The Mental Health Needs of Low-Income Pregnant Teens

Abstract

While the rates of teen childbearing have declined in the United States, adolescents who become pregnant and decide to bear and rear their babies are often from low-income, highly stressed families and communities. This article will describe the psychosocial problems of pregnant urban teens and how exposure to interpersonal trauma and current mental health problems may affect their prenatal health behavior, a vulnerable arena that has significance for infant development. It will discuss nurse home visiting as a preventive intervention with proven effectiveness in enhancing maternal prenatal health and behavior and the health and development of children born to mothers at risk, and how a nurse–family collaboration with social workers can facilitate this mission. By providing collaborative care that addresses psychosocial, health, and mental health concerns, interventions like home visiting can reach their full potential.

Keywords

teen pregnancy prenatal health risks interpersonal trauma home-visiting intervention nurse–social work collaboration

When a teenager becomes pregnant and decides to bear and rear her child, it is often a marker of other stressors and distress in her life. In New York City, for example, the rates of teen childbearing are highest among Black and Hispanic young women (Centers for Disease Control and Prevention, 2011) in the poorest boroughs (e.g., the Bronx) and neighborhoods in the city (New York City Department of Health and Mental Hygiene, 2013). National studies have shown that rates are also especially high among youth in foster care and those who have recently left the foster care system (Courtney et al., 2007). In addition, interpersonal trauma (IPT) including violence at the hands of family members and intimate partner violence (IPV) is fairly common during pregnancy for women in general (Sharps, Laughton, & Giangrande, 2007; Taillieu & Brownridge, 2010) and is frequently reported among pregnant teens (Covington, Justason, & Wright, 2001; Kennedy, 2006; Martin, Clark, Lynch, Kupper, & Cilenti, 1999; Quinlivan & Evans, 2001; Weimann, Agurcia, Berenson, Volk, & Rickert, 2000). New York City is also concerned about pregnancy among homeless young women (Thompson, Bender, Lewis, & Watkins, 2007), an event that can be related to leaving home or which can occur while homeless. Despite public school programs that seek to support pregnant teens, a pregnancy can lead to school dropout or may occur after a young woman has already left school (Boden, Fergusson, & Horwood, 2008). Urban low-income pregnant teens are thus beginning families while experiencing multiple stressors from the outset and are considered a vulnerable population (Flynn, Budd, & Modelski, 2008).

Despite these pervasive challenges, most teens who give birth deeply desire to succeed as mothers. Not all teen pregnancies are unplanned; about 10% of teens stated they wanted to become pregnant (Jaccard, Dodge, & Dittus, 2003; Klein, 2005). Qualitative inquiry has evinced that even many whose pregnancies were unplanned view pregnancy as a path toward adulthood, to create purpose and meaning in their lives and as a motivation for healthier living (Shanok & Miller, 2007; Smithbattle, 2003), or to help them relinquish a dangerous lifestyle trajectory (Montgomery, 2002). However, in addition to the challenges just enumerated, they may find that there are what Selma Fraiberg long ago called “ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975), that is, unrecognized influences from their own lives as children that can forestall their best intentions. In contemporary terms, many of the problems that these young women grow up with are now described as adverse childhood experiences (ACEs; Felitti et al., 1998), which comprise IPT: including being maltreated or neglected, witnessing violence, or having incarcerated or mentally ill parents. Even in nonclinical, more affluent populations, ACEs such as the death or departure of a parent from the home, maltreatment of various kinds, violence within the home, and other events—especially cumulative such events—are consistently associated with negative outcomes for medical health (Felitti et al., 1998) and mental health (Chapman, Dube, & Anda, 2007) that can last well into adulthood. Mental health outcomes are manifested in increased rates of posttraumatic stress disorder (PTSD), depression, anxiety, and traumatic stress (Kilpatrick et al., 2003; Lansford et al., 2002; McKay, Lynn, & Bannon, 2005). However, very few who have these additional challenges will receive adequate mental health care to address them. This article will describe what is known about the importance of prenatal health for pregnant teens, their health risks, and the potential impact of trauma on their health and mental health and discuss nurse home visiting as an effective preventive intervention. Social workers and nurses have engaged in various kinds of home visiting for over 100 years. This article will also address how nurses and social workers can enhance this method of care collaboratively to reduce the impact of multilevel stressors on high risk new mothers and their infants.

Health Risks for Pregnant Teens

The current focus on pregnant teens enrolled in home visiting programs is a function of their comparatively poor prenatal health behaviors and pregnancy outcomes. The most well-known health risks that are consistently although not always associated with teen pregnancy and childbearing are low birth weight, preterm birth (Abu-Heija, Ali, & Dakheil, 2002; Chen et al., 2007; Fraser, Brockert, & Ward, 1995; Hidalgo, Chedraui, & Chavez, 2005; Koniak-Griffin & Turner-Pluta, 2001), and fetal and infant mortality (Chen, Wen, Fleming, Yang, & Walker, 2008; de Vienne, Creveuil, & Dreyfus, 2009; Phipps, Blume, & Demonner, 2002). Some degree of elevated risk may be associated with young maternal age itself, and infants of teens who give birth at later ages often have on average better birth outcomes (Klein, 2005). However, pregnant teens generally face other challenges that are also known to affect maternal and infant outcomes. These include maternal income, educational attainment, employment prospects, and mental and physical health (Boden et al., 2008; Kulkarni, Kennedy, & Lewis, 2010; Schuyler Center for Analysis and Advocacy [SCAA], 2008). Going forward, children of teen mothers may have deficits in cognitive, academic, mental health, and psychosocial domains when compared to children of older mothers (Barlow et al., 2011; Jaffee, Caspi, Moffitt, Belsky, & Silva, 2001).

There is certainly variability in the outcomes of teen pregnancies. The general physical health of the pregnant teen, degree of family or partner support, wantedness of the pregnancy, and other psychosocial factors, when positive, act to some degree as protective elements in the face of psychological and biological immaturity (Kulkarni et al., 2010; Walker, Cooney, & Riggs, 1999). Not all teen pregnancies have negative proximal outcomes, but the highest risk teens and their children are still of greatest concern and many teens who give birth are likely to face exacerbation of preexisting cumulative psychosocial adversity after the birth of their infants (Hoffman, 2008; Kennedy, 2006; Kulkarni et al., 2010; SCAA, 2008).

The Nurse–Family Partnership (NFP) Program

Home visiting, defined as purposeful visitation in the home by helping professionals, is now widely recognized as a successful secondary preventive intervention. Comprehensive reviews of emerging practices (e.g., Coalition for Evidence Based Policy, 2014; Paulsell, Avellar, Martin, & Del Grosso, 2011) indicated that home-visiting models enhance child development and school readiness, reduce child abuse reports, and improve long-term family functioning. Nurse home visiting is an evidence-supported intervention for mothers at risk that has been shown to have positive short-term outcomes for the mothers and children who were served from pregnancy and during early childhood (Olds et al., 2004; Olds, Sadler, & Kitzman, 2007) as well as positive distal outcomes for children through adolescence and beyond (Eckenrode et al., 2010; Olds, 2006; Olds et al., 1997). The nurse home-visiting model developed by David Olds in 1977 has the most solid evidence base, and it has been rated as having the highest number of favorable impacts on outcomes as compared to other, similar programs (NFP, 2011a; Paulsell et al., 2011). Originally working at a day care center in Baltimore with children from very-low-income neighborhoods, Olds et al. (Olds, 1980, 1982; Olds, Henderson, Tatelbaum, & Chamberlin, 1986) witnessed the multiple needs of the enrolled families and their developmental consequences of maltreatment and neglect. Olds (2006) described the compromised development, attachment insecurity, and behavior problems that were common among these children as well as the multiple contextual risk factors faced by their parents (e.g., high crime rates, violence, substance use, unemployment, and trauma histories). Struck by the challenges of promoting secure attachment between parents and infants in high-risk environments, Olds and his team went on to develop an ecologically informed preventive intervention that would address the continuum of concern from the family to the community, now known as the Nurse Family Partnership (NFP) model of home visiting. Despite a record of effective care for mothers and children at risk, the psychological and psychosocial needs of enrollees and the benefits of enhancing the mental health component of the NFP program was recognized as an area requiring increased clinical support (Olds et al., 2007).

In 2003, New York City’s Department of Health and Mental Hygiene adopted the NFP model of home visiting as an intervention to enhance maternal and child health, reduce child maltreatment, and enhance child development in low-income neighborhoods in the city. There are at least three elements to the NFP intervention: (a) health education and health promotion related to pregnancy, childbirth, and infant and toddler health and development; (b) connecting the mother and child to other needed services, such as educational services, vocational training, or child care; and (c) providing a supportive, caring continuing relationship to the mother and later to both mother and child and preventing child maltreatment. A signpost of this intervention is strict fidelity to the model and adherence to 18 basic elements that define the program, both of which help to ensure replication (NFP, 2011b, 2013). The NFP model stipulates that services begin at or before 28 weeks of a first pregnancy and continue through the first 2 years of the life of the baby. Each mother is assigned a nurse who visits the mother at home weekly or twice monthly throughout the pregnancy. Following delivery, nurses visit weekly for 6 weeks, from 6 weeks to 4 months, every 2 weeks, with decreasing frequency until the end of the program, at 24 months. Schedules can be determined by mother and nurse, and nurses are more available during the time of crisis (NFP, 2009; Olds, 2006) About 40% of the mothers served by the NFP program in New York City (NFP-NYC) are teens at the time they are enrolled in the program; in fall 2013, there were over 550 pregnant teens being served.

While the NFP is designed for first-time at-risk mothers of all ages, it has been shown to benefit teen mothers as well as older ones. Both generic public health home visiting and NFP model home visits benefitted Hispanic adolescent mothers in Orange County, CA (Nguyen, Carson, Parris, & Place, 2003). Although not enough attention may be given to preventing second pregnancies among teen mothers served, high rates of retention in NFP services have been achieved in this group (Gray, Sheeder, O’Brien, & Stevens-Simon, 2006), and a study of “young” mothers (<26) receiving NFP services in the Netherlands found reduced levels of IPV among those served by an NFP program compared to those receiving “usual care” (Mejdoubi et al., 2013). In addition, a qualitative study of first-time, low-income mothers aged 20 and younger in Canada found the mothers’ reactions to their nurses were very positive, and the young mothers felt that their nurses helped them be better parents (Landy, Jack, Wahoush, Sheehan, & MacMillan, 2012), suggesting that the NFP nurse can become an important source of social support when others are not available.

Social Work and the NFP: A Collaboration

The NFP has a long record of highly effective care for mothers and children at risk and rigorous assessment of both short- and long-term public health outcomes within its stated goals (NFP, 2013; Olds, 2006; Olds et al., 2007). While the NFP-NYC model is based on nurse home visiting, as are all NFP programs, it has incorporated and enhanced a social work component. The role of social workers in the NFP model is to address the mental health needs of the mothers served, both by providing mental health care and by connecting mothers needing mental health care to other service providers. Social workers also respond to such psychosocial needs as involving the city’s child protective services when necessary and supporting young fathers who wish to remain involved with their babies despite coping with problems of their own.

Social work as a discipline can make several major contributions to the challenge of addressing the mental health needs of pregnant and parenting low-income women. First is through its biopsychosocial perspective, which encompasses social factors like poverty and racism, developmental factors like exposure to adverse experiences in early life, behavioral factors that affect both health and access to care, and psychological factors that may include mental health problems that result from multiple stressors. This lens can assist social workers in making broad-based assessments of these multilevel factors. Pregnant low-income teens exemplify the kind of population in which influences from all of these ecological levels come together. They face a complex risk profile, and the impact of their mental health needs on their pregnancy behavior, stress levels, birth outcomes, and overall functioning as young parents is understudied.

Second, social work also involves direct practice, that is, working at the level of the individual with respect to engagement, empowerment, and fostering resiliency. Social workers, like nurses, are uniquely prepared to engage and develop therapeutic trusting relationships with young women who, due to their histories, are very likely to be lacking in trust and avoidant of the kind of services that may assist them (De Rosa & Pelcovitz, 2006; Kulkarni et al., 2010). When young women make the decision to give birth, helping them understand the ways in which various forms of oppression have impacted them due to their young age, ethnicity, and poverty can help reduce shame and inadequacy. It is a challenge to principles of distributive justice when members of a disempowered group disproportionately experience cumulative disadvantage from the outset, compromising their chances to succeed as parents and otherwise (Brubaker, 2007; Furumoto-Dawson, Gehlert, Sohmer, Olufunmllayo, & Sacks, 2007; Kulkarni et al., 2010).

Prenatal Health Behavior of Pregnant Teens

The health education and promotion element of the NFP is aimed at improving maternal prenatal health and behavior. Prenatal health behaviors are defined as “activities a pregnant woman engages in that affect gestational outcomes, including her own health as well as the heath of the fetus” (Lindgren, 2005, p. 465). It is now thought to provide a foundation for health and development across the life span (Barker, 2007; Gluckman, Cutfield, Hofman, & Hanson, 2005; Li, Gonzalez, & Zhang, 2012). Poor prenatal health behavior is associated with compromised fetal development, low birth weight, and deficits in long-term medical health (Furumoto-Dawson et al., 2007; Gluckman et al., 2005) and mental health (Costello, Worthman, Erkanli, & Angold, 2007; Nilsson et al., 2005).

Generally speaking, a pregnant woman’s prenatal health comprises three basic categories assessed by most operationalized measures of pregnancy health. These include (a) maternal physical health, such as proper and balanced nutrition, appropriate weight gain, adequate rest, and exercise; (b) prenatal care, which is formal medical oversight consisting of regular medical visits, obtaining pregnancy-related information, and following medical advice; and (c) avoiding risk behavior, such as smoking, alcohol consumption, illicit substance abuse, physical harm, toxin exposure, unprotected sex, and contracting sexually transmitted infections (STIs) and HIV. The aim of the health education and promotion element of the NFP is to assist women of all ages by connecting them to appropriate prenatal medical oversight, providing pregnancy health education; preventing use of alcohol, tobacco, and substances; and ensuring proper nutrient intake (NFP, 2011c; Olds, 2006) to support healthy pregnancies and prevent adverse outcomes for mother and for infants.

Teens at baseline are at greater risk than older mothers for giving birth to low-birth-weight, preterm infants with developmental problems. Generally speaking, pregnant teens (10–19) as a group have been found to be about twice as likely as women over 20 years of age to deliver an infant that weighs less than 2,500 g and to give birth before term, or 37 weeks’ gestation, increasing the odds of neonatal morbidity and mortality (Chen et al., 2008; Klein, 2005; Tilghman & Lovette, 2008). About 14% of infants born to teens aged 17 years or younger are born preterm, versus 6% for women in their mid-late 20s. The most adverse outcomes occur more consistently with the youngest adolescents, that is, age ≤15 (Klein, 2005). Most studies that investigate gestational outcomes for teens although not all (e.g., De Vienne et al., 2009) have generally found that when controlling for potential confounders, young age remains a risk factor for preterm birth, low birth weight, and fetal mortality.

Multiple Stressors Among Pregnant Inner-City Teens

The risks of biological immaturity for young motherhood notwithstanding, pregnant and parenting teens are disproportionately likely to experience cumulative psychosocial adversity, and as such it is myopic to focus on the biology of young age as a single factor, a priori explanation. As Brubaker (2007) and Kulkarni, Kennedy, and Lewis (2010) state, many of these concerns involve disadvantage at multiple ecological levels: the individual teen, her immediate family structure, peers, and community. Pregnant and parenting teens experience these risk factors to a greater extent than nonparenting teens (Hoffman, 2008; Kennedy, 2006; Kulkarni et al., 2010; SCAA, 2008). Pertinent factors for pregnant and parenting teens include poverty, racism, substance use, and violence exposure, all of which can affect the work conducted by NFP-NYC nurses who serve primarily low-income, African American and Hispanic teens. There are notable effects of these factors on gestational outcomes above and beyond maternal age (Kramer, Seguin, Lydon, & Goulet, 2000). These vulnerabilities increase the likelihood that pregnant teens and in fact women of all ages may not have the opportunity to receive appropriate medical care, and may engage in behaviors during pregnancy that are harmful to themselves and their unborn infants. This compounded risk, absent factors that promote resiliency, may render a pregnant teen less able to sustain behaviors that support prenatal health (Kaiser & Hays, 2005; Kingston, Heaman, Fell, & Chalmers, 2012). An enhanced partnership with social workers may further assist in ameliorating the damaging effects of these risks.

High-Risk Behavior

Teens’ propensity to engage in risk behaviors has direct relevance for fetal health and developmental outcomes. Generally speaking, teens are disproportionately likely to engage in unsafe behaviors (Eaton et al., 2009), which may continue during pregnancy. They are also less likely to seek prenatal care and obtain adequate nutrition and are more likely than adult women to smoke during pregnancy (Covington et al., 2001; Kaiser & Hays, 2005; Kingston et al., 2012; Koniak-Griffin & Turner-Pluta, 2001; Martin et al., 1999). With respect to timing of health behaviors, first trimester exposure is most significant for specific aspects of neuronal development because it is then that neuronal cell groups throughout the brain are formed and extensive synaptogenesis takes place (Eckardt et al., 1998; Richardson, Ryan, Willford, Day, & Goldschmidt, 2002). Teens often do not know they are pregnant until later in their pregnancies and may engage in potentially teratogenic behavior during the first trimester.

Tobacco, Alcohol, and Substance Use During Pregnancy Among Teens

Smoking seems to be the greatest challenge during teen pregnancy. Pregnant teens aged 15–19 have the highest smoking rate of all age-groups of pregnant women, at 16.7%, particularly those in the 18–19 year age range, at 18.2% (Ventura, Hamilton, Mathews, & Chandra, 2003). Teens who smoke prior to pregnancy often continue to smoke at similar rates once they become pregnant (Cornelius, Goldschmidt, Day, & Larkby, 2002; Kaiser & Hays, 2005). Pregnant teens who smoke are significantly more likely than nonsmokers to give birth to low-birth-weight infants (Delpisheh, Attia, Drammond, & Brabin, 2005; Ventura et al., 2003). Smoking by women of all ages is associated with proximal and distal neurodevelopmental deficit in children (Li et al., 2012; Slotkin, 1998). Although little is known about the patterns of alcohol consumption of pregnant teens, there is evidence that over half of teens who drank in the year prior to pregnancy continue at least through the first trimester (Cornelius et al., 1994). These authors found that although older pregnant women generally drank more heavily than teens, the rate of sporadic bingeing during the first trimester was higher for teenagers than for adults and did not decrease until after the first trimester. This pattern of alcohol consumption is of concern as binge drinking, particularly heavily, may have neurodevelopmental impact on offspring (Eckardt et al., 1998; Henderson, Kesmodel, & Gray, 2007). With respect to illicit substances, pregnant teens are most likely to use marijuana. Cornelius, Goldschmidt, Day, and Larkby (2002) found that nearly 16% of pregnant teens continue to smoke into their first trimester. Cornelius et al. (1994) investigated interaction effects between other substances and marijuana use; for example, for teens who drank during pregnancy, marijuana use was 17 times greater than for those who did not, and for adults it was 7 times greater. Marijuana has been associated with neurological sensitivities and deficits in executive function, including cognitive and attention deficits in preschool-aged children (Goldschmidt, Richardson, Cornelius, & Day, 2004).

Diet and Nutrition

Teens are relatively unprepared for the nutritional requirements of pregnancy. Due to their lack of knowledge, sociodemographic factors that preclude access to appropriate nutrition, and their generally deficient dietary intake, pregnant teens may inadvertently provide inadequate nutritional support for their unborn infants (Flynn et al., 2008; Koniak-Griffin & Turner-Pluta, 2001; Rondó, Souza, Moraes, & Nogueira, 2004). Fetal nutrition can also be affected by physiologic factors associated with young pregnancy, that is, pregnant teens, particularly those 15 years of age and under will not have reached their growth potential and often do not gain enough weight, which may affect fetal weight because of competition for nutrients between mother and fetus and thus maternal constraint for available nutrients (Elfenbein & Felice, 2011; Rondó et al., 2004).

STIs

Pregnant teens are more likely to contract STIs than adult women. Teen sexual behavior and pregnancy have psychosocial risk factors in common, which include teens’ generally higher proclivity for engaging in high-risk behavior, having multiple partners, and eschewing condom use (Bunnell et al., 1999; Kaiser & Hays, 2005; Niccolai, Ethier, Kershaw, Lewis, & Ickovics, 2003; Santelli, DiClemente, Miller, & Kirby, 1999). As Bunnell et al. (1999) point out, high rates of STIs occur in teen girls across the board whether they are pregnant or not; they found that about 40% of their sample of 650 sexually active teens aged 14–19 years had an STD, even in a community at moderate demographic risk. Teens’ engagement in unsafe sexual behavior may be exacerbated by alcohol and substance use which can fuel disinhibition and lead to unsafe health practices (Bunnell et al., 1999; Niccolai et al., 2003; Santelli et al., 1999; SCAA, 2008).

Prenatal Medical Care

Despite all of the health risks described, pregnant teens often do not maximize their prenatal health through timely, formal medical care. Teens characteristically obtain prenatal care late in pregnancy (Debiec, Paul, Mitchell, & Hitti, 2010; Martin et al., 2010; Schuyler Center for Analysis and Advocacy, 2008; Tilghman & Lovette, 2008). Late initiation is defined as third trimester care seeking, while early initiation as first trimester care seeking (Martin et al., 2010). Some data demonstrate that 40% of teen mothers do not obtain prenatal care in the first trimester; 10% do not obtain it until the third trimester or do not seek it at all (SCAA, 2008). Other data (Martin et al., 2010) indicate that only about half of pregnant teens aged 15–19 sought care during the first trimester compared to over 70% of women aged over 25. Pregnant teens face several barriers to obtaining prenatal care. Pregnant and parenting teens and their families may have little social capital and inadequate resources and may be denied or unable to access formal health care and reproductive support (Brubaker, 2007; Tilghman & Lovette, 2008). A second reason may involve the influence of peers and family and whether they place importance on formal care and whether teens perceive medical staff and childbirth educators to be sensitive and consistent (Cox et al., 2005) and culturally competent (Daniels, Noe, & Mayberry, 2006; Tilghman & Lovette, 2008). Third, teens who become pregnancy are more likely than nonpregnant teens to have sexual abuse histories; pregnancy itself in teens may have been the result of sexual coercion. Pregnant teens as well as adult women with sexual abuse histories may find prenatal care to be triggering and invasive and to reify the power differential between themselves and medical staff (Bohn & Holz, 1996; Seng, Low, Sperlich, Ronis, & Lieberzon, 2011). Therefore, the NFP model’s emphasis on engaging mothers at risk in formal prenatal care during pregnancy may be especially relevant for the pregnant teens they serve.

Mental Health Needs: IPT and Traumatic Stress

A concern in low-resource, low-income communities served by the NFP, which can affect prenatal health and behavior, is exposure to IPT, including current IPV. In the last several decades, there has been increased attention to the deleterious impact of IPT exposure on life span health status and functioning as a major social problem (Harris, Lieberman, & Marans, 2007; Larkin, Shields, & Anda, 2012; Shonkoff et al., 2012). The ACE studies revealed that among adults, abuse, neglect, or traumatic loss early in life has a negative impact on physical (Felitti et al., 1998) and mental health (Chapman et al., 2007) in a graded, linear manner that reflects accrual of trauma exposure. Early ACEs also affect parenting capacity and attachment (Banyard, Williams, & Seigel, 2003; Lyons-Ruth & Block, 1996). In teens, ACEs are predictive of substance use (Arata, Langhinrichsen-Rohling, Bowers, & O’Brien, 2007; Ford, Elhai, Connor, & Frueh, 2010; Kilpatrick et al., 2003), depression (Arata et al., 2007; McKay et al., 2005), and PTSD (Gerson & Rappaport, 2013; Lansford et al., 2002).

Child maltreatment histories (which are among the events scored as ACEs) are commonly reported among pregnant teens (Blinn-Pike, Berger, Dixon, Kuschel, & Kaplan, 2002; Hillis et al., 2004; Kulkarni et al., 2010; Stevens-Simon & McAnarney, 1994) as is current IPT (Covington et al., 2001; Kennedy, 2006; Martin et al., 1999; Weimann et al., 2000). Rates of current IPT against women during pregnancy are high across all age-groups but higher in teens; Kennedy (2006) estimated that prevalence rates in teens range from 12% to 50%, with 75% of teens reporting cumulative exposure; Weimann, Agurcia, Berenson, Volk, and Rickert (2000) in a review, estimated that 5% to 38% of teens report IPT exposure and adults, 4% to 24%. Other studies (e.g., Martin et al., 1999) reported similar rates. Taillieu and Brownridge (2010) remind us that this may be due to teens’ exposure to both family of origin and partners as sources of violence and that they are more likely than adult women to report pregnancy violence. Empirical work (e.g., Alhusen, Lucea, Bullock, & Sharps, 2013; Gavin, Hill, Hawkins, & Maas, 2010; Lopez, Konrath, & Seng, 2011; Morland et al., 2007; Quinlivan & Evans, 2001; Seng et al., 2011) and reviews (see Sharps et al., 2007; Taillieu & Brownridge, 2010) focused on the impact of IPT, past and current, on prenatal health and behavior. The majority of this work focuses on current IPT rather than ACEs, although Gavin, Hill, Hawkins, and Maas (2010), Morland et al. (2007), and Seng, Low, Sperlich, Ronis, and Lieberzon (2011) also investigated the impact of ACEs on pregnancy risk behavior. With respect to clinical care, Morland et al. (2007) and Seng et al. (Seng et al., 2011; Seng, Sperlich, & Low, 2008) suggest that while screening for IPT is customary in obstetric settings, ACE screening should be an integral part of the discourse on pregnancy health support and integrated into the standard of care.

Mental health problems associated with histories of, or current exposure to, IPT may continue or worsen during pregnancy (Alhusen et al., 2013; Morland et al., 2007; Seng et al., 2011; Yehuda et al., 2005). In recent years, trauma-focused clinicians and researchers alike have come to recognize that survivors of ACEs present a different clinical picture than those who have experienced incident trauma as either children or adults. While the criteria for PTSD as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR; American Psychiatric Association, 2000) are often met by people who have witnessed or have been victims of any type of trauma, cumulative exposure to ACEs is associated with greater likelihood of developing PTSD (Cloitre et al., 2009; Widom, 1999) and complex posttraumatic stress (complex PTSD), which includes PTSD symptoms but as a measurable construct presents an expanded clinical picture that comprises depression, anxiety, anger, affect dysregulation, relationship difficulties, and dissociation (Briere, Kaltman, & Green, 2008; Cloitre et al., 2009; Cook et al., 2005; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

Most investigations into the impact of trauma exposure on prenatal health behavior that include mental health in their conceptual approach have focused on PTSD, as defined by the DSM IV-TR, and depression. The majority of empirical work with pregnant teens that investigated the impact of IPT on their prenatal health behaviors, however, did not position PTSD as a mediator of this relationship as the current study proposes. PTSD is associated with a range of neurohormonal alterations within the hypothalamic–pituitary axis that can have an impact on placental and pregnancy health (Yehuda et al., 2005) and also with behavioral changes, including tobacco, alcohol, and substance use (Ouimette, Moos, & Brown, 2003), that may continue during pregnancy and have an adverse impact on prenatal health and gestational outcomes (Lopez et al., 2011; Seng et al., 2011). Increased focus on the assessment of complex PTSD during pregnancy is also warranted, as this cluster of posttraumatic stress symptoms is perhaps more reflective of the lifelong health effects and functional impact of cumulative ACEs than PTSD itself, and exposure to cumulative ACEs early in life can lead to not just more severe but qualitatively different clinical outcomes (Cloitre et al., 2009; van der Kolk et al., 2005).

Of particular concern in pregnant women is the association between violence exposure and substance use. Women may be vulnerable to self-regulation through alcohol, tobacco, and drug use to cope with the psychological effects of past or current violence exposure. This is evident in adult women (Bailey & Daugherty, 2007; Gavin et al., 2010; Lopez et al., 2011; Morland et al., 2007; Ouimette et al., 2003; Seng et al., 2011; Seng et al., 2008) and teens (Martin et al., 1999; Quinlivan & Evans, 2001; Stevens-Simon & McAnarney, 1994; Weimann et al., 2000). Quinlivan and Evans (2001), for example, found that in a cohort of 537 pregnant teens, those who were experiencing IPT from partners or family were more likely than controls to smoke, drink alcohol, or use illicit drugs; had a higher incidence of prenatal infection and Pap smear abnormalities; and a higher rate of psychosocial problems including homelessness and low social support. Similar findings have been obtained by others (Martin et al., 1999; Weimann et al., 2000). As Seng et al. (2011) stated, PTSD may be an underlying mechanism that links risk behaviors, substance use, and other mental health problems during pregnancy, which is why assessments and interventions that are siloed and do not address trauma and traumatic stress may be less valid or effective.

Impact of Trauma and Traumatic Stress on the NFP Intervention

An area in need of additional inquiry within nurse home-visiting paradigms that could benefit from an enhanced social work component is the impact of enrollees’ general mental health problems (Olds et al., 2007) as well as histories of trauma, and current IPT on NFP intervention effectiveness (Stevens, Ammerman, Putnam, & van Ginkel, 2002). These factors may affect retention rates, obtaining benefits of the NFP intervention, and the formation of therapeutic alliances with nurses, for both teens and older women (Eckenrode et al., 2000; Stevens et al., 2002). NFP-NYC social workers report that they are anecdotally seeing more severe mental health problems among those they currently serve than in the past. Given what is now known about the extent of ACEs and IPT in pregnant and parenting teens and the mental health problems that often follow, it is likely that the teens they are serving, who also face multiple psychosocial stressors related to poverty and living in low-income urban neighborhoods, might suffer from complex PTSD.

Stevens, Ammerman, Putnam, and van Ginkel (2002) pointed out that trauma histories and current domestic violence has neither been well documented nor been addressed in women assisted through nurse home-visiting programs. In their study of the impact of IPT history on 123 mothers enrolled in a nurse home-visiting program similar to NFP in rural Kentucky, Stevens et al. noted that 70% of participants reported having had at least one experience of IPT across their life span. The authors found significantly decreased service delivery, in terms of both missed appointments and decreased phone contact among this subset of women. Eckenrode et al. (2000), however, found somewhat contrasting results. They found that 48% of the women in their sample who were enrolled in an NFP intervention in upstate New York had experienced partner violence, but in this case the presence of partner violence was associated with a small increase in number of nurse visits. In this longitudinal study, which investigated the effectiveness of the NFP intervention on child maltreatment rates over a 15-year period, Eckenrode et al. also found, that of the women randomized to the full NFP intervention who had experienced a greater frequency of partner violence, only one in five had fewer child maltreatment reports than a control group that did not receive NFP services, providing evidence that current IPV may reduce the impact of the NFP intervention on a stated outcome.

Obtaining a clearer sense of which participants have had the most severe trauma exposure and current mental health symptoms and directing resources appropriately may augment the likelihood that more vulnerable enrollees will benefit from and remain in the NFP home visiting program, thereby improving their chances for positive birth outcomes. Trauma-informed assessments (Banyard et al., 2003; Schechter et al., 2008; Seng et al., 2011) and interventions (Gerson & Rappaport, 2013; New York City Administration for Children’s Services, 2013; Steele, Murphy, & Steele, 2010) have been adopted with other high-risk inner-city mothers. Mental health outcomes, including PTSD and complex PTSD, should also be incorporated into health assessments with pregnant women (Morland et al., 2007; Seng et al., 2011). Social workers are in a unique position to partner with nurses to conduct baseline assessments of enrollees’ IPT exposure and mental health problems. This collaborative effort may help the NFP gain a richer understanding of which of their clients might need enhanced mental health counseling with additional trauma-focused interventions to be able to develop successful therapeutic alliances and to remain in and benefit from the NFP to the same extent as women who have experienced fewer of these stressors.

Conclusion

The authors of this article are now partnering with the NFP-NYC program to conduct research with teens served by NFP-NYC. This study examines the trauma histories of the teens, their levels of complex PTSD, their degree of attachment to the unborn baby, and how these affect their ability to engage in healthy behaviors and avoid risky ones during their pregnancy. The findings of this study are expected to document the mental health needs in this group and to identify predictors of health behaviors and attachment. The goals are to enhance the program’s capacity to meet mental health needs of teens served and to provide enhanced supports to those teens who find themselves challenged in maintaining their health during pregnancy.

Effective home-visiting practice, which is based on the assumption that social stressors influence personal problems, is complex since it must attend to specific program protocols while requiring extensive knowledge of child and family development as well as community resources to meet health, social service, and other family needs. Training, ongoing supervision, and staff support are therefore essential for effective practice. Nurses and social workers can partner effectively in all of these efforts to support care that can make a difference (Wasik, 1993). Social work is also uniquely prepared to identify external and internal sources of risk and trauma-related distress, which are so far vastly underaddressed in this group of pregnant teens, which in turn may have an impact on prenatal health and the postbirth relationship. Understanding how positive prenatal health behaviors, for example, can help “bend the curve” at all levels, that is, from the individual—neurobiology, behavior, and mental health—to the family and community (Furumoto-Dawson et al., 2007; Shonkoff et al., 2012), toward a more positive life trajectory for both mother and child, can lead to engagement with preventive interventions like nurse home visiting and policy initiatives to support them.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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