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Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies

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• Peer review
• Angela Harden , professor of community and family health 1 ,
• Ginny Brunton , research officer 2 ,
• Adam Fletcher , lecturer in young people’s health 3 ,
• Ann Oakley , professor of sociology and social policy 2
• 1 Institute of Health and Human Development, University of East London, London, E15 4LZ
• 2 Social Science Research Unit, Institute of Education, University of London, London WC1H 0NR
• 3 Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, WC1E 7H
• Correspondence to: A Harden a.harden{at}uel.ac.uk
• Accepted 12 July 2009

Objectives To determine the impact on teenage pregnancy of interventions that address the social disadvantage associated with early parenthood and to assess the appropriateness of such interventions for young people in the United Kingdom.

Design Systematic review, including a statistical meta-analysis of controlled trials on interventions for early parenthood and a thematic synthesis of qualitative studies that investigated the views on early parenthood of young people living in the UK.

Data sources 12 electronic bibliographic databases, five key journals, reference lists of relevant studies, study authors, and experts in the field.

Review methods Two independent reviewers assessed the methodological quality of studies and abstracted data.

Results Ten controlled trials and five qualitative studies were included. Controlled trials evaluated either early childhood interventions or youth development programmes. The overall pooled effect size showed that teenage pregnancy rates were 39% lower among individuals receiving an intervention than in those receiving standard practice or no intervention (relative risk 0.61; 95% confidence interval 0.48 to 0.77). Three main themes associated with early parenthood emerged from the qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations for the future. Comparison of these factors related to teenage pregnancy with the content of the programmes used in the controlled trials indicated that both early childhood interventions and youth development programmes are appropriate strategies for reducing unintended teenage pregnancies. The programmes aim to promote engagement with school through learning support, ameliorate unhappy childhood through guidance and social support, and raise aspirations through career development and work experience. However, none of these approaches directly tackles all the societal, community, and family level factors that influence young people’s routes to early parenthood.

Conclusions A small but reliable evidence base supports the effectiveness and appropriateness of early childhood interventions and youth development programmes for reducing unintended teenage pregnancy. Combining the findings from both controlled trials and qualitative studies provides a strong evidence base for informing effective public policy.

Introduction

Countries such as the United Kingdom and the United States have high teenage pregnancy rates relative to other countries. 1 2 3 Although teenage pregnancy can be a positive experience, particularly in the later teenage years, 4 5 it is associated with a wide range of subsequent adverse health and social outcomes. 6 7 These associations remain after adjusting for pre-existing social, economic, and health problems. 8 Despite the establishment of a national teenage pregnancy strategy in 1999, 9 teenage birth rates in the UK are the highest in western Europe 10 and conceptions among girls under 16 years of age in England and Wales have increased since 2006. 11

Recent research evidence shows that traditional approaches to reducing teenage pregnancy rates—such as sex education and better sexual health services—are not effective on their own. 12 13 This evidence has generated increased interest in the effects of interventions that target the social disadvantage associated with early pregnancy and parenthood. 14 15 16 17 18 19 Social disadvantage refers to a range of social and economic difficulties an individual can face—such as unemployment, poverty, and discrimination—and is distributed unequally on the basis of sociodemographic characteristics such as ethnicity, socioeconomic position, educational level, and place of residence. 20 21

The objectives of this study were to determine on the basis of evidence in qualitative and quantitative research the impact on teenage conceptions of interventions that address the social disadvantage associated with early parenthood and to assess the appropriateness of such interventions for young people in the UK.

We undertook a three part systematic review of the research evidence on social disadvantage and pregnancy in young people by using an innovative method we developed previously for integrating qualitative and quantitative research. 22 23 The first part of the review focused on quantitative controlled trials and was designed to assess the impact on teenage conceptions of interventions that address the social determinants of teenage pregnancy. The second part focused on qualitative research and examined intervention need and appropriateness on the basis of the perspectives and experiences of young people. In the third part of the review, we integrated the two sets of findings to assess the extent to which existing evaluated interventions do in fact address the social disadvantage associated with early pregnancy and parenthood as determined by the needs and concerns of young people.

The inclusion of qualitative research in systematic reviews facilitates the incorporation of “real life” experiences into evidence based policy making. 24 An ability to unpack the worldview of participants at a particular time and location has been highlighted as a key strength of qualitative research. 25 26 Although we included trials conducted in any country, we drew only on qualitative studies conducted in the UK to help assess the applicability of interventions to reduce teenage pregnancy within this country in particular.

Search strategy

Our literature searches covered seven major databases and five specialist registers (table 1 ⇓ ). Highly sensitive topic based search strategies were designed for each database. We did not use study type search filters and identified controlled trials and qualitative studies using the same strategy.

Major databases and specialist registers searched

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We included randomised and non-randomised controlled trials that evaluated interventions designed to target social disadvantage and that reported teenage conceptions or births as an outcome measure. The inclusion of trials was not restricted according to language, publication date, or country. We included any qualitative study published between 1994 and 2004 that focused on teenage pregnancy and social disadvantage among young people aged less than 20 years old living in the UK.

Relevant interventions were those that aimed to improve young people’s life opportunities and financial circumstances; for example, through educational or income support. Relevant interventions could be targeted at children, young people, or their families. Controlled trials of sex education or sexual health services and qualitative studies focusing solely on attitudes to and knowledge of sexual health or sex education were excluded.

We hand searched American Journal of Public Health (from January 1999 to January 2004), Journal of Adolescent Health (from January 1999 to February 2004), Journal of Adolescence (from February 1999 to April 2004), and Perspectives on Sexual and Reproductive Health (from issue 1, 1999, to issue 1, 2004). We also reviewed the reference lists of all studies that met our inclusion criteria and contacted experts in the field who suggested further studies to pursue.

Quality assessment

We assessed the extent to which controlled trials had minimised bias and error in their findings by using a set of criteria developed in previous health promotion reviews. 27 28 29 “Sound” trials were those that reported data on each outcome measure indicated in the study aims; used a control or comparison group equivalent to the intervention group on relevant sociodemographic measures (or, in cases with non-equivalent groups, adjusted for differences in the analysis); provided pre-intervention data for all individuals in each group; and provided post-intervention data for all individuals in each group.

The criteria we used to assess the methodological quality of the qualitative studies were built on those suggested in the literature on qualitative research. 26 30 31 32 33 Each study was assessed according to 12 criteria designed to aid judgment on the extent to which study findings were an accurate representation of young people’s perspectives and experiences (box). A final assessment sorted studies into one of three categories on the basis of quality: high quality (those meeting 10 or more criteria), medium quality (those meeting between seven and nine criteria), and low quality (those meeting fewer than seven criteria).

Criteria used to assess the quality of qualitative studies

Quality of reporting.

Were the aims and objectives clearly reported?

Was there an adequate description of the context in which the research was carried out?

Was there an adequate description of the sample and the methods by which the sample was identified and recruited?

Was there an adequate description of the methods used to collect data?

Was there an adequate description of the methods used to analyse data?

Use of strategies to increase reliability and validity

Were there attempts to establish the reliability of the data collection tools (for example, by use of interview topic guides)?

Were there attempts to establish the validity of the data collection tools (for example, with pilot interviews)?

Were there attempts to establish the reliability of the data analysis methods (for example, by use of independent coders)?

Were there attempts to establish the validity of data analysis methods (for example, by searching for negative cases)?

Extent to which study findings reflected young people’s perspectives and experiences

Did the study use appropriate data collection methods for helping young people to express their views?

Did the study use appropriate methods for ensuring the data analysis was grounded in the views of young people?

Did the study actively involve young people in its design and conduct?

Data extraction

We used a standardised tool to extract from “sound” controlled trials information on the development and content of the intervention evaluated, the population involved, and the trial design and methods. 34 Data to calculate effect sizes for pregnancy and birth rates were identified from study reports and via contact with study authors if data were incomplete or not in an appropriate form.

Data on the development, design, methods, and the populations involved were extracted from the qualitative studies in a standardised way by using an established tool designed for a broad range of study types. 35 The findings of the qualitative studies were identified within the “findings” or “results” sections of study reports and exported verbatim into NVivo (version 2; QSR, Victoria, Australia), a qualitative data analysis software package.

Data synthesis

The data synthesis was conducted in three stages according to the model described by Thomas and colleagues. 22 Firstly, we used statistical meta-analysis techniques to assess the effectiveness of the interventions in the controlled trials. Chi square statistical tests were used to test for heterogeneity (“Q statistic”) between controlled trials; when there was no significant heterogeneity, we combined effect sizes in a random effects statistical meta-analysis using Evidence for Policy and Practice Information Centre reviewer software. 36 Relative risk (RR) was used to calculate both individual study and combined effect sizes. Our procedures for meta-analysis followed standard practice in the field 37 38 39 and were similar to those used in previous reviews by the Evidence for Policy and Practice Information Centre. 29 40

Secondly, we conducted a thematic synthesis of the findings from the qualitative studies, 41 42 following established principles developed for the analysis of qualitative data. 25 43 44 Study findings were coded line by line to characterise the content of each line or sentence (for example, “frustration with rules and regulations at school,” “expectations for the future”). Codes were compared and contrasted, refined, and grouped into higher order themes (for example, “dislike of school”). The review team then drew out the implications for appropriate interventions suggested by each theme.

Thirdly, we constructed a methodological and conceptual matrix to integrate the findings of the two syntheses. The potential implications of young people’s views for interventions to prevent teenage pregnancy were laid out alongside the content and findings of the soundly evaluated interventions.

Screening of full reports against inclusion criteria, quality assessment, data extraction, and data synthesis were all carried out by pairs of reviewers working independently at first and then together. Initial screening of titles and abstracts was done by single reviewers after a period of double screening to ensure consistency across reviewers.

Study characteristics and quality

Ten controlled trials w1-w10 and five qualitative studies w11-w15 met our inclusion criteria. Six controlled trials were judged to be of sufficient methodological quality to provide reliable evidence about the impact of interventions on teenage pregnancy rates. w1-w3 w6 w7 w9 All these trials were conducted in the US and targeted disadvantaged groups of children and young people (tables 2 ⇓ and 3 ⇓ ).

 Characteristics of the six “sound” trials

 Characteristics of the interventions in the six “sound” trials

Each of the methodologically sound controlled trials evaluated one of two intervention types: ( a ) an early childhood intervention, or ( b ) a youth development programme. Three studies evaluated early childhood interventions that aimed to promote cognitive and social development through preschool education, parent training, and social skills training. w2 w3 w7 Two of these studies—the Perry Preschool Program w2 and the Abecedarian Project w3 —evaluated the long term effects of preschool education and parenting support interventions; the third—the Seattle Social Development Project—evaluated the long term effects of a school based social skills development intervention for children and their parents. w7

A further three studies evaluated youth development programmes that aimed to promote self esteem, positive aspirations, and a sense of purpose through vocational, educational, volunteering, and life skills work. w1 w6 w10 Two of these studies—Teen Outreach w1 and the Quantum Opportunities Program w6 —evaluated after school programmes based on the principle of “serve and learn,” in which community service is combined with student learning and educational support; the third—the Children’s Aid Society Carrera-Model Program—evaluated a comprehensive academic and social development intervention delivered in youth centres, which included work experience, careers advice, academic support, sex education, arts workshops, sports, and other activities. w10

In each trial, the control group received no intervention or standard education. The four controlled trials that were deemed not to be of sufficient quality also evaluated youth development programmes in the US. w4 w5 w8 w9 All five qualitative studies were judged to be of medium or high quality. w11-w15 These studies included participants from a range of areas throughout the UK and used individual interviews, focus groups, and self completion questionnaires to collect data (table 4 ⇓ ). Four studies focused on, or included, the views of young parents, w11 w12 w14 w15 but only two of these studies included the views of young fathers as well as young mothers. w14 w15

 Characteristics of the four high and medium quality qualitative studies

Quantitative studies of the effects of interventions on teenage pregnancy rates

Of the six controlled trials deemed to be of sufficient methodological quality, four measured pregnancy rates reported by young women, w1 w2 w7 w10 three measured partner pregnancy rates reported by young men, w1 w7 w10 and two measured birth rates reported by young men and young women separately w3 or together. w6 The four controlled trials measuring pregnancy rates reported by young women or young men w1 w2 w7 w10 were included in two random effects meta-analyses: one that assessed the effects of interventions on teenage pregnancies reported by young women and a second that measured the effects of interventions on teenage pregnancies reported by young men. The findings of the two controlled trials that measured birth rates w3 w6 were not subject to meta-analysis, but their findings are summarised after each meta-analysis. Tests revealed no statistical heterogeneity between the studies, suggesting that it would be appropriate to pool the effect sizes. However, effect sizes for youth development interventions and early childhood education interventions were pooled separately in recognition of the differences between these two types of intervention.

The pooled effect size from the first meta-analysis showed that early childhood interventions and youth development programmes reduced teenage pregnancy rates among young women (RR 0.61, 95% CI 0.48 to 0.77; fig 1 ⇓ ). The effect of an early childhood intervention on birth rates reported by young women was similar in the study by Campbell and colleagues w3 (0.56, 0.42 to 0.75).

Fig 1 Forest plot showing the effect of youth development programmes and early childhood interventions on pregnancy rates reported by young women

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The effect of these interventions on pregnancies reported by young men is less clear (fig 2 ⇓ ). The pooled effect size from the second meta-analysis showed that young men who had received an early childhood or youth development intervention reported fewer partner pregnancies than those who had not, but this result was not statistically significant (RR 0.59, 95% CI 0.34 to 1.02).

Fig 2 Forest plot showing the effect of youth development programmes and early childhood interventions on pregnancy rates reported by young men

Hahn and colleagues w6 evaluated a youth development programme and measured birth rates reported by both young women and young men. The intervention reduced the birth rate by 36%, although this result was of borderline statistical significance (RR 0.64, 95% CI 0.40 to 1.03).

Qualitative studies of the views and experiences of young people

Three major themes relating to teenage pregnancy emerged from the findings of the five qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations and aspirations for the future (fig 3 ⇓ ).

Fig 3 Thematic analysis of young people’s views on the role of education; training; employment and careers; and financial circumstances in teenage pregnancy

Dislike of school was a key aspect of young parents’ accounts of their lives before becoming parents and of young people identified as “at risk” of becoming teenage parents (for example, “Still be at school? I’d rather have a baby than that. I just didn’t like school, it was hard, it was horrible” w14 ). The reasons young people gave for disliking school varied (fig 3). Some related to the subject matter taught in school, which was seen as boring or irrelevant, especially for young women who had difficult or unhappy home lives and caring responsibilities (for example, “what on earth is this going to do for me?” w15 ). Other reasons related to insufficient or inappropriate support when falling behind with school work or experiencing bullying by teachers and peers (for example, “I got bullied so I just stopped going” w12 ). Some young people were frustrated with the inflexibility of “institutional life,” with all its rules and regulations (for example, “You can’t sit with your friends, which I found the best way of learning” w11 ).

Young parents reported unhappiness, rather than poverty in itself, as the most significant aspect of their childhood experiences that related to becoming a parent, although unhappiness went hand in hand with adversity and material disadvantage in their accounts. Common experiences included family conflict and breakdown, sometimes caused by violence, which could lead to living in care (fig 3). Young fathers reported violent fathers and a lack of suitable role models. Young parents noted how they had to “grow up faster” in order to survive, and also reported a lack of confidence, low self esteem, and high anxiety levels. w11 Some young women saw having a baby at an early age as a way to change their circumstances and ameliorate the effects of adversity. It is important to note, however, that not all the teenage mothers who participated in these studies had grown up unhappy or experienced personal adversity. Regardless of circumstances, some women had wanted to have a baby when they were young and looked forward to still being young when their children were older.

There were differences in the expectations and aspirations of young people who had, or wanted to have, a baby early in life and young people who had or wanted to have a baby later in life. For example, mothers who had children when they were teenagers wanted to leave school as soon as possible and get a job. In contrast, those who became pregnant later in life expected to go to university and travel. Both young mothers and young fathers believed that few opportunities were open to them apart from poorly paid, temporary work in jobs that they disliked (for example, “There are so many jobs out there that I didn’t even know existed . . . I probably could have done something but I just didn’t even think of these high paid jobs I could have done” w14 ). Young mothers described how having a baby was a more attractive option than entering the workforce, further education, or training. Young men’s lack of ambition was compounded by the low expectations their parents and peers held for them. Young people who wanted children later in life had long term plans and a more positive outlook for the future, and they described how participating in out of school activities such as sports, music, and arts improved their self esteem and motivation.

Do current interventions address the needs and concerns reported by young people?

The themes in our synthesis of qualitative studies suggest areas that should be addressed in preventive interventions, but measures to target these areas have not all been soundly evaluated for their effect on teenage pregnancy rates (table 5 ⇓ ).

 Comparison of themes arising from studies of young people’s views with interventions assessed in “sound” trials

Youth development programmes and early childhood interventions both go some way to addressing young people’s dislike of school. Two of the three youth development programmes in the controlled trials we reviewed included components designed to promote young people’s academic achievement, such as tutoring and homework assistance, w6 w10 whereas the third aimed to improve young people’s interpersonal skills so they could develop good relationships with their peers and others. w1 One early childhood intervention both taught children conflict resolution skills and trained parents to create a home environment supportive of learning. w7 We did not find any research that had tested the impact on teenage pregnancy rates of interventions designed to change the school culture and environment, such as antibullying strategies, teacher training, or involving young people in making decisions about what happens in the school.

All the youth development programmes aimed to prevent teenage pregnancy by broadening young people’s expectations and aspirations for the future. These programmes offered young people work experience in their local communities, careers advice, group work to stimulate active reflection, and discussion of future careers and employment opportunities. Two of the three soundly evaluated youth development programmes also provided out of school sports or arts activities. w6 w10

Summary of principal findings

This review sought to improve our understanding of the link between social disadvantage and teenage pregnancy by integrating evidence from qualitative studies and quantitative trials.

The evidence from the six controlled trials we looked at showed that early childhood interventions and youth development programmes can significantly lower teenage pregnancy rates. Both types of intervention target the social determinants of early parenthood but are very different in content and timing. Preschool education and support appear to exert a long term positive influence on the risk of teenage pregnancy, as well as on other outcomes associated with social and economic disadvantage such as unemployment and criminal behaviour. 45 Programmes of social support, educational support, and skills training delivered to young people have a much more immediate impact.

Our review of five qualitative studies of young people in the UK indicated that happiness, enjoying school, and positive expectations for the future can all help to delay early parenthood. Young people who have grown up unhappy, in poor material circumstances, do not enjoy school, and are despondent about their future may be more likely to take risks when having sex or to choose to have a baby.

The findings of our review are especially important in the light of evidence that sex education and sexual health services are not on their own effective strategies for encouraging teenagers to defer parenthood 12 ; they need to be complemented by early childhood and youth development interventions that tackle social disadvantage. 13 18 46 Early childhood interventions and youth development programmes provide enhanced educational and social support in the early years of life and engage young people in developing career aspirations, respectively, thus addressing some of the key themes identified within our qualitative synthesis. However, important gaps exist in the evidence on how effectively current interventions address these themes (table 5). Structural and systemic issues such as housing, employment opportunities, community networks, bullying, and domestic violence were all important issues in young people’s accounts, but these factors have yet to be addressed in appropriate interventions and evaluated as wider determinants of teenage pregnancy.

Comparison with other studies

Our review adds to a growing body of research identifying factors that may explain the association between social disadvantage and teenage pregnancy. Dislike of school, an unhappy childhood, and a lack of opportunities for jobs and education have all emerged as explanatory factors in large scale national and international epidemiological analyses. 3 9 17 18 47 48 49 Dislike of school appears to have an independent effect on the risk of teenage pregnancy. 49 Our analysis of qualitative research provides additional insight into how factors that increase the risk of teenage pregnancy may operate. For example, a dislike of school was frequently the result of bullying, frustration with rules and regulations, lack of curriculum relevance, boredom, and inadequate support.

As well as developing and testing interventions to modify these antecedents, future research on teenage pregnancy and social disadvantage needs to consider strategies that counter the stigmatisation and discrimination faced by young parents. Some of the social exclusion experienced by young parents is the result of negative societal reaction. However, there is evidence to suggest that teenage parenting can under certain circumstances be a route to social inclusion rather than exclusion. 50

Like many other systematic reviews in health promotion and public health, we found few trials conducted in the UK. 27 29 40 This raises questions about the generalisability of the trial evidence. Our inclusion of qualitative evidence permitted us to examine the appropriateness of interventions evaluated in US trials from the perspective of young people in the UK. The appropriateness of interventions is an important aspect of generalisability to consider. 51 Our inclusion of qualitative evidence does not, however, replace the need for further trials in the UK and elsewhere to address the impact of interventions designed to ameliorate the wider determinants of teenage pregnancy.

A recent study carried out in England evaluated the effects of the Young People’s Development Programme—an intensive, multicomponent youth development intervention based on the Children’s Aid Society Carrera Model Program. w10 52 In contrast to the findings of this review, the quasi-experimental study found that young women in the intervention group were more likely to report pregnancy than those in the comparison group. This finding may be the result of the potentially stigmatising effect of targeting and labelling young people as “high risk” or of introducing participants to other “high risk” young people in alternative educational settings. In comparison with the Young People’s Development Programme, the youth development programmes evaluated by the controlled trials in our review used after school programmes or interventions delivered in community settings rather than the approach of keeping young people out of mainstream schools and working with them in alternative educational settings. This difference in approach may explain the difference in the findings of the two studies and highlights the need to evaluate a revised youth development programme in the UK.

Strengths and limitations of the study

The strengths of our review include the comprehensiveness of our searches, the exclusion of methodologically weak studies, the rigorous synthesis methods used, and the inclusion of qualitative research alongside controlled trials to establish not only “what works” but also appropriate and promising intervention strategies on the basis of young people’s views on the factors associated with teenage pregnancy. Including only studies that evaluated interventions relative to control conditions over the same period of time avoids missing temporal differences between groups. Such changes include the relaxing of abortion laws and the increasing acceptability of abortion over time, which may affect self reported pregnancy rates.

The small numbers of studies we found are a limitation of the available body of research, as is the dominance of controlled trials conducted in the US (although this is a common feature of many health promotion and public health reviews). Our search strategies would have under-represented non-English language studies. As with any systematic review, we cannot be certain that we identified all relevant studies; in particular we may not have identified all unpublished studies, which are more likely to report negative findings than are published studies. We are only aware of one relevant study published since the searches for this review were carried out: the evaluation of the Young People’s Development Programme. 52 Whether this study would meet the quality criteria for our review is unclear, but it should be considered in any update.

Conclusion and policy implications

This review provides a small but reliable evidence base that early childhood interventions and youth development programmes are effective and appropriate strategies for reducing unintended teenage pregnancy rates. Our findings on the effects of early childhood interventions highlight the importance of investing in early care and support in order to reduce the socioeconomic disadvantage associated with teenage pregnancy later in life. 53 Both the early childhood interventions and the youth development programmes combined structural level and individual levels components, which is in line with many current recommendations in health promotion and public health. 54 55 A policy move to invest in youth programmes should complement rather than replace high quality sex education and contraceptive services, and should aim to improve enjoyment of school, raise expectations and ambitions for the future, and provide young people with relevant social support and skills.

What is already known on this topic

Evidence suggests that sex education and better sexual health services do not reduce teenage pregnancy rates

A number of controlled trials have tested the effects of interventions that target the social disadvantage associated with early pregnancy and parenthood, and a number of qualitative studies have considered young people’s views of the factors associated with teenage pregnancy

No systematic review has brought these quantitative trials and qualitative studies together to determine intervention effectiveness and appropriateness

What this study adds

Early childhood interventions and youth development programmes that combine individual level and structural level measures to tackle social disadvantage can lower teenage pregnancy rates

Such interventions are likely to be appropriate for children and young people in the UK because they improve enjoyment of school, raise expectations and ambitions for the future, and ameliorate the effect of an unhappy childhood in poor material circumstances

A policy move to invest in interventions that target social disadvantage should complement rather than replace high quality sex education and contraceptive services

Cite this as: BMJ 2009;339:b4254

Contributors: AH, AO, and GB designed the study and obtained funding. AH, AO, and GB wrote the review protocol. AF, GB, and AH conducted the searches, screened titles and full papers, assessed study quality, extracted data, and undertook the statistical and qualitative syntheses. All authors contributed to the drafting of the paper and approved the final submitted version. AH, AO, and GB are the guarantors. All authors had full access to all the data in the study, including statistical reports and tables, and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Funding: The review was funded by the Department of Health. AH was funded by a senior level research scientist in evidence synthesis award from the Department of Health. The researchers operated independently from the funders and the views expressed in this paper are those of the authors and not necessarily those of the Department of Health.

Competing interests: None declared.

Data sharing: Technical appendix available at http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=674 .

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode .

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• Research article
• Open access
• Published: 25 May 2016

Teenage pregnancy: the impact of maternal adolescent childbearing and older sister’s teenage pregnancy on a younger sister

• Elizabeth Wall-Wieler 1 ,
• Leslie L. Roos 1 &
• Nathan C. Nickel 1  

BMC Pregnancy and Childbirth volume  16 , Article number:  120 ( 2016 ) Cite this article

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Risk factors for teenage pregnancy are linked to many factors, including a family history of teenage pregnancy. This research examines whether a mother’s teenage childbearing or an older sister’s teenage pregnancy more strongly predicts teenage pregnancy.

This study used linkable administrative databases housed at the Manitoba Centre for Health Policy (MCHP). The original cohort consisted of 17,115 women born in Manitoba between April 1, 1979 and March 31, 1994, who stayed in the province until at least their 20 th birthday, had at least one older sister, and had no missing values on key variables. Propensity score matching (1:2) was used to create balanced cohorts for two conditional logistic regression models; one examining the impact of an older sister’s teenage pregnancy and the other analyzing the effect of the mother’s teenage childbearing.

The adjusted odds of becoming pregnant between ages 14 and 19 for teens with at least one older sister having a teenage pregnancy were 3.38 (99 % CI 2.77–4.13) times higher than for women whose older sister(s) did not have a teenage pregnancy. Teenage daughters of mothers who had their first child before age 20 had 1.57 (99 % CI 1.30–1.89) times higher odds of pregnancy than those whose mothers had their first child after age 19. Educational achievement was adjusted for in a sub-population examining the odds of pregnancy between ages 16 and 19. After this adjustment, the odds of teenage pregnancy for teens with at least one older sister who had a teenage pregnancy were reduced to 2.48 (99 % CI 2.01–3.06) and the odds of pregnancy for teen daughters of teenage mothers were reduced to 1.39 (99 % CI 1.15–1.68).

Although both were significant, the relationship between an older sister’s teenage pregnancy and a younger sister’s teenage pregnancy is much stronger than that between a mother’s teenage childbearing and a younger daughter’s teenage pregnancy. This study contributes to understanding of the broader topic “who is influential about what” within the family.

Peer Review reports

The risks and realities associated with teenage motherhood are well documented, with consequences starting at childbirth and following both mother and child over the life span.

Teenage births result in health consequences; children are more likely to be born pre-term, have lower birth weight, and higher neonatal mortality, while mothers experience greater rates of post-partum depression and are less likely to initiate breastfeeding [ 1 , 2 ]. Teenage mothers are less likely to complete high school, are more likely to live in poverty, and have children who frequently experience health and developmental problems [ 3 ]. Understanding the risk factors for teenage pregnancy is a prerequisite for reducing rates of teenage motherhood. Various social and biological factors influence the odds of teenage pregnancy; these include exposure to adversity during childhood and adolescence, a family history of teenage pregnancy, conduct and attention problems, family instability, and low educational achievement [ 4 , 5 ].

Mothers and older sisters are the main sources of family influence on teenage pregnancy; this is due to both social risk and social influence. Family members both contribute to an individual’s attitudes and values around teenage pregnancy, and share social risks (such as poverty, ethnicity, and lack of opportunities) that influence the likelihood of teenage pregnancy [ 6 , 7 ]. Having an older sister who was a teen mom significantly increases the risk of teenage childbearing in the younger sister and daughters of teenage mothers were significantly more likely to become teenage mothers themselves [ 8 , 9 ]. Girls having both a mother and older sister who had teenage births experienced the highest odds of teenage pregnancy, with one study reporting an odds ratio of 5.1 (compared with those who had no history of family teenage pregnancy) [ 5 ]. Studies consistently indicate that girls with a familial history of teenage childbearing are at much higher risk of teenage pregnancy and childbearing themselves, but methodological complexities have resulted in inconsistent findings around “parent/child sexual communication and adolescent pregnancy risk” [ 10 ]. A review of family relationships and adolescent pregnancy risk found risk factors to include living in poor neighborhoods and families, having older siblings who were sexually active, and being a victim of sexual abuse [ 10 ]. Research around the impact of sister’s teenage pregnancy has been limited to mostly qualitative studies using small samples of minority adolescents in the United States [ 5 , 11 ].

To our knowledge, no previous studies have examined the impact of an older sister’s teenage pregnancy on the odds of her younger sister having a teenage pregnancy, and compared this effect with the direct effect of having a mother who bore her first child before age 20. By controlling for a variety of social and biological factors (such as neighborhood socioeconomic status, marital status of mother, residential mobility, family structure changes, and mental health), and the use of a strong statistical design—propensity score matching with a large population-based dataset—this study aims to determine whether teenage pregnancy is more strongly predicted by having an older sister who had a teenage pregnancy or by having a mother who bore her first child before age 20.

The setting of this study, Manitoba, is generally representative of Canada as a whole, ranking in the middle for several health and education indicators [ 12 , 13 ]. At the time of the 2011 Census, approximately 1.2 million people resided in Manitoba, with more than half (783,247) living in the two urban areas, Winnipeg and Brandon [ 14 ]. Teenage pregnancy rates in Manitoba exceed the national; in 2010 teenage pregnancy rates in Canada were 28.2 per 1000, in Manitoba the rate was 48.7 per 1000 [ 15 ]. The Manitoba teen pregnancy rates in 2010 were slightly lower than rates in England and Wales (54.6 per 1000), and the United States (57.4 per 1000) [ 16 , 17 ].

The Manitoba Population Health Research Data Repository contains province-wide, routinely collected individual data over time (going back to 1970 in some files), across space (with residential location documented using six digit postal codes), for each family (with changes in family structure recorded every 6 months) and for each resident. Health variables are measured continuously from physician claims and hospital abstracts (as long as an individual remains in Manitoba) [ 18 ].

A research registry identifies every provincial resident, with information on births, arrival and departure dates, and deaths created from the provincial health registry and coordinated with Vital Statistics files. Given approximately 16,000 births annually, follow-up (about 74 % over 20 years) is comparable to that in the largest cohort studies based on primary data [ 19 ]. Previous research using similar data shows the results are not biased by individuals leaving the province or dying. Information on data linkage, confidentiality/privacy, and validity of the datasets used have been described elsewhere [ 20 – 22 ]. Children are linked to mothers using hospital birth record information; the mother was noted in essentially all cases [ 23 ]. Sisters were defined as having the same biological mother.

The cohort consists of women who were born in Manitoba between April 1, 1979 and March 31, 1994, stayed in the province until at least their 20 th birthday, had at least one older sister, and had no missing values on key variables. In this study, teenage pregnancies are defined as those between the ages of 14 and 19; pregnancies prior to age 14 were excluded due to low numbers and for comparability to other studies. For this reason, families in which at least one sister had a pregnancy before age 14 were removed (34 families). To address threats of independence, when a family had more than one younger sister (more than two daughters), one younger sister was randomly selected. Figure  1 diagrams the selection trajectory for the 17,115 individuals selected—boxes in bold indicate the included cohort. At age 14, just over 85 % of girls in this cohort were living in the same postal code as at least one older sister.

Cohort selection

Teenage pregnancy was defined as having at least one pregnancy between the ages of 14 and 19 (inclusive). A pregnancy is defined as having at least one hospitalization of with a live birth, missed abortion, ectopic pregnancy, abortion, or intrauterine death, or at least one hospital procedure of surgical termination of pregnancy, surgical removal of ectopic pregnancy, pharmacological termination or pregnancy or intervention during labour and delivery. Pregnancy status was determined by ICD-9-CM codes (for diagnoses before April 1, 2004), ICD-10-CA codes (for diagnoses on or after April 1, 2004), and Canadian Classification of Health Intervention (CCI) codes in the hospital discharge abstract database [ 24 ]. Appendix 1 presents specific codes used to determine pregnancy status.

Independent variable

The independent variables of interest were whether an individual had an older sister with a teenage pregnancy (defined for all sisters as described above) and whether an individual’s mother bore her first child before age 20.

Based on an extensive literature review and availability of information in the database, several key variables describing neighborhood, maternal, and individual characteristics were included [ 4 , 25 ]. Covariates measure characteristics in the younger sister’s life before age 14. Neighborhood socioeconomic status at age 14 was measured by the Socioeconomic Factor Index (SEFI) (higher SEFI score corresponds with lower socioeconomic status), which is generated using Manitoba (Statistics Canada) dissemination areas [ 26 ]. This index combines neighborhood information on income, education, employment, and family structure. These neighborhoods typically include between 400 and 700 urban individuals and are somewhat larger in rural areas. Neighborhood location at age 14 was divided into urban (Winnipeg and Brandon), rural south (South Eastman, Central, and Assiniboine Regional Health Authorities), and rural mid/north (North Eastman, Interlake, Parkland, Nor-Man, Churchill, and Burntwood Regional Health Authorities). The maternal characteristic included is marital status at birth of child. An individual’s number of older sisters was also accounted for.

Three time-varying covariates between birth and age 13 for the younger sister were included in the study- mental health conditions, residential mobility, and family structure change. These variables can occur at specific points in time and the timing of their occurrence can differ across individuals. Mental health is defined using the Johns Hopkins University Adjusted Clinical Group (ACG) software; this software groups medical and hospital diagnoses over the course of a year into 27 Major Expanded Diagnostic Clusters (MEDCs) [ 27 ]. If for 1 year between birth and age 13, the diagnoses an individual received fell into the ‘Mental Health’ MEDC, that individual was categorized as having mental health conditions before age 13. Residential mobility was measured by at least one residential move (defined by change in six digit postal code) between birth and age 13. At least one change in family structure (parental divorce, death, marriage, remarriage) between birth and age 13 was noted as ‘family structure change’.

Low educational achievement has been linked to an increased risk of teenage pregnancy [ 28 ]. The earliest measure of educational achievement available is the Grade 9 Achievement Index, which was built on a technique developed by Mosteller and Tukey using enrollment files, course grades, and the provincial population registry [ 29 , 30 ]. As some of the individuals in this cohort experience their first pregnancy before completing grade 9, this covariate is only appropriate for girls having their first pregnancy after their 16 th birthday. Sensitivity testing was done with this population to determine how strongly educational achievement affected the odds of the variables of interest.

Analytic approach

The relationship between pregnancy during one’s teenage years and having an older sister who became pregnant during adolescence or having a mother who bore her first child as a teenager is confounded by many measured and unmeasured characteristics. We adjusted for these confounding characteristics using 2:1 propensity score matching [ 31 ]; two controls were matched with every case as this “will result in optimal estimation of treatment effect [ 32 ]”. Propensity score matching both enables adjustment for several confounders simultaneously and facilitates diagnostic tests to identify whether the adjustment strategy created comparable exposure groups (i.e., whether women with and without an older sister who got pregnant during adolescence are similar on observed characteristics) [ 31 ]. Logistic regression models were used to calculate propensity scores for two responses—the predicted probability of having an older sister having a teenage pregnancy and the predicted probability of having a mother bearing her first child before age 20. For each model, we investigated the comparability of our two groups—those with and without an older sister having a teenage pregnancy, and those with and without a mother who bore her first child as a teenager—using two diagnostics. A kernel density plot verified that the distribution of propensity scores in our two groups overlapped [ 33 ]; each case was matched to two controls using greedy matching [ 34 ]. Second, after matching, the balance of the covariates was assessed using standard differences and t-tests. Covariate balance was checked by t-statistics calculated for the standardized differences between cases and controls for each covariate before and after matching. Any point outside of the two vertical dotted lines signified a statistically significant difference between the cases and controls on that covariate (at p  = 0.05) (Figs.  2 and 3 ).

Checking covariate balance of older sister’s teenage pregnancy status

Checking covariate balance of mother’ teenage mom status

Conditional logistic regression analysis of the matched cohorts examined the impact of an older sister’s teenage pregnancy and of a mother’s teenage childbearing on teenage pregnancy. Sensitivity analysis helped assess the validity of the assumption of no unobservable confounders, and assessed how strong the influence of unobserved covariates would have to be in order to nullify our findings [ 35 , 36 ]. The lower limit of the 99 % confidence interval (selected to be more conservative) was used to determine the threshold unobserved covariates would have to reach to void the observed relationship.

Impact of older sister having a teenage pregnancy

Table  1 displays the descriptive statistics of the covariates and outcome variables. Of the girls having an older sister with a teenage pregnancy, 40.4 % had a teenage pregnancy. This is significantly higher than the 10.3 % teenage pregnancy rate among those not having an older sister with a teenage pregnancy.

The covariates, in general, accord with social stratification theory [ 37 ]. Teens with an older sister having a teenage pregnancy were also more likely to have been born to an unmarried mother and have a mother who herself was a teenage mother (43 % versus 14 %). At age 14, approximately 42 % of those whose older sister had a teenage pregnancy lived in Rural Mid/Northern Manitoba; only 22 % of those whose older sister did not have a teenage pregnancy lived in this region at age 14. Lower teenage pregnancy was associated with residence in relatively prosperous southern Manitoba. Individuals with older sisters having teenage pregnancies were more likely to live in lower socioeconomic status neighborhood (higher SEFI scores at age 14) with higher rates of residential mobility (68 % vs 59 %), family structure change (28 % vs 16 %), and mental health issues (19 % vs 16 %).

After propensity score matching (on all variables in Fig.  2 ), the final sample consisted of 1873 cases and 3746 controls (1:2); a total of 1618 cases and 9878 controls were excluded from the analysis. T-statistics calculated for each covariate before and after matching to check for covariate balance; all covariates differed significantly in the unmatched sample and balanced in the matched sample (Fig.  2 ).

The final conditional logistic regression model indicates the odds of becoming pregnant before age 20 for those having an older sister with a teenage pregnancy to be 3.38 (99 % CI 2.77–4.13) times greater than for girls whose older sister(s) did not have a teenage pregnancy (Table  3 ).

Impact of mother’s teenage childbearing

Table  2 displays the descriptive statistics of the covariates and outcome variables. Of the girls having a teenage mother, 39.4 % had a teenage pregnancy. This is significantly higher than the 13.1 % teenage pregnancy rates among those whose mother bore her first child after age 19.

After propensity score matching (on all variables in Fig.  3 ), the final sample consisted of 1522 cases and 3044 controls (1:2); a total of 659 cases and 11890 controls were excluded from the analysis. T-statistics calculated for each covariate showed all covariates to differ significantly in the unmatched sample and to balance in the matched sample (Fig.  3 ).

The final conditional logistic regression model indicates that the odds of becoming pregnant before age 20 for those whose mother had her first child before age 20 are 1.57 (99 % CI 1.30–1.89) times greater than for girls whose mother had her first child after age 19 (Table  3 ). Thus, the impact of being born to a mother having her first child before age 20 on teenage pregnancy is much less than that of an older sisters’ teenage pregnancy.

Sensitivity analysis and limitations

With the confidence interval for the first model (examining the association between an older sister’s teenage pregnancy and a younger sister’s teenage pregnancy) ranging between 2.77 and 4.13, to attribute the higher rates of teenage pregnancy to unmeasured confounding rather than to an older sisters’ teen pregnancy status, that covariate would need to generate more than a 2.8-fold increase in the odds of teenage pregnancy and be a near perfect predictor of teenage pregnancy. In the second model (assessing the association between a mother’s teenage childbearing and a younger sister’s teenage pregnancy), the 99 % confidence interval was 1.30 to 1.89; unobserved covariates would need to produce a much smaller increase in odds of teen pregnancy to nullify this finding.

Although linkable administrative data have significant advantages, some important predictors are lacking. Information on involvement with Child and Family Services (CFS) and parental use of income assistance have recently been added to the Manitoba databases, but do not cover the cohort used here. While having a teenage mother and becoming a teenage mother have both been linked to involvement with CFS, in 2001 less than two percent of children under age 18 were in care [ 38 , 39 ]. A variable available (and applicable) for a subpopulation is educational achievement, which is highly correlated with both involvement with CFS and parental welfare use [ 40 ]. These two new measures would likely explain little additional variance in teenage pregnancy. Appendix 2 describes the cohort and propensity score matching for this additional analysis, comparing these findings with the original results in Table  3 . Educational attainment is measured using the Grade 9 Achievement Index, a standardized measure taking into account the number of courses completed in Grade 9 and the average marks of those courses. After adjusting for educational achievement, the odds of teenage pregnancy for teens with at least one older sister who had a teenage pregnancy were reduced to 2.48 (99 % CI 2.01–3.06) and the corresponding odds for teen daughters of teenage mothers were lowered to 1.39 (99 % CI 1.15–1.68).

The rate differences of teenage pregnancy were similar for those whose older sister had a teenage pregnancy (40.4 per 100 - 10.3 per 100 = 30.1 per 100) and for those whose mother bore her first child before age 20 (39.4 per 100 - 13.1 per 100 = 26.3 per 100). After propensity score matching on a series of variables, the odds of becoming pregnant for a teenager were much higher if her older sister had a teenage pregnancy than if her mother had been a teenage mother. For both older sisters’ teenage pregnancy and mother’s teenage childbearing, the odds in this study are lower than those reported elsewhere; this is likely due to the larger sample size, more rigorous methods, and inclusion of important predictors.

Several examinations of family histories in the literature show older sisters to have the greatest influence on a younger sister’s odds of having a teenage pregnancy. Controlling for family socioeconomic status, maternal parenting, and sibling relationships, teens with an older sister who had a teenage birth were 4.8 times more likely to have a teenage birth themselves; these odds increased to 5.1 if both the older sister and mother had a teenage birth [ 11 ]. Four older studies estimated the rate of teen pregnancy to be between 2 and 6 times higher for those with older sisters having a teenage pregnancy [ 41 ]. This work focused primarily on young black women in the United States and controlled for limited confounders (aside from race and age). None of the previous studies examining the impact of an older sister’s teenage pregnancy controlled for mother’s teenage childbearing or time-varying factors before age 14 (mental health, residential mobility, family structure changes); this research probably overestimated the relationship between sisters’ teenage pregnancy status.

The mechanisms driving the relationship between an older sister’s teenage pregnancy and the pregnancy of a younger adolescent sister have been examined through approaches based on social learning theory, shared parenting influences, and shared societal risk [ 41 ]. Bandura’s social learning theory indicates that “most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action” [ 7 ]. When sisters live in the same environment, seeing an older sister go through a teenage pregnancy and childbirth may make this a more acceptable option for the younger sister [ 11 ]. Not only do both sisters have the same maternal influence that may affect their odds of teenage pregnancy, having an older sister who is a teenage mother may change the parenting style of the mother. Mothers involved in parenting of their teenage daughters’ child may have “supervised their children less, communicated with their children less about sex and contraception, and perceived teenage sex as more acceptable when the older daughter’s status changed from pregnant to parenting” [ 42 ]. Finally, both sisters share the same social risks, such as poverty, ethnicity, and lack of opportunities, that increase their chances of having a teenage pregnancy [ 42 ].

Having a mother bearing her first child before age 20 was a significant predictor for teenage pregnancy. We found daughters of teenage mothers to be 51 % more likely to have a teenage pregnancy than those whose mothers were older than 19 when they bore their first child. This is quite close to the 66 % increase found by Meade et al (2008), who controlled for many of the same variables except having an older sister with a teenage pregnancy, and the time-varying covariates of family structure change, mental health conditions, and residential mobility. Meade et al. [ 9 ] did adjust for school performance; in the adjusted sub-sample, the odds ratio reduced to 1.34, indicating a 34 % increase in teenage pregnancy.

Intergenerational teenage pregnancy may be influenced by such mechanisms as “biological heritability, intergenerational transmission of values regarding family, the mother’s level of fertility, the indirect impact of socioeconomic and family environment through educational deficits or low opportunity or aspirations, and directly through the mother’s role modeling” [ 43 ]. Women bearing their first child in their adolescence are more likely to pass on “risky” characteristics, which could produce negative outcomes in their offspring [ 44 ]. Another mechanism identified as contributing to intergenerational teenage pregnancy is that daughters of teenage mothers have an increased internalized preference for early motherhood, have low levels of maternal monitoring, and are thus more likely to become sexually active at a young age and engage in unprotected sex [ 44 ]. The influence of a mother’s teenage pregnancy therefore works through the environment created and parenting style assumed as a result of a mother’s teenage childbearing.

The use of administrative data to conduct health services research has some significant advantages and limitations. Administrative data from a large birth cohort have higher levels of accuracy is not depending on recall (such as in retrospective surveys) and is ideal for examining risk factors over time due to the longitudinal follow-up [ 45 ]. These data—with a large N and a number of covariates—are well-suited for propensity scoring. A significant limitation (shared with almost all observational studies) is that certain covariates and mediating effects are unobservable due to lack of information. The data can only capture recorded variables; for example, only individuals seeking mental health treatment will receive a diagnosis, which may not be include all individuals with mental health conditions [ 46 ]. Sensitivity testing addresses this limitation, but such covariates might well have impacted study results. As mentioned above, not adjusting for involvement with child protective services (such as CFS) is a limitation. Although the number of teenage girls involved with CFS is relatively small, they may not be interacting with their mother or older sister on a regular basis and thus are less likely to model themselves after their family members. The availability of an educational predictor was an identified limitation. To account for the impact of educational achievement in our full cohort, educational outcomes would need to be available for everyone for grade 7 at the latest (as almost all teenage pregnancies occur after grade 7). Since educational achievement generally remains quite similar from year to year—grade 9 achievement is likely to be quite similar to grade 7 achievement [ 30 ]; this reduced odds ratio may better estimate the true odds. In several years, such variables can be incorporated into models of teenage pregnancy. Additionally, we were unable to identify Aboriginal individuals; this is a limitation as teenage pregnancy rates are more than twice as high in the Aboriginal population than in the general population [ 47 ]. Family and peer relationships, social norms, and cultural differences will likely never be measured through administrative data; limiting the degree to which these confounders can be controlled for.

Conclusions

This paper contributes to understanding of the broader topic “who is influential about what” within the family. The teenage pregnancy risk seen in younger sisters when older sisters had a teenage pregnancy appears based on the interaction with that sister and her child; the family environment experienced by the siblings is quite similar. Much of the pregnancy risk among teenage daughters of mothers bearing a child before age 20 seems likely to result from the adverse environment often associated with early childbearing. Given that an older sister’s teenage pregnancy has a greater impact than a mother’s teenage childbearing, social modelling may be a stronger risk factor for teenage pregnancy than living in an adverse environment.

Abbreviations

Adjusted Clinical Group

Canadian Classification of Health Intervention

Child and Family Services

International Classification of Diseases, Ninth Revision, Clinical Modification

International Classification of Diseases, 10th Revision, with Canadian Enhancements

Major Expanded Diagnostic Clusters

Manitoba Centre for Health Policy

Socioeconomic Factor Index

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Acknowledgements

The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Active Living and Seniors, or other data providers is intended or should be inferred. Data used in this study are from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy, University of Manitoba and were derived from data provided by Manitoba Health, Active Living and Seniors and Manitoba Education under project #2013/2014-04. All data management, programming and analyses were performed using SAS® version 9.3. Aggregated Diagnosis Groups™(ADGs®) codes were created using The Johns Hopkins Adjusted Clinical Group® (ACG®) Case-Mix System” version 9.

This research has been supported by the Canadian Institute for Advanced Research and the Western Regional Training Centre. The funding sources had no involvement in study design, analysis and interpretation of data, in writing the article, and in the decision to submit for publication. None of the authors received any reimbursement for participating in the writing of this paper.

Availability of data and materials

The datasets supporting the conclusions of this article are available in the research repository at the Manitoba Centre for Health Policy. Access to data is given upon approvals from the University of Manitoba Health Research Ethics Board and the Health Information Privacy Committee, and permission from all data providers. More information on access to these databases can be found at http://umanitoba.ca/faculties/health_sciences/medicine/units/community_health_sciences/departmental_units/mchp/resources/access.html .

Authors’ contributions

EW participated in the design of the study, carried out the analysis and drafted the manuscript. LR conceived of the study, and participated in its design and coordination and helped to draft the manuscript. NN participated in its design and interpretation of results. All authors read and approved the final manuscript.

Authors’ information

EW is a PhD candidate in the Department of Community Health Sciences at the University of Manitoba. LLR is a Distinguished Professor in the Faculty of Health Sciences at the University of Manitoba and a founding director of the Manitoba Centre for Health Policy. NCN is a Research Scientist at the Manitoba Centre for Health Policy and an Assistant Professor in the Department of Community Health Sciences at the University of Manitoba.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not Applicable.

Ethics approval and consent to participate

This study involved secondary analysis of de-identified data files only, with linkages to other files where identifiers have been removed or scrambled. Consent was not obtained from study subjects, as permitted under section 24(3)c of the Personal Health Information Act. Ethics approvals for this project were obtained from the University of Manitoba Health Research Ethics Board (reference number 2013-033) and the Health Information Privacy Committee (reference number 2013/2014-04).

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Pregnancy diagnosis codes

Teenage pregnancy is defined as females with a hospitalization with one of the following diagnoses (MCHP, 2013):

○ live birth: ICD-9-CM code V27, ICD-10-CA code Z37

○ missed abortion: ICD-9-CM code 632, ICD-10-CA code O02.1

○ ectopic pregnancy: ICD-9-CM code 633, ICD-10-CA code O00

○ abortion: ICD-9-CM codes 634-637 ICD-10-CA codes O03-O07; or

○ intrauterine death: ICD-9-CM code 656.4, ICD-10-CA code O36.4

Or, a hospitalization with one of the following procedures:

○ surgical termination of pregnancy: ICD-9-CM codes 69.01, 69.51, 74.91; CCI codes 5.CA.89, 5.CA.90

○ surgical removal of extrauterine (ectopic) pregnancy: ICD-9-CM codes 66.62, 74.3; CCI code 5.CA.93

○ pharmacological termination of pregnancy: ICD-9-CM code 75.0; CCI code 5.CA.88; or

○ interventions during labour and delivery, CCI codes 5.MD.5, 5.MD.60

Adjustment for educational achievement

To account for the impact of educational achievement on teenage childbearing, the grade 9 achievement index was adjusted for in a sub-population of individuals who had not had a pregnancy prior to age 16 (Fig.  4 ). As educational achievement was measured using the grade 9 achievement index (which is based on average marks in all classes and the number of credits earned during the school year [ 31 ], individuals had to have at least finished grade 9 before becoming pregnant to use this variable as a predictor.

Cohort adjustment

Older sister’s teenage pregnancy status

After propensity score matching, the final sample consisted of 1721 cases and 3442 controls (1:2). T-statistics were calculated for each covariate before and after matching to check for covariate balance (Fig.  5 ). Any point outside of the two vertical dotted lines signified a statistically significant covariate (at p  = 0.05). All covariates differed significantly in the unmatched sample. After matching, the t-statistics of all covariates fell within the non-significant region indicating balance in cases and controls.

Mother's teenage childbearing status

After propensity score matching, the final sample consisted of 1499 cases and 2998 controls (1:2). T-statistics were calculated for each covariate before and after matching to check for covariate balance (Fig. 6 ). Any point outside of the two vertical dotted lines signified a statistically significant covariate (at p = 0.05). All covariates differed significantly in the unmatched sample. After matching, the t-statistics of all covariates fell within the non-significant region indicating balance in cases and controls.

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Wall-Wieler, E., Roos, L.L. & Nickel, N.C. Teenage pregnancy: the impact of maternal adolescent childbearing and older sister’s teenage pregnancy on a younger sister. BMC Pregnancy Childbirth 16 , 120 (2016). https://doi.org/10.1186/s12884-016-0911-2

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Received : 20 January 2016

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Published : 25 May 2016

DOI : https://doi.org/10.1186/s12884-016-0911-2

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Adolescent pregnancy outcomes and risk factors.

1. Introduction

2. materials and methods, 4. discussion, 5. conclusions, 6. limitation, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Diabelková, J.; Rimárová, K.; Dorko, E.; Urdzík, P.; Houžvičková, A.; Argalášová, Ľ. Adolescent Pregnancy Outcomes and Risk Factors. Int. J. Environ. Res. Public Health 2023 , 20 , 4113. https://doi.org/10.3390/ijerph20054113

Diabelková J, Rimárová K, Dorko E, Urdzík P, Houžvičková A, Argalášová Ľ. Adolescent Pregnancy Outcomes and Risk Factors. International Journal of Environmental Research and Public Health . 2023; 20(5):4113. https://doi.org/10.3390/ijerph20054113

Diabelková, Jana, Kvetoslava Rimárová, Erik Dorko, Peter Urdzík, Andrea Houžvičková, and Ľubica Argalášová. 2023. "Adolescent Pregnancy Outcomes and Risk Factors" International Journal of Environmental Research and Public Health 20, no. 5: 4113. https://doi.org/10.3390/ijerph20054113

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Teenage pregnancy

Affiliations.

• 1 MBBS, BScMed, FRACGP, DipRANZCOG, Principal GP, Your Doctors, NSW.
• 2 MA, MSc, MBBS, Medical Director, Family Planning NSW, NSW; Clinical Associate Professor, The University of Sydney, NSW.
• 3 MBBS, MMed, FRANZCOG, DDu, PhD, MFSRH, Associate Professor, Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW.
• PMID: 32464731
• DOI: 10.31128/AJGP-02-20-5224

Background: Teenage pregnancy rates are falling in many high-resource settings, but for those who do conceive, the socioeconomic and educational disadvantage that ensues is often long lasting and intergenerational. The adverse maternal and neonatal outcomes can be ameliorated through antenatal and postnatal care that attends to the special needs of this group.

Objective: The aim of this article is to provide an overview of the social, obstetric and medical complications of teenage pregnancy and the role of the general practitioner (GP) in mitigating adverse outcomes.

Discussion: Management and prevention of teenage pregnancy requires broad efforts that involve schools, health services and the community. The GP has a key role in providing supportive continuity of care that spans the antenatal and crucial postnatal periods.

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• Study protocol
• Open access
• Published: 25 April 2019

Adolescent pregnant women’s health practices and their impact on maternal, fetal and neonatal outcomes: a mixed method study protocol

• Tahere Hadian 1 ,
• Sanaz Mousavi 2 ,
• Shahla Meedya 3 ,
• Sakineh Mohammad-Alizadeh-Charandabi 4 ,
• Eesa Mohammadi 5 &
• Mojgan Mirghafourvand 4  

Reproductive Health volume  16 , Article number:  45 ( 2019 ) Cite this article

15k Accesses

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Considering that individuals’ health practices can affect the health of both mothers and babies, this study is designed to: (a) assess adolescent pregnant women’s health practices and their relationship with maternal, fetal, and neonatal outcomes; (b) explore the perception of adolescent pregnant women about their own health practices; and (c) recommend some strategies to improve adolescent pregnant women’s health practices during pregnancy.

Methods/design

This mixed-method study with the sequential explanatory design has two phases. The first phase (quantitative phase) is a prospective study to assess the adolescent pregnant women’s health practices and its relationship with maternal, fetal, and neonatal outcomes who live in Tehran, the capital city of Iran. A cluster sampling method will be used to select 316 adolescent pregnant women who visit health centers in Tehran. The second phase is a qualitative study designed to explore the adolescent pregnant women’s perception of important aspects and factors of health practices that can affect their health outcomes. In this phase, purposive sampling and in-depth individual interviews will be conducted for data collection. The conventional content analysis approach will be employed for data analysis. In addition to literature review and nominal group technique, the findings of the qualitative and quantitative phases, will be used to recommend some strategies to support adolescent pregnant women to improve their health practices during pregnancy.

This is the first study looking into health practices in adolescent pregnant women which will be performed via a mixed-method approach, aiming to develop health practices improvement strategies. It is worth noting that there is no strategic guideline in Iran’s health system for improvement of health practices of adolescents. Therefore, it is hoped that the strategy proposed in the current study can enhance health practices of adolescents during pregnancy and ultimately improve their pregnancy and childbirth outcomes.

Ethical code

IR.TBZMED.REC.1397.670.

Plain English summary

Adolescent pregnancy is a public health concern that affects mothers, their children, and the broader community. Pregnancy and childbirth complications remain the leading cause of mortality and morbidity among female adolescents worldwide and can be influenced by lifestyle choices. The rate of adolescent pregnancy is increasing globally and due to recent changes in family planning policies in Iran, it is estimated that adolescent pregnancy will increase in the near future. The current study provides precise information about the health practices in Iranian adolescent pregnant women, and the factors related to them. This study is a mixed-method with the sequential explanatory design has two phases. The first phase (quantitative phase) is a prospective study to assess the adolescent pregnant women’s central and dispersion indices of health practices and its relationship with maternal, fetal, and neonatal outcomes who live in Tehran, the capital city of Iran. The second phase is a qualitative study designed to explore the adolescent pregnant women’s perception of important aspects and factors of health practices that can affect their health outcomes. The findings of the qualitative and quantitative study in addition to literature review and nominal group technique will be used to recommend some strategies to support adolescent pregnant women to improve their health practice during pregnancy. The strategy proposed by this study may be helpful in promoting health practices in adolescent pregnant women and improving pregnancy and childbirth outcomes in them.

Adolescents account for approximately 1.2 billion people worldwide, which is one-sixth of the world population [ 1 ]. The World Health Organization (WHO) defines an adolescent as any person between ages 10 and 19 [ 2 ]. Findings of the 2016 population census in Iran showed that out of 79,926,270 Iranian population, 11,147,381 were adolescents including 5,450,270 females [ 3 ]. Each year, approximately 16 million girls aged 15 to 19 years and 2 million girls under 15 years give birth, with 95% in low- and middle-income countries [ 4 ]. Each year, 10% of babies are born to adolescent mothers, who account for 23% of maternal mortality and complications [ 5 ]. Despite the lower rate of adolescent pregnancy in Iran compared to the global rate (nearly 7%), it is expected that changes in human population planning policies will result in an increase in this rate in following years [ 6 ].

Adolescent pregnancy is a public health concern that affects both the adolescent mother, her child, and the broader community [ 7 ]. Pregnancy and childbirth complications are the leading causes of mortality among adolescents aged 15–19 years worldwide [ 2 ]; however, the majority of these complications are preventable [ 5 , 8 ]. The adverse maternal and neonatal outcomes among adolescent pregnant women and their babies include abortion, preterm birth, anemia, postpartum depression, pregnancy hypertension, preeclampsia and eclampsia, puerperal endometritis, systemic infection, maternal mortality, low birth weight, stillbirth, and neonatal mortality [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ].

The health practices of pregnant women can affect maternal and fetal health, and pregnancy outcomes [ 17 , 18 ] and they include: avoiding tobacco, alcohol, and other illegal substances [ 19 , 20 ], avoiding high-risk sexual behaviours [ 21 ], having a healthy diet for appropriate maternal weight gain during pregnancy [ 22 ], regular exercise, adequate rest and sleep [ 23 , 24 ], oral hygiene [ 25 ], regular prenatal cares, and acquiring knowledge about pregnancy and childbirth [ 19 , 26 ].

According to the literature review, no study into health practices of Iranian adolescent pregnant women, either quantitative or qualitative, and no relevant mixed-method study was found internationally. Only one cross-sectional study has been conducted in Iran on pregnant women at gestational ages between 33 and 41 weeks. The findings of this study showed that maternal-fetal attachment and health practices during pregnancy have a significant positive relationship with neonatal outcomes. Results from few studies into pregnancy and childbirth outcomes in adolescent pregnant women in Iran showed higher prevalence of adverse outcomes of pregnancy and childbirth among this age group. A systematic review study in Iran (2017) showed that adolescents are at a higher risk of pregnancy and childbirth complications, which may disrupt Iran’s national development objectives (lowering maternal mortality and morbidity). As a result, development of a health practice improvement strategy specific to adolescents may have a significant role in achieving national development goals. Given the high risk of adolescent pregnancy, maternal and neonatal complications, and positive effect of health practices on health status and reduction in adverse maternal and neonatal outcomes, pregnancy health practices should be promoted, specifically in adolescents. To this end, identification of the status of such practices is essential. It is worth noting that the Iranian Health System lacks a strategic guideline on the improvement of health practices of adolescents.

This study aimed to determine the factors related to the health practices of adolescent pregnant women and their relationship with maternal, fetal, and neonatal outcomes. Moreover, health practices and their relevant factors will be explained from the perception of adolescent pregnant women. Then, an improvement approach to health practice in adolescent pregnant women will be developed.

The specific objectives are: 1) Determination of the health practices score of adolescent pregnant women visiting health centers in Tehran-Iran; 2) Determination of the relationship between health practices with some maternal outcomes (preeclampsia, type of delivery, anemia, pregnancy depression, and maternal weight gain) in adolescent pregnant women visiting health centers in Tehran-Iran; 3) Determination of the relationship between health practices and some neonatal outcomes (neonatal anthropometric indicators, low birth weight, preterm birth, and SGA) in adolescent pregnant women visiting health centers in Tehran-Iran; 4) Determination of the relationship between health practices and some fetal outcomes (abnormalities and stillbirth) in adolescent pregnant women visiting health centers in Tehran-Iran; 5) Determination of the relationship between socio-demographic characteristics and health practices in adolescent pregnant women visiting health centers in Tehran-Iran; 6) Determination of the relationship between health practices and maternal-fetal attachment in adolescent pregnant women visiting health centers in Tehran-Iran; 7) Exploration of the perception of adolescent pregnant women with high and low performance of health practices; 8) Exploration of the perception of adolescent pregnant women and the relationship between health practices and maternal, fetal, and neonatal outcomes; and 9) Provision of improvement strategies to health practice in adolescent pregnant women visiting health centers in Tehran-Iran.

Study design

This study uses a mixed method with an explanatory sequential approach for data collection and analysis. The mixed-method paradigm is based on the principles and logic of pragmatism. According to this paradigm, a mixed use of qualitative and quantitative approaches results in a better understanding of the problem [ 27 , 28 ]. The quantitative data will be collected in the first phase of the study. The second phase will include the collection and analysis of qualitative data. Then, qualitative and quantitative findings will be mixed in the stage of data interpretation and development of improvement strategies to health practices in adolescent pregnant women (Fig.  1 ).

Study diagram

Phase one: quantitative study

First, a prospective descriptive analytical study will be conducted to evaluate factors related to health practices in adolescent pregnant women and the relationship between health practices and maternal, fetal, and neonatal outcomes among a population of Iranian adolescent pregnant women. The target population are adolescent pregnant women visiting health centers in Tehran-Iran.

Sample size and sampling method

The sample size was calculated to be 158 based on the Madahi et al study [ 29 ], health practice variable, SD = 11.14, precision (d) of 0.02, α = 0.05, m = 123.57, and power of 90%. Regarding the use of cluster sampling, the final sample size was determined to be 316 by considering the design effect of 2.

This study will be conducted in health centers in south Tehran affiliated with the Tehran University of Medical Sciences, health centers in west and northwest Tehran affiliated with Iran University of Medical Sciences, and health centers in east and northeast Tehran affiliated with Shahid Beheshti University of Medical Sciences. In the cluster sampling, one-fourth of health centers will be randomly selected, using https://www.random.org . Then, a list of adolescent pregnant women at the gestational age between 18 and 22 weeks will be prepared using their medical profiles in each center. Then, the required samples from each health center will be determined using a proportional method and randomly selected. The researcher will explain the project to them via telephone (obtained from their medical records) and the eligible women will be invited to participate in the study.

Inclusion criteria

The eligible participants are 18 to 22 week pregnant Iranian women who are between 10 and 19 years old; without any medical conditions such as diabetes, hypertension, kidney, thyroid, and heart diseases; and live in Tehran.

Exclusion criteria

Women with multiple pregnancies, obstetric problems (such as placenta previa), history of bleeding in the current pregnancy, and plausible movement in the next four months will be excluded from the study. Moreover, exposure to stressful events during or one month before the pregnancy will lead to exclusion.

Scales and data collection

Quantitative data will be collected using the inclusion-exclusion checklist, socio-demographic and obstetrics characteristics questionnaire, Health Practice Questionnaire (HPQ), Edinburgh Postnatal Depression Scale, Maternal-Fetal Attachment Scale, and maternal, fetal, and neonatal outcome checklist. In addition, data will be collected through face-to-face interview or from medical records of the participants.

The socio-demographic and obstetrics characteristics questionnaire will include age, spouse age, educational attainment, socioeconomic status and etc.

The HPQ, designed by Lindgren in 2003, includes 34 items scored on a five-point scale anchored by “1 = never,” “2 = almost never,” “3 = sometimes,” “4 = almost always,” and “5 = always.” It measures the following six factors in pregnant women: balance between rest and activity, preventing disease and injury, diet, avoidance of harmful medicine and opiates, follow up health status and acquiring knowledge about pregnancy and childbirth. The maximum and minimum scores are 170 and 34, respectively. Higher scores reflect better practice. Items 5, 6, 7, 8, 12, 21, 22, 23, 24, 25 are inversely scored. The Farsi version of this instrument was applied on a group of pregnant women in Sirjan-Iran in 2014 and its reliability was measured using the intraclass correlation and internal consistency; where the intraclass correlation was 0.81 and Cronbach’s alpha was 0.83 [ 29 ].

The Edinburgh Postnatal Depression Scale was designed by Cox et al. (1987) to measure depression during and after pregnancy. This instrument includes 10 items with four response options, ordered from lowest-to-highest severity (Items 1, 2, and 4) and highest-to-lowest severity (Items 3, 5, 6, 7, 8, 9, 10). Items are scored between 0 and 3 based on the severity of the symptoms. The total score ranges from 0 to 30. Mothers with scores higher than the threshold of 12 have varying degrees of depression. In Iran, validity and reliability of this instrument were confirmed by Montazeri et al. and they obtained the Cronbach’s alpha of 86% [ 30 ].

The Cronley’s Maternal-Fetal Attachment Scale is a self-report instrument which evaluates the mother’s sense of attachment to her fetus. This 23-item scale is scored based on a five-point Likert scale anchored by “5 = Absolutely Yes,” “4 = Yes,” “3 = Not Sure,” “2 = No,” and “1 = Absolutely No.” Only Item 22 is scored inversely as “1 = Absolutely Yes,” “2 = Yes,” “3 = Not Sure,” “4 = No,” and “5 = Absolutely No.” The minimum and maximum scores are 23 and 115 respectively, and a higher score indicates greater attachment. Cronley reported the reliability of α = 0.85 for this instrument based on the internal consistency [ 31 ]. In Iran, validity and reliability of this instrument were confirmed by Abbasi et al. and they obtained the Cronbach’s alpha of 80% [ 32 ].

The maternal, fetal, and neonatal outcome checklist includes items on preeclampsia, type of delivery, anemia, pregnancy depression, maternal weight gain, maternal-fetal attachment, fetal abnormalities, stillbirth, neonatal anthropometric indices, low birth weight, preterm birth, and SGA.

The validity of the socio-demographic and obstetrics characteristics questionnaire and maternal, fetal, and neonatal outcome checklist will be determined using content and face validity. Reliability of the health practices, depression, and maternal-fetal attachment questionnaires will be determined through test-retest in 20 adolescent pregnant women and obtaining internal consistency (Cronbach’s alpha) and ICC (Intraclass Correlation Coefficient (. To determine the reliability of hemoglobin and hematocrit tests, the first 10 samples will be delivered to the laboratory with two different names. Then, the correlation of results will be calculated.

Data analysis

The quantitative data will be analyzed with SPSS-24. Sociodemographic and obstetrics characteristics and health practices will be described by frequency (percent), as well as mean (standard deviation) if the data are normally distributed or median (25 to 75 percentile) if they are not normally distributed. The relationship of health practices with maternal, fetal, and neonatal outcomes will be determined using the independent t and Pearson correlation tests in the bivariate analysis, and logistic linear regression adjusting the confounding variables in the multivariate analysis. The bivariate tests, including Pearson correlation, independent t -test, and one-way ANOVA, will be used to determine the relationship between socio-demographic and obstetrics characteristic with health practices. Then, the multivariate linear regression with backward strategy will be used to control confounding variables. The confounding variables will initially be controlled via inclusion and exclusion criteria. In the next stage, the multivariate tests (multivariate logistic regression and multivariate linear regression) will be applied.

Phase two: qualitative study

Phase two is an exploratory qualitative study with a conventional content analysis approach to explore health practices in adolescent pregnant women in more detail.

Sampling method

The extreme cases will be selected based on the overall mean score of the health practices obtained in the quantitative phase. Of that, women who obtain 10% of the lower and upper thresholds of the total health practices score will be selected as the extreme cases. The research participants will be selected through purposive sampling among extreme cases who have the tendency and ability to express their experience of health practices. Moreover, participants who differ from other participants in some variables, as well as those with unexpected findings will be interviewed.

Data collection

Qualitative data will be collected using in-depth and semi-structured interviews, containing open questions. Before conducting the qualitative phase, the desired items in the interview guideline will be designed based on the findings from the first phase and the relevant factors. The mechanisms of obtaining valid data and focusing on research items will be reviewed by the research team. The interview will begin with a key question, “what health practices do you adopt for yourself and your child?” Then, the interview will continue by presenting other questions, such as “what factors facilitate health practices?” or “what factors inhibit health practices?” based on the participants’ responses. The interview will continue with more in-depth items, such as “what do you mean? Why? Can you explain further? Can you give an example?” to explore the depth of their experience. During the interview, the researcher will record nonverbal data of the participants, such as tone, facial expression, and position, in a specific sheet, along with the time and place of the interview. The sampling will continue until data are saturated.

The qualitative data will be analyzed using qualitative content analysis with an inductive approach. In this approach, the data will be analyzed through frequent text reading to obtain a full understanding of it. Then, the texts will be read word by word to extract the codes. First, the objective words that contain the key concepts will be specified. The researcher continued digging the text by taking notes from the initial analysis until the major codes will be extracted. In this process, the code labels reflecting more than one key thought will be directly extracted and specified. Then, the codes will be categorized based on their difference and/or relationships. Ideally, 10–15 categories will be considered sufficient for categorization of a huge amount of data. This study uses an inductive content analysis based on the stages proposed by Graneheim and Lundman [ 33 ]. This method allows for extracting not only the explicit content of the texts, but also their implicit content with varying degrees of abstraction. Based on this method, the following five stages will be taken:

Transcribing the whole interview immediately after each session.

Multiple reading of the whole text to obtain a general knowledge of its content.

Dividing the text into semantic units, extracting a summary and coding them.

Categorizing the initial codes into classes and subclasses based on their differences and similarities.

Extracting the themes as the implicit concept and content of data.

Integration of quantitative and qualitative data

To develop improvement strategies for health practices in adolescent pregnant women, a comprehensive literature review will be carried out with a supportive approach to improve such practices. Following this, the improvement strategies to health practices in adolescent pregnant women, along with the results from qualitative and quantitative studies will be delivered to 10–12 experts. Then, their feedback and comments will be taken into account, using the nominal group technique.

Adolescent pregnancy and childbirth are associated with adverse obstetrics, maternal, and neonatal outcomes [ 9 , 10 , 11 , 12 ]. Regarding the positive effects of health practices on health enhancement and reduction of maternal and neonatal complications [ 17 , 29 ], they should be promoted during pregnancy, specifically among adolescents. To this end, the status of this practice should be identified. The current study provides precise information about the health practices in Iranian adolescent pregnant women, and the factors related to them. Data collection through qualitative and quantitative methods contribute to better understanding of health practices in adolescent pregnant women, and its relationship with maternal, fetal, and neonatal outcomes. The mixed-method approach focuses on Epistemological Pluralism. As a result, it supports the combination of opinions, approaches, and different, even contradictory, methods if they are helpful for understanding concepts [ 34 ].

The strategy proposed by this study may be helpful in promoting health practices in adolescent pregnant women and improving pregnancy and childbirth outcomes in them. Regarding the growing population of adolescents in the world, it is predicted that the global number of adolescent pregnancies will increase by 2030 [ 35 ]. It is also expected that recent changes in human population planning policies in Iran, aiming at promoting population growth policies and encouraging women to have 3 children before the age of 30, will increase this rate in future [ 6 ]. The development of health practice improvement strategies for promotion health practices in adolescent pregnant women will result in the improvement of pregnancy and childbirth outcomes.

Abbreviations

Edinburgh Postpartum Depression Scale

Health Practice Questionnaire

Maternal Fetal Attachment Scale

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Acknowledgements

We should thank the Vice-chancellor for Research of Tabriz University of Medical Sciences for their financial support.

This Study is funded by Tabriz University of Medical Sciences.

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Tahere Hadian

Women Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

Sanaz Mousavi

Member of South Asia Infant Feeding Research Network (SAIFRN), School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia

Shahla Meedya

Social determinants of Health Research Center, Tabriz University of Medical sciences, Tabriz, Iran

Sakineh Mohammad-Alizadeh-Charandabi & Mojgan Mirghafourvand

Department of Nursing, School of Medicine, Tarbiat Modares University, Tehran, Iran

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Contributions

MM, SM, SM, SMAC, EM and TH contributed to the design of the protocol. MM and TH contributed to the implementation and analysis plan. MM and TH has written the first draft of this protocol article and all authors have critically read the text and contributed with inputs and revisions, and all authors read and approved the final manuscript.

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Correspondence to Mojgan Mirghafourvand .

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Written informed consent will be obtained from each participant. This protocol has been approved by the Ethics Committee of the Tabriz University of Medical Sciences, Tabriz, Iran (code number: IR.TBZMED.REC.1397.670).

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Hadian, T., Mousavi, S., Meedya, S. et al. Adolescent pregnant women’s health practices and their impact on maternal, fetal and neonatal outcomes: a mixed method study protocol. Reprod Health 16 , 45 (2019). https://doi.org/10.1186/s12978-019-0719-4

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DOI : https://doi.org/10.1186/s12978-019-0719-4

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The prevalence of teenage pregnancy and early motherhood and its associated factors among late adolescent (15–19) years girls in the Gambia: based on 2019/20 Gambian demographic and health survey data

• Bewuketu Terefe 1  

BMC Public Health volume  22 , Article number:  1767 ( 2022 ) Cite this article

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Introduction

Pregnancy and early motherhood among teenage girls is the current issue of public health burden in developing countries. Although the Gambia has one of the highest adolescent fertility rates in Africa, there is no data record about it in The Gambia. Therefore, this study aimed to assess the prevalence of pregnancy and early motherhood and its determinants among late adolescent girls in the Gambia.

It is a secondary data analysis using the 2019–20 Gambian demographic and health survey data. A total of 2,633 weighted 15–19 years old girls were included in the study. Using Stata 14 version, a pseudo logistic regression analysis method was employed to declare factors significantly associated with pregnancy and early motherhood among 15–19 years old late-adolescent girls in the Gambia. Variables with a p -value of < 0.2 were entered into multivariable regression analysis, and after controlling other confounding factors adjusted odds ratio of 95% CI was applied to identify associated variables.

Pregnancy and early motherhood were found in 13.42% of late adolescent Gambian girls. Logistic regression analysis depicted that a unit increase in adolescent age was positively significantly associated with pregnancy and early motherhood (adjusted odds ratio [aOR] = 2.15; 95% confidence interval [CI] = 1.93,2.39), after period ended knowledge of ovulatory cycle (aOR = 1.99; 95% CI = 1.23,3.22), being from a family size of greater than ten (aOR = 1.25; 95 CI = 1.01,1.55) times more likely to become pregnant and early motherhood than their counterparts respectively. In contrast, rich in wealth (aOR = 0.35; 95% CI = 0.23,0.54), having primary education (aOR = 0.58; 95% CI = 0.43,0.79), secondary and above education (aOR = 0.12; 95% CI = 0.09,0.17).

Pregnancy and early motherhood remain significant public health challenges in the Gambia. Strengthening female education, empowerment, reproductive health life skill training and awareness, encouraging disadvantaged females, and designing timely policies and interventions are urgently needed.

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Only in developing regions did around 12 million girls aged 15–19 years become pregnant, and a minimum of 777,000 of them under 15 years gave birth with more than 10 million unintended pregnancies, 3.9 million unsafe abortions, and other related pregnancy complication-induced mortality and morbidity per a year [ 1 , 2 , 3 ]. Although early pregnancy is a global public challenge, it is more severe and mainly occurs with many other related problems in developing nations [ 4 ]. The scope of the problem has tremendous variations across regions, from 0.3%, 33%, and 83% in Korea, South-East Asia, and Bangladesh, respectively, since 2018 [ 5 , 6 ]. Early pregnancies have enormous health consequences for both mothers and their babies. In middle- and low-income nations, early pregnancy takes up 99% of death of 15–49 years mothers [ 3 ]. Mothers having early pregnancy have a higher chance of exposure to eclampsia, systemic infections, preterm, and low birth weight than their elders [ 7 ]. The consequences of early pregnancies do not end with their health, but also it has a damaging result on their social and economic status. Girls who became pregnant before their 18 years also will face violence, stigma, dropping out of school, and employment opportunities [ 8 , 9 ].

Early pregnancy and motherhood remain a tremendous public health concern. Millions of girls and their babies suffer from early and unintended pregnancies and complications [ 10 ]. Early and unintended pregnancies are major public issues globally; nevertheless, the challenge is more severe and consistent in developing countries, with an enormous variety of rates. Some African countries' reports depicted that the overall rate of early pregnancy was 18% in Kenya, 29% in Malawi and Zambia, and Ethiopia, ranging from 3 to 23% in different regional states [ 10 , 11 ]. Other multicountry analyses in sub-Saharan revealed 44.3% in Congo, 36.5% in Rwanda, and 75.6% in Chad [ 12 ]. Several studies show many factors contribute to early and unintended pregnancies and their complications in Sub-Saharan countries. For illustration, among individual factors attributed to early pregnancies, use of alcohol, level of education, curiosity, and low self-esteem were factors significantly associated with early pregnancies and their complications [ 10 , 12 , 13 , 14 ]. Health service-related factors such as the cost of contraceptives, lack of privacy at health facilities, lack of sexual education, unskilled health providers, negative attitudes toward health prodders to deliver reproductive health services, and non-friendly adolescent reproductive services also contributed to a negative impact on early and unintended pregnancies [ 13 , 14 , 15 , 16 ]. Social-cultural factors such as peer influence, coercive sexual relations, unequal gender power, absence of free education, early marriage, religion, poverty, and lack of parental counselling were other predictors of early and unintended pregnancies [ 13 , 15 , 17 , 18 , 19 , 20 , 21 ].

Studies done in the west, and central African nations, including the Gambia, have come with a high rate of adolescents maternity, up to 49% in the central African republic to 16% in Senegal, and early marriage variations from 61% in Niger to 6% in Ghana [ 22 ]. Although substantial studies did not conduct on pregnancy and early motherhood in the Gambia, few reports indicated that girls marry about ten years earlier than the mean, with significant variation across regions, 9% in Brikama to 29% in Kuntaur, with an overall burden of 14% in the country [ 23 ]. About 32% of the population is adolescent; however, only 7 to 9% utilize family planning due to poor quality of care, lack of knowledge, and other cultural constructs [ 24 ]. Teenage pregnancy and early motherhood could expose females to infections like HIV, unintended pregnancy, and high maternal mortality. In the Gambia, unintended pregnancy has shown a high rate of increase, from 18,000 in 2012 to 20,000 in 2016 [ 25 ]. A study conducted in the Gambia shows 15–19 years old females tend to experience unintended pregnancies more than the orders [ 26 ].

The study dramatically benefits rural adolescents who are twice as likely to be married and mothers at risk of maternal mortality twofold as urban mothers and in a state with more than five times the difference in maternal mortality across regions [ 23 , 27 ]. Although teenage pregnancy is increasing at an alarming rate, there is no systematic program in the Gambia that focuses on the health needs of adolescents and young people, and parents rarely have conversations with their teenage children, especially the girls, about matters of sex or adolescence [ 28 , 29 ]. Pieces of evidence from the Gambia showed that there is a significant difference in ethnicity, educational status, perception, culture, and with which parents the girl lives [ 30 , 31 ].

Recently, many African countries, the African Union, world banks, and many other stakeholders have been concerned to draft policies and soft options regarding the steadily increasing rate and complications of early and unintended pregnancies in Africa [ 32 ]. This study will have a positive influence on policymakers, planners, health institutions, women's affairs agencies, and other stakeholders to draft an effective policy to halt early and unintended pregnancies; hence many studies recommended that developing countries should develop and implement a multisectoral approach social policies, programs and plans to reduce early pregnancies and complications by increasing health care delivery quality, by empowering adolescent girls in education, family planning and use of modern contraceptive methods [ 12 , 33 ]. To the best of my searching knowledge, no data is recorded on teenage pregnancy and early motherhood in the Gambia. The study will examine the public burden patterns and pregnancy and early motherhood determinants. The study will provide preliminary information for the upcoming researchers, the Gambia government, the Gambia community, and those stakeholders who are working on women's and children's health to draft policy and implement the procedure accordingly. This study aimed to determine the potential factors of pregnancy and early motherhood among late adolescent girls 15–19 years old in the Gambia.

Methods and materials

Study design and setting.

This study was based on an extensive nationally representative based survey, Gambia Demographic Health Survey (GDHS), conducted in the Gambia from 21 November 2019 to 30 March 2020. The Gambia is located on the West African coast. It is bordered on the North, South, and East by the Republic of Senegal and on the west by the Atlantic Ocean. The country has a tropical climate characterized by the rainy season (June – October) and the dry season (November–May).

Source population and sampling technique

The survey employed a stratified two-stage cluster sampling. In the first stage, EAs were selected with a probability proportional to their size within each sampling stratum. In the second stage, the households were systematically sampled. In the first stage, 281 EAs were selected. In the second stage, an average of 25 households were selected per cluster/EA. The data is freely available in public. We accessed the dataset used for the present study after registering and receiving an authentication letter from the Demographic and Health Survey (DHS) program at The DHS Program—Gambia: Standard DHS, 2010–20 Dataset. The source of the population was all late adolescent pregnancy and early motherhood (15 to 19 years) in The Gambia. Late adolescents and early motherhood who were pregnant and/or had a child in the last five years before each survey were the study population. The adolescents’ sample weightings were used in the estimation to provide to overcome disproportional allocations of samples during data collection. Accordingly, 2,633 weighted 15–19 years old adolescent samples were included in the study yielding a response rate of 97%.

Variables of the study

Dependent variables.

The main dependent variable of this study was pregnancy and early motherhood among adolescents. The survey was taken as a dependent variable for adolescents [ 15 , 16 , 17 , 18 , 19 ] who had a child or pregnancy in the past five years. The response variable was dichotomized into "late-adolescent pregnancy = 1" and "late-adolescent non-pregnancy = 0". It might be defined as the percentage of Adolescents who became mothers, are pregnant with their first child, and have begun childbearing. These included all girls from the age of 15 to 19 years old at the survey time. The percentage of adolescent women who are mothers was calculated by dividing the number of adolescent women who have had birth by the total number of teenage women, including those without birth. The percentage of pregnant women with the first child was calculated by dividing the number of women who have not had birth but who are pregnant at the time of data collection by the total number of teenage women, including those without birth. The percentage of women who have begun childbearing was calculated by adding the number of women who either have had a birth or are pregnant at the time of the interview and dividing by the total number of teenage women, including those without a birth.

Independent variables

The independent variables included: age, educational status, wealth status, occupational status, marital status, knowledge of ovulatory cycle, knowledge of any family planning, relationship with household head, age of the household head, sex of the household head, household family size, own a mobile phone, use of the internet, frequency of watching to television, listening to the radio, reading a magazine, entries to birth history, contraceptive use and intention, region, religion, ethnicity, age at first sex, heard family planning by text messages, heard family planning from health professionals, heard family planning from traditional communicators, heard family planning from friends/relatives, place of residence and health insurance. variables were collected based on previous works of literature and scientific facts related to the outcome variable [ 34 , 35 , 36 , 37 , 38 ].

Data processing, procedure, and analysis

Data were extracted from individual records (IR) files, and further coding and transformations were done using statistical software, STATA version 14. The weighted samples were utilized for analysis to adjust for unequal probability of selection and non-response in the original survey. Descriptive, summary and analysis statistics were done using STATA version 14 software. The data were weighted using sampling weight, primary sampling unit, and strata before any statistical analysis to restore the survey's representativeness and tell the STATA to consider the sampling design when calculating standard errors to get reliable statistical estimates. Completed DHS questionnaires were carefully coded, entered, and edited after data collection was done [ 39 ]. Bivariable logistic regression was used to select candidate variables for multivariable logistic regression. In the Bivariable logistic regression, a p -value of less than 0.2 was used as a cut point to choose variables for the multivariable analysis entry. Multivariable logistic regression was used to identify independent predictors of pregnancy and early motherhood in the Gambia, controlling confounders. 95% confidence interval (CI) and p -value < 0.05 were used to determine the statistical significance. Using the variance inflation factor, a pseudo linear regression was fitted to assess multicollinearity among the independent variables. Moreover, Hosmer and Lemeshow test was used to evaluate the overall model fitness of the final regression model.

Sociodemographic characteristics study population

In this survey, 2,633 weighted samples of late adolescent girls [ 15 , 16 , 17 , 18 , 19 ] were considered for analysis. 530(20.11%) participants were 19 years old. In this study, concerning wealth status, marital status, educational background, and religious affiliation, 1,163(44.15%), 2,136(81.11%), 1,728(65.62%) and 2,556(97.10%) of them were wealthy, single, secondary and above and Islamic affiliation respectively. In the same way of expression, 1,878(71.33%), 220(8.34%), and 2,298(87.27%) of the participants did not have current work, know the ovulatory cycle, and heard about family planning from health professionals, respectively. However, 1,943((73.79%) of them did not have the intention to use the contraceptive method shortly. In place of residence, region, and ethnicity characteristics, 1,901(72.20%), 1,174(44.60%), and 862(32.73%) belonged to urban, Brikama, and Mandinka/Jahanka ethnicities, respectively. All in all, the fee of health care costs were not covered by health insurance (Table 1 ).

Factors associated with early pregnancy and motherhood

After adjusting the possible confounders, plenty of essential determinant variables were statistically significant for pregnancy and early motherhood. A unit increase in participant's age will result (AOR = 2.15, (CI 95%: (1.93,2.39)) times of high risk to have pregnancy early motherhood. In contrast, participants' wealth status and educational attainment were reversely associated with teenage pregnancy and early motherhood. Participants classified under the rich category (AOR = 0.35, (CI 95%: (0.23,0.54)) compared to the poor, having primary education (AOR = 0.58, (CI 95%: (0.43,0.79)) and secondary/higher level of education (AOR = 0.12, (CI 95%: (0.09,0.17)) times less likelihood of experiencing teenage pregnancy an early motherhood risk respectively. Regarding knowledge of the ovulatory cycle, those participants who realized their ovulatory cycle after their period ended have shown (AOR = 1.99, (CI 95%, (1.23,3.22)) times to become exposed to the risk of teenage pregnancy and early motherhood compared to their counterparts who knew ovulatory cycle. A girl from a family with more than ten members has (AOR = 1.25(CI, 95%: 1.01,1.55)) a chance of getting early pregnancy and motherhood than a girl who is a member of a family with less than ten (Table 2 ).

Based on the most recent Gambian demographic and health survey data, they aimed to assess the current national-level prevalence and identify hindering factors of teenage pregnancy and early motherhood among late female adolescents in the Gambia. The overall burden of pregnancy and early motherhood was discovered by 13.42% (12.17, 14.78). This finding is lower than studies done in Pakistan(42.5%) [ 40 ], Latin America (19.2%) [ 41 ], and Nigeria(22.9%) [ 42 ], meanwhile it is almost in agreement with studies done in South Africa (11.0%) [ 43 ]. However, it is higher than a systematic review done in Africa, northern Africa regions at 9.2% [ 44 ], and Ethiopia at 7.7% [ 45 ]. The variation might be due to differences in knowledge sociodemographic and socioeconomic dimensions and religious and cultural outlooks of early marriage. Another possible reason might be differences in the number of adolescents involved in the study and the geographical distribution of teenagers. In developed nations, most adolescents are the victim of pornography movie exposure, which is associated with premarital teenage pregnancy [ 46 ]. In addition to the individual level factors of education, attitude, analyzed number, countries profiles, and accomplishments in pregnancy and early motherhood might affect the overall burden.

The study discovered that a unit increase in age leads late-adolescent girls to have an early pregnancy and motherhood. Other literature has concluded the same finding with the current study in Nigeria [ 47 ] and Ethiopia [ 19 ]. This might be because sexual maturation reaches its peak given as age increases due to; for these reasons, adolescent sexual curiosity leads to exposure to pornography, participation in sexual activities, and increased vulnerability to sexual abuse [ 48 ]. On the other hand, in addition to participants' expression of sexual behaviours and tendencies to have sexual life, another external pressure from the parents and other relatives perhaps increases the risk of having marriage due to the parent's belief that the girl is old enough to get married. For the sake of their morale and the culture of the society, they can force girls with the idea of marrying and to prevent giving birth to a girl out of wedlock [ 24 , 49 , 50 ].

Participants classified under the rich category have a less likelihood of a positive tendency to experience early pregnancy and motherhood than poor. This is similar to studies done in Nigeria [ 42 ] and Ethiopia [ 51 ]. Studies done in Africa and the United States of America have shown that low-income girls may consider early marriage and sex as a means of income generation to lead their daily lives with money scarcity [ 13 , 52 , 53 , 54 ].

The other crucial variable which identified significant statistically was education. The study declared that participants with primary and higher educational attainment had shown less likely association to have early pregnancy and early motherhood than those who did not have formal educational attainment. This finding is in agreement with studies done in various places in Africa [ 44 ], Pakistan [ 40 ], Nepal [ 55 ], and Ethiopia [ 51 ]. This is conceivably due to more well-educated girls may have better knowledge and attitudes about the potential health and lifestyle situations than uneducated girls through school, the internet, mass media, and books [ 55 , 56 ]. With the help of better knowledge, they will be better able to prevent unwanted pregnancies and develop better plenty of preventive strategies.

Furthermore, girls who attend school for ten years marry six years later, as schooling increases autonomy, decision-making, and economic independence, causing the marriage to be postponed. Regarding g to the benefit of education on the prevention of pregnancy and early motherhood, a study stated that each additional year of schooling results in a 10% decrease in fertility and a 10% increase in contraception use [ 57 ]. These girls have more probability of realizing what type of prevention mechanism they should take, from abstinence to proper utilization of preventive pregnancy. For instance, studies done in Malawi and Kenya have revealed that the majority of sexually active teenage did not prevent pregnancy unless they used modern contraceptive methods. From here, one can understand that being exposed to training and education related to reproductive health concerns could dramatically reduce teenagers being pregnant and early motherhood.

An important variable that was one of the determinants for the outcome variable was the participants' knowledge of the ovulatory cycle; a girl who knows after the ovulatory cycle is more likely to become pregnant and become a mother than a participant who knows about her ovulatory process. This study is in agreement with the survey done in Africa [ 58 ], Ethiopia [ 51 ], and Ghana [ 59 ]. This is perhaps explained by a girl who is aware of her ovulatory cycle date of starting and ending is less likely to become pregnant. This is because a girl who is well aware of her ovulatory cycle can have sex only during the days when she is less likely to get pregnant, and perhaps she uses condoms pills and counts of ovulatory days.

Additionally, in line with findings from earlier literature, this study discovered that the likelihood of early pregnancy and motherhood increased with family size. Early pregnancies in the Philippines Indonesia, Rwanda, and Nigeria showed that large families (those with more than 10 family members) were more than twice as common as smaller numbers of household members [ 60 , 61 , 62 , 63 ]. As the number of family members increases, parents may choose to have their children work or live independently outside the home due to economic constraints. In other words, as the number of children increases, the risk of withdrawal from school, sexual intercourse exposure and pregnancy increases as girls may want to be outside the home of their own volition or become economically self-sufficient. Studies revealed that teenage females may be exposed to their parents' sexual behaviours too early in a small family setting, which later encourages their sexual interest and behaviour [ 64 , 65 ]. The study comes to the conclusion that homes with parents who get along well and set clear boundaries for their children, discipline them, and communicate against pregnancy help reduce the number of teenage pregnancies and motherhood.

Conclusion and recommendation

This study concluded that pregnancy and early motherhood burdens among late adolescent girls are comparatively high in the Gambia. The study found that the age of girls, wealth status, educational attainment, and knowledge of ovulatory cycle have shown statistically significant associations with the outcome variable of pregnancy and early motherhood in the Gambia. Better results can be achieved by empowering females’ power, strengthening girls' participation in education, paying attention to girls in need of finance, and providing life skills and reproductive health issues training.

Availability of data and materials

All data concerning this study are accommodated and presented in this document.

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Terefe, B. The prevalence of teenage pregnancy and early motherhood and its associated factors among late adolescent (15–19) years girls in the Gambia: based on 2019/20 Gambian demographic and health survey data. BMC Public Health 22 , 1767 (2022). https://doi.org/10.1186/s12889-022-14167-9

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Qualitative Research on Adolescent Pregnancy: A Descriptive Review and Analysis

This study examined qualitative research on adolescent pregnancy to determine designs and methods used and to discover emergent themes across studies. Most of the 22 studies reviewed were described as qualitative or phenomenological by design and included samples comprising either African-American and Caucasian participants or African-Americans exclusively. Based on analysis of the collective primary findings of the sample articles, four themes were identified: (a) factors influencing pregnancy; (a) pregnancy resolution; (c) meaning of pregnancy and life transitions; and (d) parenting and motherhood. Overall, the studies revealed that most adolescent females perceive pregnancy as a rite of passage and a challenging yet positive life event. More qualitative studies are needed involving participants from various ethnic backgrounds, on males' perceptions relative to adolescent pregnancy and fatherhood, and about decision-making relevant to pregnancy resolution, intimacy, and peer relationships.

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Youth taught on dangers of teenage pregnancies

Youths in the informal sector have been sensitised to the dangers of early pregnancies among teenagers.

 The youths from Kajiado, Narok and Nairobi counties were hosted for a three-day workshop organised by the Forum for African Women Educationists, Kenya chapter (FAWEK) and Mastercard Foundation.

 According to FAWEK coordinator for Narok, Nelly Naserian, an awareness campaign dubbed 'Imarisha Msichana Project' aims to significantly reduce the incidence of teenage pregnancy in Kenya.

 The campaign began during Covid-19 period after it became apparent that teenage pregnancies had significantly shot up due to lockdowns that restricted movements across the country.

 Naserian said through their research they discovered that some of the perpetrators of teen pregnancies are young men in the informal sector, especially boda boda operators.

 "We discovered that some girls including school-going were even being defiled and those above 18 years old raped majorly in slum areas in our cities, towns and pastoral areas. The young men who are active need to be sensitized and educated to know that the act is wrong and should treat the young ladies as their sisters," noted Naserian.

 The 2022 Kenya Demographics Health Survey revealed that teenage pregnancy of girls between ages 15 and 19 years old was 28 per cent in Narok, 22 per cent in Kajiado and 18 per cent in Nairobi.

 During the workshop, the youths were also educated on the dangers of drug abuse which leads to uncontrolled sex and defilement of young girls, contributing not only to teenage pregnancies but spread of venereal diseases.

 Poverty was also identified as another factor fueling teenage pregnancies in urban areas where youths who earn a living use that opportunity to lure young girls into acts of sexual intercourse by buying them commodities like sanitary pads in exchange for sexual favours.

 Samuel Nganga Waranga, chairman of boda operators in Nairobi said he has initiated talks among his members over their role in curbing the pregnancies.

 "In the talks, we encourage our fellow operators when carrying a young girl to be sure where they are taking them to and if the girl may be lying, I encourage my members to ensure they try to get the girl's parents mobile numbers so that they can inform them," said Nganga.

 He admitted that boda boda operators may have contributed to the vice unknowingly by ferrying the girls to places where they are lured into sex. "We encourage our members to be on the alert when ferrying girls," said Nganga.

 Endoosupukia chief Danse Reson in Narok said they ensure the pregnant girls resume classes after delivery. "We ensure that we look for them and return them to school, some of them having been forced into early marriages," said Reson.

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Anti-abortion researchers back riskier procedures when pregnancy termination is needed, experts say

By: sofia resnick - july 20, 2024 7:00 am.

A new paper from researchers whose abortion-pill studies were retracted touts C-sections and induced labor as alternatives for pregnant patients in medical emergencies as a federal appellate court revisits a pivotal case in Idaho. (Getty Images)

The day the U.S. Supreme Court overturned Roe v. Wade in 2022, the medical board that certifies OB-GYNs in America released a  statement  calling legal pregnancy termination and knowledge of abortion procedures “essential to reproductive health care.”

But a small number of influential anti-abortion doctors have spent the last two years trying to change the reproductive health care standards in state and federal health policy, in a way that is potentially dangerous, doctors representing major medical institutions say.

The question of when abortion is essential health care that states can’t ban is central to several ongoing lawsuits, including Moyle v. United States, testing whether emergency rooms receiving federal funding have to treat pregnant patients with stabilizing care if it might result in the end of the pregnancy.

The U.S. Supreme Court recently kicked the case back to the lower appellate court, a move that newly allows doctors in Idaho to perform emergency abortions. But the issues remain unresolved, with doctors in Idaho (as in other states) still seeking clarity  about whether what they’ve long considered necessary care is legal.

Now, as the case returns to the U.S. Court of Appeals for the Ninth Circuit, researchers behind retracted studies  claiming abortion drugs are dangerous are out with  new policy recommendations  that say when pregnancy termination is necessary, doctors should opt for procedures considered by the wider reproductive health community to carry bigger health risks, such as cesarean sections, rather than less invasive abortion procedures.

“[M]any physicians argue that it is almost never necessary to end the life of a child directly and intentionally by an abortion procedure,” public health researcher James Studnicki and OB-GYN Dr. Ingrid Skop, of the Charlotte Lozier Institute, wrote in a  paper  published this summer in Medical Research Archives, a journal of the European Society of Medicine.

“[W]hen a pregnancy endangering the life of the mother requires termination, a direct ‘dismemberment’ dilation and evacuation (D&E) abortion may be unnecessary, as delivery can usually be performed with a standard obstetric intervention such as labor induction or cesarean section (if indicated).”

Experts told States Newsroom that Charlotte Lozier’s claims contradict national standards of care. And they come at a time when states with strict abortion bans like in Texas  and  Louisiana  are seeing a rise in surgical incisions like C-sections and  hysterotomies  to end pregnancies, even though they carry higher risk, delay future pregnancies, and can  affect fertility .

“The end goal of doing a medical intervention to end a pregnancy and save a patient’s life is the same as when we do an abortion. They are just calling for more complicated, sometimes invasive procedures to get to that same end goal,” said Atlanta-based OB-GYN and complex family planning specialist Dr. Nisha Verma. “I think this is really dangerous — it creates confusion. It prevents the public from understanding that abortion is a necessary life-saving procedure.”

The Charlotte Lozier Institute has for more than a decade worked to build the anti-abortion movement’s credibility, by providing research and data to defend anti-abortion laws in legislatures and the courts. Its claims frequently contradict major American medical institutions on abortion science and safety, and their research methods have faced academic scrutiny — while continuing to wield influence.

Publications retracted

Between 2019 and 2022, Studnicki and Skop co-authored three papers in the journal “Health Services Research and Managerial Epidemiology,” two of which were used by anti-abortion plaintiffs and judges to argue for the restriction of abortion pills in a lawsuit against the U.S. Food and Drug Administration, which the Supreme Court  rejected  this term for lack of standing.

But earlier this year, Sage Journals retracted these studies following a reader-prompted investigation, in part for methodological flaws and data misrepresentation. The Charlotte Lozier researchers  have insisted  the retractions were meritless and politically motivated.

Skop, an OB-GYN from San Antonio, Texas, and Charlotte Lozier’s director of medical affairs, now has even more influence following her controversial appointment  to Texas’s maternal mortality review committee. Skop has made unfounded claims, including that abortion bans will improve maternal mortality rates and that rape or incest victims  as young as 9  can “safely give birth to a baby.” But  experts say  minors are at increased risk for serious complications like preeclampsia and likelier to give birth to low-birth-weight babies.

Last year the San Antonio-based OB-GYN served as a state expert witness when Kate Cox from Dallas asked a Texas judge to grant her an abortion for a nonviable pregnancy. Skop’s  sworn affidavit alleged Cox was not at risk of death or “substantial impairment of a major bodily function,” although Cox’s doctor recommended an abortion to preserve her health and future fertility . Denied the abortion in her home state, Cox aborted in New Mexico, and is  newly pregnant again .

As a fellow for the American College of Obstetricians and Gynecologists, which has  more than 60,000 members, Verma said she has regularly testified before Congress alongside OB-GYNs with minority-held positions on reproductive health policy like Skop and Dr. Christina Francis, CEO of the anti-abortion American Association of Pro-Life Obstetricians and Gynecologists, which comparatively has  approximately 7,500  members.

“It can be really deceptive and confusing for the public who just hear different things coming from two OB-GYNs,” Verma said.

‘Not evidence-based’

Studnicki and Skop argue that abortion is “not evidence-based” because many people do not seek abortions for physical health reasons, and because much of the existing abortion-safety and efficacy data do not involve randomized controls, i.e., comparing groups of people receiving abortion procedures with those delivering unwanted or nonviable pregnancies to term.

“Based upon the research standard of the Cochrane guidelines, our study shows the science required to consider abortion ‘evidence-based’, alone or in comparison to other interventions, does not exist,” said Studnicki in an written statement, referring to guidelines for systematic reviews named after British medical researcher Archie Cochrane . “All of us who want the best for women should desire better quality data, including comparison of abortion to other pregnancy outcomes like childbirth, so we can best address the needs of women in heartbreaking circumstances.”

They do not mention the longitudinal  Turnaway Study , produced at the University of California San Francisco, which found short- and long-term improved health and socioeconomic outcomes for women who received versus were denied wanted abortions. (Editor’s note: Reporter Sofia Resnick contributed proofreading and editing to UCSF professor Diana Greene Foster’s 2020 book about the study she led.) Anti-abortion activists have criticized that study, including in a published critique that was  retracted  following concerns about its peer review.

Studnicki and Skop did not agree to an interview but provided a  fact sheet  for their claims, which notes that OB-GYNs should adhere to guidelines set by ACOG when it comes to life-threatening situations, but also asserts that existing abortion bans do not preclude necessary care.

Claim: “Almost all induced abortions demonstrate no therapeutic intent or medical necessity.”

That abortion is not legitimate health care is a  similar argument  that a coalition of anti-abortion doctor groups including AAPLOG (of which Skop is a  member ) made in the abortion-pill case. It’s an argument Charlotte Lozier advanced in an  amicus brief  submitted to the Supreme Court in Moyle v. United States.

And it’s an argument featured in  Project 2025 , the Heritage Foundation’s blueprint for a potential future GOP presidency, which says that the federal Emergency Medical Treatment and Labor Act should not be interpreted to cover abortions. Republican presidential nominee former President Donald Trump has attempted to distance himself from Project 2025’s proposed federal abortion restrictions, although they were authored by officials from his previous administration.

But decades of research have established the  high safety record  and medical benefits of termination.

“Data from the Centers for Disease Control and Prevention (CDC) clearly shows that pregnancy is a condition that can kill you,” said Dr. Sarah Horvath, an OB-GYN and complex family planning subspecialist and researcher at Penn State University’s Hershey Medical Center, in an email. “As a mother, I can tell you that the benefits of a wanted child often, but not always, outweigh the risks of pregnancy complications and death.”

According to the  CDC , the U.S. has the highest maternal mortality rate in the developed world at 22.3 deaths per 100,000 live births as of 2022, with rates for Black women more than double, at 49.5 deaths per 100,000 live births. Research in the journal  Obstetrics & Gynecology shows that by contrast the risks from an induced abortion are smaller than the continuing a pregnancy: In the first trimester (more than 90% of all abortions), the rate of maternal death is less than 1 per 100,000 and, for abortions at 18 weeks’ gestation or higher, the risk of death is 6.7 per 100,000.

In the two years since the Dobbs decision overturned federal abortion protections, OB-GYNs in states with near or total abortion bans have reported  denying critical care  because of these new laws. Many have become  politically active , trying to impress upon lawmakers and the public that  pregnancy is highly variable  and vague exceptions to prevent death are impossible to interpret medically, especially as complications are not always immediately deadly but could become so if not treated promptly.

Claim: When the ‘separation of a mother and her baby’ is necessary, C-sections and inductions should be prioritized over induced abortion to allow parents to ‘express appropriate grief.’ 

Referring to a medically indicated abortion as the “separation of a mother and her baby,” which is not a medical term, Studnicki and Skop pose labor induction or cesarean section as the ethical choice.

“Beyond 22 weeks’ gestation, the baby will often survive separation from the mother if given active medical intervention, and even if too young or sick to survive, the family can show the child love and express appropriate grief with the assistance of supportive palliative care,” Studnicki and Skop write. “No study has compared the well-being of a woman and family who end their child’s life in these tragic circumstances to those who continue to allow their child to live until a natural death.”

Verma said depending on the situation and especially before 20 weeks, induction or a C-section could introduce unnecessary risks and delays of care. And the patient would have to wait longer to try to get pregnant again.

“I have a hard time even understanding this claim that a C-section is equally invasive and morbid to abortion procedure,” Verma said. “That’s a major abdominal surgery. We are making a large incision in the abdomen, making incisions in the tissue below the skin, pulling apart the muscles, going into the abdominal cavity, the peritoneal cavity, cutting open the uterus and removing a pregnancy. … If the patient wants to get pregnant again, after a D&E procedure, they can start trying a month later, whereas after a C-section you have to wait months to be able to safely start trying again without as much risk of your uterus rupturing in the next pregnancy.”

Verma said that sometimes C-sections do make sense in these cases, and that many of her patients do opt for labor and delivery to hold their dead or dying child, but she doesn’t believe these options should be forced on patients.

Claim: Rape and incest victims  —  who are often adolescents and children – don’t need abortions.

“The emotionally provocative scenario of a young adolescent girl seeking to abort a pregnancy conceived in rape or incest is repeated in the media at a rate which is grotesquely disproportionate to the rarity of its occurrence,” Studnicki and Skop write. “The question of importance is whether an abortion in this circumstance improves the mental or physical health status of the victimized girl. Understandably, there have been no clinical trials addressing this question, so even an abortion in this tragic circumstance cannot be characterized as an evidence-based medical intervention.”

But there is  evidence  that children and teens face greater physical health risks from pregnancy and childbirth than adults. And Verma noted that the incidence of young children getting pregnant, often by rape or incest, is small but real.

“I have treated young kids in, like the 10-, 11-year-old range,” Verma said. “It’s not something that’s happening every day, but there are many reasons why people need abortions, and that is something that we see, and it is terrible.”

Lauren Ralph, an epidemiologist and associate professor at UCSF who specializes in the impact of abortion policies on young people, told States Newsroom that  initial research  out of Texas is showing fewer young people able to access abortions. According to a national 2021-2022  patient survey , about 10% of abortion seekers were 19 and younger and about 2% were 17 and younger. Ralph noted that many rape and incest cases among young people are likely underreported.

“The rarity of it, I don’t think diminishes its importance in conversations around the reasons why people seek abortion, for young people in particular, who are victims of sexual assault,” Ralph said. “We know that they’ve had their autonomy violated once, and then if you deny them access to a wanted abortion and force them to continue a pregnancy and give birth, that violates their autonomy yet again.”

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our website. AP and Getty images may not be republished. Please see our republishing guidelines for use of any other photos and graphics.

Sofia Resnick

Sofia Resnick is a national reproductive rights reporter for States Newsroom, based in Washington, D.C. She has reported on reproductive-health politics and justice issues for more than a decade.

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Teenage Pregnancy and Its Associated Factors among School Adolescents of Arba Minch Town, Southern Ethiopia

Teenage pregnancy has long been a worldwide social, economic and educational concern for the developed, developing and underdeveloped countries. Studies on adolescent sexuality and pregnancy are very limited in our country. Therefore, this study aims to assess the prevalence of teenage pregnancy and its associated factors among school adolescents of Arba Minch Town.

Institution-based, cross-sectional study was conducted from 20–30 March 2014. Systematic sampling technique was used to select a total of 578 students from four schools of the town. Data were collected by trained data collectors using a pre-tested, self-administered structured questionnaire. Analysis was made using SPSS version 20.0 statistical packages. Multivariate logistic regression was used to identify the predictors of teenage pregnancy.

The prevalence of teenage pregnancy among school adolescents of Arba Minch Town was 7.7%. Being grade 11 student (AOR=4.6;95%CI:1.4,9.3), grade 12 students (AOR=5.8;95% CI:1.3,14.4), not knowing the exact time to take emergency contraceptives (AOR=3.3;95%CI:1.4,7.4), substance use (AOR=3.1;95%CI:1.1,8.8), living with either of biological parents (AOR=3.3;95%CI:1.1,8.7) and poor parent-daughter interaction (AOR=3.1;95%CI:1.1,8.7) were found to be significant predictors of teenage pregnancy.

Conclusions

This study revealed high level of teenage pregnancy among school adolescents of Arba Minch Town. A significant number of adolescent female students were at risk of facing the challenges of teenage pregnancy in the study area. School-based reproductive health education and strong parent-daughter relationships are recommended.

Introduction

Adolescence is a transitional period from childhood to adulthood characterized by significant physiological, psychological and social changes. However, adolescent girls suffer from a disproportionate share of teenage pregnancy which is a universal public health problem that affects maternal and child health ( 1 , 2 ).

Adolescent pregnancy and childbearing is a a global health and economic challenge nowadays. Globally, about 18 million adolescent girls between 15–19 years give birth each year (adolescent birth rate was 53 births per 1,000 women). Babies born to adolescent mothers account for 11% of all births worldwide; 95% of these occur in developing countries ( 3 ).

In subSaharan Africa, in the year 2013, 101 births per 1,000 were some of the highest rates of adolescent fertility in the world ( 4 ). Among 14.3 million adolescent girls who gave birth in 2008 worldwide, one of every three was from sub-Saharan Africa. More than 50% of adolescent girls give birth by the age of 20 in this region ( 5 ).

According to the EDHS 2016, 13% of women aged 15–19 years in Ethiopia began childbearing: 10% had a live birth, and 2% were pregnant with their first child at the time of interview. The proportion of women aged 15–19 years who began childbearing rose rapidly with age, from 2% among women aged 15 years to 28% among those aged 19 years ( 6 ).

Pregnancy at an early age is risky for the mother and the baby. Maternal conditions in adolescents cause 13% of all deaths and 23% of all Disability Adjusted Life Years (DALYs) (overall burden of disease due to pregnancy and childbirth among women of all ages). Moreover, babies born to adolescents also face a significantly higher risk of death compared to babies born to older women ( 7 ). Teenage pregnancy is the biggest killer of young girls worldwide; 1, 000, 000 teenage girls die or suffer serious injury, infection or disease due to pregnancy or childbirth every year ( 8 ). Adolescent girls aged 15 to 19 years are twice as likely to die from complications in pregnancy as are women in their twenties. The youngest girls are particularly at risk; the mortality rate for those under 15 is four times higher than for those in their 20s ( 9 ).

Teenage pregnancy also has significant long term social consequences for the adolescents, their children, their families and their communities; it led adolescents to less educational attainment and high school dropout, poor health and poverty. The children of teenage mothers are also more likely to have lower school achievement and drop out of high school, have more health problems, are incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult ( 3 , 11 – 13 ).

Although adolescent pregnancy occurs among all racial, cultural and socioeconomic groups, some adolescents are more likely than others to become pregnant ( 4 ). Factors such as economic status, education, religion, place of residence, peer's and partners' behaviours, family and community attitudes, age, mass media, lack of reproductive health services and knowledge are contributing factors to the increase of unintended pregnancy among adolescents in Ethiopia ( 14 ).

The government of Ethiopia developed strategies to achieve four major objectives: increasing access to quality reproductive health services for adolescents, increase awareness and knowledge about reproductive health issues, strengthen multisectoral partnerships, and design and implement adolescent and youth reproductive health programs. However, teenage pregnancy remains high in the country ( 15 ).

Studies on adolescent sexuality and pregnancy are very limited in our country particularly in the South Region. Therefore, this study was conducted with the aim of assessing the magnitude and identifying associated factors of teenage pregnancy among school adolescents of Arba Minch Town in order to contribute to the prevention programs by providing up-to-date information for decision-making and program implementation.

Methods and Materials

Study setting : The study was conducted from 20–30 March 2014 in Gammo Goffa Zone, Arba Minch Town, South Ethiopia. According to the latest national population projection based on the population and housing census, the total population of the town is about 103,965 people ( 16 ). The town has four sub-cities named: Secha, Abaya, Nechsar and Sikela. In the town, there are eight colleges (private and public), six high schools and two preparatory schools.

An institution-based, cross-sectional study design was employed among female students in the age range of between 15 and 19 years from the four schools in the town. The sample size for the study was calculated considering 8% prevalence of adolescent pregnancy ( 17 ), 95% certainty and 5% of margin of error between population and sample with non-response rate of 10%. Therefore, the total calculated sample size for this study was 578 students. There were 8 schools (2 preparatory and 6 high schools) in the town. After stratifying schools into preparatory and high schools, one preparatory school and three high schools were selected randomly. Proportional numbers of students were assigned to each school and then the total number of 15–19 years old female students in each grade level was obtained from the school administration. A separate sampling frame was prepared for each grade level of each school. Then, the final participants were drawn from each grade level by systematic random sampling technique (1 in every 5 students) ( Figure 1 ).

Schematic presentation of sampling procedure among schools in Arba Minch town, March 2014(n=578)

Data collection : Seven data collectors (all of them were college completed individuals working in different institutions) and two supervisors were recruited for data collection and supervision respectively. Training on the methods, objectives, and other technical aspects of the study were provided to the data collectors and supervisors. A pre-tested, structured, self-administered questionnaire was used to collect the data. The questionnaire was prepared in English and then translated into the local language (Amharic), and then back translated into English language for its consistency. For the translation and back translation purpose, we used two different individuals who speak both English and Amharic fluently.

In order to ensure the quality of the data, pretesting of the questionnaire was done in the same set-up having similar age group but not from a selected high school. Some unclear and difficult questions to understand by most of the students were corrected and rephrased accordingly during the pretest.

The sitting arrangement of the students was considered; each student took a single seat with sparse arrangement of chairs and desks. Then after, the copies of questionnaire were distributed among students after short orientation had been provided. The principal investigator and the supervisors closely supervised the data collection process.

Data analysis : Data were analysed using SPSS V-20 statistical software. Assumptions for logistic regression and multi-collinearity diagnostics were checked. Descriptive statistics was used and the results were displayed using tables. The outcome variable was dichotomized as 0 = no and 1 = yes. Binary logistic regression was carried out. Firstly, bivariate analysis was done to see the crude effect of each independent variable on the outcome variable. Only those variables with p-value < 0.25 were selected and entered into multivariate logistic regression analysis to identify the independent predictors. Adjusted odds ratio with its 95% confidence interval was used to identify factors independently associated with teenage pregnancy, and p-values < 0.05 were considered for statistical significance.

Ethical consideration : Ethical clearance was obtained from Jimma University Ethical Review Committee. A formal letter was submitted to the Education office of the Gammo Goffa Zone and subsequently to high schools of Arba Minch Town where the study took place. Written permissions from the parents of the respondents were obtained a day before the time of data collection. Oral and written permissions from the schools and the respective study subjects were obtained.

Operational definitions

Ever pregnant : was measured by asking the respondent “Have you ever been pregnant?” which includes pregnancies that ended in live birth, still birth and abortion. Then, the response was categorized as 0 = no and 1 = yes.

Emergency contraceptives : As an emergency measure, women can take special pills to prevent pregnancy within three days after they have unprotected sexual intercourse.

Know the exact time to take emergency contraceptives : individuals who know the exact time of taking emergency contraceptives (within 72 hours after unprotected sexual intercourse)

Do not know the exact time to take emergency contraceptives : individuals who do not respond as per above.

Knowledge of fertile period in the menstrual cycle : Respondents were asked a ‘yes-no’ question, “Do you know the high risk days of your menstrual period to get pregnant?” and “when are those days in the menstrual period?”. Then, the responses were categorized as 1= know (if she answers the letter of choice that contains the time 4 days before and after 14 th day of her first menstrual cycle) and 2 = don't know (if otherwise ).

Parent-daughter interaction : was measured by asking the following four questions:

• Do your parents communicate with you on issues related to sexuality, love and friendship openly?
• Do your either parents know about your love or sexual partner?
• Do your parents follow you where and with whom you stay when you are out of home?
• Do your parents like your love and sexual relationship with a boyfriend

The median score from the four questions was computed (i.e.; 1) and levelled as ‘ 1= poor interaction (if scored ≤ 1) and ‘2= good interaction (if scored >1).

A total of 560(96.9%) respondents with complete information were included in the analysis; 397(70.9%) were from urban settings. Two hundred and seventeen (38.8%) of the respondents were orthodox by religion, and Gamo was the major ethnic group accounting for 292(52.1%) of the total respondents. With regard to school type, 349(62.3%) of the respondents were high school students (grade 9 & 10) while the remaining, 211(37.7%), were preparatory school students (grade 11 and 12) ( Table 1 ).

Socio-economic characteristics and history of pregnancy among respondents in high school and preparatory schools of Arba Minch Town, March 2014 (n=560).

Fertility knowledge and pregnancy among sexually active school adolescents were assessed; from the total of 124 sexually active students, 43(34.7%) ever had history of pregnancy, and 47(37.9%) of them did not know the fertile days in their menstrual cycle. Seventy-eight (62.9%) of them started sexual intercourse at age of 17 years and above. Regarding contraceptive use, 68(54.8%) of the respondents had ever used at least one kind of modern contraceptive. About 37(29.8%) of sexually active students reported that they used substance ( Table 2 ).

Fertility knowledge and pregnancy among sexually active school adolescents in Arba Minch town, March 2014 (n=124)

We assessed the family and peer level characteristic of the respondents; about 165(29.5%) of them reported that their mothers completed secondary education. The majority, 366(65.4%), of the respondents lived with both of their biological parents. Three hundred and twenty-eight (63.2%) of them reported that they had poor parent-daughter interaction concerning issues of sexuality, love and pregnancy ( Table 3 ).

Family and peer level characteristics of respondents among school adolescents in Arba Minch Town, March 2014 (n=560)

With regard to the prevalence of teenage pregnancy, 43(7.7%) of the respondents had history of pregnancy and only 12(27.9%) of those pregnancies were wanted. Multivariate logistic regression analysis was carried out. The overall significance of the model to predict the probability of teenage pregnancy was checked [-2log likelihood=196.2, model X 2 =94.1, df=25] and the overall prediction of the model was 92.8%. Being 11 th and 12 th grade levels, substance use (alcohol/chat/cigarette), not knowing the exact time to take emergency contraceptives, living with either of biological parents, living with neither of biological parents and poor parent-daughter interaction were found to be significant predictors of teenage pregnancy in this study. However, marital status, religious participation, knowledge of fertile period of menstrual cycle and educational status of the respondents' mothers did not show significant associations with teenage pregnancy ( Table 4 )

Bivariate and multivariate logistic regression analysis of factors affecting teenage pregnancy among school adolescents in Arba Minch Town, March 2014

Teenage pregnancy is one of the most unfavourable and usually unplanned outcomes of adolescents' sexual activity. Teens are initiated to engage in unprotected sex early in life so that they are exposed to young parenthood. Many teens that become pregnant have to leave school; this has a long-term implication for them as individual, their family and their community. The prevalence of sexual activity in this study was 124 (22.1%). This finding is consistent with studies conducted among school adolescents of two towns of Ethiopia: Gondar (23.5%) and Nekemt (21.5%). However, slightly lower than the findings from Ethiopian Demographic and Health Survey (EDHS 2011) report and a study conducted among school adolescents of Ilorin, Nigeria. The findings in these studies were 24.2% and 28.2% respectively ( 20 – 21 ). The discrepancy may be due to methodological variations: EDHS included adolescents in the community whereas this study focused only on high school adolescents. Furthermore, Socio-cultural difference is there with the case of Ilorin, Nigeria. Although the Ethiopian government has been working on sexual and reproductive health issues with especial focus on the youth (including teenagers) in schools and community at large, the current study has shown that a high number of school teenagers were practicing sexual intercourse and are still at risk of teenage pregnancy.

The overall prevalence of teenage pregnancy in this study was 43(7.7%). This finding is comparable with the finding from EDHS 2011 report of Southern Ethiopia Region which was 7.9% (20).

The prevalence of teenage pregnancy among sexually active students in this study was 34.7%. This finding is comparable to the national figure reported by EDHS in which 34% of women were either mothers or pregnant with their first child by the age of 19 ( 20 ). The fiding in the current study a study is also inlines with the finding in Nigeria where 31.6% of adolescents who ever had sex experienced teenage pregnancy. However, it is much higher than the study conducted in the same country in Ilorin, Central Nigeria, among high school adolescents in which case only 5.7% of those sexually active female students had experienced teenage pregnancy ( 21 ). These variations may be due to the difference in age range of study populations as the study in Nigeria included adolescents of 10–19 years old whereas this study included those in the age range of 15–19 years (the probability of being pregnant is higher in the late adolescence stage than in early adolescence stage).

Regarding the factors contributing to teenage pregnancy, students from grades 11 and 12 were more likely to become pregnant compared to the students from grades 9 and 10. This finding is comparable with studies conducted in USA and Nekemt, Ethiopia, among school adolescents. In these studies, the prevalence of teenage pregnancy was generally increasing with increasing grade level (grades 9–12)( 19 , 22 ). Other studies reported the inverse relationship between educational attainment and teenage pregnancy rate-the more years of schooling, the fewer early pregnancies ( 7 , 23 , 24 ). However, the finding from this study contradicts this-adolescents in higher grade levels, 11 th and 12 th , were significantly more likely to experience pregnancy than those in grades 9 and 10. This might be due to the longer stay at school, the higher exposure and probability of getting sexual relation among higher grade level students than lower grade students.

Substance is a gateway for risky sexual behaviours among adolescents which results in teenage pregnancy with consequent health and social implications. Because it constitutes a deviation from conventional behaviour, it is regarded as problem behaviour ( 25 ). Adolescents who used substance (alcohol/chat/cigarette) were more likely to experience teenage pregnancy compared to those who did not use. This finding is supported by the finding from a systematic review from the European Union Countries and a study conducted in South Africa which revealed that substance use was significantly associated with teenage pregnancy ( 26 – 27 ). This could be attributed to substance use or being under the influence of substance may influence the adolescent students to unrealistically appraise the situation and also impair their verbal as well as physical resistance against unprotected sexual intercourse. Hence, the risk of teenage pregnancy is high.

The fact that having knowledge of the exact time when to take contraceptives prevents unwanted pregnancy is strongly supported by the finding from this study. The probability of experiencing pregnancy among those who know the exact time of emergency contraceptives was about 6%, but it was 10% for those who do not know. The odds of being pregnant was about three times much higher among adolescents who do not know the exact time when to take emergency contraceptives than among their counterparts. According to the report by WHO, lack of knowledge about sex and family planning and lack of skills to put that knowledge into practice put adolescents at risk of pregnancy ( 7 ).

In this study, the risk of teenage pregnancy among adolescents who were living with either of biological parents and neither of their biological parents was higher as compared to those who were living with both biological parents. This result is in line with studies conducted among adolescents in Mechakal District, Ethiopia, a study from USA and a WHO report which showed that living with both biological parents has a protective effect on the occurrence of teenage pregnancy ( 17 , 28 – 29 ). The reason could be that teens that live with biological parents are guided and get support and follow-up from their families so that they are under fence of protection that minimizes their chance of exposure to sexual experiences. Moreover, biological parents are highly responsible for their children's adoption of safer behaviours.

Parents play a critical role in the growth, development and sexual socialization of their children. Parental involvement through parent-child sexual communication presents education about sex and reproductive health to young people. Moreover, it promotes adolescents' selfesteem, transfer of sexual values, beliefs, information and expectations to their children with the aim of influencing sexual behaviours, attitudes and decision-making of their children to prevent risky behaviours and teenage pregnancy ( 30 – 33 ).

In this study, adolescents who were living in poor parent-daughter interaction conditions regarding issues of sexuality, love and pregnancy were 3.7 times more likely to experience pregnancy compared to those who lived under good parent-daughter interaction conditions. This finding is supported by a study in conducted British Columbia which reported that parent-daughter interaction concerning sexuality and reproductive health was significantly associated with teenage pregnancy ( 34 ). The possible explanation could be that female students who have good parent-daughter interaction may get good opportunity to have free discussion about sexuality and reproductive health issues thereby transfer of life skill is possible to protect themselves from teenage pregnancy.

Our study has limitations. From the very nature of the study, it assesses personal and sensitive issues related to sexual behaviours which might have caused underreporting of teenage pregnancy experiences. Thus, the findings of this study should be interpreted within these limitations.

In conclusion, the prevalence of teenage pregnancy among school adolescents is high to cause reproductive health and socio-economic challenges to adolescents in the study area. Being 11 th and 12 th grade student, substance use, not knowing the exact time to take emergency contraceptives, living arrangement and poor parent-daughter interaction were found to be significant predictors of teenage pregnancy. Special emphasis particularly in the areas of parent-daughter communication on the issues of sexuality and reproductive health, benefits of contraceptive use, and risk of substance use (alcohol, chat and cigarette smoking) are recommended.

Acknowledgements

We are very thankful to Jimma University College of Public Health and Medical Sciences for the financial support. Our special thanks go to the study participants for their response and time to complete the questionnaire. Last but not least, we would like to thank the school directors of Arba Minch Town for arranging time and place for data collection.