thesis adolescent pregnancy

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

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

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

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

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

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

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

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

Peer Review reports

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

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

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

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

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

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

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

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

Cohort selection

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

Independent variable

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

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

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

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

Analytic approach

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

Checking covariate balance of older sister’s teenage pregnancy status

Checking covariate balance of mother’ teenage mom status

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

Impact of older sister having a teenage pregnancy

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

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

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

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

Impact of mother’s teenage childbearing

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

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

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

Sensitivity analysis and limitations

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

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

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

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

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

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

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

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

Conclusions

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

Abbreviations

Adjusted Clinical Group

Canadian Classification of Health Intervention

Child and Family Services

International Classification of Diseases, Ninth Revision, Clinical Modification

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

Major Expanded Diagnostic Clusters

Manitoba Centre for Health Policy

Socioeconomic Factor Index

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Acknowledgements

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

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

Availability of data and materials

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

Authors’ contributions

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

Authors’ information

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

Competing interests

The authors declare that they have no competing interests.

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Not Applicable.

Ethics approval and consent to participate

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

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

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Pregnancy diagnosis codes

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

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

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

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

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

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

Or, a hospitalization with one of the following procedures:

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

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

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

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

Adjustment for educational achievement

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

Cohort adjustment

Older sister’s teenage pregnancy status

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

Mother's teenage childbearing status

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

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

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Published : 25 May 2016

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

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Qualitative Research on Adolescent Pregnancy: A Descriptive Review and Analysis

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

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• Published: 26 January 2024

Trends and factors associated with teenage pregnancy in Ethiopia: multivariate decomposition analysis

• Melkamu Aderajew Zemene 1 ,
• Fentaw Teshome Dagnaw 1 ,
• Denekew Tenaw Anley 1 ,
• Enyew Dagnew 2 ,
• Amare Zewdie 3 ,
• Aysheshim Belaineh Haimanot 4 &
• Anteneh Mengist Dessie 1  

Scientific Reports volume  14 , Article number:  2216 ( 2024 ) Cite this article

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Teenage is a time of transition from childhood to adulthood. This stage is a time of change and needs particular care and ongoing support. Adolescent pregnancy remains a common health care problem in low- and middle-income countries, and it is associated with higher maternal and neonatal complications. Thus, this study aimed to determine the trends and factors associated with them that either positively or negatively contributed to the change in teenage pregnancy in Ethiopia. Ethiopian Demographic and Health Survey data from 2005 to 2016 were used for this study. A total weighted sample of 10,655 (3265 in 2005, 4009 in 2011, and 3381 in 2016) teenagers was included. Trends and the proportion of teenage pregnancies for each factor over time were explored. Then, a logit-based multivariate decomposition analysis for a non-linear response model was fitted to identify the factors that contributed to the change in teenage pregnancy. Statistical significance was declared at p-value < 0.05 and the analysis was carried out on weighted data. Teenage pregnancy declined significantly from 16.6% (95% CI: 15.4, 17.9) to 12.5% (95% CI: 11.4, 13.6) in the study period, with an annual reduction rate of 2.5%. About 49.8% of the decrease in teenage pregnancy was attributed to the change in the effect of the characteristics. The compositional change in primary educational status (41.8%), secondary or above educational status (24.55%), being from households with a rich wealth index (1.41%) were factors positively contributed to the decline in teenage pregnancy, whereas being from a Muslim religion (−12.5%) was the factor that negatively contributed to the reduction in teenage pregnancy. This study has shown that teenage pregnancy declined significantly; however, it is still unacceptably high. The changes in compositional factors of teenagers were responsible for the observed reduction in the prevalence of teen pregnancy rates in Ethiopia. Educational status, religion, and wealth index were found to be significant factors that contributed to the reduction in teenage pregnancy. Therefore, intervention programs targeting adolescents should address the socio-economic inequalities of these influential factors to reduce teenage pregnancy and related complications.

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Introduction.

Teenage is a time of transition from childhood to adulthood. World Health Organization (WHO) defines the age group 10–19 years as the adolescent stage and teenagers are from 13 to 19 years adolescents 1 . This stage is a time of change and needs particular care and ongoing support. Their life is in grave danger due to physical, emotional, mental, and social changes 2 . Teenage childbearing among adolescents aged 15 to 19 is a common sexual and reproductive health (SRH) issue among young people, particularly in developing countries. It is associated with higher maternal and neonatal complications 3 . When a girl between the ages of 15 and 19 becomes pregnant for the first time or gives birth, it is referred to as teenage pregnancy or adolescent childbearing. Teenage pregnancy may drastically alter the girl’s life. For instance, teenage pregnancy often disrupts a teenager’s education, with many drooping out of school or experiencing difficulties in completing their education. This can limit their future opportunities for employment and economic stability. As a result, teenage pregnancy creates a group of young ladies with little education and little economic options who are unable to contribute to the country's progress 4 .

Every year, 2 million teenagers under the age of 15 and around 16 million adolescent girls between the ages of 15 and 19 give birth. Nearly 95% of these births which make up around 11% of all births worldwide take place in underdeveloped nations. Teenage pregnancy rates varied by region, from 2% in China to 18% in Latin America and the Caribbean to more than 50% in sub-Saharan Africa 5 .

Countries in SSA continue to have high rates of teenage pregnancies, despite many policies and programs are designed to lower this number 6 . Evidence from systematic review and meta-analysis showed that the pooled prevalence of adolescent pregnancy in Africa was 18.8%, and it was 19.3% in sub-Saharan Africa region. The highest prevalence was in East Africa with 21.5%, and the lowest was from North Africa with 9.2% 7 . Moreover, teenage pregnancy among adolescents who had ever had sex ranged from 36.5% in Rwanda to 75.6% in Chad 8 . In Zambia, teenage pregnancy has shown an overall decrease of only 2% in a period more than a decade and half 9 . In Uganda, teenagers contributed substantially to live births (26.7%), stillbirths (19.2%), low birth weight infants (42.7%), and referrals (17.3%) 10 . In Tanzania teenage pregnancy increased from the year 2010 to 2016 4 . The prevalence rate of teenage pregnancies seems to be on the increase, especially in rural communities of Zimbabwe 11 .

Findings from systematic review and meta-analysis reported the prevalence of teenage pregnancy in Ethiopia ranges from 12.5 to 30.2% 12 . Evidence from national studies revealed that teenage pregnancy reduced from 16.3% in 2000 to 12.5% in 2016 13 . On the other hand, a local study among school adolescents of Arba Minch Town, Southern Ethiopia revealed a 7.7% teenage pregnancy 14 . Another study in Kersa District, East Haraghe Zone, Oromia Regional State reported a high prevalence of teenage pregnancy with 30.2% 15 .

Numerous factors contribute to sub-Saharan Africa's high rates of adolescent pregnancies. The three main themes identified by studies as impacting adolescent pregnancies are social and economic, personal, and health service-related variables. Adolescent pregnancy rates may be decreased by community awareness, thorough sexual health education, and ensuring women education 7 , 16 , 17 .

Age, contraceptive utilization, marital status, working status, household wealth status, community-level contraceptive utilization, age at initiation of sex, media exposure, educational level, and relation to the household head were associated with adolescent pregnancy 12 , 17 , 18 , 19 . Moreover, studies in Ethiopia showed that sexual practice before the age of 15 years, not being in school, parental divorce, having an elder sister who had a history of teenage pregnancy, and not knowing fertile period in the menstrual cycle were factors associated with teenage pregnancy 3 , 12 , 18 , 20 , 21 .

Even though there have been different local studies on the prevalence and factors associated with teenage pregnancy in Ethiopia, to the best knowledge of the authors, there is limited evidence on the factors either positively or negatively contributed to the change in teenage pregnancy so far in Ethiopia. Therefore, this study aimed to examine trends, and the factors that contributed to the change in the prevalence of teenage pregnancy in Ethiopia. Thus, findings from this study will help policymakers, program managers, and scholars in evaluating and designing strategies targeting influential factors to reduce teenage pregnancy. Moreover, the results of this study will be crucial for developing intervention programs to reduce teenage childbearing and related complications.

Methods and materials

Data source.

Secondary data analysis was conducted based on the Ethiopian Demographic and Health Survey (EDHS) of 2005, 2011, and 2016. EDHS is a nationally representative population-based survey that has been conducted every five years. Demographic and Health Survey used a two-stage stratified cluster sampling technique. In the first stage, a sample of EAs was selected independently from each stratum with proportional allocation stratified by residence. In the second stage, from the selected EAs, households were taken by systematic sampling technique. The data were accessed from the DHS program official database https://www.measuredhs.com after permission was granted through an online request.

Study population

The source population was all teenagers in five years preceding each respective survey in Ethiopia, whereas those in the selected Enumeration Areas (EAs) were the study population. The sample size was determined from the individual to recode file “IR file”. A total weighted sample of 10,655 (3265 in 2005, 4009 in 2011, and 3381 in 2016) teenagers was included in this study.

Study variables

Outcome variable.

The outcome variable was teenage pregnancy taken as a binary response; 0 coded for “no” and 1 coded for “yes”.

Independent variables

The independent variables include; educational status (no education, primary education, and secondary or above), family size (less than six, greater than or equal to six), residence (urban, rural), religion (Orthodox, Muslim, Protestant, others), occupation (employed, not employed), marital status (“unmarried” which includes never in union, separated, divorced, widowed, and “married”), husband education (no education, primary education, and secondary or above), sex of head of the household (male, female), media exposure (yes, no), wealth index (poor, middle, rich), age at first marriage, contraceptive use (using modern methods, using traditional methods, non-user-intend to use later, and do not intend to use), age at first intercourse (never had sex, active before the age of 18, and active after 18 years), and age at first birth (gave birth before 18 years, gave birth after the age of 18 years) (Table 1 ).

Operational definition

Teenage pregnancy.

Teenage pregnancy is the percentage of adolescent girls who have begun childbearing, that is the sum of the percentage who gave birth and/ or the percentage who are pregnant with their first child 22 .

Wealth index

Wealth index is a composite measure of a household’s cumulative living standard divided into five quantiles using the wealth quantile data derived from the principal component analysis 22 . In this study, we recategorized into three groups as poor (includes poorer and poorest), middle, and rich (includes richer and richest).

Statistical analysis

The data were analyzed by using Stata version 16/MP software. All statistical analysis was conducted on weighted data to account for DHS complex survey design. First, a descriptive analysis was done to examine the trends with a 95% confidence interval (CI) of teenage pregnancy. Similarly, the proportion of teenage pregnancy by study participants’ characteristics was explored. Then, a logit-based multivariate decomposition analysis for a non-linear response model was implemented to determine the extent to which factors contributed to the observed change in teenage pregnancy.

In the bivariate analysis, variables with a p-value of less than 0.25 were selected for multivariate decomposition analysis. Then, a p-value of less than 0.05 with 95% CI was used to declare statistical significance after fitting to multivariate decomposition analysis in the overall decomposition.

The multivariate decomposition analysis model

Multivariate decomposition analysis for a non-linear model is used to split the difference in a distribution statistic between two groups, or its change over time, into various explanatory factors. This statistical approach uses the output from regression models to partition the components of a group difference in a statistic, such as a mean or proportion, into a component attributable to compositional differences between groups; differences in characteristics (endowments), and a component attributable to differences in the effects of characteristics (differences in coefficients). This analysis technique is equally applicable for partitioning change over time into components attributable to changing composition and changing effects 23 , 24 , 25 , 26 .

The dependent variable is the function of the linear combination of predictors and regression coefficients.

where Y denotes the N × 1 dependent variable vector, X is an N × K matrix of independent variables, and β is a K × 1 vector of coefficients. F (·) is any once-differentiable function mapping a linear combination of X(Xβ) to Y. The overall differences in components that reflect compositional differences between groups (endowments) and differences in the effects of characteristics (coefficients) between two groups A and B can be decomposed as:

The component labeled “E” refers to the part of the differential attributable to differences in endowments or characteristics, usually called the explained component or characteristics effect. The “C” component is the difference attributable to coefficients (behavioral change) usually called the unexplained component. We have chosen group A as the comparison group and group B as the reference group. Thus, E reflects a counterfactual comparison of the difference in outcome from group A’s perspective (i.e., the expected difference if group A were given group B’s distribution of covariates). C reflects the counterfactual comparison of the difference in outcome from group B’s perspective (i.e., the expected differences if group B were experienced in group A’s behavioral response to X).

In this study, we applied a decomposition analysis to account for changes in teenage pregnancy between 2005 and 2016. The model for decomposition analysis was: Logit (A) − Logit (B) = [β0A − β0B] + ΣβijA [XijA − XijB] + ΣxijB[βijA − βijB] 23

β0A was the intercept in the regression equation for EDHS 2016.

β0B was the intercept in the regression equation for EDHS 2005.

βijA was the coefficient of the jth category of the ith determinant for EDHS 2016.

βijB was the coefficient of the jth category of the ith determinant for EDHS 2005

XijA was the proportion of the jth category of the ith determinant for EDHS 2016.

XijB was the proportion of the jth category of the ith determinant for EDHS 2005.

Ethical approval

Permission to access the data was obtained from the webpage of the International Review Board of Demographic and Health Survey (DHS) program. The dataset is publicly available in requesting a concept note for a proposed project from ( https://www.measuredhs.com ). Initially, the Ethiopian Demographic and Health Survey (EDHS) followed its ethical procedures and the detail is also available in the full report 22 .

Socio-demographic characteristics

In this study, a total weighted sample of 10,655 adolescent teens were included. The mean ± Standard Deviation (SD) of age was almost similar with 16.9 ± 1.3 years. Regarding educational status, adolescent girls who were not educated decreased from 40% in 2005 to 13.8% in 2016. The proportion of teenagers who had media exposure increased from 42.5 to 52.4% in the same period (Table 2 ).

Sexual and reproductive characteristics

The mean ± SD of age at first marriage was 14.6 ± 2.2 in EDHS 2005 which raised to 15.4 ± 1.6 in EDHS 2016. About one-fourth (25.7%) of adolescent girls were sexually active before their eighteenth birth date in 2005 which later slightly decreased to 22% in 2016. Regarding knowledge of contraceptives, around 18.9% of them did not know any contraceptive methods in 2005 but decreased to 3% in 2016 (Table 2 ).

Trend of teenage pregnancy

Overall, the trend of teenage pregnancy decreased significantly (p < 0.001) with a 4.1% percent point change from 16.6% (95% CI: 15.4, 17.9) to 12.5% (95% CI: 11.4, 13.6) in the study period with an annual reduction rate of 2.5% (Fig.  1 ). In the first phase (2005–2011), teenage pregnancy reduced from 16.6% (95% CI: 15.4, 17.9) to 12.3% (95% CI: 11.3, 13.4) (Fig.  1 ).

Trend of teenage pregnancy in Ethiopia by using data from EDHS 2005–2016.

The trend of teenage pregnancy over the study period (2005–2016) varied in terms of different factors. For instance, the overall change in teenage pregnancy among rural residents was 4.6% in the study period. Based on region, the highest reduction was observed in Gambella (14.6%) percentage change followed by Beneshangul-gumz (13.5%) region. The proportion of teenage pregnancy among the orthodox religion decreased from 15.8% in 2005 to 7.7% in 2016. The prevalence of teenage pregnancy was found high among adolescents who had no media exposure 22.6% as compared to 12.2% of those who had media exposure in 2005. And it decreased to 16.7% and 8.7% in 2016 respectively (Table 3 ).

Factors associated with a change in teenage pregnancy

Decomposition analysis.

There has been a significant decline in the overall change in teenage pregnancy in Ethiopia from 2005 to 2016. The overall decomposition revealed that the decline in teenage pregnancy over time was explained by the difference in characteristics (endowments). However, the change due to the difference in the effect of the selected explanatory variables was not found to be significant (Table 4 ).

After controlling the role of change in coefficients, 49.8% of the decline in teenage pregnancy in Ethiopia was due to differences in characteristics (endowments). Thus, educational status, religion, and wealth index had a statistically significant contribution to the change in teenage pregnancy. Keeping the other variables constant, as the result of an increase in the proportion of adolescents in primary, secondary, and above school in the survey years (Table 1 ) had a statistically significant positive contribution to the decline of teenage pregnancy (Table 5 ). Followers of the Muslim religion were more likely to get married and became pregnant earlier. As a result, an increase in the proportion of Muslim followers in the survey (Table 1 ) had a significant negative impact on the decline in teenage pregnancy (Table 5 ). Regarding the wealth index, the change in the composition of the survey population from households with the rich wealth index resulted in a significant positive impact on the decrement of teenage pregnancy (Table 5 ).

Despite efforts to stop early pregnancies, teenage pregnancy has been continued as a global public health problem. Therefore, this study was designed to examine the trend and pinpoint factors that contributed to the observed reduction in teenage pregnancy during the study period. The factors associated with teenage pregnancy have been the subject of previous investigations. To the best of our knowledge, there is limited evidence on the factors that contributed to the change in teenage pregnancy in Ethiopia.

The results of this study revealed that trends in teenage pregnancy prevalence decreased significantly between 2005 and 2011, even though it showed an increase between 2011 and 2016. From 2005 to 2011, the teenage pregnancy prevalence decreased by 4.3%, while it increased by 0.2% between 2011 and 2016, with an overall decrease of 4.1% from 2005 to 2016. This decline rate in the prevalence of teenage pregnancy has been consistent with Sustainable Development Goal target 3.7.2 and study findings on the trend of teenage pregnancy from 2000 to 2011 in Eastern Africa (3.5%) 27 , but higher than the study findings from West Africa (1.7%) 27 and North America (1.2%) 28 . This could be due to the launching of the Health Extension Programme and improving access and utilization of maternal health services and decreasing the unmet need for family planning 29 . Increased political will, donor assistance, and non-governmental organization efforts to reduce early marriage in Ethiopia 30 , 31 may also have contributed to this decline in teenage pregnancy prevalence.

Knowing the trend is important, but it's also important to understand what caused the reduction in teenage pregnancy and what factors are helping to reduce it to evaluate the current implementation strategies. The overall decomposition analysis revealed that the change in teenage pregnancy due to the difference in the effects of characteristics was not significant. Keeping coefficient changes constant, the disparity in the composition of women over time was significant and responsible for 49.8% of the decline in teenage pregnancy over the entire sample survey period (2005–2016).

Among the compositional factors, the effect of religion, educational status, and wealth index before the survey were significantly associated with the reduction in teenage pregnancy. An increase in the proportion of Muslim followers in the survey had a significant negative impact on the decline in teenage pregnancy. This finding was consistent with a study conducted in Malawi and Sri Lanka 32 , 33 . The possible justification might be Muslims tend to have an earlier marriage, and low use of family planning 34 which is leading them to become extremely young mothers. However, further study is needed to investigate the effect of religion on teenage pregnancy.

An increase in the compositions of women who resides in rich households also showed a statistically significant positive contribution to the decline in teenage pregnancy. This finding was similar to a study conducted in Uganda 35 , Malawi 32 , Ethiopia 18 , 36 , South Sudan 37 , and sub-Saharan Africa 16 , 27 . A possible pathway of this influence could be that women with the lowest income tend to marry at an early age as girls’ families benefit from dowries (provided by the partner’s family often as cattle), while those with the highest income continue with their education and other career goals 38 .

The predominant decline in teenage pregnancy was due to the compositional change in teenagers’ primary or above education attainment. An increase in the proportion of teenagers having primary school education or above in the study period had a 66.4% contribution to the decline of teenage pregnancy, similar to what had been reported in other studies in Africa 16 , 20 , 32 , 35 , 37 . Teenagers who receive an education will have a greater understanding of sexual and reproductive health, including conception and fertility. The more education a girl has, the more likely she is informed about ways of preventing early pregnancy, and the more aware she is of contraceptive options. It has been also proposed that education increases adolescent prospects for success and acts as a deterrent to early parenthood 39 , 40 , 41 . Hence, to reduce the high rate of teenage pregnancy, governmental stewardship towards making primary and secondary school more accessible in Ethiopia is strongly important. Moreover, some cultural views that impede the education of girl children should be changed.

Teenage pregnancy decreased significantly in the study period; however, it is still unacceptably high. The study has shown that changes in compositional factors of teenagers was responsible for the observed reduction in the prevalence of teen pregnancy rates in Ethiopia. Educational status, religion, and wealth index were found to be significant factors that contributed to the reduction in teenage pregnancy. Therefore, intervention programs targeting adolescents should address the socio-economic inequalities of these influential factors to reducing teenage pregnancy and related complications.

Data availability

The dataset is available from the DHS program official database https://www.measuredhs.com .

Abbreviations

Adjusted odds ratio

Confidence interval

Demographic and Health Survey

Enumeration areas

Ethiopia Demographic and Health Survey

Lower- and middle-income countries

Sexual and reproductive health

World Health Organization

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Acknowledgements

The authors would like to thank the MEASURE DHS program for the on-request open access to its dataset.

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Melkamu Aderajew Zemene, Fentaw Teshome Dagnaw, Denekew Tenaw Anley & Anteneh Mengist Dessie

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Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia

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Zemene, M.A., Dagnaw, F.T., Anley, D.T. et al. Trends and factors associated with teenage pregnancy in Ethiopia: multivariate decomposition analysis. Sci Rep 14 , 2216 (2024). https://doi.org/10.1038/s41598-024-52665-5

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• Published: 05 May 2022

Pregnant adolescents’ lived experiences and coping strategies in peri-urban district in Southern Ghana

• Agnes M. Kotoh 1 ,
• Bernice Sena Amekudzie 1 ,
• Kwabena Opoku-Mensah 1 ,
• Elizabeth Aku Baku 2 &
• Franklin N. Glozah 1  

BMC Public Health volume  22 , Article number:  901 ( 2022 ) Cite this article

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Adolescence, a transition period from childhood to adulthood forms the foundation of health in later life. The adolescence period which should have been characterised by good health is often marred with life-threatening and irreparable consequences of public health concern. Teen pregnancy is problematic because it could jeopardise adolescents’ safe transition to adulthood which does not only affect adolescents, but also their families, babies and society. There is ample evidence about the determinants and effects of teen pregnancy, but it is fragmented and incomplete, especially in Sub-Sahara Africa. This study presents pregnant adolescents’ voices to explain significant gaps in understanding their lived experiences and coping strategies.

This narrative inquiry, involved in-depth interviews with 16 pregnant adolescents, who were recruited from a peri-urban district in Southern Ghana using purposive and snowball techniques in health facilities and communities respectively. The audio recorded interviews were transcribed verbatim and analysed manually using content analysis.

Many pregnant adolescents are silent victims of a hash socio-economic environment, in which they experience significant financial deprivation, parental neglect and sexual abuse. Also, negative experiences of some adolescent girls such as scolding, flogging by parents, stigmatisation and rejection by peers and neighbors result in grieve, stress and contemplation of abortion and or suicide. However, adolescents did not consider abortion as the best option with regard to their pregnancy. Rather, family members provided adolescents with critical support as they devise strategies such as avoiding people, depending on God and praying to cope with their pregnancy.

Adolescent pregnancy occurred through consensual sex, transactional sex and sexual abuse. While parents provide support, pregnant adolescents self-isolate, depend on God and pray to cope with pregnancy and drop out of school. We recommend that the Ministries of Education and Health, and law enforcement agencies should engage community leaders and members, religious groups, non-governmental organisations and other key stakeholders to develop interventions aimed at supporting girls to complete at least Senior High School. While doing this, it is also important to provide support to victims of sexual abuse and punish perpetrators accordingly.

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Adolescence, a transition period from childhood to adulthood forms the foundation of health in later life [ 1 ]. Unfortunately, the increasing adolescent population, the largest in history, which should have been characterised by good health is marred with sexual and reproductive health (SRH) challenges of public health concern especially in low- and middle-income countries (LMICs) [ 2 , 3 , 4 , 5 , 6 , 7 , 8 ]. The UNFPA reports 18.8% prevalence of adolescent pregnancy in Africa [ 9 ]. The 2014 Ghana Demographic Health Survey (GDHS) shows that 31.4% of adolescents had a child by age 19 [ 10 ]. Also, 14% of adolescents aged 15–19 years contribute to 30% of all deliveries in 2014 [ 4 , 7 ].

Teenage pregnancy, mostly unplanned, is a social problem. It truncates adolescents’ childhood and jeopardizes’ their right to a safe transition into adulthood before they are developmentally, emotionally and socially ready [ 6 , 11 , 12 ]. The transition to motherhood needs physical, psychological, social and cognitive preparedness; but most teenagers take up the role of nurturing babies inadequately prepared [ 3 , 4 , 7 , 11 ]. The teenager has to deal with the unexpected demands of being an adult, disapproval and disappointment shown by parents and relatives [ 6 , 13 , 14 ] and disruption of schooling, relationship problems with relatives, partners and peers [ 11 , 15 ].

Studies in Sub-Saharan Africa and Southern Asia show that adolescent pregnancy is associated with unhealthy environment, low educational attainment and poverty [ 4 , 16 , 17 , 18 ]; resulting in adverse health, economic and psychosocial outcomes with irreparable consequences of public health concern [ 5 , 9 , 10 , 11 , 19 ]. The adolescent, which may already be malnourished will have to share nutrients with the unborn child, often resulting in adverse outcomes [ 18 ]. In Ghana, maternal mortality rate is higher among 12–19 year olds (679 per 100,000 live births) compared to 380 and 359 per 100,000 live births among adults aged 20–24 and 25–29 years respectively [ 10 ].

There is ample evidence about the determinants and effects of teen pregnancy, but it is incomplete, especially in Sub-Sahara Africa. Several studies in sub–Saharan Africa and Southern Asia have shown that adolescent pregnancy is associated with unhealthy childhood environment, socio-economic conditions, low educational attainment, poverty, peer pressure and gender issues [ 4 , 13 , 16 , 17 , 18 ]. Also, pregnant adolescents’ experiences are multi-dimensional, ranging from physical, psycho-social and economic [ 10 , 20 ]. In Ghana, an environment that is full of sexual taboos and abstinence-only sex education, together with limited negotiation skills shape the sexual decisions and behaviours of adolescent girls. Furthermore, limited knowledge of contraception, low self-efficacy in obtaining contraceptive methods such as condoms, and lack of skills to negotiate condom use are associated with adolescent pregnancy [ 3 , 21 ]. These notwithstanding, there are gaps in the literature regarding how they got pregnant and the coping mechanisms they used.

Also, pregnant adolescents’ voices that should flame public debate, draw public health advocates’ and policy makers’ attention to the subject are almost absent. A study of this nature is relevant in Ghana in the light of public health concerns arising from the increasing rate of suicidal ideation and behaviour among adolescents. Using a narrative approach, this study explored how adolescents get pregnant, their lived experiences, and coping strategies to inform interventions for challenges of the environment in which girls grow and ultimately reduce, if not eliminate adolescent pregnancy in Ghana and other LMICs.

A narrative inquiry research design was used and it involved conducting in-depth interviews (IDIs) with pregnant adolescents who are resident in the Keta Municipal Area (KMA). This made it possible for the adolescents to give an account of their most profound experiences, stories, and narratives.

The KMA is located in the Volta Region along the eastern part of the Volta estuary. It is about 160 km from Accra the capital city of Ghana. Healthcare services are provided mainly by government, supported by Christian Health Association of Ghana (CHAG). There are 28 health facilities within the municipality. These comprise of two hospitals (one public and one CHAG), 13 health centres, four Community-based Health Planning and Services (CHPS) zones, five maternity homes and four private clinics.

Participants

Sixteen pregnant adolescents were recruited using purposive and snowball sampling techniques. Purposive sampling was used to recruit six out of the eight pregnant adolescents who had attended antenatal care (ANC) clinic at the KMA Hospital within the month preceding the study. A research team member who conducted the interviews took their contacts from the ANC register and traced them to their communities with the help of community health nurses. They were informed about the study and recruited after consenting to participate in the study. The recruitment process took two weeks. At the end of each interview, participants were asked about other pregnant adolescents. Potential participants were contacted and traced to their residents. Those who met the eligibility criteria (i.e., not more than 19 years and resident in the district) were recruited.

Data collection

Face-to-face in-depth interviews (IDIs) were conducted with pregnant adolescents using a pretested guide developed based on literature. Data collection which lasted two months was done by a research team member with Master of Public Health degree and experience in conducting in-depth interviews. The questions include information on their demographic profile, how they got pregnant, challenges they encountered and how they are coping with their situation. While fourteen interviews were conducted in Ewe (the local language) and two in English language. The interviews were conducted in conducive places, mainly at community centres and other places in the community of adolescents’ chioce.

A non-judgemental environment and dialogical approach during discussions encouraged participants to honestly tell their stories; describing how they got pregnant, their experiences and coping strategies. Drawing on the principles of saturation [ 22 ], data collection stopped at the 16 th interview when no new ideas or perspectives were emerging. The interviews were audio recorded, with each interview lasting for about 40 min.

Data analysis

The data was analysed by the research team. The recorded discussions were transcribed verbatim and analysed manually using inductive content analysis approach. This involves reading transcripts thoroughly several times and condensing the raw textual data into a summary format [ 23 ]. Both similar and different views on the subject were grouped into themes and sub-themes and clear links established between findings and research objectives. This aided the comparison of various issues mentioned. Also, participants’ statements were used to support the themes generated and illuminate their perspectives.

Trustworthiness

Trustworthiness is established when findings as much as possible reflect participants’ views [ 24 ]. Steps taken to ensure that the study is trustworthy include: building trust, notes written during the study were used to confirm participants’ responses, back translation method used to translate the interview guide and transcripts to ensure participants understand the questions as intended and their perspectives were not lost during the translation process. Also, the research team looked for verbatim quotes from participants’ narrations to support themes and subthemes generated and demonstrate issues paramount to them.

Ethical issues

The Ghana Health Service (GHS) Ethical Review Committee gave ethical approval [GHS-ERC 023/06/19] for this study. All study procedures were performed in accordance with relevant ethical principles for medical research involving human subjects. Participating in the study was preceded by a written informed consent processes communicated to prospective participants. Participants gave consent after they were informed about the study’s aim (to explore how adolescents get pregnant, their lived experiences and coping strategies), and the freedom to decline the request to participate, refuse to answer any question as well as redraw from the study anytime they wish. Written informed consent was given by all participants 18-years and above and assent obtained from parents/guardians of those under 18 years for allowing their children to participate in the study and recording the interviews. Consent was sought before audio recording interviews. A counselor was engaged to attend to participants who might show austere emotional distress during or after the interviews. Interviews were conducted in places devoid of intruders, often community centres, school compound, churches and adolescents home depending on the preference of participants to ensure privacy. Anonymity and confidentiality were guaranteed by using pseudonyms during the interviews and presentation of the results.

Socio-demographic characteristics of pregnant adolescents

The participants were aged between 12–19 years. Ten were in primary school. None were married and 14 Christians (Table 1 ).

Majority of pregnant adolescents’ fathers and mothers have no formal education. Three mothers and seven fathers attended primary school, two mothers and one father attended JHS. Only two fathers attained tertiary education. Also, majority of parents were self-employed. Only three fathers were formal sector employees (Table 2 ).

Themes and sub-themes

Three main themes that emerged from the data are: how adolescents got pregnant, pregnant adolescents’ experiences and coping strategies (Table 3 ).

How adolescents got pregnant

Of the 16 pregnant adolescents studied, six pregnancies occurred through consensual sex, five through abuse and five through transactional sex; with their ages ranging between 14–19, 12–16 and 14–17 years respectively.

Consensual sex

Participants who got pregnant through consensual sex gave the following narrations:

He is my boyfriend. We slept together. I realised I was pregnant when I missed my menses for three months. I thought it was normal until my mum said I was pregnant. I denied but it was confirmed. (14 years) My sister never allows me to go out before I met my boyfriend. He told my sister that he is dating me. We have been having sex. The pregnancy was unplanned. (18 years)

Transactional sex

Participants who got pregnant through transactional sex, narrated how financial deprivation forced them to engage in sex for money and material things:

I needed money to buy things for SHS. So, I started working in a shop. The owners’ son told me he could help me only if I had sex with him. I didn’t have any choice so I agreed. We started having sex and I became pregnant. (17 years). My father left us. My mother was caring for us. Things were difficult, I couldn’t buy books and pay my fees. My dresses and shoes were worn out. But I loved going to school. So I started asking the boy for money. He gives me money and other things. One day he asked me to wash his things and we had sex. I agreed because I needed his help. It was my first time but I got pregnant. (15 years).

• Sexual abuse

Eleven of the 16 participants were sexually abused; usually by uncles, school mates and acquaintances. The three raped and eight defiled victims were aged 16–19 years and 12–15 years respectively. They could not report the incident immediately because of shyness and fear. Those who told their family members later were beaten and silenced or threatened not to report. In all these cases only one father reported the case to the police and a few ran away. No disciplinary action was taken against any of them.

A family friend who used to visit my mother and assists me with my homework made me pregnant. One day, he asked me to pay him a visit. I went to his house and he forcefully had sex with me. When my mother threatened to report him to the police, he runway. (16 years). One evening after supper, the woman I was working for informed me that one of the fishermen we work with was looking for me. I protested that it was late and would rather meet him the following morning. But she insisted that I should meet him and that he only wanted to talk to me. So, I went and the man forcefully had sex with me. I came back and informed madam while I was bleeding. She said because it was my first time and told me to keep quiet. (16 years). My uncle asked me to fetch him a bucket of water. I went to his house with my cousin but when I returned, she wasn’t there. Suddenly, he held me from behind, covered my mouth with cloth and had sex with me. That was my first time. This continued. Later, I told my grandmother. Anytime I report she shuts me down and warned me never to mention it again. It was getting too much so I told my friends and cousins. When they told her she beat me mercilessly. My father was angry when he got to know that I’m pregnant and my uncle was responsible. (12 years).

Pregnant adolescents’ experiences

Pregnant adolescents’ experiences range from psycho-social, financial, health and educational challenges.

Psychosocial challenges

The psychosocial experiences were: denial, sadness, shame with some contemplating abortion and or suicide. They denied initially but accepted the reality later either because of ignorance about the signs of pregnancy, or fear of maltreatment. Their narratives illustrate what happened :

I realised I was pregnant when I missed my period but when my mum asked me, I denied for some time. I was afraid my mother will scold me but I later confessed . (15 years) Immediately I was told the pregnancy was 6 months, I shouted ‘it’s a lie’ because my stomach was its normal size. After that my sister and I bought test kits and did three more tests which were all positive, but I was still in a state of denial for a long time until one day my sister showed me a dark line on my stomach to prove that I was pregnant. That was when I accepted the pregnancy. (17 years)

Participants whose parents scold and or beat them recounted their experiences as follows:

When we got home from the clinic after confirming my pregnancy, I received the beatings of my life from my mother. This made me cry for days. (14 years). My mother got angry about the pregnancy and said I am not her daughter. She yells at me and says I’ve disappointed her by getting pregnant. (18 years)

Participants described how they saw their future shattered with some contemplating abortion and or suicide.

Hmm! I was very sad when I was told I was pregnant. I cried the whole day. My dreams came crushing down right in front of me. I wanted to go to school and become somebody in future. I told myself if I knew any medicine, I would have terminated the pregnancy. I also contemplated committing suicide by hanging myself with a rope. (17 years) I thought of having an abortion. It was also suggested by a friend who told me she can help me. But I couldn’t do it because we were told in class that when you try to abort a baby, you can die from the procedure. I wasn’t ready to die. (13 years).

Regarding their partners, only two adolescents accepted responsibility while the rest denied or run away. They described their partners’ behaviour as follows:

The boy denied the pregnancy and rejected me. He does not provide any support [crying] . This makes me cry most of the times I feel like dying. (14 years). My partner denied responsibility but later said we should have abortion when my mother confronted him and his parents. My mother refused aborting the pregnancy, so he no longer talks to me. His parents said they don’t want to be involved and that it’s my fault to have allowed myself to get pregnant (14 years).

Some participants suffered rejection and were scorned by their peers and neighbours. Their accounts are:

Some of my friends and children in my area do not want to talk to me. They laugh at me and tell me I’m no longer part of them because I am pregnant. It makes me sad. (13 years) Some women in the area laugh and gossip about me; saying why a little girl like me should get pregnant. They say small girl like me, instead of going to school I’m following boys and ‘penis’ and call me “funorvi” [pregnant girl]. They tell my friends to stay away from me because I will spoil [influence] them and they will become pregnant. (14 years).

Financial challenges

Almost all the pregnant adolescents studied had financial challenges. Parents stopped providing financial support at the initial stages of the pregnancy. Though parents and two partners finally provide financial support, the girls indicated it was inadequate. The following narratives show the financial challenges pregnant adolescents face:

The boy who impregnated me rejected me. He does not support me. His mother also doesn’t support me. It is difficult for me. This makes me cry most of the time and I think of dying. (14 years). My mother scolds me and says I have become a burden on her. She tells me she can only give me what I need to take care of the pregnancy. (16 years.)

Health challenges

Almost all participants reported feeling unwell, headache and anaemia. They were told at the ANC that their haemoglobin level was low. They reported their health conditions as follows:

I easily feel tired and so I am unable to work as I used to. I was told by the nurses that my blood [haemoglobin] level was low. The nurses told me to eat well (13 years). I often experience headache. After the laboratory test, the nurses told me I’m anaemic. She said I don’t eat well. She advised me to eat well and take the medicines prescribed for me. (R8, 16 years)

Educational challenges

All the in-school participants stopped going to school when the pregnancy was confirmed. They said:

I’m a very good student. I cannot register for WASSCE. My dad stopped me from going to school. I didn’t like the idea but I don’t have a choice than to stay home. (17 years) I loved going to school till I got pregnant. I was in the cultural troupe and the first in class. My mother asked me to stop going to school (15 years).

Coping with pregnancy

The pregnancies were unwanted, so participants experience psychosocial challenges and developed strategies to cope. In addition to support from parents and other family members, adolescents use avoidance of people, depending on God and prayer to cope with their pregnancy.

Support during pregnancy

Generally, parents, other family members and neighbours’ blamed adolescents for getting pregnant and were reluctant to support them initially. However, many of them later provided financial and emotional support, counselled them on how to take care of themselves. Partners who accepted responsibility for the pregnancy were generally supportive . These narratives show the support participants received was insufficient:

My family finally accepted the pregnancy and assisted me. They do not hesitate when I ask for help and advise me on how to eat and take care of myself. They sometimes help me with my chores and accompany me to the ANC. Their support gives me hope and reduce the worry. (15 years). The man responsible for my pregnancy supports me financially and encourages me. He gives me everything I need. He makes me forget my worries. He promised opening a shop for me when the child grows. (15 years). Some elderly women in the neighborhood educate me on how to take care of myself. I have enough support to keep me going (R5, 16 years).

Avoidance of people

Avoidance as a coping strategy is characterised by not going to public places and staying away from people. Pregnant adolescents stopped going to school. While some stopped going to church, others reduced the frequency of attendance, go late and or leave early. Their narratives are:

I don’t go out; I don’t go to school nor church. In my church when you get pregnant and you are not married, they will call you to the front and tell you to sit at the back. I don’t want to receive that kind of treatment so I stopped attending church. (14 years). Since I got pregnant, I stopped going out because I don’t want people to laugh at me. I stopped going to school. I sometimes go to church but late. I sit at the back and leave early so that many people will not see me. (13 years).

Dependence on God and being prayerful

Dependence on God and prayer helped many adolescents to cope with pregnancy. They explained what they did:

I’m sorry about the pregnancy but I take solace in God’s words. He said we should call on him when we are in distress and in need and he will be there for us. (19 years). I trust in God. I’m always praying to God to carry me through this pregnancy and help me deliver the baby safely. (14 years).

This study explored how adolescents get pregnant, their lived experiences, and coping strategies.

Social factors influencing adolescent pregnancy

Our results echo the evidence that sociodemographic factors such as poverty and low education are strongly associated with adolescent pregnancy [ 4 , 16 , 17 , 19 , 21 , 25 ]. Studies in Accra and Bolgatanga in Ghana found that financial deprivation was a push factor for adolescent pregnancy [ 16 , 21 ]. Most of the participants in all these studies indicated that they went into sexual relationships to get financial assistance and got pregnant as a result.

Regarding education, fewer adolescents in SHS become pregnant. This supports previous findings that teenage pregnancy is strongly associated with education below secondary level [ 10 , 26 ]. The GDHSs show that more girls with no formal or primary education got pregnant compared to those who had secondary education [ 26 ]. Additionally, majority of pregnant adolescents’ parents had no formal education. Also, mothers and most fathers work in the informal sector. These results suggest that low parental education and informal sector employment, resulting in low paid jobs could influence adolescent pregnancy. These results support the evidence that poverty is a risk factor for adolescent pregnancy.

Finally, none of the pregnant adolescents were married. This contributes to evidence in the GDHS’s report of a declining trend in child marriage in Ghana. The proportion of women married by age 15 declined from 11% in the 45–49 age group to 2% in the 15–19 age group between 1998 and 2014; indicating a declining age at first marriage. However, there was no distinct decreasing trend of teenage pregnancy over the same period [ 10 ].

Sexual exploitation and teen pregnancy

Risky social environment exposed adolescents to sexual abuse especially those aged 12–15 years. Many of them were pressured by family members and acquaintances into having sex while others were lured and defiled or raped by family members, neighbours and acquaintances but none of the perpetuators were punished.

This corroborates previous findings that young adolescents are more vulnerable to sexual abuse [ 16 , 21 , 27 ] as their first sexual experience [ 28 , 29 ]. Significantly, some adolescents below 16 years who engaged in consensual sex were actually sexually abused as it is not possible for them to give consent. Furthermore, although they agreed, they are not yet at a legal age where they can be in sexual relationships therefore, it is against the laws of Ghana.

It is therefore, worrying that though the 1996 African Charter on the Rights of the Child [ 29 , 30 ] state that a child below 16 years cannot give consent for sex, only one perpetrator has so far been arrested and the case is still in court after several months. Some adolescents were prevented from talking about and reporting their plight, lest they face the wrath of family members, others could not report because of shame and stigma. These increase girls’ vulnerability, denies them justice and does not deter boys and men from abusing them. Certainly, societal norms have played a substantial role in this problem, where society defers matters of this nature entirely to parents and families of the adolescent girls, No one interferes with the decision of a family not to take up action ostensibly to protect the abused girl from stigma or potentially not getting a husband in the future. It is also considered private to protect the family’s name especially if the perpetuator is a member. The apparent resolve by parents, families and society in general to protect abused girls and perpetuators rather perpetuates of the problem.

Challenges of pregnant adolescents

Headache and anaemia, the main health challenges mentioned by almost all the pregnant adolescents, could be linked to the physiology of pregnancy and financial challenges. As noted by Atuyambe and colleagues in their study, almost half of adolescents experience malaria and anaemia during pregnancy [ 31 ]. Lotse also explains that having financial challenges means that the adolescent mother will lack the necessary resources for balance diet and other food supplements [ 18 ]. Also, when girls become pregnant, they have limited employment opportunities and are likely to land in poverty and unable to have the needed balanced diet and required nutrition. These often results in adverse pregnancy and birth outcomes such as stillbirth, preterm birth, neonatal death, congenital anomaly, and low birth weight [ 32 ].

Girls’ education and adolescent pregnancy

All the in-school pregnant adolescents stopped going to school. This result agrees with previous findings that pregnancy truncates girls’ education [ 16 , 27 ]. However, the result contradicts the finding that school drop-out leads to early sexual activity resulting in adolescent pregnancy [ 33 ]. The possible reason could be that Ghana’s efforts in keeping girls in school resulted in many of them progressing beyond primary school. However, as they enter adolescence, pregnancy remains a threat to their retention. Furthermore, when girls become pregnant and drop out of school, they have limited employment opportunities and often land in poverty, which has ripple effects on themselves, family, and the country at large. Therefore, there is the need, not only for parents to monitor and have open sexual conversation with their children, but for school authorities to intensify adolescent school health education programmes that would keep adolescents focused on their academic work and also protect themselves against unwanted pregnancies [ 21 ].

Our finding also show that all in-school adolescents stopped going to school immediately their pregnancy became obvious. This contrasts the situation in the United States of America where pregnant African American adolescents are supported and motivated to continue schooling [ 13 ].

Psychosocial challenges of pregnant adolescents

The negative reactions show that pregnancy among adolescents is pathologised. As reported by previous findings, pregnant adolescents experience rejection, stigma and other negative reactions from family members, partners, peers and neighbours because of culture and religion [ 18 , 20 , 34 , 35 ]. These result in emotional and mental distress and shame with some having suicidal ideation [ 27 , 36 , 37 , 38 ]. In this regard, it is important to eschew religious and cultural norms and beliefs that are inimical to the psychosocial development of pregnant adolescents. This problem could be addressed if significant people and institutions in the community accept that adolescents made a mistake by getting pregnant and support them to give birth and return to school.

Furthermore, negative reactions towards pregnant adolescents reveal how gender influence people’s response to teen pregnancy. Instead of pregnancy being a shared obligation, girls are blamed for getting pregnant. Hence, men’s apparent absence in the teen pregnancy discourse illustrates a stigmatising social environment that leads to pregnant adolescents experiencing shame and stigma and more likely to report embarrassment than boys [ 12 , 34 , 39 ].

Coping strategies of pregnant adolescents

Notwithstanding society frowning upon teen pregnancy and adolescents’ grief, they were averse to abortion. Rather, their social network provided support while adolescents devised strategies to cope. This endorses previous findings that support from social network is critical to adolescents’ ability to cope with pregnancy [ 28 , 38 , 40 ]. Also, our results corroborate previous findings that pregnant adolescents withdraw from unfavorable environment as a buffer to scorning and rebuke—all of them stopped attending school. Some stopped going to church, others go late, sit at the back and leave early while they pray and believe that God will keep them safe [ 28 , 39 , 40 , 41 , 42 ]. These results suggest that churches which are expected to support pregnant adolescents as a vulnerable group are not able to do so quite well.

These coping strategies could help adolescents in several ways. An open parental communication on sexual behaviour issues at home, comprehensive sex education in school and positive attitude, self-efficacy, risk perception towards contraception, alongside with goal-setting, could be protective factors in adolescent girls’ pregnancy prevention efforts [ 25 , 41 ]. Furthermore, it is recommended that adolescent mothers who return to school adopted conscious avoidance of incisive remarks, vicarious experience as well as self-determination as coping strategies [ 43 ].

Limitations of the study

This study was conducted in only one district and information gathered could not be verified from partners and parents. However, since participants were selected from communities across the district, diverse groups of pregnant adolescents could be represented. Therefore, the findings should be applied with circumspection.

Implications for policy and practice

The Ghana Education Service (GES), the Domestic Violence and Victims Support Unit (DOVVSU) of the Ghana Police Service, Judicial Service and Social Welfare Department should collaborate with schools, communities and religious institutions to seek justice for abused pregnant adolescents, provide shelters for those whose families might want to pervert justice, help them continue schooling after delivery and parents should provide girls’ basic needs to prevent their dependence on boys and men. Although the use of contraceptives is common among Ghanaian adolescents, this has been declining from 22.1% in 2003 to 20.4% in 2014 [ 44 ]. This may be due partly to societal norms that do not encourage contraceptive use among unmarried adolescents who are expected to abstain from sex [ 45 ]. Therefore, it is important for parents, families and the society generally to encourage the use of contraceptives among adolescents. Also, the decline in contraceptive use among adolescents may be due to lack of access or inability to obtain them because of the stigma associated with going for it. It is therefore imperative for parents, families and the society to start having conversations that would lead to encouraging and motiving adolescent girls to use contraceptives. It is known that as adolescents in basic schools are becoming sexually active, there is a need for formalised contraceptive education in basic schools for correct information and education [ 46 ] in addition to abstinence which has been traditionally promoted but can no more be guaranteed as girls’ risk of engaging in unprotected sex increases.

Conclusions

The results of this study show that adolescent pregnancy occurred through consensual sex, transactional sex and sexual abuse. Despite parents’ harsh treatment and adolescents’ anger, both were averse to induced abortion. While parents provide support, pregnant adolescents self-isolate, depend on God and pray to cope with pregnancy.

Considering the implications of pregnancy for girls’ well-being, the GES, the DOVVSU and Judicial Service should collaborate with schools, communities and religious institutions to identify situations that expose girls to transactional sex and sexual abuse and provide early intervention, detect sexual abuse cases and seek justice for victims to deter perpetrators. Also, Social Welfare Department should be resourced to provide shelters for pregnant adolescents whose families might want to pervert justice and help them continue schooling after delivery. Finally, we suggest a larger study that will engage parents, partners and community leaders.

Availability of data and materials

The data are not publicly available at the moment due to confidentiality issues but can be obtained from the corresponding author on reasonable request.

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AMK and BSA conceptualised the theme and designed the study and analysed the data. BSA collected the data and AMK wrote the first draft. KOM, EAB and FNG made substantial contributions to interpretation of data and revising the manuscript critically for important intellectual content. All authors gave final approval of the version to be published.

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106 Topics about Teenage Pregnancy Essay Examples, & Tips

Want to know how to write an essay about teenage pregnancy? This issue is very hot, sensitive, and controversial. Numerous articles and researches focus on its causes and effects.

❗ Teenage Pregnancy Essay: How to Write?

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We’ve collected a list of topics about teenage pregnancy, as well as a number of tips on outlining your essay, writing an introduction, and formulating a teenage pregnancy thesis statement. Get inspired with us!

Whether approaching the subject from a demographic or medical point of view, the interest in a teenage pregnancy essay heavily roots itself in the issues of today.

With a multitude of topics dealing with different sides, from mothers and children to the government, creating a unique essay that will get you a good grade is a matter of adequately constructing your argument.

• Choose a single theme that you will address. All teenage pregnancy essay topics center on one problem but concern themselves with different facets of it. Thus, you have to decide whether you want to write about government-supported methods of pregnancy prevention or the repercussions of an increase in the number of teenage mothers.
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• Write an outline. By doing so, with or without using topic sentences, you can see how many sub-themes you touch upon and how inclusive your work is. This action will help you save time by writing and rewording the better part of your paper, as you will see potential structural issues early on.
• Construct a title. As the first thing a potential reader sees, it should be both engaging and thought-provoking. However, teenage pregnancy essay titles should grab their readers’ attention without a shock factor, intriguing them with information but not demeaning their topic. Regardless of your opinion regarding the issue, remember that you are writing about living people who deserve fair treatment.

You should draft your paper traditionally with an introduction, body, and conclusion. You can start your first paragraph with an interesting fact or statistical number to gain your audience’s attention. However, do not forget to write a thesis statement, as well as a hook.

Your introduction and conclusion should reflect each other, and that may become possible only if your first paragraph gives your reader an idea of what your stance is and what you plan to achieve in your paper. Without a thesis, you can neither expect readers to get interested in your work nor write an excellent conclusion yourself.

Understand what your teenage pregnancy essay body needs, and include only information that will help you advance your main argument.

For example, if you are writing a paper from a sociology studies perspective, then you may see that you may gain an advantage by writing from a statistical or socioeconomic perspective.

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Superb structure comes from reading up on even better examples. You can easily find a teenage pregnancy essay example or two and use them to get inspired. Do not forget to assess these sample papers on technique and information included, gauging which methods you can uplift into your own work.

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Teenage Pregnancy Thesis Statement

Early pregnancies remain one of the most acute social problems in the world. Still, formulating a teenage pregnancy thesis statement might be a challenge. To make it easier for you, we’ve prepared some examples.

• The complications associated with early pregnancies are the main cause of death for 15-19-year-old girls in the world; therefore, the problem of teenage pregnancy needs to be addressed on the governmental level worldwide.
• Teenage pregnancies have severe health, social, and economic implications both in developed and developing countries.
• Sex education in schools is the best way to prevent early pregnancies.
• Reducing social pressure on girls to marry and bear children early is the best way to lower the levels of teenage pregnancies in the least developed countries.

Are you still confused by your assignment? Let IvyPanda help you with any topic!

• Teenage pregnancies in developed countries
• How to prevent teenage pregnancies?
• Adolescent pregnancies in various regions of the world
• Teenage pregnancy as a cause of death
• Early pregnancies and health consequences
• Early childbearing and severe neonatal conditions
• Social and economic effects of teenage pregnancies
• Adolescent pregnancies in developing countries
• Causes and effects of teenage pregnancy
• Sex education as a way to prevent early pregnancies
• Teenage Pregnancy Causes and Effects In addition to this, the modern society allows the teenagers to have a lot of time and space with the opposite sex on their own, which results to instances of pregnancy at teenage hood.
• Teenage Pregnancy Concept and Problems This becomes potentially dangerous to the teenage girls due to the lack of prenatal care and the fact that her body is not fully developed to carry a pregnancy.
• Teen Pregnancy: Causes, Effects and Prevention Teenage pregnancy is the pregnancy of underage girls during their adolescent period, normally between the ages of 13 to 19 but this range varies depending on the age of the menarche and the legal age […]
• Teenage Pregnancy Major Causes and Solutions Thus, one of the manifest functions of the family is to be the meaningful unit which supports the accepted social order and is a support of the state.
• Positive Impacts of Sex Education on Teenage Pregnancies Failures of Sex Education in reducing teenage pregnancies According to the article by Stobbe, education has not achieved much in terms of helping students change their attitudes and behavior on sex and use of birth […]
• Increasing of Sex Education in Schools to Curb Teenage Pregnancy Increased sex education is important because it emphasizes on the need to abstain and use of contraceptives. It is therefore important to increase sex education in schools to avert cases of teenage pregnancies.
• Sex Education Role in Preventing Teenage Pregnancy In a bid to survive, the teens resort to prostitution as a means of earning a livelihood, which in turn leads to teenage pregnancies.
• Teenage Pregnancy and Its Consequences to the Society The opportunities of mother and the child to build a future are further depleted by these risks. Education to the youthful teens would be a valuable tool to curb early pregnancies.
• Social Aspects of Teenage Pregnancy In recent years, both in the USA and in European countries, the number of pregnant women among minors has been increasing due to a decrease in the age of sexual debut, an increase in sexual […]
• Improving Health Care Delivery: Teenage Pregnancy Due to the absence of proper support, these young individuals lack timely prenatal care and skills to support their developing fetuses.
• Teenage Pregnancies in California Socioeconomic position, teens’ surroundings, their family, and the number of resources accessible epitomize some of the teenage pregnancy causation. The Maternal, Child, and Adolescent Health Program is a different initiative from the State of California […]
• Teenage Pregnancy and Quality of Care Therefore, the most effective method of ensuring the quality of care, patient safety, and costs is conducting campaigns to prevent teenage pregnancies.
• The National Campaign End Teenage Pregnancy in Ohio The dream of most parents is to ensure their children lead to a successful future which may be affected by the occurrence of unplanned teenage birth.
• Teenage Pregnancy Problem and Decision-Making Tool The first option is the birth of a new person and the opportunity for the young mother to love and raise him.
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Educate, Support, Prevent: Strategies to Address Sexual Coercion Among Youth

Adolescents who experience sexual coercion can face a range of sexual and reproductive health outcomes leading to significant physical, emotional, and social consequences, including a higher risk of contracting sexually transmitted infections and having unwanted pregnancies as well as increased risk of experiencing depression and anxiety. Conversations around coercion and consent should happen early and often, and they require a comprehensive approach that focuses on education, prevention, and support. This tip sheet provides tips with practical examples on how to address sexual coercion and promote consent with youth in sexual and reproductive health programming.

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• v.13(4); Oct-Dec 2015

Complications in adolescent pregnancy: systematic review of the literature

Walter fernandes de azevedo.

1 Universidade Federal da Paraíba, João Pessoa, PB, Brazil.

Michele Baffi Diniz

2 Universidade Cruzeiro do Sul, São Paulo, SP, Brazil.

Eduardo Sérgio Valério Borges da Fonseca

Lícia maria ricarte de azevedo, carla braz evangelista.

Sexual activity during adolescence can lead to unwanted pregnancy, which in turn can result in serious maternal and fetal complications. The present study aimed to evaluate the complications related to adolescent pregnancy, through a systematic review using the Medical Subject Headings: “pregnancy complication” AND “adolescent” OR “pregnancy in adolescence”. Only full original articles in English or Portuguese with a clearly described methodology, were included. No qualitative studies, reviews or meta-analyses, editorials, case series, or case reports were included. The sample consisted of 15 articles; in that 10 were cross-sectional and 5 were cohort studies. The overall prevalence of adolescent pregnancy was 10%, and among the Brazilian studies, the adolescent pregnancy rate was 26%. The cesarean delivery rate was lower than that reported in the general population. The main maternal and neonatal complications were hypertensive disorders of pregnancy, prematurity and low birth weight, respectively. Adolescent pregnancy is related to increased frequency of neonatal and maternal complications and lower prevalence of cesarean delivery.

INTRODUCTION

Sexual activity in adolescence initiates earlier and earlier, with immediate undesirable consequences, such as an increased frequency of sexually transmitted diseases (STD) and pregnancy, many times also undesired, which may therefore lead to an abortion. ( 1 )

In Brazil, during the period from 2000 to 2006, the Live Birth Information System (SINASC, Sistema de Informação sobre Nascidos Vivos ) recorded a decline in participation of births in mothers aged 15 to 19 years. However, the proportion of liveborns whose mothers were not in the age group under 14 years of age remained stable. In 2006, 51.4% of the liveborns were children of mothers aged up to 24 years, with approximately 1% of mothers in the age group under 14 years; 20.6% of the mothers aged from 15 to 19 years; and 29.9% of mothers aged between 20 and 24 years. ( 2 ) In 2012, of the 2,905,789 liveborns, 560,147 (19.28%) were from adolescent mothers. ( 3 )

From the biological point of view, among the consequences of pregnancy in adolescence are the high rates of hypertensive disorders of pregnancy, anemia, gestational diabetes, delivery complications, determining an increase in maternal and fetal mortality. ( 4 - 6 ) It is important to note that some studies showed an increased trend of prenatal, intrapartum, and postpartum intercurrent events among pregnant adolescents. ( 7 , 8 )

As to problems with the newborn, gestation during adolescence is associated with higher rates of low birth weight (LBW), preterm delivery, respiratory diseases, and birth trauma, besides a higher frequency of neonatal complications and infant mortality. ( 9 - 11 )

Considering the high prevalence of adolescent gestation and its consequences, this study had the objective of analyzing complications related to adolescent pregnancy.

This is an a systematic literature review study that followed the recommendations proposed by Cochrane Collaboration. ( 12 , 13 )

The guiding issue proposed for the study was: What are the complications related to adolescent pregnancies?

Data collection took place between May and August 2012, by means of an online search in the following databases, starting from the Virtual Health Library (VHL), MEDLINE (PubMed), Latin American and the Caribbean Health Sciences Information Literature (LILACS), and the Scientific Electronic Library Online (SciELO).

To find the articles, the following descriptors were used from the Medical Subject Headings (MeSH), of the PubMed/MEDLINE database: “pregnancy complication” AND “adolescent” OR “pregnancy in adolescence”.

Inclusion criteria included original articles, entirely available for free in the online version, in English and Portuguese, and during the period from 2002 to 2012. The study included randomized clinical trials, quasi-randomized clinical trials, observational analytical studies (case-control, prospective and retrospective cohort studies), and cross-sectional descriptive studies (on prevalence), which included a clear description of the methods used. Studies carried out with large samples of adults, but that included adolescents as a subgroup, were also included.

Not included were theoretical articles, investigations with an unclear description of methods used, manuscripts based on annual statistical reports (census data, and information obtained indirectly by means of graphs or archives), qualitative studies, reviews or meta-analyses, theses and dissertations, editorials, opinion articles, case series, care reports, studies with samples not representative of a population and prior to the year 2002.

The studies were initially stratified as per types of design, and posteriorly, as to the outcomes, following Cochrane’s methodology. ( 14 )

The methodological quality of the systematic review was defined with the confidence that the design and report of the study were unbiased, ( 15 ) and was evaluated independently by two reviewers in order to check if the inclusion and exclusion criteria had been met. In case of doubts or disagreement, a third reviewer was requested to issue an official opinion on whether or not the study should be included, according to Stocco. ( 16 ) In the case of duplicate studies, the most recent one or that with the most complete information was included.

To evaluate methodological quality, and inclusion and exclusion criteria, the recommendations made by STROBE (The Strengthening the Reporting of Observational Studies in Epidemiology) were used. ( 17 , 18 ) The assessment was divided into three study categories: (A) in cases of studies that satisfied a value of ≥80% of the criteria requested; (B) cases that satisfied 79 to 50% of the criteria; and (C) in cases that satisfied <50% of the criteria established. ( 14 , 17 , 18 ) Thus, only the articles that reached a percentage >50% (classified as A or B) were considered of good quality and were included in the investigation. ( 19 )

The data analyzed were synthetized and organized by means of figures, charts, and tables.

The universe of the study was made up of 6,465 articles, 6,232 of them at PubMed/MEDLINE and 233 at LILACS and SciELO. After reading the titles and/or abstracts, 6,380 articles were excluded for presenting a focus different from the objective intended. Thus, of the 85 publications read entirely, 15 were selected that met the inclusion and exclusion criteria, as per figure 1 .

Chart 1 shows the countries of origin, year of publication, and design of the studies included in the present review.

Of the 15 articles selected, 10 had a cross-sectional design and 5 were cohort, 4 of them retrospective and 1 prospective studies. As to year of publication, most of the studies were published during the period from 2008 to 2012. The studies were conducted predominantly in Brazil, United States, countries of Europe, Africa, and Asia. All the articles selected for systematic review showed STROBE percentages >50%, and 3 were classified as STROBE A and 12 as STROBE B.

Chart 2 shows the primary characteristics of the studies regarding pregnancy complications in adolescence.

PRM: prolonged rupture of the membranes; UTI: urinary tract infection; LBW: low birth weight; VLBW: very low birth weight; SGA: small for gestational age; PROM: premature rupture of fetal membranes; BMI: body mass index.

In a study performed with 2,357 pregnant women, the frequency of adolescent women (aged under 18 years) was 4%. The most noted maternal complication was prolonged rupture of the membrane, with 20.3%, followed by pre-eclampsia (7.1%), thyroid diseases (7.1%), heart diseases (3%), and urinary tract infections (2%). Among the neonatal complications, the highlights were prematurity (39%), LBW (32%), and delayed intrauterine growth (12%). Neonatal mortality was described in 6.9% of the cases, and was significantly higher than the neonatal complications of the other deliveries. ( 20 )

Another study performed with 265 adolescent mothers (aged ≤19 years) and with 832 mothers aged between 20 and 29 years showed that of the pregnancy-related maternal complications, the most frequent were eclampsia (OR=3.18), pre-eclampsia (OR=1.82), perineal tear (OR=1.45), and episiotomy (OR=1.82); while fetal complications were LBW (OR=1.71), prematurity (OR=1.77), and early neonatal death (OR=2.18). ( 23 )

A study performed by means of analysis of data collected by the Texas of State Health Department between 1994 and 2003 assessed the complications that occurred during labor in 1,355,962 nulliparous mothers and showed that adolescent mothers (15 to 18 years) had lower rates intrapartum fever, excessive meconium, premature rupture of the membranes, placenta previa, prolonged labor, dysfunctional delivery, breech presentation, cephalopelvic disproportion, and umbilical cord prolapse, when compared to mothers aged between 25 and 29 years. ( 32 )

Mukhopadhyay et al. compared the perinatal differences between 350 adolescents (13 to 19 years) and 350 adults (20 to 29 years), both groups of primigestas, by means of medical record analysis, and demonstrated that there was a greater proportion of premature deliveries (27.7%), LBW (38.95%), and rate of stillborns (5.1%), in comparison with adult mothers. ( 29 )

One investigation researched the reasons that led the adolescent to provoke the abortion, relating the motivation with age and type of school they attended. Of the 2,592 adolescents that participated in the study, 182 (7.0%) referred having become pregnant and 149 (26.7%) having aborted. It was verified that the fear of the parent’s reaction (the most often cited reason), age, lack of support from the partner, and non-acceptance of the pregnancy were reasons that led the adolescents to provoke an abortion. The frequency of abortion was higher among the adolescents from public schools. ( 31 )

A study conducted by means of data analysis of the residents of the State of Missouri (United States) during the years 1997 to 1999 investigated the relation between infant mortality (neonatal and postnatal), socioeconomic level, and maternal age. This study involved 10,131 adolescents between 12 and 17 years, 18,954 adolescents between 18 and 19 years, and 28,899 adults (20 to 34 years), and showed that the risks of infant (OR=1.95), neonatal (OR=1.69), and postnatal (OR=2.47) mortality were significantly greater among adolescents aged 12 to 17 years than among the adults (20 to 34 years). After adjustment for race, marital status, schooling level, smoking, prenatal care, and poverty, the risk of postnatal mortality (OR=1.73) remained significantly higher for younger adolescent mothers, but not the risk of neonatal mortality (OR=1.43). ( 21 )

Researchers determined the association between a young maternal age and risk of LBW, small for gestational age (SGA), and premature delivery in 1,359 nulliparous (759) or uniparous (600) adolescents, who had diet supplementation with micronutrients and gave birth to a child analyzed within 72 hours after the delivery, from 1999 to 2001. The results showed that there was no difference in risk of LBW (OR=0.96) or SGA (OR=1.01) per year of maternal age increase among the primiparous mothers. Young maternal age did not affect the anthropometric data or gestational age of the offspring. Among primiparous adolescents, each year of increased maternal age was associated with an increase at birth in height, head and chest circumference, but not of the weight of the infant. Young maternal age (≤18 years) was associated with an increased risk of premature delivery among the primiparous mothers (OR=2.07). ( 22 )

One study analyzed perinatal data gathered between 1990 and 1999, compared the risk of adverse outcomes in nulliparous adolescents (7,845) and adolescents who had had an induced abortion (211) or a prior delivery (801). The adolescents with prior deliveries presented with greater perinatal (OR=2.35) and neonatal (OR=4.70) risks and mortality, when compared to the nulliparous participants. The adolescents with a prior abortion presented with higher risks of stillborns (OR=3.31), premature deliveries (OR=2.21), and a very low birth weight (VLBW) (OR=2.74) than the nulliparous adolescents. ( 24 )

Researchers established the temporal changes in maternal age and their impacts on the annual rate of cesarean sections and LBW by means of 91,699 data contained in an information system of Obstetrics of the National Hospital of Muhimbili, located in Dar es Salaam (Tanzania), during the period from 1999 to 2005. Based on the results, it was possible to observe that the proportion of adolescent mothers (12 to 19 years) diminished progressively over time, while that of 30 to 34 years increased. As of 1999, the risk of LBW declined, and the risk of cesarean sections increased continually up to a maximum in 2005, but the risk in adolescent mothers was lower than in mothers aged between 35 and 50 years. ( 26 )

One study investigated the relation between the first and the second pregnancy in adolescence with premature births, birth weight, and SGA, compared to adult mothers, and showed that the adolescents had a greater risk of premature birth and reduced weight of the newborn when compared to the adult mothers, especially during a second gestation. ( 28 )

A study conducted by means of the application of questionnaires and medical record analysis assessed the association between teen pregnancy and LBW in 537 adolescent mothers (10 to 19 years) and in 1,441 adult mothers (20-34 years), showing that the outcomes LBW and prematurity (OR=29.0) were associated with a low number of prenatal visits (OR=2.98), late initiation of prenatal care (OR=1.91), and low level of schooling (OR=1.95). There was a lower incidence of cesarean sections in adolescents (33.3%) than in adults (49.4%), and a lower association with pre-eclampsia and cephalopelvic disproportion. ( 25 )

Another study also showed an association between adolescent pregnancy and the late start of prenatal care (OR=1.86) and lower number of visits (OR=2.03). ( 27 )

Among the adolescents, also verified was a greater risk of prematurity (OR=1.46) and LBW (OR=1.47), besides the use of an abortive agent at the beginning of gestation (OR=2.34), and among women of an advanced age, a strong association was found between pregnancy and diabetes mellitus (OR=9.00), pre-eclampsia (OR=4.38), premature rupture of the membranes (OR=5.81), and higher frequency of cesarean sections (60.3%). ( 27 )

One study demonstrated that the chances of LBW (OR=2.70) and of prematurity (OR=5.82) were reduced when the adolescent had six or more prenatal visits. ( 34 ) Another study revealed that appropriate prenatal care decreased the chances of fetal death. ( 30 )

Prevalence of gestation in adolescence

Regarding participant inclusion criteria, four studies selected only adolescents, while the others ( 11 ) included adolescent and adult and/or advanced age mothers. Of these, eight were studies with a cross-sectional design and were used to calculate the prevalence of gestation in adolescence ( Table 1 ). The national studies demonstrated a prevalence of 26.4% (1,623/6,149).

Maternal and neonatal complications related to adolescent gestation

The most often described maternal complications in the selected studies were abortion, pregnancy-induced hypertension, hemorrhagic syndromes, urinary infection, and premature rupture, which are described on table 2 . The prevalence of cesarean sections in this population was 26.7% (530/1,983). ( 20 , 23 , 25 , 33 , 34 )

HDP: hypertensive disorders of pregnancy (pre-eclampsia, eclampsia, and HELLP); UTI: urinary tract infection; PROM: premature rupture of fetal membranes.

Most of the studies focused on verifying the relation between complications in pregnancy and prematurity and LBW among adolescent mothers, correlating them with perinatal and/or neonatal death ( Table 3 ).

PT: preterm; LBW: low birth weight.

Two studies ( 20 , 27 ) that evaluated the need for admission to a neonatal intensive care unit (NICU) demonstrated that 18.4% (119/648) of the newborns of adolescent mothers were transferred to the NICU. Only one study described the prevalence of infant death in this population, ( 21 ) which was approximately 9.6 per thousand liveborns.

Over the last decades, much has been discussed about adolescence, with a greater emphasis on its complexity and its repercussions on pregnancy during this phase. Pregnancy in adolescence is considered a public health problem that should be considered in a comprehensive manner, in order to involve the adolescent mother and the problems that surround her. ( 35 )

Nevertheless, the consideration of pregnancy during this stage as a risk factor for adverse outcomes is an oversimplification, since the phenomenon occurs in a variety of transactions and vulnerability, both of the mother and child, may be diminished by means of protective factors. ( 36 ) In this way, it becomes evident that not every pregnancy in adolescence carries a high obstetric risk. ( 37 )

Among the risk factors reported in pregnancy, low level of schooling, age under 15 years at the first sexual intercourse, absence of a partner, the maternal history of pregnancy in adolescence, and the lack of knowledge and access to contraceptive methods stood out as most significant. ( 38 ) Added to these, there is school drop-out, absence of future plans, low self-esteem, alcohol and drug abuse, lack of knowledge as to sexuality, and inappropriate use of contraceptive methods. ( 39 )

These factors may influence the adverse reproductive events in reference to the adolescent mother, and should be taken into consideration by the public health programs during preparation of strategies for preventing pregnancy in adolescence. ( 38 )

We point out that gestation during adolescence generates serious consequences for the two aspects of mother and child, such as, lack of care and abandonment of the child; emotional problems; school drop-out; job loss or a decline in options of growing in the work market; and multiparity within a short period of time. ( 40 )

One study ( 26 ) showed that the proportion of adolescent mothers decreased progressively during the period of 1999 to 2005. In Brazil, data from the Ministry of Health describe a 20% prevalence of adolescent gestations. In 2011, of the 2,913,160 liveborns, 560,889 (19.2%) were from adolescent mothers, in which 27,786 were under the age of 15 years. ( 41 )

The national studies shown here ( 20 , 25 - 27 , 29 - 30 , 32 - 33 ) demonstrated a prevalence significantly greater than that presented by the Ministry of Health, probably due to such studies having been conducted in tertiary services with a greater prevalence of high-risk pregnancies: 26.4% (1,623/6,149) versus 19.2% (560,889/2,913,160), with p<0.0001.

In literature in general, some authors demonstrated an increase in maternal-fetal complications at all stages of the gestational cycle among adolescent mothers. ( 7 , 8 , 42 , 43 ) In the present study, we observed that the complications associated with adolescent pregnancy most recurrent in literature were more often associated with the newborn than with the mother herself, with a predominance of articles emphasizing prematurity, LBW, and mortality. The occurrence of premature births, low-weight newborns, or infants with very low weight and mortality was significantly greater among babies of adolescent mothers. ( 20 , 21 , 23 - 25 , 27 - 29 , 33 , 34 )

These complications may be correlated with the low number of prenatal visits, late initiation of prenatal care, inappropriate prenatal care, and other factors, such as race, marital status, low level of schooling, smoking, and poverty. Santos et al. ( 34 ) observed a relation of the LBW with pregestational weight, pregestational body mass index, and gestational weight gain.

Supplementary literature suggests that the socioeconomic and cultural environments in which the young mother is inserted are associated with the increased frequency of low-weight and premature newborns. Additionally, it is known that prenatal care tends to be inadequate among adolescent mothers, ( 44 ) which shows the importance of prenatal visits to decrease complications of pregnancy in this age group.

Adolescent pregnancy is one of the three reproductive variables associated with greater infant mortality, primarily because it is related to a complex interaction of determining factors. In the study by Oliveira et al., ( 30 ) the presence of maternal comorbidity increased the risk of fetal and postnatal deaths. One should point out that most deaths could be avoidable and that the main failures are found in the quality of prenatal care, delivery, and neonatal care. ( 45 )

Analyzing the maternal complications related to pregnancy, the present systematic review found a smaller quantity of papers related to the topic ( 20 , 23 , 25 , 31 ) when compared to the data from fetal complications. The following complications were cited: pre-eclampsia, eclampsia, HELLP, abortion, urinary infection, and premature rupture of the ovarian membranes, among others. In general, the papers evaluated confirmed that an adolescent would be more inclined to an increase in maternal complications than would an adult pregnant woman.

The presence of comorbidity during the gestational period such as, for example, hypertension, urinary tract infection, pathological vaginal discharge, is much more common among adolescents than at other ages. ( 46 )

On the other hand, the prevalence of cesarean sections in this group was significantly lower when compared to the adult population. Data from the Information Technology Department of the Unified Healthcare System (DATASUS, Dados do Departamentode Informática dos Sistema Único de Saúde ) revealed that between 2008 and 2011, the prevalence of cesarean sections was 50.7% in the general population, and 43% in the adult population. ( 41 )

As to the presence of pre-eclampsia and eclampsia as complications of adolescent pregnancy, the results were inconclusive due to divergent data of the selected articles. Some studies declared that it was significantly greater among infants of adolescent mothers. ( 20 , 23 ) However, others observed a smaller association in adolescent mothers. ( 25 , 27 )

Of the articles analyzed, three papers cited abortion as a risk in early pregnancy, emphasizing the expression of not desiring the child, not taking the pregnancy to full-term. ( 25 , 27 , 31 ) Santos et al. ( 27 ) verified a 2.34 risk of the use of an abortive agent at the beginning of gestation in pregnant adolescents. Correia et al. ( 31 ) verified that 26.7% of the adolescents had abortions, primarily for fear of their families.

When analyzing specifically the occurrence of abortion in the population of puerperal women, Abreu ( 47 ) found a 54.7% proportion of adolescents with antecedents of abortion and identified that most were aged over 16 years (89.7%). As to the quantity of abortions, the same author observed the occurrence of two episodes of abortion, at most, among the adolescents.

It is known that adolescents who get an abortion suffer from lack of information, deficient medical care, of loneliness, and of a lack of communication in the family. ( 48 ) Additionally, abortion is responsible for increased hospital admissions, and can result in physical and psychological complications for the mother, and even death. ( 49 , 50 ) According to Granja et al., about 22% of maternal deaths in reference to pregnant adolescents had as primary causes pregnancy-induced hypertension, puerperal sepsis, and septic abortion, representing 75% of the total number of deaths. ( 51 )

Urinary infection was cited by two studies of the present systematic review. ( 20 , 27 ) A study by Nili et al. ( 20 ) showed that only 2% of the pregnant teens presented with urinary tract infections. In the study by Santos et al., ( 27 ) in urinary infection occurred in 17.1% of the adolescents. Just as the present systematic review, the study had the objective of establishing the profile of pregnancy in adolescence in a population cared for by the Unified Healthcare System (SUS, Sistema Único de Saúde ) in the city of Muriaé, in the region Zona da Mata Mineira , and verified that urinary infection was one of the most frequent complications among the adolescent puerpera, occurring with a greater proportion in adolescents over 16 years of age. ( 47 )

As to complications of the delivery, the occurrence of premature rupture of the membranes was described in three articles. ( 20 , 23 , 27 ) One study reported a 20.3% frequency of premature rupture in pregnant adolescents, suggesting that nutritional deficiencies may play an important role in this complication. ( 20 )

Yazlle et al. reported obstetric complications in 38.3% of the adolescents and among the most frequent diagnoses were problems with the fetus or the placenta, and problems with the amniotic cavity and membranes. ( 52 )

Despite the increase in coverage for this population given by Primary Care, we noted gaps in the health education and prevention programs that stimulate the use of male and female contraceptive agents, besides the inexistence of public policies directed at young pregnant women. ( 38 ) These factors collaborate towards the lack of knowledge of the adolescent about prevention methods and the appearance of an undesired pregnancy and its possible complications. Within this context, the need for prevention and control of consequences of an early pregnancy is justified. ( 40 )

Therefore, it is up to the healthcare professionals to improve listening, strengthen bonds with the adolescents, guarantee access to information and to contraceptive measures, and promote collective actions that help adolescents deal with their sexuality and develop self-care, and to also increase access to educational and recreational activities. ( 53 )

It is important to point out that this study has some limitations. Only the MEDLINE (PubMed), LILACS, and SciELO databases were used, i.e ., those considered most important in the field of health. However, other databases could have been consulted, such as EMBASE: Biomedical Answers, EBSCO, and SCOPUS. Additionally, in selected cross-sectional studies is it difficult to establish with precision the cause-effect relation, since the causal relation may suffer influences from confounding factors. The scarcity of data from good quality randomized controlled clinical studies to evaluate the complications of pregnancy in adolescence was also a limiting factor.

CONCLUSIONS

The main neonatal complications found were prematurity, low or very low birth weight, and perinatal mortality. Whereas the major maternal complications were hypertensive pregnancy disorders, abortion, urinary infections, and premature rupture of the fetal membranes. However, it is important to point out that the data are controversial as to the occurrence of pre-eclampsia.

Within this context, the importance of conducting studies for further clarification as to neonatal mortality, which seems to be strongly influenced by some determinants, such as low birth weight and prematurity, as well as maternal complications related to adolescent pregnancy. This fact reinforces the importance of prevention of these variables in prenatal and delivery care.

• Einstein (Sao Paulo). 2015 Oct-Dec; 13(4): 618–626.

Complicações da gravidez na adolescência: revisão sistemática da literatura

1 Universidade Federal da Paraíba, João Pessoa, PB, Brasil.

2 Universidade Cruzeiro do Sul, São Paulo, SP, Brasil.

A atividade sexual na adolescência pode levar a uma gravidez indesejável que por sua vez pode trazer sérias complicações maternais e fetais. O presente estudo teve por objetivo avaliar as complicações relacionadas à gravidez na adolescência, por meio de uma revisão sistemática, utilizando como descritores do Medical Subject Headings: “ pregnancy complication ” AND “ adolescent ” OR “ pregnancy in adolescence ”. Foram considerados os artigos originais completos em inglês ou português, na íntegra, que apresentassem descrição clara da metodologia. Não foram incluídos estudos qualitativos, revisões ou metanálises, editoriais, série de casos e relatos de caso. A amostra foi constituída por 15 publicações, sendo 10 com delineamento transversal e 5 com delineamento coorte. A prevalência geral de gestação na adolescência foi de 10% e, entre os trabalhos nacionais, de 26%. A prevalência de parto cesárea foi menor que a descrita na população geral. As principais complicações maternas e neonatais de mães adolescentes foram doença hipertensiva específica da gestação, prematuridade e baixo peso ao nascer respectivamente. A gestação na adolescência se relacionou a maior frequência de complicações neonatais e maternas e à menor prevalência de parto cesariana.

INTRODUÇÃO

A atividade sexual, na adolescência, inicia-se cada vez mais precocemente, com consequências indesejáveis imediatas, como o aumento da frequência de doenças sexualmente transmissíveis (DST) e gravidez, muitas vezes também indesejável, e que, por isso, pode terminar em abortamento. ( 1 )

No Brasil, no período de 2000 a 2006, o Sistema de Informação sobre Nascidos Vivos (SINASC) registrou declínio da participação dos nascimentos oriundos de mães dos grupos etários de 15 a 19 anos. Entretanto, a proporção de nascidos vivos cujas mães pertenciam ao grupo etário inferior a 14 anos se manteve estável. Em 2006, 51,4% dos nascidos vivos eram filhos de mães com idade até 24 anos, sendo aproximadamente 1% de mães do grupo etário inferior a 14 anos; 20,6% de mães com idade de 15 a 19 anos; e 29,9% de mães com idade entre 20 e 24 anos. ( 2 ) Em 2012, dos 2.905.789 nascidos vivos, 560.147 (19,28%) foram de mães adolescentes. ( 3 )

Do ponto de vista biológico, dentre as consequências da gravidez para a adolescente, citam-se maiores incidências de síndrome hipertensiva da gravidez (SHG), anemia, diabetes gestacional, complicações no parto, determinando aumento da mortalidade materna e infantil. ( 4 - 6 ) É importante notar que alguns estudos têm demonstrado aumento na incidência de intercorrências pré-natais, intraparto e pós-parto entre gestantes adolescentes. ( 7 , 8 )

No tocante aos problemas com o recém-nascido, a gravidez na adolescência está associada a taxas mais elevadas de baixo peso ao nascer (BPN), parto pré-termo, doenças respiratórias e tocotraumatismo, além de maior frequência de complicações neonatais e mortalidade infantil. ( 9 - 11 )

Considerando a alta prevalência da gestação na adolescência e suas consequências, o estudo teve o objetivo de avaliar as complicações relacionadas à gravidez na adolescência.

MÉTODOS

Trata-se de um estudo de revisão sistemática da literatura, que seguiu as recomendações propostas pela Colaboração Cochrane. ( 12 , 13 )

A questão norteadora proposta para o estudo foi a seguinte: Quais as complicações relacionadas à gravidez na adolescência?

A coleta de dados ocorreu entre os meses de maio e agosto de 2012 mediante busca on-line nas seguintes bases de dados consultadas a partir da Biblioteca Virtual de Saúde (BVS): MEDLINE (PubMed), Literatura Latino-Americana e do Caribe de Informação em Ciências da Saúde (LILACS) e Scientific Electronic Library Online (SciELO).

Para a localização dos artigos, foram utilizados os seguintes descritores do Medical Subject Headings (MeSH), da base PubMed/MEDLINE: “ pregnancy complication ” AND “adolescent” OR “pregnancy in adolescence” .

Os critérios de inclusão contemplaram artigos originais, disponíveis na íntegra gratuitamente na versão on-line , nos idiomas inglês ou português, e no período de 2002 a 2012. Foram incluídos ensaios clínicos randomizados, ensaios clínicos quase randomizados, ensaios clínicos aleatórios, estudos observacionais analíticos (estudos de caso-controle, coorte prospectivos e retrospectivos) e estudos descritivos transversais (de prevalência), que apresentavam uma descrição clara da metodologia. Estudos realizados com grandes amostras de adultos, mas que incluíam adolescentes como um subgrupo, também foram incluídos.

Não foram incluídos artigos teóricos, investigações com uma descrição pouco clara sobre a metodologia utilizada, manuscritos baseados em relatórios estatísticos anuais (dados censitários e informações obtidas de forma indireta por meio de gráficos ou arquivos), estudos qualitativos, revisões ou metanálises, teses e dissertações, editoriais, artigos de opinião, série de casos, relatos de caso, estudos com amostra não representativa de uma população e anteriores ao ano 2002.

Os estudos foram inicialmente estratificados de acordo com os tipos de desenhos e, posteriormente, em relação aos desfechos, seguindo a metodologia Cochrane. ( 14 )

A qualidade metodológica da revisão sistemática foi definida com a confiança de que o desenho e o relato do estudo estivessem livres de bias, ( 15 ) e foi avaliada independentemente por dois revisores, no sentido de se averiguar se preencheram os critérios de inclusão e exclusão. Em caso de dúvida ou discordância, foi solicitado a um terceiro revisor a emissão de parecer sobre o estudo ser ou não incluído, conforme propõe Stocco. ( 16 ) No caso de estudos duplicados, foi incluído o mais recente ou com informações mais completas.

Para avaliação da qualidade metodológica, critérios de inclusão e exclusão, foram utilizados as recomendações STROBE ( The Strengthening the Reporting of Observational Studies in Epidemiology ). ( 17 , 18 ) A avaliação foi dividida em três categorias de estudos: (A) nos casos de estudos que preenchiam valor ≥80% dos critérios solicitados; (B) nos casos que preenchiam de 79 a 50% dos critérios; e (C) nos casos que preenchiam <50% dos critérios estabelecidos. ( 14 , 17 , 18 ) Assim, apenas os artigos que atingiram um percentual >50% (classificados como A ou B) foram considerados de boa qualidade e incluídos na pesquisa. ( 19 )

Os dados analisados foram sintetizados e organizados por meio de figuras, quadros e tabelas.

O universo foi constituído por 6.465 artigos, sendo 6.232 no PubMed/MEDLINE e 233 na LILACS e SciELO. Após a leitura dos títulos e/ou resumos, foram excluídos 6.380 artigos, por apresentarem foco diferente do objetivo procurado. Assim, das 85 publicações lidas na íntegra, foram selecionadas 15, que se enquadraram nos critérios de inclusão e exclusão, conforme a figura 1 .

O quadro 1 mostra os países de origem, ano de publicação e desenho dos estudos incluídos na presente revisão.

Dos 15 trabalhos selecionados, dez apresentaram delineamento transversal e 5 apresentaram coorte, sendo 4 retrospectivos e 1 prospectivos. Quanto ao ano de publicação, a maioria dos estudos foi publicada no período de 2008 a 2012. Os estudos foram realizados predominantemente no Brasil, Estados Unidos, nos países da Europa, África e Ásia. Todos os artigos selecionados para a revisão sistemática apresentaram percentuais STROBE >50%, sendo 3 classificados como STROBE A e 12 como STROBE B.

O quadro 2 apresenta as principais características dos estudos acerca das complicações da gravidez na adolescência.

RPM: ruptura prolongada de membranas; ITU: infecção do trato urinário; BPN: baixo peso ao nascer; MBPN: muito baixo peso ao nascer; PIG: pequeno para idade gestacional; RPMO: rotura prematura das membranas ovulares; IMC: índice de massa corporal.

Em pesquisa realizada com 2.357 mulheres grávidas, a frequência de adolescentes grávidas (menores de 18 anos) foi de 4%. A complicação materna que apresentou um maior destaque foi a ruptura prolongada da membrana, com 20,3%, seguida de pré-eclâmpsia (7,1%), doenças na tireoide (7,1%), doenças cardíacas (3%) e infecções no trato urinário (2%). Dentre as complicações neonatais, destacaram-se a prematuridade (39%), o BPN (32%) e o crescimento intrauterino retardado (12%). A mortalidade neonatal foi descrita em 6,9% dos casos, sendo significativamente maior que as complicações neonatais dos demais partos. ( 20 )

Outro estudo realizado com 265 mães adolescentes (idade ≤19 anos) e com 832 mães com idade ente 20 e 29 anos mostrou que as complicações maternas relacionadas à gravidez na adolescência mais frequentes foram a eclâmpsia (OR=3,18), a pré-eclâmpsia (OR=1,82), a laceração perineal (OR=1,45) e a episiotomia (OR=1,82). Enquanto que as complicações fetais foram o BPN (OR=1,71), prematuridade (OR=1,77) e óbito neonatal precoce (OR=2,18). ( 23 )

Estudo realizado por meio de análise de dados coletados pelo Departamento de Serviço de Saúde do Estado do Texas entre 1994 e 2003 avaliou as complicações que ocorreram durante o trabalho de parto de 1.355.962 mães nulíparas e mostrou que as mães adolescentes (15 a 18 anos) tiveram menores taxas de febre intraparto, mecônio excessivo, ruptura prematura da membrana, placenta prévia, trabalho de parto prolongado, parto disfuncional, apresentação pélvica do feto, desproporção cefalopélvica e prolapso de cordão umbilical, quando comparadas às mães com idade entre 25 e 29 anos. ( 32 )

Mukhopadhyay et al. compararam as diferenças perinatais entre 350 adolescentes (13 a 19 anos) e 350 adultas (20 a 29 anos), ambas primigestas, por meio de análise de prontuários, e evidenciaram que houve uma maior proporção de partos prematuros (27,7%), BPN (38,95%) e taxa de natimortos (5,1%), em comparação às mães adultas. ( 29 )

Uma pesquisa investigou as razões que levaram adolescentes a provocarem o aborto, relacionando a motivação com idade e tipo de escola que frequentavam. Das 2.592 jovens participantes da pesquisa, 182 (7,0%) referiram ter engravidado e 149 (26,7%) abortado. Verificou-se que o medo da reação dos pais (o mais citado), a idade, a falta de apoio por parte do companheiro e não aceitar a gravidez foram razões que levaram as adolescentes a provocarem o aborto. O aborto obteve uma maior frequência entre as jovens de escola pública. ( 31 )

Estudo realizado por meio por meio de análise de dados de residentes no Estado do Missouri (Estados Unidos) durante os anos de 1997 a 1999 investigou a relação entre a mortalidade infantil (neonatal e pós-natal), nível socioeconômico e idade materna. Tal estudo envolveu 10.131 adolescentes entre 12 e 17 anos, 18.954 adolescentes entre 18 e 19 anos e 28.899 adultas (20 a 34 anos) e mostrou que os riscos de mortalidade infantil (OR=1,95), neonatal (OR=1,69) e pós-neonatal (OR=2,47) foram significativamente maiores entre adolescentes de 12 a 17 anos do que entre as adultas (20 a 34 anos). Após o ajuste para raça, estado civil, nível educacional, tabagismo, assistência pré-natal e pobreza, o risco de mortalidade pós-neonatal (OR=1,73) manteve-se significativamente maior para mães adolescentes mais jovens, mas não o risco de mortalidade neonatal (OR=1,43). ( 21 )

Pesquisadores determinaram a associação entre idade materna jovem e o risco de BPN, pequeno para a idade gestacional (PIG) e parto prematuro em 1.359 adolescentes nulíparas (759) ou uníparas (600), que tiveram suplementação da dieta com micronutrientes e que pariram uma criança que foi analisada dentro de 72 horas após o parto, no período de 1999 a 2001. Os resultados mostraram que não houve diferença no risco de BPN (OR=0,96) ou PIG (OR=1,01) por ano de aumento da idade materna entre as primíparas. A idade materna jovem não afetou a antropometria e nem a idade gestacional da prole. Entre primíparas, cada ano de aumento da idade materna foi associado ao aumento do comprimento ao nascer, cabeça e circunferência do peito, mas não peso de sua prole. A idade materna jovem (≤18 anos) foi associada com o aumento do risco de parto prematuro entre as primíparas (OR=2,07). ( 22 )

Estudo realizado por meio de análise de dados perinatais coletados no período de 1990 a 1999 comparou o risco de desfechos reprodutivos adversos em adolescentes nulíparas (7.845) e adolescentes que tiveram aborto induzido (211) ou parto anterior (801). As adolescentes com parto anterior apresentaram maiores riscos perinatais (OR=2,35), neonatais (OR=4,70) e mortalidade, quando comparadas às nulíparas. As adolescentes com aborto anterior apresentaram riscos mais elevados para natimortos (OR=3,31), nascimentos prematuros (OR=2,21) e muito BPN (OR=2,74) do que as adolescentes nulíparas. ( 24 )

Estudiosos procuraram estabelecer as mudanças temporais na idade materna e seus impactos na taxa anual de cesarianas e BPN, por meio de 91.699 dados contidos em um sistema de informação da Obstetrícia do Hospital Nacional de Muhimbili, localizado em Dar es Salaam (Tanzânia), no período de 1999 a 2005. Diante dos resultados, foi possível observar que a proporção de mães adolescentes (12 a 19 anos) diminuiu progressivamente ao longo do tempo, enquanto que a de 30 a 34 anos aumentou. A partir de 1999, o risco de BPN reduziu, e o risco de cesariana aumentou continuamente para um máximo em 2005, porém, o risco em mães adolescentes foi menor que em mães com idades entre 35 e 50 anos. ( 26 )

Pesquisa investigou a relação entre a primeira e a segunda gravidez na adolescência com nascimentos prematuros, peso ao nascer e PIG, comparando com mães adultas, e mostrou que as mães adolescentes tinham maior risco de parto prematuro e peso reduzido do bebê quando comparadas com as mães adultas, principalmente em uma segunda gestação. ( 28 )

Pesquisa realizada por meio da aplicação de questionários e análise de prontuários analisou a associação da gravidez na adolescência com o BPN em 537 mães adolescentes (10 a 19 anos) e em 1.441 mães adultas (20-34 anos), mostrando que os desfechos BPN e prematuridade (OR=29,0) estiveram associados com baixo número de consultas do pré-natal (OR=2,98), início tardio do pré-natal (OR=1,91) e baixa escolaridade (OR=1,95). Houve menor incidência de cesárea em adolescentes (33,3%) que em adultas (49,4%) e menor associação com pré-eclâmpsia e desproporção cefalopélvica. ( 25 )

Outra pesquisa também demonstrou associação entre a gravidez na adolescência e o início tardio do pré-natal (OR=1,86), e o menor número de consultas (OR=2,03). ( 27 )

Entre as adolescentes, foi verificado, ainda, maior risco de prematuridade (OR=1,46) e BPN (OR=1,47), além de uso de abortivo no início da gestação (OR=2,34) e, entre mulheres com idade avançada, constatou-se forte associação da gravidez com diabetes mellitus (OR=9,00), pré-eclâmpsia (OR=4,38), ruptura prematura de membranas (OR=5,81) e maior frequência de parto cesáreo (60,3%). ( 27 )

Estudo demonstrou que as chances de BPN (OR=2,70) e de prematuridade (OR=5,82) reduziram quando a adolescente recebeu seis ou mais consultas de pré-natal. ( 34 ) Outro estudo revelou que o pré-natal adequado diminui as chances de óbito fetal. ( 30 )

Prevalência de gestação na adolescência

Em relação aos critérios de inclusão das participantes, quatro estudos selecionaram como participantes apenas adolescentes, sendo que os demais ( 11 ) incluíram tanto mães adolescentes como mães adultas e/ou em idade avançada. Destes, oito eram estudos com delineamento transversal e foram utilizados para cálculo da prevalência de gestação na adolescência ( Tabela 1 ). Os estudos nacionais demonstram prevalência de 26,4% (1.623/6.149).

Complicações maternas e neonatais relacionadas à gestação na adolescência

As complicações maternas mais descritas nos estudos selecionados foram: abortamento, doença hipertensiva da gestação, síndromes hemorrágicas, infecção urinária e rotura prematura que são descritas na tabela 2 . A prevalência de cesárea, nessa população, foi de 26,7% (530/1.983). ( 20 , 23 , 25 , 33 , 34 )

DHEG: doença hipertensiva específica da gestação (pré-eclâmpsia, eclâmpsia e HELLP); ITU: infecção do trato urinário; RPMO: rotura prematura das membranas ovulares.

A maioria dos estudos preocupou-se em verificar a relação entre as complicações na gravidez com prematuridade e BPN entre mães adolescentes, correlacionando com a morte perinatal e/ou neonatal ( Tabela 3 ).

PT: pré-termo; BPN: baixo peso ao nascer.

Dois estudos ( 20 , 27 ) que avaliaram a necessidade de internação em unidade de terapia neonatal (UTI) demonstram que 18,4% (119/648) dos recém-nascidos de mães adolescentes foram transferidos para UTI neonatal. Apenas um estudo descreveu a prevalência de morte infantil nessa população, ( 21 ) que foi de, aproximadamente, 9,6 por mil nascidos vivos.

DISCUSSÃO

Nas últimas décadas, têm-se discutido muito a respeito da adolescência, com uma ênfase maior no que diz respeito à complexidade e às repercussões da gravidez nessa fase. A gravidez, entre as adolescentes, é considerada um problema de saúde pública, que deve ser observado de forma ampliada, de maneira a envolver a mãe adolescente e os problemas que a cercam. ( 35 )

No entanto, considerar a gravidez nessa fase como um fator de risco para desfechos adversos é algo redutor, uma vez que o fenômeno ocorre numa variedade de transações e que a vulnerabilidade, tanto da mãe quanto do bebê, pode ser diminuída por meio de fatores protetores. ( 36 ) Desse modo, pode-se evidenciar que nem toda gravidez na adolescência é de alto risco obstétrico. ( 37 )

Dentre os fatores de risco relacionados a gravidez na adolescência destacaram-se a baixa escolaridade, a idade da primeira relação sexual inferior a 15 anos, a ausência de companheiro, a história materna de gravidez na adolescência e a falta de conhecimento e de acesso aos métodos anticoncepcionais. ( 38 ) Acrescentam-se a estes o abandono escolar, a ausência de planos futuros, a baixa autoestima, o abuso de álcool e drogas, a falta de conhecimento a respeito da sexualidade e o uso inadequado de métodos contraceptivos. ( 39 )

Esses fatores podem influenciar os eventos reprodutivos adversos referentes a mãe adolescente e devem ser levados em consideração pelos programas de saúde pública durante a elaboração de estratégias para a prevenção da gravidez na adolescência. ( 38 )

Ressalta-se que a gravidez na adolescência gera sérias consequências para o binômio mãe/filho, como, por exemplo, o desamparo e abandono da criança; os problemas emocionais; o afastamento escolar; a perda do emprego ou redução das opções de crescer no mercado de trabalho; e a multiparidade em um curto período de tempo. ( 40 )

Estudo ( 26 ) evidenciou que a proporção de mães adolescentes diminuiu progressivamente durante o período de 1999 a 2005. No Brasil, dados do Ministério da Saúde descreveram uma prevalência de gestação na adolescência de 20%. Em 2011, dos 2.913.160 nascidos vivos, 560.889 (19,2%) foram de mães adolescentes, sendo que 27.786 tinham idade inferior a 15 anos. ( 41 )

Os estudos nacionais aqui apresentados ( 20 , 25 - 27 , 29 - 30 , 32 - 33 ) demonstraram prevalência significativamente maior do que a apresentada pelo Ministério da Saúde, provavelmente por tais estudos terem sido realizados em serviços de atendimento terciário com maior prevalência de gestação de alto risco: 26,4% (1.623/6.149) versus 19,2% (560.889/2.913.160), com p<0,0001.

Na literatura em geral, alguns autores têm demonstrado aumento nas intercorrências materno-fetais em todas as etapas do ciclo gestacional entre gestantes adolescentes. ( 7 , 8 , 42 , 43 ) No presente estudo, observou-se que as complicações associadas à gravidez na adolescência mais recorrentes na literatura estiveram mais associadas ao recém-nascido que propriamente à genitora, com predominância de manuscritos que enfatizaram a prematuridade, o BPN e a mortalidade. A ocorrência de nascimentos prematuros, recém-nascidos de baixo peso ou muito baixo peso e mortalidade foi significantemente maior entre os filhos de mães adolescentes. ( 20 , 21 , 23 - 25 , 27 - 29 , 33 , 34 )

Essas intercorrências podem ser correlacionadas com o baixo número de consultas de pré-natal, o início tardio de pré-natal, o pré-natal inadequado e outros fatores, como raça, estado civil, baixa escolaridade, tabagismo e pobreza. Santos et al. ( 34 ) observaram relação do BPN com o peso pré-gestacional, índice de massa corporal pré-gestacional e ganho de peso gestacional.

A literatura complementar sugere que os ambientes socioeconômico e cultural em que a jovem mãe está inserida estão associados ao aumento da frequência de recém-nascidos de baixo peso e prematuros. Além disso, sabe-se que os cuidados pré-natais tendem a ser inadequados entre as mães adolescentes, ( 44 ) o que traz à tona a importância das consultas do pré-natal para diminuição das complicações da gravidez na adolescência.

A gravidez na adolescência é uma das três variáveis reprodutivas associadas à maior mortalidade infantil, principalmente por estar relacionada a uma complexa interação de fatores determinantes. No estudo de Oliveira et al., ( 30 ) a presença de comorbidade materna aumentou o risco para óbito fetal e pós-neonatal. Deve-se destacar que a maioria dos óbitos pode ser evitáveis e que as principais falhas se encontram na qualidade da assistência ao pré-natal, ao parto e à assistência neonatal. ( 45 )

Analisando as intercorrências maternas relacionadas à gravidez na adolescência, a presente revisão sistemática encontrou uma menor quantidade de trabalhos relacionados ao tema ( 20 , 23 , 25 , 31 ) quando comparado aos dados das intercorrências fetais. Foram citados: a pré-eclampsia, a eclâmpsia, HELLP, o abortamento, a infecção urinária e a ruptura prematura das membranas ovulares, entre outros. De forma geral, os trabalhos avaliados confirmaram que a gestante adolescente estaria mais propícia ao aumento de intercorrências maternas que uma gestante adulta.

A presença de comorbidade no período gestacional como, por exemplo, hipertensão, infecção do trato urinário, corrimento vaginal patológico, é muito mais comum entre adolescentes do que em outras idades. ( 46 )

Por outro lado, a prevalência de cesariana nesse grupo foi significativamente menor quando comparada à população adulta. Dados do Departamento de Informática do Sistema Único de Saúde (DATASUS) revelaram que, entre 2008 e 2011, a prevalência de cesárea foi de 50,7% na população geral, sendo 43% na população adulta. ( 41 )

Com relação à presença de pré-eclâmpsia e eclâmpsia como complicações da gravidez na adolescência, os resultados foram inconclusivos, em virtude de dados divergentes dos artigos selecionados. Alguns estudos citaram ser significantemente maior entre os filhos de mães adolescentes. ( 20 , 23 ) Entretanto, outros observaram menor associação em mães adolescentes. ( 25 , 27 )

Dos artigos analisados, três trabalhos citaram o aborto como um risco na gravidez precoce, enfatizando a expressão de não desejar a criança, não levando a termo a gestação. ( 25 , 27 , 31 ) Santos et al. ( 27 ) verificaram um risco de 2,34 de uso de abortivo no início da gestação em adolescentes grávidas. Correia et al. ( 31 ) verificaram que 26,7% das adolescentes realizaram o aborto, principalmente por medo da família.

Abreu, ( 47 ) ao analisar especificamente a ocorrência de abortamento na população de puérperas, encontrou uma proporção de adolescente com antecedentes de abortamento de 54,7% e constatou que a maioria tinha idade superior a 16 anos (89,7%). Com relação à quantidade de abortamentos, o mesmo autor observou a ocorrência de, no máximo, dois episódios de abortamentos entre as adolescentes.

Sabe-se que as adolescentes que abortam são vítimas de falta de informação, da deficiência no atendimento médico, da solidão e da falta de comunicação na família. ( 48 ) Além disso, o abortamento é o responsável pelo aumento na frequência de internações hospitalares, podendo resultar em complicações físicas, psicológicas e até o óbito materno. ( 49 , 50 ) Segundo Granja et al., cerca de 22% dos óbitos maternos referentes a gestantes adolescentes tiveram como principais causas a hipertensão induzida pela gravidez, a sepse puerperal e o abortamento séptico, representando 75% do total das mortes. ( 51 )

A infecção urinária foi citada por dois estudos da presente revisão sistemática. ( 20 , 27 ) Estudo de Nili et al. ( 20 ) mostrou que apenas 2% das adolescentes grávidas apresentaram infecção no trato urinário. No estudo de Santos et al., ( 27 ) a infecção urinária ocorreu em 17,1% das adolescentes. Assim como a presente revisão sistemática, estudo teve por objetivo estabelecer o perfil da gravidez na adolescência em população assistida pelo Sistema Único de Saúde (SUS) no município de Muriaé, na Zona da Mata Mineira, e verificou que a infecção urinária foi uma das intercorrências mais frequentes entre as puérperas adolescentes, ocorrendo em maior proporção nas adolescentes com mais de 16 anos. ( 47 )

No que se refere às complicações do parto, a ocorrência de ruptura prematura de membranas foi descrita em três artigos. ( 20 , 23 , 27 ) Estudo relatou frequência de 20,3% de ruptura prematura em adolescentes grávidas, sugerindo que deficiências nutricionais podem desempenhar um papel importante nessa intercorrência. ( 20 )

Yazlle et al. relataram intercorrências obstétricas em 38,3% das adolescentes e, entre os diagnósticos mais frequentes, encontravam-se os problemas fetais ou da placenta, e problemas com a cavidade amniótica e membranas. ( 52 )

Apesar do aumento de cobertura para essa população na Atenção Básica, observam-se lacunas nos programas de educação em saúde e de prevenção que estimulem o uso de preservativos e contraceptivos, além de inexistirem políticas públicas direcionadas às jovens gestantes. ( 38 ) Esses fatores colaboram para falta de conhecimento da adolescente quanto aos métodos de prevenção e para o aparecimento de uma gravidez indesejada e de suas possíveis complicações. Nesse contexto, justifica-se a necessidade de prevenção e de controle das consequências de uma gravidez precoce. ( 40 )

Assim, cabe aos profissionais de saúde aprimorar a escuta, fortalecer vínculos com o jovem, garantir acesso a informações e aos métodos contraceptivos, e promover ações coletivas que auxiliem os adolescentes a lidarem com sua sexualidade, desenvolvam o autocuidado, e também ampliem o acesso a atividades educativas e recreativas. ( 53 )

É importante ressaltar que esse estudo apresenta algumas limitações. Foram utilizadas apenas as bases de dados MEDLINE (PubMed), LILACS e SciELO, consideradas as principais na área de saúde. Entretanto, outras bases de dados poderiam ter sido consultadas, como EMBASE: Biomedical Answers , EBSCO e SCOPUS. Além disso, estudos transversais selecionados são difíceis de estabelecer com precisão a relação causa-efeito, pois a relação causal pode sofrer influências de fatores de confusão. A escassez de dados provenientes de ensaios clínicos controlados randomizados de qualidade para avaliar as complicações da gravidez na adolescência também foi um fator limitante.

CONCLUSÕES

As principais complicações neonatais encontradas foram a prematuridade, o baixo ou muito baixo peso ao nascer e a mortalidade perinatal. Sugerem-se como principais complicações maternas a doença hipertensiva específica da gestação, o abortamento, a infecção urinária e a ruptura prematura das membranas ovulares. Entretanto, cabe enfatizar que os dados são controversos com relação à ocorrência de pré-eclâmpsia.

Nesse contexto, destaca-se a importância da realização de estudos para mais esclarecimentos sobre a mortalidade neonatal, que parece ser fortemente influenciada por determinantes como o baixo peso ao nascer e a prematuridade, e também sobre as intercorrências maternas relacionadas à gravidez na adolescência. Esse fato reforça a importância da prevenção dessas variáveis na assistência pré-natal e no parto.