essay on risk of pregnancy

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What are some factors that make a pregnancy high risk?

Several factors can make a pregnancy high risk, including existing health conditions, the mother’s age, lifestyle, and health issues that happen before or during pregnancy.

This page provides some possible factors that could create a high-risk pregnancy situation. This list is not meant to be all-inclusive, and each pregnancy is different, so the specific risks for one pregnancy may not be risks for another. Women who have any questions about their pregnancy should talk to a healthcare provider.

For the latest information on COVID-19 and pregnancy, visit CDC at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant-people.html .

Existing Health Conditions

• High blood pressure.  Even though high blood pressure can be risky for the mother and fetus, most women with slightly high blood pressure and no other diseases have healthy pregnancies and healthy deliveries because they get their blood pressure under control before pregnancy. Uncontrolled high blood pressure, however, can damage the mother’s kidneys and increase the risk for low birth weight or  preeclampsia . 1 It is very important for women to have their blood pressure checked at every prenatal visit so that healthcare providers can detect any changes and make decisions about treatment.
• Polycystic ovary syndrome (PCOS). Women with PCOS have higher rates of pregnancy loss before 20 weeks of pregnancy, diabetes during pregnancy (gestational diabetes), preeclampsia, and cesarean section. 2
• Diabetes.  It is important for women with diabetes to manage their blood sugar levels both before getting pregnant and throughout pregnancy. During the first few weeks of pregnancy, often before a woman even knows she is pregnant, high blood sugar levels can cause congenital anomalies. Even women whose diabetes is well under control may have changes in their metabolism during pregnancy that require extra care or treatment to promote a healthy birth. 3 Babies of mothers with diabetes tend to be large and are likely to have low blood sugar soon after birth. That is another reason for women with diabetes to keep tight control of their blood sugar.
• Kidney disease.  Women with mild kidney disease often have healthy pregnancies. But kidney disease can cause difficulties getting and staying pregnant as well as problems during pregnancy, including preterm delivery, low birth weight, and preeclampsia. Nearly one-fifth of women who develop preeclampsia early in pregnancy are found to have undiagnosed kidney disease. 4 Pregnant women with kidney disease require additional treatments, changes in diet and medication, and frequent visits to their healthcare provider. 5 , 6
• Autoimmune disease.  Conditions such as lupus and multiple sclerosis can increase a women’s risk for problems during pregnancy and delivery. For example, women with lupus are at increased risk for preterm birth and stillbirth. Some women may find that their symptoms improve during pregnancy, while others have flare-ups and other challenges. Certain medicines to treat autoimmune diseases may be harmful to the fetus, meaning a woman with an autoimmune disease will need to work closely with a healthcare provider throughout pregnancy. 7
• Thyroid disease. The thyroid is a small gland in the neck that makes hormones that help control heart rate and blood pressure. Uncontrolled thyroid disease, such as an overactive or underactive thyroid, can cause problems for the fetus, such as heart failure, poor weight gain, and brain development problems. Thyroid problems are usually treatable with medicine or surgery. 8 However, a recent NICHD-supported study found that treating mildly low thyroid function during pregnancy did not improve outcomes for mothers or their babies.
• Obesity. Being obese before pregnancy is associated with a number of risks for poor pregnancy outcomes. For example, obesity increases a woman’s chance of developing diabetes during pregnancy, which can contribute to difficult births. 9   Obesity can also cause a fetus to be larger than normal, making the birth process more difficult. NICHD research also found that obesity increases the risk for sleep apnea and disordered sleep breathing during pregnancy. Obesity before pregnancy is associated with an increased risk of structural problems with the baby’s heart. There can also be problems if overweight or obese women gain too much weight during pregnancy. NICHD research has shown that an integrated approach can help obese women to limit their weight gain during pregnancy , leading to better pregnancy outcomes. The Institute of Medicine recommends that overweight women gain no more than 15–25 pounds during pregnancy and that women with obesity gain no more than 11–20 pounds. 10
• HIV/AIDS.   HIV can pass to a fetus during pregnancy, labor and delivery, and breastfeeding. Fortunately, there are effective treatments that can reduce and prevent the spread of HIV from mother to fetus or child. Medications for the mother and for the infant, as well as surgical delivery of the baby before the “water breaks” and feeding formula instead of breastfeeding, can prevent mother-to-child transmission and have led to a dramatic decrease in transmission—to less than 1% in the United States and other developed countries. 11
• Zika infection. Although scientists and healthcare providers have known about Zika for decades, the link between Zika infection during pregnancy and pregnancy risks and congenital anomalies has only recently come to light. NICHD-supported research has shown that infants born to mothers who were infected with Zika just before and during pregnancy were at higher risk for different problems with the brain and nervous system . The most noticeable is microcephaly, a condition in which the head is smaller than normal. Zika infection during pregnancy can also increase the woman’s risk for pregnancy loss and stillbirth . Researchers are still just learning the possible mechanisms of Zika’s effects on pregnancy .
• Young age.  Pregnant teens are more likely to develop pregnancy-related high blood pressure and anemia (lack of healthy red blood cells) and to go through preterm (early) labor and delivery than women who are older. Teens are also more likely to not know they have a sexually transmitted infection (STI). Some STIs can cause problems with the pregnancy or for the baby. 12  Teens may be less likely to get prenatal care or to keep prenatal appointments. Prenatal care is important because it allows a healthcare provider to evaluate, identify, and treat risks, such as counseling teens not to take certain medications during pregnancy, sometimes before these risks become problems. 13
• Pregnancy-related high blood pressure (called gestational hypertension) and diabetes (called gestational diabetes) 15
• Pregnancy loss 16
• Ectopic pregnancy (when the embryo attaches itself outside the uterus), a condition that can be life-threatening 17
• Cesarean (surgical) delivery
• Delivery complications, such as excessive bleeding
• Prolonged labor (lasting more than 20 hours)
• Labor that does not advance
• Genetic disorders, such as Down syndrome, in the baby 15

Lifestyle Factors

• Alcohol use.  Drinking alcohol during pregnancy can increase the baby’s risk for fetal alcohol spectrum disorders (FASDs), sudden infant death syndrome, and other problems. FASDs are a variety of effects on the fetus that result from the mother’s drinking alcohol during pregnancy. The effects range from mild to severe, and they include  intellectual and developmental disabilities ; behavior problems; abnormal facial features; and disorders of the heart, kidneys, bones, and hearing. FASDs are completely preventable: If a woman does not drink alcohol while she is pregnant, her child will not have an FASD. 18 Women who drink also are more likely to have a miscarriage or stillbirth. Currently, research shows that there is no safe amount of alcohol to drink while pregnant. According to one study supported by NIH, infants can suffer long-term developmental problems even with low levels of prenatal alcohol exposure. 19
• Tobacco use.  Smoking during pregnancy puts the fetus at risk for preterm birth, certain congenital anomalies , and sudden infant death syndrome (SIDS) . One study showed that smoking doubled or even tripled the risk of  stillbirth , or fetal death after 20 weeks of pregnancy. 20 Research has also found that smoking during pregnancy leads to changes in an infant’s immune system. 21 Secondhand smoke also puts a woman and her developing fetus at increased risk for health problems. 22
• Drug use. Research shows that smoking marijuana and taking drugs during pregnancy can also harm the fetus and affect infant health. One study showed that smoking marijuana and using illegal drugs doubled the risk of  stillbirth . 20 Research also shows that smoking marijuana during pregnancy can interfere with normal brain development in the fetus, possibly causing long-term problems. 23  For more information, visit  https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-use-while-pregnant-breastfeeding .

Conditions of Pregnancy

• Multiple gestation.  Pregnancy with twins, triplets, or more fetuses, called multiple gestation, increases the risk of infants being born prematurely (before 37 weeks of pregnancy). Both giving birth after age 30 and taking fertility drugs have been linked with multiple births. Having three or more infants increases the chance that a woman will need to have the infants delivered by cesarean section. Twins and triplets are more likely to be smaller for their size than single infants. If infants are born prematurely, they are more likely to have difficulty breathing. 24
• Gestational diabetes.  Gestational diabetes occurs when a woman who didn’t have diabetes before develops diabetes when she is pregnant. Gestational diabetes can cause problems for both mother and fetus, including preterm labor and delivery, and high blood pressure. It also increases the risk that a woman and her baby will develop type 2 diabetes later in life. Many women with gestational diabetes have healthy pregnancies because they work with a healthcare provider to manage their condition.
• Preeclampsia and eclampsia.  Preeclampsia is a sudden increase in a pregnant woman’s blood pressure after the 20th week of pregnancy. It can affect the mother’s kidneys, liver, and brain. The condition can be fatal for both the mother and the fetus or cause long-term health problems. Eclampsia is a more severe form of preeclampsia that includes seizures and possibly coma.
• Previous preterm birth . Women who went into labor or who had their baby early (before 37 weeks of pregnancy) with a previous pregnancy are at higher risk for preterm labor and birth with their current pregnancy. Healthcare providers will want to monitor women at high risk for preterm labor and birth in case treatment is needed. NICHD research has shown that, among women at high risk for preterm labor and birth because of a previous preterm birth, giving progesterone can help delay birth . 25 In addition, women who become pregnant within 12 months after their latest delivery may be at increased risk for preterm birth. 26 Women who have recently given birth may want to talk with a healthcare provider about contraception to help delay the next pregnancy.
• Congenital anomalies or genetic conditions in the fetus. In some cases, healthcare providers can detect health problems in the fetus during pregnancy. Depending on the nature of the problems, the pregnancy may be considered high risk because treatments are needed while the fetus is still in the womb or immediately after birth. For example, if certain forms of spina bifida are detected in the fetus, the problems can be repaired before birth . Certain heart problems that are common among infants with Down syndrome need to be corrected with surgery immediately after birth. Knowing a fetus has Down syndrome before birth can help healthcare providers and parents be prepared to give treatment right away.
• American College of Obstetricians and Gynecologists. (2018).  FAQs: Preeclampsia and high blood pressure during pregnancy.  Retrieved October 31, 2018, from https://www.acog.org/Patients/FAQs/Preeclampsia-and-High-Blood-Pressure-During-Pregnancy  
• Office on Women's Health. (2016).  Polycystic ovary syndrome (PCOS) fact sheet . Retrieved February 6, 2017, from  http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html (PDF 126 KB)
• National Institute of Diabetes and Digestive and Kidney Diseases. (2017). Pregnancy if you have diabetes. Retrieved February 6, 2017, from https://www.niddk.nih.gov/health-information/diabetes/diabetes-pregnancy
• Williams, D., & Davison, J. (2008). Chronic kidney disease in pregnancy. BMJ, 336 (7637), 211–215. Retrieved February 8, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213870/
• National Kidney Foundation. (2016).  Pregnancy and kidney disease . Retrieved February 6, 2017, from  http://www.kidney.org/atoz/content/pregnancy.cfm  
• Kendrick, J., Sharma, S., Holmen, J., Palit, S., Nuccio, E., & Chonchol, M. (2015). Kidney disease and maternal and fetal outcomes in pregnancy. American Journal of Kidney Diseases, 66 (1), 55–59. Retrieved March 8, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485539/
• Office on Women's Health. (2012).  Autoimmune diseases fact sheet . Retrieved February 6, 2017, from  http://womenshealth.gov/publications/our-publications/fact-sheet/autoimmune-diseases.html
• Office on Women's Health. (2017).  Thyroid disease fact sheet . Retrieved February 6, 2017, from  https://www.womenshealth.gov/a-z-topics/thyroid-disease
• Vesco, K. K., Sharma, A. J., Dietz, P. M., Rizzo, J. H., Callaghan, W. M., England, L., et al. (2011). Newborn size among obese women with weight gain outside the Institute of Medicine recommendation.  Obstetrics & Gynecology, 117,  812–818.
• Institute of Medicine. (2009).  Weight gain during pregnancy . Retrieved on February 6, 2017, from http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines/Report%20Brief%20-%20Weight%20Gain%20During%20Pregnancy.pdf   (PDF 716 KB)
• American College of Obstetricians and Gynecologists. (2012).  FAQs: HIV and pregnancy.  Retrieved February 6, 2017, from http://www.acog.org/~/media/For%20Patients/faq113.pdf?dmc=1&ts=20120730T1640322605   (PDF 279 KB)
• American College of Obstetricians and Gynecologists. (2015). FAQ 103: Having a baby (especially for teens). Retrieved February 6, 2017, from http://www.acog.org/Patients/FAQs/Having-a-Baby-Especially-for-Teens  
• American Academy of Pediatrics. (2015).  Teenage pregnancy . Retrieved February 6, 2017, from  http://www.healthychildren.org/English/ages-stages/teen/dating-sex/pages/Teenage-Pregnancy.aspx  
• Eunice Kennedy Shriver  National Institute of Child Health and Human Development (NICHD). (2007).  Older mothers more likely than younger mothers to deliver by caesarean . Retrieved February 6, 2017, from http://www.nichd.nih.gov/news/releases/pages/caesarean_release_030807.aspx
• Gill, S. K., Broussard, C., Devine, O., Green, R. F., Rasmussen, S. A., Reefhuis, J.; The National Birth Defects Prevention Study. (2012). Association between maternal age and birth defects of unknown etiology: United States, 1997–2007. Birth Defects Research. Part A, Clinical and Molecular Teratology, 94 (12), 1010–1018. Retrieved February 20, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4532312/
• Grande, M., Borrell, A., Garcia-Posada, R., Borobio, V., Muñoz, M., Creus, M., et al. (2012). The effect of maternal age on chromosomal anomaly rate and spectrum in recurrent miscarriage. Human Reproduction, 27 (10), 3109–3117. Retrieved February 8, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/22888165
• Sivalingam, V. N., Duncan, W. C., Kirk, E., Shephard, L. A., & Horne, A. W. (2011). Diagnosis and management of ectopic pregnancy. Journal of Family Planning and Reproductive Health Care, 37 (4), 231–240. Retrieved February 20, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213855/
• Centers for Disease Control and Prevention. (2018).  Fetal alcohol spectrum disorders: Alcohol use in pregnancy . Retrieved October 1, 2018, from http://www.cdc.gov/ncbddd/fasd/alcohol-use.html
• Eckstrand, K. L., Ding, Z., Dodge, N. C., Cowan, R. L., Jacobson, J. L., Jacobson, S. W., et al. (2012). Persistent dose-dependent changes in brain structure in young adults with low-to-moderate alcohol exposure in utero.  Alcoholism: Clinical and Experimental Research, 36 (11), 1892–1902. Retrieved March 19, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/22594302
• NICHD. (2013). Tobacco, drug use in pregnancy can double risk of stillbirth. Retrieved March 19, 2018, from https://www.nichd.nih.gov/news/releases/Pages/121113-stillbirth-drug-use.aspx
• NICHD. (2016). Cigarette smoking during pregnancy linked to changes in baby's immune system. Retrieved March 19, 2018, from https://www.nichd.nih.gov/news/releases/122316-smoking-pregnancy
• Centers for Disease Control and Prevention. (n.d.).  Pregnant? Don't smoke . Retrieved February 6, 2017, from http://www.cdc.gov/Features/PregnantDontSmoke/
• NICHD. (2016).  Prenatal exposure to marijuana may disrupt fetal brain development, mouse study suggests.  Retrieved March 19, 2018, from  https://www.nichd.nih.gov/news/releases/Pages/031516-prenatal-exposure-marijuana.aspx
• MedlinePlus. (2015).  Twins, triplets, multiple births . Retrieved February 6, 2017, from https://medlineplus.gov/twinstripletsmultiplebirths.html#cat1
• American College of Obstetricians and Gynecologists. (2016).  FAQs: Preterm (premature) labor and birth.  Retrieved April 25, 2018, from https://www.acog.org/Patients/FAQs/Preterm-Labor-and-Birth  
• Howard, E. J., Harville, E., Kissinger, P., & Xiong, X. (2013). The association between short interpregnancy interval and preterm birth in Louisiana: A comparison of methods. Maternal and Child Health Journal, 17 (5), 933–939.

• Frontiers in Global Women's Health
• Maternal Health
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High-risk Pregnancy: Women's Experiences and New Approaches to Care

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Pregnancy involves physical, psychological, and social changes and when deemed high-risk, these experiences are amplified. High-risk pregnancy is characterized as a pregnancy in which the mother and/or fetus are at greater risk than normal of morbidity and mortality. Women and their families face significant physical, emotional, and psychological challenges due to uncertainty regarding the pregnancy outcome. The emotional and psychological experiences of women in high-risk pregnancies are profoundly influenced by the care they receive and their relationships with healthcare professionals are particularly important in this context. Person- and family-centered care models have the potential to significantly improve the quality of care and pregnancy outcomes, as they can address patient needs on an individual level. Understanding women’s experiences is essential to supporting them and their families throughout the course of the pregnancy and enabling the bonding process with their baby after the delivery. More than anything, the goal of individualized care should be to contribute to women’s well-being as well a positive pregnancy experience. This Research Topic welcomes papers concerning the experiences of women and their families with high-risk pregnancies and how their experience may be influenced by different models or approaches to care, acknowledging the complexity of factors involved. The goal is to highlight new interdisciplinary care models that are personalized, humanizing, and center women’s experience and ability to cope with the prolonged period of uncertainty that typically accompanies high-risk pregnancies. This collection will promote better-informed healthcare practices and policies that prioritize the well-being of women and their families facing high-risk pregnancies across different clinical care settings. This Research Topic, titled “High-risk Pregnancy: Women's Experiences and New Approaches to Care” welcomes papers from academics, clinicians, and other healthcare professionals in the field. Topics of interest include: - The psychosocial and emotional impact of a high-risk pregnancy diagnosis - Education needs arising from the diagnosis of a high-risk pregnancy - Aspects related to quality of care and how it influences outcomes such as access to personalized, culturally competent care and the importance of patients’ relationships with their healthcare providers - Factors related to women’s and their families’ ability to cope with prolonged uncertainty such as social support, the role of spirituality and religiousness and the perception of hope - Women’s autonomy and ethical considerations related to the decision-making during the care process - Opportunities presented by the implementation of innovative technologies in the care process Authors are welcome to submit quantitative and qualitative original research, review articles (systematic, integrative, scoping, mini, policy and practice), clinical trial, case report and brief research reports. Submissions should adhere to the guidelines and standards of Frontiers in Global Women’s Health.

Keywords : Pregnancy, High-Risk, Life Change Events, Pregnancy Complications, Prenatal Diagnosis, Mental Health, Psychological Well-Being, Hope, Spirituality, Family Relations, Life Course Perspective, Culture

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What Can Be Done to Reduce Teen Pregnancy and Out-of-Wedlock Births?

Subscribe to the center for economic security and opportunity newsletter, isabel v. sawhill isabel v. sawhill senior fellow emeritus - economic studies , center for economic security and opportunity.

October 1, 2001

• 18 min read

Why Focus on Teen Pregnancy?

Virtually all of the growth of single-parent families in recent decades has been driven by an increase in births outside marriage. Divorce rates have leveled off or declined modestly since the early 1980s and thus have not contributed to the rising proportion of children being raised by only one parent nor to the increase in child poverty and welfare dependence associated with the rise in single-parent families.

Not all non-marital births are to teen-agers. In fact, 70 percent of all births outside marriage are to women over age 20. For this reason, some argue that a focus on teens fails to address the real problem and that much more attention needs to be given to preventing childbearing, or raising marriage rates, among single women who have already entered their adult years.

But there are at least four reasons to focus on teens:

First, although a large proportion of non-marital births is to adult women, half of first non-marital births are to teens. Thus, the pattern tends to start in the teenage years, and, once teens have had a first child outside marriage, many go on to have additional children out of wedlock at an older age. A number of programs aimed at preventing subsequent births to teen mothers have been launched but few have had much success. So, if we want to prevent out-of-wedlock childbearing and the growth of single-parent families, the teenage years are a good place to start

Second, teen childbearing is very costly. A 1997 study by Rebecca Maynard of Mathematica Policy Research in Princeton, New Jersey, found that, after controlling for differences between teen mothers and mothers aged 20 or 21 when they had their first child, teen childbearing costs taxpayers more than $7 billion a year or $3,200 a year for each teenage birth, conservatively estimated.

Third, although almost all single mothers face major challenges in raising their children alone, teen mothers are especially disadvantaged. They are more likely to have dropped out of school and are less likely to be able to support themselves. Only one out of every five teen mothers receives any support from their child’s father, and about 80 percent end up on welfare. Once on welfare, they are likely to remain there for a long time. In fact, half of all current welfare recipients had their first child as a teenager.

Some research suggests that women who have children at an early age are no worse off than comparable women who delay childbearing. According to this research, many of the disadvantages accruing to early childbearers are related to their own disadvantaged backgrounds. This research suggests that it would be unwise to attribute all of the problems faced by teen mothers to the timing of the birth per se. But even after taking background characteristics into account, other research documents that teen mothers are less likely to finish high school, less likely to ever marry, and more likely to have additional children outside marriage. Thus, an early birth is not just a marker of preexisting problems but a barrier to subsequent upward mobility. As Daniel Lichter of Ohio State University has shown, even those unwed mothers who eventually marry end up with less successful partners than those who delay childbearing. As a result, even if married, these women face much higher rates of poverty and dependence on government assistance than those who avoid an early birth. And early marriages are much more likely to end in divorce. So marriage, while helpful, is no panacea.

Fourth, the children of teen mothers face far greater problems than those born to older mothers. If the reason we care about stemming the growth of single-parent families is the consequences for children, and if the age of the mother is as important as her marital status, then focusing solely on marital status would be unwise. Not only are mothers who defer childbearing more likely to marry, but with or without marriage, their children will be better off. The children of teen mothers are more likely than the children of older mothers to be born prematurely at low birth weight and to suffer a variety of health problems as a consequence. They are more likely to do poorly in school, to suffer higher rates of abuse and neglect, and to end up in foster care with all its attendant costs.

How Does Current Welfare Law Address Teen Pregnancy and Non-Marital Births?

The welfare law enacted in 1996 contained numerous provisions designed to reduce teen or out-of-wedlock childbearing including:

• A $50 million a year federal investment in abstinence education;
• A requirement that teen mothers complete high school or the equivalent and live at home or in another supervised setting;
• New measures to ensure that paternity is established and child support paid;
• A $20 million bonus for each of the 5 states with the greatest success in reducing out-of-wedlock births and abortions;
• A $1 billion performance bonus tied to the law’s goals, which include reducing out-of-wedlock pregnancies and encouraging the formation and maintenance of two-parent families;
• The flexibility for states to deny benefits to teen mothers or to mothers who have additional children while on welfare (no state has adopted the first but 23 states have adopted the second); and
• A requirement that states set goals and take actions to reduce out-of-wedlock pregnancies, with special emphasis on teen pregnancies.

Research attempting to establish a link between one or more of these provisions and teen out-of-wedlock childbearing has, for the most part, failed to find a clear relationship. One exception is child support enforcement, which appears to have had a significant effect in deterring unwed childbearing.

Are Teen Pregnancies and Births Declining?

Teen pregnancy and birthrates have both declined sharply in the 1990s (figure 1). The fact that these declines predated the enactment of federal welfare reform suggests that they were caused by other factors. However, it is worth noting that many states began to reform their welfare systems earlier in the decade under waivers from the federal government, so we cannot be sure. In addition, the declines appear to have accelerated in the second half of the decade after welfare reform was enacted. And finally, most of the decline in the early 1990s was the result of a decrease in second or higher order births to women who were already teen mothers. This decrease was related in part to the popularity of new and more effective methods of birth control among this group. It was not until the second half of the decade that a significant drop in first births to teens occurred.

Teen birthrates had also declined in the 1970s and early 1980s but in this earlier period all of the decline was due to increased abortion. Significantly, all of the teen birthrate decreases in the 1990s were due to fewer pregnancies, not more abortions.

Equally significant is the fact that teens are now having less sex. Up until the 1990s, despite some progress in convincing teens to use contraception, teen pregnancy rates continued to rise because an increasing number of teens were becoming sexually active at an early age, thereby putting themselves at risk of pregnancy. More recently, both better contraceptive use and less sex have contributed to the lowering of rates.

Given that four out of five teen births are to an unwed mother, this drop in the teen birthrate contributed to the leveling off of the proportion of children born outside marriage after 1994 (figure 2). More specifically, if teen birthrates had held at the levels reached in the early 1990s, by 1999 this proportion would have been more than a full percentage point higher. Thus, a focus on teenagers has a major role to play in future reductions of both out-of-wedlock childbearing and the growth of single-parent families.

What Caused the Decline in Teen Pregnancies and Births?

Although the immediate causes of the decline-less sex and more contraception-are relatively well established, it is less clear what might have motivated teens to choose either one. However, many experts believe it was some combination of greater public and private efforts to prevent teen pregnancy, the new messages about work and child support embedded in welfare reform, more conservative attitudes among the young, fear of AIDS and other sexually transmitted diseases, the availability of more effective forms of contraception, and perhaps the strong economy.

Some of these factors have undoubtedly interacted, making it difficult to ever sort out their separate effects. For example, fear of AIDS may have made teenagers-males in particular, for whom pregnancy has traditionally been of less concern-more cautious and willing to listen to new messages. Indeed, as shown by Leighton Ku and his colleagues at the Urban Institute in Washington, D.C., the proportion of adolescent males approving of premarital sex decreased from 80 percent in 1988 to 71 percent in 1995. The Ku study also linked this shift in adolescent male attitudes to a change in their behavior.

The growth of public and private efforts to combat teen pregnancy may have also played a role, as suggested by surveys conducted by the National Governors’ Association, the General Accounting Office, the American Public Human Services Association, and most recently and comprehensively, by Child Trends. The Child Trends study, conducted by Richard Wertheimer and his associates at the Urban Institute, surveyed all 50 states in both 1997 and 1999. The survey shows that states have dramatically increased their efforts to reduce teen pregnancy (figure 3). These efforts include everything from the formation of statewide task forces to more emphasis on sex education in the public schools and statewide media campaigns. Although such efforts have been greatly expanded in recent years, they are still relatively small. State spending on teen pregnancy prevention averages only about $8 a year per teenaged girl. In addition to being small, such efforts may or may not be effective in preventing pregnancy. Fortunately, we know more about this topic now than we did even a few years ago.

Do Teen Pregnancy Prevention Programs Work?

The short answer is “yes, some do.” Based on a careful review of the scholarly literature completed by Douglas Kirby of ETR Associates in Santa Cruz, California, a number of rigorously evaluated programs have been found to reduce pregnancy rates. Two of these programs have reduced rates by as much as one-half. One is a program that involves teens in community service with adult supervision and counseling. The other includes a range of services such as tutoring and career counseling along with sex education and reproductive health services. Both have been replicated in diverse communities and evaluated by randomly assigning teens to a program and control group. In addition, a number of less intensive and less costly sex education programs have also been found to be effective in persuading teens to delay sex and/or use contraception. Such programs typically provide clear messages about the importance of abstaining from sex and/or using contraception, teach teens how to deal with peer pressure to have sex, and provide practice in communicating and negotiating with partners.

“Abstinence only” programs are relatively new and have not yet been subject to careful evaluation, although what research exists has not been encouraging. More importantly, the line between abstinence only and more comprehensive sex education that advocates abstinence but also teaches about contraception is increasingly blurred. What matters is not so much the label but rather what a particular program includes, what the teacher believes, and how that plays out in the classroom. A strong abstinence message is totally consistent with public values, but the idea that the federal government can, or should, rigidly prescribe what goes on in the classroom through detailed curricular guidelines makes little sense. Family and community values, not a federal mandate, should prevail, especially in an area as sensitive as this one.

Do Media Campaigns Work?

Community-based programs are only part of the solution to teen pregnancy. Indeed, only 10 percent of teens report they have participated in such a program (outside of school), while on average teens spend more than 38 hours a week exposed to various forms of entertainment media. By themselves, teen pregnancy prevention programs cannot change prevailing social norms or attitudes that influence teen sexual behavior. The increase in teen pregnancy rates between the early 1970s and 1990 was largely the result of a change in attitudes about the appropriateness of early premarital sex, especially for young women. As more and more teen girls put themselves at risk of an early pregnancy, pregnancy rates rose. More recently, efforts to encourage teens to take a pledge not to have sex before marriage have had some success in delaying the onset of sex.

In an attempt to influence these attitudes and behaviors, several national organizations as well as numerous states have turned to the media for assistance. Between 1997 and 1999 alone, the number of states conducting media campaigns increased from 15 to 36. Typically, such campaigns use both print and electronic media to reach large numbers of young people with messages designed to change their behavior. Such messages can be delivered via public service announcements (PSAs) or by working with the media to incorporate more responsible content into their ongoing programming. Most state efforts rely on PSA campaigns but several national organizations are working with the entertainment industry to affect content.

Research assessing the effectiveness of media campaigns is less extensive and less widely known than research evaluating community-based programs, but it shows that they, too, can be effective. A meta-analysis of 48 different health-related media campaigns from smoking cessation to AIDS prevention by Leslie Snyder of the University of Connecticut found that, on average, such campaigns caused 7 to 10 percent of those exposed to the campaign to change their behavior (relative to those in a control group). As with community-based programs, media campaigns vary enormously in their effectiveness and need to be designed with care. But existing evidence suggests that they are a good way to reach large numbers of teens inexpensively.

Are Efforts to Reduce Teen Pregnancy Cost-Effective?

At first appearance, the finding by Rebecca Maynard that each teen mother costs the government an average of $3,200 per year suggests that government could spend as much as $3,200 per teen girl on teen pregnancy prevention and break even in the process. But, of course, not all girls become teen mothers and programs addressing this problem are not 100 percent effective so a lot of this money would be wasted on girls who do not need services and on programs that are less than fully effective.

Here is a simple but useful method to estimate how much money could be spent on teen pregnancy prevention programs and still realize benefits that exceed costs. If we accept Maynard’s estimate that reducing teen pregnancy saves $3,200 per birth prevented (in 2001 dollars), the question is how much should we spend to prevent such births? We first have to adjust the $3,200 estimate for the fact that not all teen girls will get pregnant and give birth without the intervention program. We know that about 40 percent of teen girls become pregnant and about half of these (or 20 percent) give birth. This adjustment yields the estimate that $640 (20 percent multiplied by $3,200) might be saved by a universal prevention program. (If we knew how to target the young people most at risk we could save even more than this.) However, a second adjustment is necessary because not all intervention programs are effective. Based on data reviewed by Douglas Kirby and by Leslie Snyder, a good estimate is that about one out of every ten girls enrolled in a program or reached by a media campaign might change her behavior in a way that delayed pregnancy beyond her teen years. This second adjustment yields the estimate that universal programs would produce a benefit of 10 percent of $640 or about $64 per participant. As the Wertheimer survey showed, actual spending on teen pregnancy prevention programs in the entire nation now averages about $8 per teenage girl. If the potential savings are $64 per teenage female while actual current spending is only $8 per teenage female, government is clearly missing an opportunity for productive investments in prevention programs. In fact, these calculations-while rough-suggest that government could spend up to eight times ($64 divided by $8) as much as is currently being spent and still break even.

Implications for Welfare Reform Reauthorization Research and experience over the last decade suggest several lessons for the administration and Congress as they consider reauthorization of the 1996 welfare reform legislation.

First, the emphasis in the current law on time limits, work, and child support enforcement should be maintained. The 1996 welfare reform law included a set of very important messages. To young women, it said “if you become a mother, this will not relieve you of an obligation to finish school and support yourself and your family through work or marriage. And any special assistance you receive will be time limited.” To young men, it said “if you father a child out-of-wedlock, you will be responsible for supporting that child.” Although opinions vary as to whether these messages have had an impact, in my view the decline in teen pregnancies and births together with the leveling off of the non-marital birth ratio and of the proportion of children living in single parent homes all suggest such an impact. These messages may be far more important than any specific provisions aimed at increasing marriage or reducing out-of-wedlock childbearing, and their effects are likely to cumulate over time.

Second, the federal government should fund a national resource center to collect and disseminate information about what works to prevent teen pregnancy. Until recently, little information was available about the best ways to prevent teen pregnancy. States and communities had no way of learning about each other’s efforts and teens themselves had no ready source of information about the risks of pregnancy and the consequences of early unprotected sex. Some private organizations have attempted to fill the gap without much help from public sources.

Third, Congress should send a strong abstinence message coupled with education about contraception. Surveys of both adults and teens reveal strong support for abstinence as the preferred standard of behavior for school-age youth, and they want teens to hear this message. At the same time, a majority is in favor of making birth control services and information available to teens who are sexually active. In addition, few expect all unmarried adults in their twenties to abstain from sex until marriage. And since a large proportion of non-marital births occurs in this age group, and a significant number of teens continue to be sexually active, education about and access to reproductive health services remains important through Title X of the Public Health Service Act, the Medicaid program, and other federal and state programs.

Fourth, adequate resources should be provided to states to prevent teen pregnancy, without specifying the means for achieving this goal. In addition, states that work successfully to reduce teen pregnancy should be rewarded for their efforts. A strong argument can be made that the federal government should specify the outcomes it wants to achieve but not prescribe the means for achieving them. This is especially important given some uncertainty about the effectiveness of different programs and strategies, and the diversity of opinion about the best way to proceed. It suggests the wisdom of retaining a block grant structure for TANF and avoiding earmarks for specific programs. This does not mean the federal government should not reward states that achieve certain objectives, such as an increase in the proportion of children living in two-parent families, a decline in the non-marital birth ratio, or a decline in the teen pregnancy or birth rate. Reducing early childbearing may be one of the most effective ways of increasing the proportion of children born to, and raised by, a married couple. But states should decide on the best way to achieve these outcomes, subject only to the caveat that they base their efforts on reliable evidence about what works. The evidence presented above suggests that states should be spending roughly eight times as much as they are now on teen pregnancy prevention.

Fifth, the federal government should fund a national media campaign. Too many public officials and community leaders have assumed that if they could just find the right program, teen pregnancy rates would be reduced. Although there are now a number of programs that have proved effective, the burden of reducing teen pregnancy should not rest on programs alone. Rather, we should build on the fledgling efforts undertaken at the state and national level over the past five years to fund a broad-based, sophisticated media campaign to reduce teen pregnancy. These funds should support not only public service ads but also various nongovernmental efforts to work in partnership with the entertainment industry to promote more responsible content. These media efforts can work in tandem with effective sex education and more expensive and intensive community level programs targeted to high-risk youth.

These steps have the potential to maintain the progress made over the past decade in reducing teen and out-of-wedlock pregnancies. There are only two solutions to the problem of childbearing outside marriage. One is to encourage early marriage. The other is to encourage delayed childbearing until marriage. Although commonplace as recently as the 1950s, early marriage is no longer a sensible strategy in a society where decent jobs increasingly require a high level of education and where half of teen marriages end in divorce. If we want to ensure that more children grow up in stable two-parent families, we must first ensure that more women reach adulthood before they have children.

Additional Reading

Henshaw, Stanley. 2001. U.S. Teenage Pregnancy Statistics. New York: Alan Guttmacher Institute.

Kirby, Douglas. 2001. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, D.C.: National Campaign to Prevent Teen Pregnancy.

Ku, Leighton, and others. 1998. “Understanding Changes in Sexual Activity Among Young Metropolitan Men: 1979-1995.” Family Planning Perspectives, 30(6): 256-262.

Lichter, Daniel T., Deborah Roempke Graefe, and J. Brian Brown. 2001. Is Marriage a Panacea? Union Formation Among Economically Disadvantaged Unwed Mothers. Columbus: Ohio State University.

Maynard, Rebecca A., ed. 1997. Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy. Washington, D.C.: Urban Institute.

National Campaign to Prevent Teen Pregnancy. 2001. Halfway There: A Prescription for Continued Progress in Preventing Teen Pregnancy. Washington, D.C..

National Center for Health Statistics. 2000 and 2001. National Vital Statistics Reports, 48 and 49, various issues. Hyattsville, Md.: Department of Health and Human Services.

Sawhill, Isabel. Forthcoming. “Welfare Reform and the Marriage Movement.” Public Interest.

Snyder, Leslie B. 2000. “How Effective Are Mediated Health Campaigns?” In Public Communication Campaign, edited by Ronald E. Rice and Charles K. Atkin. Thousand Oaks, Calif.: Sage.

Wertheimer, Richard, Justin Jager, and Kristin Anderson Moore. 2000. “State Policy Initiatives for Reducing Teen and Adult Non-Marital Childbearing.” New Federalism: Issues and Options for States (No. A-43). Washington, D.C.: Urban Institute.

Economic Studies Governance Studies

Center for Economic Security and Opportunity

Jeffrey C. Fuhrer

July 29, 2024

Quinn Sanderson

July 9, 2024

Kristin F. Butcher, Elizabeth Kepner , Kelli Marquardt, Brianna Smith

June 24, 2024

Teen Pregnancy: Causes, Effects and Prevention Essay

• To find inspiration for your paper and overcome writer’s block
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Introduction

Socioeconomic effects.

Teenage pregnancy is the pregnancy of underage girls during their adolescent period, normally between the ages of 13 to 19 but this range varies depending on the age of the menarche and the legal age of adulthood, which varies from one country to another. The rate of teen pregnancy is on the rise world wide due to changing lifestyles and increased fertility rate hence raising lot of social and economic concerns in the society.

The possible causes and predisposing factors of teenage pregnancies are early marriages, sexual activity during adolescence, inadequate sex education, sexual abuse, pornography, drug abuse, lower education levels, and high poverty levels.

Teenage pregnancies results into the dropouts of the teenage girls from schools. The dropouts mostly affect high school girls due to the dominant peer pressure factors and inadequate sex education.

The education of teenage a girl is significantly affected because she must drop out of school in order to prepare and take care of her baby. Statistics shows that, the teenage pregnancy is the major reason for the young girls’ dropouts in high school. These dropouts have great negative impacts on the education potential and the bright future of the girl child.

Teenage pregnancies are prone to many obstetrics complications as compared to mature women due to physiological and morphological factors. These complications demands extra healthcare attention that is very expensive, especially to the poor families. There are also serious health’s risks associated with teen pregnancies that can permanently affect the health of a teenage mother if there is no consultation of a professional obstetrician during delivery.

Social stigma and stress negatively affects the self-esteem of a pregnant teenage. When a teenage becomes pregnant, she develops fears about unplanned pregnancy, becomes frustrated, and begins to lose self-esteem and hope, as it seems to her that she has reached a premature destiny of her life.

The pregnant teen has fears of disclosing her pregnancy to any one not even his boyfriend who impregnates her, because she is worried about what they will say about her pregnancy condition. She develops stigma and confusion wondering on what kind of image she will portray to his friends, family, and teachers. She contemplates on the options of either disclosing the bad news and keep her pregnancy or keep the secret and do abortion.

Schools are required to develop programs and workshops that will provide opportunity to the students to develop their youth positively and become busy as idle minds are devils workshops.

Drug abuse and pornography should not be allowed in school because it encourages early sexual activity in teens. Girls need skills on how to avoid and protect themselves against predisposing factors and situations that prove to be very dangerous to their safety. Sex education will enable girls make their informed decisions and be responsible to their own actions and consequences.

Teen pregnancy is a major problem affecting girl child education worldwide. The increased teenage pregnancy rate is due to the change in lifestyles such as availability of pornography, drug abuse, peer pressure, increased fertility, and poverty.

Teenage pregnancy poses many challenges to the families and education system translating into serious socioeconomic problems in the society that need immediate attention to address. Teenagers are young and quite innocent on the consequences of teenage pregnancies, so they need proper parental and school guidance on the knowledge of sexuality and pregnancy.

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• Chicago (A-D)
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An Update on Research Issues in the Assessment of Birth Settings: Workshop Summary (2013)

Chapter: 3 assessment of risk in pregnancy.

Assessment of Risk in Pregnancy

R isk assessment in pregnancy helps to predict which women are most likely to experience adverse health events and enables providers to administer risk-appropriate perinatal care. While risk assessment and the challenge of defining “low risk” was a topic that was revisited several times during the course of the workshop, this chapter summarizes the Panel 2 workshop presentations which focused exclusively on the topic and included suggested topics for future research. See Box 3-1 for a summary of key points made by individual speakers. The panel was moderated by Benjamin Sachs, M.D., Tulane University, New Orleans, Louisiana. Also summarized here is the combined Panel 1 and 2 discussion with the audience (i.e., on topics covered both here and in Chapter 2 ).

IDENTIFYING LOW-RISK PREGNANCIES 1

The steady declines in maternal and neonatal mortality across the United States illustrated in Figure 3-1 are among the greatest public health achievements of the 20th century (CDC, 1999). The declines were driven by many technical and political changes, starting in 1933 when the first maternal and child morbidity and mortality reviews were convened. The shift from home to hospital births that occurred during the 1940s, coupled with the use of antibiotics and transfusions in the 1950s, drove further declines, bringing maternal mortality down to about 7 per 100,000 by 1982

______________________________________

1 This section summarizes information presented by Kimberly Gregory, M.D., M.P.H., Cedars-Sinai, Los Angeles, California.

BOX 3-1 Assessment of Risk in Pregnancy: Key Points Made by Individual Speakers

• Kimberly Gregory noted while the steady declines in maternal and neonatal mortality across the United States are among the greatest public health achievements of the 20th century, the maternal mortality rate has been increasing in recent years.
• Gregory emphasized the dynamic nature of low risk: the risk associated with childbirth can change at any point, often unexpectedly. She also emphasized the contextual nature of risk, for example with risks of both maternal and neonatal events being low in collaborative care situations where events are triaged appropriately.
• Gregory urged a greater focus on identifying conditions that call for different levels of care. Just as high-risk women need to be cared for in appropriate facilities with appropriate resources, the same may be true of low-risk women given that care of low-risk women in high-risk or high-intervention sites is associated with increased adverse events.
• Elizabeth Armstrong observed that numerous sociological and anthropological studies have identified control and safety as being especially important for the birth experience. However, control and safety have different meanings for different women. For some women, a technology-intensive birth in a hospital imparts a desired sense of control. For others, the same situation makes them feel out of control.
• Armstrong described contemporary American culture as a “risk society,” one that views birth as a high-risk and dangerous endeavor. Some social scientists believe that the attempt to classify births into varying levels of risk itself emphasizes the pathology inherent in birth rather than the normal physiology of birth.
• As described by Kathryn Menard, the purpose of risk assessment is to predict which women are most likely to experience adverse events, to streamline resources to those who need them most, and to avoid unnecessary interventions.
• Identifying low obstetric risk is a difficult challenge. Menard elaborated on how low risk is defined differently by different researchers, making it difficult to compare outcomes across settings. She emphasized the need for more consistent and evidence-based criteria of low obstetric risk and called for a greater understanding of predictors of both neonatal and maternal complications to guide decisions about level of care and a better understanding of predictors that should prompt maternal transfer.

(from greater than 800 per 100,000 in 1900). However, more recently, based on data from the Maternal, Child and Adolescent Health Division of the California Department of Public Health, there is very clear evidence that the maternal mortality rate is increasing (see Figure 3-2 ). In the mid-

FIGURE 3-1 (A) Maternal mortality rate per 100,000 live births by year, United States, 1900-1997. (B) Infant mortality rate per 1,000 live births by year, United States, 1915-1997. SOURCE: CDC, 1999.

FIGURE 3-2 Maternal mortality rate, California and the United States, 1999-2010. NOTES: HP2020, Healthy People 2020; ICD, International Classification of Diseases. State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤42 days postpartum) was calculated using ICD-10 cause-of-death classification (codes A34, O00-O95, O98-O99) for 1999-2010. U.S. data and Healthy People 2020 Objective were calculated using the same methods. U.S. maternal mortality data are published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. rates from 2008-2010 were calculated using NCHS Final Death Data (denominator) and Centers for Disease Control and Prevention Wonder Online Database ( http://wonder.cdc.gov ) for maternal deaths (numerator). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April 2013. SOURCE: California Department of Public Health, 2013.

2000s, the national rate was about 13 deaths per 100,000. In California, it was about 16 per 100,000.

What Is Low Risk?

Tasked to identify low-risk pregnancies, Kimberly Gregory began by searching the scientific literature, restricting her search to publications since 1996 and to developed countries. She searched using several combinations of terms: “low risk” and “pregnancy”; “risk assessment” and “pregnancy”; “levels of care” and “pregnancy”; and all of those same terms crossed with “midwives,” “family practice,” “birth centers,” and “home births.” Later, she updated her search to include maternal transfers. Gregory also considered discussions of low risk in consensus statements issued by representative

organizations and on the websites of the American Congress of Obstetricians and Gynecologists (ACOG), American College of Nurse-Midwives (ACNM), American Academy of Family Physicians (AAFP), and American Association of Birth Centers (AABC).

Gregory observed that the history of risk assessment in obstetrics began in 1929, in the United Kingdom (UK), when Dr. Janet Campbell implied, “the first requirement of a maternity service is effective supervision of the health of the woman during pregnancy” (Dowswell et al., 2010). Thereafter, the UK Ministry of Health set antepartum exams to begin at 16 weeks, to occur again at 24 and 28 weeks, and then to occur monthly to 36 weeks and weekly thereafter. Examiners were advised to check fundal height, fetal heart, and urine. It was advised that medical officers conduct the week 32 and 36 exams. These standards form the basis for current antenatal care, although additional screening interventions for identifying “high risk” have been added over time. Mead and Kornbrot (2004) defined the “standard primip” 2 eligible for midwifery care in the United Kingdom as a woman who is Caucasian, 20-34 years old, taller than 155 centimeters, with a singleton and vertex pregnancy greater than 37 weeks, with the delivery setting occurring as planned, and with no medical complications.

In the United States, identification of obstetric “low risk” is made more complicated than it is in the United Kingdom by questions such as, at low risk for what? Most risk-assessment models are for preterm birth, perinatal morbidity and mortality, Cesarean delivery, or vaginal birth after Cesarean or uterine rupture. No risk-assessment models, or tools, specifically address the risk of maternal morbidity and mortality. Because no such tools exist, and given that home and birth center births are supposed to be low risk, Gregory examined criteria used to identify candidates for home and birth center births as a means of identifying “low risk.”

According to criteria posted on the Open Door Midwifery website, 3 in order to be a candidate for home birth, exam and laboratory tests must be within normal limits and show no evidence of chronic hypertension, epilepsy or seizure disorder, HIV infection, severe psychiatric disease, persistent anemia, diabetes, heart disease, kidney disease, endocrine disease, multiple gestation, or substance abuse.

According to the American Public Health Association (APHA) Guidelines for Licensing and Regulating Birth Centers (APHA, 1982), birth centers themselves should specify criteria for establishing risk status in their policy and procedure manuals and clearly delineate and annually review medical and social risk factors that exclude women from the low-risk antepartum group. Referencing several older papers (Aubry and Pennington,

2 Primip is a woman who is having her first baby.

3 See http://www.opendoormidwifery.com/criteria.html .

1973; Hobel et al., 1973, 1979; Lubic, 1980; March of Dimes, Committee on Perinatal Health, 1976; Sokol et al., 1977), the APHA guidelines identify some specific high-risk conditions: recurrent miscarriage, history of still birth, history of preterm birth hypertension, diabetes, cardiac disease, anemia or Rh disease, renal disease, thyroid disease, toxemia, macrosomic infant, multiparity, “multiple problems,” systemic conditions like sarcoid or epilepsy, drug or alcohol use, and venereal disease. Gregory noted that the APHA guidelines emphasize continual evaluation through the prenatal, intrapartum, and postpartum periods. However, again, their focus is on perinatal risk, not maternal risk.

“High-risk” conditions are usually what Gregory described as a “sign of the times.” That is, they change over time. For example, Aubry and Nesbitt (1969) included tuberculosis in their list of high-risk conditions, along with bacteriuria, uterine anomalies, and other conditions. Today, in addition to many of the same conditions listed elsewhere, the American Academy of Pediatrics (AAP)/ACOG Guidelines for Perinatal Care , 7th edition (AAP and ACOG, 2012), include some new conditions: prior deep vein thrombosis or pulmonary embolism, chronic anticoagulation, and family history of a genetic disorder. Like the 1982 APHA guidelines, the AAP and ACOG 2012 guidelines emphasize ongoing risk assessment. They also emphasize referral and consultation among institutions that provide different levels of care.

So what is “low risk”? “It is the opposite of high risk,” Gregory said. She paraphrased Supreme Court Justice Potter Stewart: “I imply no criticism of … [the literature] which in those days was faced with the task of trying to define what may be undefinable…. I shall not today attempt further to define the kinds of material I understand to be embraced within that short hand description; concluding perhaps, I could never succeed in intelligibly doing so. But, I know it when I see it.”

Given Low Risk, What Happens to You?

Outcomes for low-risk mothers depend on where they deliver and who takes care of them. Villar et al. (2001) evaluated patterns of prenatal care and found no difference in risk of Cesarean, anemia, urinary tract infections, or postpartum hemorrhage between midwife, general practice, and obstetric care. They reported a trend toward lower preterm birth, less antepartum hemorrhage, and lower perinatal mortality with midwife and general practice care; significant decreases in pregnancy-induced hypertension (PIH) and eclampsia with midwife and general practice care; a significant increase in failure to diagnose malpresentation with midwife and general practice care; and a similar or higher satisfaction with midwife and general practice care.

Other studies have shown wide variation in care for healthy women, but more consistent care with complicated deliveries (Baruffi et al., 1984). Care is dictated by the structure, process, and culture where that care is being administered. For example, Gregory said evidence suggests that, for low-risk women, midwife-led care is better (i.e., results in fewer interventions) in freestanding or integrated birth centers where midwives have autonomy and where they are practicing in a small-scale setting. Midwives in integrated centers tend to incorporate the risk culture of the environment at large, such that midwives in units with high intervention rates perceive intrapartum risk to be greater and underestimate the likelihood to progress normally (Mead and Kornbrot, 2004). Gregory explained midwives in high-intervention environments are more likely to “risk out” a patient than are midwives working in low-intervention environments.

Approximately 20 percent of laboring women are transferred out of midwifery care, based on the Walsh and Devane (2012) and Hodnett et al. (2010) reviews. Lynch et al. (2005) reported an intrapartum transfer rate from hospitals without Cesarean delivery capabilities of 9.5 to 12 percent. Stapleton et al. (2013) reported that, of 18,084 women accepted for birth center care (of 22,403 who planned a birth center birth on entry to prenatal care), 13.7 percent (2,474) were transferred antenatally to a medical doctor for medical or obstetrical complications (primarily postdates, malpresentation, PIH, and nonreassuring fetal heart rate) and 0.2 percent (36) never presented to the birth center in labor. Thus, a total of 15,574 women planned and were considered eligible for birth center care at onset of labor. Of those, 4.5 percent transferred at the onset of labor but still prior to admission; another 12 percent (of those still on track for a birth center birth) were transferred intrapartum (e.g., because of arrest, nonreassuring fetal heart rate, diagnosis of breech, bleeding, PIH, cord prolapse, or seizure). Of note, less than 1 percent of the intrapartum transfers were emergency transfers, which Gregory interpreted to mean that there was plenty of time to make arrangements for getting the women safely to a nearby hospital. Also of note, 82 percent of the intrapartum transfers were for nulliparous women . Finally, another 2 percent (of those who actually delivered in the birth center) were transferred postpartum, primarily because of postpartum hypertension or postpartum hemorrhage. But again, only less than 0.5 percent of those transfers were emergency transfers, alluding to the fact that there was plenty of time to ensure that women were receiving appropriate levels of care. The researchers concluded that fetal and neonatal mortality rates among the birth center births were consistent with those of low-risk births reported elsewhere in other settings, including hospital births.

In her search for additional information to help guide the identification of obstetric low risk, Gregory identified Baskett and O’Connell (2009) as another relevant study. The researchers examined a 24-year period (1982-

2005) of maternal transfers for critical care from freestanding birth units. They identified 117 transfers out of 122,000 deliveries (so 1 in 1,000). Eighty percent of the transfers (95/117) were for intensive care unit (ICU) care and the other 20 percent (24/117) were for medical or surgical care not available at the obstetrics unit. Most transfers (101/117) were postpartum, the remainder (16/117) antepartum. Hemorrhage and hypertension accounted for 56.4 percent of indications for transfer. Overall mortality was fairly low (only 5 deaths out of 122,000 deliveries), with a death-to-morbidity ratio of 1 to 23.

In Gregory’s opinion, available data and guidelines suggest that the 30-minute rule of “decision to incision” for emergency Cesarean delivery might not be good enough (Minkoff and Fridman, 2010). She suggested that there might be specific conditions under which care providers should be thinking in terms of “golden minutes.” These include placenta previa/accreta, abruption, cord prolapse, and uterine rupture. She acknowledged, however, that, as Lagrew et al. (2006) pointed out, “most emergent Cesarean deliveries develop during labor in low-risk women and cannot be anticipated by prelabor factors” (p. 1638).

In conclusion, Gregory defined low risk as singleton, term, vertex pregnancies, and the absence of any other medical or surgical conditions. Low risk is a dynamic condition, one subject to change over the course of the antepartum, intrapartum, and postpartum periods. The change can be acute and unexpected.

Low risk can also be defined regionally or locally within the context of collaborative care. Rates of neonatal and maternal adverse events are low if events are triaged appropriately with skilled clinicians. Recognizing that 39 percent of deliveries occur in hospitals where there are fewer than 500 deliveries per year, or fewer than approximately two deliveries per day, clearly not all hospitals can provide the same standard of care. While volume is usually associated with outcome, this is not true of midwifery care. Small-scale midwifery care is associated with better outcomes in terms of fewer interventions.

Gregory urged an evaluation of risk-appropriate care within the context of both risk (low risk versus high risk) and alternate birth settings. More data are needed regarding conditions that call for high-level care, such that high-risk women and/or conditions are cared for in appropriate facilities with appropriate resources. For example, what maternal conditions require delivery at Level III (specialty) or IV (regional site)? Low-risk women may also need to be cared for in appropriate facilities with appro-

priate resources, given that care of low-risk women in high-risk or high-intervention sites is associated with increased adverse events.

SOCIOLOGICAL PERSPECTIVE ON RISK ASSESSMENT IN PREGNANCY 4

Looking beyond historical trends in childbirth and who chooses which settings, Elizabeth Mitchell Armstrong examined factors that drive women’s decisions about where to give birth. More specifically, what drives a woman’s understanding of risk? She looked through three different “lenses” on, or frameworks, for understanding, risk: (1) cultural views of risk and birth, that is, the sociocultural perception of birth in contemporary American society; (2) women’s perceptions, expectations, and experiences of birth and, in particular, the ways some women’s assessments of risk differ from those of their providers; and (3) structural conditions that affect risk.

Sociocultural Views of Risk and Birth in Contemporary American Society: The Notion of a “Risk Society”

Contemporary American culture views birth as a high-risk endeavor. The dominant cultural view of birth among medical professionals, as well as among laypersons, is that birth is inherently risky, even dangerous. Birth is depicted in popular movies like Knocked Up and in television shows like Birth Story as a chaotic, bloody affair involving lots of urgency, running around, and yelling. The model mood is one of panic. The birthing woman herself is depicted as irrational and out of control and the men around her as incompetent. Thus, birth is depicted in the media as a full-blown crisis, with vanishingly few planned home births depicted at all. In television and the movies, the only births occurring outside hospitals are precipitous ones; often, no one is in charge, and the birth resembles nothing so much as an unmitigated disaster. Also in the media, extreme pain is depicted as something with no other solution but drugs. Armstrong said, “No wonder women fear birth.”

Yet, a historical perspective on childbirth suggests that birth should be less terrifying than in the past. Today, virtually all women and babies survive birth, with the birth of a child often an emotional high that many women and men report as being among the happiest of their lives.

How has American culture come to regard birth, a natural and intrinsic part of life and human society, with such trepidation, fear, and loathing? Armstrong suspects that the answer lies, in part, in a broader set of cultural

4 This section summarizes information presented by Elizabeth Mitchell Armstrong, Ph.D., M.P.A., Princeton University, Princeton, New Jersey.

shifts that have transformed modern society and in the evolution of what Beck (1992, 1999) calls a “risk society.” A risk society is one where the notion of risk overshadows all social life and where the identification and management of risk are the principle organizing forces. Beck (1999) argues that modern society has become a risk society “in the sense that it is increasingly occupied with debating, preventing, and managing the risks that it, itself, has produced” (Beck, 2006). As both Beck (1992, 1999) and Giddens (1999) argue, modern life is increasingly perceived in terms of danger and organized around the pursuit of safety. This increased awareness of risk has led to a pervasive sense of uncertainty and attempts to control the future.

Based on theories of risk articulated by Beck (1992, 1999) and Giddens (1999), Armstrong shared some insights that she deems relevant to risk assessment at birth. First, many of the risks being considered are what Beck calls “manufactured risks,” that is, risks created by human intervention, as opposed to risks created by weather or other natural events. Second, the omnipresence of risk in modern society has led to the emergence of a collective risk consciousness and a prevailing ethos of risk avoidance. Beck notes that much of this is organized around “attempt[ing] to anticipate what cannot be anticipated” (Beck, 2006). Third, the relationship between risk and trust is inverse; that is, science and technological expertise have become more important in society and at the same time the public has lost trust in both the content and conduct of science. Fourth, as Beck (1999) contends, some social actors have greater authority than others to define risk.

It is this fourth phenomenon, that some social actors have greater authority than others to define risk that leads to what anthropologist Brigitte Jordan calls “authoritative knowledge” (Jordan, 1997; Jordan and Davis-Floyd, 1992). According to Armstrong, Jordan argues that in any particular domain of human life there may be several knowledge systems or ways of understanding the world. Some of these ways of understanding may carry greater weight than others, either because they explain the state of the world better or because they are associated with a stronger power base, or for both reasons. As one kind of knowledge begins to dominate, other knowledge systems are delegitimized and dismissed (Jordan, 1980, 1997). For example, in his description of the evolution of American medicine, Paul Starr (1982) points to the tremendous “cultural authority” accorded one form of medical practice, allopathic medicine, to the exclusion of other forms of medicine that flourished in the late 19th century. The important thing to keep in mind about authoritative knowledge, Armstrong explained, is that it is socially constructed. Yet, it is viewed as being a natural order, with many people failing to recognize the ways it is socially constituted. In the realm of birth, obstetrics embodies authoritative knowledge. As such, obstetrics crowds out other ways of knowing and other ways of birth, limiting women’s awareness of alternative modes of birth.

When birth is viewed through this lens of a “risk society,” it is easier to understand the climate of fear, not confidence, that surrounds American birth and how it is that we think of birth as dangerous. Contemporary organization of maternity care reflects our “risk society.” According to Armstrong, Ray De Vries (2012) has noted that even our attempt to classify births into varying risk levels is itself a powerful reframing of birth, one that emphasizes the pathology inherent in birth, rather than the normal physiology of birth.

Another force shaping the way women perceive the risk of birth is the polarization (Declercq, 2012) in views of birth, which are often characterized as the medical versus midwifery models of birth. Different attributes are associated with the different models (e.g., pathology with the medical model, physiology with the midwifery model), with the two models often considered to be “diametrically opposed.” In Armstrong’s opinion, this polarization of views of birth not only obscures the fact that birth is a physiological process with the potential for pathology (i.e., it is not “either/or”), but also affects cultural perceptions of risk and structures the options available to women.

Women’s Views of Risk

Numerous sociological and anthropological studies of contemporary American childbirth demonstrate that women’s experiences of birth are marked by a range of sometimes contradictory feelings. Women express fear while putting emphasis on being safe or feeling safe. Additionally, both women and their providers voice varying levels of trust and distrust in the female body. Finally, the desire for control is paramount in many discussions of birth. Armstrong identified control and safety as being particularly important.

Control can have different meanings and different implications. In a qualitative study of women’s birth experiences, Namey and Lyerly (2010) documented the multiple meanings of control in the context of birth and concluded that control matters but its meaning varies widely among women and can have implications for their choice of birth setting. Armstrong said, for some women, technology-intensive birth in the hospital imparts a desired sense of control. But for other women, that same situation makes them feel out of control.

Safety too can have different meanings and different implications. The prevailing cultural view is that the hospital is the safe place to give birth. Indeed, in Armstrong’s opinion, most women trust modern medical care to ensure safe births. Yet, studies show that many women who birth in hospitals end up very dissatisfied with their birth experiences (Declercq et al., 2002, 2006). The very high rate of routine interventions is part of why

they end up so dissatisfied. A desire for safety drives many women’s choices to birth outside of a hospital. Precisely what historically sent women to the hospital to birth in the first place—a desire to avoid risks and to experience a safer birth—is what motivates some women to avoid the hospital for birth today. If women choose birth outside the hospital, it is not because they are reckless or heedless of risks. Rather it is because their understanding of risk and safety is very different.

A number of studies have assessed women’s decision making around home birth and have identified a common set of themes (Boucher et al., 2009; De Vries, 2004; Klassen, 2001). Some women choose home birth for religious reasons (Klassen, 2001). Armstrong speculated that perhaps the higher rates of home births in Pennsylvania and Indiana, which were evident on one of the maps shown by MacDorman, reflect the Amish populations in those states. Yet, even among women for whom religious beliefs are a primary motivation for choosing home birth, many of those women report some of the same ideas about birth that other women who choose home births for nonreligious reasons report. That is, they perceive home as being a place where they can feel in control and where they will feel safe. In addition to feelings about control and safety, trust appears to be another determinant of home birth choice. Women who choose home births often report that they trust their body’s ability to birth and that they have a deep level of trust with their care provider.

The Role of Structure

Debates about home birth typically do not consider a structural perception of risk. Yet, in Armstrong’s opinion, it is an important perspective to consider. That is, what systems support or impede women’s decisions about birth settings? By examining systems of transport and transfers, one can begin to see the ways that institutional arrangements can actually increase risks for low-risk women delivering outside the typical setting. According to Armstrong, numerous studies, as well as court cases, have demonstrated “the trouble with transport” (Davis-Floyd, 2003). In Armstrong’s opinion, that we have failed to develop a system of transport and transfer that protects women and babies from adverse outcomes is not just a failure of infrastructure. It is also morally fraught because of the deep polarizations that exist in thinking about birth (as physiology versus pathology) and because of deep levels of mistrust among provider communities. So not only do we lack the infrastructure for transport and transfer, we lack cultural consensus to develop that infrastructure and ensure its smooth functioning. Armstrong noted that in other societies where home birth is a viable option for women, most notably in the United Kingdom and in the Netherlands, systems have evolved for assessing risk and ensuring smooth transfer—thus

reducing risk and ensuring safety for women who choose to birth outside of the hospital.

Areas for Future Social Science Research

In conclusion, Armstrong identified several areas where social scientists can contribute to gaining a better understanding of birth settings. First, they can help to achieve a better understanding of the notion of “good birth.” What is a good birth? Where (setting) and how (under the care of which providers) can good births happen as often as possible? Second, they can help to achieve a better understanding of women’s decision-making processes (e.g., where do expectations of birth come from?) and ways to foster trust between women and maternity care providers. Finally, they can explore ways to change the structural landscape around birth and develop high-functioning systems of transport and transfer.

PRESENTATION ON ASSESSMENT OF RISK IN PREGNANCY 5

By way of disclosure, Kathryn Menard began her talk by describing what she called her “vantage point.” She is the mother of three children and maternal fetal medicine specialist and educator; she works in a perinatal regional center at the University of North Carolina at Chapel Hill where about 3,700 babies are delivered annually. The center has a “24-7” midwifery practice that is well integrated into the care plan such that women can transition seamlessly from the midwifery practice to the generalist or maternal-fetal medicine practice. Many of her complicated antepartum patients choose midwifery-style births, with intrapartum care provided under the direct supervision of midwives but with physician backing. She noted that there is a freestanding birth center in town, just a couple of miles away from the hospital.

Why Assess Risk?

The purpose of risk assessment is to predict which women are most likely to experience adverse health events. The predictions can be used to streamline resources to those who need them most and avoid overuse of technology and intervention. Focusing resources on those who need them most and avoiding unnecessary interventions can lead to better care, better health, and lower cost.

When thinking about risk-appropriate perinatal care, it is important

5 This section summarizes information presented by M. Kathryn Menard, M.D., M.P.H., University of North Carolina at Chapel Hill, North Carolina.

to consider the entire continuum of care: preconception/interconception care (i.e., identifying modifiable risk factors and emphasizing prevention), antepartum care, intrapartum care, and neonatal care. Menard focused her comments on intrapartum care (care of the mother during labor and delivery).

Regionalization of Perinatal Care

Menard emphasized the role of regionalization within the context of perinatal care (care of the fetus or newborn from the 28th week of pregnancy through the 7th day postdelivery). In 1970, reports from Canada emphasized the importance of integrated systems that promote delivery of care to mothers and infants based on level of acuity; the reports showed that neonatal mortality was significantly lower in obstetrics facilities that had neonatal instensive care units (NICUs). In 1976, TIOP I (Toward Improving the Outcome of Pregnancy) described a model system for regionalized perinatal care that included definitions for varying levels of perinatal care based on both neonatal and maternal characteristics (March of Dimes, Committee on Perinatal Health, 1976). The early perinatal regional centers focused on education, dissemination of information, and referral resources and systems for maternal transport.

Evidence indicates that regionalization saves lives. For example, Lasswell et al. (2010) reported that infants smaller than 1,500 grams born at Level I or II hospitals had increased odds of death (38 percent versus 23 percent), compared to similarly sized infants born at Level III hospitals. Similarly, infants born at less than 32 weeks gestation in Level I or II hospitals had increased odds of death (15 percent versus 17 percent), again compared to similarly preterm infants born at Level III hospitals.

While the regionalization of systems, combined with advances in technology, has contributed to improvements in neonatal survival rates, there is not much information about other benefits of regionalized systems, including how regionalization impacts maternal mortality or morbidity. Nor is there much information about the potential harm of regionalization.

Early regionalization efforts emphasized both maternal and neonatal care. In 2012, the AAP issued a new policy statement regarding levels of perinatal care. The maternal characteristics that were included in the earlier policy statements (i.e., TIOP I) were removed, such that the policy statement contains no reference whatsoever to maternal care (Barfield et al., 2012). Likewise, the new Guidelines for Perinatal Care , 7th edition (AAP and ACOG, 2012), contains minimal reference to maternal care indicators. The current climate (2012) is also characterized by an emphasis on value-based health care, that is, an emphasis on increased quality at decreased

cost, an increased emphasis on patient-centered care, and greater recognition of a woman’s right to choose her site of birth.

What We Know About Neonatal Care in Different Settings

Menard remarked that while outcomes associated with different birth settings would be the topic of detailed presentations to follow, she wanted to provide a context for those talks (see Chapter 4 for a summary of that more detailed discussion). She mentioned the Wax et al. (2010) meta-analysis, which reported that planned home birth delivery of term babies is associated with less medical intervention but a two- to threefold increase in neonatal mortality. Data on delivery of term babies in freestanding birth centers is limited, so similar claims cannot be made. The Hodnett et al. (2012) Cochrane review reported that delivery of term babies in alternative hospital settings, that is, colocated midwifery units, are associated with higher rates of spontaneous vaginal delivery, more breastfeeding, more positive views of care, and no difference in either neonatal or maternal outcomes (all compared to conventional hospital settings). That review was based on 10 randomized controlled trials (N = 11,795). Finally, with respect to the delivery of term babies in a hospital setting, Menard mentioned Snowden et al. (2012), who reported that a higher delivery volume may be associated with lower neonatal morbidity. Very little is known about collaborative care models within the hospital environment and whether such models impact either neonatal or maternal outcomes.

What We Know About Maternal Care in Different Settings

Because maternal mortality is an uncommon event, examining maternal mortality is like “looking at the tip of the iceberg,” in Menard’s opinion. And while severe maternal morbidity is an active area of conversation today, it is not measured in a consistent manner. Much of the conversation revolves around how to define and monitor severe maternal morbidity. Nor are factors that predict the need for a higher level of care well defined. The scientific basis for making those decisions is limited, with different predictors being used in different circumstances.

“Low Obstetric Risk”

Different researchers define “low obstetric risk” differently. Menard gave four examples. First, in a randomized trial conducted in Australia (the COSMOS trial) on primary midwifery continuity care versus usual care within a tertiary care center, McLachlan et al. (2012) used these inclusion criteria: singleton, uncomplicated obstetric history (no stillbirth, neonatal

death, consecutive miscarriages, fetal death, preterm birth <32 weeks, isoimmunization, gestational diabetes), no current pregnancy complications (e.g., fetal anomaly), no precluding medical conditions (no cardiac disease, hypertension, diabetes, epilepsy, severe asthma, substance use, significant psychiatric disorder, BMI >35 or <17), and no prior Cesarean.

Second, in a randomized controlled trial of simulated home birth in the hospital (midwife-led care) versus usual care in the United Kingdom, MacVicar et al. (1993) used very different inclusion and exclusion criteria: nulliparous 6 and multiparous 7 women were included, but women with prior Cesareans were not; their definition of exclusionary maternal illness was more loosely defined (“no maternal illness such as diabetes, epilepsy, and renal disease”); and, while their definition of past obstetrical history was not as specific (no prior stillbirth, neonatal death, or small for gestational age), they included a history of elevated maternal serum alpha-fetoprotein.

Third, Bernitz et al. (2011) used yet another set of inclusion and exclusion criteria in their randomized controlled trial of three hospital levels in Norway. Their inclusion criteria were healthy, low-risk women without any disease known to influence pregnancy; singleton; cephalic; BMI <32; smokes <10 cigarettes/day; no prior operation on the uterus; and 36 weeks, 1 day to 41 weeks, 6 days gestation. Finally, a randomized controlled study in Ireland on midwifery care versus consultant-led care (Begley et al., 2011) used yet another entirely different set of exclusion criteria (e.g., BMI <18 or >29; smoking ≥20 cigarettes per day).

Menard emphasized the need for consistent and evidence-based criteria of “low obstetric risk” so that valid comparisons across settings can be made and our understanding of birth settings advanced.

Research Needed to Describe “Risk”

In addition to developing uniform definitions of risk factors, several other research steps need to be taken in order to advance our understanding of risk. Menard called for a greater understanding of essential resources for each of the various birth settings, predictors of neonatal complications to guide decisions about level of neonatal care (i.e., predictors beyond the context of birth weight, which is how most current neonatal care criteria are based), predictors of maternal complications to guide decisions about level of maternal care, and predictors that should prompt maternal transport.

With respect to determining predictors of maternal care, Menard remarked that the concept of levels of maternal care (i.e., birth center versus Level 1 [basic] versus Level 2 [specialty] versus Level 3 [subspecialty] versus

6 A woman who has never given birth.

7 A woman who has given birth two or more times.

Level 4 [regional perinatal center]) is being developed and promoted as a strategy to expand regionalized perinatal care. Ideally, the strategy will be applied uniformly across all states so that surveillance can be standardized. But doing so, she opined, will require a complementary set of predictors of maternal complications to guide decisions about which level of care a woman should receive.

With respect to predictors that should prompt maternal transport, the question is, if a woman has a birth experience in a birth center or a facility with a lower level of care, what are the important signs and symptoms that indicate she should be moved to a higher level of care?

Menard identified several additional research topics that would help to define “risk”: uniform definitions of maternal and neonatal morbidity; definitions of family perceptions and satisfaction with care; the role of the care provider and the role of continuity of care; the role of the care “system” and how to optimize that system (i.e., interprofessional working relationships, consultations, hand-offs, transfer of care); cultural issues, such as threshold for intervention in high-level facilities; and patient perception of risk and the influence of her perception of risk on birth outcomes and perception of care.

DISCUSSION WITH THE AUDIENCE 8

Following Menard’s presentation, the workshop was opened to questions and comments by members of the audience. Topics addressed included international birth setting trends and risk guidelines; perception of risk among women entering pregnancy and how it varies depending on age, culture, and other factors; the large proportion of non-Hispanic black women who deliver unplanned out-of-hospital births; the increasing rate of home births in the United States; how economic factors drive birth setting decisions; the need for infrastructure in states without birth center regulations; and the challenge of transfer (legal and professional mistrust issues).

International Birth Setting Trends and Risk Guidelines

The audience raised two separate sets of issues related to birth setting assessment outside of the United States. First, it was suggested that there might be lessons to be learned from antepartum risk guidelines being used in the United Kingdom, including the fact that the guidelines were created by conducting a systematic review of the international evidence and reaching consensus among a stakeholder panel.

8 This section summarizes the discussion that occurred at the end of Panels 1 and 2, immediately following Kathryn Menard’s presentation.

Second, a remark was made about the increasing percentage of women in the Netherlands who are choosing hospital deliveries. Specifically, according to a workshop participant, the number of women in the Netherlands choosing hospital deliveries has increased from 23 to 38 percent over the past 20 years. The participant emphasized that this is very different than what is happening in the United States, where a growing percentage of women are seeking home deliveries. He also emphasized that the trend is occurring in a country, the Netherlands, with a long history of home births. “I want the record to show,” he said, “that [in the Netherlands] it is considered a privilege to have a hospital birth.” Elizabeth Armstrong agreed that, yes, more women in the Netherlands are seeking hospital births, but she warned that the reasons for the trends are complex and that the trend does not necessarily mean that women feel unsafe in home birth settings. Another participant who identified herself as being from the Netherlands agreed with Armstrong that the reasons for the increasing trend in hospital births are complex. They include demographic changes, that is, more older women entering pregnancy, as well as more primips; media portrayal of pregnancy as something to be feared; increased prenatal testing; and a diverse immigrant population, with varying cultural perceptions of pregnancy. She noted primary care in the Netherlands is midwife-led care, adding that the rate of home birth in the Netherlands is about 19 percent, with another 12 percent of women giving birth in a hospital but with their midwives and without attendance by obstetricians.

Perception of Risk and How It Varies Depending on Age, Culture, and Other Factors

A participant suggested that perception of risk might be changing as the percentage of older women entering pregnancy increases. The implication was that older women are not as healthy as younger women and therefore may perceive pregnancy as a riskier experience than younger women do. Kathryn Menard agreed that women entering pregnancy are less healthy than in the past because they are older and suggested that perhaps the increasing maternal morbidity and mortality trends being observed in the United States are related to that demographic change. She emphasized the importance of maternal morbidity and mortality surveillance.

More generally on the issue of perception of risk, Nigel Paneth observed, “The question about risk is always: what can you control?” Centuries ago, losing a child in infancy was considered normal and unpreventable. Changes in infant (and maternal) mortality over time have changed what women consider as unpreventable, or uncontrollable. For example, the likelihood of a woman dying during pregnancy dropped 100-fold during the

20th century. Today, the risk of a woman dying during pregnancy is more controllable than it was in the past.

An audience member commented on the role of culture and how a woman’s perception of risk might reflect her own place of birth. Armstrong replied that, while there has not been much research addressing the role of place of birth in perception of risk, women who have experienced other maternity care systems enter the U.S. system with a certain set of expectations. This is true even of primips who have not actually delivered themselves but nonetheless have an understanding of how birth works in the culture they come from.

Armstrong further observed that social disadvantage can also impact choice of birth setting. Some socially disadvantaged women, whether it is because of race or ethnicity, socioeconomic status, or immigrant status, perceive medicalized, high-technology hospital birth as being of a higher status and therefore more desirable than home birth. That perception is not necessarily related to risk or safety.

Disparity in Outcomes Among Ethnicities

The panelists were asked why as many as 66 percent of home deliveries by non-Hispanic black women are unplanned and what research is needed to find the answer(s). Marian MacDorman clarified that the incidence of home births in general is much lower for non-Hispanic black women, perhaps because fewer non-Hispanic black women have access to care providers that allow that option, and that the proportion of unplanned home births is high but the absolute numbers are low. With respect to research, she emphasized the importance of directly asking women about their preferences and experiences. She also suggested promoting more services in areas and neighborhoods where non-Hispanic black women live and training more minority care providers.

Another audience member speculated that at least some of the large percentage of African American women who report on birth certificates that their home birth was “unplanned” reflects a growing preference in free birthing, which is birthing without the assistance of a care provider. She noted that free birthing is on the rise in places like Maryland where Medicaid provisions for home birth have been removed, and that many women who choose free birthing report “unplanned” on their birth certificates because they think it will draw less attention.

Paneth observed that the “big monster in the room” is not that 66 percent figure, rather the “huge health disparity between black and white infant mortality.” That, in his opinion, is the greater research challenge. What is causing such extreme preterm birth among African American women? While many research teams are pursuing answers, the question remains.

Why the Percentage of Home Births in the United States Is Increasing

The panelists were asked to reflect on why the percentage of home births in the United States is increasing. MacDorman replied that birth certificate data do not reveal why certain birth options are chosen, or not chosen. She referred to the large number of studies in the medical literature based on having directly asked women why they chose home births. Women who choose home births express desire for low-intervention physiologic births in environments where they feel comfortable and more in control over which interventions will be induced, and they express concern about the high rates of Cesarean delivery and other interventions in hospital settings.

Another audience member asked whether there might be a correlation between change in percentage of home births and increased access to licensed midwifery offering the option of transfer. That is, do states exhibiting greater increases in percentage of home births provide greater access to licensed midwifery offering the option of transfer? MacDorman agreed that the question would serve as an excellent topic for future research.

Economic Factors Driving Birth Setting Choice

An audience member commented on the role of health insurance in birth setting choice and observed that a significant number of women who would choose to deliver outside of the hospital are not able to do so because their insurance will not cover out-of-hospital deliveries. The audience member also mentioned liability insurance and observed that in some states Medicaid will not cover a home birth midwife unless the midwife carries a level of liability insurance that most home birth midwives do not carry. Panelist MacDorman agreed that economic factors contribute to the complexity of the issue of choice. She remarked that studies have shown that the cost of a home birth is about one-third the cost of a hospital birth, but in fact home births cost women much more than hospital births if they are not covered by insurance.

The Need for Infrastructure in States with Birth Center Regulations

In response to remarks made by Nigel Paneth about a birth center in Michigan closing after a breech delivery, an audience member commented on the fact that Michigan is one of the few states without licensure for freestanding birth centers. Breech deliveries are outside of the national standard for birth centers. The implication was that states without regulations, such as Michigan, need infrastructure to help avoid this type of problem.

The Challenge of Transfer

A participant observed that transfer is legally fraught for liability reasons. For example, in Virginia, midwives are licensed and practice legally. Yet, some hospitals report each and every transfer to the state licensing board, which presents a real challenge for the midwives. She asked the panelists if any of their research points to a way forward. Armstrong added that the patchwork of state laws that govern who can attend births compounds the legal challenge. However, she cautioned that moving forward will require more than legal reform. Addressing the challenge of transfer will require a multipronged approach, one that also involves rebuilding trust among the different communities of care providers. She described the mistrust that currently exists among communities of care providers as “endemic and corrosive.” MacDorman agreed that trust is a core issue.

Two other participants echoed concerns about liability and the important role that state legislation plays in either restricting or promoting collaboration during transfer. For example, malpractice carriers telling physicians that they cannot provide midwifery backup significantly restricts collaboration. The state of Washington has been very forward thinking in its requirement that insurers who provide malpractice insurance provide such insurance to midwives, thereby promoting collaboration.

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More than 30 years ago, the Institute of Medicine (IOM) and the National Research Council (NRC) convened a committee to determine methodologies and research needed to evaluate childbirth settings in the United States. The committee members reported their findings and recommendations in a consensus report, Research Issues in the Assessment of Birth Settings (IOM and NRC, 1982). An Update on Research Issues in the Assessment of Birth Settings is the summary of a workshop convened in March, 2013, to review updates to the 1982 report. Health care providers, researchers, government officials, and other experts from midwifery, nursing, obstetric medicine, neonatal medicine, public health, social science, and related fields presented and discussed research findings that advance our understanding of the effects of maternal care services in different birth settings on labor, clinical and other birth procedures, and birth outcomes. These settings include conventional hospital labor and delivery wards, birth centers, and home births. This report identifies datasets and relevant research literature that may inform a future ad hoc consensus study to address these concerns.

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Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice

Purpose of review.

To briefly review results of the latest research on the contributions of depression, anxiety, and stress exposures in pregnancy to adverse maternal and child outcomes, and to direct attention to new findings on pregnancy anxiety, a potent maternal risk factor.

Recent findings

Anxiety, depression, and stress in pregnancy are risk factors for adverse outcomes for mothers and children. Anxiety in pregnancy is associated with shorter gestation and has adverse implications for fetal neurodevelopment and child outcomes. Anxiety about a particular pregnancy is especially potent. Chronic strain, exposure to racism, and depressive symptoms in mothers during pregnancy are associated with lower birth weight infants with consequences for infant development. These distinguishable risk factors and related pathways to distinct birth outcomes merit further investigation.

This body of evidence, and the developing consensus regarding biological and behavioral mechanisms, sets the stage for a next era of psychiatric and collaborative interdisciplinary research on pregnancy to reduce the burden of maternal stress, depression, and anxiety in the perinatal period. It is critical to identify the signs, symptoms, and diagnostic thresholds that warrant prenatal intervention and to develop efficient, effective and ecologically valid screening and intervention strategies to be used widely.

INTRODUCTION

For more than a decade, psychiatry and related disciplines have been concerned about women experiencing symptoms of anxiety and depression during pregnancy and in the months following a birth. Current Opinion in Psychiatry alone published relevant reviews in 1998, 2000, 2004, 2007, 2008, 2009, and 2011, usually addressing the clinical management of postpartum depression or the effects of antidepressant use on mothers and their babies. Meanwhile, a parallel literature has grown rapidly in other health disciplines, especially behavioral medicine, health psychology, and social epidemiology, regarding stress in pregnancy and the implications for mothers, infants, and development over the life course. The purpose of this article is to briefly review results of the latest research on effects of negative affective states (referring throughout to anxiety and depression) and stress exposures in pregnancy, mainly regarding effects on birth outcomes. We direct attention specifically to recent research on pregnancy anxiety, a newer concept that is among the most potent maternal risk factors for adverse maternal and child outcomes [ 1■■ ]. By highlighting these developments, we hope to encourage synthesis and new directions in research and to facilitate evidence-based practices in screening and clinical protocols.

Psychiatric research on pregnancy focuses mostly on diagnosable mental disorders, primarily anxiety, and depressive disorders [ 2 , 3 ] and somewhat on posttraumatic stress disorder following adverse life events or childbirth experiences. However, a large body of scientific research outside psychiatry provides extensive information on a wide range of clinical symptoms during pregnancy, as measured with screening tools such as the Edinburgh Postpartum Depression Scale (EPDS), for example, the Beck Depression Inventory, or the Center for Epidemiological Studies Depression Scale. Scores on these measures are sometimes dichotomized in order to create depressed/nondepressed groups of women as a proxy for diagnostic categories, but continuous scores of symptom severity are more often used in research. Symptoms typically show linear or dose–response associations with outcomes such as preterm birth (PTB), low birth weight (LBW), or infant abnormalities. Our current understanding of negative affective states in pregnancy is based largely on these studies of symptomatology, not investigations of confirmed diagnoses, perhaps because investigators lacked clinical expertise or funding to conduct diagnostic interviews. More studies of confirmed diagnoses would be helpful, particularly with larger samples and controlling for antidepressant medications and other relevant variables. Nonetheless, research findings on symptoms of anxiety and depression in pregnancy are informative for clinicians regarding prenatal screening, early detection, prevention, and treatment of perinatal mood disturbances among expecting and new mothers.

Estimates of the prevalence of depression during pregnancy vary depending on the criteria used, but can be as high as 16% or more women symptomatic and 5% with major depression [ 2 ]. Firm estimates for prenatal anxiety do not exist, nor is there agreement about appropriate screening tools, but past studies suggest that a significant portion of women experience prenatal anxiety both in general and about their pregnancy [ 1■■ , 3 ]. Evidence of high exposure to stress in pregnancy is more widely available, at least for certain subgroups of women. For example, a recent study of a diverse urban sample found that 78% experienced low-to-moderate antenatal psychosocial stress and 6% experienced high levels [ 4 ]. Some of the stressors that commonly affect women in pregnancy around the globe are low material resources, unfavorable employment conditions, heavy family and household responsibilities, strain in intimate relationships, and pregnancy complications.

A large body of research is now available regarding stress and affective states during pregnancy as predictors of specific pregnancy conditions and birth outcomes [ 5 , 6 ]. The most commonly studied are PTB (<37 weeks gestation) and LBW (≤2500 g). Both are of US and international significance due to high incidence in many parts of the world and also consequences for infant mortality and morbidity. It has been estimated that two-thirds of LBW infants are born preterm. Thus, there are likely to be both common and unique etiological pathways [ 1■■ , 7■■ ]. Current theoretical models emphasize biopsychosocial and cultural determinants and interactions of multiple determinants in understanding these birth outcomes [ 8 , 9■■ , 10 – 12 ].

STRESS IN PREGNANCY

The literature on stress in pregnancy and birth outcomes is reviewed in two subsections, one on PTB and the other on LBW.

Stress and preterm birth

More than 80 scientific investigations on stress and PTB were recently reviewed by Dunkel Schetter and Glynn [ 7■■ ], of which a majority had prospective designs, large samples, and validated measures, and were fairly well controlled for confounds such as medical risks, smoking, education, income, and parity. These studies can be grouped by the type of stress examined. Of the more than a dozen published studies assessing `major life events in pregnancy', a majority found significant effects; women who experienced major life events such as the death of a family member were at 1.4 to 1.8 times greater risk of PTB, with strongest effects when events occurred early in pregnancy. The majority of a second, smaller group of studies on catastrophic, community-wide disasters (e.g., earthquakes or terrorist attacks) also showed significant effects on gestational age at birth or PTB. A third small set of studies on chronic stressors, such as household strain or homelessness, all reported significant effects on PTB. Finally, a majority of past investigations on neighborhood stressors such as poverty and crime indicated significant effects on gestational age or PTB. In comparison, studies on daily hassles and perceived stress did not consistently predict PTB. Thus, of the many distinguishable forms of stress, many (but not all) contribute to the risk of PTB.

Stress and low birth weight

A second area of developing convergence concerns the effects of stress on infant birth weight and/or LBW, reviewed recently by Dunkel Schetter and Lobel [ 9■■ ]. Again these studies can be organized by type of stressor. Evidence suggests that `major life events' somewhat consistently predicted fetal growth or birth weight, whereas measures of `perceived stress' had small or nonsignificant effects. `Chronic stressors', however, have been even more robust predictors of birth weight. For example, unemployment and crowding predicted 2.0 to 3.8 times the risk of LBW among low-income women in one study [ 13 ]. An important source of chronic stress is `racism or discrimination' occurring both during the pregnancy and over a woman's lifetime [ 14 ]. Racism and discrimination contribute to birth outcomes independently of other types of stress [ 15 ]. A growing number of studies have demonstrated that racism and discrimination prospectively predict birth weight, particularly in African–American women [ 16 ]. Although this literature has focused mainly on women in the USA, it is relevant to minority women in other countries [ 17 ].

In summary, chronic strain, racism, and related factors such as neighborhood segregation are significant risk factors for LBW [ 18 ]. Of note, investigations of chronic stress and racism do not usually take into account depressive symptoms. Yet, depression may be an important mechanism whereby the effects of exposure to chronic stress and racism influence fetal growth and birth weight, likely via downstream physiological and behavioral mechanisms [ 9■■ ].

ANXIOUS AND DEPRESSED AFFECT IN PREGNANCY

Recent research on symptoms of anxiety and depression during pregnancy is reviewed similarly within two subsections distinguishing findings on PTB from those on LBW.

Affect and preterm birth

State anxiety during pregnancy significantly predicted gestational age and/or PTB in seven of 11 studies recently reviewed [ 7■■ ], but only in combination with other measures or in subgroups of the sample. More consistent effects have been found for `pregnancy anxiety' (also known as `pregnancy-specific anxiety' and similar to `pregnancy distress'). Pregnancy anxiety appears to be a distinct and definable syndrome reflecting fears about the health and well being of one's baby, of hospital and health-care experiences (including one's own health and survival in pregnancy), of impending childbirth and its aftermath, and of parenting or the maternal role [ 1■■ , 19 ]. It represents a particular emotional state that is closely associated with state anxiety but more contextually based, that is, tied specifically to concerns about a current pregnancy. Assessment of pregnancy anxiety has entailed ratings of four adjectives combined into an index (`feeling anxious, concerned, afraid, or panicky about the pregnancy [ 20 ]' or use of a 10-item scale reflecting anxiety about the baby's growth, loss of the baby, and harm during delivery, as well as a few reverse-coded items concerning confidence in having a normal childbirth) [ 21 ]. Other measures exist as well.

There is remarkably convergent empirical evidence across studies of diverse populations regarding the adverse effects of pregnancy anxiety on PTB or gestational age at birth [ 7■■ , 19 ]. More than 10 prospective studies have been conducted on this topic, all of which report significant effects on the timing of birth. An early study found that the 10-item scale scores combined with a standard measure of state anxiety predicted gestational age of the infant at birth, controlling for medical risk factors, ethnicity, education, and income; these results were also independent of the effects of a woman's personal resources (sense of mastery, self-esteem, and dispositional optimism) [ 21 ]. Use of multidimensional modeling techniques later revealed that state anxiety, pregnancy anxiety, and perceived stress all predicted the length of gestation, but pregnancy anxiety (as early as 18 weeks into pregnancy) was the only significant predictor when all three indicators were tested together with medical and demographic risks controlled [ 20 ]. At least three large, well controlled, prospective studies have replicated these results using similar pregnancy anxiety measures [ 22 – 24 ]. The largest of these was a prospective study of 4 885 births finding that women with high pregnancy anxiety were at 1.5 times greater risk of a PTB, controlling for socio-demographic covariates, medical and obstetric risks, and specific worries over a high-risk condition in pregnancy [ 23 ].

In sum, recent evidence is remarkably convergent, indicating that pregnancy anxiety predicts the timing of delivery in a linear manner. Further, pregnancy anxiety predicts risk of spontaneous PTB with meaningful effect sizes across studies, comparable to or larger than effects of known risk factors such as smoking and medical risk. These effects hold for diverse income and ethnic groups in the USA and in Canada. The consistency of these findings paves the way for investigating the antecedents and correlates of pregnancy anxiety, mechanisms of effects, and available treatments.

In contrast, relatively few of the more than a dozen studies on depressed mood or symptoms of trauma found significant effects on gestational age or PTB [ 9■■ ]. A Swedish study found that elevated antenatal depressive symptoms predicted increased risk for PTB [odds ratio (OR) = 1.56] [ 25 ], and a recent meta-analysis concluded that PTB was associated with depression across 11 studies. However, in general, effect sizes were relatively small across studies with an average OR of 1.13 [confidence interval (CI 1.07–1.30)] [ 26 ].

Affect and low birth weight

Recent evidence points more often to the role of maternal depressive symptoms in the etiology of LBW as compared with the etiology of PTB [ 27■■ ]. The recent meta-analysis on depression in pregnancy, cited earlier, evaluated 20 studies and found that high depressive symptoms were associated with 1.4 to 2.9 times higher risk of LBW in undeveloped countries, and 1.2 times higher risk on average in the USA [ 26 ]. Another recent review found relatively large effects of maternal depressive symptoms on infant birth weight across several studies, with the largest effects for low-income or low social status women and women of color [ 9■■ ]. Furthermore, although there are few studies on diagnosed disorders, one study reported that mothers with a depressive disorder had 1.8 times greater risk of giving birth to a LBW infant [ 28 ]. Thus, evidence appears to be stronger for contributions of depressive symptoms or disorder to slower growth of the fetus and LBW than to the timing of delivery or PTB, and these effects are pronounced for disadvantaged women [ 29 ]. In contrast, very few studies have demonstrated any effects of anxiety on LBW, with rare exceptions [ 30 ].

STRESS AND NEGATIVE AFFECTIVE STATES IN PREGNANCY AND INFANT OR CHILD OUTCOMES

Evidence for effects of maternal stress, depression, and anxiety in pregnancy on adverse neurodevelopmental outcomes for the child is substantial [ 31 ], through a process known as `fetal programming' [ 5 , 32 ]. Research utilizing animal models indicates that maternal distress negatively influences long-term learning, motor development, and behavior in offspring [ 33 , 34 ]. Evidence suggests that this occurs via effects on development of the fetal nervous system and alterations in functioning of the maternal and fetal hypothalamic pituitary adrenal (HPA) axes [ 34 – 36 ]. Maternal mood disorders have also been shown to activate the maternal HPA axis and program the HPA axis and physiology of the fetus [ 37 , 38 ]. In short, a mother's stress exposure and her affective states in pregnancy may have significant consequences for her child's subsequent development and health [ 5 , 39 – 43 ]. This evidence has been reviewed in many articles and spans effects on attention regulation, cognitive and motor development, fearful temperament, and negative reactivity to novelty in the first year of life; behavioral and emotional problems and decreased gray matter density in childhood; and impulsivity, externalizing, and processing speed in adolescents [ 44 – 47 ]. Of note, many of these findings involve the effects of prenatal pregnancy anxiety on infant, child, or adolescent outcomes. Maternal stress has also been linked to major mental disorders in offspring [ 40 , 47 ].

SUMMARY AND KEY ISSUES

In summary, there is substantial evidence that anxiety, depression, and stress in pregnancy are risk factors for adverse outcomes for mothers and children. More specifically, anxiety in pregnancy is associated with shorter gestation and has adverse implications for fetal neurodevelopment and child outcomes. Furthermore, anxiety about a particular pregnancy seems to be especially potent. Finally, chronic strain, exposure to racism, and depressive symptoms in mothers during pregnancy are associated with lower birth weight infants with consequences for development as well. These differential risk factors and related pathways to PTB and LBW deserve further investigation. Beyond this, women with high stress, anxiety, and depressive symptoms in pregnancy are more likely to be impaired during the postpartum period. Postpartum affective disturbance and stress in turn impair parenting quality and effectiveness [ 48 ]. Figure 1 summarizes the evidence that has been briefly reviewed in a simple schematic with connections in bold representing those with notably stronger and more consistent evidence. This simple diagram can be elaborated further to include associations among the various types or forms of stress and to include mediated pathways to birth outcomes. For example, major life events or community catastrophes can be hypothesized to increase pregnancy anxiety, and long-term chronic strain to increase risk of depression. The effects of chronic strain on LBW via depression are also not depicted but are worthy of further research. Together, the evidence and developing consensus that biological and behavioral mechanisms explain these findings lay the groundwork for a next era of psychiatric and collaborative interdisciplinary research on pregnancy.

Summary of evidence on depression, anxiety and stress. GA, gestational age at birth; LBW, low birth weight; PTB, preterm birth.

Why pregnancy anxiety?

It is not clear why `pregnancy anxiety' has such powerful effects on mothers and their babies. In fact, the nature of this concept has not yet received sufficient attention to be fully explicated. Possibly what makes it potent is that measures of pregnancy anxiety capture both dispositional characteristics, or traits, and environmentally influenced states. For example, women who are most anxious about a pregnancy seem to be more insecurely attached, of certain cultural backgrounds, more likely to have a history of infertility or to be carrying unplanned pregnancies, and have fewer psychosocial resources [ 49 ]. These results suggest that existing vulnerabilities that predate pregnancy may interact with the social, familial, cultural, societal, and environmental conditions of pregnancy to increase levels of pregnancy anxiety, producing effects on the maternal–fetal–placental systems, especially during sensitive periods such as early pregnancy. This process can then adversely influence fetal development by programming the fetus's HPA axis and also have effects on the initiation of labor via maternal, fetal, and placental hormonal exchanges. Although there is much we do not know, a worthwhile future goal for clinical researchers may be to identify women high in anxiety before conception, as well as women high in anxiety during pregnancy, and especially those women who are anxious about specific aspects of their pregnancies – about this child and this birth, and about competently parenting with this partner. These women would appear to be targets for early intervention such as evidence-based interventions for stress reduction, mood regulation treatments such as cognitive behavioral therapies, pharmacological treatments, and follow-up care during postpartum to prevent a range of adverse outcomes for mother, child, and family.

Clinical screening for affective symptoms in pregnancy

Clinical screening for depression or anxiety in prenatal and postpartum healthcare has been widely recommended but is also potentially problematic. The issues concern what screening tools to use; what cutoffs to adopt for identifying women at risk; the need for expert clinicians to follow up on those women who score above thresholds to make diagnoses; and, for those who have established diagnoses, the availability of affordable and efficacious treatments [ 50 ]. These issues must be resolved for prenatal (and postpartum) clinical screening to be recommended widely. For example, the EPDS, which is a gold standard used widely in clinic settings for depression screening both prepartum and postpartum, actually measures both depressive and anxiety symptoms, which may contribute to confusion about risks [ 51 ]. In addition, experts have questioned the validity of a diagnosis of depressive disorders using standard diagnostic criteria for mood disturbance because they include typical somatic symptoms of pregnancy such as fatigue, sleep disturbance, and appetite changes [ 52 ]. Also relevant is one recent study reporting that women with both depression and anxiety disorders were at highest risk of LBW, as compared with those with only depressive or anxious symptoms or none [ 53 ]. Combinations of symptoms have received very little research attention. Furthermore, little research thus far has examined the feasibility and utility of screening for prenatal stress or pregnancy anxiety.

If broad screening for affective symptoms during pregnancy results in high rates of false-positive results, low rates of clinical follow-up and referral, insufficient or ineffective education for women about the meaning of screening results, lack of treatment, and/or absence of proven evidence-based interventions, then clinical screening as a standard procedure in specific prenatal settings is of questionable value. Nonetheless, if important preconditions can be met, screening for pregnancy anxiety, state anxiety, depressive symptoms, and stress in pregnancy stands to provide potentially important clinical benefits for mothers and their children [ 54 , 55 ].

The broader context of pregnancy

An essential consideration in implementing widespread effective prenatal screening, diagnosis, and treatment is the context of a woman's pregnancy. The context includes her partner, family, friends, neighborhood, and larger community, all of which are known to influence a woman's mental health and responses to a diagnosis of disorder. Therefore, attention must be paid to these levels of influence in any attempts to screen and treat depression, anxiety, pregnancy anxiety, or stress in pregnancy. For example, a woman's ability to understand or respond to a diagnosis of a mood or anxiety disorder and accept treatment may be facilitated by involving her partner, closest relative, or friend in follow-up after screening. Families and communities can undermine or enhance efforts to screen and treat women in pregnancy as a result of their beliefs, values, and level of information (or misinformation). Although these issues are known barriers to community mental health treatment in diverse populations, they have not yet been addressed in establishing appropriate clinical procedures in pregnancy for follow-up of widespread screening for affective disorders. It may also be useful to identify a range of protective and resilience factors such as mastery, self-efficacy and social support in women for the purpose of intervention planning [ 2 , 56■■ ]. If efforts are directed to strengthening women's psychosocial resources as early as possible, ideally before conception, it is possible that prenatal health and outcomes could be better optimized.

In conclusion, although considerable, rigorous research now demonstrates the potential deleterious effects of negative affective states and stress during pregnancy on birth outcomes, fetal and infant development, and family health, we do not yet have a clear grasp on the specific implications of these facts. Key issues for the next wave of research are as follows: disentangling the independent and comorbid effects of depressive symptoms, anxiety symptoms, pregnancy anxiety, and various forms of stress on maternal and infant outcomes; better understanding the concept of pregnancy anxiety and how to address it clinically; and further investigating effects of clinically significant affective disturbances on maternal and child outcomes, taking into account a mother's broad socio-environmental context. As our knowledge increases, it will be critical to identify the signs, symptoms, and diagnostic thresholds that warrant prenatal intervention and to develop efficient, effective, and ecologically valid screening and intervention strategies to be used widely. If risk factors can be identified prior to pregnancy and interventions designed for preconception, many believe this window of opportunity is our best bet [ 57 ]. Interdisciplinary research and collaboration will be crucial, however, to meeting these objectives and in order to reduce the burden of maternal stress, depression, and anxiety in the perinatal period.

• Anxiety, depression, and stress in pregnancy are risk factors for adverse outcomes for mothers and children.
• Anxiety regarding a current pregnancy (`pregnancy anxiety') is associated with shorter gestation and has adverse implications for preterm birth, fetal neurodevelopment and child outcomes.
• Chronic strain (including long-term exposure to racism) and depressive symptoms in mothers during pregnancy are associated with lower birth weight with many potential adverse consequences.
• These distinguishable risk factors and related pathways to distinct birth outcomes merit further investigation.
• It is critical to agree upon the signs, symptoms and diagnostic thresholds that warrant prenatal intervention and to develop efficient, effective, and ecologically valid screening and intervention strategies that can be used widely.

Acknowledgements

The contributions of collaborators Laura Glynn, PhD, Calvin Hobel, MD, and Heidi Kane, PhD to this program of work are gratefully acknowledged.

Conflicts of interest There are no conflicts of interest .

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as: ■ of special interest ■■ of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 162).

Home — Essay Samples — Nursing & Health — Teenage Pregnancy — The Health Issues and Risk of Teenage Pregnancy in Philadelphia

The Health Issues and Risk of Teenage Pregnancy in Philadelphia

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The risk of teenage pregnancy in philadelphia, background information, possible solutions, best solution.

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The prevalence of adolescent pregnancy and its associated consequences in the Eastern Mediterranean region: a systematic review and meta-analysis

• Mehdi Varmaghani 1 , 2 ,
• Asma Pourtaheri 3 ,
• Hamideh Ahangari 3 &
• Hadi Tehrani 1 , 4  

Reproductive Health volume  21 , Article number:  113 ( 2024 ) Cite this article

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Adolescent pregnancy is one of the public health problems that both mother and baby suffer from its consequences. This study was conducted to estimate the prevalence and consequences of adolescent pregnancy in the Eastern Mediterranean region.

In this systematic review and meta-analysis, four databases (PubMed, ProQuest, Web of Science and Scopus) were systematically searched for relevant articles published from 1990 to 2022. The screening process for articles was conducted in accordance with the PRISMA guidelines. Joanna Briggs checklists were used to assess the quality of included studies. A random effects model was performed for the meta-analysis. Narrative synthesis of adolescent pregnancy prevalence, as well as a meta-analysis of adolescent pregnancy prevalence was performed using STATA 14.

The review included 12 studies and 94,189 study participants. The prevalence of adolescent pregnancy was [9% (95% CI 6.9, 11.2, p < 0.001)]. Pregnancy outcomes included preeclampsia [12.9%(95% CI 7.3,18.5, p < 0.001)], low birth weight [16.1%(95% CI 7.4–24.8, p < 0.001)], anemia [33%(95% CI 14.4, 51.7, p < 0.001)], and cesarean delivery [15.9%(95% CI 11.1–20.7, p < 0.001)].The results showed that 16.9% of deliveries were cesarean sections.

The study's findings indicate that adolescent pregnancy is prevalent in the Middle East region and is associated with negative outcomes for teenagers. Therefore, it is necessary to carry out effective interventions to reduce adolescent pregnancy.

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Introduction

The World Health Organization (WHO) defines adolescent pregnancy as the occurrence of pregnancy in girls aged 10 to 19 years old, and the United Nations International Children's Fund (UNICEF) defines AP as pregnancy in girls 13–19 years old [ 1 , 2 ]. About 21 million girls between the ages of 15 and 19 in developing countries become pregnant each year, and nearly 12 million of them give birth. In developing countries, at least 777,000 births were reported to mothers under the age of 15 [ 3 ].

Adolescent pregnancy is a well-known public health problem that has multiple impacts on individuals, families, and society as a whole [ 4 ]. The pattern of adolescent pregnancy is different in developing and developed countries. In developing countries, most teenage pregnancies occur among married girls [ 5 ]. In developed countries, adolescent pregnancy usually occurs outside of marriage [ 6 ]. The United States has the highest adolescent pregnancy rate in the developed world, with 57 pregnancies per 1000 girls aged 15 to 19, according to a 2015 study [ 7 ]. The rate of teenage births has decreased annually since 2009, reaching a new record low. However, the United States continues to have a higher rate of teenage births compared to several other developed nations such as Canada and the United Kingdom [ 8 , 9 ].

Researchers have identified socio-cultural factors such as poverty [ 10 ], and early marriage [ 11 , 12 ], individual factors such as excessive alcohol consumption [ 13 ], the inability to resist sexual temptation [ 14 ], lack of related health services and the cost of contraceptives [ 15 ], the lack of comprehensive sex education as influencing adolescent pregnancy [ 16 ].

Adolescent pregnancy is associated with high maternal and infant morbidity and mortality, which can have a significant impact on the socioeconomic development of a country [ 17 ]. Additionally, adolescents are at higher risk for adverse pregnancy and birth outcomes compared with older women [ 18 ]. Pregnancy and childbirth complications are the leading cause of death globally among adolescent girls aged 15 to 19. The lifetime risk of maternal death for a 15 year-old girl is 1 in 37 in sub-Saharan Africa, compared with 1 in 6500 in Europe and 1 in 7800 in Australia and New Zealand [ 19 ]. Low birth weight, prematurity, abnormal blood pressure during pregnancy and infection are the most important factors in maternal and neonatal mortality [ 20 ].

Many governments have developed adolescent pregnancy prevention strategies [ 21 , 22 ], and are working to achieve the Sustainable Development Goals (SDGs) and reduce the global maternal mortality ratio to 70 per 100,000 live births [ 23 ]. However, the social, cultural, and political conditions in the Eastern Mediterranean region seriously challenge the implementation of adolescent pregnancy prevention programs. Shared geographical, ethnic, tribal and cultural characteristics contribute to the prevalence of teenage marriage in the region. Reproduction has been considered a racial and tribal prerogative and followed religious teachings [ 24 ].

The determinants and outcomes of adolescent pregnancy have been characterized in several systematic studies [ 25 , 26 ]. In a systematic review, Fan (2022) suggested that adolescent pregnancy is one of the consequences of child marriage [ 27 ]. In several studies, the prevalence of adolescent pregnancy has been systematically reported in African countries [ 28 , 29 , 30 ]. To date, the prevalence of adolescent pregnancy in the Eastern Mediterranean region has not been systematically investigated. Estimating the prevalence of adolescent pregnancy and its consequences may assist concerned countries and indicate the need for interventions to control adolescent pregnancy. This systematic review and meta-analysis aimed to assess the prevalence and outcomes of adolescent pregnancy in the Eastern Mediterranean region.

Study design and search strategy

In this review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 31 ]. We searched PubMed, ProQuest, Web of Science, and Scopus databases to identify relevant articles. Systematic searches were performed based on Medical Subject Headings (Mesh) terms, selected keywords, and free words as search terms. The search terms included ‘‘adolescent pregnancy’’, incidence, and prevalence combined by the Boolean operators ‘‘AND’’ and ‘‘OR’’ (Table S1). In addition, in this search, the names of all countries within the Eastern Mediterranean were combined with the above search terms.

Study selection and eligibility criteria

We included English-language scientific articles or theses published between 1990 and 2022. Further, included articles needed to be cross-sectional, cohort, case–control, or intervention studies, reporting on adolescent pregnancy. Qualitative articles, as well as articles published as review studies, editorials, comments, presentations, or conference abstracts, were excluded. We screened the references of the selected articles to retrieve any other articles that may not have been included in this review. Further details are given in Table S2.

Definition of adolescent pregnancy

In this study, pregnancies between the ages of 10–19 years were introduced as adolescent pregnancy according to the WHO definition. The marital or celibate status of pregnant adolescents was unknown in the included studies. Adolescent pregnancy was identified among women who attended health centers for antenatal care or attended hospital for delivery care.

Data extraction

To select eligible articles, we removed duplicates, and then articles were screened using title, abstract, and full-text. Data extraction tools for research information included authors and year of publication, study area, study design, sample size, age range, and prevalence of adolescent pregnancy. Two independent researchers conducted all stages of the review (search, screening, and data extraction). If both reviewers (AP, HA) agreed 100%, the article was included in the review. In addition, any disagreements between authors regarding the eligibility of articles were resolved through consultation or discussion with the first and second authors (MV, HT).

Quality assessment

There were two types of study design in this systematic review (cross-sectional, case–control). Therefore, we used two separate Joanna Briggs checklists [ 32 ]. To compare the quality assessment score, the scores of each study were presented as percentages. The quality assessment score in the cross-sectional design was between 14 and 28%. The quality assessment score in the control case design was between 10 and 40%. JBI scores above 70% were considered to indicate high quality, while scores ranging from 50 to 70% indicated medium quality, and scores below 50% indicated low quality [ 33 , 34 , 35 ]. More details of the quality assessment of articles are shown in Tables S3, S4.

Statistical methods and analysis

We entered data into Microsoft Excel and performed meta-analyses using STATA 14 software.

Forest plots were used to show the prevalence of adolescent pregnancy in Eastern Mediterranean. In addition, subgroup analyses were performed by different study specifications, such as study design (retrospective or cross-sectional) for resolving heterogeneity. The quality of the included articles was poor, so subgroup analysis was not performed based on the quality of the articles. The pooled prevalence of adolescent pregnancy outcomes (anemia, preeclampsia, low birth weight, cesarean section) was also determined. In this study, the funnel plot was utilized to assess publication bias. However, due to a limited number of studies meeting the criteria for inclusion in the meta-analysis, the funnel plot results alone were not conclusive. Subsequently, an Egger’s regression was conducted which revealed significant publication bias. The overall estimate was adjusted by employing the trim-and-fill method to accommodate for the approximate number of studies that were excluded due to censorship. It is worth mentioning The trim-and-fill method is a two-step approach derived from funnel plots, designed to both detect publication bias and correct results accordingly [ 36 ].

Study selection

Through the electronic database search, 4066 records were retrieved. After removing the duplicate articles, and reviewing the abstracts and the full text of the articles, 10 articles were eligible to be included in the study [ 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. Two articles were added after a hand search of references [ 47 , 48 ]. The final 12 articles were included in a systematic review and meta-analysis (Fig.  1 ).

Flow diagram of the included studies for the systematic review and meta-analysis of prevalence and consequence of adolescent pregnancy in Eastern Mediterranean

Characteristics of included studies

The included studies reported the prevalence of adolescent pregnancy in seven countries. In total, five studies (41.6%) were from Iran [ 39 , 40 , 43 , 44 , 47 ], two studies (16.6%) were from Saudi Arabia [ 38 , 41 ] and one article was included from the countries Iraq (8.3%) [ 46 ], Oman (8.3%) [ 37 ], Lebanon (8.3%) [ 42 ], Jordan (8.3%) [ 48 ], and Pakistan (8.3%) [ 45 ]. Articles were published from 1995 to 2020. The sample size of the studies ranged from a minimum of 382 [ 43 ] to a maximum of 26,207 [ 48 ]. Overall, 94,189 participants were included in this review (Table  1 ). Four articles (33.3%) had a cross-sectional design [ 43 , 44 , 46 , 47 ] and eight articles (66.7%) had a retrospective design [ 37 , 38 , 39 , 40 , 41 , 42 , 45 , 48 ].

Prevalence of adolescent pregnancy in Eastern Mediterranean

After adjustment, the pooled prevalence of adolescent pregnancy in Eastern Mediterranean was 9% (95% CI 6.9, 11.2, p < 0.001). Two Iranian studies reported the highest [ 43 ] and lowest [ 47 ] prevalence rates. The highest prevalence was observed in the study from Kalhor et al. [31.9% (95% CI 27.5–36.8)] and the lowest prevalence was observed in study from Zahiri et al. [0.9% (95% CI 0.7–1.1)].

The cross-section design studies [ 41 , 43 , 44 , 46 , 47 ] showed a higher prevalence of adolescent pregnancy 13.6% (95% CI 5.5–21.7, p < 0.001) compared with retrospective studies 6.6% (4.3–8.9) (Fig.  2 ).

A – D : Prevalence of adolescent pregnancy ( A ) and sub-group analysis based on Study design ( B ), Anemia ( C ), Preeclampsia ( D ) in EM

Consequences of adolescent pregnancy

Consequences of adolescent pregnancy included in this analysis were anemia, preeclampsia, low birth weight (LBW), cesarean section, and Normal Vaginal Delivery (NVD). A separate analysis was conducted for each variable. Seven articles [ 37 , 38 , 39 , 41 , 45 , 46 , 48 ] were included to determine the prevalence of anemia in adolescent pregnancy. The meta-analysis indicated that anemia was seen in 33% (95% CI 14.4, 51.7, p < 0.001) of adolescent pregnancies (Fig.  2 A–D). All 12 studies were used to measure the prevalence of pre-eclampsia in AP. The result of the meta-analysis showed that 12.9% (95% CI 7.3, 11.2, p < 0.001) of the adolescent pregnancies developed preeclampsia (Fig.  2 A–D). Seven studies [ 38 , 39 , 42 , 44 , 45 , 46 , 48 ] were included to assess LBW in adolescent pregnancy. The results showed that 16.1% (95% CI 7.4–24.8, p < 0.001) of adolescent pregnancies were associated with LBW. Nine articles [ 37 , 38 , 39 , 40 , 42 , 43 , 44 , 47 , 48 ] were used to assess the prevalence of cesarean section in adolescent pregnancies. The results showed that 15.9% (95% CI 11.1–20.7, p < 0.001) of the deliveries were cesarean sections. Six articles [ 37 , 38 , 39 , 42 , 43 , 48 ] were examined to determine the prevalence of NVD in adolescent pregnancy. The meta-analysis showed that 72.5% (53.7–91.3) of AP ended with NVD (Fig.  3 A–C).

A – C : Sub-group analysis based on Low birth weight ( A ), Caesarian section ( B ), and Normal vaginal delivery ( C ) in EM

Reporting publication biases

The meta-analysis revealed a significant publication bias in the included articles, as indicated by Egger’s regression test and the funnel plot's asymmetry (bias = 20.57, 95% CI 9.18–31.96, p = 0.002) (Figs.  4 , 5 ). To address this bias, a non-parametric Trim-and-fill model was employed, identifying six potential studies on adolescent pregnancy prevalence that were omitted from the analysis. With this correction, the estimated pooled prevalence of adolescent pregnancy, accounting for random effects, was 2.8% (95% CI 0.6–5.1, p = 0.01) (Table S5).

Contour-enhanced funnel plot displaying approximate 95% confidence interval boundaries to identify publication bias

Egger’s Publication bias plot

We conducted this systematic review and meta-analysis to determine the prevalence and consequences of adolescent pregnancy in Eastern Mediterranean. Adolescent pregnancy is recognized as a serious risk to the health of mothers and infants. The pooled prevalence of adolescent pregnancy in Eastern Mediterranean countries was 9%. Early marriage is likely to lead to high fertility rates among adolescent girls. Teenage marriage is common in most countries in the region and political and social instability, war, civil unrest, and widespread displacement increase the chances of getting married early in Eastern Mediterranean.

The outcomes of adolescent pregnancy

Across the studies included in this review, about 33% of the adolescents suffered anemia during pregnancy, which may reflect the nutritional deficiency in adolescents. Adolescence is a critical period of growth and development, and adolescent mothers are still undergoing physical maturation themselves. This can lead to increased nutritional demands that may not be adequately met, especially if the adolescent has limited access to a balanced and nutrient-rich diet. Other evidence also confirms this finding [ 49 , 50 ]. Pregnant adolescents have more nutritional needs than adults, however, higher rates of nutritional deficiencies have been reported in pregnant adolescents [ 51 ]. In our study, the prevalence of preeclampsia in adolescent pregnancy was 12.9%. Preeclampsia mainly affects nulliparous women [ 52 ]. Micronutrient deficiencies, insufficient calcium intake [ 53 ], and Body Mass Index > 30 [ 54 ] increase the risk of preeclampsia. Limited antenatal care may be associated with the risk of preeclampsia in pregnancy [ 55 , 56 ]. In some studies, low rates of diabetes and chronic hypertension were introduced as protective factors for preeclampsia in adolescent pregnancy [ 57 , 58 ].

LBW was defined as a birth weight of less than 2500 g. About 15–20% of all births in the world, (more than 20 million births a year) [ 59 ], and 19.3% of births in Eastern Mediterranean were LBW [ 60 ]. In our study, 16.1% of infants were born with an LBW. In most studies, LBW is considered one of the consequences of adolescent pregnancy [ 61 , 62 , 63 ]. Physical immaturity, low gestational weight, and poor nutritional status in adolescent pregnancy may be responsible for low weight gain [ 55 , 64 ]. Adolescent pregnancy and consequent low birth weight are a serious challenge to achieve the goal of reducing 30% of low birth weight babies, which is one of the goals of the World Health Organization by 2025. Reaching this goal would translate to a reduction from approximately 20 million to about 14 million infants with LBW.

In all articles, the number of mothers with NVD was higher than with cesarean Sect. (72.5%, vs 16.9%). Different cesarean section rates have been reported in studies [ 65 ]. Several studies [ 58 , 66 , 67 ] suggest that pregnant adolescents have higher rates of cesarean section. In some studies, lower rates were reported [ 68 , 69 ], while another study found no difference between adolescent and adult women [ 70 , 71 ]. Biological immaturity of the pelvis, hypertension, diabetes, high body mass index, high infant weight, and preterm birth affect the type of childbirth in adolescents. Of course, the influence of the family and the choice of delivery method should not be underestimated [ 72 ].

The meta-analysis uncovered a notable bias in the published articles, highlighted by Egger's regression test, the funnel plot's lack of symmetry, and the trim-and-fill method. The sensitivity analysis conducted using the mentioned methods reveals a notable shift in the calculation of the prevalence rate. This suggests that the number of studies conducted in the Eastern Mediterranean region is limited, highlighting the necessity for additional research endeavors. Another factor that may account for these variations should also be considered. Publication bias review models and sensitivity analysis models have been utilized in numerous studies [ 73 , 74 ].

Limitations of the Study

This review has certain limitations. In clinical-based studies, prepared prevalence data may indicate bias because the studied population may not be representative of the overall population. We were unable to obtain national surveys in the region, and the number of studies reporting the prevalence of adolescent pregnancy was small, which could affect the estimation of the results. Another limitation of the study was the inclusion of retrospective studies, although there were precise criteria for the inclusion of studies that did not interfere with the calculation of the prevalence of adolescent pregnancy. Another limitation was related to the low quality of the studies, which made it impossible to comment on the results with certainty.

Conclusions

Given the prevalence of adolescent pregnancy, effective interventions are essential to reduce adolescent pregnancy and its consequences, ultimately contributing to the achievement of sustainable development goals. Recognizing patterns of prevalence in regions can can inform the development of strategies for managing the consequences of adolescent pregnancy in Eastern Mediterranean. By understanding the regional variations and tailoring interventions accordingly, policymakers and healthcare providers can more effectively address the unique challenges faced by different regions and work towards reducing the incidence of adolescent pregnancy.

Availability of data and materials

All the data can be obtained from the corresponding author upon a reasonable request.

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Varmaghani, M., Pourtaheri, A., Ahangari, H. et al. The prevalence of adolescent pregnancy and its associated consequences in the Eastern Mediterranean region: a systematic review and meta-analysis. Reprod Health 21 , 113 (2024). https://doi.org/10.1186/s12978-024-01856-4

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Fentanyl misuse during pregnancy can cause severe birth defects

The number of babies born with severe birth defects affecting their growth and development is rising, as researchers now have strong evidence that illicit fentanyl is causing the problems.

Hospitals have identified at least 30 newborns with what has been identified as “fetal fentanyl syndrome,” NBC News has learned. The babies were born to mothers who said they’d used street drugs, particularly fentanyl, while pregnant.

“I have identified 20 patients,” said Dr. Miguel Del Campo, a medical geneticist at Rady Children’s Hospital in San Diego who specializes in children exposed to drugs and alcohol in utero. “I fear that this is not rare, and I fear kids are going unrecognized.”

The syndrome was first identified in 10 babies last fall by geneticists at Nemours Children’s Health in Wilmington, Delaware. The infants had specific physical birth defects: cleft palate, unusually small heads, drooping eyelids, webbed toes and joints that weren’t fully developed. Some had trouble feeding.

Published research about the babies caught Del Campo’s attention. He’d previously diagnosed some children with similar abnormalities with fetal alcohol syndrome, even though their mothers denied drinking while pregnant.

“After reading the paper and thinking about things,” he said, “I have recognized the potential for exposure to fentanyl.”

Dr. Karen Gripp, a geneticist at Nemours, and her team were the first to identify the 10 babies with fetal fentanyl syndrome last fall. “This is another huge piece of the puzzle” explaining the defects, she said.

The birth defects in the babies closely resemble a rare genetic condition called Smith-Lemli-Opitz . It’s a condition that affects how fetuses make cholesterol, which is critical for the brain to develop properly. But none of the babies had Smith-Lemli-Optiz.

The mothers’ reported drug use was a strong clue as to what was causing the defects, but there was no scientific evidence that fentanyl stopped cholesterol production in developing fetuses.

When Gripp and a team of researchers at the University of Nebraska Medical Center exposed human and mouse cells to fentanyl, they discovered that the drug directly disrupted their ability to make cholesterol.

“This is not something that people had known before, that fentanyl interferes so significantly with cholesterol metabolism,” Gripp said. “This is so important because cholesterol needs to be synthesized as the embryo develops.”

Their paper explaining the connection was published in Molecular Psychiatry in June.

Who is at risk

Illicit fentanyl use during pregnancy is a known risk factor for preterm birth and stillbirth. Babies born after significant fentanyl exposure in utero may have seizures, vomiting, diarrhea and be irritable, fatigued and have trouble feeding.

But despite a rise in fentanyl misuse, even during pregnancy , there is no indication of a concurrent rise in birth defects. And most babies exposed to fentanyl in utero aren’t born with the defects that are hallmarks of the fetal fentanyl syndrome.

The new research helps to explain that.

While two copies of the gene that causes Smith-Lemli-Optiz result in the syndrome, cells with just one copy of that gene were more likely to be affected by fentanyl exposure.

That is, a single copy of the gene may make some babies more vulnerable.

“Not everyone is equally susceptible,” Dr. Karoly Mirnics, one of the study authors and director of the University of Nebraska Medical Center's Munroe-Meyer Institute, said in a press release announcing the results. “The potentially adverse effects of any medication or chemical compound might depend on your genes, lifestyle and environmental factors. One drug might not cause problems for me and might be catastrophic for you.”

Gripp expects the number of documented fetal fentanyl cases will rise with awareness and continued research.

“The group is growing,” she said. “We anticipate that there will be many more patients.” 

Del Campo, also an associate professor at the University of California San Diego, said it’s critical to diagnose babies appropriately with fetal fentanyl syndrome so doctors can follow them long term.

“We need to know how these kids are doing. I have some 2 year-olds that are very concerning,” he said. “They’re just not growing or developing.”

Erika Edwards is a health and medical news writer and reporter for NBC News and "TODAY."

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COVID-19 vaccination in pregnancy: ambiguity in decision-making

Affiliations.

• 1 School of Health, Te Herenga Waka, Victoria University of Wellington, 22 Trusham Court, Paraparaumu 5032, New Zealand.
• 2 School of Health, Te Herenga Waka, Victoria University of Wellington, PO Box 600, Wellington 6140, New Zealand.
• PMID: 37935170
• PMCID: PMC10629973
• DOI: 10.1093/heapro/daad144

Throughout the COVID-19 pandemic, pregnant women/people were identified as an at-risk group of severe COVID-19 disease. Consequently, vaccine uptake among this group became a public health priority. However, the relationship between pregnancy and vaccination decision-making is complex, and the heightened uncertainty and anxiety produced through the pandemic further exacerbated this immunization decision. This study explores COVID-19 vaccination decision-making during pregnancy in Aotearoa New Zealand by using an online story completion survey tool. Ninety-five responses were received and analysed using thematic analysis where ambiguity was a core facet within and across stories. Three ambiguities were identified, including who makes the decision (agential), what the risks are (risk) and how immunity to this threat can be best achieved (immunity). We discuss the implications of this ambiguity and how the strong desire to protect the baby persisted across accounts. The recognition of the rather persistent ambiguity in vaccination decision-making helps conceptualize influencing factors taken into account in a more nuanced manner for further research, public health campaigns and health professionals. Future public health campaigns can consider redistributing responsibility for vaccination decision-making in pregnancy, traverse an either/or perspective of 'natural' and 'artificial' immunity-boosting and consider how risk is perceived through anecdotes and viral immediacy.

Keywords: COVID-19; decision-making; pregnancy; story completion; vaccination.

© The Author(s) 2023. Published by Oxford University Press.

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Viral hepatitis in pregnant mexican women: its impact in mother–child binomial health and the strategies for its eradication.

1. Introduction

2. patients and methods, 2.1. patients, 2.2. variables extracted from medical records, 2.3. statistical analysis, 4. discussion, 4.1. hav in pregnancy, 4.2. hbv and hdv in pregnancy, 4.3. hcv in pregnancy, 4.4. hev in pregnancy, 4.5. placental alterations in viral hepatitis, 4.6. mexican strategies to eliminate viral hepatitis and their impact on pregnant women and their children, 5. concluding remarks, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

García-Romero, C.S.; Guzmán, C.; Martínez-Ibarra, A.; Cervantes, A.; Cerbón, M. Viral Hepatitis in Pregnant Mexican Women: Its Impact in Mother–Child Binomial Health and the Strategies for Its Eradication. Pathogens 2024 , 13 , 651. https://doi.org/10.3390/pathogens13080651

García-Romero CS, Guzmán C, Martínez-Ibarra A, Cervantes A, Cerbón M. Viral Hepatitis in Pregnant Mexican Women: Its Impact in Mother–Child Binomial Health and the Strategies for Its Eradication. Pathogens . 2024; 13(8):651. https://doi.org/10.3390/pathogens13080651

García-Romero, Carmen Selene, Carolina Guzmán, Alejandra Martínez-Ibarra, Alicia Cervantes, and Marco Cerbón. 2024. "Viral Hepatitis in Pregnant Mexican Women: Its Impact in Mother–Child Binomial Health and the Strategies for Its Eradication" Pathogens 13, no. 8: 651. https://doi.org/10.3390/pathogens13080651

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EPA bans DCPA pesticide in 'historic' move to protect unborn babies, pregnant women

Aug. 6 (UPI) -- The federal Environmental Protection Agency on Tuesday issued an "historic" emergency order to stop the use of the pesticide Dacthal, or DCPA, in order to fully look at the serious health risks it poses to unborn babies and pregnant women.

This is the first time in almost 40 years the agency has taken this type of emergency action, according to the EPA. Advertisement

"DCPA is so dangerous that it needs to be removed from the market immediately," said Michal Freedhoff, assistant administrator for the EPA' Office of Chemical Safety and Pollution Prevention, said in a statement .

On Tuesday, it was announced that an emergency suspension had been applied to all registrations of the pesticide dimethyl tetrachloroterephthalate, otherwise known as DCPA or Dacthal, under the 1947 Insecticide, Fungicide and Rodenticide Act, which was signed into law by former President Harry S. Truman . Advertisement

This decision by the EPA arrived due to the fact, the federal agency says, evidence is indicating how pregnant women exposed to the DCPA pesticide can possibly lead to irreversible fetus damage when exposed in utero, with changes linked to it like low birth weight, impaired brain development, decreased IQ and impaired motor skills later in life, some of which may be irreversible.

Nearly 20% of fresh, frozen and canned fruits and vegetables that Americans eat contain concerning levels of pesticides, a new report finds .

Farmworkers, in particular, face burdensome conditions in the fields and often face exposure to harmful pesticides while working to feed others, according to Rep. Raul Grijalva, D-Ariz.., who hailed Tuesday's EPA action which he says "prioritizes farmworker health and safety, especially for pregnant women, by suspending this harmful chemical from our agricultural systems."

It comes after "unprecedented efforts" by the White House over the last few years to get what it called "long-overdue" data on the pesticide from its sole manufacturer, U.S- based AMVAC Chemical Corporation, in order to assess its overall risk.

In April of 2022, the Biden EPA issued the hardly-used Notice of Intent to Suspend DCPA based on AMVAC's failure to submit the complete set of required data almost 10 years after the EPA's 2013 request and January 2016 due date for the new data went unanswered. By April this year, the EPA was warning farmworkers about the risks of the pesticide as it reveled the government agency was developing "next steps" to address the risks of Dacthal. Advertisement

"We must continue to build on this progress and ensure all farmworkers are given the protection, worker's rights, and overtime pay they deserve," said Grijalva.

The EPA says it consulted with the U.S. Department of Agriculture to better understand how growers use DCPA and its likely alternatives to the pesticide.

It was first introduced in 1958 to control weeds in agricultural and non-agricultural settings for crops such as broccoli, Brussels sprouts, cabbage and onions, according to an EPA report .

"This emergency decision is a great first step that we hope will be in a series of others that are based on listening to farmworkers, protecting our reproductive health, and safeguarding our families," Mily Treviño Sauceda, executive director of Alianza Nacional de Campesinas, said.

• Fruits, vegetables contain concerning levels of pesticides, report finds
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Opinion David Wallace-Wells

Food as You Know It Is About to Change

Credit... Alma Haser

Supported by

By David Wallace-Wells

Opinion Writer

• July 28, 2024

This essay is part of What to Eat on a Burning Planet, a series exploring bold ideas to secure our food supply. Read more about this project in a note from Eliza Barclay, Opinion’s climate editor.

From the vantage of the American supermarket aisle, the modern food system looks like a kind of miracle. Everything has been carefully cultivated for taste and convenience — even those foods billed as organic or heirloom — and produce regarded as exotic luxuries just a few generations ago now seems more like staples, available on demand: avocados, mangoes, out-of-season blueberries imported from Uruguay.

But the supermarket is also increasingly a diorama of the fragility of a system — disrupted in recent years by the pandemic, conflict and, increasingly, climate change. What comes next? Almost certainly, more disruptions and more hazards, enough to remake the whole future of food.

The world as a whole is already facing what the Cornell agricultural economist Chris Barrett calls a “food polycrisis.” Over the past decade, he says, what had long been reliable global patterns of year-on-year improvements in hunger first stalled and then reversed. Rates of undernourishment have grown 21 percent since 2017. Agricultural yields are still growing, but not as quickly as they used to and not as quickly as demand is booming. Obesity has continued to rise, and the average micronutrient content of dozens of popular vegetables has continued to fall . The food system is contributing to the growing burden of diabetes and heart disease and to new spillovers of infectious diseases from animals to humans as well.

And then there are prices. Worldwide, wholesale food prices, adjusted for inflation, have grown about 50 percent since 1999, and those prices have also grown considerably more volatile, making not just markets but the whole agricultural Rube Goldberg network less reliable. Overall, American grocery prices have grown by almost 21 percen t since President Biden took office, a phenomenon central to the widespread perception that the cost of living has exploded on his watch. Between 2020 and 2023, the wholesale price of olive oil tripled ; the price of cocoa delivered to American ports jumped by even more in less than two years. The economist Isabella Weber has proposed maintaining the food equivalent of a strategic petroleum reserve, to buffer against shortages and ease inevitable bursts of market chaos.

Price spikes are like seismographs for the food system, registering much larger drama elsewhere — and sometimes suggesting more tectonic changes underway as well. More than three-quarters of the population of Africa, which has already surpassed one billion, cannot today afford a healthy diet; this is where most of our global population growth is expected to happen this century, and there has been little agricultural productivity growth there for 20 years. Over the same time period, there hasn’t been much growth in the United States either.

How climate change could transform yields of two major crops

Projected change in corn and wheat yields in 2050, based on an upper-middle scenario for global warming.

Change in crop yield in 2050

Corn production in 2050

Drought conditions have already led Mexico to import a record amount

of corn in recent years. Climate change could further decrease its yields.

China is the world’s second-largest

producer of corn, but yields are projected to decrease across most of the country.

Wheat production in 2050

Pakistan, where wheat accounts for nearly two-thirds

of all calories

consumed, could

see sharp declines.

The U.S., one of the largest exporters of wheat, could see increased yields, especially in more northern latitudes.

Drought conditions have already led Mexico to import a record amount of corn in recent years. Climate change could further decrease its yields.

Rising temperatures could make the highlands of Peru

a more productive area for corn.

Pakistan, where wheat accounts for nearly two-thirds of all calories consumed, could see sharp declines.

producer of corn,

but yields are

projected to decrease across most of the country.

consumed, could see sharp declines.

Sources: Jägermeyr et al. (2021) “ Climate Impacts on Global Agriculture Emerge Earlier in New Generation of Climate and Crop Models ,” Nature Food ; World Bank; U.S.D.A.

Note: Yields shown are for the SSP370 middle-upper warming scenario and are compared with a 1983-2013 baseline.

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