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Social issues of teenage pregnancy
REVIEW
Social issues of teenage pregnancy
static until the late 1990s. However, since then, the rate has been steadily declining (Figure 2). In England and Wales, the under 18 conception rate reached an all-time low level at 16.8 conceptions per 1000 women aged 15e17 years in 2018. Approximately 50% of these conceptions continue to term, whereas half result in induced abortion. The teenage pregnancy rate in Scotland has shown a similar trend and the under 18 conception rate was 16.3 per 1000 women in 2017. In Scotland, England and Wales, the teenage abortion rate has been steadily declining since 2008. It is important to note that teenage pregnancy rates only include live births, stillbirths and abortions. Miscarriages, which may account for up to 25% of all pregnancies, are not included. In Northern Ireland, where until October 2019, termination of pregnancy was illegal except to save the woman’s life or prevent long term or permanent physical or mental harm to the woman, statistics have been presented in terms of birth rates as opposed to conception rates; the teenage birth rate in 2014 was 9.5 per 1000 women under 20 years. This was the lowest rate on record. In the UK, teenage pregnancy is often associated with poor social and health outcomes for mother and child. Globally, complications of pregnancy and childbirth are the second highest cause of death amongst teenagers. Furthermore, whilst teenage deliveries account for 11% of all births worldwide, they account for 23% of the overall burden of disease in disability adjusted life years (DALYs) attributed to pregnancy and childbirth. Maternal mortality is higher amongst teenagers than women aged 20e24 years worldwide. However, this varies between countries and globally the risk of teenage maternal mortality is less than for women aged over 30 years. Box 1 outlines adverse health outcomes associated with teenage pregnancy in the UK. This paper will now focus on the social issues associated with teenage pregnancy.
Sinead MC Cook Sharon T Cameron
Abstract The UK has the highest rate of teenage pregnancies in Western Europe and within the UK higher rates are found amongst women with certain social risk factors, such as those who live in areas of higher deprivation. Teenage pregnancy can be a positive event for some young women. However, there are a number of adverse social outcomes associated with teenage motherhood in the UK, including being more likely to live in poverty, being unemployed or having lower salaries and educational achievements than their peers. Furthermore, children of teenage mothers are more likely to become teenage parents themselves. Strategies to tackle social issues associated with teenage pregnancy need to involve concurrent interventions, including education, skill building, clinical and social support for teenage mothers and contraception services for young people and pregnant teenagers.
Keywords adolescent; social class; social problems; teen; teenage pregnancy
Introduction The United Nations Children’s Fund (UNICEF) defines teenage pregnancy as conceiving between the ages of 13e19 years old. However, in everyday speech the term teenage pregnancy is often used to describe young women who become pregnant when they have not yet reached legal adulthood, the age of which varies across the world. Furthermore, the terms adolescent, young person and child are often used interchangeably with teenager, despite each having different definitions. The UNICEF definition of teenage pregnancy will be used for this article. Globally, around 16 million teenage women give birth each year, accounting for around 11% of all births; 95% of these occur in low- and middle-income countries. The UK has the highest teenage pregnancy and birth rate in Western Europe (Figure 1). Throughout most countries in Western Europe, the total fertility rate and number of teenage births has been decreasing and the age at first birth increasing since the 1970s. In the UK, teenage pregnancy and birth rates were high compared to the rest of Europe and remained relatively
Social issues increasing the risks of teenage pregnancy A number of social factors have been associated with an increased risk of teenage pregnancy and teenage pregnancy itself has also been linked to an increased risk of a number of adverse social outcomes. Teenage pregnancy in the UK is therefore often both a marker of social and economic disadvantage at a young age and a cause of further disadvantage, including emotional and physical health problems. However, teenage pregnancy rates vary significantly between different countries, and similarly the social factors associated with teenage pregnancies also vary. In many countries with the highest rates of teenage pregnancies, it is associated with child and adolescent marriage. In these contexts, teenage childbearing is often an accepted social norm. For example, in Niger, which has the world’s highest teenage pregnancy rate (79.1/1000 women under 20 years) and also the highest rate of child marriage, 87% of women are married before they reach 18 years old and 50% will have had a child by this age. Most high-income countries have low teenage pregnancy rates and the majority of pregnancies are amongst unmarried teenagers. In the UK, 96% of teenage conceptions occur amongst unmarried teenagers. Furthermore, the majority of teenage pregnancies are unplanned. Unplanned pregnancies can often be associated with binge drinking of alcohol amongst teenagers. As can be seen in Figure 1, some European countries have
Sinead M C Cook MFSRH MSc(Distinction) BSc(Hons) MBChB(Hons) PGA Med Ed(SRH) DTMH is a Specialist Trainee 4 in Community Sexual and Reproductive Health, Cardiff and Vale UHB, UK. Conflicts of interest: none declared. Sharon T Cameron MD MFSRH FRCOG is a Consultant in Sexual and Reproductive Health at Chalmers Sexual Health Centre, NHS Lothian, and Honorary Professor at the University of Edinburgh, UK. Conflicts of interest: none declared.
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Teenage birth rates in selected European Countries in 2016 Switzerland Slovenia Netherlands Denmark Italy Germany Greece Spain Portugal Ireland Croatia France Czech Republic Estonia Latvia United Kingdom Poland Hungary Bulgaria Romania 0
2
4
6
8
10
12
14
16
18
Live births per 1,000 women aged 10–19 years
Figure 1 Teenage birth rates in selected European Countries in 2016.
particularly low teenage birth rates compared to others. In the Netherlands and Scandinavian countries, the comparatively low rates of teenage births have been attributed to high levels of contraception use, comprehensive sex education, and a culture of openness regarding discussing sexual matters. In other countries, such as Spain and Italy, low rates of teenage births have been attributed to socially conservative traditional values that stigmatize unmarried teenage mothers. However, this can be
seen as a rather simplified view of why rates of teenage pregnancies are low in these countries, and there are likely a number of social factors at play. The different importance of these factors has been the subject of much debate. There has correspondingly been much debate as to why the teenage pregnancy rate and particularly the number of unplanned pregnancies in the UK are so high. Several factors are likely to have been important in the decrease in teenage
Under 18 conception rate England and Wales
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Conceptions per 1,000 women aged 15–17 years
60
Figure 2 Under 18 conception rate England and Wales.
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have lower educational achievement. The relationship of low educational achievement to higher rates of teenage pregnancy remains, even when adjusted for socioeconomic status. Teenagers from areas of higher deprivation who become pregnant are also more likely to continue with the pregnancy than undergo termination of pregnancy. However, over recent years, there has been a trend of more pregnant teenage women from deprived areas opting for abortion. A review of qualitative studies examining teenagers’ opinions found three major themes relating to increased risk of teenage motherhood: dislike of school poor material circumstances and unhappy childhood low expectations and aspirations for the future These themes are further expanded in box 3. While some of these factors overlap with the factors discussed above, they provide more personal insights into broad groups such as low educational attainment and socioeconomic group and how these factors may be associated with increased rates of teenage births. For example, some teenagers see having a baby as a way to change their circumstances and ameliorate the effects of adversity.
Adverse health outcomes associated with teenage pregnancy: C
C C C
Young mothers are three times more likely to suffer from postpartum depression Infant mortality is 60% higher Infants are more likely to be premature and of lower birth weights Infants are more likely to have congenital anomalies in central nervous, gastrointestinal and musculoskeletal/integumental systems
Box 1
pregnancies. Early coitarche is associated with an increased risk of teenage pregnancy in the UK. When compared to the Netherlands, however, despite approximately the same numbers of under 16s admitting to being sexually active (around one third), Dutch teenagers are much more likely to use reliable contraception from the beginning of their sexual lives. Between 8% and 22% of teenagers in the UK use no contraception at their first intercourse, and this is higher for those under 16 years old. Moreover, of those who do use contraception, many use less reliable methods. Within the UK, some groups of teenagers have higher rates of teenage pregnancy than others. Social factors that appear to be associated with increased rates of teenage pregnancy within the UK are summarized in box 2. Poverty and social deprivation are highly associated with teenage pregnancy rates and the outcomes from teenage pregnancies. Social deprivation is a composite measure that can include a variety of indicators, including the teenage woman’s educational level, health and employment status, and their parents’ income and occupation. Women from areas of higher deprivation have the highest rates of teenage pregnancies, with 50% of all teenage pregnancies occurring in the 20% most deprived areas, despite the most substantial reductions in teenage pregnancies in recent years having been in deprived areas. Women who had below average educational achievement at ages 7 and 16 years old also have a significantly higher chance of becoming a teenage mother. Young fathers are also more likely to come from lower socioeconomic groups and
Social consequences of teenage pregnancy Whilst becoming a parent can be a positive and life-enhancing experience for some teenagers, teenage pregnancy, and particularly teenage childbearing, is associated with a number of negative social outcomes in the UK. However, it is important to recognize that some of these risks are likely associated with the previously
Themes from qualitative literature associated with higher likelihood of becoming a teenage parent within the UK C
C
Factors associated with higher rates of teenage pregnancy within the UK C C C C
C C
C C C
C
Have to grow up faster Violence Poor housing Frequent moves Family conflict and breakdown Lack of good role models
Low expectations and aspirations for the future
Box 2
Lack of support if experiences difficulties at home or school Difficulties making friends Bullying Boredom Frustration with rules and regulations Lack of relevance
Poor material circumstances and unhappy childhood
Lower socioeconomic status Living in or leaving a care home Being involved in crime Some ethnic minority groups: Caribbean, Pakistani and Bangladeshi Homelessness School excludes, truants and young people underperforming at school Children of teenage mothers Depression Having been sexually abused in childhood
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Dislike of school
Bad work experiences Lack of local opportunities Low or no expectations from others Need to escape from or change difficult circumstances Desire to leave school as soon as possible and get a job Having a baby as most attractive option
Box 3
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teenagers who are pregnant or parents. A widespread UK stereotype of a teenage mother is someone receiving state benefits, who is a burden on society, with poor educational attainment and whose children have suboptimal life chances. Stigma and stereotyping can increase the risk of teenage mothers not accessing services and becoming more socially isolated. In contexts and areas where teenage childbearing is socially accepted, there is often more familial and social support for the mother. Moreover, viewing all teenage pregnancies as undesirable ignores that some teenagers want to become parents and find parenthood happy and rewarding.
stated underlying associations with teenage pregnancy, such as social deprivation. Also, teenage parents tend to access fewer antenatal and maternity services, which may negatively impact on social and health outcomes. However, studies that have attempted to adjust for pre-existing social disadvantage have found that the teenage childbearing still carries an excess increased risk of negative outcomes. Teenage mothers have higher risks of living on lower incomes, lower educational achievements, difficulties with housing, and family conflicts when compared to their peers. Teenage mothers are also more likely to be socially isolated. Young fathers also appear to have similar educational, economic and employment outcomes to teenage mothers, but there is much less data on this group. Children born to teenage mothers are more likely to be born into poverty and become teenage parents themselves (box 4). Teenage pregnancy strategies in the UK often attempt to break the cycle of teenage mothers coming from worse social situations, which can continue and worsen following becoming a teenage parent, resulting in their children being brought up in poor social circumstances and having a higher chance of becoming a teenage parent themselves. Furthermore, reducing rates of teenage pregnancy is thought to have the potential to reduce other social problems, such as increasing female education and reducing child poverty.
How to reduce teenage pregnancies and mitigate the negative social outcomes associated with teenage pregnancy? There are strategies aiming to reduce teenage pregnancies and negative social outcomes associated with teenage pregnancy both across the world and in the UK. In 1999, the UK government introduced a Teenage Pregnancy Strategy, which set itself a high target to reduce the rate of teenage pregnancies in England and Wales by 50% by 2010; this was not met, the actual decrease was 13.3%. The strategy also aimed to increase the proportion of teenage parents in education, employment and training to reduce their risk of long-term social exclusion. The number of teenage mothers engaged in employment, education or training doubled during the period of the strategy. The strategy involved health promotion campaigns, improving health services and school sex education. Despite being discontinued 2010, the teenage pregnancy rate has continued to fall. The target of a reduction in teenage pregnancies by 50% has now been met; in 2015, the rate had reduced by 55%. It is argued that it was the strategy’s multi-faceted approach that was key to its success since teenage pregnancies are influenced by various interconnected factors. However, some people contend that wider societal changes not influenced by the strategy have contributed to declining teenage pregnancies. These include less alcohol consumption amongst teenagers and changes in the way teenagers interact, such as increasing use of social media and the internet. Although there is no longer a specific teenage pregnancy strategy in the UK, reducing teenage pregnancy rates is still on the policy agenda as a devolved issue in all four nations in the UK. For example, in March 2017, sex and relationships education was made compulsory in secondary schools in England; this was deemed to be of great importance in continuing to reduce teenage pregnancies.
Teenage pregnancy: a social problem? Teenage pregnancy and parenthood in the UK are associated with certain social risks factors and outcomes. Considering teenage pregnancy in terms of negative social outcomes has led to teenage pregnancy being considered a social problem. Hence, strategies to try to reduce teenage pregnancy rates in the UK have been developed. However, some people have criticized framing teenage pregnancy as a social problem for a number of reasons. Firstly, associations between negative social outcomes and teenage pregnancy are likely not directly causal, but rather a complex chain of circumstances. Focussing prevention efforts on at risk groups and teenage mothers can risk blaming individuals and focussing on behaviour change, while ignoring the wider social situation. Also, focussing on at-risk groups does not appear to reduce teenage pregnancies; one programme actually appeared to increase rates of teenage pregnancy. Furthermore, considering pregnant teenagers as problem or risk groups can increase stereotyping and the stigma felt by
Primary prevention of teenage pregnancy and supporting teenagers who become pregnant Reducing rates of teenage pregnancy and improving outcomes for teenage parents and their children requires a comprehensive strategy with multiple elements. A Cochrane review found that a combination of health education and contraceptive promotion is effective at reducing teenage pregnancy rates. However, interventions that target wider social determinants, such as addressing economic inequalities and improving education and employment opportunities in areas of high deprivation are also important. Child and youth development programmes that target academic and social skills can reduce teenage pregnancy rates. Programmes that seem to be particularly successful combine the following elements:
Negative social outcomes for teenage mothers C
C C
C
C
Employment/economic: 22% more likely to be living in poverty by age 30 than mothers aged over 23 years; less likely to be employed and if employed more likely to be on lower incomes than their peers Education: 20% more likely to have no qualification by age 30 Housing: More likely to be living in rented, poor quality housing and to have to move during pregnancy Family: more likely to be lone parents and find themselves in a family conflict Children: children of teenage mothers are more likely to become teenage parents themselves
Box 4
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Learning support for those who are struggling academically Relationship skills development Parental involvement Work experience opportunities, volunteering, and out of school activities Support for those experiencing family breakdown and conflict As well as focussing on primary prevention of teenage pregnancy, it is important to provide support for teenage mothers and to reduce rapid repeat pregnancies (pregnancies occurring soon after childbirth, miscarriage or abortion). One fifth of pregnancies amongst under 18 year olds in the UK are repeat pregnancies and nearly 1 in 4 teenagers presenting for an abortion have had a previous pregnancy. Two or more pregnancies before age 20 is a risk factor for both adverse obstetric outcomes such as preterm birth and low birthweight and negative social outcomes. Programmes that appear to be most successful at reducing rapid repeat pregnancies integrate clinical and social services and include home visits and easily accessible and youth-friendly contraceptive, antenatal and postnatal services. These services should also provide easy access to the most effective long-acting reversible contraceptives (LARCs), such as subdermal implants and intrauterine methods. Provision of these methods reduces the likelihood of rapid repeat pregnancies by 35 times. It is particularly important to address social exclusion associated with teenage motherhood, through improving access to health services, providing educational support, further education and training, employment support and childcare and income support and housing assistance. There are a number of programmes in the UK, including the CAN (Classes & Advice Network) parenting scheme that is a network of parenting classes focussed in areas of high deprivation and the Care to Learn programme that provides support for teenage mothers who want to continue or further their education.
abortion and how to access abortion services may also avoid late presentation for termination of pregnancy. Whenever consulting with teenagers, it is import to consider risk assessment, potential abuse, and child protection issues. It is important to have a good understanding of child sexual exploitation and safeguarding, which can be achieved through attending regular safeguarding training. Competence to make independent decisions for contraceptive use (Fraser competence) should be assessed and documented for young people under the age of 16 years old (or under 18 years old in state care) (see box 5). All services need to ensure that they are friendly and accessible to young people. Health workers should try to make teenagers feel comfortable and welcome to relieve embarrassment or feelings of stigmatization. Accessibility includes physical location and timings. The ability to have out-of-hours appointments during evenings and weekends and to be able to either drop-in or make fixed appointments is very important for teenagers. Some hospitals have dedicated young people’s sexual and reproductive health and/or maternity services. Services need to be universal and inclusive, but there are some particular socially disadvantaged groups that have difficulty accessing services. These groups need additional tailored support. They include teenage mothers and also other young people who are: Living in deprived areas From a minority ethnic group, refugees, asylum seekers and people recently arrived in the UK Looked after or leaving care Excluded from school or do not attend regularly or have poor educational attainment
Guidelines for provision of contraception to under-16s Department of health guidance: “a doctor or health profession is able to provide contraception, sexual or reproductive health advice and treatment, without parental knowledge or consent, to a young person aged under 16, provided that:
How can the obstetrician and gynaecologist contribute? Whilst many of the interventions required are broad and outwith the immediate clinical setting, there are many ways in which clinicians can contribute to reducing negative social outcomes associated with teenage pregnancy. Firstly, it is important to discuss contraception and sexual health opportunistically when consulting with young people. LARCs should be promoted to all women who are keen to prevent pregnancy and particularly to teenagers. Teenagers should also be made aware of how to access emergency contraception if required. The UK Medical Eligibility Criteria (UKMEC) advises that teenagers and nulliparous women can safely use all LARCs, including intrauterine contraceptives. It is important to build appropriate consultation skills and allow extra time for consultations with teenagers. Improving access and availability of youth-orientated contraception services may help to reduce teenage pregnancies. During any contraceptive consultation, it is also important to offer sexually transmitted infection (STI) screening, and advise using double protection i.e. condoms plus another method of contraception, due to the high prevalence of STIs in under 20 year olds in the UK. Opportunities should be sought to discuss these topics without a parent present whenever possible. Provision of clear, non-judgemental information about
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C C
She/he understands the advice provided and its implications Her/his physical or mental health would otherwise be likely to suffer and so provision of advice or treatment is in their best interest.”
In addition, it is good practice to follow the criteria set out by Lord Fraser in 1985, commonly known as Fraser guidelines: C C
C
C
C
“The young person understands the health professional’s advice The health professional cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice The young person is very likely to begin or continue having intercourse with or without contraceptive treatment Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer The young person’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent.”
Box 5
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Unemployed or not in education or training Homeless Living with mental health problems Living with physical or learning disabilities Living with HIV/AIDS Substance misusers (including alcohol misusers) Criminal offenders Contraception discussions and plans for future contraception should occur with all teenagers who present when pregnant, whether they opt to continue with the pregnancy or for termination. In general, if possible, young women should leave the hospital following delivery or termination with their chosen contraceptive or if not with a clear plan for accessing their chosen method of contraception. The National Institute for Health and Care Excellence recommend that all teenage mothers should be offered a named midwife but that their care should also involve the multidisciplinary team, including an obstetrician with an interest in teenage pregnancy and the woman’s general practitioner. Studies have shown that when provided with optimal antenatal care, outcomes for teenage mothers improve. When consulting with teenage mothers, there should be strong links with relevant external agencies, as many of the related social issues cannot be dealt with by the health care sector alone. In many areas of the UK there is the opportunity to refer pregnant teenagers to the Family Nurse Partnership (FNP). This is a preventative programme that supports teenage mothers from pregnancy until their children are two years old. It aims to improve social outcomes for teenage mothers and their children. Studies in both the UK and the USA have shown that the programme improved rates of smoking cessation, breastfeeding, antenatal appointment attendance, self-esteem and return to education or employment.
building, support for teenage mothers and contraception services for young people and pregnant teenagers. A
Practice Points C
C
C
C
C
C
FURTHER READING Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraceptive choices for young people. 2010, http://www. fsrh.org/standards-and-guidance/documents/cec-ceu-guidanceyoung-people-mar-2010/ (accessed 23 June 2017). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraception after pregnancy. 2017, https://www.fsrh.org/ documents/contraception-after-pregnancy-guideline-january2017/contraception-after-pregnancy-guideline-final27feb.pdf (accessed 23 June 2017). NICE Guidelines. PH51 Contraceptive services with a focus on young people up to the age of 25. 2014. National Institute for Health and Care Excellence, http://www.nice.org.uk/guidance/ph51/chapter/ about-this-guidance (accessed 23 June 2017). Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. Interventions for preventing unintended pregnancies among adolescents. Cochrane Database Syst Rev 2009; 7. Wellings K, Jones KG, Mercer CH, et al. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet 2013; 382: 1807e16.
Conclusion Within the UK, higher rates of teenage pregnancies are found amongst women from areas of higher deprivation and some other groups such as those with lower educational achievements or living in care homes. Teenage pregnancy can be a positive event for some young women. However, there are a number of adverse social outcomes associated with teenage motherhood in the UK. Strategies need to attempt to break a cycle of those with worse social circumstances having a higher risk of becoming a teenage parent, which then leads to worse social outcomes for them and their children and their children having a higher chance of becoming a teenage parent themselves. Strategies need to involve concurrent interventions, including education, skill
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Despite declining over recent years, teenage pregnancy rates in the UK are still the highest in Western Europe Social deprivation is associated with higher rates of teenage pregnancy in the UK, therefore it is important to be aware of an increased likelihood of social issues when interacting with pregnant teenagers Teenage pregnancy is associated with negative stereotypes and stigma which can impact on young pregnant women’s use of services and increase social isolation A multidisciplinary approach is essential when providing clinical and social support for teenage mothers Contraception, antenatal and postnatal services must be young person friendly Contraception should be discussed with all pregnant teenagers and a contraceptive plan made to reduce the risk of rapid repeat pregnancies
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Social issues of teenage pregnancy
static until the late 1990s. However, since then, the rate has been steadily declining (Figure 2). In England and Wales, the under 18 conception rate reached an all-time low level at 16.8 conceptions per 1000 women aged 15e17 years in 2018. Approximately 50% of these conceptions continue to term, whereas half result in induced abortion. The teenage pregnancy rate in Scotland has shown a similar trend and the under 18 conception rate was 16.3 per 1000 women in 2017. In Scotland, England and Wales, the teenage abortion rate has been steadily declining since 2008. It is important to note that teenage pregnancy rates only include live births, stillbirths and abortions. Miscarriages, which may account for up to 25% of all pregnancies, are not included. In Northern Ireland, where until October 2019, termination of pregnancy was illegal except to save the woman’s life or prevent long term or permanent physical or mental harm to the woman, statistics have been presented in terms of birth rates as opposed to conception rates; the teenage birth rate in 2014 was 9.5 per 1000 women under 20 years. This was the lowest rate on record. In the UK, teenage pregnancy is often associated with poor social and health outcomes for mother and child. Globally, complications of pregnancy and childbirth are the second highest cause of death amongst teenagers. Furthermore, whilst teenage deliveries account for 11% of all births worldwide, they account for 23% of the overall burden of disease in disability adjusted life years (DALYs) attributed to pregnancy and childbirth. Maternal mortality is higher amongst teenagers than women aged 20e24 years worldwide. However, this varies between countries and globally the risk of teenage maternal mortality is less than for women aged over 30 years. Box 1 outlines adverse health outcomes associated with teenage pregnancy in the UK. This paper will now focus on the social issues associated with teenage pregnancy.
Sinead MC Cook Sharon T Cameron
Abstract The UK has the highest rate of teenage pregnancies in Western Europe and within the UK higher rates are found amongst women with certain social risk factors, such as those who live in areas of higher deprivation. Teenage pregnancy can be a positive event for some young women. However, there are a number of adverse social outcomes associated with teenage motherhood in the UK, including being more likely to live in poverty, being unemployed or having lower salaries and educational achievements than their peers. Furthermore, children of teenage mothers are more likely to become teenage parents themselves. Strategies to tackle social issues associated with teenage pregnancy need to involve concurrent interventions, including education, skill building, clinical and social support for teenage mothers and contraception services for young people and pregnant teenagers.
Keywords adolescent; social class; social problems; teen; teenage pregnancy
Introduction The United Nations Children’s Fund (UNICEF) defines teenage pregnancy as conceiving between the ages of 13e19 years old. However, in everyday speech the term teenage pregnancy is often used to describe young women who become pregnant when they have not yet reached legal adulthood, the age of which varies across the world. Furthermore, the terms adolescent, young person and child are often used interchangeably with teenager, despite each having different definitions. The UNICEF definition of teenage pregnancy will be used for this article. Globally, around 16 million teenage women give birth each year, accounting for around 11% of all births; 95% of these occur in low- and middle-income countries. The UK has the highest teenage pregnancy and birth rate in Western Europe (Figure 1). Throughout most countries in Western Europe, the total fertility rate and number of teenage births has been decreasing and the age at first birth increasing since the 1970s. In the UK, teenage pregnancy and birth rates were high compared to the rest of Europe and remained relatively
Social issues increasing the risks of teenage pregnancy A number of social factors have been associated with an increased risk of teenage pregnancy and teenage pregnancy itself has also been linked to an increased risk of a number of adverse social outcomes. Teenage pregnancy in the UK is therefore often both a marker of social and economic disadvantage at a young age and a cause of further disadvantage, including emotional and physical health problems. However, teenage pregnancy rates vary significantly between different countries, and similarly the social factors associated with teenage pregnancies also vary. In many countries with the highest rates of teenage pregnancies, it is associated with child and adolescent marriage. In these contexts, teenage childbearing is often an accepted social norm. For example, in Niger, which has the world’s highest teenage pregnancy rate (79.1/1000 women under 20 years) and also the highest rate of child marriage, 87% of women are married before they reach 18 years old and 50% will have had a child by this age. Most high-income countries have low teenage pregnancy rates and the majority of pregnancies are amongst unmarried teenagers. In the UK, 96% of teenage conceptions occur amongst unmarried teenagers. Furthermore, the majority of teenage pregnancies are unplanned. Unplanned pregnancies can often be associated with binge drinking of alcohol amongst teenagers. As can be seen in Figure 1, some European countries have
Sinead M C Cook MFSRH MSc(Distinction) BSc(Hons) MBChB(Hons) PGA Med Ed(SRH) DTMH is a Specialist Trainee 4 in Community Sexual and Reproductive Health, Cardiff and Vale UHB, UK. Conflicts of interest: none declared. Sharon T Cameron MD MFSRH FRCOG is a Consultant in Sexual and Reproductive Health at Chalmers Sexual Health Centre, NHS Lothian, and Honorary Professor at the University of Edinburgh, UK. Conflicts of interest: none declared.
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Teenage birth rates in selected European Countries in 2016 Switzerland Slovenia Netherlands Denmark Italy Germany Greece Spain Portugal Ireland Croatia France Czech Republic Estonia Latvia United Kingdom Poland Hungary Bulgaria Romania 0
2
4
6
8
10
12
14
16
18
Live births per 1,000 women aged 10–19 years
Figure 1 Teenage birth rates in selected European Countries in 2016.
particularly low teenage birth rates compared to others. In the Netherlands and Scandinavian countries, the comparatively low rates of teenage births have been attributed to high levels of contraception use, comprehensive sex education, and a culture of openness regarding discussing sexual matters. In other countries, such as Spain and Italy, low rates of teenage births have been attributed to socially conservative traditional values that stigmatize unmarried teenage mothers. However, this can be
seen as a rather simplified view of why rates of teenage pregnancies are low in these countries, and there are likely a number of social factors at play. The different importance of these factors has been the subject of much debate. There has correspondingly been much debate as to why the teenage pregnancy rate and particularly the number of unplanned pregnancies in the UK are so high. Several factors are likely to have been important in the decrease in teenage
Under 18 conception rate England and Wales
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2015
2013
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Conceptions per 1,000 women aged 15–17 years
60
Figure 2 Under 18 conception rate England and Wales.
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have lower educational achievement. The relationship of low educational achievement to higher rates of teenage pregnancy remains, even when adjusted for socioeconomic status. Teenagers from areas of higher deprivation who become pregnant are also more likely to continue with the pregnancy than undergo termination of pregnancy. However, over recent years, there has been a trend of more pregnant teenage women from deprived areas opting for abortion. A review of qualitative studies examining teenagers’ opinions found three major themes relating to increased risk of teenage motherhood: dislike of school poor material circumstances and unhappy childhood low expectations and aspirations for the future These themes are further expanded in box 3. While some of these factors overlap with the factors discussed above, they provide more personal insights into broad groups such as low educational attainment and socioeconomic group and how these factors may be associated with increased rates of teenage births. For example, some teenagers see having a baby as a way to change their circumstances and ameliorate the effects of adversity.
Adverse health outcomes associated with teenage pregnancy: C
C C C
Young mothers are three times more likely to suffer from postpartum depression Infant mortality is 60% higher Infants are more likely to be premature and of lower birth weights Infants are more likely to have congenital anomalies in central nervous, gastrointestinal and musculoskeletal/integumental systems
Box 1
pregnancies. Early coitarche is associated with an increased risk of teenage pregnancy in the UK. When compared to the Netherlands, however, despite approximately the same numbers of under 16s admitting to being sexually active (around one third), Dutch teenagers are much more likely to use reliable contraception from the beginning of their sexual lives. Between 8% and 22% of teenagers in the UK use no contraception at their first intercourse, and this is higher for those under 16 years old. Moreover, of those who do use contraception, many use less reliable methods. Within the UK, some groups of teenagers have higher rates of teenage pregnancy than others. Social factors that appear to be associated with increased rates of teenage pregnancy within the UK are summarized in box 2. Poverty and social deprivation are highly associated with teenage pregnancy rates and the outcomes from teenage pregnancies. Social deprivation is a composite measure that can include a variety of indicators, including the teenage woman’s educational level, health and employment status, and their parents’ income and occupation. Women from areas of higher deprivation have the highest rates of teenage pregnancies, with 50% of all teenage pregnancies occurring in the 20% most deprived areas, despite the most substantial reductions in teenage pregnancies in recent years having been in deprived areas. Women who had below average educational achievement at ages 7 and 16 years old also have a significantly higher chance of becoming a teenage mother. Young fathers are also more likely to come from lower socioeconomic groups and
Social consequences of teenage pregnancy Whilst becoming a parent can be a positive and life-enhancing experience for some teenagers, teenage pregnancy, and particularly teenage childbearing, is associated with a number of negative social outcomes in the UK. However, it is important to recognize that some of these risks are likely associated with the previously
Themes from qualitative literature associated with higher likelihood of becoming a teenage parent within the UK C
C
Factors associated with higher rates of teenage pregnancy within the UK C C C C
C C
C C C
C
Have to grow up faster Violence Poor housing Frequent moves Family conflict and breakdown Lack of good role models
Low expectations and aspirations for the future
Box 2
Lack of support if experiences difficulties at home or school Difficulties making friends Bullying Boredom Frustration with rules and regulations Lack of relevance
Poor material circumstances and unhappy childhood
Lower socioeconomic status Living in or leaving a care home Being involved in crime Some ethnic minority groups: Caribbean, Pakistani and Bangladeshi Homelessness School excludes, truants and young people underperforming at school Children of teenage mothers Depression Having been sexually abused in childhood
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Dislike of school
Bad work experiences Lack of local opportunities Low or no expectations from others Need to escape from or change difficult circumstances Desire to leave school as soon as possible and get a job Having a baby as most attractive option
Box 3
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teenagers who are pregnant or parents. A widespread UK stereotype of a teenage mother is someone receiving state benefits, who is a burden on society, with poor educational attainment and whose children have suboptimal life chances. Stigma and stereotyping can increase the risk of teenage mothers not accessing services and becoming more socially isolated. In contexts and areas where teenage childbearing is socially accepted, there is often more familial and social support for the mother. Moreover, viewing all teenage pregnancies as undesirable ignores that some teenagers want to become parents and find parenthood happy and rewarding.
stated underlying associations with teenage pregnancy, such as social deprivation. Also, teenage parents tend to access fewer antenatal and maternity services, which may negatively impact on social and health outcomes. However, studies that have attempted to adjust for pre-existing social disadvantage have found that the teenage childbearing still carries an excess increased risk of negative outcomes. Teenage mothers have higher risks of living on lower incomes, lower educational achievements, difficulties with housing, and family conflicts when compared to their peers. Teenage mothers are also more likely to be socially isolated. Young fathers also appear to have similar educational, economic and employment outcomes to teenage mothers, but there is much less data on this group. Children born to teenage mothers are more likely to be born into poverty and become teenage parents themselves (box 4). Teenage pregnancy strategies in the UK often attempt to break the cycle of teenage mothers coming from worse social situations, which can continue and worsen following becoming a teenage parent, resulting in their children being brought up in poor social circumstances and having a higher chance of becoming a teenage parent themselves. Furthermore, reducing rates of teenage pregnancy is thought to have the potential to reduce other social problems, such as increasing female education and reducing child poverty.
How to reduce teenage pregnancies and mitigate the negative social outcomes associated with teenage pregnancy? There are strategies aiming to reduce teenage pregnancies and negative social outcomes associated with teenage pregnancy both across the world and in the UK. In 1999, the UK government introduced a Teenage Pregnancy Strategy, which set itself a high target to reduce the rate of teenage pregnancies in England and Wales by 50% by 2010; this was not met, the actual decrease was 13.3%. The strategy also aimed to increase the proportion of teenage parents in education, employment and training to reduce their risk of long-term social exclusion. The number of teenage mothers engaged in employment, education or training doubled during the period of the strategy. The strategy involved health promotion campaigns, improving health services and school sex education. Despite being discontinued 2010, the teenage pregnancy rate has continued to fall. The target of a reduction in teenage pregnancies by 50% has now been met; in 2015, the rate had reduced by 55%. It is argued that it was the strategy’s multi-faceted approach that was key to its success since teenage pregnancies are influenced by various interconnected factors. However, some people contend that wider societal changes not influenced by the strategy have contributed to declining teenage pregnancies. These include less alcohol consumption amongst teenagers and changes in the way teenagers interact, such as increasing use of social media and the internet. Although there is no longer a specific teenage pregnancy strategy in the UK, reducing teenage pregnancy rates is still on the policy agenda as a devolved issue in all four nations in the UK. For example, in March 2017, sex and relationships education was made compulsory in secondary schools in England; this was deemed to be of great importance in continuing to reduce teenage pregnancies.
Teenage pregnancy: a social problem? Teenage pregnancy and parenthood in the UK are associated with certain social risks factors and outcomes. Considering teenage pregnancy in terms of negative social outcomes has led to teenage pregnancy being considered a social problem. Hence, strategies to try to reduce teenage pregnancy rates in the UK have been developed. However, some people have criticized framing teenage pregnancy as a social problem for a number of reasons. Firstly, associations between negative social outcomes and teenage pregnancy are likely not directly causal, but rather a complex chain of circumstances. Focussing prevention efforts on at risk groups and teenage mothers can risk blaming individuals and focussing on behaviour change, while ignoring the wider social situation. Also, focussing on at-risk groups does not appear to reduce teenage pregnancies; one programme actually appeared to increase rates of teenage pregnancy. Furthermore, considering pregnant teenagers as problem or risk groups can increase stereotyping and the stigma felt by
Primary prevention of teenage pregnancy and supporting teenagers who become pregnant Reducing rates of teenage pregnancy and improving outcomes for teenage parents and their children requires a comprehensive strategy with multiple elements. A Cochrane review found that a combination of health education and contraceptive promotion is effective at reducing teenage pregnancy rates. However, interventions that target wider social determinants, such as addressing economic inequalities and improving education and employment opportunities in areas of high deprivation are also important. Child and youth development programmes that target academic and social skills can reduce teenage pregnancy rates. Programmes that seem to be particularly successful combine the following elements:
Negative social outcomes for teenage mothers C
C C
C
C
Employment/economic: 22% more likely to be living in poverty by age 30 than mothers aged over 23 years; less likely to be employed and if employed more likely to be on lower incomes than their peers Education: 20% more likely to have no qualification by age 30 Housing: More likely to be living in rented, poor quality housing and to have to move during pregnancy Family: more likely to be lone parents and find themselves in a family conflict Children: children of teenage mothers are more likely to become teenage parents themselves
Box 4
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Learning support for those who are struggling academically Relationship skills development Parental involvement Work experience opportunities, volunteering, and out of school activities Support for those experiencing family breakdown and conflict As well as focussing on primary prevention of teenage pregnancy, it is important to provide support for teenage mothers and to reduce rapid repeat pregnancies (pregnancies occurring soon after childbirth, miscarriage or abortion). One fifth of pregnancies amongst under 18 year olds in the UK are repeat pregnancies and nearly 1 in 4 teenagers presenting for an abortion have had a previous pregnancy. Two or more pregnancies before age 20 is a risk factor for both adverse obstetric outcomes such as preterm birth and low birthweight and negative social outcomes. Programmes that appear to be most successful at reducing rapid repeat pregnancies integrate clinical and social services and include home visits and easily accessible and youth-friendly contraceptive, antenatal and postnatal services. These services should also provide easy access to the most effective long-acting reversible contraceptives (LARCs), such as subdermal implants and intrauterine methods. Provision of these methods reduces the likelihood of rapid repeat pregnancies by 35 times. It is particularly important to address social exclusion associated with teenage motherhood, through improving access to health services, providing educational support, further education and training, employment support and childcare and income support and housing assistance. There are a number of programmes in the UK, including the CAN (Classes & Advice Network) parenting scheme that is a network of parenting classes focussed in areas of high deprivation and the Care to Learn programme that provides support for teenage mothers who want to continue or further their education.
abortion and how to access abortion services may also avoid late presentation for termination of pregnancy. Whenever consulting with teenagers, it is import to consider risk assessment, potential abuse, and child protection issues. It is important to have a good understanding of child sexual exploitation and safeguarding, which can be achieved through attending regular safeguarding training. Competence to make independent decisions for contraceptive use (Fraser competence) should be assessed and documented for young people under the age of 16 years old (or under 18 years old in state care) (see box 5). All services need to ensure that they are friendly and accessible to young people. Health workers should try to make teenagers feel comfortable and welcome to relieve embarrassment or feelings of stigmatization. Accessibility includes physical location and timings. The ability to have out-of-hours appointments during evenings and weekends and to be able to either drop-in or make fixed appointments is very important for teenagers. Some hospitals have dedicated young people’s sexual and reproductive health and/or maternity services. Services need to be universal and inclusive, but there are some particular socially disadvantaged groups that have difficulty accessing services. These groups need additional tailored support. They include teenage mothers and also other young people who are: Living in deprived areas From a minority ethnic group, refugees, asylum seekers and people recently arrived in the UK Looked after or leaving care Excluded from school or do not attend regularly or have poor educational attainment
Guidelines for provision of contraception to under-16s Department of health guidance: “a doctor or health profession is able to provide contraception, sexual or reproductive health advice and treatment, without parental knowledge or consent, to a young person aged under 16, provided that:
How can the obstetrician and gynaecologist contribute? Whilst many of the interventions required are broad and outwith the immediate clinical setting, there are many ways in which clinicians can contribute to reducing negative social outcomes associated with teenage pregnancy. Firstly, it is important to discuss contraception and sexual health opportunistically when consulting with young people. LARCs should be promoted to all women who are keen to prevent pregnancy and particularly to teenagers. Teenagers should also be made aware of how to access emergency contraception if required. The UK Medical Eligibility Criteria (UKMEC) advises that teenagers and nulliparous women can safely use all LARCs, including intrauterine contraceptives. It is important to build appropriate consultation skills and allow extra time for consultations with teenagers. Improving access and availability of youth-orientated contraception services may help to reduce teenage pregnancies. During any contraceptive consultation, it is also important to offer sexually transmitted infection (STI) screening, and advise using double protection i.e. condoms plus another method of contraception, due to the high prevalence of STIs in under 20 year olds in the UK. Opportunities should be sought to discuss these topics without a parent present whenever possible. Provision of clear, non-judgemental information about
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C C
She/he understands the advice provided and its implications Her/his physical or mental health would otherwise be likely to suffer and so provision of advice or treatment is in their best interest.”
In addition, it is good practice to follow the criteria set out by Lord Fraser in 1985, commonly known as Fraser guidelines: C C
C
C
C
“The young person understands the health professional’s advice The health professional cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice The young person is very likely to begin or continue having intercourse with or without contraceptive treatment Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer The young person’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent.”
Box 5
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Unemployed or not in education or training Homeless Living with mental health problems Living with physical or learning disabilities Living with HIV/AIDS Substance misusers (including alcohol misusers) Criminal offenders Contraception discussions and plans for future contraception should occur with all teenagers who present when pregnant, whether they opt to continue with the pregnancy or for termination. In general, if possible, young women should leave the hospital following delivery or termination with their chosen contraceptive or if not with a clear plan for accessing their chosen method of contraception. The National Institute for Health and Care Excellence recommend that all teenage mothers should be offered a named midwife but that their care should also involve the multidisciplinary team, including an obstetrician with an interest in teenage pregnancy and the woman’s general practitioner. Studies have shown that when provided with optimal antenatal care, outcomes for teenage mothers improve. When consulting with teenage mothers, there should be strong links with relevant external agencies, as many of the related social issues cannot be dealt with by the health care sector alone. In many areas of the UK there is the opportunity to refer pregnant teenagers to the Family Nurse Partnership (FNP). This is a preventative programme that supports teenage mothers from pregnancy until their children are two years old. It aims to improve social outcomes for teenage mothers and their children. Studies in both the UK and the USA have shown that the programme improved rates of smoking cessation, breastfeeding, antenatal appointment attendance, self-esteem and return to education or employment.
building, support for teenage mothers and contraception services for young people and pregnant teenagers. A
Practice Points C
C
C
C
C
C
FURTHER READING Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraceptive choices for young people. 2010, http://www. fsrh.org/standards-and-guidance/documents/cec-ceu-guidanceyoung-people-mar-2010/ (accessed 23 June 2017). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraception after pregnancy. 2017, https://www.fsrh.org/ documents/contraception-after-pregnancy-guideline-january2017/contraception-after-pregnancy-guideline-final27feb.pdf (accessed 23 June 2017). NICE Guidelines. PH51 Contraceptive services with a focus on young people up to the age of 25. 2014. National Institute for Health and Care Excellence, http://www.nice.org.uk/guidance/ph51/chapter/ about-this-guidance (accessed 23 June 2017). Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. Interventions for preventing unintended pregnancies among adolescents. Cochrane Database Syst Rev 2009; 7. Wellings K, Jones KG, Mercer CH, et al. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet 2013; 382: 1807e16.
Conclusion Within the UK, higher rates of teenage pregnancies are found amongst women from areas of higher deprivation and some other groups such as those with lower educational achievements or living in care homes. Teenage pregnancy can be a positive event for some young women. However, there are a number of adverse social outcomes associated with teenage motherhood in the UK. Strategies need to attempt to break a cycle of those with worse social circumstances having a higher risk of becoming a teenage parent, which then leads to worse social outcomes for them and their children and their children having a higher chance of becoming a teenage parent themselves. Strategies need to involve concurrent interventions, including education, skill
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Despite declining over recent years, teenage pregnancy rates in the UK are still the highest in Western Europe Social deprivation is associated with higher rates of teenage pregnancy in the UK, therefore it is important to be aware of an increased likelihood of social issues when interacting with pregnant teenagers Teenage pregnancy is associated with negative stereotypes and stigma which can impact on young pregnant women’s use of services and increase social isolation A multidisciplinary approach is essential when providing clinical and social support for teenage mothers Contraception, antenatal and postnatal services must be young person friendly Contraception should be discussed with all pregnant teenagers and a contraceptive plan made to reduce the risk of rapid repeat pregnancies
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