Comparison of Adolescent, Young Adult, and Adult
Women’s Maternity Experiences and Practices
WHAT’S KNOWN ON THIS SUBJECT: Some studies demonstrate
that adolescents have different perinatal risks and outcomes than
nonadolescents. Few studies have explored the maternity
experiences or practices of adolescents that may underlie these
differences, or compared these with nonadolescents by using
a nationally representative sample.
WHAT THIS STUDY ADDS: Adolescents and young adults were
more likely to experience physical abuse, late prenatal care
initiation, poor prenatal health behaviors, lower breastfeeding
initiation and duration rates, postpartum depression, and lower
folic acid supplementation than adult women.
abstract
BACKGROUND AND OBJECTIVE: Pregnant adolescents face unique chal-
lenges. Understanding the experiences, knowledge, and behaviors of
adolescents during the pregnancy and postpartum periods may con-
tribute to improvement of their maternity care. The purpose of this
study was to compare the maternity experiences, knowledge, and
behaviors of adolescent, young adult, and adult women by using a na-
tionally representative sample.
METHODS: This study used data from the Canadian Maternity Experi-
ences Survey (N = 6421). The weighted proportions of each variable
were calculated by using survey sample weights. Logistic regression
was used to estimate odds ratios. Bootstrapping techniques were
used to calculate variance estimates for prevalence and 95% confi-
dence intervals.
RESULTS: Adolescents and young adults were more likely to experience
physical abuse in the previous 2 years, initiate prenatal care late, not
take folic acid before or during pregnancy, have poor prenatal health
behaviors, have a lower cesarean delivery rate, have lower breastfeed-
ing initiation and duration rates, experience more stressful life events,
experience postpartum depression symptoms, and rate their infant’s
health as suboptimal than adult women. Adolescents were more likely
to rate their own health as suboptimal.
CONCLUSIONS: Adolescents have unique needs during pregnancy and
postpartum. Health care professionals should seek to provide care in
a manner that acknowledges these needs. Pediatrics 2012;129:e1228–
e1237
e1228 KINGSTON et al
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AUTHORS: Dawn Kingston, RN, BSc, MSc, PhD,a Maureen
Heaman, RN, PhD,a Deshayne Fell, MSc,b and Beverley
Chalmers, DSc(Med), PhD,c on behalf of the Maternity
Experiences Study Group of the Canadian Perinatal
Surveillance System, Public Health Agency of Canada
aFaculty of Nursing, University of Manitoba, Winnipeg, Manitoba,
Canada; bBetter Outcomes Registry & Network (BORN) Ontario,
Ottawa, Ontario, Canada; and cDepartment of Obstetrics and
Gynaecology, Ottawa Hospital Research Institute, University of
Ottawa, Ontario, Canada
KEY WORDS
abuse, adolescent, Canada, Maternity Experiences Survey,
perinatal care, postpartum, pregnancy
ABBREVIATIONS
aOR—adjusted odds ratio
CI—confidence interval
CV—coefficient of variation
EPDS—Edinburgh Postnatal Depression Scale
MES—Maternity Experiences Survey
OR—odds ratio
All individuals meet the criteria for “author” as defined in the
Pediatrics author guidelines. Each author contributed to the
conception and design of the study. Dr Kingston conducted the
analysis, with guidance and feedback from Drs Heaman and
Chalmers and Ms Fell. Each individual was involved in the
interpretation of the data. Dr Kingston drafted the article; Drs
Heaman and Chalmers and Ms Fell critically reviewed the article
and suggested revisions. Each author approved the final version
for submission to Pediatrics.
Dr Kingston’s current affiliation is Faculty of Nursing, Edmonton
Health Clinic Academy, University of Alberta, Edmonton, Alberta,
Canada.
www.pediatrics.org/cgi/doi/10.1542/peds.2011-1447
doi:10.1542/peds.2011-1447
Accepted for publication Jan 5, 2012
Address correspondence to Dawn Kingston, RN, BSc, MSc, PhD,
Faculty of Nursing, Edmonton Health Clinic Academy, Room 5-258,
University of Alberta, 11405-87th Ave, Edmonton, Alberta, T6G 1C9,
Canada. E-mail: Dawn.Kingston@ualberta.ca
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: During the course of this research, Dr Kingston was
supported by the Strategic Training Initiative in Research in
Reproductive Health Sciences (Canadian Institute of Health
Research-Public Health Agency of Canada) and a post-doctoral
fellowship from Dr Heaman’s Chair in Gender and Health
(Canadian Institute of Health Research) as well as the Public
Health Agency of Canada. Dr Heaman is supported by a Chair in
Gender and Health from the Canadian Institutes of Health
Research.

A decline in the prevalence of adoles-
cent pregnancy has been observed over
the past 2 decades in several countries.1
Nevertheless, the risk profile that ado-
lescents possess in terms of the cir-
cumstances that contribute to their
pregnancy, the adverse maternal and
child outcomes associated with ado-
lescent pregnancy, and the limitations
imposed on their future and that of their
child suggest that adolescent pregnancy
continues to represent an important
public health issue. Some studies have
found that, compared with older moth-
ers, adolescent mothers have greater
risks for delivering preterm, low birth
weight, and small for gestational age
infants.2 A large body of evidence also
suggests that children of adolescent
mothers are at greater risk for edu-
cational disabilities,3 mental health
disorders,4 and having an adolescent
pregnancy.5 Pregnant adolescents also
face distinct challenges as they seek to
resolve developmental tasks related to
both their adolescence and pregnancy,
a process that represents a “dual de-
velopmental crisis” of conflicting goals
that can impede healthy transition to
motherhood.6
The unique needs presented by adoles-
cents during pregnancy and postpartum
have prompted the development of
models of prenatal and postpartum
care specific to adolescents.7 However,
the main focus with respect to adoles-
cent pregnancy has been its prevention,
with less attention paid to addressing
the needs of the adolescent once preg-
nant or after birth. Understanding the
needs and experiences of pregnant and
postpartum adolescents would contrib-
ute to health care professionals’ ability
to provide effective care for this group.
A few studies have used qualitative ap-
proaches to describe specific aspects of
adolescent pregnancy and motherhood,
including the adjustment to pregnancy
and motherhood,8 postpartum depres-
sion,9 breastfeeding,10 and in-hospital
PEDIATRICS Volume 129, Number 5, May 2012
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postpartum experiences.11 Studies that
have compared the experiences of ado-
lescents with nonadolescents suggest
that adolescents may be more likely to
have higher rates of intimate partner
violence,12 postpartum depression,13
and smoking during pregnancy,14 whereas
findings related to their obstetrical
experiences are equivocal, with some
studies reporting increased risks15 and
others describing similar or lower risks.16
Many of these studies were conducted
outside of North America by using small
samples with distinct characteristics.
Other national studies of maternity
experiences have excluded adolescents
,18 years of age (United States)17 or
have not studied their experiences sepa-
rately (United Kingdom).18 The purpose of
this study was to extend the current state
of knowledge on adolescent pregnancy
and motherhood by using a nationally
representative sample to compare the
maternity experiences, knowledge, and
behaviors of Canadian adolescent, young
adult, and adult women. We hypothesized
that the maternity experiences of ado-
lescents would differ from adult women
but would be similar in some aspects to
young adult women.
METHODS
This study used data from the Maternity
Experiences Survey (MES) of the Public
Health Agency of Canada, the first survey
designed to provide insight into Cana-
dian women’s knowledge, experiences,
and practices during pregnancy, birth,
and the early postpartum period.19 The
sampling frame comprised 58 972 women
who had completed the 2006 Canadian
Census of Population and were $15
years of age; had delivered a live, sin-
gleton infant in the 3 months before the
census; and were living with their infant
at the time of the interview.20 From this
group, a stratified random sample of
8542 women was drawn. Women living
on First Nations reserves or in institu-
tions at the time of the survey were
ARTICLE
excluded for operational reasons. Ad-
olescent mothers were oversampled.
Details of the sampling process, survey
development and pilot testing, survey
methods, and data quality are reported
elsewhere.20 The survey was conducted
by trained female interviewers from
Statistics Canada though computer-
assisted telephone interviews lasting,
on average, 45 minutes. The overall re-
sponse rate was 78% (n = 6421), which
included 167 adolescent and 6254 non-
adolescent mothers. The response rates
for adolescent and nonadolescents
were 63.5% and 78.5%, respectively.
The majority of mothers (96.9%) were
interviewed between 5 and 9 months’
postpartum.
The research protocol was reviewed by
Health Canada’s Science Advisory Board
and Research Ethics Board and the Fed-
eral Privacy Commissioner. Approval was
received from Statistics Canada’s Policy
Committee before implementation.
Definition of Selected Variables
An adolescent was defined as a woman
who was 15 to 19 years old at the time of
the birth of her infant, a young adult as
20 to 24 years old, and an adult as $25
years old. Age-appropriate education
was scored as in Hellerstedt et al.21 For
adolescents, we subtracted the number
of years of completed education from
the maternal age. A score of $6 implied
age-appropriate education, whereas a
score ,6 indicated low educational at-
tainment for age. For women aged $20
years, age-appropriate education was
defined by the completion of high school,
and low education was defined by its
noncompletion. The Edinburgh Postnatal
Depression Scale (EPDS) is a 10-item
screening tool to identify postpartum
depressive symptoms in the previous 7
days where a score of $13 is indicative
of postpartum depression.22 As in the
US-based national survey of maternity
experiences, the Pregnancy Risk As-
sessment Monitoring System,23 the MES
e1229
used a modified version of the Newton
and Hunt Scale that had been used in
pregnant adolescents and adults to
measure stressful life events (Table 1).
Women were asked to indicate whether
they experienced any of 13 stressful life
events during the 12-month period be-
fore the birth of their infant.24 Similar to
the Pregnancy Risk Assessment Moni-
toring System, high stress was defined
as $3 stressful life events and low
stress was defined as ,3 events. Other
variables are defined in Tables 1 to 5.
Data Analysis
Theweightedproportionsofeachvariable
were calculated by using survey sample
weights where the weighted sample
represented 73 797 women. For demo-
graphic variables, logistic regression
was used to calculate unadjusted odds
ratios (ORs) comparing adolescents with
adult women, and young adults with
adult women. For all other variables, we
used multivariable logistic regression
models to calculate adjusted odds ratios
(aORs) comparing adolescents with
women aged $25 years, and women
aged 20 to 24 years with those aged $25
years, adjusted for age-appropriate

TABLE 1 Comparison of Psychosocial Variables for Adolescents Compared With Adult Women, and for Young Adults Compared With Adult Women
Variable Adolescents Aged 15–19 y, Young Adult Women Aged 20–24 y, Adult Women Aged $25 y,
(Weighted n = 2262) (Weighted n = 9965) (Weighted n = 63 832)

Weighted % aORa (95% CI) Weighted % aORa (95% CI) Weighted % aORa (95% CI)
Attitude toward timing of pregnancy
Wanted to be pregnant then or sooner 27.5 56.7 77.1
Wanted to be pregnant later or not at all 72.5 6.16 (4.41–8.61) 43.3 2.52 (2.08–3.05) 22.9 1.00 (reference)
Attitude toward pregnancy
Was happy about being pregnant 74.8 90.5 94.1
Was unhappy or neither happy/unhappy 25.2 3.62 (2.34–5.59) 9.5 1.40 (1.02–1.93) 5.9 1.00 (reference)
Support during pregnancy
Support available all or most of the time 87.0 90.1 86.5
Support available none, little, 13.0 1.10 (0.72–1.69) 9.9 0.68 (0.48–0.94) 13.5 1.00 (reference)
or some of the time
Support during postpartum period
Support available all or most of the time 83.5 85.7 83.8
Support available none, little, 16.5 1.34 (0.93–1.93) 14.3 0.89 (0.67–1.18) 16.2 1.00 (reference)
or some of the time
Experienced any physical abuse in past 2 y
No 59.0 78.2 91.8
Yes 41.0 4.87 (3.44–6.90) 21.8 2.29 (1.78–2.93) 8.2 1.00 (reference)
No. of types of abusive acts experienced
in previous 2 y
None 59.0 78.2 91.8
1 10.7b 2.41 (1.42–4.08) 8.5 1.95 (1.37–2.77) 3.7 1.00 (reference)
2 6.5b 3.34 (1.73–6.43) 4.7 2.08 (1.22–3.53) 1.9 1.00 (reference)
$3 23.8 5.23 (2.88–9.51) 8.6 2.55 (1.56–4.17) 2.4 1.00 (reference)
The person who was violent toward you
was your partner, husband, or boyfriendc
No 47.7 38.0 44.1
Yes 52.3 1.11 (0.55–2.24) 62.0 1.53 (0.80–2.92) 55.9 1.00 (reference)
The person who was violent toward you was
a family memberc
No 79.3 86.0 90.5
Yes 20.7b 5.73 (2.40–13.70) 14.0b 2.41 (0.94–6.14) 9.5b 1.00 (reference)
Perceived stress in 12 mo before birth
Most days somewhat or not stressful 87.0 88.2 87.6
Most days very stressful 13.0b 0.85 (0.53–1.36) 11.8 0.88 (0.67–1.17) 12.4 1.00 (reference)
No. of stressful life events in 12 mo before birth
,3 56.1 66.3 86.5
$3 43.9 3.17 (2.23–4.50) 33.7 2.80 (2.29–3.43) 13.5 1.00 (reference)
EPDS score at time of interview
,13 86.0 90.7 93.1
$13 14.0 2.29 (1.48–3.54) 9.3 1.43 (1.03–1.99) 6.9 1.00 (reference)
a Adjusted for age-appropriate education, parity, and marital status at the time of the interview.
b CV: 16.6–33.3. Based on Statistics Canada data quality guidelines, CVs #16.5% are reliable estimates, CVs between 16.6% and 33.3% are marginal, and those .33.3% are unreliable because of

the high level of error inherent in the estimate and therefore unreportable.
c Asked of women who experienced abuse or violence in the past 2 years (adolescent, weighted n = 646; 20- to 24-year-olds, weighted n = 1287; $25-year-olds, weighted n = 2769).

e1230 KINGSTON et al
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education, parity, and marital status at
the time of the interview. The Bootvare
V30.SPS Program (Version 3.0) was
used to calculate estimates of the vari-
ance and coefficients of variation (CVs)
for prevalence and 95% confidence
intervals (CIs) for ORs. Statistical sig-
nificance for all analyses was set at P ,
.05. Missing data represented ,5% of
all records,20 and missing cases were
therefore excluded from these analyses.
RESULTS
Approximately 3% of the women in our
sample were 15 to 19 years of age at the
time of giving birth (2262 of 73 797). The
mean age was 18.1 years for adoles-
cents, 22.4 years for young adults, and
31.2 years for adult women. Adolescents
were more likely to be single, pri-
miparous, and not have attained their
age-appropriate level of education com-
pared with adult women (Table 2). Ap-
proximately 10% of adolescents were
multiparous.
Psychosocial Variables
Compared with adult women (22.9%),
adolescents (72.5%) and young adults
(43.3%) were more likely to report
wanting to be pregnant later or not at all
(Table 1). Both adolescents and young
adults were also more likely to report
that they were unhappy or neither
TABLE 2 Comparison of Demographic Variables for Adolescents Compared With Adult Women, and for Young Adults Compared With Adult Women
Variable
Weighted %
Age-appropriate education
Yes
No
Marital status
Married or common-law
Single (separated, divorced, never
married, widowed)
Parity
Multiparous
Primiparous
a CV: 16.6–33.3. Based on Statistics Canada data quality guidelines, CVs #16.5% are reliable estimates, CVs between 16.6% and 33.3% are marginal, and those .33.3% are unreliable because of
the high level of error inherent in the estimate and therefore unreportable.
PEDIATRICS Volume 129, Number 5, May 2012
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happy/unhappy about their pregnancy,
although almost three-quarters of ado-
lescents were happy about their preg-
nancy. No differences in perceived social
support during pregnancy or the post-
partum period were observed between
adolescents and adult women. Rates of
physical abuse in the 2 years before the
interview were significantly higher in
adolescents (41.0%) and young adults
(21.8%) compared with adult women
(8.2%), with most experiencing .1 form
of abuse. All 3 groups identified the
primary source of abuse as the partner;
in addition, adolescents were almost
6 times as likely to report that they had
been abused by a family member. Al-
though more adolescents and young
adults reported experiencing $3 stress-
ful life events in the year before the birth
of their infant, no differences were
found in levels of perceived stress
between the groups. The proportion of
adolescents (14.0%) and young adults
(9.3%) with an EPDS score of $13 was
significantly higher than adult women
(6.9%).
Health Behaviors
Rates of taking a folic acid supplement
before or during pregnancy were signifi-
cantly lower in adolescents and young
women compared with adult women
(Table 3). In addition, 64.1% of adolescents
Adolescents Aged 15–19 y, Young Adult Women Aged 20–24 y,
(Weighted n = 2262) (Weighted n = 9965)
Unadjusted OR Weighted %
(95% CI)
82.7 75.1
13.1a 1.92 (1.27–2.89) 22.3
51.6 79.3
48.4 17.75 (13.49–23.35) 20.7
9.8a 34.8
90.2 13.27 (8.97–19.61) 65.2
ARTICLE
and 44.7% of young adults indicated that
(before pregnancy) they did not know
that folic acid could help prevent some
birth defects compared with 17.4% of
adult women who knew this fact. Both
adolescents and young adults were
more likely to report smoking before
and during pregnancy and the post-
partum period, living with someone who
smoked, and using illicit drugs before
pregnancy than adult women.
Pregnancy, Postpartum, and Labor
and Delivery Experiences
Adolescents (15.3%) and young adults
(7.7%) were more likely to initiate
prenatal care after the first trimester
than adult women (4.4%) (Table 4). Al-
though both groups were also more likely
to attend prenatal classes compared
with adult women, .50% of adolescents
did not attend classes. Adolescents
(20.4%) and young adults (19.7%) were
significantly less likely to have a cesar-
ean delivery than adult women (27.6%).
No differences were found between
groups in their overall rating of the labor
and birth experience or the presence of
a partner during labor and delivery.
The proportion of adolescents who in-
tended to exclusively breastfeed (70.2%)
was significantly lower than adult
women (75.9%), and both adolescents
(83.6%) and young adults (89.3%) had
Adult Women Aged $25 y,
(Weighted n = 63 832)
Unadjusted OR Weighted % Unadjusted OR
(95% CI) (95% CI)
91.0
3.64 (2.96–4.47) 7.5 1.00 (reference)
95.0
4.94 (3.99–6.12) 5.0 1.00 (reference)
59.1
2.71 (2.32–3.15) 40.9 1.00 (reference)
e1231
TABLE 3 Comparison of Health Behaviors for Adolescents Compared With Adult Women, and for Young Adults Compared With Adult Women
Variable Adolescents Aged 15–19 y, Young Adult Women Aged 20 to Adult Women Aged $25 y,
(Weighted n = 2262) 24 y, (Weighted n = 9965) (Weighted n = 63 832)

Weighted % aORa (95% CI) Weighted % aORa (95% CI) Weighted % aORa (95% CI)
Took a multivitamin with folic acid or a folic
acid supplement in the 3 mo before
becoming pregnant
Yes 19.3 33.9 62.8
No 80.7 6.17 (4.30–8.85) 66.1 3.41 (2.81–4.14) 37.2 1.00 (reference)
Took a multivitamin with folic acid or a folic
acid supplement during the first 3 mo
of pregnancy
Yes 72.8 83.2 91.3
No 27.2 4.41 (3.07–6.33) 16.8 2.08 (1.56–2.78) 8.7 1.00 (reference)
Before pregnancy knew that taking
folic acid could help prevent some
birth defects
Yes 35.9 55.3 82.6
No 64.1 5.69 (4.25–7.62) 44.7 3.22 (2.67–3.89) 17.4 1.00 (reference)
Any smoking in the 3 mo before pregnancy
No 45.3 56.7 82.4
Yes 54.7 1.35 (2.77–5.36) 43.3 2.69 (2.20–3.29) 17.6 1.00 (reference)
Any smoking during pregnancy
No 71.1 76.4 92.2
Yes 28.9 4.90 (3.37–7.12) 23.6 3.26 (2.50–4.26) 7.8 1.00 (reference)
Any smoking during postpartum period
No 49.1 66.1 87.3
Yes 50.9 6.19 (4.46–8.60) 33.9 2.96 (2.37–3.69) 12.7 1.00 (reference)
Lived with someone who smoked at any time
during pregnancy
No 37.9 57.1 81.0
Yes 62.1 6.85 (5.07–9.25) 42.9 2.88 (2.38–3.49) 19.0 1.00 (reference)
Any illicit drug use before pregnancy
No 75.0 83.8 95.3
Yes 25.0 3.70 (2.47–5.56) 16.2 2.89 (2.17–3.86) 4.7 1.00 (reference)
a Adjusted for age-appropriate education, parity, and marital status at the time of the interview.

lower breastfeeding initiation rates than
adult women (90.8%). Rates of early ces-
sation of breastfeeding (ie, ,3 months)
were high among adolescents (81.1%)
and young adults (70.0%), and adoles-
cents who continued breastfeeding
were less likely to breastfeed exclu-
sively. Both adolescents and young
adults were more likely to place their
infants in a position other than on their
back for sleeping. Adolescent women
were also more likely to rate their own
health and that of their infant as less
than excellent or very good (good, fair,
or poor) compared with adult women.
Health Care Utilization and
Information Needs
There was little variation in health care
utilization across groups. No differences
were found in the proportions of women
who were contacted by a health care pro-
vider after birth, visited a health care
provider for a nonroutine visit for them-
selves or their infants, and were very
satisfied with their own or their infant’s
care since birth (Table 5). No differences
were observed in women’s views of their
providers’ care during pregnancy, labor
and birth, and the immediate post-
partum period (eg, respect, privacy,
compassion, competency, involvement
in decision-making, information given)
(data not shown). Similarly, no differ-
ences were found in the rates of women
who did not have enough information on
the effects of having an infant on partner
relationships, physical demands experi-
enced postpartum, negative feelings
postpartum, postpartum depression,
changes in sexual responses and feel-
ings, how to use birth control, and the
effect of using illicit drugs during preg-
nancy (data not shown). Adolescents
were more likely to indicate they did not
have enough information on how to
breastfeed (9.6%) compared with women
aged $25 years (7.6%).
DISCUSSION
Our main findings indicate that the ma-
ternity experiences of adolescents differ
from women aged $25 years, particu-
larly in the areas of physical abuse,
psychosocial health, health behaviors
before and during pregnancy, the rating
of their own and their infant’s health,
prenatal care initiation, and breastfeed-
ing. We also found that the maternity

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 ARTICLE

TABLE 4 Comparison of Pregnancy, Delivery, and Postpartum Experiences for Adolescents Compared With Adult Women, and for Young Adults
Compared With Adult Women
Variable Adolescents Aged 15–19 y, Young Adult Women Aged 20 to Adult Women Aged $25 y,
(Weighted n = 2262) 24 y, (Weighted n = 9965) (Weighted n = 63 832)

Weighted % aORa (95% CI) Weighted % aORa (95% CI) Weighted % aORa (95% CI)
Received prenatal care later than wanted
No 82.4 87.2 89.2
Yes 17.6 1.23 (0.82–1.84) 12.8 1.03 (0.78–1.37) 10.8 1.00 (reference)
Initiated prenatal care late (after first trimester)
No 84.7 92.3 95.6
Yes 15.3 3.85 (2.47–5.99) 7.7 1.51 (1.02–2.41) 4.4 1.00 (reference)
Attended prenatal classes
No 50.5 2.16b (1.53–3.05) 65.9 2.15b (1.72–2.63) 68.0 1.00 (reference)
Yes 49.5 34.1 32.0
Partner present during labor
Yes 83.8 90.7 95.6
No 16.2 1.10 (0.65–1.87) 9.3 1.26 (0.86–1.86) 4.4 1.00 (reference)
Partner present during birth
Yes 78.8 87.7 93.5
No 21.2 1.27 (0.82–1.98) 12.3 1.27 (0.93–1.72) 6.5 1.00 (reference)
Type of delivery
Vaginal 79.6 80.3 72.4
Cesarean 20.4 0.64 (0.46–0.90) 19.7 0.57 (0.46–0.72) 27.6 1.00 (reference)
Overall rating of labor and birth experience
Very or somewhat positive 74.2 79.6 80.3
Other (very negative, somewhat negative, 25.8 0.98 (0.70–1.36) 20.4 0.93 (0.74–1.16) 19.7 1.00 (reference)
neither positive nor negative)
Intended to exclusively breastfeed
Yes 70.2 73.7 75.9
No 29.8 1.63 (1.20–2.20) 26.3 1.19 (0.96–1.47) 24.1 1.00 (reference)
Initiated any breastfeeding
Yes 83.6 89.3 90.8
No 16.4 2.55 (1.76–3.71) 10.7 1.49 (1.12–1.97) 9.2 1.00 (reference)
Received help to start breastfeeding
in hospital
Yes 83.8 83.4 80.1
No 16.2 1.40 (0.94–2.08) 16.6 0.97 (0.75–1.25) 19.9 1.00 (reference)
Offered free formula sample in hospital
No 47.9 61.5 65.2
Yes 52.1 1.42 (1.08–1.87) 38.5 1.00 (0.83–1.21) 34.8 1.00 (reference)
Had enough information about community
breastfeeding supports
No 15.6 1.14 (0.71–1.83) 16.8 1.21 (0.92–1.58) 13.1 1.00 (reference)
Yes 84.4 83.2 86.9
Any breastfeeding for $3 moc
Yes 18.9 30.0 41.2
No 81.1 2.55 (1.76–3.71) 70.0 1.49 (1.12–1.97) 58.5 1.00 (reference)
Exclusive breastfeeding for $3 moc
Yes 34.1 46.3 53.3
No 65.9 2.04 (1.52–2.73) 53.7 1.13 (0.94–1.37) 46.7 1.00 (reference)
Infant sleep position
Back 70.4 72.8 78.4
Other (side, stomach, other) 29.6 1.53 (1.13–2.08) 27.2 1.44 (1.17–1.77) 21.6 1.00 (reference)
Maternal rating of infant’s health
Excellent or very good 88.6 91.6 93.1
Other (good, fair, poor) 11.4 2.30 (1.44–3.65) 8.4 1.29 (0.90–1.84) 6.9 1.00 (reference)
Maternal rating of self-reported health
Excellent or very good 59.0 65.0 74.2
Other (good, fair, poor) 41.0 2.26 (1.66–3.08) 35.0 1.48 (1.22–1.80) 25.8 1.00 (reference)
a Adjusted for age-appropriate education, parity, and marital status at the time of the interview.
b Unadjusted OR for adolescents was 0.48 (95% CI: 0.38–0.62) and for 20- to 24-year-olds was 0.91 (95% CI: 0.78–1.07). Adjustment according to marital status and education produced little

variation in the ORs; however, the addition of parity to the model resulted in an aOR for adolescents and 20- to 24-year-olds .2.
c Based on the subset of women who initiated breastfeeding (adolescent, weighted n = 1889; 20- to 24-year-olds, weighted n = 8846; $25-year-olds, weighted n = 57 645).

PEDIATRICS Volume 129, Number 5, May 2012 e1233

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TABLE 5 Comparison of Health Care Utilization and Knowledge of Various Topics for Adolescents Compared With Adult Women, and for Young Adults
Compared With Adult Women
Variable Adolescents Aged 15–19 y, Young Adult Women Aged 20 to Adult Women Aged $ 25 y,
(Weighted n = 2262) 24 y, (Weighted n = 9965) (Weighted n = 63 832)

Weighted % aORa (95% CI) Weighted % aORa (95% CI) Weighted % aORa (95% CI)
Infant taken to physician or other health care provider for
problem or illness other than routine check-up
No 45.3 51.5 51.9
Yes 54.7 1.09 (0.83–1.44) 48.5 1.15 (0.96–1.37) 48.1 1.00 (reference)
Mother’s satisfaction with infant care since birth
Very or somewhat satisfied 92.6 93.8 94.2
Other (somewhat dissatisfied, very dissatisfied, neither 7.3 1.35 (0.77–2.37) 6.2 0.84 (0.55–1.28) 5.8 1.00 (reference)
satisfied nor dissatisfied)
Was contacted at home by a health care provider (public health
nurse, or midwife) after birth
Yes 95.9 92.8 93.3
No 4.1b 0.41 (0.17–1.02) 7.2 1.08 (0.73–1.58) 6.7 1.00(reference)
Mother saw health care provider after birth other than for
a routine postpartum visit
No 69.1 74.5 71.9
Yes 30.9 0.97 (0.72–1.32) 25.5 0.73 (0.59–0.90) 28.1 1.00 (reference)
Mother’s satisfaction with her postpartum care
Very or somewhat satisfied 87.8 89.7 91.2
Other (somewhat dissatisfied, very dissatisfied, neither 12.2 1.30 (0.65–2.57) 10.3 1.07 (0.68–1.70) 8.8 1.00 (reference)
satisfied nor dissatisfied)
a Adjusted for age-appropriate education, parity, and marital status at the time of the interview.
b CV: 16.6–33.3. Based on Statistics Canada data quality guidelines, CVs #16.5% are reliable estimates, CVs between 16.6% and 33.3% are marginal, and those .33.3% are unreliable because of

the high level of error inherent in the estimate and therefore unreportable.

experiences of adolescents were more
similar to young adults than adult
women, and observed a gradual decline
in the gradient of prevalence of the
various adverse maternity experiences
with age.
One of the most striking findings in this
study was the high prevalence of phys-
ical abuse reported by adolescents. Our
data indicate that physical abuse is a
common experience among pregnant
adolescents,theyare likely toexperience
multiple forms of abuse, and that while
most women who reported abuse in-
dicated their partners were the source
of abuse, adolescents also reported high
rates of abuse by family members. Some
have suggested that higher rates of
abuse in adolescents in general may be
due to exposure to a broader array of
abusers (eg, family, partner, peers) or a
greater vulnerability to coercive relation-
ships.12 Rates of adolescent abuse re-
ported in other studies vary widely;
however, they are consistently higher
than those of nonadolescents.12 Although
much research has focused on the im-
pact of abuse on the risk of adolescent
pregnancy, little research has explored
the experience of abuse in pregnant or
postpartum adolescents. However, the
association of abuse with greater risk of
unintended pregnancy, substance abuse
during pregnancy,25 induced and spon-
taneous abortion,26 and poor current
and future mental health27 suggests that
adolescent mothers and their children
may be particularly vulnerable to its
detrimental consequences. Our findings
add to this body of literature by demon-
strating that young adults are also more
likely to experience abuse compared
with adult women.
Our finding that rates of unintended
pregnancy continue to be high in both
adolescents and young adults was con-
sistent with a national study conducted in
the United States, which found that among
women who had been pregnant 82% aged
15 to 19 years who had been pregnant and
64% aged 20 to 24 years experienced
unintended pregnancy.28 This study also
observed that the rate of unintended
pregnancy in adolescents was stable
during 2001–2006 but increased in 20-
to 24-year-olds.28
Few studies have addressed the issue of
psychosocial stress in pregnant ado-
lescents.29 The common occurrence of
stressful life events in adolescents
highlights the potential for stress-
related consequences in almost one-
half of the adolescent women who
become pregnant, including increased
substance abuse, difficulty in maternal
adjustment, and postpartum emotional
distress.29,30 The greater prevalence of
postpartum depressive symptoms in
adolescents is consistent with a review
which suggested that this finding may be
related to social isolation, high levels
of parenting stress, weight/shape dis-
turbance, family conflict, low mater-
nal self-efficacy, lack of treatment of
postpartum depression, and unrealistic
expectations that result in adolescents
being unprepared for the daily tasks of
motherhood.31

e1234 KINGSTON et al
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Our finding that the majority of ado-
lescents did not take a folic acid sup-
plement before pregnancy or know
about its benefits in preventing neural
tube defects may be related to the un-
planned nature of most adolescent pre-
gnancies.32 The higher prevalence of
smoking and drug abuse in adolescents
before pregnancy was anticipated based
on other studies33; however, it is con-
cerning that adolescent health behav-
iors during pregnancy continue to be
substantially poorer than adult women.
The finding that more than one-quarter
of adolescents did not take folic acid
during the first trimester and continued
to smoke during pregnancy may in part
be explained by late recognition of the
pregnancy and/or delayed entry to pre-
natal care. Similar to studies conducted
under various health care systems in
other countries, 34,35 we found that
Canadian adolescents were more likely
to initiate prenatal care after the first
trimester. One study that explored bar-
riers to prenatal care among adoles-
cents found that deterrents were largely
service related and included negative
attitudes toward physicians, lack of
perceived importance of early pre-
natal care, confusion about available
prenatal care services, and desire for
an adolescent-only clinic.35
In our study, rates of cesarean delivery
were lower in adolescents than in adult
women. Although consistent with other
studies,36–39 some have also reported
similar16 or higher15 rates of cesarean
deliveries in adolescents compared
with nonadolescents. Although reasons
for the lower rate of cesarean delivery
in adolescents are speculative, some
have suggested that this may be due to
the fact that most adolescents are
nulliparous and lower cesarean rates
are associated with nulliparity,37,38 the
prevalence of medical complications as-
sociated with cesarean delivery increa-
ses with age,39 or that physiologic factors
associated with younger age (eg, lower
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resistance in uterine muscle) may con-
tribute to a shorter duration of second
stage and a lower likelihood of cesarean
delivery.38 Similar to our study, others
have reported lower rates of breast-
feeding initiation and exclusive breast-
feeding, as well as shorter durations, in
adolescents compared with nonadoles-
cents.40 We did not find other studies to
compare our results with regarding the
perception of suboptimal health in post-
partum adolescents and their infants,
but it may, in part, be related to un-
realistic prebirth expectations.
CONCLUSIONS
Much research has focused on exploring
the predictors of adolescent pregnancy
and evaluating prevention approaches,
with comparatively little work directed
at understanding the needs of pregnant
and postpartum adolescents or explor-
ing the continuum of risk among ado-
lescent, young adult, and adult women.
This study used a nationally repre-
sentative sample to address this gap
by comparing a wide array of maternity
experiences between adolescents and
nonadolescents in Canada. As such, it
extends previouswork that has described
the demographics and characteristics of
Canadian adolescent mothers.41 Despite
the strengths of the large, nationally
representative sample and the diversity
of topics addressed, some limitations
must be acknowledged. The prevalence
of adolescent pregnancy in our sample
(3.1%) was lower than that reported in
the Canadian Perinatal Health Report
(4.8%) using vital statistics and hospi-
talization data,42 despite attempts to
oversample adolescents. The relatively
low number of adolescent participants
may have precluded the ability to detect
significant differences between adoles-
cents and women aged $25 years on
some variables and may limit the gen-
eralizability of the findings. Further-
more, the experiences of adolescents
who responded to the MES may differ
ARTICLE
from those who did not participate. As
in most surveys, social desirability may
influence responses surrounding health
behaviors during pregnancy. We did not
have an adequate sample size to ex-
plore variations in experiences between
younger and older adolescents, although
some of the needs and outcomes of
these 2 groups differ.2 In addition, the
MES did not include adolescents aged
,15 years. Finally, selection bias in
the adolescents invited to participate in
the survey may have been introduced
through the exclusion of women whose
infants were not living with them at the
time of the survey.
Several implications and recommenda-
tions for future research can be drawn
from this study. The issue of adolescent
physical abuse emerged as a significant
finding in this study, and one that merits
close attention. Given the limited re-
search on abuse among pregnant ado-
lescents, future studies should seek to
expand our knowledge of its epidemi-
ology. Although the Society for Obste-
tricians and Gynaecologists of Canada
and the American College of Obstetri-
cians and Gynecologists recommend
routine screening of all pregnant women
for abuse,43,44 screening for domestic
violence during pregnancy is not uni-
versal, and we know little about preg-
nant adolescents’ patterns of divulging
this sensitive information. In addition,
addressing the safety needs of pregnant
adolescents may differ considerably
from this process in older mothers.
Some research has studied trends in
prenatal care initiation among ado-
lescents34; however, few data have
addressed factors that influence pre-
natal care initiation in this group. Group-
based models of prenatal care, such as
CenteringPregnancy,7 offer a promising
approach to overcoming barriers to
prenatal care utilization as well as ad-
dressing the specific physical and psy-
chological needs of pregnant adolescents
while preparing them for life with their
e1235
new infant.7 Given that the majority of
adolescents wanted to delay childbear-
ing, the prevention of unwanted preg-
nancies remains a priority. Programs
that support new adolescent mothers,
such as “teen-tots,” have been effective in
preventing repeat pregnancies.45,46 These
programs have also been shown to im-
prove maternal and infant health,45 which
may in part address the perception of
suboptimal maternal and infant health
that we observed.
The findings of this study also highlight
the need to understand and address
factors that contribute to low initia-
tion and early cessationofbreastfeeding
among adolescents.Studies suggest that
adolescents have unique beliefs and
learning needs regarding breastfeeding
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e1237
 Comparison of Adolescent, Young Adult, and Adult Women's Maternity
Experiences and Practices
Dawn Kingston, Maureen Heaman, Deshayne Fell, Beverley Chalmers and on behalf
of the Maternity Experiences Study Group of the Canadian Perinatal Surveillance
System, Public Health Agency of Canada
Pediatrics 2012;129;e1228
DOI: 10.1542/peds.2011-1447 originally published online April 23, 2012;

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 Comparison of Adolescent, Young Adult, and Adult Women's Maternity
Experiences and Practices
Dawn Kingston, Maureen Heaman, Deshayne Fell, Beverley Chalmers and on behalf
of the Maternity Experiences Study Group of the Canadian Perinatal Surveillance
System, Public Health Agency of Canada
Pediatrics 2012;129;e1228
DOI: 10.1542/peds.2011-1447 originally published online April 23, 2012;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/129/5/e1228

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