Research has demonstrated the impact of teen pregnancy on adolescents as well as their offspring. Children born to teenage mothers are more likely to be of low birth weight and to be born prematurely (Martin et al., 2010). The incidence of having a low-birth-weight infant (<2,500 g) among adolescents is more than double the rate for adults, and the neonatal death rate (within 28 days of birth) is almost three times higher (Klein, 2005; Cox, 2008). Children of teen mothers are at higher risk of lower cognitive attainment and lower academic achievement, and also exhibit greater behavioral problems (Hoffman & Maynard, 2008). Long term, the sons of teen mothers are significantly more likely to be incarcerated and the daughters of teen mothers are significantly more likely to become teen mothers (Farber, 2009).

Teen mothers are more likely to interrupt their education or drop out of high school, leading to limited vocational opportunities (Hoffman & Maynard, 2008). Often however, pregnancy in adolescence places mothers at greater risk of poverty (Meade, Kershaw, & Ickovics, 2008).

Repeat births before 18 years of age have an even stronger negative effect on high school completion. Factors associated with increased high school completion for pregnant teenagers include race (black teenagers fare better than do white teenagers), being raised in a smaller family, presence of reading materials in the home, employment of the teenager’s mother, and having parents with higher educational levels (Klein, 2005).

Teens face physical challenges during pregnancy due to immature development and inadequate nutritional intake. Biological factors that have been consistently associated with negative pregnancy outcomes are poor nutritional status, low prepregnancy weight and height, poor pregnancy weight gain, and parity. In addition, adolescent pregnancy has been associated with medical problems including pregnancy-induced hypertension, anemia, and STDs. The mortality rate for adolescent mothers, although low, is twice that for adult pregnant women (Klein, 2005). Lack of or late entry to prenatal care is a contributing factor to prenatal morbidity and mortality. As the authors found from their own clinical practice and research, despite intense case management and outreach, almost half (45  %) of the pregnant teens seen in an urban adolescent clinic did not begin prenatal care until the end of the first trimester at 12 weeks or later (Aruda et al., 2008). Some teens deny or ignore their pregnancy and avoid prenatal care despite being eligible for medical coverage.

Teenage pregnancy is not a new phenomenon; however, over the years the sociocultural context has varied along with changing societal attitudes toward women, marriage, and adolescence (Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource Center). Their publication, Teen pregnancy prevention: Exploring out-of-school approaches, provides a summary of the historical trends in teenage pregnancy. In the late nineteenth and early twentieth centuries, society focused on the unmarried condition of pregnant women, rather than on age. Unwed mothers were characterized as immoral. Numbers increased with industrialization and the movement of young women from rural areas to cities, where they were beyond family control. In 1904, the concept of adolescence as a distinct time of transition was introduced by G. Stanley Hall. The early to mid twentieth century was influenced by the eugenics movement which was based on the beliefs that the wrong people were having children. Unmarried, sexually active young women were seen as unfit. The concept of prevention was introduced in the social work field, to try to ensure that poverty and delinquency were not passed from one generation to another. Post World War I focused more on the “unwed mothers” and “illegitimate children” versus the age of the mother. Post World War II, unmarried teenagers who became pregnant were classified as delinquents or having emotional or psychological problems. Prior to the 1960s, most teenage pregnancies led to marriage—hence the term shotgun marriage—and thus the pregnancy was a societal nonissue. This subtle societal shift is documented even through literature searches in databases such as PsychInfo, where “UNWED MOTHERS” became a search term in1973, followed in 1985 by the search term “ADOLESCENT MOTHERS.”

During the 1960s and early 1970s, more women decided not to get married and public concern rose; teen pregnancy was presented as a medical problem requiring increased access to clinics, birth control and abortion. There was a shift from viewing “teen pregnancy” as a moral problem to viewing it as a psychological or a health problem, with estimates of the economic costs to society. The 1970s and 1980s saw a dramatic increase in research of the causes and consequences of teen pregnancy, emphasizing the negative outcomes for teen mothers and their children, without considering preexisting socioeconomic factors. The teen parent was depicted as “perpetrator of poverty” (Furstenberg, 2003), and a social problem requiring government intervention. From 1990 to present, teen pregnancy is still stigmatized as a social problem, and yet the media’s focus on individual teen parents may actually glamorize the role. Adolescent pregnancy research and prevention efforts broaden beyond individual behavior to explore the link between socioeconomic factors and disadvantage, the social determinants of health.

Consistent with current health guidelines, such as Bright Futures (Hagan et al., 2008), clinicians often find it helpful to view adolescence in stages: early adolescence (11–14 years), middle adolescence (15–17 years), and late adolescence (18–21 years). The period of early adolescence is marked by the physical transformations of puberty along with a shift from dependence on parents to increased independence. Appearance and feeling “normal” become vitally important.

Of particular importance for young adolescents has been the trend toward earlier entry into puberty. In the nineteenth century when data were first recorded, the average age of first period or menarche was 16 or 17. Since then, the age of menarche has decreased by 3 months for every decade and now appears to be leveling off at age 12, with earlier menarche noted in black and Hispanic youth (Cox, 2008). The age range and pattern for the development of secondary sex characteristics in girls are breast buds (8–12); pubic hair (11–14); and menarche (9–16). Male pubertal development typically begins about 2 years later than females. The pattern for male puberty is as follows: testicles enlarge (as early as 9-1/2); pubic hair (10–15); onset of spermarche; and lengthening of genitals (11–14) (McNeeley & Blanchard, 2009). While the development of secondary sex characteristics gives young adolescents the appearance of being more mature, their brain development, in particular their prefrontal cortex, is still maturing. The prefrontal cortex is responsible for advanced reasoning, including the ability to plan, understand cause and effect, think through scenarios, and manage impulses. From a developmental perspective, it is not surprising that curious, socially driven teens, who are in the process of forming their personal identity, might engage in sexual relations as a means for meeting their basic needs for belonging, intimacy, and mastery (Weinberger, Elvevag, & Giedd, 2005; NIMH, 2011).

Early puberty has been linked to earlier romantic expectations and experiences. A recent, nationwide multiyear survey found that girls who experience menarche before age 12 were more likely to live with or marry someone at an earlier age (Cavanagh, 2011). Teens who mature earlier and initiate intercourse at younger ages have been found to have a greater number of sexual partners (Abma, Martinez, Mosher, & Dawson, 2004).

Pregnancy in an early adolescent is vastly different from pregnancy in an older adolescent. Health care for early adolescents requires comprehensive support to maximize nutritional intake and growth for both the pregnant teen and her fetus (Cox, 2008). For teens younger than 15 years, there are increased risks for prematurity, low birth weight, and mortality. While survey reports indicate a decline, 6  % of youth reported initiating sexual intercourse before age 13, and 13  % of youth reported having had intercourse by 15 years of age (Abma, Martinez, & Coben, 2010). Younger teenagers are especially vulnerable to coercive and nonconsensual sex. A 2002 study of girls who were age 14 or younger when they first had sex found that 18  % characterized their first sexual experience as involuntary, and 27  % indicated it was unwanted (Kirby, 2007). One of the caveats of identifying pregnancy in a young adolescent is to be alert for the risk of incest or sexual assault.

One of the hallmarks of middle adolescence (high school years) is intense interest in peer activities. Indeed, as peer group values become more important, so too the potential for conflicts with parents increases. Likewise a sense of omnipotence and immortality may lead to adolescent risk-taking behavior. At this stage there is usually an increase in dating activity or involvement in partnering relationships, and as such more opportunity for sexual experimentation and intercourse (Radzic, Sherer, & Neinstein, 2008). It is not surprising that most young people have sex for the first time at about age 17 (Guttmacher, 2011).

Half (46  %) of all adolescents have had sexual intercourse by graduation from high school, with only slightly more than a third (39  %) using a condom at last intercourse (CDC, 2011c). Teens having sex tend to do so sporadically, as suggested by the report that only 34  % of sexually active youth had had sex in the prior 3 months. Because of the sporadic nature of teen sexual activity, adolescents often do not plan to have sex on a particular occasion, but sometimes do so anyway, and this unprotected intercourse places them at risk for pregnancy. Age of sexual partner is another risk factor. Research indicates that when adolescent females have sex at a young age with much older partners, there is a greater chance that their first sexual experience was involuntary or unwanted and that they can become pregnant because under these circumstances intercourse is more likely to be unprotected (Kirby, 2007).

In late adolescence, there is the potential for greater independence and movement toward adult roles and responsibilities; however, there is significant variation, depending upon what developmental tasks they have managed to accomplish up to that point, in the context of both their assets or protective factors and stressors or risk factors. The term “emerging adults” that was coined for 18–25-year-olds connotes the complex developmental process that older adolescents experience (Arnett, 2000). Birthrates overall by race and ethnicity are consistently higher for ages 18–19 than for 15–17. Although downward trends for both age groups have been similar, long-term declines were smaller for older teens (Ventura & Hamilton, 2011). A decrease in the median age of menarche, coupled with an increase in the median age of marriage for females to 25.3 years, results in a protracted period of time—nearly a decade—during which youth are at risk for unprotected intercourse and the consequences of an unintended pregnancy and STIs (Guttmacher, 2011).

New research on adolescent brain development provides an understanding of cognitive differences. It is important to remember that adolescents think differently than adults do (Weinberger et al., 2005). Immature cognitive processing and egocentric thinking can lead to distortions in judgment and the belief that a pregnancy could not possibly happen to them, often leading to delays in pregnancy diagnosis. Emotional factors, such as fear or shame, can perpetuate denial. For some adolescents, finding out that they are pregnant initially can be immobilizing, leading them to simply ignore it and hope that things will work out. Under stress, an adolescent may revert to concrete thinking and focus on daily routines, which can subvert abstract decision making and planning for the future. Due to immature cognitive development, becoming a parent during early or middle adolescence has limitations because a teen parent may not accurately perceive and/or respond to her child’s intentions or needs (Farber, 2009).

The initial challenge in working with pregnant adolescents is identification of the pregnancy. Adolescents present for pregnancy testing under a variety of circumstances. While most women have pregnancy concerns with delayed or missing periods, many adolescents may ordinarily have irregular periods for a number of medical reasons, and thus they may not be concerned by amenorrhea (missed menstrual periods). Similarly, many teens mistake early pregnancy implantation bleeding/staining for a light period. When scheduling a medical appointment or walking in for an urgent care visit, an adolescent may be hesitant to divulge sensitive information. This reluctance to disclose sexual history underscores the importance of confidentiality for adolescent reproductive health visits, which is supported by law in all 50 states (English, Bass, Boyle & Eshragh, 2010).

Health professionals need to be prepared to ascertain an adolescent’s “hidden agenda.” As we know from YRBSS data, approximately half of all teens are sexually active and thus it is recommended that all adolescents be screened for sexual risk behaviors. Many young women may be unaware of the possibility of being pregnant or reluctant to raise the question until a health care provider inquires about their sexual activity. Despite the availability of home pregnancy test kits, research has demonstrated that only approximately one-third of adolescents presenting to clinics have already conducted a pregnancy test at home and thus were seeking confirmation and referral (Shew, Hellerstedt, Sieving, Smith, & Fee, 2000). For many adolescents, the cost of a home pregnancy test kit may be prohibitive or they may be reluctant to purchase a pregnancy test from their neighborhood pharmacy because of privacy concerns. Adolescents are selective regarding to whom they disclose information and may refrain from disclosing their concern about a pregnancy unless they feel comfortable. Health professionals are encouraged to create welcoming, adolescent-friendly environments.

Estimates are that one-third of the population of children has special health care needs. Adolescents with chronic health conditions often underestimate their ability to become pregnant or may engage in unprotected intercourse, in an attempt to test their fertility status. Sexual risk assessments are especially important for adolescents with chronic medical conditions, such as cystic fibrosis, diabetes, renal disease, and cancer. One cannot assume that an adolescent is abstinent or using protection, even if she has a serious medical condition or is on medication that has known teratogenic effects. The authors have worked with many teens whose desire to become or remain pregnant outweighed what was in their own best interest from a medical perspective, including patients who were post-transplant or on chemotherapy. Likewise, teens with complex mental health issues, such as depression, anxiety, or substance abuse, are at risk for engaging in unprotected sexual activity (Aruda, Waddicor, Frese, Cole, & Burke, 2010).

All teens, regardless of any preexisting health issues, should be counseled about their potential reproductive capacity (i.e., fecundity) and the risks of unprotected intercourse. “In normally fertile couples, cycle fecundity averages 20  % and does not exceed approximately 35  % even when coitus is carefully timed” (Fritz & Speroff, 2011, p. 1,155). After 3, 6, or 12 months of exposure, approximately 57, 72, and 85  % of sexually active couples will attain a pregnancy (Fritz & Speroff, 2011). Adolescents who have never been pregnant and therefore begin to doubt that they can ever become pregnant need to understand their future risk for pregnancy and what they can do to protect their reproductive health status, such as ensuring adequate intake of folic acid (http://www.womenshealth.gov/publications/our-publications/fact-sheet/folic-acid.cfm#b).

Once a pregnancy is confirmed, it is important to assess the adolescent’s emotional response, coping skills, and social support resources. Options counseling is one of the most important aspects of early pregnancy management. It is imperative for clinicians to utilize neutral, factual information and nondirective statements when discussing options. For example, the following script was previously developed for a multidisciplinary adolescent practice (Aruda, 2007). “You have a decision to make about your pregnancy. Any pregnant adolescent has three options. Alphabetically, these options are: (a) abortion or pregnancy termination; (b) continuing the pregnancy and arranging for an adoption, infant care, or foster care; and (c) continuing the pregnancy, entering prenatal care, and becoming a parent. At this point, which option do you think you will choose?”