs of the pregnant adolescent require attention when designing prenatal care services. The CenteringPregnancy model of group prenatal care provides education and support for young women in an active and developmentally appropriate environment. Thirteen groups of adolescents (N 124) have completed the Centering program at the Teen Pregnancy Center at Barnes Jewish Hospital in St. Louis, Missouri. Evaluation data suggest that the model has encouraged excellent health care compliance, satisfaction with prenatal care, and low rates of preterm birth and low birth weight infants. J Midwifery Womens Health 2004;49:412 420 2004 by the American College of Nurse-Midwives. keywords: adolescent, pregnancy, preterm, prenatal care

INTRODUCTION Although there has been a steady decline in the adolescent pregnancy rate since the early 1990s, 896,000 young women under the age of 20 became pregnant in the United States in 1997. The birth rate for adolescents aged 15 to 19 dropped by 13% from 1990 through 1997 (from 59.9 to 52.3 per 1000 adolescents per year). Over the same time period, the abortion rate declined by almost one-third from 40.3 to 27.5 per 1000 pregnancies,1 more than twice the drop in the birth rate for adolescents. This disparity between dropping birth rates and dropping abortion rates may reect an increased number of unplanned births among adolescents.2 It may also reect the steady increase in education regarding responsible sexual behavior as well as an increase in the number of adolescents using contraception during that same time period, a trend that continues through 2001.3,4 Despite encouraging trends, the reported birth rate of 45.8 births per 1000 adolescents in 20014 remains a signicant social, economic, and health concern. Adolescent Development Adolescence is the transition between childhood and adulthood, a period of biological maturity and a time to prepare for participation in society. It is a developmental phase of rapid and intense physical growth and profound emotional changes, a time of daily struggle with changing bodies, emotions, intellect, social and family relations, and values.5 The psychosocial developmental tasks of adolescence include developing self-esteem, acceptance of physical and emotional changes, independence, increasing relationships with peers, and the establishment of love and work relationships.6,7 Adolescent thought is egocentric, with two major characteristics: the imaginary audience and the personal fable.8 The imaginary audience is the adolescents belief that

others are as preoccupied with her as she herself is. This is reected in the attention-getting behaviors so common in this age group. The personal fable is the adolescents sense of personal uniqueness and indestructibility. Adolescents are generally self-centered and may believe that they are not bound by the rules of nature that govern others. It is this feeling of invincibility, the inability of the adolescent to anticipate or believe in the possible consequences of behavior, that often precipitates adolescent pregnancy. Adolescent Pregnancy Adolescent pregnancy represents a developmental threat. As the adolescent is struggling to grow physically and emotionally and develop during the pubertal years, the pregnant adolescent must also adjust to the physical and emotional changes that accompany pregnancy, build a relationship with the fetus, and develop an identity as a mother. Pregnancy may actually inhibit the growth of individual identity and personality and interfere with the completion of the developmental tasks of adolescence.9 Although adolescents who become pregnant come from all socioeconomic classes, races, faiths, and geographic locations, they usually t into all four of the most widely accepted categories of risk: bearing children at an early age; having low socioeconomic status, being poorly educated, and being unmarried.10 Many adolescents enter pregnancy with poor health habits, and many do not make the necessary adjustments in lifestyle that are necessary to promote a healthy pregnancy. Teens often receive limited or no prenatal care.11 Adolescents are generally thought to be at greater risk for gestational morbidity, especially excessive weight gain, preeclampsia, eclampsia, cephalopelvic disproportion, premature labor dystocia, operative delivery, and complications at birth. Research over the past decade, however, is inconsistent; it appears that many of these complications are, in fact, not increased when factors such as prenatal care and coexisting illness are taken into account.1216 It is clear that the incidence of low birth weight (LBW) and preterm
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Address correspondence to Mary Alice Grady, CNM, MS, 6245 Pershing Avenue, St. Louis, MO 63130. E-mail: MAG1294@bjc.org

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2004 by the American College of Nurse-Midwives Issued by Elsevier Inc.

births are disproportionately higher among adolescents than among their older counterparts.17 This is an important consideration because LBW is the leading cause of neonatal and infant morbidity and mortality today.18 Social support for the pregnant and parenting adolescent comes primarily from her mother and from the father of the baby.16 This is in contrast to the normative development of strong peer social support relationships. For the pregnant adolescent, peer support, if present, may be unhelpful at its best and stressful at its worst.19,20 Adolescent mothers often experience negative social pressure, social isolation from their friends, and alienation from their families. There is a signicant relationship between the amount and quality of the social support a pregnant or parenting adolescent receives and her health, her general life circumstances, and the health and well-being of her child.20,21 These correlations hold true regardless of the source of the social support. The unique developmental needs of pregnant adolescents require prenatal care services focused on assessment, health promotion, preventive clinical services, social support, continuity of care, and education. There are two other issues concerning health services for adolescents: accessibility and affordability. Locating these services in programs specically designed to serve pregnant and parenting teenagers may increase adolescents use of health care services. Programs that include psychosocial as well as medical support have had demonstrable effects in lowering risks associated with poor pregnancy weight gain, preterm delivery, and LBW.22,23 The CenteringPregnancy model, with its emphasis on assessment, education, and support, was deemed to be the ideal model for this endeavor. The CenteringPregnancy model is a comprehensive prenatal program in which small groups of pregnant women come together for 90-minute sessions throughout their pregnancies with one postpartum session.24 Care is provided within the group context through facilitative leadership and focuses on assessment, education, and group support directed toward self-care responsibility. The model, although not developed specically for adolescents, seems optimally suited for use with teens because the care, education, and support components can easily be based on their developmental needs. It seems to be acceptable to adolescents because the original pilot data indicated 92% compliance in the teen groups.24 The purpose of this article is to describe the implementation and evaluation of a CenteringPregnancy program specically designed to facilitate positive outcomes in an

adolescent population that traditionally has more adverse outcomes. APPLICATION OF CENTERINGPREGNANCY IN ST. LOUIS FOR AN ADOLESCENT POPULATION The Teen Pregnancy Center, an urban, hospital-based clinic at Barnes Jewish Hospital, was established in collaboration with Washington University School of Medicine in February 1999 as the only multidisciplinary program in the St. Louis metropolitan area to provide specialized prenatal care for adolescents 17 years of age and younger. The Teen Pregnancy Center team includes three certied nursemidwives, a social worker, a nutritionist, a registered nurse, an education coordinator, a secretary, and a medical assistant. The multidisciplinary team meets weekly to discuss patient care issues, as well as the development and functioning of the clinic. In the rst 2 years of functioning, the Teen Pregnancy Center provided traditional prenatal care every 2 weeks supplemented with childbirth preparation classes and regular visits with the social worker or nutritionist. Classes were primarily didactic, the content was inconsistent based on which speakers were available, and adolescents were placed in the classes simply based on the day and time of their prenatal appointment. In addition, when at the Teen Pregnancy Center, adolescents experienced long wait times between their prenatal visit, their class, and their visit with the social worker or nutritionist. Evaluation of these rst 2 years led to the Teen Pregnancy Center teams decision to explore other alternatives for a prenatal care program. CenteringPregnancy was the model chosen because it de-medicalizes pregnancy and birth by involving adolescents directly in self-care activities. The model offers group education and peer support that is responsive to the unique characteristics of the adolescents. In addition, the Teen Pregnancy Center team believed the model would consolidate care and decrease wait times, thus improving the efciency of the care provided. In March 2001, CenteringPregnancy was incorporated as the model of care to be used for all adolescents receiving prenatal care at the Teen Pregnancy Center at Barnes Jewish Hospital. Adolescents at the Teen Pregnancy Center have an initial prenatal health assessment and physical with a CNM and a social and nutritional evaluation by the social worker and the nutritionist, respectively, prior to entering a Centering group. During this rst visit, young women are introduced to CenteringPregnancy and are offered the opportunity to join a Centering group. CenteringPregnancy is the only model of prenatal care available at the Teen Pregnancy Center since March 2001. Adolescents who prefer traditional prenatal care are scheduled with a nurse practitioner or nurse-midwife within the clinic system for their next prenatal visit and no longer receive care and services available at the Teen Pregnancy Center.
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Mary Alice Grady, CNM, MS, is in clinical practice at the Teen Pregnancy Center at Barnes Jewish Hospital. She is adjunct faculty at Washington University School of Medicine. Kathaleen C. Bloom, CNM, PhD, is an Associate Professor in the School of Nursing at the University of North Florida in Jacksonville, Florida. She is in clinical practice at the West Jacksonville Family Health Center.

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Adolescents choosing CenteringPregnancy prenatal care at the Teen Pregnancy Center are grouped with 8 to 12 other young women with an estimated due date within a 6-week period of time. Centering group sessions begin between 12 and 18 weeks gestation and continue every 2 weeks throughout pregnancy for a total of 12 sessions. Each Centering group has two cofacilitators that include one CNM and either the nurse facilitator or the education coordinator at the Teen Pregnancy Center. Teens follow up with the social worker once a month to address any social needs or concerns. The CenteringPregnancy curriculum has been modied, adding content on sexually transmitted diseases, abuse issues, and parenting issues to meet the specic needs and requests of the adolescents at the clinic. Games including Breastfeeding Bingo and Contraception Jeopardy have been added for enjoyment and reinforce knowledge about breastfeeding and contraception. Since the Teen Pregnancy Center was developed in 1999, the clinic hours have been early evening from 3:30 to 7:00 PM so that adolescents do not have to miss school to attend prenatal visits. Missouri Medicaid health plans provide transportation for clients prenatal visits and the clinic social worker, secretary, and nurse help young women arrange for this service when needed. Peer Assistant Program A Peer Assistant Program has been developed at the Teen Pregnancy Center whereby an adolescent who has graduated from the Teen Pregnancy Center is paired with each Centering group to serve as an experienced expert and role model. Peer assistants are active participants during group discussions and provide assistance to adolescents during self-assessment procedures. Peer assistants also help with room setup, snack preparation, patient evaluations, and preparation of folders for Centering groups. Adolescents in Centering groups welcome the peer assistants and are very interested in their pregnancy, childbirth, and parenting experiences. It is also a positive experience for the peer assistants as reected in their reactions, The best part about being in groups again is that you still get to learn more and you get to see other girls go through their pregnancy and help them out. Another peer assistant commented, You get to talk to other teens around your age . . . and tell them about things that you should do with your kids that will have a big impact on them in the long run. Other Teen Pregnancy Center Programs Adolescents enrolled in Centering at the Teen Pregnancy Center are encouraged to bring family members, fathers, and friends to the Centering group. Fathers and grandparents join the Centering group for assessments and are then invited to join their own support group for education and discussion related to their needs and concerns. This gives pregnant adolescents an opportunity to raise issues and concerns that can be difcult to discuss in the presence of
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fathers and grandparents and also promotes support and involvement of fathers and other family members. A Literacy Program encourages clients to select a childrens book at each prenatal visit and have a library of books to read to their babies after birth. The Teen Pregnancy Center has created an incentive program in which adolescents receive Baby Bucks for positive health behaviors and achievement of goals such as attending prenatal visits, choosing a pediatric care provider, or graduating from high school. Baby Bucks are printed at the Teen Pregnancy Center and can be used to purchase donated items such as a car seat, clothes, and other baby items. The Teen Pregnancy Center offers a Postpartum group and a New Moms group to provide support and assistance after delivery. Program support is provided through grants and donations from corporations, foundations, and individual donors. EVALUATION OF TEEN PREGNANCY CENTER OUTCOMES Research Questions The Teen Pregnancy Center developed an evaluation program prior to the implementation of CenteringPregnancy in March 2001 to address the following research questions: What are the health visit attendance rates for adolescents in CenteringPregnancy groups? What are the perinatal outcomes for adolescents in CenteringPregnancy groups? What is the level of satisfaction for teens in Centering groups? The Human Studies Committee at Washington University School of Medicine approved this research study. Data Collection Information was collected on health visit attendance and perinatal outcomes on all clients in Centering groups from March 2001 through April 2003 who gave birth at Barnes Jewish Hospital. The perinatal outcomes of interest were incidence of LBW dened as infants weighing less than 2500 g at birth, preterm delivery rate dened as delivery at less than 37 weeks gestation, cesarean birth rate, breastfeeding rate dened by client report of breastfeeding recorded on the postpartum progress note when discharged from the hospital, and identication of a pediatric provider at the time of delivery recorded on the labor and delivery nursing admission assessment. Breastfeeding and pediatric provider identication were obtained from the 1998 hospital database and from Centering participant chart review. Centering group attendance sheets, prenatal records, and inpatient and clinic medical records were also reviewed. Information on the number of prenatal visits, postpartum visit attendance, and return for well-woman care after a postpartum visit was collected from adolescents in Centering groups. Teen satisfaction with CenteringPregnancy was
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Table 1. Responses to Evaluation I

Agree n (%) I I I I I like the organization of my prenatal care this way (group sessions). feel that I have learned a lot about prenatal care during the sessions. am enjoying being with other pregnant women in this group. feel as if I am being prepared well for the labor/delivery process. feel as if I am being prepared well for caring for a new baby. 65 (94) 69 (100) 64 (93) 65 (94) 68 (98.5) Disagree n (%) 0 0 0 1 (1.5) 0 Uncertain n (%) 4 (6) 0 5 (7) 3 (4.5) 1 (1.5)

From 10 of 13 Centering groups, 69 of 100 participants responded: 69% response rate.

also evaluated. Adolescents who participated in Centering groups completed two evaluations of the program available in the CenteringPregnancy workbook. These were developed by Sharon Rising to assess client satisfaction. The rst evaluation was completed at prenatal session 7, and the second evaluation was completed during session 10 or at the postpartum session. Characteristics of the Sample A total of 159 adolescents enrolled in CenteringPregnancy prenatal care; 124 adolescents have given birth after completing the CenteringPregnancy prenatal care program between March 2001 and April 2003. Nine adolescents were comanaged by the Teen Pregnancy Center and the high-risk obstetric clinic and are included in the Centering group. Two adolescents with twin gestations also completed the Centering program and are included in the Centering group. All adolescents completing the program (N 124) are included in the data collection and analysis. Thirty-ve adolescents transferred out of the Teen Pregnancy Center and are not included in the data collection or analysis. Reasons for transfer included insurance problems (1), transfer to high-risk clinic (2), preference for traditional care (8), loss to follow-up after the rst visit (9), and moving or other issues associated with location or days and times of the clinic sessions (15). Prenatal and Postpartum Visits Adolescents participating in Centering groups had very consistent prenatal care (mean number of prenatal visits, 11.5). Nearly 87% of adolescents in Centering groups returned for a postpartum visit within 8 weeks after delivery; 89.5% (N 111) of Centering group participants also returned for well-women follow-up care after 8 weeks postpartum. Pregnancy Outcomes The Centering group had a low rate of preterm delivery (10.5%), as well as a low rate of LBW infants (8.9%). The cesarean section rate was 13.7%. The Centering group had
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breastfeeding rates at hospital discharge of 46%, and 79% identied a pediatric provider at delivery. Client Satisfaction Adolescents Centering evaluation responses were very positive. Two evaluations available in the CenteringPregnancy workbook are recommended by Rising for use as evaluative tools when using the CenteringPregnancy Model. Sixty-nine of 100 clients in 10 adolescent Centering groups completed the rst evaluation (69% response rate). The group facilitator did not distribute Evaluation I in 3 of the 13 Centering groups. Evaluation I asks participants, on a scale of 110 with 1 being worst and 10 being best, I would give this prenatal program and overall rating of. . . . The mean satisfaction rating was 9.2. Responses to other questions asked in Evaluation I are summarized in Table 1. Twelve Teen Pregnancy Center Centering groups completed the second evaluation. This includes 88 of 113 clients (77.9% response rate). The group facilitator did not distribute Evaluation II in 1 of the 13 Centering groups. Almost all of the young women got to know others in the group, were comfortable having physical assessments done in the group setting, believed the prenatal assessments were adequate, and were comfortable with men in the group. Although the vast majority believed it was important to get the group together after delivery, less than half were planning to keep in contact with group members (see Tables 2 and 3). When adolescents were asked what they liked about the program, as well as what they would like to see changed, the responses were overwhelmingly positive. They spoke about the importance of the group with comments such as, I thought I was alone until I talked with everyone in the program. They were in the same situation I was in and The best thing about this group is that it lets girls know that they are not the only ones who are pregnant. It builds self-esteem and courage to go through parenting at a young age. They also emphasized the value of the education component, saying: Its really fun to come to a program that teaches you a lot of things you thought you knew until you came here and By being in a group, I learned a lot more than I would have by myself. Finally, they spoke to
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Table 2. Responses to Evaluation II: Topics Covered

Well Covered n (%) 69 (78) 62 (71) 43 (49) 55 (63) 61 (69) 52 (59) 40 (45) 53 (60) 46 (52) 45 (51) 66 (75) Covered n (%) 18 (21) 25 (28) 36 (41) 32 (36) 22 (25) 35 (40) 34 (39) 31 (35) 35 (40) 32 (36) 21 (24) Needed More n (%) 1 (1) 1 (1) 8 (9) 1 (1) 5 (6) 1 (1) 14 (16) 4 (5) 7 (8) 11 (13) 1 (1)

Topic Pregnancy issues Nutrition Exercise/relaxation Childbirth preparation Pregnancy problems Infant care/feeding Postpartum issues Contraception Communication/self-esteem Abuse issues Parenting

From 12 of 13 Centering groups, 88 of 113 participants responded: 77.9% response rate.

the value of peer support with comments such as, I realized other moms-to-be were feeling the same as I was, I got to know a lot of girls and sort of gave them advice on pregnancy and childbirth, and I felt like I had someone to talk to when I needed it and didnt know how to say it. COMPARISON GROUPS For descriptive purposes, perinatal outcomes of the adolescents in the CenteringPregnancy were compared with two groups of adolescents. The rst comparison group (2001 group) consists of adolescents 17 years of age or younger who gave birth at Barnes Jewish Hospital in 2001 excluding adolescents receiving no prenatal care and teens participating in Centering groups through the Teen Pregnancy Center. Birth weight, gestational age, and delivery type data were collected from the delivery logbook by a CNM. No other information on the variables of interest for this comparison group was available in the delivery logbook. The second comparison group (1998 group) consists of all adolescents 17 years of age and younger who gave birth at Barnes Jewish Hospital in 1998. These data were

collected from a 1998 maternal database that included data on all women delivering at Barnes Jewish Hospital in 1998. The adolescents in the 1998 comparison group were not a part of the Teen Pregnancy Center and received prenatal care through the hospital clinic, a private physician, or an outside clinic. This group includes all teens who delivered at Barnes Jewish Hospital in 1998 including teens with no prenatal care. The 2 analysis was used to analyze differences between the Centering group and each comparison group. The demographic characteristics of the Centering group (N 124), group 1 from 2001 (N 144), and group 2 from 1998 (N 233) are listed in Table 4. The age range of Centering participants is 11 to 17, with a mean of 15.85 (SD 1.24). The 2 analysis revealed statistically signicant differences in age between the Centering group and each comparison group, with the 2001 group and 1998 group being an average of approximately 6 and 4 months older, respectively. All three groups are predominately African American. However, there is a statistically signicant difference in the percentage of African Americans between the Centering group and the 1998 comparison group, with the 1998 group having a lower percentage of African Americans. The Centering group adolescent clients had a lower no-show rate compared with all women seen for traditional prenatal care at the Barnes Jewish Hospital obstetrics clinic in 1998 (19% versus 28%, respectively). Clinic no-show rates were calculated in 1998 by the clinic nurse manager by using the number of prenatal appointments missed compared to the total number of prenatal visits scheduled for women of all ages in the obstetrician/gynecologist clinic. Adolescent-specic prenatal visit attendance rates were not available. There were statistically signicant differences in the incidence of preterm birth and LBW infants for adolescents in the Centering group compared with both comparison groups. Adolescents in Centering groups had a lower incidence of preterm births and fewer LBW infants than both the 2001 and 1998 comparison groups (see Table 4).

Table 3. Responses to Evaluation II: Group Care

Yes n (%) 86 (98) 84 (96) 19 (22) 87 (99) 84 (95.5) 75 (85) 85 (97) 50 (57) No n (%) 2 (2) 3 (3) 65 (74) 1 (1) 4 (4.5) 13 (13) 3 (3) 37 (42) Dont Know n (%)

Question Did you get to know other women in the group? Were you comfortable having your physical assessments in the group setting? Would you rather have had your physical assessment in an exam room? Did you feel satised that the assessment was adequate? Was it OK with you to have men in the group? Was it OK to have men present in the room during the physical assessment? Do you think it is important to get the group together once or twice after you deliver? Are you planning to keep in contact with any of the other group members?
From 12 of 13 Centering groups, 88 of 113 participants responded: 77.9% response rate.

3 (3)

1 (1)

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Table 4. Demographic Characteristics and Outcomes of the Centering and Two Comparison Groups
Centering n 124 Age [mean (SD)] Race African American (%) Caucasian (%) Other (%) Preterm deliveries 37 wk (%) Low birth weight 2500 g (%) Cesarean births (%)
* P .05 compared to Centering group.

2001 Comparison Group n 144 16.5 (0.9)* 130 (90.3) 13 (9.0) 1 (0.7) 37 (25.7) 33 (22.9) 21 (14.6)

1998 Comparison Group n 233 16.3 (1.2)* 198 (85.0)* 35 (15.0)* 0 (0.0) 54 (23.2)* 42 (18.3)* 37 (15.9)

15.85 (1.2) 116 (93.6) 6 (6.3) 1 (1.0) 13 (10.5) 11 (8.87) 17 (13.7)

P .02 compared to Centering group.

There were no signicant differences in the number of cesarean births between groups. DISCUSSION AND IMPLICATIONS The CenteringPregnancy model provides support for young women in an active, developmentally appropriate environment and has demonstrated excellent health care compliance, high levels of client satisfaction, and good pregnancy outcomes at the Teen Pregnancy Center of Barnes Jewish Hospital. The adolescents in Centering groups at the Teen Pregnancy Center, at-risk for LBW and preterm infants because of their age, educational level, race, and socioeconomic status, had a 50% lower rate of LBW and preterm birth than the comparison groups. Because the content of the prenatal care for Centering participants, in terms of assessment and pregnancy management, was identical to that received in traditional prenatal care, these outcomes may be related, at least in part, to the education and support components. The lower incidence of LBW and preterm infants is similar to the ndings of other prenatal programs for at-risk groups that emphasize support as a major component of the program.2528 A matched cohort study found higher birth weights for term and preterm infants using the CenteringPregnancy Care Model than for traditional prenatal care.29 The apparent better outcomes may also be related to selection bias. The analyzed sample did not include teens who moved, declined the Centering program, or who were lost to follow-up. This group may have been at increased risk of poorer outcomes. Analyses can be done that impute different preterm birth rates to the 35 adolescents who transferred out of the Centering program and for whom we do not have data. For example, if we assume that all 35 teens who transferred out of the program delivered before 37 weeks, the rate of preterm delivery could be as high as 30%. This would be somewhat higher than both the 2001 and 1998 comparison groups. Because it is unlikely that all transferred teens delivered preterm, an alternate assumption would be that this group had the same 26% preterm
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delivery rate as the 2001 comparison group. Under this assumption, the preterm birth rate for the total group would be 14%. Similar calculations for LBW deliveries suggest that the LBW rate for the total group would be about 12%. Such a sensitivity analysis suggests that preterm and LBW outcomes could still be better in the Centering group even if the transferred teens were included. A synthesis of 14 randomized clinical trials involving more than 11,000 women concluded that additional social support was not related to improved birth outcomes.30 This discrepancy may be related to the error inherent when comparing randomized trials and observational studies that are more prone to bias. However, it is also possible the high attendance rate for prenatal care at the Teen Pregnancy Center and other adolescent-specic programs may be responsible for improved outcomes.31 The synthesis of randomized trials did not control for prenatal care attendance rates. The increased attendance at prenatal care may be reective of an active environment with peer interaction. This model of prenatal care, with its opportunity to discuss positive health behaviors and nutrition with peers, may increase motivation to promote a healthy pregnancy, thus contributing to the lower incidence of LBW and preterm infants. Adolescents in Centering groups at the Teen Pregnancy Center have self-reported breastfeeding rates at the time of discharge (46%) that are almost double those in the 1998 comparison group (28%). Seventy-nine percent of the Centering group and 52% of the 1998 comparison group identied a pediatric provider at hospital discharge. The 2 analysis revealed statistically signicant differences in breastfeeding and pediatric provider rates between the Centering group and the 1998 comparison group (P .02). Comparison data for breastfeeding and pediatric provider identication rates were only available from the 1998 comparison group. Improved breastfeeding rates may be in part due to the inherent differences between groups. However, a sensitivity analysis including transfers from the Teen Pregnancy Cen417

ter assuming breastfeeding rates for transfers of 28% similar to the rates of the 1998 comparison group suggests the breastfeeding rate could be as high as 42% even if the transferred teens were included. This analysis suggests breastfeeding rates would still be higher for Centering participants. There were no changes in hospital policy related to breastfeeding over the time period studied. The institution where the populations studied delivered does not have a baby-friendly designation, and all women have ready access to formula while hospitalized. Although breastfeeding may be challenging for teens because of varying levels of motivation and comfort with breastfeeding and demands of school and work, initiation is the critical rst step to promoting breastfeeding. Often pregnancy is the rst independent health care experience for an adolescent. The CenteringPregnancy model provides the education, support, and safety an adolescent needs to make her way through the many difculties, challenges, and transitions that arise during pregnancy and motherhood. A positive, supportive prenatal health experience may encourage and empower adolescents to care for themselves and their children. Adolescents in the Centering groups demonstrated several positive indicators of continuing health promotion including high attendance at a postpartum visit within 8 weeks of delivery. This is similar to previous ndings that postpartum visits are more likely to occur when adolescents have been enrolled in adolescent-specic programs.31 At postpartum visits, adolescents and providers discuss and nalize contraception decisions, discuss issues related to returning to work or school, and provide an opportunity to screen for postpartum depression. In addition, the majority of the adolescents at the Teen Pregnancy Center identied a pediatric care provider prior to delivery, a critical rst step for well-baby follow-up. One adolescent pregnancy has a major inuence on an adolescents future life, but two adolescent pregnancies can be devastating. In 1999, more than 20% of adolescents in the United States had a repeat pregnancy within 2 years.32 Currently, 111 adolescents in Centering groups have continued to receive follow-up well-women care at the Teen Pregnancy Center and Womens Wellness Center. Of those adolescents returning for well-women care, seven (6.3%) have had a repeat pregnancy within 1 year after delivery. Perhaps a positive prenatal experience has encouraged adolescents in group care to return for follow-up visits and ongoing contraceptive counseling, which may contribute to lower repeat pregnancy rates. The Centering curriculum provides information on contraception, encourages goal setting, and may empower and promote self-esteem in adolescents, which may have an impact on repeat pregnancy for girls who continue to attend the program. However, we have not measured these specically in our clients. Education and active participation in care may help adolescents feel more in control of their bodies and their contraceptive decisions.
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Almost every adolescent who participated in Centering groups was extremely satised with her prenatal care experience. The peer support, group sharing, and discussions were the best part of prenatal care for most of the adolescents who completed an evaluation. The staff at the Teen Pregnancy Center has also expressed this high level of satisfaction. They believe the Centering model has promoted bonding and empowerment in the adolescents who participate. One staff member commented, The teens in most groups have bonded and have developed a support network here and have really learned a lot by actually completing their own assessments. One labor and delivery staff nurse said, I can tell which teens go through your program. Theyre more prepared and they know how to talk to us and tell us what they want. LIMITATIONS Limitations of this project include the self-selection of adolescents into either CenteringPregnancy or traditional prenatal care. Adolescents choosing the Teen Pregnancy Center and CenteringPregnancy may be a more motivated group of adolescents, and this may inuence birth outcomes and prenatal visit attendance. The 2001 comparison group excluded adolescents receiving care at the Teen Pregnancy Center in 2001 and could inuence comparisons between Centering and the 2001 comparison group. Socioeconomic status is associated with perinatal outcomes. We did not have data to compare the groups with regard to these indices, but given the overall population and community served by this institution, it is assumed that the groups were comparable on socioeconomic status. The majority of teens in Centering received adequate prenatal care. Specic prenatal care attendance rates are not available for adolescents in Comparison group 1 or Comparison group 2. Prenatal care information for both groups would allow for better comparisons to the Centering group because prenatal care has been shown to inuence birth outcomes. In addition, because this was a demonstration project without a true control group, the between-group comparisons and statistical power are limited. Finally, the inuence of supplementary programs offered at the Teen Pregnancy Center on pregnancy outcomes, health visit attendance, and satisfaction with care cannot be measured in this demonstration project. These programs include the Baby Bucks incentive program, the Literacy Program, the Fathers Support Group, and the Peer Assistant Program. FUTURE PLANS For adolescents, pregnancy is a life-changing event, an important time of transition, and the beginning of life as a new parent. Pregnancy, however, is just the beginning. Although CenteringPregnancy is an ideal model of care for adolescents, their needs for education, peer support, and ongoing assessment do not end with delivery. The rst year of life for the infant and the adolescent mother is a time of
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attachment, adjustment, and development. The Teen Pregnancy Center staff has recently added three New Moms sessions after delivery for each Centering group and is examining the feasibility of a group-based parenting model for postpartum, family planning, and well-baby care for adolescent mothers and their infants through the rst year after birth. The consequences of adolescent motherhood for both the child-mother and the infant have been well documented. Thirty percent of adolescent mothers will fail to complete high school, and those who do graduate are less likely to go to college.13 Children of adolescent mothers may be at higher risk for unintentional injury and/or illness33,34 and for cognitive or emotional delays.35 A postpartum model based on the same principles as the CenteringPregnancy model has the potential for a positive impact on adolescent mothers and their children.36 CONCLUSION The CenteringPregnancy model worked well in this population of adolescents. The model appears to be valuable in terms of consistency in and satisfaction with prenatal care. CenteringPregnancy allows adolescents to explore their feelings and concerns about pregnancy and parenting in a safe and supportive environment. Adolescents often realize that they can change health behaviors and gain support from other young women in the group. The fact that we were able to demonstrate differences in LBW and preterm birth is gratifying. This was, however, a demonstration project, not a research study. Randomized, controlled studies are needed to validate the models role in these improved pregnancy outcomes for adolescents.
Program support for this demonstration project was received from the Episcopal-Presbyterian Charitable Health and Medical Trust, Copeland/ Citigroup, First Book-St. Louis, and Ronald McDonald House Charities of Greater St. Louis. Thank you to the Teen Pregnancy Center Team including Maureen Foster, CNM, MSN, Debbie Hollander, CNM, MSN, Linda Amsden, RN, Lorien Carter, MSW, Terri Madison, Tina Pruitt, Granada Walker, LCSW, Amber Wamhoff, RD, and our peer assistants.

6. Havinghurst RJ. Human development and education. New York: McKay, 1953. 7. Erikson E. Identity: Youth and crisis. New York: Norton, 1968. 8. Elkind D. Egocentrism in adolescence. Child Dev 1967;38: 102534. 9. Drake P. Addressing developmental needs of pregnant adolescents. J Obstet Gynecol Neonat Nurs 1996;25:518 24. 10. Knuppel RA, Drukker JE. High risk pregnancy: A team approach. 2nd ed. Philadelphia (PA): Saunders, 1993. 11. The Alan Guttmacher Institute. Teen sex and pregnancy. New York: Alan Guttmacher Institute, 1999. 12. Fraser AM, Brockert JE, Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995;27(332):11137. 13. Lee MC, Suhng LA, Lu TH, Chou MC. Association of parental characteristics with adverse outcomes of adolescent pregnancy. Fam Pract 1998;15:336 42. 14. Jolly MC, Sebire N, Harris J, Robinson S, Regan L. Obstetric risks of pregnancy in women less than 18 years old. Obstet Gynecol 2000;96:9626. 15. Gortzak-Uzan L, Hallak M, Press F, Katz M, Shoham-Vardi I. Teenage pregnancy: Risk factors for adverse perinatal outcome. J Matern Fetal Med 2001;10:3937. 16. Koniak-Grifn D, Turner-Pluta C. Health risks and psychosocial outcomes of early childbearing: A review of the literature. J Perinat Neonat Nurs 2001;15:117. 17. Felice ME, Feinstein RA, Fisher MM, Kaplan DW, Olmedo LF, Rome ES, et al. Adolescent pregnancyCurrent trends and issues: 1998 American Academy of Pediatrics Committee on Adolescence, 1998 1999. Pediatrics 1999;103:516 20. 18. Guyer B, Hoyert DL, Martin JA, Ventura SJ, MacDorman MF, Strobino DM. Annual summary of vital statistics1998. Pediatrics 1999;104:1229 46. 19. Stevenson W, Maton KI, Teti DM. Social support, relationship quality, and well-being among pregnant adolescents. J Adolesc 1999; 22:109 21. 20. Logsdon MC, Birkimer JC, Ratterman A, Cahill K, Cahill N. Social support in pregnant and parenting adolescents: Research, critique, and recommendations. J Child Adolesc Psychiatry Nurs 2002; 15:7583. 21. Clemmons D. The relationship between social support and adolescent mothers interactions with their infants: A meta-analysis. J Obstet Gynecol Neonat Nurs 2001;30:410 20. 22. Koniak-Grifn D, Anderson NL, Verzemnieks I, Brecht ML. A public health nursing early intervention program for adolescent mothers: Outcomes from pregnancy through 6 weeks postpartum. Nurs Res 2000;49:130 8. 23. Scarr EM. Effective prenatal care for adolescent girls. Nurs Clin North Am 2002;37:51321. 24. Rising SS. Centering pregnancy: An interdisciplinary model of empowerment. J Nurse Midwifery 1998;43:46 54.

REFERENCES
1. Ventura SJ, Mosher WD, Curtin SC, Abma JC, Henshaw S. Trends in pregnancy rates for the United States, 1976 97: An update. Natl Vital Stat Rep 2001;49:19. 2. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24 9, 46. 3. The Alan Guttmacher Institute. Family planning annual report: 2001 Summary. New York: The Alan Guttmacher Institute, 2001. 4. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM, Sutton PD. Births: Final data for 2001. Natl Vital Stat Rep 2002;51: 1102. 5. Steinberg L, Morris AS. Adolescent development. Annu Rev Psychol 2001;52:83110. Journal of Midwifery & Womens Health www.jmwh.org

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25. Gonzalez-Calvo J, Jackson J, Hansford C, Woodman C. Psychosocial factors and birth outcome: African American women in case management. J Health Care Poor Underserved 1998;9:395419. 26. Schell LM, Ravenscroft J, Czerwinski SA, Stark AD, Grattan WA, Gordon M. Social support and adverse pregnancy outcome in a high-risk population. J Public Health Manag Pract 1997;3:1326. 27. Rothenberg A, Weissman A. The development of programs for pregnant and parenting teens. Soc Work Health Care 2002;35:6583. 28. Heins HC Jr, Nance NW, Ferguson JE. Social support in improving perinatal outcome: The Resource Mothers Program. Obstet Gynecol 1987;70:2636. 29. Ickovics J, Kershaw T, Westdahl C, Rising SS, Klima C, Reynolds H, et al. Group prenatal care improves preterm birth weight: Results from a matched cohort study at public clinics. Obstet Gynecol 2003;102:1051 8. 30. Hodnett ED. Support during pregnancy for women at increased risk. Cochrane Database Syst Rev 2000;2:CD000198.

31. Bensussen-Walls W, Saewyc EM. Teen-focused care versus adult-focused care for the high-risk pregnant adolescent: An outcomes evaluation. Public Health Nurs 2001;18:424 35. 32. Dailard C. Reviving interest in policies and programs to help teens prevent repeat births. Guttmacher Rep Public Policy 2000;3:12 11. 33. Dukewich TL, Borkowski JG, Whitman TL. Adolescent mothers and child abuse potential: An evaluation of risk factors. Child Abuse Negl 1996;20:103147. 34. Phipps MG, Blume JD, DeMonner SM. Young maternal age associated with increased risk of postneonatal death. Obstet Gynecol 2002;100:4816. 35. Sommer KS, Whitman TL, Borkowski JG, Gondoli DM, Burke J, Maxwell SE, et al. Prenatal maternal predictors of cognitive and emotional delays in children of adolescent mothers. Adolescence 2000;35:87112. 36. Klima CS. Centering pregnancy: A model for pregnant adolescents. J Midwifery Womens Health 2003;48:220 225.

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Volume 49, No. 5, September/October 2004