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Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa
IJG-08600; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
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CLINICAL ARTICLE
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Wendy Mphatswe ⁎, Hopolang Maise, Motshedisi Sebitloane
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Article history: Received 13 May 2015 Received in revised form 14 September 2015 Accepted 27 January 2016
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1. Introduction
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Teenage pregnancy is a major public health challenge globally, with approximately 15 million female adolescents aged 15–19 years giving birth annually, accounting for 10% of births worldwide [1]. Additionally, teenage pregnancies account for approximately 5 million induced abortions worldwide [1]. Sub-Saharan Africa has one of the highest birth rates among women aged 15–19 years, at 119 births per 1000 women, compared with an average of 53 per 1000 women in other low-income nations [1]. In South Africa, 12.2% of all births registered by the Department of Home Affairs in 2011 were to teenagers aged 15–19 years [2]. A study performed in four provinces of South Africa [3], including 3123 participants, showed a teenage pregnancy rate of 19.2%; of these pregnancies, 6.7% were terminated. South Africa has the worst epidemic of HIV globally: in 2012, more than 6 million people in the country were living with HIV, with just over individuals aged 15–24 years accounting for 20% of infections [4]. The HIV prevalence among pregnant women in KwaZulu-Natal province is approximately 37.4%, and 16% of pregnant women aged 15–19 years are HIV-positive, compared with 12.7% nationally [4]. Teenagers engaging in unprotected sexual intercourse in this environment are
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Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa
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Objective: To determine the prevalence of repeat teenage pregnancy and the interval between first/most recent and repeat pregnancies, as well as to evaluate the sexual/reproductive health characteristics of teenagers with repeat pregnancies. Methods: A prospective observational study was undertaken at a hospital in KwaZulu-Natal, South Africa, between May and September 2013. Teenagers aged 13–19 years who were pregnant, had recently delivered, or had terminated a pregnancy were enrolled. A questionnaire was used to obtain data. Results: Among 341 participants, 281 (82.4%) were seen for a first pregnancy and 60 (17.6%) for a repeat pregnancy. The interval between first/most recent and repeat pregnancies was 24 months or lower in 45 (75.0%) of repeat pregnancy participants. Only 58 (17.0%) participants had previously used contraception (54 [93.1%] of whom stopped within 12 months) and 28 (8.2%) had used emergency contraception. More participants with repeat pregnancy than with first pregnancy had a positive HIV status (18 [30.0%] vs 26 [9.3%]; P b 0.001), more than one sexual partner in the past 12 months (21 [35.0%] vs 35 [12.5%]; P b 0.001), and a partner at least 5 years older (38 [63.3%] vs 128 [45.6%]; P b 0.001). Conclusion: High repeat pregnancy rates, low contraception use, and high HIV prevalence among teenagers in South Africa is worrying. Focused interventions targeting teenagers following their first pregnancy need to be urgently implemented. © 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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Keywords: Adolescent reproductive health Contraception HIV Repeat teenage pregnancy Teenage pregnancy
⁎ Corresponding author at: P.O. Box 18663, Dalbridge, 4014, Durban, South Africa. Tel.: +27 31 260 4390, +27 79 300 1499. E-mail address: [email protected] (W. Mphatswe).
undoubtedly at an increased risk of contracting HIV and sexually transmitted infections. These risks exacerbate the importance of addressing teenage sexuality beyond the need to prevent unintended pregnancies. Teenage pregnancy is associated with various adverse maternal and perinatal outcomes, including anemia, hypertensive disorders, preterm birth, cesarean delivery, low birth weight, and a higher risk of death [5,6]. Repeat births among adolescents have an even higher risk of preterm birth, very low birth weight, stillbirths, and perinatal and neonatal mortality [7]. These observations emphasize the importance of preventing a second pregnancy among adolescents. Teenage pregnancy is also associated with adverse socioeconomic and psychological consequences. In a country such as South Africa, where the number of child-headed families and orphans is already high as a result of HIV/AIDS [8], early motherhood undoubtedly worsens social challenges. In South Africa, 25%–31% of individuals attending high school (15–19 years) are reported to be sexually active, with 18% of girls being in relationships with partners who are at least 5 years older than them [9,10]. Furthermore, only one-third of pregnant girls return to school following delivery [9]. These factors impact negatively on future educational achievement and economic progress later in life [10]. With such high teenage pregnancy rates in South Africa, it is inevitable that repeat pregnancy will occur during adolescence. Although the prevalence of teenage pregnancy has been widely documented in South Africa, the prevalence of repeat teenage pregnancy remains unclear and the associated factors have not been explored. A thorough
http://dx.doi.org/10.1016/j.ijgo.2015.09.028 0020-7292/© 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
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A prospective observational study was conducted at Prince Mshiyeni Memorial Hospital (PMMH) in Umlazi, KwaZulu-Natal, South Africa, which serves a population of almost 2 million. Teenagers aged 13–19 years attending the prenatal clinic, labor ward, gynecology outpatient patient department, or termination-of-pregnancy clinic at PMMH between May 1 and September 30, 2013, were enrolled. Participants could be pregnant, have recently delivered, or have terminated a pregnancy. No other specific inclusion criteria other than availability were defined. Ethics approval was obtained from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal and all participants gave informed consent. To represent approximately 30% of all teenage pregnancies managed at PMMH per annum—a proportion deemed feasible and convenient—341 participants would have to be enrolled. Data were collected through a questionnaire administered by a research assistant, and further information relevant to the study was verified from patient clinical charts. Participant demographic and socioeconomic data, and sexual history data (including number of sexual partners, HIV status, contraception use, gravidity, and interval between pregnancies) were collected. Information about family history, mother's age, and the marital status of participants' parents was also collected. All data were entered into a database and validated by the investigators. SPSS version 19 (IBM, Armonk, NY, USA) was used to assess univariate associations between variables of interest and repeat pregnancy. P b 0.05 was considered statistically significant.
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3. Results
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A total of 341 teenagers were interviewed, 281 (82.4%) of whom were seen for a first pregnancy and 60 (17.6%) for a repeat pregnancy. Only 2 (0.6%) were married. All participants were of black ethnic origin and 324 (95.0%) participants had a high-school-level education (Table 1). Most participants lived with one or both of their parents (Fig. 1). A total of 121 (35.5%) participants did not live with their biological mother owing either to death (n = 80) or other reasons not disclosed (n = 41). Almost all participants were in stable relationships (Table 2). Despite the partners of 204 (59.8%) participants being employed, only 47 (23.0%) partners were in permanent jobs. Among the 60 participants with a previous pregnancy, 56 (93.3%) had one previous pregnancy and 4 (6.7%) had two. Among the 64 previous pregnancies, 46 (71.9%) had concluded with a live birth and 18 (28.1%) with fetal loss (details on the causes of fetal loss or the number of induced abortions were not obtained). Most repeat pregnancies occurred within 24 months after the first or most recent pregnancy (Fig. 2). Teenagers experiencing repeat pregnancies were found to be older than those experiencing their first pregnancy (P b 0.001) (Table 3). More individuals with repeat pregnancy than with a first pregnancy had had more than one sexual partner in the preceding 12 months or a partner who was at least 5 years older (P b 0.001 for both) (Table 3). Repeat pregnancies were associated with a significantly higher prevalence of HIV (30.0% vs 9.3%) and were associated with an increased likelihood of previous contraception use (P b 0.001 for both). Although 332 (97.4%) participants knew their own HIV status, only 217 (63.6%) participants reported any knowledge of their partner's HIV status. A subanalysis showed that 31 (19.7%) of 157 teenagers in intergenerational relationships (excluding 9 of unknown HIV status)
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17 (5.0) 324 (95.0) 21 (6.2) 320 (93.8) 125 (36.7) 43 (31–60) 25 (7.3) 80 (23.5) 15 (6.9) 176 (81.1) 26 (12.0) 241 (70.7) 50 (14.7) 42 (12.3) 8 (2.3) 7 (2.1) 1 (0.3) 0 4 (1.2)
Values are given as median (range) or number (percentage). t1:30 n = 217; 80 were deceased and 44 participants did not know their mother's t1:31 education level. t1:32 b
were HIV positive, compared with 13 (7.4%) of 175 with peer-group partners (P = 0.001). A total of 331 (97.0%) pregnancies were unplanned, and none were reported to be as a result of rape or sexual abuse. Among 58 participants who had used contraception previously, 54 (93.1%) had primarily used an injectable contraceptive method. Non-compliance with contraception use as a result of adverse effects was reported by 49 (84.5%) of the 58 previous users. Poor access to family planning was reported by only 3 (5.2%) participants, 1 (1.7%) wanted to fall pregnant, and the remaining 5 (8.6%) had no specific reasons for no longer using contraception.
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4. Discussion
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A repeat pregnancy prevalence of 17.6% was found among teenagers interviewed in the present study. Similar findings have been reported in the USA and Germany, with repeat teenage pregnancy rates of 18.3% [11] and 17.3% [7], respectively. A recent review of teenage pregnancy in South Africa [9] reported that the determination of accurate, comparable long-term figures regarding teenage fertility and pregnancy is hampered by the fact that vital statistics on fertility, pregnancy, and abortion are not routinely collected in the country. Although fertility
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Agea, y Black ethnic origin Highest educational level Primary school High school Employment Employed Unemployed Parents married Mother's characteristics Age, y Aged b35 y Mother deceased Mother's highest educational levelb Tertiary High school Primary school Source of financial support Parents Grandparents Other Partner Cigarette smoking Alcohol use Illicit drug use Marijuana use
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Table 1 Demographic characteristics.
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understanding of the factors that contribute to teenage pregnancy and repeat pregnancy is crucial if suitable and sustainable interventions are to be developed. The aim of the present study was to determine the prevalence of repeat pregnancies among adolescents and the interval between pregnancies, and to evaluate the sexual and reproductive health factors associated with teenage first and repeat pregnancies.
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2.4% 7.9% 14.7% Partner 4.7%
Parents Siblings 70.4%
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Fig. 1. Living arrangements of participants.
Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
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W. Mphatswe et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
t2:3
Characteristic
All participants (n = 341)
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20
Age at sexual debut a, y N1 sexual partner in past 12 mo Stable relationship Intergenerational relationship Partner employed HIV status of partner Unknown Positive Negative HIV status of participantb Positive Negative Previous contraception use Stopped within 12 months of use Ever heard of emergency contraception Ever used emergency contraception Ever pregnant in the past
15 (11–19) 56 (16.4) 332 (97.4) 166 (48.7) 204 (59.8)
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18 (16–19) 15 (11–18) 14 (23.3) 21 (35.0) 18 (30.0) 38 (63.3) 47 (78.3)
First pregnancy (n = 281) 17 (13–19) 15 (11–19) 66 (23.5) 35 (12.5) 26 (9.3) 128 (45.6) 11 (3.9)
P value
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b0.001b 0.223b 0.564c b0.001c
t3:4 t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11
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Values are given as mean (range) or number (percentage), unless otherwise indicated. t3:12 t test. t3:13 χ2 test. t3:14
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the fact that the partner's HIV status was unknown by 37.0% of the study participants. An unexpected finding of the present study was the alarmingly high number of teenagers whose mothers were deceased in both the first and repeat pregnancy groups. This high percentage could be attributed to the effects of the HIV epidemic in South Africa resulting in AIDS orphans, illustrating the negative social impact of the epidemic [8,16]. The expanded South African antiretroviral therapy program is thought to be responsible for a current improved life expectancy [17]. However, the benefits are yet to be determined with regard to the survival of parents beyond the teenage years of their offspring. Risk factors for teenage first and repeat pregnancies previously established include the absence of a close mother–daughter relationship, a mother who herself was a teenage mother, not living with parents, and an unsupportive mother [10]. The presence of a mother in a teenager's life is crucial, especially because teenagers who have supportive mothers are able to return to school faster after pregnancy, which decreases the risk of repeat pregnancies [9]. With less than 40% of parents reported to be married and up to 14.7% of teens primarily cared for by grandparents in the present study, such poor social dynamics and family structure undoubtedly make for an environment in which teenage pregnancy and repeat teenage pregnancy prevail. The most important, consistent, and strongest risk factor for repeat pregnancy has been previously shown to be failure to initiate longacting reversible contraception (LARC), such as subdermal implants or intrauterine devices (IUDs), following delivery or an induced abortion [14,15]. Teenage mothers who do not initiate LARC have up to a 35-fold increased risk of a repeat pregnancy within 2 years compared with teenagers using LARCs [13]. Interventions to prevent repeat
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Age, y Average age at sexual debut, y Mother deceased More than one sexual partner in past 12 months Positive HIV status Partner ≥5 years older than participant Ever used contraception
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Repeat pregnancy (n = 60)
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44 (13.3) 288 (86.7) 58 (17.0) 54 (93.1) 157 (46.0) 28 (8.2) 60 (17.6)
trends, as measured by the number of live births, can be reliably estimated from national datasets, pregnancy rates, including induced and spontaneous abortions, cannot [9,12]. Given these challenges, it is not surprising that data on repeat teenage pregnancy is scarce in South Africa. In the present study, the interval between pregnancies was less than 2 years in 75.0% of repeat pregnancies, which is a much higher percentage than those reported in previous studies in Australia and the USA (33%–45%) [13–15]. There was a strong association between repeat pregnancies and having a partner who was at least 5 years older, as well as with a higher prevalence of HIV infection. Despite a comparable age of sexual debut in both the repeat and first pregnancy participants, teenagers with partners at least 5 years older had a higher prevalence of HIV infection than did those with peer-group partners. The lower HIV rates in teenagers having peer-group partners compared with those with older partners are corroborated by previous reports [12]. These findings highlight the problem of safe-sex negotiation in the context of intergenerational relationships. Repeat pregnancy participants were likely to have had more than one sexual partner in the preceding 12 months and to be HIV-positive, thus alluding to risky behavior leading to consequent pregnancy and HIV infection. Nevertheless, the identification of teenagers prone to risky behavior is poor within the South African health system, as are strategies to curb such behavior. This point is emphasized by 60%
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Values are given as mean (range) or number (percentage). 9 had missing/unknown HIV status.
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Table 3 Factors associated with repeat teenage pregnancies.a
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Time since first/most recent pregnancy, mo Fig. 2. Time interval between first/most recent and repeat pregnancy.
Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
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The authors have no conflicts of interest.
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pregnancies include dedicated adolescent prenatal and postnatal clinics, flexible clinic hours, mother and baby pair visits, counselling, home visits, use of social media, telephone reminders, and continuous counselling [18,19]. Nevertheless, these interventions have had limited success even when paired with contraception provision [13]. One US study [15] demonstrated that teenage mothers who had a repeat pregnancy were as likely to be compliant with such programs as were those who did not become pregnant again. Although these social support and counselling interventions seem inferior to the initiation of LARCs with regard to the prevention of repeat pregnancies, the provision of support remains vital. Despite a history of previous contraception initiation among many repeat pregnancy participants in the present study, use was not sustained and most stopped within 1 year. Long-term contraceptive continuation is certainly a challenge for teenagers who are likely to abandon contraception between relationships and resume intercourse before reinitiating contraception [14]. LARCs, however, have been shown to have a higher continuation rate than other methods at 12 months and 2 years [20,21]. Additionally, LARCs have emerged as an effective, safe, and acceptable tool to prevent teenage pregnancy and repeat pregnancies [22]. Because all contraceptive methods have adverse effects, counselling and support is crucial for teenagers using LARCs. Timing of insertion of the implant or IUD in the immediate postpartum period or after abortion is more effective than delaying for 4–6 weeks, with no reported adverse clinical outcomes for both the lactating mother and breastfed infant [20,23]. This is an attractive option for teenagers because they tend to resume sexual intercourse early, before initiating any form of contraception [24]. Delaying beyond the immediate postpartum period could be too late or the opportunity could be missed because many might not return for insertion. At the time of the present study, subdermal implants were not yet freely available in South Africa, and the uptake of IUDs has been low even among older women. The rollout of the subdermal implant commenced late in 2013 in South Africa; its success will depend on the health system's ability to reach intended users, especially teenagers. The present study was conducted at one center, which limits the ability to generalize the findings to other populations. However, the population in Umlazi should not differ significantly from similar communities in South Africa. Given the scarcity of similar literature focusing on South Africa, the present study provides a baseline analysis of the size of the challenge. The study was not designed to make comparisons between first and repeat teenage pregnancy characteristics; a larger study aiming to compare these groups is required to confirm the observations. Additionally, because the investigation was not a cohort study, assessing the true incidence of repeat teenage pregnancy is beyond its scope. Nevertheless, determining the prevalence of repeat pregnancy in this high-risk group and an analysis of the interval between pregnancies is invaluable in making a case for better strategies to counteract this public health challenge. The high repeat pregnancy rates, low contraception use, and associated increased vulnerability to HIV among teenagers is worrying. Focused interventions that target teenagers following their first pregnancy need to be urgently implemented to reduce repeat pregnancy rates and improve overall teenage sexual and reproductive health. Factors that contribute towards teenage pregnancy and high repeat pregnancy rates cut across social, psychological, and economic domains such that they are not entirely within the influence of the formal health system. Strategies will need to take account for the context in which these pregnancies arise and target the risk factors through a multi-sectorial approach. The provision of LARCs to teenagers is a promising public health strategy, but its success will depend on the method's uptake and retention rates. Future research is required to evaluate the cost-effectiveness of LARCs in nulliparous and parous adolescents, as well as its impact on other social indicators such as school completion. Data on repeat teenage pregnancy rates needs to form part of routine national datasets to inform preventive strategies, monitoring, and evaluation.
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Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
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CLINICAL ARTICLE
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Wendy Mphatswe ⁎, Hopolang Maise, Motshedisi Sebitloane
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Article history: Received 13 May 2015 Received in revised form 14 September 2015 Accepted 27 January 2016
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1. Introduction
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Teenage pregnancy is a major public health challenge globally, with approximately 15 million female adolescents aged 15–19 years giving birth annually, accounting for 10% of births worldwide [1]. Additionally, teenage pregnancies account for approximately 5 million induced abortions worldwide [1]. Sub-Saharan Africa has one of the highest birth rates among women aged 15–19 years, at 119 births per 1000 women, compared with an average of 53 per 1000 women in other low-income nations [1]. In South Africa, 12.2% of all births registered by the Department of Home Affairs in 2011 were to teenagers aged 15–19 years [2]. A study performed in four provinces of South Africa [3], including 3123 participants, showed a teenage pregnancy rate of 19.2%; of these pregnancies, 6.7% were terminated. South Africa has the worst epidemic of HIV globally: in 2012, more than 6 million people in the country were living with HIV, with just over individuals aged 15–24 years accounting for 20% of infections [4]. The HIV prevalence among pregnant women in KwaZulu-Natal province is approximately 37.4%, and 16% of pregnant women aged 15–19 years are HIV-positive, compared with 12.7% nationally [4]. Teenagers engaging in unprotected sexual intercourse in this environment are
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Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa
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Objective: To determine the prevalence of repeat teenage pregnancy and the interval between first/most recent and repeat pregnancies, as well as to evaluate the sexual/reproductive health characteristics of teenagers with repeat pregnancies. Methods: A prospective observational study was undertaken at a hospital in KwaZulu-Natal, South Africa, between May and September 2013. Teenagers aged 13–19 years who were pregnant, had recently delivered, or had terminated a pregnancy were enrolled. A questionnaire was used to obtain data. Results: Among 341 participants, 281 (82.4%) were seen for a first pregnancy and 60 (17.6%) for a repeat pregnancy. The interval between first/most recent and repeat pregnancies was 24 months or lower in 45 (75.0%) of repeat pregnancy participants. Only 58 (17.0%) participants had previously used contraception (54 [93.1%] of whom stopped within 12 months) and 28 (8.2%) had used emergency contraception. More participants with repeat pregnancy than with first pregnancy had a positive HIV status (18 [30.0%] vs 26 [9.3%]; P b 0.001), more than one sexual partner in the past 12 months (21 [35.0%] vs 35 [12.5%]; P b 0.001), and a partner at least 5 years older (38 [63.3%] vs 128 [45.6%]; P b 0.001). Conclusion: High repeat pregnancy rates, low contraception use, and high HIV prevalence among teenagers in South Africa is worrying. Focused interventions targeting teenagers following their first pregnancy need to be urgently implemented. © 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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Keywords: Adolescent reproductive health Contraception HIV Repeat teenage pregnancy Teenage pregnancy
⁎ Corresponding author at: P.O. Box 18663, Dalbridge, 4014, Durban, South Africa. Tel.: +27 31 260 4390, +27 79 300 1499. E-mail address: [email protected] (W. Mphatswe).
undoubtedly at an increased risk of contracting HIV and sexually transmitted infections. These risks exacerbate the importance of addressing teenage sexuality beyond the need to prevent unintended pregnancies. Teenage pregnancy is associated with various adverse maternal and perinatal outcomes, including anemia, hypertensive disorders, preterm birth, cesarean delivery, low birth weight, and a higher risk of death [5,6]. Repeat births among adolescents have an even higher risk of preterm birth, very low birth weight, stillbirths, and perinatal and neonatal mortality [7]. These observations emphasize the importance of preventing a second pregnancy among adolescents. Teenage pregnancy is also associated with adverse socioeconomic and psychological consequences. In a country such as South Africa, where the number of child-headed families and orphans is already high as a result of HIV/AIDS [8], early motherhood undoubtedly worsens social challenges. In South Africa, 25%–31% of individuals attending high school (15–19 years) are reported to be sexually active, with 18% of girls being in relationships with partners who are at least 5 years older than them [9,10]. Furthermore, only one-third of pregnant girls return to school following delivery [9]. These factors impact negatively on future educational achievement and economic progress later in life [10]. With such high teenage pregnancy rates in South Africa, it is inevitable that repeat pregnancy will occur during adolescence. Although the prevalence of teenage pregnancy has been widely documented in South Africa, the prevalence of repeat teenage pregnancy remains unclear and the associated factors have not been explored. A thorough
http://dx.doi.org/10.1016/j.ijgo.2015.09.028 0020-7292/© 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
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A prospective observational study was conducted at Prince Mshiyeni Memorial Hospital (PMMH) in Umlazi, KwaZulu-Natal, South Africa, which serves a population of almost 2 million. Teenagers aged 13–19 years attending the prenatal clinic, labor ward, gynecology outpatient patient department, or termination-of-pregnancy clinic at PMMH between May 1 and September 30, 2013, were enrolled. Participants could be pregnant, have recently delivered, or have terminated a pregnancy. No other specific inclusion criteria other than availability were defined. Ethics approval was obtained from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal and all participants gave informed consent. To represent approximately 30% of all teenage pregnancies managed at PMMH per annum—a proportion deemed feasible and convenient—341 participants would have to be enrolled. Data were collected through a questionnaire administered by a research assistant, and further information relevant to the study was verified from patient clinical charts. Participant demographic and socioeconomic data, and sexual history data (including number of sexual partners, HIV status, contraception use, gravidity, and interval between pregnancies) were collected. Information about family history, mother's age, and the marital status of participants' parents was also collected. All data were entered into a database and validated by the investigators. SPSS version 19 (IBM, Armonk, NY, USA) was used to assess univariate associations between variables of interest and repeat pregnancy. P b 0.05 was considered statistically significant.
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A total of 341 teenagers were interviewed, 281 (82.4%) of whom were seen for a first pregnancy and 60 (17.6%) for a repeat pregnancy. Only 2 (0.6%) were married. All participants were of black ethnic origin and 324 (95.0%) participants had a high-school-level education (Table 1). Most participants lived with one or both of their parents (Fig. 1). A total of 121 (35.5%) participants did not live with their biological mother owing either to death (n = 80) or other reasons not disclosed (n = 41). Almost all participants were in stable relationships (Table 2). Despite the partners of 204 (59.8%) participants being employed, only 47 (23.0%) partners were in permanent jobs. Among the 60 participants with a previous pregnancy, 56 (93.3%) had one previous pregnancy and 4 (6.7%) had two. Among the 64 previous pregnancies, 46 (71.9%) had concluded with a live birth and 18 (28.1%) with fetal loss (details on the causes of fetal loss or the number of induced abortions were not obtained). Most repeat pregnancies occurred within 24 months after the first or most recent pregnancy (Fig. 2). Teenagers experiencing repeat pregnancies were found to be older than those experiencing their first pregnancy (P b 0.001) (Table 3). More individuals with repeat pregnancy than with a first pregnancy had had more than one sexual partner in the preceding 12 months or a partner who was at least 5 years older (P b 0.001 for both) (Table 3). Repeat pregnancies were associated with a significantly higher prevalence of HIV (30.0% vs 9.3%) and were associated with an increased likelihood of previous contraception use (P b 0.001 for both). Although 332 (97.4%) participants knew their own HIV status, only 217 (63.6%) participants reported any knowledge of their partner's HIV status. A subanalysis showed that 31 (19.7%) of 157 teenagers in intergenerational relationships (excluding 9 of unknown HIV status)
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17 (5.0) 324 (95.0) 21 (6.2) 320 (93.8) 125 (36.7) 43 (31–60) 25 (7.3) 80 (23.5) 15 (6.9) 176 (81.1) 26 (12.0) 241 (70.7) 50 (14.7) 42 (12.3) 8 (2.3) 7 (2.1) 1 (0.3) 0 4 (1.2)
Values are given as median (range) or number (percentage). t1:30 n = 217; 80 were deceased and 44 participants did not know their mother's t1:31 education level. t1:32 b
were HIV positive, compared with 13 (7.4%) of 175 with peer-group partners (P = 0.001). A total of 331 (97.0%) pregnancies were unplanned, and none were reported to be as a result of rape or sexual abuse. Among 58 participants who had used contraception previously, 54 (93.1%) had primarily used an injectable contraceptive method. Non-compliance with contraception use as a result of adverse effects was reported by 49 (84.5%) of the 58 previous users. Poor access to family planning was reported by only 3 (5.2%) participants, 1 (1.7%) wanted to fall pregnant, and the remaining 5 (8.6%) had no specific reasons for no longer using contraception.
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4. Discussion
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A repeat pregnancy prevalence of 17.6% was found among teenagers interviewed in the present study. Similar findings have been reported in the USA and Germany, with repeat teenage pregnancy rates of 18.3% [11] and 17.3% [7], respectively. A recent review of teenage pregnancy in South Africa [9] reported that the determination of accurate, comparable long-term figures regarding teenage fertility and pregnancy is hampered by the fact that vital statistics on fertility, pregnancy, and abortion are not routinely collected in the country. Although fertility
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Agea, y Black ethnic origin Highest educational level Primary school High school Employment Employed Unemployed Parents married Mother's characteristics Age, y Aged b35 y Mother deceased Mother's highest educational levelb Tertiary High school Primary school Source of financial support Parents Grandparents Other Partner Cigarette smoking Alcohol use Illicit drug use Marijuana use
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Table 1 Demographic characteristics.
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understanding of the factors that contribute to teenage pregnancy and repeat pregnancy is crucial if suitable and sustainable interventions are to be developed. The aim of the present study was to determine the prevalence of repeat pregnancies among adolescents and the interval between pregnancies, and to evaluate the sexual and reproductive health factors associated with teenage first and repeat pregnancies.
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2.4% 7.9% 14.7% Partner 4.7%
Parents Siblings 70.4%
Grandparents Other
Fig. 1. Living arrangements of participants.
Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
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t2:3
Characteristic
All participants (n = 341)
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20
Age at sexual debut a, y N1 sexual partner in past 12 mo Stable relationship Intergenerational relationship Partner employed HIV status of partner Unknown Positive Negative HIV status of participantb Positive Negative Previous contraception use Stopped within 12 months of use Ever heard of emergency contraception Ever used emergency contraception Ever pregnant in the past
15 (11–19) 56 (16.4) 332 (97.4) 166 (48.7) 204 (59.8)
t2:21 t2:22
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18 (16–19) 15 (11–18) 14 (23.3) 21 (35.0) 18 (30.0) 38 (63.3) 47 (78.3)
First pregnancy (n = 281) 17 (13–19) 15 (11–19) 66 (23.5) 35 (12.5) 26 (9.3) 128 (45.6) 11 (3.9)
P value
t3:3
b0.001b 0.223b 0.564c b0.001c
t3:4 t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11
b0.001c b0.001c b0.001c
Values are given as mean (range) or number (percentage), unless otherwise indicated. t3:12 t test. t3:13 χ2 test. t3:14
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the fact that the partner's HIV status was unknown by 37.0% of the study participants. An unexpected finding of the present study was the alarmingly high number of teenagers whose mothers were deceased in both the first and repeat pregnancy groups. This high percentage could be attributed to the effects of the HIV epidemic in South Africa resulting in AIDS orphans, illustrating the negative social impact of the epidemic [8,16]. The expanded South African antiretroviral therapy program is thought to be responsible for a current improved life expectancy [17]. However, the benefits are yet to be determined with regard to the survival of parents beyond the teenage years of their offspring. Risk factors for teenage first and repeat pregnancies previously established include the absence of a close mother–daughter relationship, a mother who herself was a teenage mother, not living with parents, and an unsupportive mother [10]. The presence of a mother in a teenager's life is crucial, especially because teenagers who have supportive mothers are able to return to school faster after pregnancy, which decreases the risk of repeat pregnancies [9]. With less than 40% of parents reported to be married and up to 14.7% of teens primarily cared for by grandparents in the present study, such poor social dynamics and family structure undoubtedly make for an environment in which teenage pregnancy and repeat teenage pregnancy prevail. The most important, consistent, and strongest risk factor for repeat pregnancy has been previously shown to be failure to initiate longacting reversible contraception (LARC), such as subdermal implants or intrauterine devices (IUDs), following delivery or an induced abortion [14,15]. Teenage mothers who do not initiate LARC have up to a 35-fold increased risk of a repeat pregnancy within 2 years compared with teenagers using LARCs [13]. Interventions to prevent repeat
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Age, y Average age at sexual debut, y Mother deceased More than one sexual partner in past 12 months Positive HIV status Partner ≥5 years older than participant Ever used contraception
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Repeat pregnancy (n = 60)
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Variables
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44 (13.3) 288 (86.7) 58 (17.0) 54 (93.1) 157 (46.0) 28 (8.2) 60 (17.6)
trends, as measured by the number of live births, can be reliably estimated from national datasets, pregnancy rates, including induced and spontaneous abortions, cannot [9,12]. Given these challenges, it is not surprising that data on repeat teenage pregnancy is scarce in South Africa. In the present study, the interval between pregnancies was less than 2 years in 75.0% of repeat pregnancies, which is a much higher percentage than those reported in previous studies in Australia and the USA (33%–45%) [13–15]. There was a strong association between repeat pregnancies and having a partner who was at least 5 years older, as well as with a higher prevalence of HIV infection. Despite a comparable age of sexual debut in both the repeat and first pregnancy participants, teenagers with partners at least 5 years older had a higher prevalence of HIV infection than did those with peer-group partners. The lower HIV rates in teenagers having peer-group partners compared with those with older partners are corroborated by previous reports [12]. These findings highlight the problem of safe-sex negotiation in the context of intergenerational relationships. Repeat pregnancy participants were likely to have had more than one sexual partner in the preceding 12 months and to be HIV-positive, thus alluding to risky behavior leading to consequent pregnancy and HIV infection. Nevertheless, the identification of teenagers prone to risky behavior is poor within the South African health system, as are strategies to curb such behavior. This point is emphasized by 60%
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50%
Frequency,%
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126 (37.0) 19 (5.6) 196 (57.5)
Values are given as mean (range) or number (percentage). 9 had missing/unknown HIV status.
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Table 3 Factors associated with repeat teenage pregnancies.a
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40% 30%
26.7 21.7
20% 10% 1.7
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Time since first/most recent pregnancy, mo Fig. 2. Time interval between first/most recent and repeat pregnancy.
Please cite this article as: Mphatswe W, et al, Prevalence of repeat pregnancies and associated factors among teenagers in KwaZulu-Natal, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.09.028
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The authors have no conflicts of interest.
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Conflict of interest
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pregnancies include dedicated adolescent prenatal and postnatal clinics, flexible clinic hours, mother and baby pair visits, counselling, home visits, use of social media, telephone reminders, and continuous counselling [18,19]. Nevertheless, these interventions have had limited success even when paired with contraception provision [13]. One US study [15] demonstrated that teenage mothers who had a repeat pregnancy were as likely to be compliant with such programs as were those who did not become pregnant again. Although these social support and counselling interventions seem inferior to the initiation of LARCs with regard to the prevention of repeat pregnancies, the provision of support remains vital. Despite a history of previous contraception initiation among many repeat pregnancy participants in the present study, use was not sustained and most stopped within 1 year. Long-term contraceptive continuation is certainly a challenge for teenagers who are likely to abandon contraception between relationships and resume intercourse before reinitiating contraception [14]. LARCs, however, have been shown to have a higher continuation rate than other methods at 12 months and 2 years [20,21]. Additionally, LARCs have emerged as an effective, safe, and acceptable tool to prevent teenage pregnancy and repeat pregnancies [22]. Because all contraceptive methods have adverse effects, counselling and support is crucial for teenagers using LARCs. Timing of insertion of the implant or IUD in the immediate postpartum period or after abortion is more effective than delaying for 4–6 weeks, with no reported adverse clinical outcomes for both the lactating mother and breastfed infant [20,23]. This is an attractive option for teenagers because they tend to resume sexual intercourse early, before initiating any form of contraception [24]. Delaying beyond the immediate postpartum period could be too late or the opportunity could be missed because many might not return for insertion. At the time of the present study, subdermal implants were not yet freely available in South Africa, and the uptake of IUDs has been low even among older women. The rollout of the subdermal implant commenced late in 2013 in South Africa; its success will depend on the health system's ability to reach intended users, especially teenagers. The present study was conducted at one center, which limits the ability to generalize the findings to other populations. However, the population in Umlazi should not differ significantly from similar communities in South Africa. Given the scarcity of similar literature focusing on South Africa, the present study provides a baseline analysis of the size of the challenge. The study was not designed to make comparisons between first and repeat teenage pregnancy characteristics; a larger study aiming to compare these groups is required to confirm the observations. Additionally, because the investigation was not a cohort study, assessing the true incidence of repeat teenage pregnancy is beyond its scope. Nevertheless, determining the prevalence of repeat pregnancy in this high-risk group and an analysis of the interval between pregnancies is invaluable in making a case for better strategies to counteract this public health challenge. The high repeat pregnancy rates, low contraception use, and associated increased vulnerability to HIV among teenagers is worrying. Focused interventions that target teenagers following their first pregnancy need to be urgently implemented to reduce repeat pregnancy rates and improve overall teenage sexual and reproductive health. Factors that contribute towards teenage pregnancy and high repeat pregnancy rates cut across social, psychological, and economic domains such that they are not entirely within the influence of the formal health system. Strategies will need to take account for the context in which these pregnancies arise and target the risk factors through a multi-sectorial approach. The provision of LARCs to teenagers is a promising public health strategy, but its success will depend on the method's uptake and retention rates. Future research is required to evaluate the cost-effectiveness of LARCs in nulliparous and parous adolescents, as well as its impact on other social indicators such as school completion. Data on repeat teenage pregnancy rates needs to form part of routine national datasets to inform preventive strategies, monitoring, and evaluation.
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