School-based Prenatal Services : Can Similar Outcomes be Attained in a Nonschool Setting?

School-based Prenatal Services: Can Similar Outcomes be Attained

a

in a Nonsc hool Setting? Barbara Taylor, Marjorie Berg, Lucy Kapp, Laura E. Edwards

ABSTRACl

The purpose of this study is to evaluate whether enhancement of hospital- based prenatal care of adolescents results in pregnancy outcomes comparable to those found in adolescents receiving care at school-based clinics. An initial study comparing hospital clinic and school clinic programs administered by the St. Paul Maternal and Infant Care Project (MIC) from 1973-1976 indicated that delivered teens from the high school clinics had earlier and more frequent prenatal visits and fewer low birth weight babies than delivered adolescents who received care ar hospital based clinics. After the initial study of 1976. MIC hospital bared services for the adolescents were enhanced to include additional educational and wpport services.

A follow up study, (1976-1979) was subsequently conducted, using criteria similar to the previous study, to compare the results of hospital and school-based programs for pregnant teens. The follow up data demonstrated that the School Group initiated care much earlier and had significantly more prenatal visits than the Comparison Group, but the Comparison Group demonstrated a dramatic improvement in both areas when compared to the first study.

Rates of obstetrical complications and infant outcomes were more similar for both groups than in the initial study, supporting the premise that while the school provides a superior setting for provision of prenatal services, similar services af nonschool sites can be greatly enhanced and can demonstrate significant improvement in obstetrical outcomes.

INTRODUCTION Teen-age pregnancy has been described as “the

problem that hasn’t gone away.” Between 1973 and 1978, the number of pregnant teens increased from 10% to 11070.’ Zelnick states that 16.2% of all unmarried girls between the ages of 15 and 19 became pregnant in 1979.* It has been predicted that if current trends con- tinue, 40% of all girls now aged 14 will become pregnant before age 20.’

The often-reported complications and poor outcomes associated with teen pregnancies are largely preventable with early and consistent care. However, teens (particu- larly young adolescents) are less likely than adult women to receive adequate prenatal care and the short term medical and psychosocial problems of unplanned adolescent childbearing are compounded by “long term, profound consequences for the patient, the child, her family and society as a whole.”3-’

As recently as the early 1970s, few school districts

provided comprehensive health and educational services for adolescents. According to 1975 figures, only 350 out of 117,000 school districts across the country provided special programs for pregnant teen-agers. This indicates that educational services were available for only one out of three pregnant girls.6 One response to this problem was the High School Clinic program developed by the St. Paul Maternal and Infant Care (MIC) Project. In association with the St. Paul-Ramsey Medical Center’s (SPRMC) Department of Obstetrics and Gynecology, the St. Paul Department of Public Health and the St. Paul Public Schools, MIC initiated a clinic program of comprehensive adolescent health services in one public high school in 1972.’ This program is currently in four St. Paul public high schools.

Since its inception, the MIC Project has provided services for a large number of adolescents. Through the program’s comprehensive approach, it is possible to educate students for healthy lifestyles, screen for health problems and remediate identified health problems. Except for the previous study, no research has been identified that compares school-based and hospital- based adolescent prenatal care programs.

In the initial study of 1973-1976, (Study I), prenatal care, obstetrical complications and infant outcomes for MIC teen patients who received care in high school clinics were compared with those who received care at a special nonschool MIC teen clinic.’ That study demonstrated that teens who delivered after receiving care at the high school clinics had earlier and more frequent prenatal visits, fewer obstetrical complications, less complicated deliveries and fewer low birth weight babies than did those who received care at the nonschool teen clinic. As a result of the first study, the MIC Project improved and personalized services at the nonschool site in an effort to make prenatal care and pregnancy outcome statistics more similar for both groups. Since, it

480 JOSH October 1983, Vol. 53, No. 8

was impossible to provide identical services at both sites, the school-based site remained the more comprehensive of the two.

~~ ~

TABLE I

School Study Grwp Comparison Croup

47.21 “ - 2 5 ) Low Risk 58.5% jN=31)

High Risk 8-15 39.6% “121) 4 7 . 2 1 (N-25)

Very High Risk 16+ 1.9% (N-1) 5.7% “-3)

41.5% 52.9%

DATA ANALYSIS A follow-up study was done to evaluate the effects of

enhancing the MIC Adolescent Prenatal Program at the hospital site. As in Study I, Study I1 compares two groups of delivered adolescents, matched for race, who received care through the MIC Project from 1976 through 1979. The School Group consisted of a total sample (N = 53, ages 14-18) of teens who received prenatal care at MIC’s high school clinics. The Comparison Group consisted of a random sample of delivered teens (N = 53, ages 14-18 drawn from a total sample of 185) who received cared at a nonschool hospital-based MIC Adolescent Clinic. Information was obtained from a retrospective analysis of obstetric summary coding sheets completed at delivery for each patient.

Data was collected and entered into the in-house data base management system. Analysis was documented through the use of the Statistical Package for the Social Sciences (SPSS). The capabilities of this package allowed for analysis of the data including analysis of frequencies, means and standard deviations. The test of significance used was the chi-square test. While in the initial study (1973-76) marked differences were noted between the two groups, it is of particular interest that in this study, outcomes were more similar than those found previously. However, differences in the study were not found to be statistically significant.

Criteria compared in this study were: the trimester that prenatal care was initiated: total number of prenatal visits; obstetrical complications of anemia; urinary tract infections; toxemia; cephalo-pelvic disproportion; and infant birthweight. Additional variables evaluated for the current study only were: parity; weight gain in pregnancy; risk score; type of delivery; gestational age at delivery; Apgars at one and five minutes; and number of days the infant was hospitalized after delivery.

Patients at each site received care from a multi- disciplinary team, consisting of nurse clinician, obste- trician- gynecologist, social worker, nutritionist, dental hygienist and health educator. At the high school clinic sites (School Group) a core staff of nurse clinician, social worker and clinic attendant were available to teen patients daily during school hours for “drop in” consultations, while other staff members were available weekly for scheduled appointments. In contrast, at the nonschool teen clinic, (Comparison Group) the entire staff was available only for scheduled appointments

during one three hour clinic session per week. However, all nonschool clinic staff were accessible by phone throughout the week, and additional emergency appointments were available at MIC Clinics at SPRMC when necessary.

RESULTS Demographic Data

Demographic data identified included age, race and parity. The average age at registration for each group was almost identical; the average age of the School Group was 16.2 years and the Comparison Group, 16.3 years. Because race has historically been an important factor in obstetric outcomes, the racial composition of the total School Group was used as the standard by which the Comparison Group was randomly selected in each ~ t u d y . ~ . ’ ~ The parity of the two groups was similar. Two teens in each group had a previous full-term delivery. Seven (13.2%) of the School Group had previous miscarriages or abortions, compared to five (9.4%) of the Comparison Group.

Risk score, a predictor of pregnancy outcome, is determined at SPRMC at the first prenatal visit, updated at 36 weeks and again at delivery.” It is based upon an assessment of demographic factors, medical and obstetric history, and current medical, nutritional, and psychosocial status. Low risk is defined as a score less than seven, while scores greater than seven are predictive of problematic pregnancy outcomes. At delivery, the incidence of high risk scores was 20% greater in the Comparison Group than in the School Group. (See Table 1). Risk scores at delivery were the only risk scores recorded in the obstetric summary sheets.

Prenatal Care It is evident in Figure 2 that the School Group

achieved a high standard of early registration (nearly 60%) of teen prenatals for care during the first trimester.

More than 90% of the School Group had six or more prenatal visits and more than 55% had 12 or more visits.

JOSH October 1983, Vol. 53, No. 8 481

(See Figure 3). In this study, 86.6% of the Comparison Group completed six or more visits. and 43.3% completed 12 or more visits.

Figure 1 Racial Composition

STUDY I

i Caucasian

Native American

[170 Black

Hispanic

Figure 2 Pregnancy Trimester at First Prenatal Visit

su School Group

0 Comparison G r o

1st 2nd 3rd TRIMESTER

I

1 s t 2nd 3rd TRIMESTER

Figure 3 Total Number of Prenatal Visits

School Group - 0 Comparison cr t

: R 9

;I VISITS

VISITS

Figure 4 Antepartum Complications


Obstetric Complications The obstetrical complications noted in Figure 4 show

some minor differences between the two groups in the areas of anemia, uterine tract infections and toxemia. The assumption is that slightly higher complication rates in the school group are related to the differences in population. The School Group represents an inner-city population, while the Comparison Group was drawn from a wide area, including the suburbs. However, the differences noted were not found to be statistically sig- hificant, and infant outcomes were positive.

Both groups indicated high percentages of nutritional problems. This study reviewed weight gain, including underweight and overweight, as different perspectives of nutritional problems. Both groups were observed to be in the normal to high range of weight gain rather than in the inadequate or low percentage range.

Obstetric Outcomes Both School and Comparison Groups demonstrated

successful infant outcomes at delivery. The incidence of delivery by Cesarean birth differed in the two groups: 22.6% of the School Group had Cesarean births as did 13.2% of the Comparison Group. A similar contrast was found in comparing one minute Apgar scores of infants in the two groups; 24.5% of infants in the School Group had low Apgar scores at one minute, while 13.2% of infants in the Comparison Group had low Apgars. However, at five minutes, no difference in the two groups was present. The incidence of premature ( e 37 weeks) and low birthweight ( 4 2,500 grams) infants in the two groups was nearly equal: 11.3% in the School Group and 13.2% in the Comparison Group. Therefore, in spite of potentially problematic deliveries, prompt intervention and close monitoring resulted in favorable outcomes in both groups.

A difference also was found in the number of days of hospitalization for the infants in the two groups. Thirty- two percent of the newborns in the School Group were hospitalized for more than four days, in contrast to 17% of the infants in the Comparison Group.

DISCUSSION Schwartz has noted that adolescent obstetrical prob-

lems include inadequate prenatal care due to late pregnancy confirmation, and infrequent prenatal clinic visit^.^ A retrospective look at eight years of data from a special teen clinic program in New York City showed that only 12.1% began care in the first trimester, and 31.6% did not begin until the third trimester. In that study, 44% of teen prenatals made six or fewer prenatal clinic visits, and just 55.9% made seven or more visits.'*

A four and one half year long study of the outcomes of more than 4,000 teen-age pregnancies at Temple Univer- sity Hospital revealed that between 22%-30% of the teens under 20 failed to register for care before the third trimester, and 25% of this group made five or fewer prenatal visits.'' These studies corroborate the infrequency of early and consistent prenatal care obtained by many pregnant teen-agers.

In contrast, in both Study I and Study 11, MIC teen prenatal groups initiated care relatively early in pregnancy. However, in Study I1 the nonschool Comparison Group showed a marked improvement in early initiation of care, while the School Group maintained their previous positive statistics in this area. In Study 11, the Com- parison Group also made a dramatic improvement in the number of prenatal visits when compared to Study I, while the School Group demonstrated consistent superi- ority in this area. These figures reflect the progress the program has made in lowering the percentage of adolescents initiating prenatal care late in pregnancy and in en- couraging continuity of care.

Pregnant adolescents constitute a high risk population with the primary problems of anemia, preeclampsia and inadequate nutrition evident throughout the anteparturn period. It is well documented that the nutritional needs of the adolescent female are the highest of any female age group and their nutritional intake is the poorest. Anemia, defined as a hemoglobin below 11 grams, is directly related to nutritional intake. Miller, et al. have reported that mild preeclampsia, (blood pres- sure of 140/90 for two readings in a six hour period) has been shown to occur in adolescents who have low caloric intake, borderline levels of protein intake and low circulating levels of vitamin B6." Study 1 indicated a high percentage of nutritional problems in both study groups. Therefore, in Study I1 we used more specific information relating to weight gain: underweight (0-10 pounds) and overweight (36+ pounds). The St. Paul MIC Project recommends a weight gain during pregnancy of 22-32 pounds. The Comparison Group maintained a more stable and average weight gain in comparison to the higher percentages of overweight and underweight in the School Group. The presence of urinary tract infections in pregnancy are significant to the problem of premature labor. In Study 11, urinary tract infections were noted to be greatly reduced in the Comparison Group.

Delivery complications and poor infant outcomes in the adolescent population have been well documented. However, these complications have been attributed to multiple factors, including not only age of the mother but also poverty, poor nutritional status, late initiation of prenatal care and gynecological immaturity. The


incidence of contracted pelvis in adolescents has been reported to range between 10% and 409‘0.’~ Although there was an increase in the incidence of cephalo-pelvic disproportion in our School Study Group, the majority of patients delivered spontaneously without problems.

The average rate of Cesarean births is about 15%-20% for all ages. However, the national trend toward increased Cesarean deliveries makes it difficult to interpret this rate. In Study 11, the incidence of Cesarean sections in the Comparison Group ( 1 3.2%) correlates closely with Placek and Taffel’s 1978 figure of 11.8% for mothers under 20 years of age.I5 Of more importance, Cesarean birth did not seem to be related to number of prenatal visits or infant outcomes. The majority of births in both groups were spontaneous normal deliveries.

Effects of increased rates of Cesarean births in the School Group include lower one minute infant Apgar scores and increased hospital stay for both mother and infant. In Study 11, Apgar scores at one minute were lower in the School Group than the Comparison Group, but by five minutes 94.3% of infants had scores of seven or more.

In addition, 32% of the infants born to the School Group were hospitalized more than four days, as were 24% of those born to the Comparison Group. Miller reports that 42% of her respondents’ infants were hospitalized more than four days after birth although her population was slightly younger, with a higher pro- portion of minorities than found in the MIC population. I ’

The incidence of low birth weight and prematurity in the two groups was very similar although an increase for the school study group in Study I1 was noted when compared to Study I. These figures correlate closely with 1978 national prematurity rates of 10% for older teen- agers (15-19); 8.1% for whites and 14.4% for other races; and 9% LBW for older adolescents.1J This corroborates the finding of Fiser, et al., that except for the very young adolescent there is no greater tendency for low birthweight as a result of age.5J3J6 Factors such as poverty, nutritional status and associated behavioral factors are more important than biological age.

SUMMARY AND CONCLUSIONS An understanding of the normal psychosocial and

cognitive development of adolescents, including the formation of a stable sense of identity and the move- ment from concrete to abstract reasoning, is basic to planning a successful prenatal care program for pregnant teen-agers.6*16J8 These concepts are constant reference points for MIC teen program development.

Study I1 Criteria emographic Data:

Age (%I Race: Native American

Hispanic Black Caucasian

N 1 1 Term Infants Premtures Miscarriages or

Living Children

Parity :

Abortions

renatal Care: Trimester Registered:

First Second Third

Number of Visits: Minimum - 1-5 Average - 6-11

12-17 18-23 24-29

B Complications: Anemia

Toxemia CPD Cephalo-Pelvic

Urinary Tract Infection

Disproportion - dditional Obstetric Variables:

Weight Gain: 0-10 lbe. - L o w

11-35 lbs. - Normal 36t lbs. - High

CLINIC DATA SCHOOL DATA N=53

16.38 1.9% 3.8% 34.0% 60.4%

3.8% 3.8%

7.5% 3 . 8 %

43.4% 45.3% 11.3%

13.2% 43.3% 39.6% 3.7% 0%

9.4% 3.8%

17.0% 5.6%

1.9% 71.7% 26.4%

Overweight - 36 lbs. + 5.7% Underweight - 0-10 lbs. 7.5%

Low Risk 0-7 optimum 47,2% High Risk 8-15 17.2% Very nigh Risk 16+ 5.7%

Risk Score:

,Te: ‘The following material is not illustrated on graphs. Type of Delivery:

N S M Normal Spontaneous Vaginal Delivery 86.8%

C-Section 13.2%

-

ifant Outcomes Gestational age at delivery

5 37 Weeks - Premature > 37 Weeks - Term

Infant Birthweight < 2500 9 5 . - Low Bisth 2501-3999 gms. - Average

4000 gms. - Excessive size

Apgar Scores: 1 Minute 1-6

7-10 Optimum 5 Minutes 1-6

7-10 Days Infant Kospitalited:

< 4 .4

13.2% 86.8%

13.2% 84.9%

1.98

13.29 86.8% 5.7%

94.3%

83% 9*

N=53

16.28 1.9% 3.8%

34.0% 60.4%

3.8% 1.9%

13.2% 3 . 8 %

58.5% 37.7%

9 . 8 %

7.5% 35.8% 45.2%

7 . 5 %

3.7%

13.2% 9.4%

18.9% 11.3#

0 %

62.3% 37.7% 11.3% 5.7%

5 8 . 5 %

39.6% 1 . 9 %

77.4% 22.6%

11.3% 88.7%

11.39 86.8%

1.9%

24.5% 75.5% 5.7%

94.31

67.8% 32.1\

484 JOSH Octobtr 1983, Vol. 53, No. 8

The value of an interdisciplinary team to better meet the multiple medical, sociaVemotiona1, nutritional and educational needs of the adolescent in crisis has been de~cribed.*~-~I Effective functioning of the multidisci- plinary team requires a nonjudgmental, warm and sensi- tive approach, focusing on the needs of individual adolescents.

Youngs and Niebyl discussed the common attributes of successful teen prenatal programs, and noted that “improved communication between community, school and medical services lead to early diagnosis, referral and complementary . . . care” of pregnant adolescents.20 Study I revealed the unique effectiveness of the MIC Program in providing comprehensive prenatal services in a public high school clinic setting, a site that provides optimum opportunity for cooperation between community, school and medical provider. As a result of that study, the MIC staff were challenged to improve and personalize services at the nonschool MIC teen clinic to make obstetric outcomes more similar to those at the high school clinic.

The changes made to improve services available to patients at the nonschool MIC teen clinic included the introduction of primary nursing, so that each patient had a consistent health care provider with whom to relate, in person or by phone. A comprehensive nursing assessment and education tool was developed based on Reva Rubens’ description of tasks to be completed during each trimester of pregnancy.22 This was implemented by the primary nurse at the first patient visit, and updated at each subsequent visit. An interdisciplinary team care plan was completed for each patient within a week of their initial visits, and was updated at a later team conference when the patient reached 32 weeks of pregnancy; earlier and/or more frequent conferences were held for teens with special needs. Many of these procedural changes also occurred at the high school clinics. However, these changes were even more crucial for the nonschool population, since this constituted a much larger group, with clinic services available to them only on a weekly basis. Furthermore, most of these adolescents had dropped out of school, thus having access to fewer support services than pregnant teens seen in the high school clinics.

Additional features initiated only at the nonschool clinic included a “self-care card” to enable the teen to become aware of and involved in the progress of her pregnancy. A weekly prenatal class series was expanded from an occasionally available option, to a comprehensive series of 17 classes addressing prenatal, labor and delivery, parenting, and future planning issues. (At the school clinics, one or two series of prenatal classes were conducted during the school year.) Prenatal classes at

the nonschool clinic were held weekly just prior to the teen prenatal clinic, facilitating class attendance. An informal support group, led by the MIC Health Educa- tor, met immediately after the prenatal class, and provided a chance for pregnant and delivered teens to share parenting concerns. Interest in these groups has been consistently high, and in response to requests by delivered adolescents an evening parenting support group has been piloted with demonstrated success.

Although it cannot be conclusively proven that outcomes described were due to the programmatic changes described, improved outcomes in the nonschool group correlated closely with significant program revisions. These findings served to provide substantial direction for future program planning activities within the MIC Project.

The relevance of the current study is highlighted most meaningfully when compared with the previous study (1973-76). In comparing the results of the two studies, it is evident that major improvements in a nonschool clinic site can enhance patient outcomes.

Findings of MIC Sudies I and 11, along with other research cited, confirms the belief that the public high school is an optimum location for adolescent prenatal health services, since the educational, psychosocial, and medical needs of the adolescent can be addressed in this setting. However, the follow-up Study I1 demonstrates that enhanced hospital-based prenatal services, conducted by staff attuned to the needs of pregnant and delivered teen-agers, can result in similar positive pregnancy and delivery outcomes comparable to those found in school-based programs.

References 1 . Lincoln R, Dryfus J , et al: Teen-uge Pregnuncy: The Problem

That Husn’t Gone Away. Alan Guttmacher Institute, New York, 1981.

2. Zelnick M, Kantner J: Sexud Activity. Contraceptive Use and Pregnancy Among Metropolitan-Areu Teenagers: 197 1-1979. Family Planning Perspectives 12(5):230-237, 1980.

3. Schwartz D: Perspectives on Adolescent Pregnancy, Wisc Med

4. Dott A, Fort A: Medical and Social Factors Affecting Early Teen Pregnancy, A m J OB-GYN 532-536, June 15, 1976.

5 . Merritt T, Lawrence R, Naeye R: The Infants of Adolescent Mothers, Pediutr Ann 3(3):32-51, 1979.

6. Bennett VV, Borden JI: The Effects of a School Program on Teenage Mothers and Their Children, Am J Orthopsychiufry

7. Steinman M, Edwards L, Hakanson E: An Experimental Comprehensive High School Clinic, A m J Public Heulfh

8. Berg M, Taylor B, Edwards L, Hakanson E: Prenatal Care for Pregnant Adolescents In A Public School, J Sch Health 49(1):143-153, January 1979.

9. Israel S, Deutschberger J: Relation of Mothers’ Age to Obstetric Performance, Obstet Gyneco/24:411417, 1964.

10. Wiener G, Milton T: Demographic Correlates at Low Birth- weight, Am J Epidem 91:260-272, 1970.

J 79(3):35-36, 1980.

47(4):671-678, 1977.

67(8):765-766, 1977


11. Edwards LE, Barrada MI, et al: A Simplified Antepartum RiskScoring System, Obstet Gynecof 5q2N237-240, 1979.

12. Chanis M, O’Donohue N, Stanford A: Adolescent Pregnancy, J Nurse Midwifery 24(3):18-22, 1979.

13. Hutchins F, Kendell N, Robina J: Experience With Teenage Pregnancy, Obstet Gynecol54(1):1-5, 1979.

14. Miller P, Choquette J, et al: Adolescent Pregnancy, J Fam Pract 5(5), 1977.

15. Miller, S : Children as Parents - A Progress Report on a Study of Childraising and Childbearing among 12-15 Year olds. Child Welfare League of American, 1981.

16. Elster A, McAnavrey E: Medical and Psychosocial Risks of Pregnancy and Childbearing During Adolescence, Pediatr Ann 9(3), 1980.

17. Peoples M, Barrett A: A Model for the Delivery of Health Care to Pregnant Adolescents, JOGN Nursing pp. 339-345, November- December 1979.

18. Copeland D: Unwed Adolescent Primigravidas Identify Subject Matter for Prenatal Classes, JOGNNursing pp. 245-253, July-August 1979.

TO: NAME

ADDRESS

CITY STATE ZIP CODE 0

19. Highley B, Sinita E: The Development of Maternity Services for Young Women Utilizing the Maternity Nurse Practitioner. ANA Publication UO-74. pp. 76-89, 1973.

20. Youngs D, Nebyl J: Teenage Pregnancy, J Maine Med Assoc 67:2%-299, October 1976.

21. Burst H: Adolescent Pregnancy and Problems, J Nurse Midwiferv 24(2): 19-24, 1979.

22. Rubens R: Maternal Tasks in Pregnancy, Maternal-Child Nursing J 4:143-153, Fall 1978.

Barbara Taylor, RN, MPH, is Nurse Clinician, Lucy Kapp, MS, CHE, is Health Education Coordinator, Marjorie Berg, RN, MPH, is Nursing Coordinator, and Laura E. Edwards, MD, is Medical Director, for the St. Paul Maternal Infant Care Project, St. Paul-Ramsey Medical Center, 640 Jackson St . , St. Paul, MN 55101.

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~~

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School-based Prenatal Services : Can Similar Outcomes be Attained in a Nonschool Setting?

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