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PEDIATRICS Vol. 113 No. 2 February 2004, pp. 320-327

The Association Between Adverse Childhood Experiences and Adolescent Pregnancy, Long-Term Psychosocial Consequences, and Fetal Death

Susan D. Hillis, PhD, MS*, Robert F. Anda, MD, MS*, Shanta R. Dube, MPH*, Vincent J. Felitti, MD, FACP{ddagger}, Polly A. Marchbanks, PhD* and James S. Marks, MD, MPH*

* National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
{ddagger} Department of Preventive Medicine, Southern California Permanente Medical Group (Kaiser Permanente), San Diego, California

Objectives. Few reports address the impact of cumulative exposure to childhood abuse and family dysfunction on teen pregnancy and consequences commonly attributed to teen pregnancy. Therefore, we examined whether adolescent pregnancy increased as types of adverse childhood experiences (ACE score) increased and whether ACEs or adolescent pregnancy was the principal source of elevated risk for long-term psychosocial consequences and fetal death.

Design, Setting, and Participants. A retrospective cohort study of 9159 women aged ≥18 years (mean 56 years) who attended a primary care clinic in San Diego, California in 1995–1997.

Main Outcome Measure. Adolescent pregnancy, psychosocial consequences, and fetal death, compared by ACE score (emotional, physical, or sexual abuse; exposure to domestic violence, substance abusing, mentally ill, or criminal household member; or separated/divorced parent).

Results. Sixty-six percent (n = 6015) of women reported ≥1 ACE. Teen pregnancy occurred in 16%, 21%, 26%, 29%, 32%, 40%, 43%, and 53% of those with 0, 1, 2, 3, 4, 5, 6, and 7 to 8 ACEs. As the ACE score rose from zero to 1 to 2, 3 to 4, and ≥5, odds ratios for each adult consequence increased (family problems: 1.0, 1.5, 2.2, 3.3; financial problems: 1.0, 1.6, 2.3, 2.4; job problems: 1.0, 1.4, 2.3, 2.9; high stress: 1.0, 1.4, 1.9, 2.2; and uncontrollable anger: 1.0, 1.6, 2.8, 4.5, respectively). Adolescent pregnancy was not associated with any of these adult outcomes in the absence of childhood adversity (ACEs: 0). The ACE score was associated with increased fetal death after first pregnancy (odds ratios for 0, 1–2, 3–4, and 5–8 ACEs: 1.0, 1.2, 1.4, and 1.8, respectively); teen pregnancy was not related to fetal death.

Conclusions. The relationship between ACEs and adolescent pregnancy is strong and graded. Moreover, the negative psychosocial sequelae and fetal deaths commonly attributed to adolescent pregnancy seem to result from underlying ACEs rather than adolescent pregnancy per se.

Key Words: adolescent pregnancy • child abuse • domestic violence • alcoholism • children of impaired parents • drug abuse

Abbreviations: ACE, adverse childhood experience • RR, relative risk • CI, confidence interval • OR, odds ratio

Received for publication Feb 7, 2003; Accepted May 14, 2003.


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