Research

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OBSTETRICS

Inadequate prenatal care and risk of preterm delivery among

adolescents: a retrospective study over 10 years
Katherine E. Debiec, MD; Kathleen J. Paul, MPH; Caroline M. Mitchell, MD, MPH; Jane E. Hitti, MD, MPH
OBJECTIVE: The aim of this study was to determine whether inade-

quate prenatal care is associated with increased risk of preterm birth

among adolescents.
STUDY DESIGN: We selected a random sample of women under age
20 years with singleton pregnancies delivering in Washington State between 1995 and 2006. Multivariate logistic regression was used to assess the association between prenatal care adequacy (percent of expected visits attended, adjusted for gestational age) and preterm birth.

term birth (n 84 [24.1%]; adjusted odds ratio [aOR], 7.4), compared

with those attending 75-100% of recommended visits (n 346
[3.9%]). Women with less than 25%, 25-49%, or 50-74% of expected
prenatal visits were at significantly increased risk of preterm birth; risk
decreased linearly as prenatal care increased (n 60 [9.5%], 132
(5.9%], 288 [5%]; and aOR, 2.5, 1.5, and 1.3, respectively).
CONCLUSION: Inadequate prenatal care is strongly associated with

preterm birth among adolescents.

RESULTS: Of 30,000 subjects, 27,107 (90%) had complete data.

Women without prenatal care had more than 7-fold higher risk of pre-

Key words: adolescent, prenatal care, preterm birth, teen pregnancy

Cite this article as: Debiec KE, Paul KJ, Mitchell CM, et al. Inadequate prenatal care and risk of preterm delivery among adolescents: a retrospective study over 10
years. Am J Obstet Gynecol 2010;203:122.e1-6.

he US teenage pregnancy rate is one

of the highest among industrialized
nations.1 Although the rate of teen pregnancy declined between its peak of 61.8
births per 1000 teens aged 15-19 years in
1991 and reached a low of 40.5 in 2005,
preliminary data for 2006-2007 show
that over those 2 years, rates have risen to
42.5 births per 1000 girls aged 15-19
years.2
Data suggest that pregnant teenagers
are more likely than adult women to sufFrom the Department of Obstetrics and
Gynecology, University of Washington
School of Medicine, Seattle, WA.
Presented at the American College of
Obstetricians and Gynecologists District VIII
Annual Meeting, Los Cabos, Mexico, Sept. 25,
2008
Received Sept. 3, 2009; revised Dec. 29,
2009; accepted March 1, 2010.
Reprints not available from the authors.
C.M.M. is supported by the National Institute of
Child Health and Human Development
Womens Reproductive Health Research
Award.
0002-9378/free
2010 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2010.03.001

For Editors Commentary,

see Table of Contents

122.e1

fer adverse medical and obstetric outcomes, such as hypertensive disease, anemia, infection, and depression, during
pregnancy and may continue to have consequences, like depression later in life, delayed or discontinued education, or increased utilization of public assistance.1,3-6
Age younger than 17 years is associated
with a 1.5-1.9 times increased risk of preterm birth.7 Preterm birth, defined as delivery before 37 weeks gestational age, affects more than 10% of live births annually
in the United States and is responsible for
three-quarters of all neonatal mortality
and 35% of all health care spending for infants in the United States.7,8
Prenatal care may decrease adverse
pregnancy outcomes for teenage pregnant women by reducing risk factors
through education and social support.9,10 Teenage and adult mothers
probably differ in their access to and utilization of prenatal care.2 We hypothesize that inadequate prenatal care will increase the risk of preterm birth for
adolescents.

M ATERIALS AND M ETHODS

We used Washington State birth record
data to conduct a population-based co-

American Journal of Obstetrics & Gynecology AUGUST 2010

hort study of women who delivered between the years 1995 and 2006. Eligible
subjects were women under 20 years of
age who had singleton births during the
study period. From this population,
30,000 women were selected at random
for inclusion. Women with pregnancies
affected by fetal malformations or chromosomal abnormalities were excluded,
as were women with recorded gestational age at delivery greater than 43
weeks. The primary outcome was delivery at less than 37 weeks. The primary
exposure of interest was adequacy of prenatal visits. The study received approval
from the University of Washington Institutional Review Board.
Preterm birth was defined as gestational age less than 37 weeks at the time
of delivery. To classify adequacy of prenatal care, we calculated a ratio of the
actual number of prenatal visits compared with the expected number of visits
for a delivery at a given gestational age.
We used the American College of Obstetrics and Gynecology guidelines for
the schedule of prenatal care visits to calculate the expected number of visits: every 4 weeks from the first prenatal visit
through 28 weeks, every 2-3 weeks from
28 weeks until 36 weeks, and weekly
thereafter.11

Obstetrics

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Research

TABLE 1

Gestational age at delivery by visit category

Percentage of observed/expected prenatal visits
Variable

None, n (%)

<24%, n (%)

25-49%, n (%)

50-74%, n (%)

75-100%, n (%)

>100%, n (%)

Total, n (%)

Total births

349 (1.3)

629 (2.3)

2254 (8.3)

5718 (21.1)

8983 (33.1)

9174 (33.8)

27,107

37 weeks

265 (75.9)

569 (90.5)

2122 (94.1)

5430 (95.0)

8637 (96.1)

8214 (89.5)

25,237 (93.1)

37 weeks

84 (24.1)

60 (9.5)

132 (5.9)

288 (5.0)

346 (3.9)

960 (10.5)

1870 (6.9)

32-36 weeks

62 (17.8)

54 (8.6)

119 (5.3)

252 (4.4)

320 (3.6)

841 (9.2)

1648 (6.1)

32 weeks

22 (6.3)

6 (0.9)

13 (0.6)

36 (0.6)

26 (0.3)

119 (1.3)

222 (0.8)

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

Debiec. Inadequate prenatal care and risk of preterm delivery in adolescents. Am J Obstet Gynecol 2010.

We created a ratio of observed to expected visits, similar to Kotelchucks

prenatal care index (APNCU-Adequacy
of Prenatal Care Utilization Index).12
For the purposes of analysis, we divided
adequacy of prenatal care into 6 categories: no prenatal care, less than 25%, 2549%, 50-74%, 75-100%, and greater
than 100% of expected. We used an observed to expected visit ratio of 75-100%
of prenatal visits as our referent or ideal
category. Other data included maternal
age, race, insurance, smoking, first-trimester bleeding, prior preterm birth,
pregestational diabetes, hypertensive
disease, and culture-positive Neisseria
gonorrhea or Chlamydia trachomatis.
Data for N gonorrhea and C trachomatis
were available only after 2002.
All analyses were conducted using
Stata 10.0 (Stata Corp, College Station,
TX). One-way ANOVA and 2 tests were
used to test for differences in demographic, reproductive, and behavioral
variables across the 6 exposure categories
of prenatal care adequacy. Univariate logistic regression was used to assess the
crude association between prenatal care
and preterm birth.
In the multivariate analysis, variables
that were potential confounders based
on the univariate analysis or were
strongly associated with preterm birth in
the literature were included in all models
(maternal age, race/ethnicity, marital
status, maternal smoking, and prior preterm birth); subjects missing data for any
of these variables were excluded from all
analyses.
A subgroup analysis by teen age
groups (maternal age 15 years, 16-17

years, and 18-19 years) was conducted,

as was a multinomial logistic model with
3 categories of birth outcome (32
weeks, 32-36 weeks, 37 weeks). We
conducted a stratified analysis in 3 year
blocks to assess change in risk during the
study period.
To detect a 30% difference in the rate
of preterm birth for teens with poor prenatal care (80% power and significance
level of alpha 0.05), we required a
sample size of 15,000. There are approximately 8000 live births to teens annually
in Washington State. Assuming that
20% of all births in Washington State
would have the variables of interest recorded completely, it was presumed that
there would be data on 1600 teen births
annually. Therefore, we determined that
we needed to review approximately 10
years of data to detect a 30% difference in
the rate of preterm birth for teens with
poor prenatal care.

R ESULTS
Of the random selection of 30,000
women under age 20 years with singleton
births in Washington State from 1995 to
2006, 27,107 (90%) had complete data
and were included in this analysis. We
excluded 642 subjects (2%) because their
pregnancies were affected by fetal malformations (n 634) or their recorded
gestational age at delivery was greater
than 43 weeks (n 8). An additional
2251 subjects (8%) were excluded for
missing maternal race, marital status,
maternal smoking, and prior preterm
birth or parity variables.
The overall rate of preterm birth in
this population was 7% (Table 1). A total

of 349 women received no prenatal care,

whereas 8983 attended 75-100% of expected visits. For teens with no prenatal
care, 24.1% of births were preterm, compared with 3.9% preterm births with 75100% of visits and 10.5% preterm births
for more than 100% of visits. Eightyeight percent of preterm births occurred
between 32 and 36 weeks gestational
age.
Women with inadequate prenatal care
were younger and more likely to be unmarried, nulliparous, have government
or charity-funded insurance, smoke during pregnancy, and have a history of
preterm birth (Table 2). Women with
first-trimester bleeding, pregestational
diabetes, and preeclampsia were more
likely to have attended more than 100%
of anticipated prenatal care visits. Rates
of chronic hypertension were similar between groups. There was no significant
difference in N gonorrhea or C trachomatis prevalence by prenatal care visit category for years with available data.
In the univariate analysis, women who
had no prenatal care were at nearly
8-fold higher risk of preterm birth (odds
ratio [OR], 7.9; 95% confidence interval
[CI], 6.110.3), compared with those
who attended 75-100% of the recommended visits (Table 3). Women who
had less than 25%, 25-49%, or 50-74% of
the recommended prenatal care visits
were also at significantly increased risk of
preterm birth, and risk appeared to decrease linearly as prenatal care increased.
Women who had more than 100% of the
recommended prenatal care were also at
higher risk of preterm birth (OR, 2.9;
95% CI, 2.6 3.3).

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TABLE 2

Demographics of study populationa

Percentage of observed/expected prenatal visits
Characteristic

None
(n 349)

<25%
(n 629)

17.5 1.4

Age, y

25-49%
(n 2254)

17.6 1.4

50-74%
(n 5718)

17.7 1.4

75-100%
(n 8983)

17.8 1.3

>100%
(n 9174)

17.9 1.2

P valueb

17.9 1.2

.001

................................................................................................................................................................................................................................................................................................................................................................................

Single

313 (90)

514 (82)

1784 (79)

4372 (77)

6857 (76)

6870 (75)

.001

Nulliparous

272 (94)

427 (92)

1710 (95)

4580 (97)

7599 (98)

7811 (98)

.001

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Race

.......................................................................................................................................................................................................................................................................................................................................................................

White

202 (58)

293 (47)

1219 (54)

3458 (61)

6125 (68)

.001

6558 (72)

.......................................................................................................................................................................................................................................................................................................................................................................

Black

31 (9)

53 (8)

170 (8)

390 (7)

449 (5)

465 (5)

Other

116 (33)

283 (45)

865 (38)

1870 (33)

2409 (27)

2151 (23)

Uninsured

121 (62)

331 (80)

1086 (76)

2669 (71)

4132 (67)

4092 (63)

.001

Smoking

94 (27)

147 (23)

486 (22)

1223 (21)

2023 (23)

2150 (23)

.017

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
c
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Chronic hypertension

1 (1)

10 (1)

18 (1)

26 (1)

43 (1)

.197

................................................................................................................................................................................................................................................................................................................................................................................

Preeclampsia

18 (5)

15 (2)

112 (5)

305 (5)

546 (6)

.001

742 (8)

................................................................................................................................................................................................................................................................................................................................................................................

First-trimester bleeding

5 (1)

3 (0.5)

19 (0.8)

51 (0.9)

82 (0.9)

128 (1.4)

.005

Diabetes

2 (1)

5 (1)

27 (1)

57 (1)

100 (1)

165 (2)

.001

C trachomatis

6 (4)

10 (5)

41 (5)

79 (4)

114 (4)

113 (4)

.924

N gonorrhea

1 (1)

4 (1)

Prior preterm birth

3 (1)

3 (0.5)

8 (0.4)

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
d
................................................................................................................................................................................................................................................................................................................................................................................
d

4 (1)

4 (1)

8 (1)

.386

46 (0.5)

.001

................................................................................................................................................................................................................................................................................................................................................................................
e

31 (0.5)

32 (0.4)

................................................................................................................................................................................................................................................................................................................................................................................
a

Valid (n 27,107) unless otherwise stated; Tests: 1-way analysis of variance for continuous variables, for categorical variables; n 18,424; n 8222; Among parous women only.
b

Debiec. Inadequate prenatal care and risk of preterm delivery in adolescents. Am J Obstet Gynecol 2010.

In the univariate analysis, there was an

increased odds of preterm birth associated with black race (1.3; 95% CI, 1.1
1.6), prior preterm birth (1.5; 95% CI,
1.12.0), and first-trimester bleeding
(2.5; 95% CI, 1.8 3.5). Increasing maternal age (0.94; 95% CI, 0.91 0.97) and
use of public funds (0.8; 95% CI, 0.7
0.9) were associated with decreased risk
of preterm birth.
For the multivariate analysis, the
model was adjusted for factors determined a priori (maternal age, ethnicity,
smoking, prior preterm birth) or those
determined to be significant in the univariate analysis (marital status). When
adjusted for potential confounders, results were similar; all categories of inadequate and more than adequate prenatal
care were associated with statistically significant increased risk of preterm birth
(Table 3).
In addition to the analyses presented
here, multivariate analyses stratified by
year of delivery (1995-1997, 1998-2000,
2001-2003, 2004-2006) or type of insur122.e3

TABLE 3

Odds of preterm birth

Variable

OR (95% CI)

aOR (95% CI)b

(n 27,107)

No prenatal care

7.9 (6.110.3)

7.4 (5.79.7)

25%

2.6 (2.03.5)

2.5 (1.93.3)

2549%

1.6 (1.31.9)

1.5 (1.21.8)

5074%

1.3 (1.11.5)

1.3 (1.11.5)

75100%

Referent

Referent

100%

2.9 (2.63.3)

2.9 (2.63.3)

Maternal age

0.94 (0.910.97)

Marital status

1.09 (0.971.2)

Rural

0.93 (0.831.04)

Black race

1.3 (1.11.6)

Prior preterm birth

1.5 (1.12.0)

Use of public funds

0.8 (0.70.9)

Smoked

1.0 (0.91.2)

First-trimester bleeding

2.5 (1.83.5)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

aOR, adjusted odds ratio; CI, confidence interval.

a

Univariate analysis; b aOR: adjusted for maternal age, ethnicity, marital status, smoking, and prior preterm birth.

Debiec. Inadequate prenatal care and risk of preterm delivery in adolescents. Am J Obstet Gynecol 2010.

American Journal of Obstetrics & Gynecology AUGUST 2010

Obstetrics

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were at 6 times the risk of moderately

preterm birth (aOR, 5.9; 95% CI,
4.4 8.0).

TABLE 4

Odds of preterm birth by agea

Variable

Age <15 y (n 1584)

16-17 (n 7349)

18-19 (n 18,173)

No prenatal care

3.5 (1.4-9.0)

8.1 (5.1-12.8)

7.9 (5.5-11.3)

25%

2.3 (0.93-5.5)

2.5 (1.5-4.2)

2.5 (1.7-3.6)

25-49%

1.1 (0.54-2.2)

1.8 (1.2-2.5)

1.4 (1.1-1.9)

50-74%

1.1 (0.65-2.0)

1.4 (1.1-1.9)

1.2 (1.0-1.5)

75-100%

Referent

Referent

Referent

100%

2.3 (1.4-3.8)

2.7 (2.1-3.4)

3.1 (2.7-3.7)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
a

Adjusted odds ratio: adjusted for maternal age, ethnicity, marital status, smoking, and prior preterm birth.

Debiec. Inadequate prenatal care and risk of preterm delivery in adolescents. Am J Obstet Gynecol 2010.

ance (Medicaid, health maintenance organization, commercial insurance) as

well as multivariate analyses adjusting
for pregestational diabetes and preeclampsia yielded similar results (data
not shown). Variables for which there
was a significant amount of missing data
(such as the use of public funds and firsttrimester bleeding) were excluded from
the final multivariate analysis because
they significantly decreased power, but
when the model was run with those variables included, there were no significant
differences (data not shown).
Adequacy of prenatal care was assessed by looking at total prenatal visits,
rather than the date of prenatal care initiation. Although a delayed initial prenatal visit was also associated with increased risk of preterm birth, the total
number of visits continued to predict the
risk of preterm birth when stratified by
the timing of the first visit (data not
shown).
Multivariate regression analyses stratified by maternal age produced similar

results (Table 4). For all teenagers,

women with no prenatal care were at
highest risk of preterm birth when compared with subjects who attended
75-100% of expected visits. Attendance
at greater than 100% of expected visits
was also associated with significantly increased odds of preterm birth. For teens
aged 16-19 years, women who had less
than 25%, 25-49%, or 50-74% of the recommended prenatal care visits were at
significantly increased risk of preterm
birth. Results were qualitatively similar
for teens aged 15 years or less but did not
reach statistical significance, likely because of the small numbers of deliveries
in this group.
In the multinomial logistic regression
analysis, ORs were generally larger for
associations with very preterm birth
(32 weeks) compared with moderately
preterm birth (32-36 weeks) (Table 5).
Specifically, women with no prenatal
care had more than 25 times the risk for
very preterm birth (adjusted OR [aOR],
25.5; 95% CI, 14.2 45.7), whereas they

TABLE 5

Multinomial regression of preterm deliverya

Variable

<32 wks

32-36 wks

No prenatal care

25.5 (14.2-45.7)

5.9 (4.4-8.0)

25%

3.4 (1.4-8.3)

2.4 (1.8-3.2)

25-49%

2.0 (1.0-3.9)

1.4 (1.2-1.8)

50-74%

2.1 (1.3-3.6)

1.2 (1.0-1.4)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

75-100%

Referent

Referent

..............................................................................................................................................................................................................................................

100%

4.9 (3.2-7.4)

2.8 (2.4-3.2)

..............................................................................................................................................................................................................................................
a

Research

Adjusted odds ratio: adjusted for maternal age, ethnicity, marital status, smoking, and prior preterm birth.

Debiec. Inadequate prenatal care and risk of preterm delivery in adolescents. Am J Obstet Gynecol 2010.

C OMMENT
This study sought to examine the relationship between prenatal care and preterm birth in adolescents. Our findings
come from a random sample of more
than 30,000 women under age 20 years
who delivered in Washington State between 1995 and 2006. A major result of
this study is that adolescents who received no prenatal care or attended less
than 75% of expected visits were at much
higher risk of preterm birth than those
with optimal prenatal care utilization.
This finding is robust, persisting even
after controlling for recognized risk factors for preterm birth. Our results are
consistent with prior studies of prenatal
care for adolescents, which show that
prenatal care programs that provide
comprehensive medical and psychosocial services could improve maternal
health and birth outcomes, including
rates of preterm birth.10,13-15
The conclusions of this study must be
interpreted in light of limitations in the
dataset and study design. It is possible
that factors other than the amount or
quality of prenatal care are responsible
for the preterm births in this study. For
example, this study cannot adequately
control for such factors as infectious
exposure, socioeconomic status, and
drug use, which may differ between the
groups.
This study is a retrospective study utilizing an established database. The accuracy of birth data is dependent on several
sources including patient records, prenatal care documentation, and patient
recall, some of which may not be accurate. Accrual of birth certificate data is a
complex and variable process. Although
the Washington State birth database
does perform checks for reasonable
range of visits and gestational ages, it
does not specifically compare gestational
age at delivery or number of prenatal visits with hospital or prenatal records.
In addition, the dataset, although
comprehensive, has only limited information on some variables. For example,

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the cause of preterm birth is not clearly

identifiable from this set of data. The
causal pathways for preterm birth caused
by premature rupture of membranes
versus spontaneous labor could be different and might affect the interpretation of the results. Certain variables that
may be associated with preterm birth,
such as exposure to N gonorrhea and C
trachomatis have been recorded only
since 2002, precluding analysis of the relationship between sexually transmitted
infection and preterm birth in this study.
Other variables such as insurance status
and other socioeconomic information
are inconsistently reported and thus
were not included for final analysis.
Whereas we did observe that almost
one-quarter of all teens without prenatal
care had a preterm birth, the overall rate
of preterm birth in this study population
was lower than expected (7%). This is
somewhat surprising, given that the rate
of preterm birth in the United States is
more than 10% and that teen pregnancy
is thought to be associated with increased preterm birth.7 Although the Pacific Northwest in general, and Washington State in particular, has one of the
lowest rates of preterm birth in the nation, there may be other factors contributing to the low rate of preterm birth observed here.16
The low overall rate of preterm birth in
this study may be accounted for by features of the study population. For instance, black race is a known risk factor
for preterm birth, as is prior preterm
birth.7 In this sample, a mere 6% of subjects were black and less than 1% of our
subject had a prior preterm birth. In addition, there are two estimates of gestational age in the Washington State birth
record data: the recorded gestation estimate recorded at delivery and the gestational age calculated from the last menstrual period.
The gestation estimate tends to demonstrate a lower percentage of preterm
delivery than the calculated age. A priori,
we opted to use the most conservative
estimate, given that many teens have
poor recollection of their last menstrual
period. This likely contributed to the low
rate of preterm birth seen in our study.
122.e5

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Another notable finding of this study
was that although the majority of preterm births occurred at 32-36 weeks, inadequate prenatal care was more
strongly associated with very preterm
birth (32 weeks) than moderately preterm birth (32-36 weeks). This could
suggest that there may be different causal
pathways for preterm birth among adolescents underutilizing prenatal care or
that prenatal care helps to prevent early
preterm births. Alternatively, it could be
a manifestation of late initiation of prenatal care. The financial impact and
long-term health complications of infants born very preterm provide a significant impetus to discover interventions
to reduce deliveries prior to 32 weeks.
An unexpected finding of this study is
that women with greater than 100% of
expected visits were at an increased risk
of preterm birth compared with those attending 75-100% of visits. A possible explanation of this result is that women
who attend more than expected prenatal
care visits may have had maternal or fetal
conditions like diabetes or chronic hypertension that required closer surveillance than uncomplicated pregnancies,
and such conditions could be independent risk factors for preterm birth.
The study design precludes definitive
clarification of this finding, but this explanation is consistent with prior work
by Kogan et al,17 which showed that intensive utilization of prenatal care was
associated with such factors as multiple
birth and that rates of preterm birth did
not improve in the period during which
increased prenatal care utilization was
observed.
There may be several reasons for adolescents to have delayed or inadequate
access to prenatal care, including fear of
familial repercussions, depression, coexistence of other risk-taking behaviors, or
inadequate access to medical care.
Hueston et al18 have shown that lack of
health care coverage may be a significant
impediment to early prenatal care. In
other studies, expanded access to publicly funded prenatal care was associated
with a reduction in inadequate use of
prenatal care.19
Possible etiologies for preterm labor
and delivery include infectious and psy-

American Journal of Obstetrics & Gynecology AUGUST 2010

chosocial factors.20-22 Prenatal care may

allow for treatment of symptomatic or
unrecognized lower genital tract infections; modification of lifestyle habits
such as smoking, diet, drug and alcohol
use; and an opportunity for intervention
in violent or socially isolating situations.
Attentive prenatal care for young
mothers may have transformative effects
on individual women and offers a
unique opportunity to prevent future
unwanted pregnancies, access social services, and attend educational programs.23 Whereas the present study was
not designed to assess etiologies of preterm birth or reasons for inadequate prenatal care utilization among adolescents,
it demonstrates the importance of prenatal care for improving perinatal outcomes and the need for continued advocacy to diminish barriers to adolescents
seeking health care. Our results suggest
that efforts should be made to attract
pregnant teenagers to prenatal care at an
early gestational age and encourage attendance at prenatal visits. Further research should be done to determine impediments to prenatal care access,
initiation, and attendance.
f
ACKNOWLEDGMENTS
We thank the Washington State Department of
Health for data access and acknowledge Dr Patricia Starzyk for her guidance and Mr Bill
OBrien for data management and programming assistance.

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4. Koniak-Griffin D, Turner-Pluta C. Health risks
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