8 Adolescent Pregnancy: Where Do We Start?
8.6 PROGRAMS AND RESOURCES FOR PREGNANT ADOLESCENTS .1 Community-Based Nutrition Programs
The recommendation for obese women to gain at least 15 lb is to reduce risk for deliv-ering small for gestational age infants [13]. The American Dietetic Association (ADA) suggests that efforts should also be focused on assisting the postpartum adolescent to return to a healthy weight to reduce risk to future pregnancies [23]. There is no benefit in weight gain above the range suggested, and some indication of harm to mother and baby has been reported (see Chap. 5, “Obesity in Pregnancy”). Very young teens may be the exception to this for reasons discussed earlier regarding difficulties meeting nutrient recommendations. However, more studies are needed to determine whether changes to the IOM recommendations are warranted for the adolescent.
The overall issue of weight gain may be problematic for teens responding to the
“skinny” image presented in pervasive media. Croll in Guidelines for Adolescent Nutri-tion Services [30] presents an entire chapter dedicated to body image issues and tools to assist teens to establish a healthy appreciation for their unique appearance. She suggests that routine patient counseling should include assessment for body image concerns, and if present, teens should be provided with appropriate resources to address these issues.
In her book, Croll provides specific questions to use in assessing body image, and suggests several strategies and tools to use with teens and their parents on body distortion, dieting, and media literacy. The same source [30] also has a chapter by Alton on eating disorders and offers diagnostic criteria and treatment information for these psychiatric syndromes with disturbed body images.
Chapter 8 / Adolescent Pregnancy: Where Do We Start? 107 phones who knows these resources), understand how they can be utilized to assist the adolescent, and know their limits. Networking with community health care providers and health service employees is a skill that can be modeled for these young learners.
In addition, each community should have some way to access the WIC program.
Many adolescent patients will be eligible for WIC services. To be eligible, the pregnant adolescent must meet specific residency, income, and nutritional risk criteria as specified by WIC. To qualify based on nutritional risk, the adolescent must have a medically-based risk such as anemia, be underweight (less than 100 pounds) or overweight (over 200 pounds), have a history of pregnancy complications or poor pregnancy outcomes, or have other dietary risks such as failure to meet the dietary guidelines for any food groups or have inappropriate nutrition practices, e.g., pica.
The WIC fact sheet states in part [31]: “In most WIC state agencies, WIC participants receive checks or vouchers to purchase specific food each month that are designed to supplement their diets. A few WIC state agencies distribute the WIC foods through warehouses or deliver the foods to participants’ homes. The foods provided are high in one or more of the following nutrients: protein, calcium, iron, and vitamins A and C.
These are the nutrients frequently lacking in the diets of the program’s target population.
Different food packages are provided for different categories of participants.
“WIC foods include iron-fortified infant formula and infant cereal, iron-fortified adult cereal, vitamin C-rich fruit or vegetable juice, eggs, milk, cheese, peanut butter, dried beans/peas, tuna fish, and carrots. Special therapeutic infant formulas and medical foods may be provided when prescribed by a physician for a specified medical condition.”
The WIC program was started in 1974. Since its inception, numerous studies have been performed to evaluate its effectiveness, and it has earned a reputation of being one of the most effective nutrition intervention programs in the United States [32]. Various studies performed by Food and Nutrition Services (FNS) of the US Department of Agriculture (USDA) and other entities have demonstrated benefits for WIC participants including longer pregnancy duration, less low-birth-weight infants, reduced infant morbidity and mortality, improved infant feeding practices, and higher diet quality of pregnant and postpartum mothers [32].
The WIC program is a proven effective resource that should be pursued for any preg-nant adolescent who qualifies. The general guidelines for the program are nationwide, but each individual state has flexibility in implementing the program. Contacting the local agency implementing the program and obtaining details of community specifics will allow tailoring of interventions to build around the existing programs. The webpage www.fns.usda.gov/wic/Contacts/ContactsMenu.HTM has agency contacts listed by state.
Providing a list for your patients of the locations of WIC offices along with other local resources such as food banks, churches with meals, etc should be considered.
8.6.2 Group Programs
Educational and support groups have been used successfully to promote healthy behav-iors in various populations with chronic diseases such as diabetes [33]. Several differ-ent group programs have been described specifically for the pregnant adolescdiffer-ent [34–36].
Each program addresses nutrition differently, however. The Pregnancy Aid Center (PAC) located in Maryland has been providing care to pregnant adolescents since 1995, and was described by Bowman and Palley [35]. As part of this program, participants meet with social workers in groups; social workers then assist these individuals with direct service provision including transportation to and assistance with registration in government
programs, including Medicaid and WIC. Bowan and Palley tracked 40 adolescent partici-pants for a year and reported improved mean maternal weight gain and birth weights over the background statistics for the area they served. These authors postulated that the indi-vidual contact with social workers, who provided flexible services to participants, helped to reduce program-related anxiety. Other reported positive outcomes of the program included an increase in the number of participants who received regular prenatal care, and a reported 100% participation rate in WIC services for their study population [35].
Another program designed to deliver prenatal care with an emphasis on nutrition is the CenteringPregnancy program developed by Sharon Rising. This program uses a structured curriculum with clearly defined nutrition objectives. The content of the curriculum is based on assessment, education, and skills building, and support [36]. CenteringPreg-nancy uses the benefits of group interaction, emphasizes individual responsibility for health, and combines it with well-designed information on important topics such as prenatal nutrition and infant feeding [37]. Although preliminary, outcome data suggest that this program has promise for reducing the incidence of preterm birth and low birth weight in a cost effective manner [33, 38, 39].
Nutrition experts at the University of Minnesota as part of their Leadership, Educa-tion and Training Program in Maternal And Child NutriEduca-tion have proposed a method of counseling pregnant adolescents in individual and group sessions based on motivational negotiation [40]. This technique has been described as “a dance,” in which the provider is the expert in knowledge, and the client is the expert in her abilities, struggles, and motivation. Motivational negotiation is a fairly new counseling technique that has shown promise in changing adult and adolescent dietary and health-related behaviors. The tech-nique and its applications for the pregnant adolescent are described in more detail and can be accessed from the webpage www.epi.umn.edu/let/nutri/pregadol/index.shtm.
8.6.3 Internet-Based Programs and Resources
Our lives are increasingly influenced by the World Wide Web, which is now accessible in our schools, workplaces, libraries, and homes. This technology has even greater impact on the young as they have grown up with computers. Teenagers routinely access health information on the Web. Therefore, computers can be a useful way of facilitating teenage acquisition of health-related information. Importantly, the adolescent must be educated on where to find accurate Web-based information.
The following is a list of websites that provide adolescents and their parents with important, reliable information on prenatal care and related considerations. These web-sites will change as the Web grows, but these are web-sites to explore and to share with your adolescent patients.
1. http://www.marchofdimes.com/pnhec/159_153.asp. The March of Dimes provides good factual information on weight gain, a printable chart, a game to play about what to put in your grocery cart and other information presented at an appropriate reading level.
2. http://www.nlm.nih.gov/medlineplus/pregnancy.html#cat11. Medline has several topics for nutrition in pregnancy and gives links to other good sources including Environmental Protection Agency recommendations for fi sh and shellfi sh in pregnancy.
3. http://www.MyPyramid.gov/. This site presents the new food pyramid, with a chance to register for an individualized record of food and activity. At present, it does not have accommodation for pregnancy, and has a specific disclaimer for pregnancy and
Chapter 8 / Adolescent Pregnancy: Where Do We Start? 109 lactation, but a dietitian could provide extra information to personalize the pyramid. See Chap. 1 (“Nutrient Recommendations and Dietary Guidelines for Pregnant Women”) for a discussion of how the nutrients in the six food intake patterns, within the recom-mended energy intake ranges for pregnancy, of the MyPyramid Food Guidance System compare with the RDAs for other nutrients in pregnancy.
4. http://win.niddk.hig.gov/publications/two.htm. Fit for Two has tips for pregnancy. This is not specifi cally for teens, but has appropriate reading level, good pictures, and graphics, very appealing.
5. http://www.nal.usda.gov/fnic/pubs/bibs/gen/vegetarian.htm presents a list of resources for vegetarians that are useful for providers and consumers.
6. http://www.vrg.org/nutrition/protein.htm has information on protein for vegetarians, including vegans. Sample menus are provided.
7. http://www.clevelandclinic.org/health/health-info/docs/1600/1674.asp?index=4724 provides information on appropriate diet for vegetarians.
8. http://teamnutrition.usda.gov/library.html is a general resource on nutrition for young teens, not specifi c to pregnancy, but it is a useful source for colorful materials. There is also information about school lunch programs.
9. http://www.fns.usda.gov/wic/ provides information about the WIC program, including how to register.
10. http://www.nal.usda.gov/wicworks/ is a link to a 12-unit training module for WIC staff.
It has continuing education credits for nurses and dietitians. The material covered is useful for any provider of nutrition education and includes information and guidance for leading group discussions on nutrition topics.
Other sources to explore include the state agriculture department, dairy industry mate-rials, and local university extension service fact sheets. The Web makes information from other states just as accessible as your own state or local university. For example, at www.nal.usda.gov/fnic/pubs/bibs/topics/pregnancy/pregcon.html there is a bibliography of available resources for nutrition, some specific to adolescents and includes ordering information for many materials.
These websites will give you a place to begin developing resources. Ask your teen patients to let you know when they find a site they like; use them as sources for Web news.
Assist them in evaluating the information presented on different websites; encourage them to screen the information carefully before implementing recommendations. Some questions to ask include:
● Who wrote the pages and is the author an expert?
● What does the author say is the purpose of the site?
● When was the site created and last updated?
● What is the source of information? Can it be confirmed?
● Why is the information useful for my purpose? [41, 42]
8.6.4 Other Resources
Story and Stang’s Nutrition and the Pregnant Adolescent: A Practical Reference Guide 2000 [13] is a very useful text for any program providing nutrition education.
There are handouts, suggestions for topics, and techniques and many hints for this area.
This text is available in downloadable form at www.epi.umjn.edu/let/pubs/nmpa.shtm.
The Journal of Midwifery and Women’s Health provides several nutritional topics in their Share with Women series. You can go to their website at www.jmwh.org and print out information on weight gain during pregnancy, folic acid, eating safely during pregnancy, and others. These are provided courtesy of the American College of Nurse Midwives.
The March of Dimes produces many printed resources, in addition to their online materials, for nutrition education, including an easy to read booklet, video on healthy pregnancy for teens, and other fact sheets and materials. These may be accessed by going to the professional section on the website www.marchofdimes.org.
The Philadelphia Department of Public Health has produced a beautiful brochure supported by Title V, called “Healthy Foods, Healthy Baby.” It has great illustrations of two teenagers, and takes them through pregnancy and the decision to breastfeed, in 28 pages. There are sections on eating out, grocery shopping, weight gain, and nausea and vomiting. It includes weight chart and graph. The new nutrition pyramid information is included in the 2007 version. It is available for order at: http://www.phila.gov/health/
units/mcfh.
For those interested in implementing CenteringPregnancy (described above), the association provides handbooks, self-assessment surveys, and printed information along with recommendations for teaching aids as part of its initial training (www.centering-pregnancy.com).
A larger concern throughout the provision of services to adolescents may be the attitudes of providers. Are they viewed as “problems” since their pregnancy presents risks? Kenneth R. Ginsberg proposes that professionals look to the patient’s strengths, build on them, and reframe the issue in terms of what opportunities are present in the situation [43]. This framework is consistent with Motivational Negotiation [39] and the techniques presented in CenteringPregnancy [36–38]. For example, pregnancy gives a young woman and her partner the chance to expand their knowledge of nutrition so they can produce the healthiest child in the neighborhood. They can use that protein to make brain cells, and consume those vitamins to make a healthy immune system. Ginsberg [43] suggests that we consider resilience theory and move beyond the “problem” to recognize the competency and strengths of the young woman.