research paper on adolescent pregnancy

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Environ Res Public Health
• PMC10002018

Adolescent Pregnancy Outcomes and Risk Factors

Jana diabelková.

1 Department of Public Health and Hygiene, Medical Faculty, University of Pavol Jozef Šafárik, Šrobárova 2, 041 80 Košice, Slovakia

Kvetoslava Rimárová

Peter urdzík.

2 Department of Gynaecology and Obstetrics, Medical Faculty, Louis Pasteur University Hospital, University of Pavol Jozef Šafárik, Trieda SNP 1, 040 11 Košice, Slovakia

Andrea Houžvičková

Ľubica argalášová.

3 Institute of Hygiene, Faculty of Medicine, Comenius University in Bratislava, Špitálska 24, 813 72 Bratislava, Slovakia

Associated Data

The data presented in this study are available on request from the corresponding author.

One of the major social and public health problems in the world is adolescent pregnancy. Adolescent pregnancy is strongly associated to less favorable results for both the mother and the newborn. We conducted this research to ascertain the impact of teenage age on neonatal outcomes and also observed the lifestyles of pregnant teenage girls. We conducted a study of 2434 mothers aged ≤19 years (n = 294) or 20–34 years (n = 2140) who gave birth in 2019–2020 at the Department of Gynaecology and Obstetrics of Louis Pasteur University Hospital in Košice. The data on mothers and newborn infants have been reported from the reports on mothers at childbirth. Women between the ages of 20 and 34 served as the reference group. The teenage mothers were more likely to become pregnant if they were unmarried (OR = 14.2; 95% CI = 9.3–21.6; p < 0.001) and had a basic education or lack of education (OR = 16.8; 95% CI = 11.5–24.6; p < 0.001). Additionally, they were more likely to smoke when pregnant (OR = 5.0; 95% CI = 3.8–6.6; p < 0.001). Low birth weight was more common in newborns born to adolescent mothers than in those born to adult mothers ( p < 0.001). Our findings showed that infants of teenage mothers often had lower birth weights (−332.6 g, p < 0.001). Adolescent mothers were associated with lower Apgar scores at the first minute ( p = 0.003). As compared with the control group, pregnant teenage girls had a greater prevalence of preterm deliveries in our research ( p = 0.004). This study finds significant age-related disparities in neonatal outcomes between mothers. These results might be used to identify vulnerable groups who need special assistance and actions to reduce the probability of negative outcomes for such groups.

1. Introduction

Adolescent pregnancies are a global public health problem. Teenage pregnancy is the pregnancy of 10- to 19-year-old girls [ 1 ]. Adolescents are further divided into early (10–14 years old), middle (15–17 years old), and late adolescents (over 17 years old) [ 2 ].

According to the World Health Organization, adolescent pregnancies are a global problem for both developed and developing countries. Although the global teenage birth rate has decreased, there are regional differences in the rates of change. Adolescent pregnancies have decreased globally, from 64.5 per 1000 women in 2000 to 42.5 per 1000 women in 2021. However, there are huge differences in levels between and within countries. While the estimated global teenage birth rate has decreased, the actual number of childbirths to teenagers continues to be high. Pregnancy in girls under the age of 19 is severe in every aspect and requires very complex and long-term solutions [ 1 ].

The transition from childhood to adulthood occurs during the phase of adolescence, during which there are numerous changes in the physiological, anatomical, structural, and psychological aspects. Because many teenagers are not physically or mentally prepared for pregnancy and childbirth, they are more likely to experience complications that can have serious health consequences. Giving birth during adolescence has serious consequences for the health of the mother and her infant [ 1 ]. The adolescent age group is associated with adverse pregnancy outcomes [ 2 , 3 ].

The rate of teenage pregnancies has recently been greatly affected by several significant factors. The decreasing age at menarche is one of the factors that can affect a woman’s fertility. Since the 19th century, the age at menarche has been decreasing at a rate of 2–3 months per decade in many European countries, resulting in an overall decrease of about 3 years. Most of the decrease in menarche age is related to better nutrition and health. The onset of first sexual activity occurs at a significantly younger age, which is another contributing element. Teenage pregnancy, therefore, remains a serious social, economic, and health problem [ 4 ].

Young maternal age is more likely a marker for one or more other maternal risk factors associated with poor birth outcomes. Poverty, low education, and inadequate family support are also problems. These factors increase the risk of sexually transmitted infections, unsafe abortions, and birth complications, all of which are exacerbated by inadequate prenatal care [ 5 ]. For girls, early pregnancies can have social consequences such as lower status in the household and community; stigmatization; abuse by family, peers, and partners; and early and forced marriage. Early pregnancy and childbirth during adolescence can hinder a girl’s otherwise healthy development into adulthood and negatively affect her educational opportunities, financial security, and health. Many teenage girls who are pregnant cannot continue their education or work because they are pregnant. This can have a big impact on their future [ 6 ]. In addition, children born to parents who cannot care for them face additional dangers. In the first few years of a child’s life, the mother–child relationship declines. This is primarily due to the mother’s immaturity. When teenage mothers are victims of sexual assault, the situation is even worse. Apart from their mothers, these children tend to be brought up by their grandparents and relatives, with frequent changes in caregivers. Children have a higher risk of being abused or neglected and a higher risk of failing in school and are more likely to engage in criminal behavior later on [ 7 ].

The economic, social, and political development and progress of any country depend on the healthy size of adolescents and children. As a result, the healthier the teenager is, the healthier the nation and future generations will be. Teenagers thus need special attention from us.

Understanding the issue is necessary to develop and carry out prevention initiatives to decrease teen pregnancy. Knowledge about the target groups, teenage pregnancy and birth outcomes, and the risk and preventive factors related to teenage pregnancy is needed. This information is important in choosing which risk and protective factors to target and, thus, better implementing the effective implementation of evidence-based adolescent pregnancy prevention practices.

Examining the newborn outcomes and risk variables associated with adolescent pregnancies was the aim of the present research.

2. Materials and Methods

The research took place in the years 2019–2020 in eastern Slovakia. This study included 2434 newborns and their mothers. Data were collected at the University of Pavel Jozef Šafárik’s Faculty of Medicine and the Louis Pasteur University Hospital’s Gynecology and Obstetrics Clinic in Košice. This hospital has a higher prevalence of mothers with high-risk pregnancies because it is the East Slovakian center for low birth weight and preterm birth.

The data were obtained from hospital records. Available information included the mother’s education, marital status, lifestyle, and when prenatal care began. Additionally, the Apgar scores at 1 and 5 min, the newborn’s gestational age, and the newborn’s weight were recorded. The total number of mothers in the results tables was different because not all the data for each mother were available in the clinical records. The study excluded women who were carriers of multiple pregnancies because they had a higher risk of preterm birth and lower birth weights of their newborns. Thus, women with multiple pregnancies were not included among the participants.

Maternal age was defined as the mother’s age in completed years at the time of delivery. The youngest women recruited to the cohort were 14 years old; therefore, the data for this study were limited to women aged 14–34 years at delivery who had a singleton pregnancy. The results for women under the age of 19 were compared with the results for women in the reference group (20–34 years). The age range of 20 to 34 years was chosen as the reference group because this age range had the lowest risk of developing age-related problems.

In our records, a woman who smoked at least one cigarette per day while pregnant was considered a smoker. All women who consumed 15 g of alcohol per day were considered alcohol consumers. This is equivalent to 0.5 L of 12-degree beer, 0.3 L of wine, or 0.5 dL of strong alcohol.

The neonatal outcome variables of interest in this study were low birth weight (less than 2500 g), very low birth weight (less than 1500 g), extremely low birth weight (less than 1000 g), macrosomia (birth weight greater than 4000 g), preterm birth (less than 37 weeks gestation), very preterm birth (less than 32 weeks gestation), extremely preterm birth (less than 28 weeks gestation), and low Apgar score at the first and fifth minutes (less than 7).

Most mothers completed eight prenatal care visits. Thus, we divided the group of mothers into two groups: those who had fewer than eight antenatal visits and those who had eight or more visits.

The IBM SPSS Statistics 23.0 program (IBM SPSS Statistics for Windows, Version 23.0. IBM Corp., Armonk, NY, USA) was used to analyze the data. The data were given as median (min–max), mean (standard deviation), and number (percent).

The data were processed using both primary characters and modified characters (categorized). Most of the findings were statistically significant, and the analysis included important discoveries that were related to the collected empirical data. The χ2 independence test, with a significance level of 0.05, was used to assess the frequency of individual variations of characteristics in the analyzed groups and subgroups. The Student’s t -test was used to compare the arithmetic means of continuous variables. The odds ratio, or, was used to compare the frequency of social and anamnestic variables in the adolescent mothers and mothers from the reference group.

Data were available for 2434 pregnancies for this analysis. A total of 294 (12.1%) of these births included teenagers between the ages of 14 and 19. The controls were 27.9 ± 3.9 years old on average, whereas the adolescents’ mean age was 17.4 ± 1.4. Table 1 displays the characteristics of the study’s participants.

Characteristics of the sample by maternal age.

Numbers in bold indicate statistically significant values.

Our study demonstrated that adolescent mothers had lower levels of education ( p < 0.001), only primary school (84.1%). About 46% of teenage girls reported smoking during pregnancy. In the reference group, the proportion of smokers was 14.6% ( p < 0.001). Alcohol consumption during pregnancy was relatively low at 0.6%, and the data on alcohol use were not statistically significant ( Table 1 ).

In the adolescent group, there were up to 45.7% of women ( p < 0.001) who went to the doctor after the first trimester. Most mothers completed eight prenatal care visits. Therefore, we divided the group of mothers into two groups: those who had fewer than eight antenatal visits and those who had eight or more visits. Up to 75.9% of teenage girls who were pregnant had fewer than eight clinic visits ( p < 0.001) ( Table 2 ).

Antennal care received by the respondents.

Adolescent girls were significantly more likely to be single (OR = 14.2; 95% CI = 9.3–21.6; p < 0.001), to have less education (OR = 16.8; 95% CI = 11.5–24.6; p < 0.001), and to smoke during pregnancy (OR = 5.0; 95% CI = 3.8–6.6; p < 0.01). They were more likely to visit a doctor for the first time during pregnancy after the first trimester (OR = 0.3; 95% CI = 0.2–0.3; p < 0.001) and were more likely to visit a doctor fewer than eight times (OR = 4.0; 95% CI = 3.0–5.3; p < 0.001) during pregnancy ( Table 3 ).

OR of various risk variables for adolescent mothers’ reproductive outcomes.

OR—odds ratio; CI—confidence interval. Numbers in bold indicate statistically significant values.

Table 4 shows the results for newborns. Infants born to teenage mothers had a significantly higher rate of low birth weight than those born to women who were adults ( p < 0.001). Our findings showed that children born to teenage mothers weighed less on average (−332.6 g, p < 0.001). In contrast to the control group, pregnant adolescents in our analysis had a higher prevalence of premature births ( p = 0.004). Children of adolescent mothers had a lower first-minute Apgar score ( p = 0.003).

Neonatal outcomes.

4. Discussion

Pregnancy in adolescence is a health problem worldwide. Teenagers themselves are a high-risk group in need of high-priority interventions. In general, most pregnancies in adolescence are extra-marital and unintended [ 2 ]. The teenage mothers in this research were more likely to be single (OR = 14.2; 95% CI = 9.3–21.6; p < 0.001), which is similar to previous studies [ 5 , 8 , 9 , 10 ].

Psychological immaturity is common among adolescent mothers. Because they do not understand the value of family planning, they often engage in risky sexual behavior and become pregnant while still in school and still living with their parents [ 9 ]. This study confirms that teenage mothers are significantly more likely to have a low level of education ( p < 0.001). These findings agreed with those of other research investigations carried out in other nations [ 2 , 9 ]. Adolescent girls often drop out of school due to pregnancy or childbirth. Sometimes problems at school and poor school performance appear even before pregnancy. Some teenage girls who are not doing well in school may find motherhood an attractive option. When these variables combine, young mothers have fewer career possibilities, often resulting in lower earnings for the rest of their lives [ 9 , 11 ]. Early pregnancies are significantly reduced by education; the more years of education, the lower the rate of early pregnancies [ 1 ].

Quitting smoking has a direct impact on the health of the fetus. Teenagers in our research were more likely to smoke during pregnancy (OR = 5.0; 95% CI = 3.8–6.6; p < 0.001). Previous research has shown that several high-risk activities are associated with a higher likelihood of pregnancy. These activities included the use of tobacco products, drinking alcohol, drug use, and risky sexual behavior [ 9 , 10 , 12 , 13 , 14 ].

Teenagers need accurate information about where to go when they need advice and help. Numerous studies have highlighted the benefits of prenatal care in minimizing pregnancy risks [ 9 , 15 , 16 , 17 ]. Unlike controls, pregnant adolescent girls in our study used prenatal care services less frequently. This was confirmed by a later gestational age at the first visit ( p < 0.001) and a lower number of visits to the doctor during pregnancy ( p < 0.001). This may be a result of a lack of information about the community services offered and the benefits of providing early and routine care. Teenagers may think they are not entitled to prenatal care, or they may choose to keep the pregnancy a secret [ 9 , 11 , 18 ]. Pregnant teenagers often interrupt school attendance, partly because of their participation in prenatal care. If clinic times are compatible with school attendance and medical staff are sensitive to adolescent needs, antenatal visits are more likely to be attended. Therefore, the needs of adolescents must be taken into account when providing prenatal care. However, direct study comparisons are difficult as there are different definitions of appropriate prenatal care. Regardless of how prenatal care is defined, the data suggest that adolescents tend to receive less adequate care than adult women [ 3 , 8 , 14 , 19 , 20 , 21 ]. Similar findings were obtained by Kassa et al. [ 22 ], who found that the number of antenatal care visits was lower in the teenage group and that doctor visits started later in pregnancy in this group. De Vienne et al. [ 23 ], on the other hand, did not find a difference between younger and older women in the analyzed age categories. Quinlivan and Evans published a study [ 24 ] comparing the outcomes of adolescents attending either a general or a specialist antenatal clinic for teenagers. In adolescent pregnancy clinics, prenatal care was provided by a multidisciplinary team and included social support and thorough infection screening. The rate of preterm births has decreased significantly as a result of the care provided at teen pregnancy clinics. According to the authors, the key strategies were the prevention of ascending infections of the genital tract and the provision of comprehensive treatment for teenagers. Healthcare professionals should be aware that teenage pregnancies are high-risk pregnancies and educate young women about the value of prenatal care and frequent antenatal visits.

In our study, preterm births were more common among pregnant teenage mothers than in controls ( p = 0.004), which is similar to previous studies [ 25 , 26 , 27 , 28 , 29 , 30 ]. Due to the fact that preterm birth is a complex pregnancy problem, it is complicated to identify the exact cause. According to Debiec et al. [ 17 ], preterm birth is more common in teenagers who receive insufficient prenatal care, which supports the hypothesis that poor prenatal care is a risk factor for preterm birth. However, Chen et al. [ 4 ] point out that the risk of preterm birth persisted even in women who received adequate prenatal care. Yadav et al. [ 10 ] found that preterm birth was significantly more common in teenagers. According to them, the rise might be attributed to biological immaturity and socioeconomic deprivation. Clinically indicated preterm births may be the result of medical conditions such as intrauterine growth restriction or spontaneous labor. Both spontaneous preterm birth and intrauterine growth restriction are associated with maternal malnutrition, and there is strong evidence linking both conditions to maternal smoking during pregnancy [ 13 , 18 , 31 , 32 , 33 , 34 , 35 ]. Adolescent mothers are more likely to deliver preterm due to gynecological immaturity (such as a short cervix [25 mm] and a small uterine volume) and susceptibility to subclinical infections. Other studies suggest that these risks are related to biological immaturity in adolescent females and are not related to social deprivation, smoking, or inadequate prenatal care [ 27 , 36 , 37 ].

In this study, the percentage of low birth weight in infants born from adolescent mothers was higher than in mothers who gave birth in adulthood ( p < 0.001), which is similar to previous studies [ 23 , 27 , 28 , 29 , 38 , 39 ]. It is thought that growing adolescents may compete with the fetus for resources, which might hinder fetal development and lead to low-birth-weight newborns or newborns that are small for their gestational age [ 40 ]. Marvin-Dowle et al. [ 40 ] conducted research in England among women aged 19 years and 20–34 years to examine the relationship between maternal and newborn outcomes in teenage women. Extremely low birth weight was found to be significantly more common in the teenager group compared with the control group.

Extremely underweight newborns have a higher risk of death within the first few months of life [ 12 ] as well as long-term problems with their physical and cognitive development [ 9 , 11 ]. Extremely low birth weight was not more common in our study cohort of adolescent mothers ( p = 0.246).

The term Apgar, or appearance, pulse, grimace, activity, and respiration, was created by Doctor Virginia Apgar. This score is a simple method for evaluating neonates one and five minutes after birth. A newborn’s Apgar score is determined by several variables, including color, heart rate, reflexes, muscle tone, and breathing. Scores for each item range from 0 (zero), 1, or 2, with a total score of 7 to 10 considered good [ 41 ]. No significant difference in the low Apgar score between adolescent and adult pregnancies was found when compared with hospital-based retrospective cohort research in Nepal by Yadav et al. [ 10 ]. Due to several sociodemographic, obstetric, and dietary factors, low Apgar scores occur more frequently in teenage pregnancies than in adult pregnancies [ 3 , 22 ]. In a study conducted over 6 years in Japan with 30,831 women under the age of 25 who were pregnant with a singleton, Ogawa et al. [ 29 ] examined the relationship between adolescent pregnancy and adverse outcomes. They found that low Apgar scores were significantly more common among adolescent mothers than among mothers aged 20 to 24 [ 29 ]. Low Apgar scores are associated with infant complications such as breathing difficulties, feeding problems, hypothermia, and seizures [ 42 ]. Low Apgar scores at five minutes correlate with mortality and may indicate a higher likelihood of cerebral palsy [ 41 ]. In our study, the difference in the prevalence of low Apgar scores between adolescent mothers and the control group was confirmed only when the Apgar score was evaluated after the first minute ( p = 0.003).

The development of social policy can be improved by having a thorough understanding of all these socioeconomic factors that influence teen pregnancy.

The first and most important step in strategies to reduce adolescent pregnancies and associated poor neonatal outcomes should be to “prevent it”. Measures to reduce the prevalence of teenage pregnancy also include increasing the importance of education. Although there are many different techniques to prevent a young girl from becoming pregnant, sexual abstinence is the only one that is 100% successful. This approach is the only one that ensures zero pregnancy risk and safeguards the adolescent from contracting any STDs. It is important to make teenagers aware of the responsibility that comes with sexual activity. The more information teenagers receive about this topic, the higher the chance that they will behave cautiously.

Teenagers should be educated about the negative consequences of teenage pregnancy, especially by their parents and at school. Building adolescents’ knowledge, skills, resilience, and aspirations through relationships and education helps them delay sexual activity until they are ready; enjoy healthy, consensual relationships; and use family planning methods. Schools may play a role by encouraging students to make mature decisions about their sex and by disseminating the knowledge needed to prevent adolescent pregnancy.

Teenagers are more likely to have their first sexual experience later in life if they and their parents have open discussions about relationships and sexual health from a young age. When parents spend time discussing sex and family planning with their children, they can have a significant impact on their decisions. Some parents have trouble talking about this topic. The barriers to parental communication include embarrassment, concern that discussion may encourage early sexual activity, and uncertainty about how to properly answer questions. Parents and all practitioners who come into contact with young people therefore need guidance on how to talk to them.

5. Conclusions

In conclusion, pregnancies in adolescents should be considered high-risk pregnancies. It is necessary to emphasize the need for comprehensive prenatal care for pregnant adolescent children because insufficient prenatal care can be harmful to both the mother and her fetus. Promoting early and thorough prenatal care is a key strategy if adolescent pregnancy outcomes are to be improved. Addressing teen pregnancy also requires a major effort by families, service providers, schools, faith-based and community organizations, recreation centers, policymakers, and youth. Teenagers should be educated about the negative consequences of teenage pregnancy, especially by their parents and at school. Our results confirm the relatively high prevalence of pregnant adolescent girls who smoked. Education should therefore also focus more on the risks associated with the use of substances during pregnancy.

The most important elements in preventing unwanted teenage pregnancies are a functional and stable family, good relations between parents, and good relations between parents and children. Parents should be the main source of information about sex. Adolescent pregnancy is not only a medical problem but also a social and societal problem, so society also plays an important role in preventing unwanted pregnancies, spreading awareness among young people, and holding them accountable for their actions.

6. Limitation

The conclusions of this study must be interpreted in light of limitations in the dataset and study design. For example, this study cannot adequately control for such factors as infectious exposure and drug use, which may differ between the groups.

Funding Statement

This work was supported by grants KEGA No. 008UPJŠ-4/2020, KEGA 010UPJŠ-4/2021 of the Ministry of Education, Science, Research and Sport of the Slovakia and 015UK-4/2022. We also thank the directory board of the Department of Gynaecology and Obstetrics at Louis Pasteur University Hospital in Košice for assistance with organization of sample collection at the hospital wards.

Author Contributions

J.D., K.R. and P.U. designed the project; J.D. and A.H. participated in data analysis; J.D. was responsible for interpretation and writing of the final version for publication; K.R. and E.D. were responsible for funding acquisition and project administration; J.D. performed the literature search and drafted sections of the manuscript; K.R., E.D. and Ľ.A. provided critical revision of the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Louis Pasteur University Hospital, Košice, Slovakia, 2019/EK/2014.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

• 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

699k Accesses

36 Citations

46 Altmetric

Metrics details

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

Chen XK, Wen SW, Fleming N, Demissie K, Rhoads GG, Walker M. Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. Int J Epidemiol. 2007;36:368–73.

Article   CAS   PubMed   Google Scholar  

Kingston D, Heaman M, Fell D, Chalmers B. Comparison of adolescent, young adult, and adult women’s maternity experiences and practices. Pediatrics. 2012;129:e1228–37.

Article   PubMed   Google Scholar  

Hoffman SD, Maynard R. Kids Having Kids: Economic Costs & Social Consequences of Teen Pregnancy. Washington, DC: The Urban Institute Press; 2008.

Google Scholar  

Woodward L, Fergusson DM, Horwood LJ. Risk factors and life processes associated with teenage pregnancy: Results of a prospective study from birth to 20 years. J Marriage Fam. 2001;63:1170–84.

Article   Google Scholar  

East P, Reyes B, Horn E. Association between adolescent pregnancy and a family history of teenage births. Perspect Sex Reprod Health. 2007;39:108–15.

Article   PubMed   PubMed Central   Google Scholar  

Akella D, Jordan M. Impact of social and cultural factors on teen pregnancy. J Health Dispar Res Pract. 2011;8:41–62.

Bandura A. Social learning theory. New York: General Learning Press; 1977.

Ferraro AA, Cardoso VC, Barbosa AP, Da Silva AAM, Faria CA, De Ribeiro VS, Bettiol H, Barbieri MA. Childbearing in adolescence: intergenerational dejà-vu? Evidence from a Brazilian birth cohort. BMC Pregnancy Childbirth. 2013;13:149.

Meade CS, Kershaw TS, Ickovics JR. The intergenerational cycle of teenage motherhood: an ecological approach. Health Psychol. 2008;27:419–29.

Miller B, Benson B. Family relationships and adolescent pregnancy risk: A research synthesis. Dev Rev. 2001;21:1–38.

Article   CAS   Google Scholar  

East PL, Slonim A, Horn EJ, Trinh C, Reyes BT. How an adolescent’s childbearing affects siblings’ pregnancy risk: a qualitative study of Mexican American youths. Perspect Sex Reprod Health. 2009;41:210–7.

Oreopoulos P, Stabile M, Walld R, Roos L. Short, medium, and long term consequences of poor infant health: An analysis using siblings and twins. J Hum Resour. 2008;43:88–138.

Shanahan M, Gousseau C. Using the POPULIS framework for interprovincial comparison of expenditures on health care. Med Care. 1999;37:JS83–JS100.

Statistics Canada. Focus on geography series, 2011 census. 2014.

McKay A. Trends in Canadian National and Provincial/Territorial teen pregnancy rates: 2001-2010. Can J Hum Sex. 2012;21:161–75.

Office of National Statistics. Conceptions in England and Wales, 2010. Newport, CN: Office for National Statistics; 2012.

Kost K, Henshaw S. U.S. teenage pregnancies, births and abortions. 2014.

Nickel N, Chateau D, Martens P, Brownell M, Katz A, Burland E, Walld R, Hu M, Taylor C, Sarkar J, Goh C, Team TPE. Data resource profile: Pathways to health and social equity for children (PATHS Equity for Children). Int J Epidemiol. 2014;43:1438–49.

Power C, Kuh D, Morton S. From developmental origins of adult disease to life course research on adult disease and aging: Insights from birth cohort studies. Annu Rev Public Health. 2013;34:7–28.

Ladouceur M, Leslie W, Dastani Z, Goltzman D, Richards J. An efficient paradigm for genetic epidemiology cohort creation. PLoS One. 2010;5:e14045.

Roos L, Gupta S, Soodeen R, Jebamani R. Data quality in an information-rich environment: Canada as an example. Can J Aging. 2005;24:153–70.

Roos L, Nicol J. A research registry: Uses, development, and accuracy. J Clin Epidemiol. 1999;52:39–47.

Currie J, Stabile M, Manivong P, Roos L. Child health and young adult outcomes. J Hum Resour. 2010;45:517–48.

Concept: Teenage pregnancy [ http://mchp-appserv.cpe.umanitoba.ca/viewConcept.php?conceptID=1248 ].

McCall SJ, Bhattacharya S, Okpo E, Macfarlane G. Evaluating the social determinants of teenage pregnancy: A temporal analysis using a UK obstretics database from 1950 to 2010. J Epidemiol Community Health. 2015;69:49–54.

Chateau D, Metge C, Prior H, Soodeen R. Learning from the census: The socio-economic factor index (SEFI) and health outcomes in Manitoba. Can J Public Heal. 2012;103 Suppl 2:S23–7.

The Johns Hopkins University. The Johns Hopkins ACG case-mix system (Version 6.0 Release Notes). 2003.

Manlove J. The influence of high school dropout and school disengagement on the risk of school-age pregnancy. J Res Adolesc. 1998;8:187–220.

Mosteller F, Tukey J. Data analysis and regression: a second course in statistics. Reading: Addison-Wesley; 1977.

Roos L, Hiebert B, Manivong P, Edgerton J, Walld R, MacWilliam L, de Rocquigny J. What is most important: Social factors, health selection, and adolescent educational achievement. Soc Indic Res. 2013;110:385–414.

Rosenbaum P, Rubin D. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70:41–55.

Austin PC. Statistical criteria for selecting the optimal number of untreated subjects matched to each treated subject when using many-to-one matching on the propensity score. Am J Epidemiol. 2010;172:1092–7.

Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar Behav Res. 2011;46:399–424.

Parsons LS. Reducing Bias in a Propensity Score Matched-Pair Sample Using Greedy Matching Techniques. Cary, NC: Ovation Research Group; 2001.

Jiang M, Foster M, Gibson-Davis C. Breastfeeding and child cognitive outcomes: A propensity score matching approach. Matern Child Health J. 2011;15:1296–307.

Rosenbaum P. Observational studies. New York: Springer; 1995.

Book   Google Scholar  

Singh S, Darroch JE, Frost JJ, the Study Team. Socioeconomic disadvantage and adolescent women’s sexual and reproductive behaviour: The case of five developed countries. Fam Plann Perspect. 2001;33:251–89.

Jutte D, Roos N, Brownell M, Briggs G, MacWilliam L, Roos L. The ripples of adolescent motherhood: Social, educational and medical outcomes for children of teen and prior teen moms. Acad Pediatr. 2010;10:293–301.

Kusch L: Number of kids in care soars to all-time high. Winnipeg Free Press . Retrieved from http://www.winnipegfreepress.com/local/number-of-kids-in-care-soars-to-all-time-high-278761011.html . 2014.

Brownell M, Roos NP, MacWilliam L, Leclair L, Ekuma O, Fransoo R. Academic and social outcomes for high-risk youths in Manitoba. Can J Educ. 2010;33:804–36.

East P, Felice M. Pregnancy risk among the younger sisters of pregnant and childbearing adolescents. J Dev Behav Pediatr. 1992;13:128–36.

East PL. The first teenage pregnancy in the family: Does it affect mothers’ parenting, attitutes, or mother-adolescent communication? J Marriage Fa. 1999;61:306–19.

Kahn JR, Anderson K. Intergenerational patterns of teenage fertility. Demography. 1992;29:39–57.

Jaffee S, Caspi A, Moffitt TE. Why are children born to teen mothers at risk for adverse outcomes in young adulthood? Results from a 20-year longitudinal study. Dev Psychopathol. 2001;13:377–397.

Jutte D, Roos L, Brownell M. Administrative record linkage as a tool for public health research. Annu Rev Public Health. 2011;32:91–108.

Bolton J, Au W, Walld R, Chateau D, Martens P, Leslie W, Enns M, Sareen J. Parental bereavement after the death of an offspring in a motor vehicle collision: A population-based study. Am J Epidemiol. 2013;179:177–85.

Murdoch L. Young Aboriginal Mothers in Winnipeg. Winnipeg, MB: Prairie Women’s Health Centre of Excellence; 2009.

Download references

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).

Author information

Authors and affiliations.

Manitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Health Sciences, College of Medicine, University of Manitoba, 408-727 McDermot Avenue, Winnipeg, Manitoba, R3E 3P5, Canada

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

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Elizabeth Wall-Wieler .

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.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 20 January 2016

Accepted : 14 May 2016

Published : 25 May 2016

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

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Teenage pregnancy
• Familial influence
• Social modelling
• Intergenerational effects
• Linkable administrative data

BMC Pregnancy and Childbirth

ISSN: 1471-2393

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Understanding the Psychological Impacts of Teenage Pregnancy through a Socio-ecological Framework and Life Course Approach

Affiliations.

• 1 Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, California, San Francisco.
• 2 Department of Pediatrics, Division of Adolescent and Young Adult Medicine, Adolescent and Young Adult Health National Resource Center, University of California, California, San Francisco.
• 3 The Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, University of California, California, San Francisco.
• PMID: 34991169
• DOI: 10.1055/s-0041-1741518

The relationship between mental health and teenage pregnancy is complex. Mental health can be both an antecedent and contributing factor to teenage pregnancy and a concurrent factor wherein pregnancy itself can contribute to depression. Expectant and parenting teens (EPT) are faced with the simultaneous challenges of pregnancy and parenting while navigating the developmental tasks of adolescence which increases their risk for mental health problems. In addition, adolescents growing up in stressful community or home situations where their parents experienced depression, further places them and their children at greater risk of repeated patterns over time. However, adverse mental health outcomes are not inevitable. The socio-ecological model combined with a life course perspective provides a framework for understanding the complexity of risk and protective factors at multiple levels that influence knowledge, attitudes, behaviors, and other health outcomes later in life and across generations. This approach has important implications for reducing adolescents' risk of an unintended/mistimed pregnancy and improving mental health and other outcomes for EPT. This paper describes the prevalence of mental health problems in EPT and using a socio-ecological framework and life course perspective explains variations in mental health outcome among EPT. Implications for interventions and innovative approaches are also discussed.

Thieme. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Research Support, U.S. Gov't, P.H.S.
• Life Change Events
• Mental Health
• Pregnancy in Adolescence* / psychology

• 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

14k Accesses

5 Citations

9 Altmetric

Metrics details

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

World Health Organization

World Health Organization. Adolescents:health risks andsolutions; 2017. Avaiavle from:www.who. int/mediacentre/factsheets/fs345/en/.

World Health Organization. WHO Guidelines Approved by the Guidelines Review Committee. WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Health Outcomes Among Adolescents in Developing Countries. Geneva: World Health Organization Copyright (c) World Health Organization 2011. Avaiable from: https://www.ncbi.nlm.nih.gov/books/NBK304954/ .

Population and Housing Censuses Iran. National Census of Population and Housing of Iran; 2016.

World Health Organization. Adolescent pregnancy. Geneva 2014. Available from: Declarations https://apps.who.int/iris/bitstream/handle/10665/112320/WHO_;jsessionid=8F7CB114DE4A06D16891A43BDE58C807?sequence=1 .

United Nations Population Fund UNP. UNFPA annual report 2007. Available at: https://www.unfpa.org/publications/unfpa-annual-report-2007 . Accessed 30 May 2015.

Karamouzian M, Sharifi H, Haghdoost AA. Iran's shift in family planning policies: concerns and challenges. Int J Health Policy Manag. 2014;3(5):231–3.

Article   Google Scholar  

Chandra-Mouli V, Camacho AV, Michaud PA. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. J Adolesc Health. 2013;52(5):517–22.

Hawkins L, Spitzer RF, Christoffersen-Deb A, Leah J, Mabeya H. Characteristics and surgical success of patients presenting for repair of obstetric fistula in western Kenya. Int J Gynaecol Obstet. 2013;120(2):178–82.

Kingston D, Heaman M, Fell D, Chalmers B. Comparison of adolescent, young adult, and adult women's maternity experiences and practices. Pediatrics. 2012;129(5):e1228–37.

Quinlivan JA, Evans SF. Teenage antenatal clinics may reduce the rate of preterm birth: a prospective study. BJOG. 2004;111(6):571–8.

Malabarey OT, Balayla J, Klam SL, Shrim A, Abenhaim HA. Pregnancies in young adolescent mothers: a population-based study on 37 million births. J Pediatr Adolesc Gynecol. 2012;25(2):98–102.

Fleming NA, Tu X, Black AY. Improved obstetrical outcomes for adolescents in a community-based outreach program: a matched cohort study. J Obstet Gynaecol Can. 2012;34(12):1134–40.

Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014;121 Suppl 1:40–8.

Article   CAS   Google Scholar  

Aliyu MH, Luke S, Kristensen S, Alio AP, Salihu HM. Joint effect of obesity and teenage pregnancy on the risk of preeclampsia: a population-based study. J Adolesc Health. 2010;46(1):77–82.

Torvie AJ, Callegari LS, Schiff MA, Debiec KE. Labor and delivery outcomes among young adolescents. Am J Obstet Gynecol. 2015;213(1):95.

Usta IM, Zoorob D, ABU-MUSA A, Naassan G, Nassar AH. Obstetric outcome of teenage pregnancies compared with adult pregnancies. Acta Obstet Gynecolo Scand. 2008;87(2):178–83.

Lindgren K. Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy. Res Nurs Health. 2001;24(3):203–17.

Widen E, Siega-Riz AM. Prenatal nutrition: a practical guide for assessment and counseling. J Midwifery Women’s health. 2010;55(6):540–9.

Arslan Ozkan I, Mete S. Pregnancy planning and antenatal health behaviour: findings from one maternity unit in Turkey. Midwifery. 2010;26(3):338–47.

Green-Raleigh K, Lawrence JM, Chen H, Devine O, Prue C. Pregnancy planning status and health behaviors among nonpregnant women in a California managed health care organization. Int Perspect Sexual Reprod Health. 2005;37(4):179–83.

Lindgren K. Testing the health practices in pregnancy questionnaire-II. JOGNN. 2005;34(4):465–72.

Weisman CS, Hillemeier MM, Downs DS, Feinberg ME, Chuang CH, Botti JJ, et al. Improving women's preconceptional health: long-term effects of the strong healthy women behavior change intervention in the Central Pennsylvania Women's health study. Womens Health Issues. 2011;21(4):265–71.

Stutzman SS, Brown CA, Hains SM, Godwin M, Smith GN, Parlow JL, et al. The effects of exercise conditioning in normal and overweight pregnant women on blood pressure and heart rate variability. Biol Res Nurs. 2010;12(2):137–48.

Zavorsky GS, Longo LD. Adding strength training, exercise intensity, and caloric expenditure to exercise guidelines in pregnancy. Obstet Gynecol. 2011;117(6):1399–402.

Codato LA, Nakama L, Cordoni L Jr, Higasi MS. Dental treatment of pregnant women: the role of healthcare professionals. Cien Saude Colet. 2011;16(4):2297–301.

Feinberg ME, Jones DE, Kan ML, Goslin MC. Effects of family foundations on parents and children: 3.5 years after baseline. J Fam Psychol. 2010;24(5):532–42.

Johnson RB, Onwuegbuzie AJ. Mixed methods research: a research paradigm whose time has come. Educ Res. 2004;33(7):14–26.

Creswell J, Clark V. Designing and conducting mixed methods research. 2nd ed. Los Angles: Sage Pubns; 2011.

Google Scholar  

Maddahi MS, Dolatian M, Khoramabadi M, Talebi A. Correlation of maternal-fetal attachment and health practices during pregnancy with neonatal outcomes. Electron Physician. 2016;8(7):2639–44.

Montazeri A, Torkan B, Omidvari S. The Edinburgh postnatal depression scale (EPDS): translation and validation study of the Iranian version. BMC Psychiatry. 2007;7(1):11.

Cranley MS. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res. 1981;30(5):281–4.

Abasi A, Tafazoli M, Esmaeili H. The effect of foetal movement counting on primipara maternal foetal attachment. J Mazandaran Univ Med Sci. 2010;20(77):53–60.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.

Tashakkori A, Creswell JW. The new era of mixed methods. J Mixed Methods Res. 2007;1(1):3–7.

World Health Organization. Adolescent pregnancy 2018 [updated 23 February; cited 29 2018 May]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy .

Download references

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.

Availability of data and materials

Not applicable.

Author information

Authors and affiliations.

Students’ Research Committee, Tabriz University of Medical sciences, Tabriz, Iran

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

Eesa Mohammadi

You can also search for this author in PubMed   Google Scholar

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.

Corresponding author

Correspondence to Mojgan Mirghafourvand .

Ethics declarations

Ethics approval and consent to participate.

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).

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 13 March 2019

Accepted : 15 April 2019

Published : 25 April 2019

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

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Health practices
• Adolescent pregnant women
• Mixed method

Reproductive Health

ISSN: 1742-4755

• General enquiries: [email protected]

• - Google Chrome

Intended for healthcare professionals

• Access provided by Google Indexer
• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• Teenage pregnancy and...

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

• Related content
• 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

• View inline

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

• Download figure
• Open in new tab
• Download powerpoint

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 .

• ↵ Department for Education and Skills. Teenage Pregnancy: accelerating the strategy to 2010 . Department for Education and Skills, 2006 . http://www.dcsf.gov.uk/everychildmatters/resources-and-practice/ig00156/ .
• ↵ Holgate HS, Evans R, Yuen FKO. Teenage pregnancy and parenthood: global perspectives, issues and interventions . Routledge, 2006 .
• ↵ United Nations International Children’s Emergency Fund. A league table of teenage births in rich nations. Innocenti Report Card No. 3 . UNICEF Innocenti Research Centre, 2001 .
• ↵ Hoffman SD. Teenage childbearing is not so bad after all—is it? A review of new literature. Int Fam Plan Perspect 1998 ; 30 : 236 -9. OpenUrl CrossRef
• ↵ Bonell CP. Why is teenage pregnancy conceptualised as a social problem? A review of quantitative research from the USA and UK. Cult Health Sex 2004 ; 6 : 1 -18. OpenUrl PubMed
• ↵ Ermisch J. Does a ‘teen-birth’ have longer-term impacts on the mother? Suggestive evidence from the British household panel survey . Institute for Social and Economic Research, 2003 .
• ↵ Pevalin DJ. Outcomes in childhood and adulthood by mother’s age: evidence from the 1970 British cohort study . Institute for Social and Economic Research, 2003 .
• ↵ Berrington A, Diamond I, Ingham R, Stevenson J, Borgoni R, Hernández I, et al. Consequences of teenage parenthood: pathways which minimise the long term negative impacts of teenage childbearing: final report . University of Southampton, 2005 .
• ↵ Social Exclusion Unit. Teenage pregnancy . HMSO, 1999 .
• ↵ UNICEF. Child poverty and perspective: an overview of child wellbeing in rich countries . UNICEF, 2007 .
• ↵ Office for National Statistics. Conception statistics in England and Wales, 2007 . ONS, 2009 .
• ↵ DiCenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. BMJ 2002 ; 324 : 1426 -34. OpenUrl Abstract / FREE Full Text
• ↵ Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, et al. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial. BMJ 2007 ; 334 : 133 . OpenUrl Abstract / FREE Full Text
• ↵ Allen E, Bonell C, Strange V, Copas A, Stephenson J, Johnson AM, et al. Does the UK government’s teenage pregnancy strategy deal with the correct risk factors? Findings from a secondary analysis of data from a randomised trial of sex education and their implications for policy. J Epidemiol Community Health 2007 ; 51 : 20 -7. OpenUrl
• ↵ Cheesbrough S, Ingham R, Massey D. A review of the international evidence on preventing and reducing teenage conceptions: the United States, Canada, Australia and New Zealand . Health Development Agency, 2002 .
• ↵ Kane R, Wellings K. Reducing the rate of teenage conceptions: an international review of the evidence: data from Europe . London School of Hygiene and Tropical Medicine, University of London, 2003 .
• ↵ McLeod A. Changing patterns of teenage pregnancy: population based study of small areas. BMJ 2001 ; 323 : 199 -203. OpenUrl Abstract / FREE Full Text
• ↵ Fletcher A, Harden A, Brunton G, Oakley A, Bonell C. Interventions addressing the social determinants of teenage pregnancy. Health Educ 2008 ; 108 : 29 -39. OpenUrl CrossRef
• ↵ Wellings K, Kane R. Trends in teenage pregnancy in England and Wales: how can we explain them? J R Soc Med 1999 ; 92 : 277 -82. OpenUrl Abstract / FREE Full Text
• ↵ Evans T, Brown H. Road traffic crashes: Operationalizing equity in the context of health service reform. Int J Inj Contr Saf Promot 2003 ; 10 : 11 -2. OpenUrl CrossRef
• ↵ Anand S, Razak F, Davis A, Jacobs R, Vuksan V, Teo K, et al. Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects. Int J Epidemiol 2006 ; 35 : 1239 -45. OpenUrl Abstract / FREE Full Text
• ↵ Thomas J, Harden A, Oakley A, Oliver S, Sutcliffe K, Rees R, et al. Integrating qualitative research with trials in systematic reviews: an example from public health. BMJ 2004 ; 328 : 1010 -2. OpenUrl FREE Full Text
• ↵ Harden A, Thomas J. Methodological issues in combining diverse study types in systematic reviews. Int J Soc Res Meth 2005 ; 8 : 257 -71. OpenUrl CrossRef
• ↵ Graham H, McDermott E. Qualitative research and the evidence base of policy: Insights from studies of teenage mothers in the UK. J Soc Policy 2005 ; 35 : 21 -37. OpenUrl CrossRef Web of Science
• ↵ Pope C, Ziebland C, Mays N. Qualitative research in health care: Analysing qualitative data. BMJ 2000 ; 320 : 114 -6. OpenUrl FREE Full Text
• ↵ Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res 1998 ; 8 : 341 -51. OpenUrl Abstract / FREE Full Text
• ↵ Oakley A, Fullerton D, Holland J, Arnold S, France-Dawson M, Kelly P, et al. Sexual health education interventions for young people: a methodological review. BMJ 1995 ; 310 : 158 -62. OpenUrl Abstract / FREE Full Text
• ↵ Peersman G, Oakley A, Oliver S, Thomas J. Review of effectiveness of sexual health promotion interventions for young people . EPPI-Centre, 1996 .
• ↵ Thomas J, Sutcliffe K, Harden A, Oakley A, Oliver S, Rees R, et al. Children and healthy eating: a systematic review of barriers and facilitators . EPPI-Centre, University of London, 2003 .
• ↵ Boulton MR, Fitzpatrick R, Swinburn C. Qualitative research in health care II: a structured review and evaluation of studies. J Eval Clin Pract 1996 ; 2 : 171 -9. OpenUrl CrossRef PubMed
• ↵ Cobb AK, Hagemaster JN. Ten criteria for evaluating qualitative research proposals. J Nurs Educ 1987 ; 26 : 138 -43. OpenUrl PubMed
• ↵ Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000 ; 320 : 50 -2. OpenUrl FREE Full Text
• ↵ Medical Sociology Group. Criteria for the evaluation of qualitative research papers. Medical Sociology News 1996 ; 22 : 69 -71. OpenUrl
• ↵ Peersman G, Oliver S, Oakley A. Review guidelines: data collection for the EPIC database . EPPI-Centre, 1997 .
• ↵ EPPI-Centre. Guidelines for extracting data and quality assessing primary studies in educational research (version 0.97) . EPPI-Centre, 2002 .
• ↵ Thomas J, Brunton J. EPPI-Reviewer 3.0: analysis and management of data for research synthesis .: EPPI-Centre, 2006 .
• ↵ Cooper H, Hedges L. The Handbook of Research Synthesis . Russell Sage Foundation, 1994 .
• ↵ Egger G, Davey-Smith D, Altman D. Systematic reviews in health care: meta-analysis in context . BMJ Group, 2001 .
• ↵ Lipsey MW, Wilson DB. Practical Meta-Analysis . Sage Publications Inc, 2001 .
• ↵ Rees R, Kavanagh J, Burchett H, Shepherd J, Brunton G, Harden A, et al. HIV Health promotion and men who have sex with men (MSM): a systematic review of research relevant to the development and implementation of effective and appropriate interventions . EPPI-Centre, 2004 .
• ↵ Harden A, Garcia J, Oliver S, Rees R, Shepherd J, Brunton G, et al. Applying systematic review methods to studies of people’s views: an example from public health research. J Epidemiol Community Health 2004 ; 58 : 794 -800. OpenUrl Abstract / FREE Full Text
• ↵ Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008 ; 8 : 45 . OpenUrl CrossRef PubMed
• ↵ Bryman A, Burgess G. Analysing Qualitative Data . Routledge, 1994 .
• ↵ Miles M, Huberman A. Qualitative Data Analysis . Sage, 1994 .
• ↵ Zoritch B, Roberts I, Oakley A. The health and welfare effects of day-care: a systematic review of randomised controlled trials. Soc Sci Med 1998 ; 47 : 317 -27. OpenUrl CrossRef PubMed Web of Science
• ↵ Stephenson J, Strange V, Forrest S, Oakley A, Copas A, Allen E, et al. Pupil-led sex education in England (RIPPLE study): cluster-randomised intervention trial. Lancet 2004 ; 364 : 338 -46. OpenUrl CrossRef PubMed Web of Science
• ↵ Wiggins M, Oakley A, Sawtell M, Austerberry H, Clemens F, Elbourne D. Teenage parenthood and social exclusion: a multi-method study . Social Science Research Unit Report, 2005 .
• ↵ Bonell CP, Strange VJ, Stephenson JM, Oakley AR, Copas AJ, Forrest SP, et al. The effect of various dimensions of social exclusion on young people’s risk of teenage pregnancy: development of hypotheses from analysis of baseline data arising from a randomized trial of sex education. J Epidemiol Community Health 2003 ; 57 : 871 -6. OpenUrl Abstract / FREE Full Text
• ↵ Bonell C, Allen E, Strange V, Copas A, Oakley A, Johnson A, et al. The effect of dislike of school on risk of teenage pregnancy: testing of hypotheses using longitudinal data from a randomised trial of sex education. J Epidemiol Community Health 2005 ; 59 : 223 -30. OpenUrl Abstract / FREE Full Text
• ↵ McDermott E, Graham H. Resilient young mothering: social inequalities, late modernity and the ‘problem’ of ‘teenage’ motherhood. J Youth Studies 2005 ; 8 : 59 -79. OpenUrl CrossRef
• ↵ Bonell C, Oakley A, Hargreaves J, Strange V, Rees R. Assessment of generalisability in trials of health interventions: suggested framework and systematic review. BMJ 2006 ; 333 : 346 -9. OpenUrl FREE Full Text
• ↵ Wiggins M, Bonell C, Sawtell M, Austerberry H, Burchett H, Allen E, Strange V. Health outcomes of youth development programme in England: prospective matched comparison study. BMJ 2009;339:b2534.
• ↵ Acheson D. Independent inquiry into inequalities in health . The Stationery Office, 1998 .
• ↵ Dhalgren G, Whitehead M. European strategies for tackling inequalities in health: levelling up part 2 . World Health Organisation, 2007 .
• ↵ Graham H. Social determinants and public health policy in the UK. In: Killoran A, Swann C, Kelly M, eds. An evidence-based approach to public health and tackling health inequalities: opportunities and challenges . Oxford University Press, 2006 .

Early pregnancy in schools: a socio-ecological analysis of the determinants among teenage girls in Koudougou, Burkina Faso

• Find this author on Google Scholar
• Find this author on PubMed
• Search for this author on this site
• ORCID record for Patrice Ngangue
• For correspondence: [email protected]
• Info/History
• Preview PDF

Introduction Early pregnancy among adolescents in school has several consequences on the adolescent herself, her family, the whole community, and the child-to-be. This article explores the factors determining early pregnancy among 15-19-year-old secondary school students in Koudougou in Burkina Faso.

Methods A descriptive and exploratory qualitative study was conducted through focus groups with adolescents and youth in schools and individual interviews with parents, teachers, health workers, and community leaders. The socio-ecological model guided all stages of the study. A thematic analysis of the recorded and transcribed data was conducted using Nvivo 12 software.

Results A lack of knowledge and information and wrong perceptions about sexuality at the individual level; peer pressure and poverty at the interpersonal level; lack of awareness among teachers and students and health workers’ attitudes at the organizational level; the influence of new information technologies or the media and parents’ irresponsibility at the community level; and the insufficient of sexual and reproductive health services for adolescents as well as the lack of sanctions and law against early pregnancy at the political level were found as enablers. Barriers were the use of contraceptive methods and sexual abstinence; parents-children communication; teachers’ training on sexual sensitization, the creation of youth centers on school campuses and the introduction of sexual education courses; education through media and religion; willingness to introduce sexual education courses in school curricula and legal sanctioning of dealing and consuming drugs in schools.

Conclusion The study highlighted that the problem of early pregnancy in schools can be solved by acting on the determinants at all levels of the socioecological model by implementing preventive strategies.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study did not receive any funding

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval was obtained from the Burkina Faso Health Research Ethics Committee (CERS); number: 2021-12-288.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

All data produced in the present work are contained in the manuscript

List of acronyms and abbreviations

View the discussion thread.

Thank you for your interest in spreading the word about medRxiv.

NOTE: Your email address is requested solely to identify you as the sender of this article.

Citation Manager Formats

• EndNote (tagged)
• EndNote 8 (xml)
• RefWorks Tagged
• Ref Manager
• Tweet Widget
• Facebook Like
• Google Plus One

Subject Area

• Sexual and Reproductive Health
• Addiction Medicine (316)
• Allergy and Immunology (617)
• Anesthesia (159)
• Cardiovascular Medicine (2276)
• Dentistry and Oral Medicine (279)
• Dermatology (201)
• Emergency Medicine (370)
• Endocrinology (including Diabetes Mellitus and Metabolic Disease) (798)
• Epidemiology (11575)
• Forensic Medicine (10)
• Gastroenterology (678)
• Genetic and Genomic Medicine (3576)
• Geriatric Medicine (336)
• Health Economics (616)
• Health Informatics (2304)
• Health Policy (913)
• Health Systems and Quality Improvement (863)
• Hematology (335)
• HIV/AIDS (752)
• Infectious Diseases (except HIV/AIDS) (13149)
• Intensive Care and Critical Care Medicine (755)
• Medical Education (359)
• Medical Ethics (100)
• Nephrology (388)
• Neurology (3346)
• Nursing (191)
• Nutrition (506)
• Obstetrics and Gynecology (651)
• Occupational and Environmental Health (645)
• Oncology (1756)
• Ophthalmology (524)
• Orthopedics (209)
• Otolaryngology (284)
• Pain Medicine (223)
• Palliative Medicine (66)
• Pathology (437)
• Pediatrics (1001)
• Pharmacology and Therapeutics (422)
• Primary Care Research (406)
• Psychiatry and Clinical Psychology (3058)
• Public and Global Health (5983)
• Radiology and Imaging (1221)
• Rehabilitation Medicine and Physical Therapy (714)
• Respiratory Medicine (811)
• Rheumatology (367)
• Sexual and Reproductive Health (350)
• Sports Medicine (316)
• Surgery (386)
• Toxicology (50)
• Transplantation (170)
• Urology (142)

Women's health researchers explore pregnancy and postpartum muscle strength

A decade-long partnership between the University of Hawaiʻi at Mānoa and the Federal University of Rio Grande do Norte (UFRN) has yielded significant advancements in global research and scholarship, particularly in women's health.

Catherine Pirkle from UH Mānoa's Thompson School of Social Work & Public Health and Saionara Câmara from UFRN's Department of Physical Therapy have been at the forefront of this collaboration, providing interdisciplinary and global health experiences to students and fellows from Northeast Brazil and Hawaiʻi.

"Our ongoing collaboration epitomizes UH Mānoa's dedication to fostering impactful global connections through robust partnerships, amplifying our collective efforts towards advancing women's health research on a global scale," said Pirkle, an associate professor in the Office of Public Health Studies at UH Mānoa.

Interventions for adolescent mothers

Their latest joint endeavor, a paper titled "Muscle strength during pregnancy and postpartum in adolescents and adults," published in PLOS ONE , adds to their growing body of work. The research offers compelling evidence advocating for interventions aimed at adolescent mothers, emphasizing the importance of lower-body resistance training to mitigate the risk of disability as these mothers age.

"Our research provides important insights into why adolescent mothers experience disability more frequently and at earlier ages than women who give birth as adults, and identifies ways to lower the disability risks," said Câmara, a professor at UFRN.

Student-involved research

Over the past decade, Pirkle and Câmara have co-authored 20 peer-reviewed scientific articles, all of which have involved students in the research process. Their studies have covered a wide range of topics, from exploring the links between teen pregnancy and obesity and heart disease to investigating the impact of urinary incontinence on the health of older women.

Their collaboration has also extended beyond research publications. As principal investigators on two Fogarty International supported research grants, they have facilitated bi-directional exchanges of students between UH Mānoa and UFRN. This exchange program has enabled trainees from Hawaiʻi to gain valuable experience in Northeast Brazil and vice versa, enriching their academic and professional development.

Both Pirkle and Câmara are Fulbright scholars, further highlighting the international recognition of their contributions to the field of women's health research.

More information: Maria Luiza da Silva Santos et al, Muscle strength during pregnancy and postpartum in adolescents and adults, PLOS ONE (2024). DOI: 10.1371/journal.pone.0300062

Provided by University of Hawaii at Manoa

Women with obesity do not need to gain weight during pregnancy, new study suggests

The guidelines for weight gain during pregnancy in obese women have long been questioned. New research from Karolinska Institutet supports the idea of lowering or removing the current recommendation of a weight gain of at least 5 kg. The results are published in The Lancet .

International guidelines from the US Institute of Medicine (IOM) state that women with obesity should gain a total of 5 to 9 kg during pregnancy, compared to 11.5 to 16 kg for normal-weight women. The guidelines have long been questioned, but there has been no evidence to warrant a re-examination.

A new study from Karolinska Institutet in Sweden now shows that there are no increased health risks for either the mother or the child with weight gain below current guidelines for women with obesity class 1 and 2 (BMI of 30-34.9 and 35-39.9 respectively). On the contrary, for women with obesity class 3 (BMI over 40), weight gain below current guidelines might even be beneficial for those with class 3 obesity.

The study supports previous calls to either lower or remove the current recommended lower limit of a weight gain of at least 5 kg, according to Kari Johansson, docent at the Department of Medicine, Solna.

"We hope that our research can inform a re-examination of national and international guidelines on weight gain during pregnancy," she says.

The study is based on electronic medical records and registry data for 15,760 women with obesity in Stockholm and Gotland (the so-called Stockholm Gotland Perinatal Cohort). 11,667 of the women in the study had obesity class 1, 3,160 had obesity class 2 and 933 had obesity class 3. The study included singleton pregnancies that delivered between 2008 and 2015. The women were followed for a median of eight years after delivery.

Ten known adverse outcomes associated with weight gain during pregnancy were studied: pre-eclampsia, gestational diabetes, excess postpartum weight retention, maternal cardiometabolic disease, unplanned caesarean delivery, preterm birth, large for gestational age and small for gestational age at birth, stillbirth and infant death. These adverse outcomes were assigned weights according to their severity and combined into an adverse composite outcome.

Overall, the study shows no increased risks of the adverse composite outcome with weight gain below current IOM guidelines in women with obesity classes 1 and 2. For women with obesity class 3, on the contrary, weight gain values below the guidelines or weight loss were associated with reduced risk of the adverse composite outcome. For example, an absence of weight gain (i.e. 0kg) was associated with a risk reduction of about 20 per cent.

"Based on this, we have concluded that weight gain below current recommendations is likely safe in pregnancies with obesity, and might even be beneficial for those with class 3 obesity," says Kari Johansson.

The results also indicate that there is a need for specific recommendations for women with class 3 obesity.

"Unlike today, this group could receive separate recommendations," says Kari Johansson.

The researchers will now proceed with similar studies on overweight, normal weight and underweight women.

The study was conducted in collaboration with the University of British Columbia, Canada, the University of Pittsburgh, USA, and the University of California, USA. Funders were Karolinska Institutet Research Grants and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

Kari Johansson and co-authors Lisa Bodnar and Jennifer Hutcheon are part of a WHO initiative for global standards for weight gain during pregnancy. However, the views expressed in the study do not reflect the views of the WHO. Olof Stephansson is co-founder and co-owner of a Swedish pregnancy app, One Million Babies. No other conflicts of interest are reported.

• Diet and Weight Loss
• Pregnancy and Childbirth
• Diseases and Conditions
• Teen Health
• Birth weight
• Bulimia nervosa
• Weight Watchers
• Weight machine
• Weight training

Story Source:

Materials provided by Karolinska Institutet . Note: Content may be edited for style and length.

Journal Reference :

• Kari Johansson, Lisa M Bodnar, Olof Stephansson, Barbara Abrams, Jennifer A Hutcheon. Safety of low weight gain or weight loss in pregnancies with class 1, 2, and 3 obesity: a population-based cohort study . The Lancet , 2024; DOI: 10.1016/S0140-6736(24)00255-1

Cite This Page :

Explore More

• High Carbon Impact of Tourism at Yellowstone
• Extreme Starburst Galaxy
• Asthma: Disease May Be Stoppable
• Stellar Collisions and Zombie-Like Survivors
• Tiny Robot Swarms Inspired by Herd Mentality
• How the Brain Regulates Emotions
• Evolution in Action? Nitrogen-Fixing Organelles
• Plastic-Free Vegan Leather That Dyes Itself
• Early Mesozoic Animals: High Growth Rates
• Virus to Save Amphibians from Deadly Fungus?

Trending Topics

Strange & offbeat.

• Program Finder
• Admissions Services
• Course Directory
• Academic Calendar
• Hybrid Campus
• Lecture Series
• Convocation
• Strategy and Development
• Implementation and Impact
• Integrity and Oversight
• In the School
• In the Field
• In Baltimore
• Resources for Practitioners
• Articles & News Releases
• In The News
• Statements & Announcements
• At a Glance
• Student Life
• Strategic Priorities
• Inclusion, Diversity, Anti-Racism, and Equity (IDARE)
• What is Public Health?

Research Identifies Characteristics of Cities That Would Support Young People’s Mental Health

Survey responses from global panel that included young people provide insights into what would make cities mental health-friendly for youth

As cities around the world continue to draw young people for work, education, and social opportunities, a new study identifies characteristics that would support young urban dwellers’ mental health. The findings, based on survey responses from a global panel that included adolescents and young adults, provide a set of priorities that city planners can adopt to build urban environments that are safe, equitable, and inclusive. 

To determine city characteristics that could bolster youth mental health, researchers administered an initial survey to a panel of more than 400, including young people and a multidisciplinary group of researchers, practitioners, and advocates. Through two subsequent surveys, participants prioritized six characteristics that would support young city dwellers’ mental health: opportunities to build life skills; age-friendly environments that accept young people’s feelings and values; free and safe public spaces where young people can connect; employment and job security; interventions that address the social determinants of health; and urban design with youth input and priorities in mind. 

The paper was published online February 21 in  Nature .

The study’s lead author is Pamela Collins, MD, MPH, chair of the Johns Hopkins Bloomberg School of Public Health’s Department of Mental Health. The study was conducted while Collins was on the faculty at the University of Washington. The paper was written by an international, interdisciplinary team, including citiesRISE, a global nonprofit that works to transform mental health policy and practice in cities, especially for young people.

Cities have long been a draw for young people. Research by UNICEF projects that cities will be home to 70 percent of the world’s children by 2050. Although urban environments influence a broad range of health outcomes, both positive and negative, their impacts manifest unequally. Mental disorders are the leading causes of disability among 10- to 24-year-olds globally. Exposure to urban inequality, violence, lack of green space, and fear of displacement disproportionately affects marginalized groups, increasing risk for poor mental health among urban youth.

“Right now, we are living with the largest population of adolescents in the world’s history, so this is an incredibly important group of people for global attention,” says Collins. “Investing in young people is an investment in their present well-being and future potential, and it’s an investment in the next generation—the children they will bear.” 

Data collection for the study began in April 2020 at the start of the COVID-19 pandemic. To capture its possible impacts, researchers added an open-ended survey question asking panelists how the pandemic influenced their perceptions of youth mental health in cities. The panelists reported that the pandemic either shed new light on the inequality and uneven distribution of resources experienced by marginalized communities in urban areas, or confirmed their preconceptions of how social vulnerability exacerbates health outcomes. 

For their study, the researchers recruited a panel of more than 400 individuals from 53 countries, including 327 young people ages 14 to 25, from a cross-section of fields, including education, advocacy, adolescent health, mental health and substance use, urban planning and development, data and technology, housing, and criminal justice. The researchers administered three sequential surveys to panelists beginning in April 2020 that asked panelists to identify elements of urban life that would support mental health for young people.

The top 37 characteristics were then grouped into six domains: intrapersonal, interpersonal, community, organizational, policy, and environment. Within these domains, panelists ranked characteristics based on immediacy of impact on youth mental health, ability to help youth thrive, and ease or feasibility of implementation. 

Taken together, the characteristics identified in the study provide a comprehensive set of priorities that policymakers and urban planners can use as a guide to improve young city dwellers' mental health. Among them: Youth-focused mental health and educational services could support young people’s emotional development and self-efficacy. Investment in spaces that facilitate social connection may help alleviate young people’s experiences of isolation and support their need for healthy, trusting relationships. Creating employment opportunities and job security could undo the economic losses that young people and their families experienced during the pandemic and help cities retain residents after a COVID-era exodus from urban centers.  

The findings suggest that creating a mental health-friendly city for young people requires investments across multiple interconnected sectors like transportation, housing, employment, health, and urban planning, with a central focus on social and economic equity. They also require urban planning policy approaches that commit to systemic and sustained collaboration, without magnifying existing privileges through initiatives like gentrification and developing green spaces at the expense of marginalized communities in need of affordable housing.

The authors say this framework underscores that responses by cities should include young people in the planning and design of interventions that directly impact their mental health and well-being. 

“ Making cities mental health friendly for adolescents and young adults ” was co-authored by an international, interdisciplinary team of 31 researchers led by the University of Washington Consortium for Global Mental Health, Urban@UW, the University of Melbourne, and citiesRISE. Author funding is listed in the Acknowledgements section of the paper.

Related Content

Student Spotlight: Glendedora Dolce

Study Estimates Nearly 70 Percent of Children Under Six in Chicago May Be Exposed to Lead-Contaminated Tap Water

Hidden Food Insecurity: The Adolescents Who Aren’t Getting Enough to Eat

A Zero-Emissions Transition Would Save Kids’ Lives

Child Diarrhea Has a Cheap and Easy Fix—Why Isn’t It Reaching Patients?

You are using an outdated browser. Please upgrade your browser or activate Google Chrome Frame to improve your experience.

• CENTERS & INSTITUTES

Research team examines role of parenting on LGBTQ mental health, substance use

Posted on April 2, 2024

by Matthew Smith

A paper published in Adolescent Research Review by a team featuring University of North Carolina at Chapel Hill School of Social Work faculty and students sheds light on parenting and its effect on LGBTQ youth.

Led by Associate Professor and Prudence and Peter Meehan Early Career Distinguished Scholar Melissa Lippold , Associate Professor and L. Richardson Preyer Early Career Scholar William Hall , graduate research assistants Denise Yookong Williams and Hayden Dawes were co-authors on the paper. UNC School of Social Work alum Melissa Jenkins and UNC School of Education Professor Roger Mills-Koonce also contributed to the study.

Lippold expanded on the study, its findings, and how she hopes its findings can help parents care for their children in the future.

Read the full paper online at Adolescent Research Review .

What was the overall purpose of the study?

Even though there is substantial research on parenting and its impacts on mental health and substance use in general, there has not been a lot of research on parenting LGBTQ youth. This is important because we know families are powerful influences on development, and interventions for parents and queer youth could potentially have large impacts. We decided to systematically review the literature on parenting and queer youth mental health and substance use. We also conducted a meta-analysis, which quantifies the effect of parenting across multiple studies.

Historically, why have queer youth faced higher rates of mental health and substance use challenges?

Queer youth face more stressors than heterosexual youth. For example, they face higher rates of harassment, rejection and discrimination. We know from minority stress theory and other research that these increases in stress can take a toll and can increase the risk of mental health challenges and substance use.

What research questions did you address as part of the systematic review?

We had three questions: What parenting factors are risk factors for mental health or substance use outcomes among queer youth? What parenting factors are protective factors for mental health or substance use outcomes among queer youth? And lastly, what is the magnitude and direction of parenting factors associated with mental health and substance use outcomes among queer youth?

What did the findings of the review show?

The findings showed a few things. First, we found that parenting matters for queer youth — that more parental support and less rejection were associated with less depression/anxiety and less substance use. Secondly, there was some evidence in the meta-analysis that parental rejection had stronger effects than parental support on queer youth mental health. Lastly, there is a need for a lot more research on parenting queer youth. Most of the studies were cross-sectional and they did not follow youth over time, making it harder to fully understand the long-term effects of parenting. Importantly, our measures of parenting, especially support, are very limited. Expanded conceptual models and new measures are needed that can capture how parents can affirm queer youth identity and promote queer youth well-being.

Did any of the findings surprise you or make you reexamine existing ideas/norms related to how to parent queer youth?

I was surprised that there were not more studies on parenting queer youth, given how important we know parenting is during adolescence .

The findings suggest that parental rejection may have a bigger impact than parental acceptance. Why might this be the case?

There are a couple of reasons that the effects of rejection were stronger than support. First, negative experiences can elicit really strong emotions. We know that negative emotions and thoughts about experiences can linger and last longer than positive ones. This can be important as rumination about negative events — thinking about them often — can increase the risk for depression. Secondly, the field has really limited measures on positive aspects of parenting queer youth. A lot of studies use general support measures — things like if you feel loved by your parent. Such measures don’t capture the ways parents might affirm their child’s sexual orientation and support queer youth identity. In contrast, most studies on rejection do measure rejection due to sexual orientation. Because of this, our studies may be better at capturing the effects of rejection than support.

A major point of the review was comparing parental care between families with queer youth versus comparing queer youth families and heterosexual youth families. Why was this an important element of the review?

A lot of existing research focuses on comparing the experiences of queer youth to heterosexual youth. Such research can tell us important information. But in this study, we really wanted to center the queer youth experience. By identifying risk and protective factors within families of queer youth, rather than in comparison to heterosexual youth, we can gain an understanding of family processes among queer youth specifically.

After completing the review, what are some of the interventions that may work best for families with queer youth to ensure that their mental health needs are met?

Interventions that aim to reduce parental rejection may be really important. We know a lot of families that initially reject their children eventually become more accepting, but we don’t have a lot of interventions that help parents become more accepting. Interventions that can facilitate acceptance would be crucial. We need more interventions in this area.

How do you hope this review helps researchers and clinicians in the future?

I hope it highlights the important role that parents play in queer youth mental health and substance use and leads to the development of more parent-based interventions. Parents matter and developing programs that increase parent support and reduce rejection will improve queer youth well-being.

Related stories

Research shines light on child protection services reporting

A paper featuring UNC School of Social Work Assistant Professor Rebecca Rebbe as the lead author examines the interactions between families and CPS.

UNC School of Social Work ranked fourth in national research expenditures

University of North Carolina at Chapel Hill School of Social Work researchers helped the school secure a top four placement in the latest NSF HERD Survey.