A cautionary note

Abstract

I am concerned that the hope of preventing second and higher order pregnancies to teenage mothers Klerman and colleagues' recent report [1] raises will spark a flurry of costly, time and labor intensive investments in home visitation programs. While this intervention strategy may prove beneficial for other reasons. [2], two consideration should give us pause about its unique utility as a solution to this tenacious problem. First, although the three interventions the authors compare were randomized trials, the populations that were randomized were very different. Teens could only enter the postpartum phase of the nurse home visitation trials at delivery [2]. By contrast, many of those randomized in the other two trials were already 6- to-9 months postpartum when the Klerman life-table time-clock started [3]. By eliminating some of those at highest risk for conception and capturing others at a point in their reproductive careers where they may have already experienced contraceptive side-effects or boyfriend cajoling that make the consequences of conception less onerous than those of daily contraceptive use this “rolling admissions” policy creates a selection bias, the effects of which are impossible to estimate. Because this methodologic problem calls the validity of these trials into question, it will be critical to level the playing field before dismissing the intervention strategies they were designed to test. Secondly, while the gain in the “Memphis” trial was statistically significant, with at least 20% of those in the intervention group conceiving during the first and 42% during the second postpartum year, (incident rates comparable to those quoted nationally in the absence of any intervention [4]), it is far less impressive from a clinical standpoint. Indeed the findings have been sufficiently consistently so across the various trials of this intervention [2], that based on the results of the present analysis it seems safest to conclude that intensive pre- and post-natal home visitation is not the key to this Pandoran box. Nonetheless because the therapeutically optimal combination of incentives and disincentives remains elusive I agree with the authors that we need to continue to ask why. However the critical question is not the one they pose: “Why (do) teenage mothers choose to have closely spaced second births ?” (1), (most will say they don't and the conversation will likely stop there [5]). Rather what we need to ask ourselves and our teenage patients is why these young women whose carefully braided hair and beautifully acryliced nails testify to their cognitive capacity for deductive reasoning and future-oriented planning are unwilling to take the steps necessary to prevent conceptions they say they and their boyfriends, at a minimum wish to postpone.