Adolescent Pregnancy in the U.S. Military: What We Know and What We Need to Know

David A Klein and William P Adelman
Military Medicine

Jun 30, 2008 20:00 EDT

INTRODUCTION

Adolescent pregnancy is a significant public health problem in the United States that costs American taxpayers $9.1 billion per year.1 Adolescent mothers have lower rates of high school and college completion than other mothers, and higher rates of single parenthood, poverty, sexually transmitted infections, and health complications of pregnancy. Their children have: lower average birth weight than other mothers' children; higher rates of premature birth, abuse, poverty, poor school performance, incarceration, and chronic health problems; and greater likelihood of becoming teen parents themselves.1-11

It is reasonable to suspect that such phenomena in the general adolescent population may likewise apply in the subpopulation consisting of adolescent dependent children of military personnel and in the subpopulation consisting of young, active duty military personnel. Furthermore, the potential for adolescent pregnancy in military populations to adversely impact the military services' mission readiness, resource allocation, and family unity is a serious concern.

Nevertheless, the influence of teenage pregnancy within the military health care system is thus far largely unknown. Identifying and addressing unintended adolescent pregnancy issues within the military is therefore critical. This article reviews the current adolescent pregnancy data for the national population and for military populations, to identify areas in which further study would benefit military health care.

ADOLESCENT PREGNANCY IN THE UNITED STATES

Multiple articles have reported on adolescent pregnancy in the United States.5,9 This section reviews factors they identified in the overall population that are salient for our consideration of the military populations. Between 750,000 and 900,000 15- to 19-year-olds become pregnant in the United States each year.12 Of seven teenage pregnancies, four end in live births, two in induced abortion, and about one in fetal loss.10 Nearly 90% of adolescent births occur outside of marriage and are unplanned.9

Risk Factors for Pregnancy

Risk factors for adolescent pregnancy include sexual debut in early adolescence, minority race, ineffective contraception, and lack of access to confidential services.

Early Sexual Debut

More than 45% of high school females and 48% of high school males have had sexual intercourse,13 the average age of first intercourse being 17 for girls and 16 for boys.5,14 Approximately one-fourth of all youth report intercourse before age 15,5,14 and sexual debut in early adolescence is a risk factor for adolescent pregnancy. Predictors of sexual intercourse during early adolescence include early pubertal development, poverty, sexual abuse, cultural and family patterns of early sexual activity, poor school performance, dropping out of school, lack of career or life goals, and lack of attentive, nurturing parents.5,15-17 Adolescents vary in their concern about pregnancy, and ambivalent attitudes are highly associated with impending conception.18,19

Race and Geography

Non-Caucasian race and Hispanic ethnicity are risk factors for adolescent pregnancy. Minority teenagers are 2.5 times more likely to give birth than their non-Hispanic Caucasian peers.10 Teen birth rates vary by geography, although this phenomenon may be confounded by local demographic variables. In 2004, the birth rate for 15- to 19-year-olds ranged from just over 18 per 1,000 in New Hampshire to 62.6 per 1,000 in Texas and 66.7 per 1,000 in the District of Columbia.6

Ineffective Contraception and Confidentiality

Unintended pregnancy results from "ineffective contraception" (i.e., nonuse, inconsistent use, or incorrect use of contraceptives, or use of unreliable methods).20 A significant cause of ineffective contraception is lack of access to confidential services. Bona-fide confidentiality between adolescents and care providers increases the likelihood of discussion about sex, sexually transmitted illnesses, and pregnancy prevention.21,22 Conversely, mandatory parental involvement and concerns about nonconfidentiality cause adolescents to delay obtaining contraceptive services.9,20,23,24 In a regional survey of suburban adolescents, <20% of teens said they would seek care related to birth control, sexually transmitted infections, or drug use if parental notice were mandated.25

Although a large majority of teenagers desire confidential care, fewer than half think their usual providers will honor a confidentiality request,22 and nearly half do not know where to obtain confidential services.26 Pediatric practices are less likely than internal medicine practices and family medicine practices to offer services for medically emancipating conditions, and they are less likely than family medicine practices to offer confidential services to adolescents.27 Most teenagers eventually seek pregnancy protection from physicians, but the average length of time from onset of sexual activity to presentation to the physician for contraceptives is between 9.5 and 14 months.20,28,29 This delay increases the risk of unintended pregnancy and, indeed, half of teenage pregnancies occur within 6 months from the onset of sexual activity.

Outcomes of Pregnancy

Infants born to teenage mothers are at higher risk for low birth weight, premature birth, and small size for gestational age3,8,30 and inherit additional lifelong risks including poor academic performance, poverty, and incarceration.4,9,31 They are also more likely to become teen parents themselves.32 Adverse outcomes persist in teenage populations after controlling for confounding factors such as race, family income, marriage status, educational level, and use of prenatal care.3,33

Economics of Pregnancy

Every year, public funds exceeding $9.1 billion dollars ($1,430 per child) are spent on sequelae of teenage pregnancy.1 Furthermore, annual health care expenditures for newboms to 4-year-olds with mothers younger than age 17 are up to 40% higher than those for children with 20- to 21-year-old mothers." Differences in health care spending are due in part to disparities in the health profiles of children born to mothers of specific ages, and in part due to differences in health care system utilization patterns.17,11

ADOLESCENT PREGNANCY IN THE MILITARY

The pregnancy and birth rates in adolescent military populations are underexplored, as are the health consequences in this population. Moreover, independent risk factors for adolescent pregnancy in the military population are unknown. The military population is not immune to any of the risk factors for teen pregnancy listed above, and teen pregnancy is not demonstrably lower in the military than in the civilian health care system.

As noted above, minority race is a risk factor for adolescent pregnancy in the general population. Minority races are disproportionately represented within the U.S. military services.34 However, because the military services have universal health care and a distinct culture, it cannot be assumed that race independently predicts adolescent pregnancy in military populations.

To what extent state-to-state differences in pregnancy rates arise from cultural and socioeconomic differences is unclear, and thus it is unknown whether the diverse, relocated military populations in each state are affected by such factors. Determining the current birth and pregnancy rates for military affiliated or dependent teenagers in each state or specified area and comparing them to state averages would help elucidate military influence upon pregnancy and birth rates.

MILITARY DEPENDENT ADOLESCENTS: WHAT WE KNOW

A person younger than 21 (or 23, if a full-time student) is entitled to full military health care services if he or she is financially dependent on a parent or sponsor who is on active duty or retired from active duty. For the purposes of this discussion, we define "dependent" as a person, other than the spouse of an active duty service member, who is entitled to full military health care services by virtue of dependency on an active duty or retired service member. Twelve- to 23-year-olds comprise 28.5% of all dependents of active duty personnel (Table I.) There are nearly 435,000 10- to 19-year-old female dependents in the military health care system.34-36

Military rank and associated pay grade are proxies of socioeconomic status.34,37 Approximately 3% of female dependents aged 12 to 18 are daughters of at least one parent or sponsor within the lowest enlisted ranks of E1-E4.34 These ranks correlate with a base pay between $1,178.00 and $2,018.40 per month.38 An additional 24% have a parent or sponsor with a rank of E5 or E6, which suggests that at least one parent may earn between $1,814.10 and $2,526.60 per month.38 The effect of socioeconomic status upon adolescent pregnancy rates within the military health care system is not known. In the setting of universal health care and the unique cultural milieu of the military, the relevance of financially oriented risk-stratifying models is similarly unknown.

Risk Factors for Pregnancy

There are no rigorous and representative studies examining data on the rate of dependent pregnancy in the military health care system. Therefore, it is impossible to identify which risk factors for unintended pregnancy are most relevant to the military dependent population. There are conflicting data regarding the general risk profile of adolescents who grow up in the military health care system.

Military-affiliated adolescent dependents may be less susceptible to risky behaviors than adolescents in nonmilitary families.35,39-41 By age 17, the typical military-affiliated teenager has attended five schools,41 some of which may be located outside the continental United States, and has experienced myriad approaches to sexuality education.42,43 Increased relocation frequency has been associated with elevated parental perceptions of military teenagers' conduct and behavior39 perhaps because frequent moves develop teenagers' resiliency and coping skills and limit their access to high-risk behavioral influences. A study of teenaged dependents' risk-taking behaviors in two separate active duty adolescent medicine clinics found behaviors like sexual activity and substance abuse at rates significantly below the national averages.35 Also, a Military Family Institute survey of 6,500 adolescent dependents found that this population succeeds at least as well as, and in some cases better than, their civilian peers in educational achievement, involvement in recreational activities, alcohol and drug avoidance, and general health.41 These studies suggest that adolescent dependents of military personnel are less prone to behaviors associated with risk for pregnancy.

In contrast, other evidence suggests that teenaged military dependents are at least as susceptible to risky behaviors as their civilian counterparts.44-47 Military adolescents experience unique Stressors associated with multiple relocations, frequent separations from peers and family, and the worry or reality of losing a loved one. In one study of teenagers in a pair of military adolescent medicine clinics, dating and sexual behavior were found to be as prevalent as among nonmilitary dependent populations.48 Twenty percent to 33% of high school age females in these clinics dated active duty males, and nearly 15% of these relationships progressed to sexual intercourse. Potential military-specific influences on these behaviors were not studied.

A study in an overseas population found teenaged military dependents engaged in slightly less illicit drug use and slightly more alcohol use than teenagers nationally, with comparable sexual behavior.46 Another study demonstrated a higher prevalence of Chlamydia trachomatis in the teenage dependent cohort than was seen in numerous high-risk nonmilitary-affiliated populations.45

There remains insufficient evidence to conclusively determine the impact of the military dependent lifestyle upon adolescent risk-taking behaviors. Multiple small studies in specific geographic areas suggest that teenaged dependents are at least as likely, if not more likely, to engage in behavioral antecedents to pregnancy, but these studies fail to shed light on which aspects of the military experience, if any, put teenagers at risk. In contrast, larger studies identify potential protective factors of military life. Additional studies are needed to elucidate the unintended pregnancy rate of adolescent dependents and associated risk behaviors.

Confidential health care is critical to prevention of adolescent pregnancy, but the extent to which teenage dependents within the military health care system have access to confidential services is unclear. Some ways of improving access to confidential military health care have been found. For example, in one study, 35% of parents of minors presenting to adolescent medicine clinics in the military health care system disagreed or strongly disagreed with their teens' having confidential patient-physician interaction. However, after a brief educational intervention, only 14% still disagreed at the time of visit and follow-up.49 Another military study offered a model of confidential adolescent women's health care, at low cost, through shared departmental resources at a large community hospital.50 This model provided a previously underserved, high-risk population with increased access to health care.

Effects of Parental Absence

Understanding the short- and long-term effects of parental separation (including long-term deployment) on adolescent dependents is important. Data collected from various U.S. military populations suggest that mild to moderate clinical and subclinical behavioral and psychological symptoms emerge in the context of parental deployment,40,44,51-54 although many of these studies focus on younger children. However, an additional body of research found that many adolescents are resilient and resourceful in coping with parental deployment.40 It is clear that symptoms tend to emerge at magnified levels in a vulnerable family structure or where a child has pre-existing emotional problems requiring counseling.53,54 Prolonged paternal absence is a risk for sexual activity and teenage pregnancy in civilian populations,55 but there have been no studies of military populations describing a relationship between these constructs, so further research in the military setting is needed.

Neonatal Outcomes

Data linking age, especially in the context of race, to neonatal outcomes in the military dependent population are limited.56-59 A focused teen prenatal clinic at a large Army medical center, however, demonstrated through empirical evidence that adverse outcomes approximated those in a low-risk, general population and were better than expected for the targeted cohort.60 Further risk stratification for poor pregnancy outcomes in the dependent community and investigation of comprehensive supportive services will be beneficial.

Economics

The net economic impact of teenage pregnancy on military medicine is unclear, and data are confounded by redirection of operational resources, support for training programs, and the presence of the military's fixed health care infrastructure.61 The Department of Defense covers the cost of all obstetric and pediatric care for its beneficiaries but does not cover the long-term postnatal care of infants born to dependents. In a routine, uncomplicated pregnancy, TRICARE seeks more than $1,500 from secondary insurance companies in reimbursement for expenses such as physician fees for care in military treatment facilities, and more than $5,500 for inpatient maternal and neonatal care costs incurred if the delivery is outside of military treatment facilities.62 Further research to quantify the health care costs of teenage pregnancy and childbirth might lead to efforts to improve primary prevention in the military, which could ultimately lead to robust net savings.

MILITARY DEPENDENT ADOLESCENTS: WHAT WE NEED TO KNOW

Further study is needed to: (1) rigorously determine the incidence and prevalence of adolescent dependent pregnancy and associated known risk factors as well as military descriptors, and (2) identify and evaluate any unique military risk factors and protective factors associated with unintended pregnancy (Table II).

ACTIVE DUTY ADOLESCENTS AND THEIR SPOUSES: WHAT WE KNOW

Pregnancy information about active duty service members (unlike their adolescent dependents) is readily available. Almost one-third of first births to active duty females are to women younger than 21 (Table III). In 2004, at least 585 male and 122 female active duty members became parents for the first time at age 18 or younger. Of the 7,038 total births to previously nulliparous active duty women in 2004, 20-year-olds demonstrated the highest incidence (n = 1,188). Furthermore, as of 2004, there were 111,736 active duty junior-enlisted (E1-E4) parents who might be at risk for the outcomes related to lower socioeconomic status.34 This suggests that the youngest service members-those most relied upon as the fighting force-may be the most at risk for unintended pregnancy and its adverse effects.

Pregnancy Risk Factors

Among the active duty population, risky sexual activity is highest among the youngest personnel. In a survey of 112 active duty females, the adolescent subgroup (i.e., those between 17 and 19 years old; n = 35) reported greater number of sexual partners, frequency of intercourse, and nonuse of any birth control method, and less of an understanding of the reproductive cycle.63 It is not surprising, then, that this same population experiences the most sexually transmitted infections (STI). Since STI are markers for high-risk activity, data on their occurrence in the military population are useful markers for potential for unintended pregnancy. STI occur at rates above the national averages in military recruits,64,65 young military personnel,66 and military ethnic minorities.66 Furthermore, the youngest military personnel have higher rates of STI than those found in a variety of other military populations and settings.66,67

High levels of intercourse-related morbidity in the military services arise from causes similar to those in the civilian population. A 2002 survey found that only 42% of unmarried sexually active military personnel had used condoms during their latest episode of vaginal or anal intercourse. This varied by gender (female = 33.2%), by age (<20 years of age = 47.9%), and-somewhat less-by education level and pay grade.68 The survey also found that, among service members of any age who reported having a casual sexual partner, approximately 75% used condoms "half the time or less."68 Much less information is readily available regarding reasons for unplanned pregnancy than regarding reasons for STI acquisition.

Two studies examined the reasons for unplanned pregnancy in the military.69,70 Conducting 2,348 telephone interviews of active duty females revealed that over half of the pregnancies in this population were unplanned. Half the pregnancies stemmed from contraceptive nonuse and the other half from contraceptive failure or misuse. In a multivariate analysis, the statistical predictors of pregnancy in this cohort were age (odds ratio for age <20 years = 9.5, p = 0.02) and unmarried marital status (odds ratio for unmarried = 6.6; p < 0.0001).70 Interventions targeting adolescent active duty personnel were recommended.

Real or perceived unavailability of confidential care may contribute to pregnancy among young active duty personnel. Actual or suspected compromises in health care privacy, secondary to military command interest in soldier health status, may discourage use of family planning and contraception services.

No published data suggest that military service protects against unintended adolescent pregnancy, but no large studies addressing this subject exist. As discussed above, adolescent military personnel, who make up the bulk of the fighting force, are at highest risk for unintended pregnancy and lack of mission readiness. The degree to which they understand and appreciate the possible consequences of their sexual activity needs more investigation to determine whether this population would benefit from educational intervention.

Abortion in the Military Services

U.S. law (10 USC sections 1093a and 1093b) prohibits use of Department of Defense (DOD) funds to perform abortions, except where the life of the mother would be endangered if the fetus were carried to term, and prohibits use of DOD facilities to perform abortions except when the life of the mother would be endangered if the fetus were carried to term or in a case in which the pregnancy is the result of an act of rape or incest.71,72 Additional legal constraints exist in overseas environments.71

Although surveys of all known abortion providers consistently demonstrate that nearly one-third of all adolescent pregnancies in the United States end in elective abortion-a number that totaled 215,000 in 2002(9,10) with higher prevalence in densely populated areas73-abortion rates in military populations are not known. Due to the complexity of identifying rates of abortion among military personnel and their dependents, it is difficult to determine and compare the rates of adolescent pregnancy, which include not only live births but also spontaneous and elective abortions. This information is important to ascertain, however, as it might help explain potential differences in birth rates between the military and national averages.

Neonatal Outcomes

Active duty women generally appear to be at higher risk than civilian women for adverse pregnancy outcomes74-77 including preterm labor,74 primary Cesarean sections, transfer because of preterm complications, pregnancy-induced hypertensive syndromes, and intrauterine growth restriction,75 although trends in patient age are less apparent in this group than among civilian groups. Efforts to explain these differences have led to hypotheses regarding the psychosocial milieu of the military community such as reactions to gender roles, social support issues for women,78 stress from partner deployment,79 and work stress,80 found in particularly high levels among young service members.68 Studies addressing the influence of substance use, marital status, and the use of prenatal care services on pregnancy outcomes in the military services have not satisfactorily explained the variation,68,76,81,82 and more research to determine the operative risk factors is needed. Meanwhile, efforts at military hospitals to establish specialty prenatal interventions for high-risk groups,83 including teenagers,60,84 have successfully minimized outcome disparities.

Military Readiness Outcomes

Unplanned pregnancy adversely impacts military readiness. Research after the Persian Gulf War showed that the nondeployable rate for women was three times greater than that of men and was largely influenced by pregnancy.85 In 2002, approximately 17% of military women indicated that they had been pregnant within the past year or were currently pregnant, and 37% reported having been pregnant within the past 5 years.68 The medically confirmed pregnant active duty member is classified as nondeployable for up to 1 year from the time of diagnosis and is typically relieved of certain training duties, including marksmanship, field exercises, aircraft flying, and riding in tactical vehicles.86 Pregnancy continues to be a source of loss of fighting strength in current conflicts, especially among the junior-enlisted population.87 Postparturition retention rates are also impacted.86 Notably, multidisciplinary programs to prevent unintended pregnancy in the military overseas environment have been effective.88,89 The armed forces must try to reduce rates of teenage pregnancy so as to maintain the military readiness of its service members and to decrease rates of separation from military service.

Economics

The DOD funds all medical expenditures occasioned by pregnancy in the active duty population except elective abortions. Economic consequences of active duty pregnancy include not only costs related to personnel loss and resource depletion, but also costs of evacuating women identified in the operational theater as pregnant.90 Thus, effective predeployment screening programs and preventive educational efforts are financially desirable.

ACTIVE DUTY ADOLESCENTS AND THEIR SPOUSES: WHAT WE NEED TO KNOW

Although we know that the youngest active duty members engage in the riskiest sexual behaviors, we do not know why, nor do we know whether the military culture influences these behaviors (Table IV). What are the reasons for their use of ineffective contraceptive measures and their incorrect use of effective ones? What are the reasons for nonuse of any contraception? Definitive answers to these questions are areas for further study.

CONCLUSION

A detailed understanding of the causes and effects of adolescent pregnancy in the military services is essential for mission readiness, resource conservation, and reduction of stress for service members and their families. The myriad of known risks for unintended adolescent pregnancy is underexplored in the military population. There have been few studies with external validity regarding young, active duty men and women or teenage dependent children of active duty or retired service members. Further studies focused on these populations are critically needed for the future improvement of military medicine.

ACKNOWLEDGMENTS

We acknowledge Margaret Freiberg for her editorial assistance with this project.

© 2008 Association of Military Surgeons of the United States Provided by ProQuest LLC. All Rights Reserved.

Source: Military Medicine