Child Adolesc Soc Work J (2012) 29:151166

DOI 10.1007/s10560-011-0250-0

Best Practice for Adolescent Prenatal Care:

Application of an Attachment Theory Perspective
to Enhance Prenatal Care and Diminish Birth Risks
Janis B. Feldman

Published online: 20 October 2011

Springer Science+Business Media, LLC 2011

Abstract The purpose of this article is to present a best practice model for
adolescent prenatal care. Increasing rates of unplanned pregnancies coupled with
the highest rates of all age groups with inadequate prenatal care make this population especially vulnerable to birth risks and maternalinfant relational problems.
While there is much literature on individual level variables that affect prenatal care
adherence such as age, poverty, low self-esteem, and transportation, there is little
practice based research knowledge on diminishing potential birth risks by repairing
and building the maternalinfant (fetus) relationship prior to the actual birth of the
child. Using findings from the authors former study, practitioner experience, and a
review of evidence based literature, the article presents an innovative attachment
theory based prenatal care model for social work practitioners and other health care
professionals working with pregnant adolescents.
Keywords Prenatal care
Attachment theory
Adolescent pregnancy

Best practice adolescent prenatal care
Unintended adolescent pregnancy

Adequate adolescent prenatal care
Prenatal attachment

Unintended or unplanned pregnancies are a major health concern associated with

increased risks of parental prenatal detrimental behaviors, abortions, and negative
social and birth outcomes. About one-half of all pregnancies are defined as those
reported by the mother to be untimed (occurring too early or too late) or unplanned
and unwanted at the time of conception (Finer and Henshaw 2006; Santelli et al.
2003; U.S. Department of Health and Human Services 2005a, n.d.). An
overwhelming amount or 82% of U.S. adolescent births of those age 19 and under
J. B. Feldman (&)
University of TexasPan American, 1201 West University Dr., Edinburg, TX 78541-2999, USA
e-mail: jfeldman@utpa.edu

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J. B. Feldman

are described as unplanned or unintended (Annie E. Casey Foundation 2008, 2009;

Child Trends 2007a, May; U.S. Department of Health and Human Services 2005b,
2006; Ventura et al. 2004, June 15).
Unplanned pregnancies coupled with delayed prenatal care are linked with
premature births, infant death, low birthweight and maternal morbidity as well as to
infantmaternal relational difficulties (Child Trends, 2007a, May; Martin et al.
2007; Mistri and Kendrick 2008). Adolescent low birthweight statistics in 2006
were 10.5% compared to the general population at 8.3% (U.S. Department of Health
and Human Services 2009, January 7).
This article seeks to present a best practice model with the aim of lowering
adolescent pregnancy and birth risks by enhancing the motherinfant (fetus)
attachment relationship through the prenatal care arena. Traditional medical
prenatal care (American Academy of Pediatrics and American College of
Obstetricians and Gynecologists 2007) is enhanced by integrating the major
findings of our study strengthening prenatal attachment (Feldman 2007). Support
expectations, or knowing that another (others) would be available after the birth of a
child, was the salient predictor of prenatal attachment in a sample of 129 pregnant
adolescents ages 19 and younger. Other significant factors were: (a) planning the
pregnancy, (b) less stress, (c) gestational age, (d) knowing other in household
receives government assistance, (e) quickening, (f) lack of social isolation (friends),
and (g) self-esteem (see Tables 1, 2).
The rationale for using the factors found to enhance attachment to pregnancy is
that they could encourage attachment to prenatal care services. The assumption is
that having a program relevant to the adolescents attachment needs, as opposed to
traditional prenatal care, could improve the rate of prenatal care attendance, and, as
a result, diminish pregnancy and birth risks. The prenatal care arena offers an
excellent setting to assist adolescent women with reparation of maternal and other
attachment issues and, in turn, offers the possibility of enhancing the mothers care
(attachment) of her pregnancy. This effort to integrate the prenatal attachment
relational aspect (Muller 1989) between mother and infant (fetus) as important to
outcome is in line with Quinlivan and Evans (2005) study on adolescent prenatal
care suggesting that interventions with an attachment focus may have merit
(p. 199).
There is little research on diminishing potential birth risks by working on
repairing and building the maternalinfant (fetus) relationship prior to the actual
birth of the child through an attachment theory perspective even though there are
studies on preventing adolescent pregnancies and advocating for adolescent prenatal
centered care versus adult centered care (Black et al. 2006; Mayers et al. 2008;
Sangalang et al. 2006; Vedova-Della et al. 2008). As it is important to prevent
unplanned births, it is equally important to promote physically and emotionally
healthy births, especially for those adolescents of non-Latina Black and Latina
populations who demonstrate higher rates of disparities in prenatal care attendance
and pregnancy risks compared to the non-Latina white population (Child Trends
2007b, Winter; Feldman and Pittman 2008; U.S. Department of Health and Human
Service 2009, January 7).

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Table 1 Demographic and other variables of sample

N = 129 adolescentsa

Number or time

Percentage or mean

Age

1319 years

16.10

Single status

117

93%

Ethnicity
African American

84

65%

Latina

25

20%

Caribbean Islands

16

12%

Non-Latina, white

4%

8th12th

31% (10th)

Grade level
Gestational age

340 weeks

26.25

1st trimester prenatal care

34

59%

Using birth control at conception of baby

33

26%

Age of 1st sexual intercourse

12 to 19

13.4

One

55

44%

Twothree

45

36%

Pregnancy previous

21

17%

Sexually transmitted diseases history

10

8%

Sexual abuse history

20

16%

Previous substance use

76

60%

With mother

91

91%

With father

17

18%

39

42%

Age

1533 years

19.60

Contact almost daily

93

88%

Full time work

44

43%

Student

33

30%

Sexual partners

Live

Family income: $1500 or less/monthly)

Father of baby

Not all respondents answered each time

Adolescent Pregnancy and Birth: the Extent of the Problem

Healthy People 2010, a comprehensive disease promotion prevention agenda
established through the U.S. Department of Health and Human Services (2000), had
set the goal of decreasing unintended pregnancies from 50 to 30% by 2010.
However, for the first time since 1991, the 2006 United States adolescent birth data
revealed a 3% increase in the number of births within 1 year to 41.9 per 1,000
adolescents 1519 years old (Child Trends, 2007a, May, b, Winter; National
Campaign to Prevent Teen Pregnancy 2009, January; US Department of Health and
Human Services 2009, January 7). The United States continues to have the highest
rate of adolescent pregnancies among industrial nations with approximately 750,000

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Table 2 Significant factors
enhancing prenatal attachment

J. B. Feldman

Independent variables

Sig T

Support expectations

.0129

Current feelings (less stress)

.0091

Planning the pregnancy

.0167

Gestational age

.0337

Knowing other in household receives

government benefits

.0786

Quickening

.3344

Current friends (lack of isolation)

.3620

Self esteem
Constant

.3905

Multiple R

.57783

R2

.33389

Adjusted R2

.28060

Standard error

8.07184

6.26560

Significant F

.0000

adolescents between the ages of 1519 years of age becoming pregnant annually
(Guttmacher Institute 2006; Hamilton et al. 2007; UNICEF 2007; U.S. Department
of Health & Human Services 2008b, October 22). Latina women ages 1519 had the
highest adolescent birth rate at 82% per 10,000 compared to 41.7 per 1,000 per all
other adolescent groups (Martin et al. 2007; National Campaign to Prevent Teen
Pregnancy 2009, January).
Statistics on adolescent pregnancy (Guttmacher Institute 2006; Hamilton et al.
2007; National Campaign to Prevent Teen Pregnancy 2009, January) have focused
on individual level variables such as income, age, education, and transportation as
being problematic to obtaining prenatal care. A broader research agenda is needed
that includes the context and the culture through which pregnancies occur.
Health care groups maintain that adequate traditional prenatal care is the most
effective approach for lowering pregnancy and birth risks (American Academy of
Pediatrics and American College of Obstetricians and Gynecologists 2007; Annie E.
Casey Foundation 2009; Guttmacher Institute 2003; U.S. Department of Health and
Human Services 2010). However, adequate prenatal care follows a traditional
medical model of care, often unappealing to adolescents, beginning within the first
trimester of pregnancy and consisting of at least 80109% of recommended visits
(American College of Obstetricians and Gynecologists 2007; U.S. Department of
Health and Human Services 2000, April, 2008a, October 15). Adolescents under the
age of 20 had the worst rate of any age group at 56.5% for initiating early prenatal
care (U.S. Department of Health and Human Services 2007a, b).
While the adolescent attachment literature is increasing (Ammaniti et al. 2007;
Bailey et al. 2007; Diamond et al. 2007; Long 2009; Scharf and Mayseless 2007),
there is a lack of information addressing attachment at the prenatal stage of
development. This article uses an attachment theory framework to present a model

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for prenatal care for adolescents. The reasoning to use the attachment perspective is
based on the premise that the quality of the mothers responsiveness to her infants
gestures profoundly affects the infants development (Ainsworth et al. 1978;
Bowlby 1969, 1980, 1988; Sroufe et al. 2005).

Prenatal Attachment and Support Expectations: Conceptual Definitions

An important premise of this paper is the concept of prenatal attachment that refers
to the connection that the pregnant woman feels toward her fetus (Muller 1989). The
studys viewpoint asserts that attachment between mother and infant (fetus) begins
at the prenatal stage of development. Seminal works on pregnancy adaptation
(Deutch 1945; Rubin 1973, 1975) describe how the mother recognizes her fetus as a
separate, viable individual through a series of maternal tasks as she is developing an
emotional connection, or attachment, to her infant. Subsequent research discuss
prenatal attachment and how that the motherinfant relationship starts prior to birth
(Condon 1993; Bielawska-Batorowicz and Siddiqui 2008; Feldman 2007; Muller
1989; Vedova-Della et al. 2008; Lounds et al. 2005). Sroufe et al. (2005) validate
the importance of parental expectations, or prenatal expectations, before the child is
born by stating:
The transactional process of mutually influencing exchanges between
organism and environment begins at conception. We believe it is important
to begin our assessments in the prenatal period because we want to understand
the circumstances into which a child is born, and because we wanted to study
the developmental process from the beginning. (pp. 1314).
This article expands the notion of attachment by including the support
expectations model (Levitt 1991, 2005) that includes the mother-figure as well as
other attachment figures, or support expectations persons, that are important to the
person in her/his social network. Support expectations refer to a particular type of
social support that involves ones perception that help will be available in some
future time from close persons in ones support network when needed. These
supports serve to stabilize relationships and are functionally equivalent to trust
(Levitt 2005; Levitt et al. 1993). Given that the adolescent stage involves a turning
toward peers as secure base figures, the Support Expectations Model helps to better
understand the adolescent stage when multiple attachments are common (Belsky
1999; Coffman et al. 1994, 1995; Kahn and Antonucci 1980; Levitt 2005).
The Adolescent Viewpoint
Adolescence is a period of major physical and social changes (Bartels and Zeki
2004; Steinberg 2005; National Campaign to Prevent Teen Pregnancy 2005). The
capacity for the adolescent to re-organize relationships with caregivers, to form
intimate friendships and relationships, to negotiate sexuality, and to become more
autonomous from the mother is powerfully predicted by the cumulative quality of

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J. B. Feldman

care received, circumstances with other attachment figures, and from her own
mothers representations of early attachment experiences (Main and Hesse 1990;
Main and Solomon 1990; Pajulo et al. 2006; Roisman et al. 2005).
Reliance on parents as main attachment figures decreases for the adolescent, but
does not necessarily cease, as the peer group or social network functions as a secure
base providing an important source of support (Ammaniti et al. 2007; Levitt et al.
1993; Scharf and Mayseless 2007). Adolescents with secure attachments are better
prepared to work through the challenges of the adolescent stage (Belsky 1999;
Cooper et al. 1998; Kobak et al. 1993; Kobak and Sceery 1988; Sroufe et al. 2005).
Avoidant adolescents and those with insecure-disorganized attachment patterns may
shun or seek out casual or exploitative encounters. Anxious adolescents, as they
crave closeness, are prone to risky sexual experiences (Ammaniti et al. 2007).
Adolescents coming from difficult home situations have a much harder time
working through the normal separation from the secure base (parents) (Levitt
2005; Moran et al. 2005). It follows that understanding the adolescents attachment
patters during pregnancy is essential.
Adolescent Pregnancy Viewpoint
Adolescent births profoundly alter the mothers developmental course occurring at
an untimely period of life when she is cognitively unprepared to parent (Black et al.
2006; Mayers et al. 2008), As she struggles to gain independence from her own
parent, the pregnancy frequently causes her to become more dependent causing
conflicts, depression, and rage at her caregiver(s) with less or inappropriate attention
given to the developing infant (Terry-Humen et al. 2005; Mayers and Siegler 2004;
Larson 2004).
The relationship the adolescent has with her developing infant is influenced by
attachment experiences she had and is having with her own mother, her view of
herself as a parent, and other significant attachments she has formed. These maternal
representations or prenatal expectations are activated during pregnancy and can
serve to help or hinder the mothers care of her expectant child as well as have an
impact on the caregiving and subsequent infant/childs attachment organization
(Sroufe et al. 2005; Stern 1995; Zeanah 2007). Helping the mother become more
sensitive and aware of how her own maternal representations affect her mothering
gives her a better understanding of how her own care of her child is influenced by
her past experiences. This enables her understand the need to explore her own
maternal relationship in order to be a better parent (Fraiberg et al. 1975; Lounds
et al. 2005; National Campaign to Prevent Teen Pregnancy 2005).

Best Practice Framework for Adolescent Prenatal Care

A framework fpr adolescent prenatal care follows by incorporating findings of our
(Feldman 2007) study, practitioner experience, review of the literature, and a Social
Work perspective. Case vignettes will follow to illustrate points.

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Quantitative Process
The intake process would include a combination of quantitative and qualitative
methods. The demographic data would include questions related to the studys
significant findings of gestational age, quickening, and other living in home
receiving financial benefits. Instruments would be administered and scored
according to the particular developers method. The Support Expectations Index
(Levitt 1991) would be administered with resulting scores ranging from a low of .00
indicating no expectations to a high of 84.00 indicating high expectations.
Scores of 42.00 and higher would indicate the extent of expectations was frequent
or occasional while scores of 42.00 and below would indicate minimal or no
expectations and be considered in need of attention due to having little
perceived support available.
The Prenatal Attachment Inventory (PAI) (Muller 1989) would be given to
determine extent of prenatal attachment. The PAI scores range from a possible
21.00 (low attachment) to possible 84.00 (high attachment). Scores of 69.00 and
higher would be considered adequately attached while scores of 54.00 and below
would be considered in need of attention.
Factors related to Self esteem would be assessed according to the Rosenberg selfesteem (RSE) (Rosenberg 1994) instrument. Scores range from .00 to 100.0 with
higher scores indicating problems with self-esteem. This well-known measure has a
Guttman Scale coefficient of reproducibility of .92 indicating excellent stability.
The relationship with ones one mother would be obtained through the Childs
Attitude Toward Mother (CAM) (Hudson 1993). The CAM scores range from .00 to
100 with scores higher than 30 indicative of problems. The instrument has a mean
alpha score of .94.
Qualitative Process
During the intake process, open ended questions would be asked of the adolescent in
order to better understand the meaning of certain variables such as planning the
pregnancy and intention of pregnancy. Semi-structured interviews would give
the adolescent an opportunity to talk about her history, family, significant others,
and other personal situations. A major focus will be on what choices, if any, she had
about the pregnancy, who may have been some of the leading family members or
non-related individuals, and/or cultural factors influencing the pregnancy. This area
would add information to the definition of intention of pregnancy which presently
is narrow in scope and refers to the womans conscious decision at the time of
conception. She would also be able to speak about the meaning of friendships and/or
the impact of social isolation due to the pregnancy. The adolescent would be asked
to draw and elaborate on a series of concentric figures as she named the individuals
closest to her as closest to her center according to the Support Expectations
Model (Kahn and Antonucci 1980; Levitt 2005). The interviews would allow the
adolescent to present information freely and add important material to the structured
measurements.

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The adolescent pregnant women, determined through the interviewing and

structured testing to have attachment and support expectations problems emanating
from deprivation, trauma, childhood abuse, and other stressful factors, would be
encouraged to attend a weekly group of peers led by an attachment-theory trained
clinician. These groups would be set-up in tandem with the usual medical prenatal
appointments. The group setting is an ideal vehicle to work through attachmentmaternal sensitivity issues and build self-esteem (Polansky et al. 2006). The
adolescents would be given the choice to bring their support expectations
person(s) to the group according to the Support Expectations Model (Levitt 1991,
2005). The following vignette illustrates the importance of asking the adolescent
who she prefers to accompany her into groups instead of the professional assuming
who is best to accompany her to the group. A 15 year old Black, African American
pregnant adolescent remarked during an initial interview at a local community
prenatal clinic:
Why cant I bring my boyfriend? Why should my mother come? She is never
home. My boyfriend helps me out the most. I know he will be helping me if I
need him. My mother doesnt care about this stuff. Why do you people always
think a mother should come, maybe I dont agree that she should come! My
boyfriend is the one who is with me all the time and the one who worries about
me.
An important component of any interview and treatment process would be to
integrate a cultural perspective as the greater percentages of pregnant adolescents
attending public programs are Black, African American, or Latina. For example, as
Latina women had the highest adolescent birth rate in 2006 (Martin et al. 2007), a
Latina prenatal community clinic of predominately Latina adolescents would need
to include a Latina/o cultural values perspective that includes the importance of the
family hierarchical unit (familismo), views of motherhood as being paramount,
respect (respeto), knowledge of traditional gender roles (machismo and marianismo), congeniality (personalismo), and knowledge of culturally-based healing care
(curanderismo) (Guilamo-Ramos et al. 2006; Rodriguez et al. 2007; Ryan et al.
2005; Vexler 2007). An example of a 15 year old Latina pregnant adolescent telling
her health care administrator why she is unable to attend a Sunday group outing:
I really want to go. I am not being resistant like you say but Sundays are a
special day for all my family. Everybody comes from Jersey and from the
Bronx and we have a big lunch. I do not want to be disloyal to mi familia (my
family)!
An equally important aspect to consider with any immigrant group is the level of
acculturation and history of migration. Studies have demonstrated that acculturation
is a risk factor for adolescent pregnancy, social maladjustment, psychopathology,
and substance use. The developing and maintaining a bi-cultural identity seems to
have protective factors that mediate risk factors of acculturation and should be
integrated in treatment. Positive outcomes have been found for Latina/o adults and
youths who maintain a bicultural-identity of retaining basic cultural values while
integrating aspects of the dominant or new culture (McHatton et al. 2007; Muir et al.

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2004; Schwartz et al. 2005; Smokowski and Bacallao 2007). For example, 17 year
old pregnant Latina arriving to one her parenting classes remarked to the counselor:
I want my mother coming in with me. She is my mother. I have no secrets
from her. She has to hear what the doctor says so she can ask him the
questions. We are a family, we have no secrets. You are asking me to be
disloyal. I cant do that! I would be ashamed to go on without her. Even
though I have been in this country over ten years, it is important for me to
involve my family in my care. That way they can help me. We stick together.
Placement in a group setting would function to ameliorate maternal attachment
disturbances by integrating the following attachment-related concepts: (1) to serve
as a supportive framework to provide a safe haven in which new feelings and
experiences are tested, (2) to explore and modify internal working models of self
and others, (3) to encourage awareness and working through of past and present
hurts, (4) to encourage sensitivity and responsiveness toward pregnancy/infant
signals, and (5) to provide a peer group to serve as attachment figures. As pregnant
adolescents tend to be isolated from the mainstream of adolescent life as well as
suffer from feelings of shame, the group provides a support system where she can
feel part of a community of others. Enhancing current and developing new support
relationships enables group members to use these relationships outside of group and
in the future when the baby is born. One 15 year old African American pregnant
adolescent with Latina ancestry attending a prenatal clinic for adolescents remarked
to a group member:
I really hated to come here at the beginning. I feel so embarrassed about my
pregnancy. My family says I have brought shame and dishonor to everyone. I
am not allowed to go to church with them anymore. All the time they told me
that having a baby is the most important thing a girl can do but they did not tell
me how not to have a baby! They say I have to hide away for months, forget
everyone, and pretend I am not pregnant. I dont want to be ashamed. Some
girls in this group feel exactly the way I do and that is why I come. This group
helps me out and I am now glad that I come here.
The group leader serves as a safe haven figure who allows the group members
to test out painful feelings simultaneously being available to provide comfort, as
needed. The leader is instrumental in functioning as an attachment-support giving
person and helps the members connect to other support person(s) in the group
during times of fear or need as they deal with their uncomfortable feelings. She/he
encourages the support expectations person(s) to be responsively attentive to the
particular adolescent member working through traumas. Concurrently the adolescent members are integrating new experiences that help them become more
sensitive to their pregnancy and responsive to their infant (fetus) signals.
Focusing on early traumas that continue to influence the pregnant adolescent
behavior will give her the opportunity to work through these issues with peers but
under the guidance of a trained professional. It is well known that the peer group is
influential at the adolescent stage of development, however, the adolescents
cognitive capacity to plan, understand ramifications of behavior, control impulses is

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still not fully developed (Bailey et al. 2007; Bettmann and Jasperon 2010).
Discussions of loss or trauma can result in disorganization and disorientation. As the
adolescent is testing and exploring new avenues, she is offered the security, safety,
and protection by the leader. This helps to reduce the adolescents anxiety and fear.
Adolescents who have experienced childhood maltreatment and trauma are
generally classified with having an unresolved/disorganized/disoriented attachment.
Maltreatment that occurs within the family context is usually chronic and
cumulative. These adolescents have difficulty integrating past memories and
experiences. They frequently display lapses in conversation when discussing painful
issues. The adolescent sees others as untrustworthy and likely harmful (Long 2009).
The group would be used to provide an alternative experience for the adolescent so
that she may become more able to discuss her traumas without fear of depression. A
leader commented to a group of pregnant adolescents in a community health clinic:
Some of you are frightened to talk about these issues. It hurts all over again.
This is understandable. We will do it slowly and no one is forced to discuss
anything they do not want. I am interested in helping you. I am here to listen
and help to try to make these things less painful. I know how hard it can be.
While it would be simplistic to assume that an attentive supportive leader would
be able to break through all difficult barriers, it is a step forward. Some research has
demonstrated that shorter term intervention focused on the quality of the mothers
responsiveness to her infant have been found to be more effective than modifying the mothers representational structure of herself and others (BakermansKranenburg et al. 2003; van IJzendoorn et al. 1995). However, other research
affirms that building the mothers sensitivity and responsiveness to her infant
necessitates gaining awareness and re-experiencing attachment pattern to her own
mother (Moran et al. 2005; Long 2009). For some of these adolescents, being heard
and listened to regarding their thoughts about the pregnancy and future child is a
new experience. In response to the leaders comments above, a 16 year old Latina
group member stated:
You know, nobody ever listened to me, everybody just yells at me. Nobody
even asks me what I think. You ask me about my baby. I can talk about how
scared I am of her, will she be born o.k.? Will I know how to raise her? My
mother never asked me anything; she just slapped me and pushed me. I dont
even remember what was so horrible but it was.
The leader helps the adolescents re-experience earlier traumas and to make the
connection between being a parent and being parented. As Fraiberg et al. (1975)
stated when our therapy has brought the parent to remember and reexperience his
childhood anxiety and suffering, the ghosts depart, and the afflicted parents become
the protectors of their children against repetition of their own conflicted past
(pp. 420421). A 15 year old Chinese American adolescent remarked after the birth
of her baby said to the hospital birthing center social worker:
If it wasnt for my other social worker, I would never understand why I felt so
afraid all the time that I was pregnant. My mother always told me that she was

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afraid of me because I was such a problem child. She was always strict with
me. Chinese mothers are so strict! Now I understand that it was because my
mom thinks that all babies are trouble and it is not how I feel. My social
worker calls it the ghosts in the nursery that have to be sent away!

Discussion and Limitations

A best practice approach to enhance prenatal care is presented based on findings of a
previous study (Feldman 2007). Because of the concern that adolescent pregnancy
rates have increased coupled with the fact that adolescents have a low rate of
receiving adequate prenatal care leading to birth risks and exacerbation and/or
bringing about of emotional problems, it is essential that evidence based methods
for prenatal care be applied that are relevant to the adolescent population. Social
workers need to continue to focus on developing best practice approaches in order
to accurately plan and intervene with sound approaches (Guttmacher Institute 2007,
Spring). This paper is a beginning effort to develop a best practice approach for the
adolescent prenatal care populations that will need to be validated in future research.
Major health care initiatives focus on preventing adolescent pregnancies;
however, little attention is given to ensure that adolescents who do become
pregnant have healthier children (Annie E. Casey Foundation 2009; Guttmacher
Institute 2006; National Campaign to Prevent Teen Pregnancy, n.d). Prenatal care is
a significant health care practice that needs critical evaluation especially as it relates
to the adolescent population. There have been few changes regarding the care since
the Public Health Report of 1989 that focuses on quantity rather than on quality as a
measure of adequate care (Public Health Service 1989).
A limitation posed on the study is that pregnancies are described as unintended
or intended based on retrospective data of the womans conscious intention at the
time of conception (U.S. Department of Health and Human Services 2005a, n.d.).
These definitions need to take into account the socio-cultural factors including
family or boyfriend attitudes and the underlying, emotional factors influencing
pregnancy planning (Finer and Henshaw 2006; Santelli et al. 2003). Adolescent
births are described as unintended. However, because of definition problems, we
may fail to understand and plan adequately for those who do indeed plan their
pregnancies.
Adolescent births and birth risk costs the U. S. taxpayers approximately $9.1
billion in 2004. At least 1.9 billion was for increased public sector health care
expenses, $2.3 billion for child welfare benefits, $2.1 billion for state prison
systems, and $2.9 billion in lost monies due to less taxes paid by the children of
adolescent mothers over their own adult life. The approximately 7 million
adolescent births between 1991 and 2004 cost the public over $160 billion (National
Campaign to Prevent Teen Pregnancy 2006, October).
The focus of federal policies of the last decade had been on funding abstinenceonly programs but a recent federally funded evaluation conducted over 9 years at a
cost of over $8 million concluded that abstinence-only programs had no impact on
adolescent behaviors and that even some statements, such as sex before marriage,

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were wrong and harmful (Trenholm et al. 2007, April; Guttmacher Institute 2007,
Spring). The Obama administration has demonstrated a more realistic, scientific
approach toward sex education and planning for adolescents (Barot 2009, Winter).
It is the premise of this article to state that working through attachment
difficulties may enhance prenatal care attendance. The author seeks to present an
attachment relational intervention pathway for pregnant adolescents through which
difficulties can be re-worked that could potentially enhance prenatal care adherence
and lead to healthier pregnancies and births. Future studies would necessitate
exploring whether indeed using the articles best practice framework does indeed
increase attachment (adherence) to prenatal care and lower birth risks.
The current challenge is to obtain funding for research and program implementation for the adolescent population that addresses realistic, easily accessible family
planning and contraceptive education. This is a population that does not vote and
has little clout. The responsibility is ours, as health professionals and social workers,
to give them voice.

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Guidelines for perinatal care (6th ed.). Evanston: Author.
Ammaniti, M., Nicolais, G., & Speranza, A. M. (2007). Attachment and sexuality during adolescence:
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