Objectives. This study described a medical home model for adolescent mothers and their children, and their 1- and 2-year preventive care, repeat pregnancy, and psychosocial outcomes.

Methods. In this prospective, single cohort demonstration project, adolescent mothers (14–18 years old) and their children received care in a medical home. Demographic, medical and social processes, and outcomes data were collected at enrollment through 24 months. Change over time and predictors of repeat pregnancy were analyzed.

Results. A total of 181 adolescents enrolled, with 79.6% participating for 2 years. At 2 years, 90.2% of children were completely immunized. Children and adolescent mothers met standards for health care visits, and adolescent condom use improved. Rates of cumulative repeat pregnancy were 14.7% and 24.6%, school attendance 77.6% and 68.7%, and employment 21.2% and 32.3% at 1 and 2 years, respectively.

Conclusions. A medical home model with comprehensive and integrated medical care and social services can effectively address the complex needs of adolescent parents and their children.

Adolescent mothers are at risk for depression and low self-esteem, and face significant health and socioeconomic risks.1–5 Although most complete high school, they do so later than their peers, and have lower earnings.6 Their children face significant long-term risks, with increased rates of adolescent pregnancy, school failure, and behavioral problems.7 Young fathers often disengage with their children over time.8,9 At least 20% of adolescent pregnancies in this country occur in adolescents who have already given birth to at least 1 child.7 Delaying repeat pregnancy may enhance outcomes for both mothers and their children.10–13

To address the complex and multidimensional needs of adolescent parents, intervention programs must provide a broad scope of services, targeting life and reproductive health skills, addressing social needs, and providing preventive care while teaching effective parenting behaviors.10 Multidisciplinary programs have demonstrated improved child development and maternal long-term outcomes and modest reductions in repeat pregnancy.12,14–17 Our previous work showed that adolescent parenting groups embedded within a medical and social services model enhanced self-esteem and decreased stress.18

The medical home has been promoted as a transformative model for children with complex needs and is potentially an effective strategy for addressing the multiple medical, social, and educational needs of adolescent families.19–21 The American Academy of Pediatrics (AAP) published a 1992 policy statement, which was modified in 2002, defining medical homes to include 8 desirable characteristics: accessible, family centered, continuous, comprehensive, coordinated, compassionate, developmentally appropriate, and culturally sensitive.22,23 In 2001, the AAP recommended this approach for adolescent parents.24,25 In 2007, the Joint Principles of the Patient-Centered Medical Home added emphasis on quality, safety, and value.26 First described in the 1980s, teen-tot programs contained many of the elements of a medical home. They provided medical care and psychosocial support in an efficient, “one stop shopping” model.27,28 However, few comprehensive evaluations of these programs have been published.29,30 In this study, we describe a family-centered medical home model for adolescent mothers, fathers, and their children. We hypothesized that adolescent families receiving care within the teen-tot model would have improved medical and social outcomes compared with local and national benchmarks. We presented data on 3 major outcomes: (1) maternal and child health preventive care indicators, (2) repeat pregnancy rates and contraceptive adherence, and (3) adolescent life skills, including education, job attainment, and independent living.

The setting was an urban teen-tot program, serving adolescent parents and their children, based in a children’s hospital in the Northeast. The medical home model program was embedded within a large primary care practice.

Eligible adolescent mothers (n = 181), younger than 19 years at delivery, were recruited between January 2002 and January 2005. They lived in urban neighborhoods contiguous to the hospital, which had an overall poverty rate of 20% and adolescent pregnancy rate twice the Massachusetts state rate of 21.7 per 1000.31 They were recruited from an associated adolescent prenatal clinic and through community-based adolescent support agencies, and enrolled in the project usually within 1 week of their child’s birth.

Program Model

Project Raising Adolescent Families Together was designed as a medical home that delivered comprehensive health and social support services to adolescents and their children with the goals of (1) providing optimum health care with case management, (2) promoting a low rate of subsequent pregnancies, and (3) improving life skills and transition to independence (Figure 1). Adolescents received prenatal care at an adjacent hospital, and staff met monthly with the obstetrical program to discuss cases, creating a bridge for adolescent postnatal care.

At the newborn visit, adolescents met their medical provider and social worker. Pediatric and adolescent care followed the Bright Futures Guidelines.32 Visits to the medical home included scheduled preventive care, problem-based returns, and urgent or sick care. Visit lengths were 30 to 60 minutes. Flexible scheduling provided timely appointments to maximize compliance, and the program tolerated late arrivals.33 No-shows received phone calls. The larger primary care practice provided evening hours for urgent needs. At each clinic appointment, adolescents received medical care, met with the nurse for contraceptive counseling (with Title X free supplies34), and received a social services “check-in” focused on discussing resource needs, school, daycare, and relationships. Social workers were available 5 days per week to handle emergencies often related to housing, domestic violence, or mental health concerns.

Evaluation Design

The evaluation involved a prospective single-cohort study with assessments conducted at program enrollment and at 12- and 24-month follow-up. Trained research assistants obtained baseline demographic information using face-to-face structured interviews at approximately 2 weeks postpartum, including data on education, living situation, relationships, work, psychological history, and family history. Program outcomes included program retention, health care utilization, immunization rates (from computerized clinic database), contraceptive use, repeat pregnancies (from clinic chart), depressive symptoms, social support, and self-reported school or work attendance. Children were fully immunized if they received 4 acellular pertussis vaccine, 3 inactivated poliovirus vaccine, 3 hepatitis B, 3 Haemophilus influenzae type b, 1 measles, mumps, rubella vaccine, and 1 varicella-zoster virus immunizations by age 24 months.35 The Duke-UNC Functional Social Support Questionnaire36 was used to assess social support, and the Center for Epidemiological Studies Depression Scale for Children short version (CES-DC) was used to assess depressive symptomatology.5,37 Benchmark comparison data were obtained through a systematic literature review and chosen from studies of urban, Black and Latino adolescent parent populations.

Analysis

We computed response frequencies for categorical variables, and means and SDs for continuous variables. Medical home utilization was defined as the total number of adolescent and child visits during the study period. We used the McNemar test for paired analyses and linear mixed effects modeling to assess change in our primary outcome variables from enrollment to 12 and 24 months. These included use of contraception (none, condoms, oral contraceptives, or depot medroxyprogesterone [DMPA]), indicators of adolescent financial independence and social support (living with parents, receipt of Medicaid, child support from father), repeat pregnancy, and percentage of infants having up-to-date immunizations. To identify potential medical home-related predictors of the dichotomous outcome of repeat pregnancy, we used the χ2 test to examine bivariate associations between participant characteristics at baseline, use of contraception, program utilization, and any repeat pregnancy by 24 months. We entered all variables that had a P value < .2 into a multiple logistic regression model to determine the independent effect of each variable. We constructed categorical variables for all continuous variables (adolescent mother and child age, and number of program visits) because of skewed data distributions. A P value < .05 was used as criteria for statistical significance. Data were analyzed using SPSS 15.0 (IBM, Chicago, Illinois).

A total of 181 adolescent mothers were enrolled in the teen-tot medical home program during the study period. Table 1 summarizes the demographic characteristics at the time of program entry. The majority were primiparous and of Black or Latino race/ethnicity. Self-described culture of origin was American (55.2%), Puerto Rican (24.1%), Haitian (5.3%), Dominican (4.2%), and other (12.2%). Most received financial and child care support from their own families, as well as support from the father of their child. The high mean CES-DC score of 19.1 was suggestive of substantial depressive symptomatology among these adolescent mothers.

Table

TABLE 1— Adolescent Mothers’ Demographic Characteristics at Enrollment: Raising Adolescent Families Together Program, 2002–2007

TABLE 1— Adolescent Mothers’ Demographic Characteristics at Enrollment: Raising Adolescent Families Together Program, 2002–2007

VariableOverall
Adolescent mother’s age, y
 Mean ±SD17.8 ±1.2
 Range14–18
Baby’s age, mo
 Median1.6
 25th–75th percentile0.7–6.6
Primiparous, %92.0
Race/ethnicity, %
 Black41.4
 Latina39.2
 Biracial or other19.3
Medicaid recipient, %93.9
Any religious participation, %65.1
Attends school, %64.1
Employed, %5.5
Lives with parents, %55.8
Support from own family, %
 Income65.7
 Social support87.8
 Child care61.3
 Any of the above77.0
Support from father of baby or partner, %
 Income61.3
 Social support70.6
 Child care64.8
 Any of the above80.9
Support from FOB’s family, %
 Social support only36.3
 Social support and child care22.0
Depressive symptoms scorea
 Mean ±SD19.1 ±10.2
 Adolescents with scores ≥ 15, %56
Social support score,b mean ±SD488.2 ±109.5

Note. FOB = father of baby; TAFDC  = Transitional Aid to Families with Dependent Children. The sample size was n = 183.

aCenter for Epidemiologic Studies - Depression Scale for Children. Possible score range = 0–60 with score of > 15 suggestive of significant depressive symptoms.

bDuke-University of North Carolina Functional Social Support Questionnaire. Possible scores range up to 672.

Tables 2 and 3 summarize health care and outcomes at baseline, 12, and 24 months compared with published studies. In longitudinal analyses, there were significant increases in adolescents living independently, being employed, and using condoms. Father financial support of their children decreased significantly. Completed immunizations remained consistently high and, at 24 months, were well above established national benchmarks.38–40 Nearly half of adolescents used DMPA during the study period, with a mean of 47.0% ±3.7% across all follow-up assessments compared with a mean of 11.8% ±2.9% for oral contraceptives plus the contraceptive patch. Use of DMPA at any time was positively associated with clinic visits (8.3%, 0–8 visits; 40.5%, 9–11 visits, 61%, > 12 visits; P = .009). From program enrollment to 12 months, there was little change in the mean depressive symptoms score (19.1 ±10.2 to 19.8 ±11.5 respectively); however, there was a marginal decline in the social support score (488.2 ±109.5 to 458.9 ±122.0; P = .07).

Table

TABLE 2— Health Care, Contraception, and Repeat Pregnancy for Adolescent Mothers and Infants at 12 and 24 Months Compared With National Benchmarks or Previous Studies: Raising Adolescent Families Together Program, 2002–2007

TABLE 2— Health Care, Contraception, and Repeat Pregnancy for Adolescent Mothers and Infants at 12 and 24 Months Compared With National Benchmarks or Previous Studies: Raising Adolescent Families Together Program, 2002–2007

3 Months After Delivery (n = 181)12 Months (n = 163)24 Months (n = 144)aComparators and Benchmarks
Attrition1020.4Teen-tot model (Simon) 1 y 12%, 2 y 23%38
Home visiting (Barnet) 1 y 26%, 2 y 25%39
Adolescent mother medical visits/yTeen-tot (Simon) total mother and child visits at 1 y = 6 ±238
 Mean ±SD1.9 ±1.22.5 ±21
 ≥ 1 visit, %84.486.7
Child medical visits/y
 Mean ±SD4.6 ±1.63.1 ±1.8Denver Stepped Intervention 0–15 mo ≥ 6 visits 65%40
 % with recommended visitsb42.460.6National well child care rates for children with public insurance (Byrd) 35%41
Uses condoms sometimes or always, %41.056.764.6*Home visiting intervention (Barnet) 50% at 1 y, 55% at 2 y39
Home visiting intervention (Black) 78% at 1 y16
Uses oral contraceptives, %14.79.011.7School based intervention (Key) 12% at 24 mo14
Home visiting intervention (Black) 29% at 24 mo16
Uses DMPA, %46.643.250.5School-based Intervention (Key) 71% at 1 y17
Teen-tot model (Simon) 18.9% at 1 y38
Home visiting (Black) 57% at 2 y16
Any repeat pregnancy (cumulative), %014.724.6Teen-tot model (Simon) 1 y 14%, 2 y 35%38
Home-visiting Intervention (Barnet) 1 y 19%, 2 y 45%39
Home-based mentoring (Black) intervention 11% vs control 24%, 2 y16
Child immunizations up to date, %86.490.2Age 24 mo rate: HEDIS benchmark 90%; CHPCC 85%; Boston 86.6%; MA state rate 84.9%; US 77%35,40,42,43

Note. CHPCC = Children’s Hospital Primary Care Center; DMPA = depot medroxyprogesterone; HEDIS = Healthcare Effectiveness Data and Information Set.

aMcNemar Test for related samples used to assess differences in response frequencies over time.

bRecommended visits age 1–12 months = 5 and age 12–24 months = 8.

*P < .01.

Table

TABLE 3— Life Skills and Progress toward Independence for Adolescent Mothers and Infants at 12 and 24 Months Compared With National Benchmarks or Previous Studies: Raising Adolescent Families Together Program, 2002–2007

TABLE 3— Life Skills and Progress toward Independence for Adolescent Mothers and Infants at 12 and 24 Months Compared With National Benchmarks or Previous Studies: Raising Adolescent Families Together Program, 2002–2007

At Birth of Child (n = 181) Valid %12 Months (n = 163) Valid %24 Months (n = 144) Valid %Comparators and Benchmarks
Adolescent mother in school or graduated64.177.668.7Home visiting model (Barnet) 2 y = 71%39
Public health nursing (Koniak-Griffin) 2 y = 65%4
Adolescent mother employed5.521.232.3*Boston 2006 employment rate for all adolescents = 34.3%44
Adolescent mother living with parent(s) or family55.844.836.8*Adolescent mothers living in multigenerational households (Oberlander) at 1 y = 78%, at 2 y = 54%45
Adolescents living with their mother (Black) at 2 y = 72%16
Received income from TAFDC51.752.855.6NA
Received Medicaid93.991.489.6NA
Father supporting child financially61.348.647.9*Young, disadvantaged father’s financial support at 1 y (Gavin) = 11.9%8
Teen-tot model (Cox) 33% at 2 y9

Note. NA = not applicable; TAFDC = Transitional Aid to Families with Dependent Children.

*P < .01.

Table 4 summarizes the associations between adolescent mother characteristics at baseline and rates of repeat pregnancy at 2 years. Adolescents who were older than 18 years at program enrollment, or who received more support from their own family or from the baby’s father’s family had higher rates of repeat pregnancy (all marginal). Those with more medical home visits had higher rates of repeat pregnancy. Finally, contraception use, particularly DMPA, significantly reduced likelihood of repeat pregnancy. In multiple logistic regression analysis controlling for demographics and other potentially significant covariates, only contraception use remained statistically significant. We found that use of DMPA had an adjusted odds ratio of 0.19 (95% confidence interval = 0.05–0.69; P = .037) for reduction of repeat pregnancy compared with no contraception.

Table

TABLE 4— Rates of 1 or More Repeat Pregnancies by Year 2 Follow-Up: Raising Adolescent Families Together Program, 2002–2007

TABLE 4— Rates of 1 or More Repeat Pregnancies by Year 2 Follow-Up: Raising Adolescent Families Together Program, 2002–2007

VariableNo.Any Repeat Pregnancy by Year 2, No. (%)P
Baseline characteristics
Adolescent mother's age, y.054
 < 189318 (19.4)
 ≥ 188828 (31.8)
Baby’s age, mo.157
 < 1215035 (23.3)
 ≥ 123111 (35.5)
Race/ethnicity.253
 Black7421 (28.4)
 Latina7019 (27.1)
 Biracial or other355 (14.3)
Depressive symptoms scorea.82
 < median5616 (28.6)
 ≥ median5918 (30.5)
Social support scoreb.952
 < median5817 (29.3)
 ≥ median5717 (29.8)
Support from FOB.112
 None345 (14.7)
 Any14741 (27.9)
Support from FOB’s family.084
 None7515 (20.0)
 Social support only6615 (22.7)
 Child care3915 (38.5)
Support from own family.059
 None426 (14.3)
 Any13940 (28.8)
By year 2
Total YPP visits.027
 0–8528 (15.4)
 9–115612 (21.4)
 ≥ 127326 (35.6)
Birth control use.027
 None2111 (52.4)
 Non-Depo methods3513 (37.1)
 Depo Provera5211 (21.2)
School/employment.878
 In school or work10433 (31.7)
 In neither3310 (30.3)
Receipt of TANF.422
 Never4412 (27.3)
 Some of the time6513 (20.0)
 All of the time7121 (29.6)

Note. FOB = father of baby; TANF = Temporary Assistance for Needy Families; YPP = Young Parents Program. P values determined by χ2 test.

aCenter for Epidemiologic Studies - Depression Scale for Children. Possible score range = 0–60 with score of > 15 suggestive of significant depressive symptoms.

bDuke-University of North Carolina Functional Social Support Questionnaire. Possible scores range up to 672.

Our evaluation showed that a family-centered medical home model for adolescent parents and their children effectively engaged them in a wide range of medical and social services. Adolescent parents are a high-risk group, and the adolescents studied had histories of family dysfunction, depression, and suicidal ideation.3,5 Their support systems were often unreliable. Although most had some family support at delivery, this decreased over time, as did support from the father of their baby. The flexible medical home provided a safety net. Open scheduling allowed patients easy access to services. Adolescents appreciated the family-centered approach as previously reported.45 Clinic attrition was low compared with other adolescent parenting programs.29

The medical home facilitated delivery of high quality care as evidenced by child immunization rates consistently above national, state, and local benchmarks.35,40,43 This was noteworthy, given that children living in poverty or Black children have lower immunization rates nationally.35 Although only 42.4% of infants met the recommended number of 6 well-child visits during year 1, compliance with care increased to 60.6% in year 2, and 84.4% and 86.7% of adolescents met visit recommendations in years 1 and 2, respectively.47 The program surpassed rates of well care in a national study in which only 35% of publicly insured children received recommended preventive visits41 and was higher than rates reported for adolescent parent clinics where “clinic attendance” ranged from 40% to 75%.29 The team approach facilitated longer clinic visits. A recent study showed increased well-child visit duration was associated with more anticipatory guidance and family satisfaction.48 Adolescent health care, however, was not limited to scheduled visits. Rather, counseling on reproductive health and social needs assessment occurred every time adolescents brought their child in for health care, and our study showed significant increase in use of condoms over 2 years. Almost 50% of adolescents continued use of DMPA for contraception. By contrast, adolescent mothers often start hormonal contraception, but use decreases over time, leading to high risk of repeat pregnancy.48

Cumulative repeat pregnancy rates at 12 months (14.7%) and 24 months (24.6%) for project adolescents were lower than those in many previous reports, in which the 24-month rate ranged up to 42%. However, decreasing repeat pregnancy proved challenging.7,49 Corcoran’s meta-analysis of adolescent parent programs showed a 50% reduction in the odds of pregnancy during the first 19 months but no reductions thereafter.13 In our study, rates were highest during the first 12 months and associated with not using contraception. Adolescents experiencing repeat pregnancy visited the medical home more often, probably reflecting increased need for services.

Previous studies showed that use of DMPA has a strong impact on repeat pregnancy.38 We found that the medical home was associated with increased use of DMPA, which in turn reduced likelihood of repeat pregnancy by the second year. Use of long-acting contraception, such as Mirena-Intrauterine Devices (Bayer AG, Leverkusen, Germany) or Implanon (Merck & Co., Inc., Whitehouse Station, New Jersey), has the potential to provide even more effective pregnancy prevention, but was not available during this study. Contrary to previous studies, we found no association between repeat pregnancy and maternal depression.50 We previously reported that adolescents who had high depressive symptoms showed decreased symptoms as social support increased during year 1.3 It was possible that within a medical home, depressed adolescents were identified early, attended more visits, and received effective contraception, which decreased pregnancy risk.

Family functioning was addressed through integration of social services into medical care. Our longitudinal data showed that adolescents continued in school at high rates for 24 months and established independent households. By 24 months, only 36.8% of adolescents were still living with their parents or families compared with 50% of adolescent mothers in the study of multigenerational adolescent parent households by Oberlander et al.45 Rates of school continuation were similar to an intervention using home visiting, which showed improved school continuation but no positive impact on repeat pregnancy, depression, or connection to primary care.42 Our program school continuation rate of 77.6% at 12 months and 68.7% at 24 months was remarkable given the low national rate of high school graduation or General Equivalency Diploma completion of 56% among 22-year-old women who were adolescent mothers.51 Adolescent employment rates were higher than rates for all Massachusetts adolescents.44 The majority of fathers maintained contact with their children, but unfortunately paternal financial support and committed parental relationships decreased over time. We described similar findings in a previous 1995 study.9 These findings reflected the challenges faced by urban, non-White young males who have high rates of school failure and incarceration. It also suggests that programs should specifically support young fathers and build positive co-parenting relationships.

There were several limitations to this study. There was no comparison group that did not receive services within a medical home; however, we compared our data with national norms and other adolescent parenting programs.52 We also tracked multiple outcomes over time with methodology commonly used for medical quality improvement. Subjects were all low income, urban minority adolescents, and results might not be generalized to other populations. Further studies are needed that include a control group of adolescent parents who do not receive care within a teen-tot model. In addition, studies should examine long-term child developmental and educational outcomes as well as adolescent education completion, job performance, and mental health. Cost-effectiveness studies are also needed.

In conclusion, the teen-tot medical home was an effective model of care for high-risk adolescent parents and their children, and demonstrated improved medical and reproductive health care and child immunization rates. The model described included many of the elements that decrease recidivism outlined in the repeat adolescent pregnancy review by Klerman10: in-depth, sustained relationships between adolescents and caring providers, highly trained personnel, one-on-one discussions of the downside of repeat pregnancy, future goal setting, embedded family planning, support for return to school, and help with transition to independence. The family-centered medical home brings these elements together in a model that can adjust to the needs of the adolescent, her baby, and potentially her partner and family.

Acknowledgments

We would like to thank the staff and patients in the Young Parents Program. This research was supported in part by the Office of Adolescent Pregnancy Programs (grant 5AP PA 002033-02-C), Leadership Education in Adolescent Health (grant T71 MC 00009 Maternal and Child Health Bureau; Title 5, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services, and The Edgerly Family.

Human Participant Protection

The study was approved by the institutional review board of Children’s Hospital Boston, and informed consent was obtained.

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Joanne E. Cox, MD, Matthew P. Buman, PhD, Elizabeth R. Woods, MD, MPH, Olatokunbo Famakinwa, MD, MPH, and Sion Kim Harris, PhD, CPHJoanne E. Cox and Olatokunbo Famakinwa are with the Division of General Pediatrics, Children’s Hospital Boston, Boston, MA. Matthew P. Buman is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix. Elizabeth R. Woods and Sion Kim Harris are with the Division of Adolescent/Young Adult Medicine, Children’s Hospital Boston. Sion Kim Harris is also with the Clinical Research Program, Children’s Hospital Boston. “Evaluation of Raising Adolescent Families Together Program: A Medical Home for Adolescent Mothers and Their Children”, American Journal of Public Health 102, no. 10 (October 1, 2012): pp. 1879-1885.

https://doi.org/10.2105/AJPH.2012.300766

PMID: 22897537