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ORIGINAL RESEARCH |
From the Brown Medical School, Departments of 1Obstetrics and Gynecology, 3Community Health, and 4Medicine, and 2Women & Infants Hospital of Rhode Island, Rhode Island Hospital, Providence, Rhode Island.
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ABSTRACT |
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 ABSTRACT PARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Three hundred pregnant adolescents presenting for their first prenatal visit participated in a cohort study that addressed attitudes about pregnancy. All participants were aged younger than 20 years and gave informed consent. The outcome of interest was a positive response to the question "Did you have any fears that you wouldn’t be able to get pregnant?" Independent measures included health history and demographic variables.
RESULTS: Among participants, 42% stated they had fears about not being able to conceive. The total sample included 20% 12–15 year olds, 39% 16–17 year olds and 41% 18–19 year-olds. There was no statistically significant difference in fear of not being able to conceive by maternal age, reported sexually transmitted disease rates, or age at first intercourse. More adolescents who expressed fear of infertility had a previous spontaneous abortion, previous pelvic examination, and were sexually active for a longer period of time compared with those without this fear.
CONCLUSION: A large proportion of pregnant adolescents in this study expressed fear that they would not be able to conceive. Understanding the basis of the fear is critical to appreciating its association with current and future adolescent pregnancy and contraceptive use.
LEVEL OF EVIDENCE: III
One of the reasons often cited by adolescents for not using contraception is that the adolescent thought she was unable to conceive. Although pregnancy intention among adolescents is poorly defined, much of this literature focuses on why adolescents failed to use contraceptives and their ambivalent or positive feelings about having a child.7,8 In our clinical experience, multiple adolescents have expressed concern about their ability to become pregnant. Few studies have looked at adolescents’ fears of not being able to conceive and this fear potentially affecting their decision to use contraception. A study examining nulliparous, sexually experienced adolescent females between 14 and 18 years of age seeking routine medical care reported that 21.5% of participants had concerns about their fertility. There were many factors associated with this fear. The factors most strongly correlated with this fear were having a history of a sexually transmitted disease (STD), having discussed concerns about infertility with another person, an older partner, a partner who desires a pregnancy, and a desire for pregnancy.7
Many programs aimed at decreasing rates of teenage pregnancy are built on the assumption that teenagers wish to avoid pregnancy. However, the effectiveness of these programs depends on whether they are addressing adolescents’ needs, fears, and desires regarding reproduction. If an adolescent fears that she may not be able to conceive, is she likely to be taking precautions to avoid pregnancy? Wimberly et al5 conducted focus groups of adolescents exploring adolescents’ understanding of the definition of fertility and what factors they believed caused infertility. A majority of participants had been exposed to the word fertility and had a rough idea of its meaning as the ability to become pregnant. They associated infertility with a variety of causes, including having a sexually transmitted disease, male factors, substance abuse, and using contraceptives.6
In the present study, we surveyed pregnant adolescents attending their first prenatal visit about their pregnancy intentions, including whether they had fears about not being able to conceive before their current pregnancy. Reflecting on our own clinical experience and the limited research in this area, we hypothesized that pregnant adolescents who expressed fears of not being able to conceive would be older, have higher rates of reporting previous STDs and previous spontaneous abortion, and have used contraception less consistently than adolescents who did not express that they had fears of not being able to conceive.7 Conceptually, there are many factors that might contribute to adolescents’ fear of not being able to conceive, including demographic background, health behaviors and history, social behaviors, media influences, and family experiences. In turn, this fear, along with other influences such as ambivalent or positive feelings about pregnancy and lack of access to contraception, may lead to inadequate or no contraceptive usage. These sexually active teenagers who are not using adequate contraception put themselves at risk for becoming pregnant. We chose to investigate the question of fear of not being able to conceive in adolescents who were pregnant to gain a better understanding of the perception of pregnancy in a diverse, high-risk population. The information gained has the potential to enhance the development of counseling and pregnancy prevention interventions for adolescents.
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PARTICIPANTS AND METHODS |
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The adolescents were recruited during their first prenatal visit. Informed consent was obtained from the participant, and if she was aged younger than 18 years, consent was also obtained from her parent or legal guardian. Adolescents were eligible to participate if they were attending their first prenatal visit, if their estimated date of delivery was before their 20th birthday, they agreed to subsequent review of their records, they were able to give informed consent, and able to speak and read English. Trained research assistants interviewed all participants. The 30-minute interview included questions regarding the teenager’s demographic background, life plans, social supports, family and peer relationships, financial status, health history, and behavioral risks.
The interview took place in a private setting. In cases where participants’ answers raised a concern about safety or depression, referrals were made to social services for further assessment and management. This notification and referral practice was clearly explained during the informed consent process.
To assess recruitment efficiency of this convenience sample, a period of recruitment was reviewed, January 2003 through November 2003. Of the 241 teenagers meeting eligibility criteria during this period, 148 teenagers were informed about the study; 62% were successfully consented and recruited for participation, and 25% declined. The remaining 13% were unable to be successfully recruited because of issues involving appropriate informed consent (minor’s parents not available to formally consent, language or intellectual barriers not permitting appropriate consent). The same recruitment approaches were used throughout the study period.
The main outcome for this study was determined by asking the participants to "think back to the time just before you were pregnant, and how you felt about pregnancy at that time." Then they were asked, "Did you have any fears that you wouldn’t be able to get pregnant?" The answer to this question was dichotomous, yes or no.
Race or ethnicity was assessed through two separate questions. The first was "Do you consider yourself to be Hispanic or Latina?" with the response being recorded as yes or no. The follow-up question was "What race do you consider yourself to be?" with responses modeled after the expanded U.S. Census categories. Participants were asked if they were currently in school and then a follow-up question was asked regarding the highest grade they completed.
Sexual history included age at first intercourse, length of time sexually active, age of the father of the baby, and number of lifetime partners. Gynecologic history included age of menarche, history of sexually transmitted disease, and prior pelvic examination. Obstetric history included number of previous pregnancies and their outcomes, including live births, spontaneous abortions, and terminations. Participants were also asked about a history of sexual abuse. Health habits included current and past use of tobacco, alcohol, and drugs.
Contraceptive use included direct questions regarding usage during the time of conception, lifetime usage, and what types of birth control methods were used. Reasons for not using birth control around the time of conception were evaluated on a five-point scale assessing participant agreement with each of six statements (strongly agree, mildly agree, unsure, mildly disagree, strongly disagree). Examples of these statements include, "I wanted to get pregnant" and "I didn’t think I could get pregnant."
Independent variables, including demographic, health history, and contraceptive practices, were compared between those who expressed fear and those without fear. The analysis for this study included t test for continuous variables, and 
2 or Fisher exact tests for categorical variables. Stata 8.0 (StataCorp LP, College Station, TX) was used for the statistical analysis.
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RESULTS |
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Of the 300 adolescents participating in this study, 42% (n=126) answered, "yes" to the question, "Did you have fears that you wouldn’t be able to get pregnant?" There was no statistically significant difference when we examined responses to the question about fear of not being able to conceive by maternal age (P=.93). Younger adolescents, aged 14–15 years, were just as likely to have this fear as the older adolescents, 18–19 years old.
There was no difference in the proportion of reported STDs between those participants with a fear and those without (25% compared with 21% P=.29). Age at first intercourse was also similar between the two groups. There was a statistically significant difference found in the mean length of time of being sexually active, 2.6 years in those with a fear compared with 2.0 years in those without a fear (P<.01). Another difference found was that those with a fear of not being able to conceive were more likely to have previously had a pelvic examination (63% compared with 52% P=.04). Analysis of previous pregnancies showed that adolescents with a previous spontaneous abortion were more likely to fear not being able to conceive (55%, n=21) compared with 31% (n=16) P=.02). However, there were no differences when comparing previous terminations or live births (Table 2).
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Participants who stated that they had a fear that they were unable to conceive were less likely to be using contraception than their counterparts, but this was not statistically significant (17% compared with 26% P=.09). For those teenagers who were not using contraception at the time of conception, more detailed questions examining the reasons why they were not using contraception were asked (Table 3). A significantly higher proportion of teenagers with the fear of not being able to conceive agreed with the following statements, "I wanted to get pregnant," "I didn’t think I could get pregnant," "I didn’t want to use birth control," and "my partner didn’t want to use birth control." The two groups had similar proportions agree that they experienced side effects from birth control or that they didn’t think they were going to have sex.
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DISCUSSION |
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Sexually active adolescents who do not consistently use contraception are at high risk for conceiving. In our study, all of the participants were pregnant adolescents and remarkably, almost one half of the participants answered yes to the question "Did you have fears that you wouldn’t be able to get pregnant?" In a study by Rainey et al6 only 21.5% of nonpregnant adolescents had concerns about their fertility.7 Some factors associated with this fear, such as a desire for pregnancy, were the same between this study and ours. However, other factors that were significant in the study by Rainey et al, like reporting a history of an STD or having an older partner, were not found to be significant in our study. These differences could be attributed to differences in the study populations and in the study designs.
We hypothesized that demographic and health history factors would be different between those adolescents with a fear and those without this fear, including that the teenagers with a fear of not being able to conceive would have a higher rate of previous sexually transmitted diseases. We assumed that these teenagers would have been more likely to encounter practitioners and been counseled on the long-term consequences of untreated sexually transmitted diseases.11 Although teenagers that expressed fear about pregnancy were more likely to have undergone a pelvic examination, there was no statistically significant difference found between the two groups on STD history. Pelvic exams are done for numerous reasons, including annual primary care examinations, cervical cancer screening, symptomatic pelvic complaints including signs of an STD, contraceptive counseling, and pregnancy or suspicion of pregnancy. Although we did not delve into the reasons why the teenagers in our study had undergone previous pelvic exams, teenagers may have sought care due to a suspicion of having an STD or seeking contraception which may have led to counseling regarding risks of STDs and unprotected intercourse. Many teenagers may have concerns regarding their ability to become pregnant and encounters with a medical professional could be potential educational opportunities.
One of the differences between the two groups was that those with a fear of not being able to conceive had a higher rate of previous spontaneous abortion. It is possible that those teenagers with a previous spontaneous abortion would have concerns that this event may reoccur, or that having an abortion could have precipitated an inability to become pregnant again. They may equate the fear of not being able to conceive with the fear of not being able to carry a pregnancy to delivery.
It was surprising that the younger aged participants were just as likely as older teenagers to have a fear of not being able to conceive. Why would such young adolescents have this fear? One consideration is that adolescents of all ages are exposed to and influenced by popular media. It is possible that popular media is adding to this fear of not being able to conceive among teenagers regardless of their own personal experiences. In one study, teenagers stated that they had been exposed to the concept of fertility through the media, and named talk shows as their source of information.6 We explored reasons for adolescents having fears about not being able to conceive in another convenience sample of adolescents from our adolescent pregnancy clinic. Reasons often cited for fears of not being able to conceive were very practical, including: that they were having frequent unprotected intercourse and yet not getting pregnant and that a family member had struggled with infertility. These reasons are consistent with our finding that teenagers with a fear of not being able to conceive have been sexually active for a longer period of time than those who did not express this fear.
Although not statistically significant, those with a fear of not being able to conceive were less likely to be using contraception at the time of conception than those without this fear. However, their reasons for not using birth control were significantly different. The adolescents with a fear of not being able to conceive were more likely to report wanting a pregnancy and not wanting to use birth control. There may be a link between wanting a pregnancy and fearing not being able to have one. Thirty-one percent of the participants who had fear of not being able to conceive agreed with the statement "I wanted to get pregnant." It is logical that teenagers who want to become pregnant are less likely to be using contraception. Also if they fear that they are unable to conceive and they desire a pregnancy then they may be more likely to try to conceive now instead of waiting until they are older. Perhaps the teenagers who desired a pregnancy have had multiple unprotected sexual encounters in an attempt to conceive but did not conceive. This may understandably lead to their thinking that they were unable to conceive. Similarly, those teenagers who had been sexually active longer were more likely to have fears about not being able to conceive. Since this is a cross-sectional analysis, causality cannot be established between the fear of not being able to conceive and contraceptive use. However, this relationship raises an important question to be addressed in future studies.
Only 64% of the teenagers who feared that they are unable to conceive agreed with the statement, "I didn’t think I could get pregnant" when asked about their reasons for not using birth control. Although a higher correlation between the two questions might be expected, some adolescents might fear that they cannot conceive, but do not really believe that they are unable to conceive. Also, if a teenager fears that she cannot conceive, she may be inclined not to use contraception to test her fertility.
We chose to include pregnant adolescents for our study participants because this is a group of sexually active teenagers that have proven themselves at high risk for becoming pregnant. However, using this restricted sample limits the applicability of the data to groups of other teenagers, including nonpregnant and those who choose to terminate their pregnancy. Teenagers who choose to terminate their pregnancy may be more likely to have fears about not being able to conceive. These teenagers may have been having unprotected intercourse to test their own fertility, although the resulting pregnancy was not wanted. It is also possible that they had less of a fear, but were inadequately using contraception for other reasons. This study does not include these other groups of teenagers, but does highlight the need to investigate the issue of fears about infertility among adolescents, potentially aiding in teenager pregnancy prevention programs.
There are many teenagers who fear that they are unable to become pregnant. More studies are needed to further address where this fear comes from, the extent of it, and how it influences choices adolescents make. Questioning adolescent patients about whether they have concerns about their ability to conceive might be helpful in targeting counseling messages. For example, when dispensing contraception it would be important to stress that the contraceptive method being used is a temporary means of preventing pregnancy and does not cause long-term infertility. Decreasing the rate of adolescent pregnancy relies on our understanding of teenagers’ perception of pregnancy and how it influences the choices they make.
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Footnotes |
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This study was partially funded through a grant from the Brown University Office of the Vice President of Research and the Rhode Island Foundation.
Corresponding author: Emily M. White, MD, Women and Infants’ Hospital, 101 Dudley Street, Providence, RI 02905; e-mail: ewhite{at}wihri.org.
doi:10.1097/01.AOG.0000240137.99609.2e
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REFERENCES |
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2. Centers for Disease Control and Prevention (CDC). National and state-specific pregnancy rates among adolescents—United States, 1995–1997. MMWR Morb Mortal Wkly Rep 2000;49:605–11.[Medline]
3. The Alan Guttmacher Institute. Facts in brief: teen sex and pregnancy. New York (NY): The Alan Guttmacher Institute; 1999.
4. Stevens-Simon C, Kelly L, Singer D. Absence of negative attitudes toward childbearing among pregnant teenagers: a risk factor for a rapid repeat pregnancy? Arch Pediatr Adolesc Med 1996;150:1037–43.[Abstract]
5. Wimberly YH, Kahn JA, Kollar LM, Slap GB. Adolescent beliefs about infertility. Contraception 2003;68:385–91.[Medline]
6. Rainey DY, Stevens-Simon C, Kaplan DW. Self-perception of infertility among female adolescents. Am J Dis Child 1993;147: 1053–6.[Abstract]
7. Bruckner H, Martin A, Bearman PS. Ambivalence and pregnancy: adolescents’ attitudes, contraceptive use and pregnancy. Perspect Sex Reprod Health 2004;36:248–57.[Medline]
8. Kelly L, Sheeder J, Stevens-Simon C. Teen home pregnancy test takers: more worried or more wishful? Pediatrics 2004;113:581–4.
9. Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002. Vital Health Stat 23 2004;(24):1–48.
10. Stevens-Simon C, Kelly L, Singer D, Cox A. Why pregnant adolescents say they did not use contraceptives prior to conception. J Adolesc Health 1996;19:48–53.[Medline]
11. Mardh PA. Tubal factor infertility, with special regard to chlamydial salpingitis. Curr Opin Infect Dis 2004;17:49–52.[Medline]
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