EFFECT OF MATERNAL AGE ON
PREGNANCY OUTCOME
Pedro A. Poma, MD, FACOG, FACS
Chicago, Illinois
Adolescent pregnancies represent 20 percent
of deliveries in this country. It is commonly
mentioned that adolescent pregnancies are
often associated with increased obstetrical
and pediatric risks. Two groups of "high risk"
parturients (adolescents, N=130; older, N=
150) are compared. Demographic character-
istics, complications of pregnancy, labor, de-
livery, and postpartum are evaluated.
The outcome of pregnancy is similar for
both groups of women in most of the parame-
ters studied. Adolescent pregnancies have
serious socioeconomic implications, but ado-
lescence per se does not increase the risks of
complications to mother and fetus.
In this country the number of deliveries, except
for those occurring in young adolescents, has been
decreasing. Evidently the lifestyle and socioeco-
nomic future of an adolescent will be affected by
becoming a parent.
During the last decade it has been recognized
that adolescent pregnancy is a sociological prob-
lem with medical consequences.' It is often stated
that adolescents have a higher risk for major and
minor obstetrical complications, a higher risk for
prematurity, and a higher perinatal mortality.2'3 It
is also contended that the higher risk for adoles-
cent pregnancies is related more to poverty, in-
adequate nutrition, and poor health before preg-
nancy rather than to maternal age. The purpose of
this study is to determine whether maternal age
has any influence on the pregnancy outcome of
primiparous women admitted in labor.
From the Department of Obstetrics and Gynecology, Mount
Sinai Hospital Medical Center, and Rush Medical College,
Chicago, Illinois. Requests for reprints should be ad-
dressed to Dr. Pedro A. Poma, 1200 Superior Street, Suite
402, Melrose Park, IL 60160.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981
METHODS
Mount Sinai Hospital is a 466-bed teaching in-
stitution that serves Chicago's inner city. Most of
the women served by the Obstetrics and Gynecol-
ogy Department at this hospital are black and 91
percent receive public assistance-conditions that
cause them to be considered at a high obstetrical
risk.4 The Adolescent Group (A) was comprised of
women admitted in labor during their first preg-
nancy who were 16 years of age and younger.
Women who were 20 years of age and older were
assigned to the Older Group (0). Women who had
had previous pregnancies, including abortions,
were excluded from the study. Due to interest in
evaluating another risk factor, the characteristics
of pelvic architecture, only women who had avail-
able x-ray pelvimetry films were included.
One hundred and thirty women comprised the
Adolescent Group (A) and 150 the Older Group
(0). All records were reviewed for demographic
characteristics, complications of pregnancy, char-
acteristics of labor, delivery, and puerperium.
Neonatal factors were also studied. The difference
between the incidence of these characteristics and
complications was noted and their statistical sig-
nificance was determined by the standard error of
the differences. When pertinent, appropriated in-
cidences available in the literature are noted.
RESULTS
The women studied in the groups represent 20.4
percent of the total primiparas delivered at this
institution during the periods 1972 to 1979 for the
adolescents and 1972 to 1977 for the older women.
The mean age is 15.4 years (range 13-16 years) for
adolescents and 24.1 years (range 20-37 years) for
the older parturients.
1031
MATERNAL AGE AND PREGNANCY OUTCOME

TABLE 1. DEMOGRAPHIC CHARACTERISTICS

Adolescent (130) Older (150)
Number % Number %
Ethnicity
Black 123 94.6* 103 68.7
Hispanic 6 4.6 24 16.0*
White 0 17 11.3
Other 1 0.8 6 4.0
Payment Method
Public Assistance 121 93.1* 72 48.0
Insurance 6 4.6 43 28.7*
Cash 3 2.3 35 23.3*
*P<0.001

According to Table 1, adolescents have a sta-
tistically higher proportion of black women on
public assistance. Obviously, the adolescents have
not been able to find permanent employment. The
older group has a higher proportion of women who
could afford cash and private insurances.
Table 2 lists common diagnoses associated with
pregnancy that are similar in both groups. The
mean length of gestation for both groups is similar:
39.9 weeks (range A = 34-44 weeks; 0 = 36-44
weeks). This is similar to 39.5 weeks reported by
McAnarney et a15 and Hulka and Schaaf.6
In this study, the incidence of antepartum
anemia is comparable with that reported by Spel-
lacy et a17 (A = 1.4, 0 = 0.9); others have noted a
slightly higher incidence (A = 3.6, 0 = 8.4),6 (A =
5.6, 0 = 6).8
The incidence of acute hypertension of preg-
nancy in this study (toxemia) is statistically similar
in both groups. This incidence is also similar to the
incidence reported by Spellacy et al.7 (Black A =
mild 12.2, severe 2.6; black 0 = mild 12, severe
2.6.) These authors' incidence of chronic hyper-
tension (A = 2.6, 0 = 3.7) is somewhat higher
than the incidence found in the current study.
Hulka and Schaaf,6 reported a comparable inci-
dence of acute hypertension (A = 4.4, 0 = 13.5),
as did Mc Anamey et al5 (A = 4-8). The incidence
of the present study is lower than that reported by
Duenholter et al8 (A = 34.2, 0 = 25.3). In this
study, there are no cases of eclampsia.
The incidence of diabetes mellitus is similar in
the groups studied. Spellacy et a17 reported that A
= 0, 0 = 0.5. In the current study, the incidence of
antepartum urinary tract infection is lower than
that reported by Spellacy et al (A = 15.7, 0 =
16.8).7
In our study, the incidence of premature rup-
ture of membranes is statistically similar between
the groups. But the incidence of prolonged rupture
of membranes is higher among the older parturi-
ents (24 cases, 16 percent) than among the adoles-
cents (6 cases, 4.6 percent, P<0.001). This inci-
dence is higher than that reported by Spellacy et al
(A = 2.6, 0 = 4.9).7 However, the degree of oc-
currence of amnionitis is similar between the
groups in our study (A = 0.8, 0 = 2).
There were other less common diagnoses pres-
ent: one case of congenital heart disease (A) and
one case of rheumatic heart disease (0), two cases
of epilepsy (A), one case of sickle cell trait, and
one case of treated pulmonary tuberculosis in each
group. There were three Rh negative women in
each group. Three older women (two percent) had
a reactive VDRL test and another was a heroin
addict. The incidence of lues and gonorrhea re-
ported by Spellacy et a17 was 4.9 percent (A) and
3.0 percent (0), higher than the incidence found in
this study.
In our study, the adolescents had a total of 131
newborns, 42 percent of whom were female. There
was one set of twins in their total. The older group
had a total of 154 newborns, 41 percent of whom
were female. There were four sets of twins from
the older women. One of the older parturients had
the first twin born vaginally and the second ab-
dominally due to acute severe fetal distress. The
different fetal positions were statistically similar

1032 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981
 MATERNAL AGE AND PREGNANCY OUTCOME

TABLE 2. COMPLICATIONS OF PREGNANCY

Adolescent (130) Older (150)

Diagnosis Number % Number %
Anemia 1 0.8 0
Acute hypertension
Mild 19 14.6 17 11.3
Severe 4 3.1 4 2.7
Chronic hypertension 1 0.8 1 0.7
Diabetes mellitus
Class A 1 0.8 4 2.7
Class B 0 1 0.7
Urinary infection 3 2.3 5 3.3
Premature rupture of 17 13.1 33 22.0
membranes

TABLE 3. DELIVERY OUTCOME

Adolescent Older
Number % Number %
Fetal Position*
Anterior 94 71.8 122 79.2
Posterior 23 17.5 18 11.6
Transverse 5 3.8 6 3.9
Breech 9 6.9 5 3.2
Type of Delivery
Spontaneous vertex 70 53.9 64 42.6
Assisted breech 6 4.6 2 1.3
Forceps low 15 11.5 25 16.7
Forceps mid 2 1.5 7 4.7
Cesarean 37 28.5 52 34.7
*Adolescents 131 (twins, one set); older 154 (twins, 4 sets), face 2, transverse lie 1

when adolescents were compared to the older par-
turients (Table 3). As expected, the incidence of
other than anterior presentations was higher among
the forceps deliveries in both groups.
The incidence of assisted breech deliveries was
similar among the studied groups and to the results
reported by Spellacy et a17 (A = 0, 0 = 3.9). In our
study, the incidence of forceps deliveries was simi-
lar between the groups A and 0. Our incidence of
midforceps deliveries is comparable to the re-
ported incidence by Duenhoelter et al8 (A = 4.2, 0
= 2.1). In our study, the incidence of abdominal
deliveries was similar between the studied groups,
but higher than the commonly reported incidence.
Cephalopelvic disproportion (CPD) was the most
common indication for cesarean delivery (A =
22.3, 0 = 26.7) which is similar to the incidence (A
= 24.6, 0 = 18.5) reported by Duenhoelter et al.8
CPD was followed by fetal distress (A = 3.8, 0 =
5.3) and breech presentation (A = 2.3, 0 = 1.3). In
two older women (1.3 percent) who had abdominal
delivery, the cause was soft tissue dystocia (uter-
ine fibroids). The differences between the adoles-
cents and older parturients are not statistically
significant. Duenhoelter et al8 reported a total
lower incidence for abdominal deliveries (A =
10.4, 0 = 7). At our institution, during the years of
this study the mean cesarean rate was 11.3 per-
cent, with a mean primary cesarean rate of 7.1
percent. The study groups were obviously se-
lected because of suspicion of abnormal pelves;
this explains the four-fold increased incidence of

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981 1033
 MATERNAL AGE AND PREGNANCY OUTCOME

TABLE 4. LENGTH OF LABOR: VAGINAL DELIVERIES

Adolescent (93) Older (98)

Number % Number %
First Stage
(hours)
0-8 28 30.1 25 25.5
8.1-16 47 50.5 50 51.0
>16 18 19.4 23 23.5
Second Stage
(minutes)
0-30 46 49.5 58 59.2
31-90 38 40.9 29 29.6
>90 9 9.7 11 11.2

TABLE 5. APGAR SCORES

Adolescent (131) Older (154)

Number % Number %
Apgar 1
9-10 62 47.3 77 50.0
6- 8 62 47.3 66 42.8
3- 5 5 3.8 9 5.8
1- 2 1 0.8 0
0 1 0.8 2 1.4
Apgar 5
9-10 118 90.0 131 85.1
6- 8 10 7.7 20 12.9
3- 5 2 1.5 1 0.6
1- 2 0 - 0
0 1 0.8 2 1.4

cesarean deliveries as compared to that of our
general population. Even then, those figures are
not necessarily very high; reports currently avail-
able in the lay and professional literature mention
a 25 percent (and even higher) incidence for ab-
dominal deliveries in this country. There is serious
public concern about this incidence and measures
have been initiated to reduce this increasing inci-
dence of abdominal deliveries.
In this study, the reasons for pelvimetry are
similar between adolescents and older parturients.
The most common reasons are suspected CPD (A
= 60.8, 0 = 65.3), induction of labor (A = 36.2, 0
= 32), and suspected breech presentation (A =
3.1, 0 = 2.7). Several other studies&9 have dem-
onstrated a higher incidence of smaller pelves
among adolescents as compared to the more ma-
ture women. This finding, however, should not be
constructed as evidence that adolescents have a
higher risk for abdominal deliveries, nor as an in-
dication for pelvimetry, for pelvic size is but one
of the multiple factors influencing the outcome of
labor and delivery.
This study and others have demonstrated that
age, per se, has no influence on the route of deliv-
ery. In the current study, 34.7 percent of older
parturients were delivered abdominally compared
to 28.5 percent of adolescents. Although this rep-

1034 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981
 MATERNAL AGE AND PREGNANCY OUTCOME

TABLE 6. NEWBORN WEIGHT

Adolescent Older
Grams Number % Number %
<2500 11 8.4 11 7.1
2501-3500 81 61.8 102 66.3
3501-4500 38 29.0 40 26.0
>4500 1 0.8 1 0.6

TABLE 7. VAGINAL DELIVERIES: COMPLICATIONS

Adolescent (93) Older (98)
Complications Number % Number %
Lacerations 3 3.3 6 6.2
Hemorrhage 6 6.5 4 4.1
Blood Transfusion 4 4.3 1 1.0
Gonorrhea 1 1.1 1 1.0
Urinary Infection 2 2.2 2 2.1
Hematuria 0 - 1 1.0
Fever 7 7.5 9 9.2
Endometritis 2 2.2 4 4.1
Infected Episiotomy 0 1 1.0
Reactive Depression 0 1 1.0
Acute Hypertension 2 2.2 2 2.1

resents a higher incidence of cesarean deliveries
for older women, the difference is not statistically
significant.
Table 4 illustrates the length of labor for vaginal
deliveries. The average duration of the first stage
of labor is 10.9 hours and the second stage is 40
minutes for adolescents. For the older women,
these values are 12.0 hours and 39 minutes, re-
spectively. These differences are not significant
and are in agreement with much of the reported
literature.5'8 Hulka and Schaaf6 found shorter
labors among adolescents when compared to older
women.
Table 5 shows the Apgar scores. The mean
Apgar score at one minute is 8.1 for A and 8.0 for
0. The five minutes mean score is 9.4 for A and
9.3 for 0. Among the adolescents, one 15-year-old
had a stillborn in an assisted breech delivery (4,550
gm), and another 15-year-old with a normal pelvis
had a spontaneous OA vertex delivery (3,540 gm),
Apgar 5/5 who died within 48 hours of birth.
Among the older women there were two still-
births: one to a 20-year-old who had an assisted
breech delivery (3,120 ggm) with evidence of hy-
dramnios and hydrocephalus, and the other to a
24-year-old Class B diabetic with a normal pelvis
who was delivered by low forceps (3,610 gm).
There is no record of neonatal mortality among the
older women. In this study, the incidence of peri-
natal mortality is statistically similar between ado-
lescents and older women. Our incidence of still-
births (A = 0.8, 0 = 1.4) is similar to others re-
ported in the literature: (1.6)2; (A = 3.6, 0 = 1.7)6;
(A = 2.6, O = 1.2)7; and (A = 1.3, o = 2.5).8 Our
incidence of neonatal death (A = 0.8) is also com-
parable to the incidence previously reported:
(black A = 2.7, black 0 = 0.6)7 and (A = 1.7,0 =
l.3).8
Table 6 shows the newborn weights. The mean
newborn weight between adolescents and older
parturients is similar (3241.3 gm; ranges A =
2,065-4,550 gm, 0 = 2027-4840 gm). The mean

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MATERNAL AGE AND PREGNANCY OUTCOME

TABLE 8. CESAREAN: COMPLICATIONS

Adolescent (37) Older (52)
Complications Number ° Number %
Anemia 9 24.3** 1 1.9
Hemorrhage 5 13.5 4 7.7
Blood Transfusion 7 18.2* 2 3.8
Paralytic lleus 2 5.4 5 9.6
Atelectasis 1 2.7 1 1.9
Gonorrhea 2 5.4 0
Urinary Infection 1 2.7 5 9.6
Amnionitis/Endometriti 11 29.7 10 19.3
Phlebitis 0 1 1.9
Reactive Serology 0 1 1.9
Fever 12 32.4 21 40.4
Wound Infection 3 8.1 1 1.9
Dehiscence 0 2 3.8
Acute Hypertension 1 2.7 0
*P=0.05
**P<0.01

newborn weight is similar to the available litera-
ture (3,010 gm),5 (A = 3157 gm, 0 = 3222 gm),6
and (A = 2914, 0 = 2449).8
The percent of smaller for dates (<2,500 gm) (A
= 8.4, 0 = 7.1) is comparable to those cases re-
ported in the literature (A = 12, 0 = 8),2 (8-11),5
(A = 12.9, 0 = 9.2),6 and (A = 10).9 Spellacy et a17
found a higher incidence of smaller newborns
among the adolescents (black A = 20, black 0 =
8.6). In our study, the proportion of different new-
born weights is not different among adolescents
and older women.
Table 7 lists the complications of vaginal de-
liveries. The incidence of complications is statisti-
cally similar between adolescents and older partu-
rients. Similar incidence of hemorrhage is reported
in the literature.7'8 The incidence of fever is com-
parable to that reported by Hulka and Schaaf (A =
3.6, 0 = 4.2).6
Table 8 lists complications following cesarean
deliveries. The incidence of anemia and blood
transfusions is significantly higher among adoles-
cents than among the older parturients. Spellacy et
a17 reported a comparable incidence of hemor-
rhage (A = 12.5, 0 = 17.4), but Sandstrom9 found
a lower incidence (A = 2. 1, 0 = 2.2), as did Hulka
and Schaaf6 who reported that anemia occurred at
a rate of A = 3.5 and 0 = 16, following cesarean
delivery.
The incidence of acute hypertension following
delivery (A = 2.2, 0 = 2.1) is similar to that re-
ported in the literature (A = 2.9, 0 = 5).6 The
incidence of post-cesarean endometritis (A = 29.7,
0 = 19.3) is comparable to that reported by Spel-
lacy et al (black A = 17.4, black 0 = 6.5).7
As expected, in this study the incidence of
common complications following cesarean deliver-
ies, either for group A or 0, is significantly higher
than the incidence of complications following vag-
inal deliveries (hemorrhage, blood transfusions,
P<0.05; fever, P<0.01; and endometritis, P<
0.005). Paralytic ileus and atelectasis are compli-
cations encountered following only abdominal de-
liveries. These findings are in agreement with most
authors who find cesarean deliveries associated
with a higher maternal morbidity and mortality.10"'I
Table 9 depicts the length of stay following de-
livery. The mean length of stay following vaginal
delivery was 3.9 days for adolescents and 3.7 days
for the older women. The mean length of stay fol-
lowing cesarean deliveries was 7.9 days for ado-
lescents and 7.2 days for the older women. This is
in agreement with the reported literature.8
COMMENTS
None will question the fact that the parturients
studied, especially the adolescents, belong to a

1036 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981

TABLE 9. POST DELIVERY LENGTH OF STAY (DAYS)
Adolescent (93)
Number % Number
Vaginal
<4 33 35.5
4-5 56 60.3
>5 4 4.3
Cesarean
<7 4 10.8
7-9 28 75.7
>9 5 13.5
"'high risk" obstetrical population. First preg-
nancy, low economic status, suspicion of con-
tracted pelvis, and high incidence of abdominal
deliveries are all recognized to be high risk factors.
Still, the adolescents in this study, except for their
need for more transfusions following cesarean de-
liveries, did not experience greater difficulty in
pregnancy, labor, delivery, or postpartum than did
the older primiparas who served as controls.
The study design may have prevented the in-
clusion of premature deliveries and small-for-dates
infants because women who were in labor and at
term by dates were included (whether they had
prenatal care or not). The need for pelvimetry is
probably less likely to be considered by an obste-
trician who is aware of the presence of a small
fetus. Still, adolescents in this study, as in several
others, have an obstetrical performance similar to
the more mature primiparas. The findings of ade-
quate obstetrical performance should not be taken
as necessarily advocating adolescent pregnancies.
The years of adolescence are difficult years.
These individuals are trying to identify them-
selves, to encounter themselves, and to know
themselves. Adolescents are no longer children
yet not quite adults. They often vacillate between
these stages.
Adolescence is a period of emotional turmoil.
Ambivalence is a common emotional reaction to
pregnancy at any age. Currently, many pregnant
women are commonly faced with the dilemma of
whether to abort or to carry the pregnancy to
term. A pregnancy occurring to an adolescent will
most likely complicate her maturation process.
Some pregnant adolescents are not even aware of
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981
MATERNAL AGE AND PREGNANCY OUTCOME
Older (98)
%
39 39.8
53 54.1
6 6.2
10 19.2
41 78.9
1 1.9
their condition until late in pregnancy. Obviously,
denial ("'It can't happen to me"; "I didn't go all
the way"; "'No, no one gets pregnant standing
up"; and other myths), a normal protecting mech-
anism, prevents these young women from seeking
prompt attention, learning about good habits and
nutrition, and receiving adequate counseling and
support.
Ovulation and menstruations are often not reg-
ular happenings during the first 18 months follow-
ing menarche; thus amenorrhea does not always
indicate pregnancy, as it does later in life. Enter-
taining the possibility of pregnancy could be a ter-
rifying experience for the individuals involved.
Equally terrifying could be the discussion of this
occurrence and showing the evidence of preg-
nancy to parents, relatives, neighbors, teachers,
health care workers, and even physicians. The
pelvic examination required to confirm the diag-
nosis of pregnancy may be the first for the adoles-
cent. All these concerns may even further delay
the diagnosis.
Another difficulty that an adolescent may have
to deal with when admitted to the health system is
the reaction of the health workers. A physician,
for example, may feel frustrated and angry when
faced with a pregnant adolescent. The physician's
reaction to this specific situation is directly related
to his previous experiences. The physician may
recall his adolescent years and compare those
memories with his patient's current situation,
condition, reactions, and activities, thus evaluat-
ing or judging the patient by the physician's own
standards. A physician may also react as a parent
and relate to his young patient as if she were his
1037
MATERNAL AGE AND PREGNANCY OUTCOME
child (especially if there are adolescents in the
physician's home). A physician may also adversely
react as a member of society, antagonistic to mod-
em habits or to the fact that this mother and child
might be dependent upon tax-supported programs.
Many of these considerations contribute to ado-
lescents who often begin prenatal care late in their
pregnancies and have fewer office visits per preg-
nancy than older women.7 The number of adoles-
cent pregnancies has increased not only because
of an increase in premarital sex, but also because
of a higher fertility rate for this age group, the large
number of persons in this age group and the fact
that the age of menarche has decreased. Finally,
the length of the fertile period among women is
longer now than it was in previous generations.
Adolescent pregnancies are not necessarily en-
couraged by the prospective environment ("a
baby to love"; "'someone who will care for me";
"'with a baby, I'll get public assistance and a place
of my own"), nor by the significant persons who
may pamper her as someone special. Some teen-
agers are pregnant because they planned to be so
and are happy.'2 Others (19 years and younger)
even attend physicians' offices for infertility eval-
uations (18 months of regular intercourse with no
evidence of pregnancy). For physicians with these
experiences, the distress of these women is similar
to that of women in their 30s who are concerned
about becoming pregnant. A teenager who does
not perceive pregnancy as a problem will not be
influenced by advice such as "'pregnancy is better
after 20," or by contraceptive counseling. Patients
make their own decisions, even though physicians
may not always agree with them. Physicians rarely
become involved in sex education and contracep-
tive advice. Only 20 percent of adolescents using a
contraceptive mnethod (and most do not) have ob-
tained the necessary information and prescription
from their private physician.'3
Adolescents, especially during pregnancy, re-
quire additional counseling. During this period,
their growing talents should be furthered. They
should be encouraged to continue their schooling;
and, if they are in good health, no increased risks
should be expected. Adolescents may be able to
date their conception better than older women (ie,
the occasion may be associated with an anniver-
sary). The pregnant adolescent, like other per-
sons, should make decisions herself (with ade-
quate counseling) because it is she who will have
1038 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 73, NO. 11, 1981
to live with that decision. Her maturation process
will be stymied if someone else makes decisions
for her.'4 The perinatal period should be utilized,
in addition to prenatal and newborn care educa-
tion, to improve her communications skills and
self-esteem. The young woman must be assisted in
obtaining an independent sense of worth, allowing
her to be in touch with self (sexually and other-
wise), assisting her to learn how to avoid peer
pressure and to understand both gender responsi-
bility in sexual expression (regarding alternatives
to intercourse, mature expression, and control of
sexual desires).
In summary, 130 adolescents and 150 mature
primiparas were studied. This study, as do many
others, demonstrates that a healthy adolescent
does not have an increased risk during pregnancy,
labor, delivery, and postpartum compared to more
mature women. Finally, the socioeconomic con-
siderations of an adolescent pregnancy are dis-
cussed.
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1. Reycroft D, Kessler AK. Teenage pregnancy. N Engi
J Med 1980; 303:516-18.
2. Turnbull CD, de Haseth LC. Teenage pregnancy in
North Carolina: A 10-year study. NC Med J 1977; 38:701-06.
3. Keith L, Berger GS. Control of reproduction in the
puerperal state. In Aladjem S (ed): Obstetrical Practice. St.
Louis, CV Mosby, 1980, p 333.
4. Poma PA. Health care expectations among urban
women. J Nat Med Assoc 1981; 73:637-44.
5 McAnarney ER, Roghmann KJ, Adams BN, et al. Ob-
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adolescents. Pediatrics 1978; 61:199-205.
6. Hulka JF, Schaaf JT. Obstetrics in adolescents: A
controlled study of deliveries by mothers 15 years of age
and under. Obstet Gynecol 1964; 23:678-85.
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first pregnancy: A controlled study. South Med J 1978; 71:
768-71.
8. Duenhoelter JH, Jimenez JM, Baumann G. Preg-
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9. Sandstrom B. Pregnancy in the young teenage
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10. Evrard JR, Gold EM. Cesarean section and maternal
mortality in Rhode Island: Incidence and risk factors.
Obstet Gynecol 1977; 50:594-97.
11. Minkoff HL, Schwarts RH. The rising cesarean sec-
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12. Ryan GM Jr, Sweeney PJ. Attitudes of adolescents
toward pregnancy and contraception. Am J Obstet Gynecol
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13. Freeman EW, Rickels K. Adolescent contraceptive
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