ARTICLE
Fertility Rate Trends Among Adolescent Girls With
Major Mental Illness: A Population-Based Study
aWomen’s
WHAT’S KNOWN ON THIS SUBJECT: Although fertility rates among
adolescents have declined in recent years, certain groups of
adolescent girls remain at risk. Whereas adolescents with major
mental illness have many risk factors for teenage pregnancy,
their fertility rates have not been yet to be examined.
KEY WORDS
adolescent pregnancy, epidemiology, mental health
WHAT THIS STUDY ADDS: Fertility rates among adolescent girls
with major mental illness are almost 3 times higher than among
unaffected adolescents and are not decreasing to the same
extent. Mental health considerations are highly important for
pregnancy prevention and for perinatal interventions targeting
adolescents.
AUTHORS: Simone N. Vigod, MD, MSc, FRCPC,a,b,c Cindy Lee
Dennis, PhD,a,b Paul A. Kurdyak, MD, PhD,a,c,d John Cairney,
PhD,c,e Astrid Guttmann, MD, MSc,b,c,f and Valerie H. Taylor,
MD, PhDa,b
College Hospital and Women’s College Research
Institute, Toronto, Ontario, Canada; bUniversity of Toronto,
Toronto, Ontario, Canada; cInstitute for Clinical Evaluative
Sciences, Toronto, Ontario, Canada; dCentre for Addiction and
Mental Health, Toronto, Ontario, Canada; eMcMaster University,
Hamilton, Ontario, Canada; and fHospital for Sick Children,
Toronto, Ontario, Canada
ABBREVIATIONS
ASFR—age-specific fertility rate
CI—confidence interval
CIHI-DAD—Canadian Institutes of Health Information–Discharge
Abstract Database
ICD-9—International Classification of Diseases, Ninth Revision
ICD-10-CA—Canadian version of the International Classification of
Diseases, 10th Revision
OHIP—Ontario Health Insurance Plan
Dr Vigod conceptualized and designed the study, carried out the
analyses in conjunction with Ms Kinwah Fung (analyst), and
drafted the initial manuscript; Dr Dennis assisted with study
conceptualization and reviewed and revised the manuscript; Drs
Kurdyak, Cairney, and Guttmann assisted with study design and
reviewed and revised the manuscript; Dr Taylor conceptualized
the study and reviewed and revised the manuscript; and all
authors approved the final manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-1761
doi:10.1542/peds.2013-1761
Accepted for publication Dec 17, 2013
Address correspondence to Simone N. Vigod, MD, MSc, FRCPC,
Department of Psychiatry, Women’s College Hospital, 76 Grenville
St, Toronto, ON, Canada M5S 1B2. E-mail: simone.
[email protected]
(Continued on last page)
abstract
OBJECTIVE: Fertility rates among adolescents have decreased substantially in recent years, yet fertility rates among adolescent girls with
mental illness have not been studied. We examined temporal trends
in fertility rates among adolescent girls with major mental illness.
METHODS: We conducted a repeated annual cross-sectional study of
fertility rates among girls aged 15 to 19 years in Ontario, Canada
(1999–2009). Girls with major mental illness were identified through
administrative health data indicating the presence of a psychotic,
bipolar, or major depressive disorder within 5 years preceding
pregnancy (60 228 person-years). The remaining girls were classified
into the comparison group (4 496 317 person-years). The age-specific
fertility rate (number of live births per 1000 girls) was calculated
annually and by using 3-year moving averages for both groups.
RESULTS: The incidence of births to girls with major mental illness was
1 in 25. The age-specific fertility rate for girls with major mental illness
was 44.9 per 1000 (95% confidence interval [CI]: 43.3–46.7) compared
with 15.2 per 1000 (95% CI: 15.1–15.3) in unaffected girls (rate ratio:
2.95; 95% CI: 2.84–3.07). Over time, girls with major mental illness had
a smaller reduction in fertility rate (relative rate: 0.86; 95% CI: 0.78–
0.96) than did unaffected girls (relative rate: 0.78; 95% CI: 0.76–0.79).
CONCLUSIONS: These results have key clinical and public policy implications. Our findings highlight the importance of considering major
mental illness in the design and implementation of pregnancy prevention programs as well as in targeted antenatal and postnatal programs
to ensure maternal and child well-being. Pediatrics 2014;133:e585–
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PEDIATRICS Volume 133, Number 3, March 2014
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Adolescents comprise a vulnerable
group with respect to pregnancy and
parenting outcomes.1 They are at increased risk of multiple adverse outcomes, including preterm birth, poor
fetal growth, stillbirth, postpartum depression, and psychosocial instability
across the perinatal period.2–9 Public
health and school- and communitybased interventions to reduce pregnancies among adolescents have led to
reductions of up to 35% in Canada, the
United States, the United Kingdom, and
in other developed countries over the
past several years.10–12 However, certain
groups of adolescents remain at
higher risk of pregnancy, including
minority groups and those with family
and/or economic instability.10,13,14 Adolescent girls with major mental illnesses, including major depression,
bipolar disorder, and psychotic disorders such as schizophrenia, have
several risk factors associated with
teenage pregnancy, including poverty
and early childhood trauma,15–18 but
trends in fertility rates among adolescent girls with mental illness diagnosed before pregnancy have not
been documented.
Knowledge about the burden of preexisting serious mental illness among
adolescent mothers is important because having a major mental illness is
associated with a higher rate of adverse pregnancy outcomes among adult
women such as preterm birth and poor
fetal growth.19–21 Furthermore, the negative impact of maternal mental illness
on child development and child psychopathology is substantial.22–24 Given that
adolescents are at high risk of adverse
pregnancy outcomes, children of adolescent mothers with mental illness may
be “doubly” vulnerable due to the independent risks associated with being
the child of both an adolescent and
a woman with a major mental illness.
Information about fertility rates among
adolescents with major mental illness
e586
will have important implications for
clinical care, research, and public policy. It will help inform the development
of interventions targeting pregnancy
prevention and optimization of outcomes for adolescent mothers and
their children. Also, if fertility rates are
high in this group, it will underscore
the importance of future research to
quantify the level of risk for these adolescent mothers’ children. To begin to
address the knowledge gaps in this
area, we undertook a population-based
study among adolescents in Ontario,
Canada. Our primary objective was to
examine age-specific fertility rates
(ASFRs; live births per 1000 girls ages
15–19 years) over a 10-year period,
comparing adolescent girls with and
without major mental illness diagnosed
before pregnancy. Our secondary objective was to identify factors that
could explain observed differences between groups.
METHODS
Study Design
We completed a repeated cross-sectional
study of ASFRs for all adolescent girls
aged 15 to 19 years in the province of
Ontario, Canada over a 10-year study
period (1999–2009). By using populationbased health administrative data, we
calculated annual ASFRs among adolescent girls with major mental illnesses
diagnosed before pregnancy (psychotic
disorders, bipolar disorder, and major
depressive disorder) and compared
these rates with those of adolescent girls
without a previous major mental illness
diagnosis.
Data Sources
We used multiple linked population
health administrative databases from
the Institute for Clinical and Evaluative Sciences in Toronto, Ontario, an
independent nonprofit research organization that uses a variety of administrative databases to evaluate universally
VIGOD et al
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available health care services and their
effectiveness in the province of Ontario.
Patient-level records in these databases
are anonymously linked through the
use of a unique identifier (scrambled
health care number). The data quality in
these administrative databases has
been examined and found to be complete, reliable, and accurate with respect to demographic information,
primary diagnoses for inpatient services, and billing claims for physician
services.25 We used the Registered
Persons Database containing gender,
age, and postal code for all Ontario
residents eligible for health care
services, to identify all adolescent girls
aged 15 to 19 years in each fiscal year
from 1999 to 2009. We used the Canadian
Institute of Health Information–Discharge
Abstract Database (CIHI-DAD) and the
Ontario Mental Health Reporting System
Database for hospitalization-related data
and the Ontario Health Insurance Plan
Database (OHIP) for physician billing data
to identify girls with major mental illness.
We also used the MOMBABY data file, an
existing cumulative data set derived from
the CIHI-DAD that provides linked maternal and newborn health records for all
newborns delivered in hospital. Births are
identified in the MOMBABY data file by
using the main patient service code for
“obstetric delivery” and/or hospital diagnostic codes indicating obstetric delivery, and the data file includes flags to
identify live births. This data file has been
used extensively in multiple publications examining population-based pregnancy outcomes in Ontario.26,27
Cohort
For a previous study, we created annual
samples of Ontario women aged 15 to 49
years at the midpoint of each 12-month
period starting from April 1, 1999, until
April 1, 2009.28 For this study, we restricted the cohort to adolescent girls
aged 15 to 19 years. The number of
adolescent girls in each fiscal year
ranged from a minimum of 379 303 to
ARTICLE
a maximum of 437 534, resulting in
a total of 4 556 545 person-years for
the overall study period.
Exposure
For the primary analysis, we chose to
combine girls with major depression,
bipolar disorder, and psychotic disorders into 1 category of major mental
illness because psychiatric diagnoses
are very fluid between these categories
for adolescents.29,30 For each 12-month
period, an adolescent was assigned to
the major mental illness group if: (1)
she had been hospitalized with a discharge diagnosis of any psychotic disorder, bipolar disorder, or major
depressive disorder on the basis of International Classification of Diseases,
Ninth Revision (ICD-9), codes of 295 to
298 or the Canadian version of the International Classification of Diseases,
10th Revision (ICD-10-CA), codes of F20,
F22 to F25, or F28 to F33; or (2) if she had
$1 physician OHIP service claims for
these disorders (OHIP codes 295–298,
based on ICD-9 classification), any of
which were within the 5-year period
preceding the estimated date of conception of the index pregnancy. This
mental illness classification was used by
the Manitoba Centre for Health Policy to
profile the treatment prevalence of
mental health disorders in Manitoba,
Canada, and has been used in previous
Institute for Clinical and Evaluative Sciences studies.28,31,32 The remaining girls
were classified into the comparison
group. For a subgroup analysis, we identified girls within the major mental illness
group who had any diagnosis of schizophrenia and/or another psychotic disorder (OHIP/ICD-9: 295, 297, 298; ICD-10-CA:
F20, F22, F23, F24, F25, F28, F29) during the
look-back period and classified them into
a “primary psychotic disorder” subgroup.
The remaining girls in the major mental
illness group were classified into a “primary mood disorder” subgroup (OHIP/
ICD-9: 296; ICD-10-CA: F30–F33).
Outcomes
We measured annual ASFRs in the 15- to
19-year age band among girls with
major mental illness and a comparison
group. The ASFR is a measure of the
number of live births per unit of population. It is the measure used by the
World Health Organization to take into
account the age structure of the population and is globally used to measure
fertility rates among adolescent girls.33
By definition, the ASFR includes only
live births, such that it is not a perfect
reflection of pregnancy rates. To address this issue, we also measured
stillbirth rates separately in both
groups to be compared in a secondary
analysis.
Covariates
We measured parity, socioeconomic
status, and place of residence (urban
versus rural location). Parity was derived from the maternal health record
in the CIHI-DAD. Socioeconomic status
was approximated by using quintiles of
neighborhood income derived from
Ontario postal code data. Place of residence was defined by using postal code
data where urban areas were those with
an urban core of $10 000 individuals.
Statistical Analyses
We calculated the number of girls with
and without major mental illness who
delivered a live-born infant during
the study period and described both
groups in terms of the study covariates.
We calculated overall and annual ASFRs
for each group by dividing the number
of live births to eligible adolescent girls
in each fiscal year by the total number of
eligible adolescent girls in that fiscal
year; the data are presented in terms of
the number of live births per 1000 eligible girls.33
To achieve the primary objective, we
compared ASFRs between adolescents
with and without major mental illness,
PEDIATRICS Volume 133, Number 3, March 2014
creating an ASFR ratio and 95% confidence interval (CI) overall and for
each fiscal year. To investigate change
over time within each group, we used
3-year moving averages to reduce
variability and calculated relative
ASFR and 95% CIs comparing the final
3 years of the study (2007–2009) with
the first 3 years of the study (1999–
2001) for affected and unaffected
adolescents separately. In secondary
analyses, we compared ASFRs between girls with “primary psychotic
disorders” and “primary mood disorders.” In addition, we compared
stillbirth rates between girls with and
without major mental illness.
To achieve the secondary objective,
we adjusted the overall ASFR ratio for
the study covariates by using generalized estimating equations to account for clustering of participants,
presenting each variable’s contribution to the model using rate ratios
and 95% CIs.
Analysis was conducted by using SAS 9.2
for UNIX (SAS Institute, Cary, NC). Permission to complete this study was
granted by the Sunnybrook Health
Sciences Centre Research Ethics Board
in Toronto, Ontario.
RESULTS
Adolescents with previously diagnosed
major mental illness represented 60
228 person-years in the cohort (1.1% to
1.4% of the sample for any given fiscal
year). Girls in the major mental illness
group were more likely to be multiparous compared with unaffected girls
(3.6% vs 1.4%), but the breakdown of
socioeconomic status and place of
residence was relatively similar; ∼22%
of girls in the major mental illness
group were in the lowest neighborhood
income quintile compared with 20% of
unaffected girls, and almost all girls in
both groups were living in urban areas
(87.5% and 86.5% of affected and unaffected girls, respectively).
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There were 71 098 births among adolescent girls in Ontario over the study
period, and 2707 (3.8%) were to girls
in the major mental illness group. Of
these births, 795 (29.3%) were to girls
with a primary psychotic disorder and
1912 (70.6%) were to girls with a primary mood disorder. The overall ASFR
among adolescents with major mental
illness was 44.9 per 1000 (95% CI: 43.3–
46.7) compared with 15.2 per 1000
(95% CI: 15.1–15.3) among unaffected
girls, resulting in a rate ratio of 2.95
(95% CI: 2.84–3.07) (Table 1). Over time,
the ASFR among adolescents with major mental illness decreased, but not in
a linear form (Table 1). Using 3-year
moving averages to reduce annual
variability in the data, a similar trend
was observed (Fig 1), and the relative
ASFR comparing fiscal years 2007–
2009 with 1999–2001 was 0.86 (95% CI:
0.78–0.96). For unaffected girls, there
was a consistent downward trend using 3-year moving averages (Fig 1), and
the relative ASFR comparing fiscal
years 2007–2009 with 1999–2001 was
0.78 (95% CI: 0.76–0.79). There was no
difference in ASFRs between girls from
the major mental illness group who
had a diagnosis of a primary psychotic
disorder (overall ASFR: 45.0; 95% CI:
41.9–48.3) and those with a primary
mood disorder (overall ASFR: 44.9; 95%
with a decrease of 22% among unaffected girls.
CI: 42.9–47.0) (ASFR ratio: 1.00; 95% CI:
0.92–1.09). The stillbirth rate was 7.04
per 1000 births among girls with
major mental illness (95% CI: 5.43–8.66)
compared with 6.61 per 1000 births
(95% CI: 6.30–6.92) among unaffected
girls, a nonsignificant difference.
There has been minimal antecedent
literature on this topic. Two clinical
studies revealed high rates of teenage
pregnancy among girls with bipolar
disorder.34,35 To our knowledge, however, this is the first population-based
study to show that adolescents with
major mental illnesses are at higher
risk than unaffected adolescents of
becoming teenage parents. Although
we could not explain all of the reasons
for the observed increase in birth rate,
multiparity, low socioeconomic status,
and rural region of residence all independently increased the risk of adolescent birth in our study. This finding
is consistent with the literature on
known risk factors for adolescent
pregnancy, including previous adolescent pregnancy, poverty, minority status (in the United States), and history
of childhood trauma, including sexual
abuse.10,13,14,36 As such, our findings
add considerably to how we understand
the clinical situation of adolescent pregnancy and have clear implications for
public policy and program development.
First, despite outreach to reduce adolescent pregnancy rates, girls with major
mental illness are a specific at-risk
group. Preventive programs in most
Study covariates explained some of the
difference in ASFRs between groups.
Multiparity, low socioeconomic status,
and rurality were all independently
associated with increased birth rates,
and inclusion of these covariates in the
multivariable model reduced the ASFR
ratio comparing girls in the major
mental illness group with unaffected
girls to 1.87 (95% CI: 1.77–1.96) (Table 2).
DISCUSSION
Adolescent girls with a major mental
illness diagnosed before pregnancy
accounted for almost 1 in 25 adolescent
births, corresponding to an overall
ASFR almost 3 times higher than the
rate for adolescent girls without major
mental illness. Although fertility rates in
both affected and unaffected adolescent girls decreased over time, the gap
between the groups appeared to be
increasing slightly over our 10-year
study period. The ASFR among adolescents with major mental illness decreased by only ∼14% in comparison
TABLE 1 ASFRs Among Adolescents With and Without Psychotic Disorders, Bipolar Disorder, and Major Depressive Disorder in Ontario (1999–2009)
Adolescent Girls With Major Mental Illnessesa
Fiscal Year
Total Number
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
All years
4252
4584
5041
5244
5371
5565
5780
5965
6012
6146
6268
60 228 person-years
Number of Live Births ASFRb (95% CI)
228
245
241
249
219
227
223
243
283
272
277
2707
Adolescent Girls Without Major Mental Illnesses
Total Number
53.6 (46.9–61.1)
375 051
53.4 (47.0–60.6)
384 349
47.8 (42.0–54.2)
392 163
47.5 (41.8–53.8)
400 483
40.8 (35.6–46.5)
406 952
40.8 (35.7–46.5)
412 786
38.6 (33.7–44.0)
421 449
40.7 (35.8–46.2)
421 571
47.1 (41.7–52.9)
422 635
44.3 (39.2–49.8)
427 612
44.2 (39.1–49.7)
431 266
44.9 (43.3–46.7) 4 496 317 person-years
Number of Live Births ASFRb (95% CI)
7165
6810
6546
6264
6185
5835
5822
6022
6032
5991
5719
68 391
a
Major mental illnesses include psychotic disorders, bipolar disorder, or major depressive disorder.
ASFR per 1000 eligible girls.
c Compares girls with psychotic disorders, bipolar disorder, and major depressive disorder with girls without these major mental illnesses.
b
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ASFR Ratioc (95% CI)
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19.1 (18.7–19.6)
17.7 (17.3–18.1)
16.7 (16.3–17.1)
15.6 (15.3–16.0)
15.2 (14.8–15.6)
14.1 (13.8–14.5)
13.8 (13.5–14.2)
14.3 (13.9–14.7)
14.3 (13.9–14.6)
14.0 (13.7–14.4)
13.3 (12.9–13.6)
15.2 (15.1–15.3)
2.81 (2.46–3.20)
3.02 (2.66–3.43)
2.86 (2.52–3.26)
3.04 (2.67–3.45)
2.68 (2.34–3.07)
2.89 (2.53–3.29)
2.79 (2.44–3.19)
2.85 (2.51–3.24)
3.30 (2.93–3.72)
3.16 (2.80–3.57)
3.33 (2.95–3.76)
2.95 (2.84–3.07)
ARTICLE
FIGURE 1
ASFRs for adolescent girls with and without major mental illness using 3-year moving averages.
TABLE 2 Comparison Between Girls With
and Without Major Mental Illness
Variable
Unadjusted
Mental health group
Major mental illness
No major mental illness
Adjusteda
Mental health group
Major mental illness
No major mental illness
Parity
0
1
$2
Neighborhood income
quintile
Highest
4
3
2
Lowest
Region of residence
Rural
ASFR Ratio
(95% CI)
2.95 (2.84–3.07)
Ref
1.87 (1.77–1.96)
Ref
Ref
13.5 (12.9–14.1)
15.8 (15.4–16.2)
Ref
1.33 (1.28–1.38)
1.81 (1.75–1.88)
2.27 (2.19–2.36)
3.04 (2.95–3.15)
1.42 (1.39–1.46)
Data are presented for models unadjusted and adjusted
for study covariates. Ref, referent group.
a All variables were adjusted for all other variables in the
model.
developed countries have not focused
explicitly on mental health as a risk factor, which may partly explain why fertility
rates are not decreasing as rapidly in
this group. Improved consideration of
mental health issues in prevention programs might be beneficial, and there are
some intervention models that might be
adapted for this purpose. For example,
several school-based targeted prevention programs for students identified
as being at risk of engaging in impulsive
behaviors such as substance misuse
have shown benefit not only in preventing substance misuse but also in
preventing emotional and behavioral
problems.37 Such programs are mainly
psychoeducational and use motivational
strategies to focus on enhancing decisionmaking skills in situations involving
impulsive behaviors. These types of programs could be modified for girls with
major mental illness, or within adolescent
mental health programs where these
girls are being clinically treated. Services
focused on counseling girls who already
have delivered 1 child may also be important because the rates of multiple
births are higher among those with major
mental illness. A second major implication of our findings relates to antenatal
and postnatal care programming.
Whereas most adolescent pregnancy
programs are equipped to help girls with
complex social situations, the identification of such a high prevalence of preexisting serious mental illness among
adolescent mothers indicates that a
more intensive level of mental health
care may be needed during pregnancy
and postpartum. Engaging adolescents
in health services can be extremely
challenging so antenatal mental health
PEDIATRICS Volume 133, Number 3, March 2014
assessment and treatment would likely
have optimal uptake at the point of
care. In the postnatal period, many
different public health and communitybased programs exist for adolescent
parenting and child care, but our
findings suggest that there should be
an increased focus on how to accommodate teens with significant mental
health issues. Community programs
(eg, breastfeeding, financial, parenting,
and nutrition support) are often all run by
different agencies, posing access challenges for any adolescent mother; those
with major mental illnesses may have
even greater difficulty navigating and engaging with these fragmented resources.
There are important strengths to this
analysis. We were able to generate
population-level fertility rate estimates
for girls with and without major mental
illness, and as such, our findings are
likely to be widely generalizable. The
adolescent fertility rate in Canada was
last reported at 12.3 in 2010 according
to a World Bank report published in
2012.38 This same report showed that
this was a decrease from 14.7 per 1000
in January 2002. Our rates (for adolescents in the unaffected group) are
remarkably consistent with these
numbers, as is the observed downward trend in fertility rate. Populationbased data are particularly appropriate
for a study such as ours, where it is
difficult to assemble a clinical cohort
large enough to detect differences in
birth rates. At the same time, administrative health data do not capture all
pertinent variables, and as such, it is
difficult to isolate major mental illness
as a causal factor in teenage pregnancy.
For example, we could investigate the
impact of parity, socioeconomic status,
and region of residence but not rates of
sexual abuse history, housing situation,
substance use, behavioral disorders,
and/or symptoms of other psychiatric
disorders that did not result in presentation to the health care system.
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Given that the adjusted ASFR ratio for
differences between groups was ,2.0,
residual confounding might explain the
association between major mental illness and the risk of adolescent pregnancy. There are other minor limitations
relevant to the outcome variable. Data
on births in Ontario have excellent validity; however, we missed births occurring outside of the hospital (,0.01% in
Ontario).27 Because the ASFR includes
only live births, it is not intended to be a
measure of pregnancy rates. We compared stillbirth rates between our 2
groups, and there was no significant
difference. However, we do not know
whether adolescents with mental illness are more or less likely to terminate
a pregnancy or have a miscarriage.
Also, consistent with global estimates of
the adolescent fertility rate, we did not
count births to girls aged 13 or 14
years.12 The latter limitation is unlikely
to be significant given that the vast
majority of adolescent pregnancies occur among older teens.39
CONCLUSIONS
Almost 1 in every 25 adolescent births in
Ontario, Canada, is to a girl diagnosed
before pregnancy with major depression, bipolar disorder, or a psychotic disorder. This situation raises
issues of broad societal concern because of the potential negative impacts
both for the adolescent mothers and for
their children. Our results suggest that
interventions targeting reproductive
health and decision-making for adolescent girls with mental illness, as well
as targeted antenatal and postnatal
programs to ensure maternal and child
well-being, are needed. Interventions
that systematically integrate adolescent mental health and reproductive
health care may help reduce adolescent
fertility rates as well as optimize
pregnancy and child development outcomes in this group. At present, there is
very little information on the combined
impact of having both a major mental
illness and being an adolescent on
pregnancy outcomes, nor how this may
affect child developmental outcomes.
Future research will be required to
highlight specific health disparities for
programs and interventions to target.
ACKNOWLEDGMENT
We thank Ms Kinwah Fung for assistance with data set creation and
analysis.
REFERENCES
1. Pinzon JL, Jones VF. Care of adolescent
parents and their children. Pediatrics.
2012;130(6). Available at: www.pediatrics.
org/cgi/content/full/130/6/e1743
2. Birkeland R, Thompson JK, Phares V. Adolescent motherhood and postpartum depression. J Clin Child Adolesc Psychol.
2005;34(2):292–300
3. Gavin AR, Lindhorst T, Lohr MJ. The prevalence and correlates of depressive symptoms among adolescent mothers: results
from a 17-year longitudinal study. Women
Health. 2011;51(6):525–545
4. Lewis LN, Hickey M, Doherty DA, Skinner SR.
How do pregnancy outcomes differ in
teenage mothers? A Western Australian
study. Med J Aust. 2009;190(10):537–541
5. Restrepo-Méndez MC, Barros AJ, Santos IS,
et al. Childbearing during adolescence and
offspring mortality: findings from three
population-based cohorts in southern Brazil.
BMC Public Health. 2011;11:781
6. DuPlessis HM, Bell R, Richards T. Adolescent pregnancy: understanding the impact
of age and race on outcomes. J Adolesc
Health. 1997;20(3):187–197
7. Gortzak-Uzan L, Hallak M, Press F, Katz
M, Shoham-Vardi I. Teenage pregnancy:
risk factors for adverse perinatal outcome. J Matern Fetal Med. 2001;10(6):
393–397
e590
8. Malamitsi-Puchner A, Boutsikou T. Adolescent pregnancy and perinatal outcome.
Pediatr Endocrinol Rev. 2006;3(suppl 1):
170–171
9. Taşdemir S, Balci E, Günay O. Comparison
of life quality of pregnant adolescents with
that of pregnant adults in Turkey. Ups J
Med Sci. 2010;115(4):275–281
10. Lavin C, Cox JE. Teen pregnancy prevention:
current perspectives. Curr Opin Pediatr.
2012;24(4):462–469
11. Centers for Disease Control and Prevention.
Vital signs: teen pregnancy—United States,
1991–2009. MMWR Morb Mortal Wkly Rep.
2011;60(13):414–420
12. Bearinger LH, Sieving RE, Ferguson J,
Sharma V. Global perspectives on the sexual and reproductive health of adolescents:
patterns, prevention, and potential. Lancet.
2007;369(9568):1220–1231
13. Basch CE. Teen pregnancy and the achievement gap among urban minority youth.
J Sch Health. 2011;81(10):614–618
14. Elfenbein DS, Felice ME. Adolescent pregnancy.
Pediatr Clin North Am. 2003;50(4):781–800.
15. McLaughlin KA, Green JG, Alegría M, et al.
Food insecurity and mental disorders in
a national sample of U.S. adolescents. J Am
Acad Child Adolesc Psychiatry. 2012;51(12):
1293–1303
VIGOD et al
Downloaded from by guest on June 18, 2017
16. McLaughlin KA, Costello EJ, Leblanc W,
Sampson NA, Kessler RC. Socioeconomic
status and adolescent mental disorders.
Am J Public Health. 2012;102(9):1742–1750
17. Mills R, Scott J, Alati R, O’Callaghan M,
Najman JM, Strathearn L. Child maltreatment and adolescent mental health problems in a large birth cohort. Child Abuse
Negl. 2013;37(5):292–302
18. Turner WC, Muck RD, Muck RJ, Stephens RL,
Sukumar B. Co-occurring disorders in the
adolescent mental health and substance
abuse treatment systems. J Psychoactive
Drugs. 2004;36(4):455–462
19. Bodén R, Lundgren M, Brandt L, Reutfors J,
Andersen M, Kieler H. Risks of adverse
pregnancy and birth outcomes in women
treated or not treated with mood stabilisers
for bipolar disorder: population based cohort study. BMJ. 2012;345:e7085
20. Wisner KL, Sit DK, Hanusa BH, et al. Major
depression and antidepressant treatment:
impact on pregnancy and neonatal outcomes. Am J Psychiatry. 2009;166(5):557–
566
21. Jablensky AV, Morgan V, Zubrick SR, Bower
C, Yellachich LA. Pregnancy, delivery, and
neonatal complications in a population
cohort of women with schizophrenia and
major affective disorders. Am J Psychiatry.
2005;162(1):79–91
ARTICLE
22. Beardslee WR, Versage EM, Gladstone TR.
Children of affectively ill parents: a review
of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1998;37(11):1134–1141
23. Schubert EW, McNeil TF. Prospective study
of adult mental disturbance in offspring of
women with psychosis. Arch Gen Psychiatry. 2003;60(5):473–480
24. Kim-Cohen J, Moffitt TE, Taylor A, Pawlby SJ,
Caspi A. Maternal depression and children’s
antisocial behavior: nature and nurture effects.
Arch Gen Psychiatry. 2005;62(2):173–181
25. Williams JI, O’Brien BJ, Sellors C, Grootendorst
P, Willison D. A summary of studies on the
quality of health care administrative databases in Canada. In: Goel V, Williams JI,
Anderson GM, Blacksterin-Hirsch P, Fooks C,
Naylor CD, eds. Patterns of Health Care in
Ontario. The ICES Practice Atlas. Ottawa,
Canada: Canadian Medical Association;
1996:339–345
26. Urquia ML, Ying I, Glazier RH, Berger H, De
Souza LR, Ray JG. Serious preeclampsia
among different immigrant groups. J
Obstet Gynaecol Can. 2012;34(4):348–352
27. Maaten S, Guttman A, Kopp A, Handa M,
Jaakkimainen L. Chapter 2: Care of women
during pregnancy and childbirth. In:
Jaakkimainen L and Upshur, RE eds. Primary
Care in Ontario ICES Atlas. Toronto, Canada:
28.
29.
30.
31.
32.
33.
Institute for Clinical Evaluative Sciences;
2006:15–34
Vigod SN, Seeman MV, Ray JG, et al. Temporal trends in general and age-specific
fertility rates among women with schizophrenia (1996-2009): a population-based
study in Ontario, Canada. Schizophr Res.
2012;139(1-3):169–175
Bromet EJ, Kotov R, Fochtmann LJ, et al.
Diagnostic shifts during the decade following first admission for psychosis. Am J
Psychiatry. 2011;168(11):1186–1194
Mattanah JJ, Becker DF, Levy KN, Edell WS,
McGlashan TH. Diagnostic stability in adolescents followed up 2 years after hospitalization. Am J Psychiatry. 1995;152(6):
889–894
Tataryn DJ, Mustard CA, Derksen S. The
Utilization of Medical Services for Mental
Health Disorders. Winnipeg, Canada: Manitoba Centre for Health Policy and Evaluation; 1994
Becker T, Hux J. Risk of acute complications
of diabetes among people with schizophrenia in Ontario, Canada. Diabetes Care.
2011;34(2):398–402
World Health Organization. World health
statistics indicator compendium. Geneva,
Switzerland: World Health Organization;
2011
34. Heffner JL, DelBello MP, Fleck DE, Adler CM,
Strakowski SM. Unplanned pregnancies in
adolescents with bipolar disorder. Am J
Psychiatry. 2012;169(12):1319–1319
35. Goldstein BI, Strober MA, Birmaher B,
et al. Substance use disorders among
adolescents with bipolar spectrum disorders. Bipolar Disord. 2008;10(4):469–
478
36. Noll JG, Shenk CE, Putnam KT. Childhood
sexual abuse and adolescent pregnancy:
a meta-analytic update. J Pediatr Psychol.
2009;34(4):366–378
37. Conrod PJ, O’Leary-Barrett M, Newton N,
et al. Effectiveness of a selective, personalitytargeted prevention program for adolescent
alcohol use and misuse: a cluster randomized controlled trial. JAMA Psychiatry. 2013;
70(3):334–342
38. Adolescent fertility rate (births per 1000
women ages 15-19) in Canada. Available at:
www.tradingeconomics.com/canada/adolescentfertility-rate-births-per-1-000-women-ages15-19-wb-data.html. Accessed February 28,
2013
39. Menacker F, Martin JA, MacDorman MF,
Ventura SJ. Births to 10-14 year-old
mothers, 1990-2002: trends and health
outcomes. Natl Vital Stat Rep. 2004;53(7):
1–18
(Continued from first page)
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: No authors received payments for their efforts on this project. Dr Vigod received a one-time consulting fee from Multi-Dimensional Health
Care for consulting for the development of continuing health care activities related to perinatal mental health; Drs Kurdyak, Cairney, and Guttmann receive funding
from the Ontario Ministry of Health and Long-Term Care for evaluation of a Provincial Child and Adolescent Mental Health Strategy; Dr Taylor receives funding from
Bristol-Myers Squibb for an investigator-initiated study and has been a speaker for Astra-Zeneca, Bristol-Myers Squibb, Eli Lilly, and Lundbeck; the other authors
have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This work was supported by a Team Grant (OTG-88591) from the Canadian Institutes of Health Research. In addition, this study was supported by the
Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. The opinions, results, and
conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is
intended or should be inferred.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
PEDIATRICS Volume 133, Number 3, March 2014
e591
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Fertility Rate Trends Among Adolescent Girls With Major Mental Illness: A
Population-Based Study
Simone N. Vigod, Cindy Lee Dennis, Paul A. Kurdyak, John Cairney, Astrid
Guttmann and Valerie H. Taylor
Pediatrics; originally published online February 10, 2014;
DOI: 10.1542/peds.2013-1761
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on June 18, 2017
Fertility Rate Trends Among Adolescent Girls With Major Mental Illness: A
Population-Based Study
Simone N. Vigod, Cindy Lee Dennis, Paul A. Kurdyak, John Cairney, Astrid
Guttmann and Valerie H. Taylor
Pediatrics; originally published online February 10, 2014;
DOI: 10.1542/peds.2013-1761
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/early/2014/02/04/peds.2013-1761
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on June 18, 2017