Declines in teen pregnancy have been dramatic over the past several decades, but stark disparities remain that correspond to geographic and racial differences. Minority youth in the Southern United States have much higher teen pregnancy and birth rates than national averages. During 2013-2014, the average teen birth rate in the United States was approximately 25 births per 1,000 15- to 19 year olds, with a rate of 18 for Whites, 37 for African Americans, and 40 for Hispanics. In Louisiana, teen birth rates were nearly 50% higher (38/1,000) with a rate of 30 for Whites and 48 for both African Americans and Hispanics (Romero et al., 2016). Eighteen percent of births to teens were to mothers who already had one or more children, indicating a rapid repeat pregnancy rate (Gavin et al., 2013). Children born to adolescent mothers are more likely to have academic difficulties, behavioral disorders, substance abuse, early sexual initiation, and are more likely to become adolescent parents themselves. Compared with nonparenting teens, adolescent mothers are at greater risk for dropping out of school, having limited vocational opportunities, living in persistent poverty, and suffering from depression (Hodgkinson, Beers, Southammakosane, & Lewin, 2014 ; Lee, 2009 ; Madigan, Wade, Tarabulsy, Jenkins, & Shouldice, 2014 ; McCracken & Loveless, 2014 ; Nord, Moore, Morrison, Brown, & Myers, 1992). Monetary costs of adolescent pregnancy and childbearing are also high, with Louisiana spending an estimated $152 million on teen childbearing in 2010 (National Conference of State Legislatures, 2014).
Services available to support adolescent parents and their children fall into four general categories: (1) school-based, (2) home-based, (3) comprehensive community-based, and (4) medical setting-based (Savio Beers & Hollo, 2009). For example, Nurse Family Partnership (NFP) and Healthy Start Programs provide prenatal and early childhood home visitation. The NFP has proven long-term benefits to their participants (Kitzman et al., 2000 , 2010). However, both programs are limited by location and staff availability. In contrast, medical homes exist more broadly, and present an opportunity for addressing the needs of adolescent parents and their children within an existing system. Medical homes can intervene with teen mothers at the time of their babies' routine well-child care, for example. Therefore, adolescent mother and child needs can be identified and addressed at the same visit, and a multidisciplinary approach can be pursued commensurate to each clinic's resources. These “Teen-Tot” programs have shown positive results in various domains (Akinbami, Cheng, & Kornfeld, 2001). For example, a program in Boston has shown lower repeat pregnancies, increased use of birth control, higher school continuation rates, and improved rates of well-child care for newborns (Cox, Buman, Woods, Famakinwa, & Harris, 2012).
Many risks associated with teen parenting are attributable to early disadvantage and adversity, rather than maternal age (SmithBattle, 2009). Therefore, New Orleans is a city ripe for interventions in teen parenting with demographics reflecting a high-risk population. Twenty-seven percent of the population lives in poverty, including two in five children. The city is 60% African American and 37% of African American families with children live in poverty. There are few clinical services in New Orleans devoted to preventive health needs of adolescents with children, despite adolescent birth rates reaching 20% to 25% of total births in some neighborhoods (Child and Family Health in New Orleans: A Life Course Perspective of Child and Family Health at a Neighborhood Level, 2013). Due to this service gap, we sought feedback from young mothers themselves to better capture the lived experience of teen parenting in the city. We sought to explore barriers and unmet needs relating to medical and social support as perceived by teen mothers, and elicit suggestions for improving their healthcare through the medical home.
Study Design and Methods
Setting and Participants: Focus groups were conducted at an academic pediatric clinic located in a low-income area of New Orleans. The clinic serves primarily Medicaid-insured children (>95%) and has been the site of previous studies on adolescent reproductive health. Participants included English-speaking mothers who had their first child within the past 5 years and were age 15 to 21 at the time of that birth. Although the study's emphasis was teen parenting (<19 years old), we extended inclusion criteria to maximize recruitment. Participants were recruited through flyer distribution, convenience sampling at the clinic, and snowball sampling. A few were recruited through direct referrals by community organizations, such as NFP and Healthy Start. Institutional Review Board Approval through Louisiana State University Health Sciences Center was granted, and written informed consent or assent (with parental consent) was obtained from all participants.
Data Collection and Analysis: Four focus groups occurred over 5 months in the summer and fall of 2015. Focus groups were led by a trained facilitator using an interview guide, as shown in Table 1. Each focus group lasted about 90 minutes, and discussions were audio recorded. Recordings were transcribed by a research assistant, and analyzed by two different coders. Coders identified underlying themes independently, and then themes were compared and refined.
All participants were African American (N = 18). Their average age when they gave birth was 18.1 years (range 15-21 years). Average age during the study was 19.9 years (range 17-25 years). Their children's average age was 1.5 years (range 0-5 years). Seven main themes were identified, as described below:
Reactions to Pregnancy: Reactions to pregnancy included shock, denial, anger, embarrassment, and excitement. One participant described her sadness: I shed a couple tears because I was like, dang, I didn't make it. I had just graduated. Another said: Reality hits you. When I found out I was pregnant something hit me like this is not a game or a joke. You have to get your life together. Everything changes. Participants described family reactions to their pregnancies. One described how she and her mother found out about her pregnancy in the Emergency Room at 2 a.m., and her mother then walked all the way home from the hospital because there was some madness in her. Another participant described how her father would not look at her after initially finding out she was pregnant. One participant's mother took her to an abortion clinic, but she (the participant) just walked out and went to school. However, most also described that their families eventually rallied around them and provided support. My mom got mad for a split second, then got into baby mode.
Changes with Motherhood: Participants described changes ranging from physical changes like stretch marks and weight fluctuations, to more identity-related changes of motherhood. One participant said, After I had my baby I was like, nobody is going to tell me what to do. I was overprotective. Another said that You have to get that mother phase and realize I really am a mother. It does not hit you right then. It hit me now and I am like ‘That's my baby. I had her. Others stated a commonly expressed idea such as I don't think about me anymore... everything is for her. Participants also discussed challenges of caring for a child, such as My baby has an attitude, screaming like I am doing something to him; and, Google was my best friend because I was too scared to keep coming to the doctor. Others expressed a lack of privacy and freedom; I can't even go to the restroom alone. Although uncommon in this cohort, some participants experienced depression. One participant shared: When I had my baby, I was depressed and could not stop crying...I wanted to kill myself and the baby. That's how it was. My doctor got me some services and talked to me. Then I got it together, this is what it is. This baby is not going anywhere. He [the baby's father] had to get that through my head, but I really wanted to give up. If it was not for him supporting me, my baby would probably be in foster care somewhere... You don't want to bring a baby into a world you can barely survive in, a struggling world. Another described her situation: I actually was diagnosed with severe postpartum [depression] when my son turned 2. The doctor was sorry that he didn't catch it then and there, that was kinda hard...but I did not know the signs. Many participants described changes in their social lives: You lose friends, you can't go out with them anymore and I had to change a lot. I stopped smoking weed and I never smoked cigarettes.
Experiences with Healthcare: Participants had diverse reflections on their prenatal and postpartum healthcare, ranging from feeling violated to loving their doctor. Several participants said they were not given enough information about medical procedures, leaving them feeling uncomfortable, violated, and even in pain. One participant noted; Especially when you are getting close to your due date, they show no mercy. Scheduling and long wait times also presented a barrier to accessing services. One stated, You only get seen for two minutes, but you have to wait an hour. When asked about where they currently received healthcare for themselves, at least 10 different locations were mentioned, and not all participants replied. Participants revealed many challenges around receiving care for themselves, such as: I stopped using Medicaid at 19 and that was really hard and I just went to the emergency room every time. For anything...I went almost every day. Postpartum healthcare instability was especially problematic, as illustrated by one participant: It was hectic. I didn't get back to the doctor until the baby was 4 months old. By then I was pregnant again.
Contraception: Participants used varying forms of contraception after giving birth, including Depo-Provera, oral contraceptives, and long-acting reversible contraceptives (LARCs). But several used either nothing or condoms only. They expressed several misconceptions and barriers regarding contraception, for example, They had patches but I didn't want them to be there and you have to put the patch in the same spot when you put it on. Other barriers to contraception ranged from fear of side effects to lack of access. One participant said, I wanted the IUD but they didn't have it right then and there and I had to get the pill.
Support Systems: Most participants listed family, including the baby's father and his family, as being major parts of their support system. Several mentioned relying on female relatives, such as mothers and sisters. Participants also received support from outside services, including programs like NFP, Healthy Start, lactation nurses, and doctors' offices. As one participant said, I lean on everybody. But there were also several examples of conflict and stress arising from support systems. One participant had difficulty with her boyfriend's mother, stating, She went against everything I said...she said breastfeeding was nasty. Most continued to have a relationship with their child's father. As one stated, We had to learn how to co-parent because we were not getting along. Another said, If you and your partner don't stay together, then it is very hard. He will come and sleep over, but he is not there 24/7. Fathers were generally helpful with childcare and expenses, but participants felt teen fathers had less responsibility.
Challenges in Daily Life: Overwhelmingly, the most common challenge faced by participants was childcare. Participants revealed: People don't mind watching your children once they get big enough to do stuff on their own. People don't like holding little babies and I have had to reschedule a lot of appointments around childcare. Another disclosed that without childcare, I've had to quit jobs and stop going to school. Financial strains were also discussed. One participant shared: It is stressful. They cut off my daycare and are talking about cutting off [my child's] Medicaid. Those who were employed expressed sadness over missing their babies. They shared: I rarely see my child because I work and go to school and I work 2 jobs...she just looks at me and says DaDa.
Suggestions for a Medical Home: When asked about how a doctor or clinic could better support teen parents, a number of suggestions emerged. Examples are included in Table 2. One participant summed up several of suggestions: I would have a hot line so you could call if you can't come in and ask questions, and there would be a nurse that helps you. I would provide parenting classes, a place for the children with toys. If you need help breastfeeding then I would make sure there is somebody there for you to talk to. Someone to show you how to use condoms...Birth control and all of them. That way it is a one stop shop...With kids have somebody show them the steps and resources.
Clinical Nursing Implications
This study was unique in using teens' lived experiences to better understand the landscape of teen parenting in a Southern city, especially relating to healthcare and the role a medical home could play. Discussions confirmed these young women faced many adverse circumstances as mothers. Some of these barriers and opportunities are summarized below in “Suggested Clinical Implications.”
Most participants expressed feeling stress and increased responsibility with parenting, and a few described experiencing depression after becoming a parent. Other studies have described adolescent parents as particularly vulnerable to mental health problems, given the challenges of their own continuing development in the setting of childrearing, and have proposed mental health support as a priority in caring for teen parents (Hodgkinson et al., 2014 ; Leplatte, Rosenblum, Stanton, Miller, & Muzik, 2012). Depression, in particular, can have potentially negative impacts on their parenting abilities (Birkeland, Thompson, & Phares, 2005 ; Cox et al., 2008). Therefore, all adolescent parents should be routinely screened for depression using a validated tool, such as the Edinburgh Postnatal Depression Scale (Venkatesh, Zlotnick, Triche, Ware, & Phipps, 2014). For participants accessing medical care, almost all were accessing it somewhere different than the others, and many had relied on an Emergency Department. Others mentioned still receiving care from their obstetrician, which implies continued care for reproductive health, but suggests there is no medical home monitoring their other ongoing adolescent health needs, as would be addressed during well-child care. Several participants expressed doubts and incorrect knowledge about contraception. Consistent with other studies, use of LARCs was low, when hormonal contraception was used at all, putting participants at risk for repeat pregnancy (Wilson, Fowler, & Koo, 2013). This reflects a need for care within a medical home, so that contraceptive counseling and provision can continue beyond the postpartum visit with their obstetrician. Previous studies have shown that teens value a close, personal relationship with their healthcare provider, and want to be given respect and support (Cox et al., 2005 ; Michels, 2000 ; Savio Beers & Hollo, 2009). A Teen-Tot model of care in which nurses and doctors longitudinally meet the health needs of young parents while also monitoring their mental health and social needs may be well suited to offer this sort of care for teen mothers with children, given the varied experiences and gaps with healthcare currently described.
As this study has shown, teen mothers rely heavily on family for support. Even when asked about their personal feelings regarding their pregnancies, most participants also related family reactions. Grandparents become essential in providing financial and childcare support. Despite this, money and childcare remain teen mothers' biggest challenges in daily life. Family is often very involved with parenting the infant. Although many adolescents benefit from parenting advice and support, some participants described interactions with family members that negatively impacted their parenting. Therefore, any system designed to serve this unique population should also support the larger family (Pinzon & Jones, 2012). For example, a grandmother in conflict with her daughter over parenting decisions could be invited to attend well-child appointments, during which parenting issues could be mediated and the teen mother's own parenting abilities enhanced and encouraged.
Services for teen parents have been examined previously, and recommendations for their care in medical settings published. The developmental stage of adolescent parents is often emphasized in the literature with a focus on multidisciplinary care (Savio Beers & Hollo, 2009). Researchers continue to explore other issues in adolescent parenting, such as the significance of fathers and coparenting, and how these might be feasibly addressed in medical homes (Lewin et al., 2015). Suggestions made by our study's cohort aligned with suggestions made by previous research in Teen-Tot care, such as a focus on mental health, contraception, social services, and parenting classes. Our cohort also expressed an interest in weight loss and nutrition. Many of our cohort's suggestions—such as having a clinic with an on-site pharmacy, transportation, and extended office hours—reflected their difficulty navigating logistical barriers to healthcare.
Our study examined experiences of young mothers with the goal of informing a medical home's role in their care; however, various models of support may occur independently or in partnership with medical providers to address their needs. For example, a mental health screening performed by a home visiting program may provide the first indication of postpartum depression in a new mother for which the physician can prescribe treatment and referrals for counseling. Group parenting classes provided by a school-based health clinic may deliver education around contraception that can then be accessed through the medical home. Conversely, medical providers may discover barriers to education completion or the receipt of financial benefits that can best be navigated with the help of a community-based organization.
One benefit of our study was the appreciation many participants expressed at having an opportunity to connect with teens like themselves. This implied feelings of isolation in their new identities as young mothers, and may have suggested experiences of stigmatization, as a desire for peer groups and support has been demonstrated previously (Cox et al., 2005). This was a small qualitative study with several limitations. All participants were African American adolescents in an urban setting whose experiences may not reflect those of teen mothers in other populations. The study also had a selection bias due to the nonrandom nature of recruitment.
The topic of interventions in teen parenting, especially relating to the medical home, is only rarely considered in recent literature, so this work is a contribution to current understanding of these special families. Our results confirm teen parenting is an ongoing, unique challenge, despite efforts of many community and governmental programs in providing various forms of support. Adolescent mothers in our study required: better access to mental health screening; a consistent medical home; increased contraceptive knowledge and access; and parenting education and support groups. A Teen-Tot model of care could be beneficial in supporting these families, and close gaps in medical, mental health, and social care. However, ongoing qualitative evaluations will remain imperative in determining the feasibility and effects of interventions as perceived by teen parents across different populations and locations.
The authors would like to thank the Louisiana Public Health Institute for their logistical and transcription support, and Children's Hospital of New Orleans for use of their facilities at Kids First TigerCARE Clinic.
This research was supported by a grant from the American Academy of Pediatrics Community Access to Child Health program. Support was also provided in part by U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Suggested Clinical Implications
- Teen mothers from disadvantaged and adverse backgrounds have increased risks for rapid repeat pregnancy, depression, and academic difficulties.
- Teen mothers often have fragmented and/or misinformed contraceptive care, necessitating ongoing reproductive health counseling.
- Like all women with infants, teen mothers require regular screening for postpartum depression, and access to mental health resources.
- Teen mothers often experience logistical and economic challenges that a medical home may help identify and address.
- A Teen-Tot approach to adolescent and child care in the medical home can facilitate multidisciplinary care in which nurses partner with other team members to provide healthcare, mental health screenings, and social support screenings while forming a longitudinal relationship with the families and providing connections to other community resources.
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