Health Outcomes Among Adolescents Giving Birth: A Younger Canary in the Coal Mine

In the 2010s, a series of reports changed how we understand maternal mortality in the United States. First, rates of maternal mortality are high in the United States compared to peer nations¹ and are rising.² Second, maternal health outcomes remain plagued by longstanding inequities: Black and Indigenous individuals face a 3–4 times higher risk of maternal mortality compared to White individuals.³ Third, complications from pre-existing chronic conditions, rather than traditional obstetric complications, play an increasingly important role in fueling these sober statistics.³ Finally, in 2018, a groundbreaking report from the Centers for Disease Control and Prevention (CDC) revealed an even larger challenge: the overall death rate among reproductive-aged individuals, not just those giving birth, was increasing.⁴ Maternal mortality was suddenly seen as the “canary in the coal mine” warning of a much larger problem.⁵ Clinical and policy efforts to improve maternal health clearly needed a broader focus on the health of all individuals with the capacity to give birth.

In this month’s issue of Obstetrics & Gynecology, Staniczenko et al⁶ (see page XX) shed light on a previously underexplored aspect of the maternal health crisis: trends in health and health outcomes among adolescents giving birth. The study team examined a national cohort of 73,198,143 hospitalizations for birth occurring between 2000 and 2018, including 6,447,694 births to adolescents aged 11–19 years (8.7%). Almost all births to adolescents were identified among individuals aged 15–19 years (98.7%). The study team found that births to adolescents steadily declined over the study period. In fact, the proportion of births to individuals aged 15–19 years decreased by more than half, dropping from approximately 12% (2000) to 5% (2018) of all births. The finding of an absolute and relative decline in births to adolescents identified in this study mirrors recent CDC reports.⁷

Severe maternal morbidity and mortality (SMM) is often defined as unexpected outcomes of labor and birth that result in significant short- or long-term consequences for a mother’s health. Severe maternal morbidity and mortality affects a much larger proportion of the birthing population than the most adverse of maternal health outcomes — mortality — and is often studied in order to understand how to address and prevent future cases of both maternal morbidity and mortality. The finding that the risk of incurring SMM is greater among adolescents compared to individuals aged 20–54 years is also consistent with other recent studies.⁸ However, the study team also found that the rate of SMM among adolescents giving birth has increased over the last two decades, mirroring trends in the overall birthing population. It is troubling, but not surprising, that SMM is increasing among adolescents and that this has largely gone undetected. National SMM surveillance efforts are hindered by siloed administrative data across different health systems, insurers, and geographic boundaries. Further, national survey data do not reflect whether postpartum individuals have experienced SMM.

The increasing prevalence chronic conditions among adolescents giving birth identified by the study team, which has also largely gone undetected, is particularly elucidating. Like SMM surveillance, there is currently a shortage of epidemiologic data examining the prevalence of chronic conditions among adolescents, including among adolescents giving birth. Many surveys and surveillance systems for chronic disease fail to recognize adolescents as a distinct developmental stage, instead grouping adolescents with either children or adults. There is also wide variability in how adolescents are categorized across different data sources and studies, making comparisons and consensus difficult. The study team found that the prevalence of every physical and behavioral health condition examined (obesity, asthma, pregestational diabetes, substance use, and a composite of other common psychiatric conditions) increased over the last two decades among adolescents giving birth. While the present study is not causal in nature, each of these conditions has been independently associated with increased risk for maternal morbidity and mortality. Moreover, the authors find that the prevalence of pre-gestational diabetes increased at a higher rate among individuals aged 11–19 years compared to individuals aged 20–54 years. Taken together, the findings from this study support the possibility that there may be a widening pipeline of individuals entering pregnancy with comorbid conditions for years to come. These findings are a clear call to further investigate the health status of both childbearing adolescents and the overall adolescent population.

The findings of the present study are also a call to further explore inequalities in adolescent health. First, if adolescents giving birth are found to have higher rates of chronic conditions compared to the overall adolescent population, this would point to possible inequitable access to high quality preconception care among adolescents giving birth. Such barriers could include access to clinicians knowledgeable about providing contraception to adolescents with chronic conditions. Second, the study found that births to non-Hispanic black and Hispanic individuals comprise a larger proportion of births to adolescents than births to individuals at older ages. This finding suggests there is a need to also explore differential barriers to high quality prepregnancy care among adolescents of different racial and ethnic identities. Future work should also discern whether there is differential risk for SMM among adolescents of different racial and ethnic identities. The drivers of any such disparities, including systemic racism, must be addressed. It is increasingly understood that it is also important to examine health outcomes at the intersection of more nuanced racial, ethnic, and geographic identities given the heterogeneity of the U.S. population and established differential health risks based on geographic factors such as rural residence. Finally, adverse maternal health outcomes incurred before and after hospitalization for birth as well those associated with pregnancies not resulting in livebirth must be considered in future studies among both adolescent and older individuals giving birth.

This study by Staniczenko et al published in this month’s issue of Obstetrics & Gynecology should serve as a call to action for directing clinical and research resources towards a greater understanding of the causes of SMM among adolescents giving birth and the larger health profile of the adolescent population. The study findings, particularly those of rising rates of SMM and chronic conditions among adolescents giving birth, are an important reminder that to address preventable maternal morbidity and mortality in the United States, we must continue to broaden our focus on the health of all individuals with the capacity to give birth.

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