Adolescent Pregnancy - Risk Factors, Adverse Effects, Advice on Contraceptive Methods

Most teenage girls do not plan to get pregnant, but in some countries, many do. Adolescent pregnancies carry extra health risks to both the mother and the baby. Often, teens do not get prenatal care soon enough, which can lead to problems later on. They have a higher risk for pregnancy-related high blood pressure and its complications. Risks for the baby include premature birth and a low birth weight.

In this article:
Adolescent Pregnancy: Scope of the problem
Risk factors for teenage and adolescent pregnancy
Adverse effects of teenage and adolescent pregnancy
Provision of advice or treatment
Methods of contraception
Key facts about teenage pregnancy

Adolescent Pregnancy: Scope of the problem

Birth rates

There has been a marked, although uneven, decrease in the birth rates among adolescent girls since 1990, but some 11% of all births worldwide are still to girls aged 15 to 19 years old. The vast majority of these births (95%) occur in low- and middle-income countries.

The 2014 World Health Statistics indicate that the average global birth rate among 15 to 19 year olds is 49 per 1000 girls. Country rates range from 1 to 299 births per 1000 girls, with the highest rates in sub-Saharan Africa.

Adolescent pregnancy remains a major contributor to maternal and child mortality, and to the cycle of ill-health and poverty.

Contexts

For some adolescents, pregnancy and childbirth are planned and wanted, but for many they are not. Adolescent pregnancies are more likely in poor, uneducated and rural communities. In some countries, becoming pregnant outside marriage is not uncommon. By contrast, some girls may face social pressure to marry and, once married, to have children. More than 30% of girls in low- and middle-income countries marry before they are 18; around 14% before they are 15.

Some girls do not know how to avoid getting pregnant: sex education is lacking in many countries. They may feel too inhibited or ashamed to seek contraception services; contraceptives may be too expensive or not widely or legally available. Even when contraceptives are widely available, sexually active adolescent girls are less likely to use them than adults. Girls may be unable to refuse unwanted sex or resist coerced sex, which tends to be unprotected.

Risk factors for teenage and adolescent pregnancy

Many factors predispose adolescents to getting pregnant in their teens. Although these factors cut across all social levels, evidence indicates that rates of teenage pregnancy are higher in societies and areas of social deprivation. Adolescent and teenage girls particularly at risk are those who:

• Have been, or are in care (private- or government-funded).
• Are homeless.
• Are underachieving at school.
• Are involved in crime.
• Are themselves children of adolescent or teenage mothers.
• Are from certain ethnic minority groups.

Fears that sex education will make adolescents and teenagers more likely to experiment with sex have been shown to be unfounded. There is little evidence about the best method, but it has been shown that education given responsibly to teenagers does reduce unintended pregnancies in adolescents in the long run.

Adverse effects of teenage and adolescent pregnancy

Health effects

Pregnancy and childbirth complications are the second cause of death among 15 to 19 year olds globally. Some 3 million unsafe abortions among girls aged 15 to 19 take place each year, contributing to maternal deaths and to lasting health problems.

Early childbearing increases the risks for both mothers and their newborns. In low- and middle-income countries, babies born to mothers under 20 years of age face a 50% higher risk of being still born or dying in the first few weeks versus those born to mothers aged 20-29. The younger the mother, the greater the risk to the baby. Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects.

Pregnant woman. Credit: Joey Thompson (Unsplash)

Abortion carries its medical and emotional adverse effects, whilst continuing pregnancy carries a higher risk of maternal and fetal disadvantage. See these separate articles, How to Prevent Unsafe Abortions, ans also Abortion: Risks, Consequences and Health Effects for more details.

Women who get pregnant in their teens are more likely to suffer anaemia (low blood level), eclampsia (life-threatening seizures or convulsions due to pregnancy), puerperal endometritis (infection of the lining of the womb following childbirth) and postnatal depression (low mood and depression following childbirth). The fetus (unborn baby) is at risk of higher rates of perinatal mortality (death of baby during pregnancy or within one month after birth), low birth weight, sudden infant death syndrome and substance dependence.

Economic and social consequences

Adolescent and teenage pregnancy is a serious social problem. Having children at a young age can damage young women's mental and physical health, limit their education and career prospects, and increase their risk of living in poverty and social isolation.

Adolescent pregnancy can also have negative social and economic effects on girls, their families and communities. Many girls who become pregnant have to drop out of school. A girl with little or no education has fewer skills and opportunities to find a job. This can also have an economic cost with a country losing out on the annual income a young woman would have earned over her lifetime, if she had not had an early pregnancy.

Consequences on the child

Children born to teenagers are much more likely to experience a range of negative outcomes in later life. Children born to adolescent or teenage parents are also much more likely to become teenage parents themselves.

Provision of advice or treatment

If you're a pregnant teen, you can help yourself and your baby by:

• Getting regular prenatal care (also called antenatal care, or ANC)
• Taking your prenatal vitamins for your health and to prevent some birth defects (particularly folic acid and B vitamins)
• Avoiding smoking, alcohol, and drugs such as cocaine
• Using a condom, if you are having sex, to prevent sexually transmitted diseases that could hurt your baby, see the separate article Sexually Transmitted Infections; and also the section 'Methods of contraception' below

Contraceptive advice should be provided to all competent young persons, including those aged under 16 years. If you are a parent, you should make out time to properly educate your children as soon as they become teens. On the other hand, your doctor or nurse or other healthcare provider can also provide this advise.

Methods of contraception

Abstinence from sex is the best method of preventing adolescent and teenage pregnancy; however, where this is not possible or adhered to, then contraception becomes a key method of preventing adolescent pregnancy. Contraception may be oral, depots and implants, intrauterine devices, barrier methods, and emergency contraception. See below for more details.

Age alone should not limit contraceptive choices, including intrauterine methods. Provided that there are no medical contra-indications, young women should choose whichever method of contraception they prefer, but:

• Before menarche (the first menstrual cycle, or first menstrual bleeding), condoms are preferred for contraception and to prevent sexually transmitted infections. Hormonal methods of contraception are not advised for this age group.
• For young women using a hormonal or intrauterine contraceptive, condoms should also be used to prevent sexually transmitted infections.
• Vaginal ring: the combined contraceptive vaginal ring is not recommended for women below 18 years of age because safety and efficacy have only been established for women aged 18 to 40 years.

Choice of contraception may be affected by:

• How discreet the method is.
• How easy the method is to forget.
• Effectiveness.
• Safety.
• Side-effect profile.
• Invasiveness.
• Ease of use.
• Knowledge and understanding of the options available.

Lack of adherence and discontinuation of contraception are more likely to be issues in young people. Long-acting reversible contraception (LARC) are methods that provide effective contraception for prolonged periods without requiring the woman to do anything. They include injections, devices inserted into the uterus (also called intrauterine devices, or simple IUDs) and implants into the skin (also called subdermal contraceptive implants). They are the most effective reversible methods of contraception because they do not depend on the compliance of the woman. LARC methods are very beneficial because they are not user-reliant and therefore have lower failure rates because they are constantly protecting the woman in the background, from getting pregnant, whether she remembers or not.

Oral contraceptives

The combined oral contraceptive pill (COCP) offers non-contraceptive advantages in terms of controlling irregular menstrual cycles, premenstrual symptoms and heavy or painful periods. Treatment courses can also be run together to avoid menstruation during examinations, etc.

Effectiveness depends upon taking the pill as instructed and in typical use is associated with a pregnancy rate of 90 per 1,000 women per year. Teenagers are particularly at risk because they may forget and so miss to take their pills.

COCPs may improve vulgaris (also called pimples). Co-cyprindiol (sold as Dianette®) is a COCP and is used for severe acne which has not responded to oral antibiotics; however, it has a higher risk of venous thromboembolism (abnormal blood clots forming in veins). See the separate article, Acne (or Pimples): Causes, Risk Factors, Self-Help Advise and Treatment.

Progestogen-only contraceptive pills (POCPs) are less suitable because of the need for them to be taken regularly, although desogestrel POCPs may be the most appropriate for adolescents and teenagers, as the missed pill window is 12 hours rather than 3 (meaning you are still protected against pregnancy even if you forget and miss to take your desogestrel pill by upto 12 hours).

Depots and implants

Depot injections are reliable and provide a contraceptive effect for 8-12 weeks. However, because of its side effects of loss of bone mineral density, medroxyprogesterone acetate (sold as Depo-Provera®) should be used in adolescents only when other methods of contraception are inappropriate.

The etonogestrel-releasing implant (sold as Nexplanon®) may be a suitable option and provides effective contraception for up to three years.

Intrauterine devices

The copper-based intrauterine contraceptive device (IUCD) and the progestogen-releasing intrauterine system (IUS) may be considered, although it may be difficult to insert a coil into a nulliparous uterus (a uterus that has never given birth) and there is no protection against sexually transmitted diseases. See the separate article, Sexually Transmitted Infections, for more details.

There is a small increase in risk of pelvic infection in the 20 days after IUCD insertion, but there is no increased risk after the first 20 days.

Barrier methods

A diaphragm may be suitable for some girls in stable relationships, but storing and transporting the device may be difficult if not telling their parents.

Male and female condoms are relatively unreliable if used alone.

Condoms, if combined with other methods, enhance effectiveness and protect against sexually transmitted diseases.

In certain countries, for example the UK, male and female condoms are handed out free from contraception and sexual health clinics and young people's services, and some general practices and genitourinary medicine (GUM) clinics. You may want to chesk if this obtains where you live; otherwise meet and discuss with your doctor or other healthcare provider.

Emergency contraception

Emergency contraception is an intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse (UPSI) or failure of the contraceptive method used. There are now three methods of emergency contraception (the copper IUCD, levonorgestrel and ulipristal acetate) but the IUCD is the only one which provides ongoing contraception, and are preferrable.

This provides a good opportunity to ask your doctor or ther healthcare provider for contraception advice and counselling for the future.

Progestogen-only emergency contraception can be obtained in your local community pharmacies.

Key facts about teenage pregnancy

Evidence from the WHO regarding adolescent pregnancy show:

• About 16 million girls aged 15 to 19 and some 1 million girls under 15 give birth every year—most in low- and middle-income countries.
• Complications during pregnancy and childbirth are the second cause of death for 15-19 year-old girls globally.
• Every year, some 3 million girls aged 15 to 19 undergo unsafe abortions.
• Babies born to adolescent mothers face a substantially higher risk of dying than those born to women aged 20 to 24.

The WHO published guidelines in 2011 with the UN Population Fund (UNFPA) on preventing early pregnancies and reducing poor reproductive outcomes. These made recommendations for action that countries could take, with 6 main objectives:

• reducing marriage before the age of 18;
• creating understanding and support to reduce pregnancy before the age of 20;
• increasing the use of contraception by adolescents at risk of unintended pregnancy;
• reducing coerced sex among adolescents;
• reducing unsafe abortion among adolescents;
• increasing use of skilled antenatal, childbirth and postnatal care among adolescents.

WHO is also involved in a variety of joint efforts with related agencies and programmes, such as the “H4+” initiative that includes UNAIDS, UNFPA, UNICEF, UN Women and the World Bank.

Reference(s):
1). World Health Organization (2017). Adolescent pregnancy. Available Online.
2). US National Library of Medicine-Medline Plus (2017). Teenage Pregnancy. Available Online.
3). Faculty of Sexual and Reproductive Healthcare (2010). Contraceptive Choices for Young People. Available Online.
4). Family Planning Association (FPA), 2010. Factsheet. Teenage pregnancy. Available Online.
5). Ganchimeg T, Ota E, Morisaki N, et al; Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014 Mar121 Suppl 1:40-8. doi: 10.1111/1471-0528.12630
6). Malamitsi-Puchner A, Boutsikou T; Adolescent pregnancy and perinatal outcome. Pediatr Endocrinol Rev. 2006 Jan3 Suppl 1:170-1.
7). Oringanje C, Meremikwu MM, Eko H, et al; Interventions for preventing unintended pregnancies among adolescents. Cochrane Database Syst Rev. 2009 Oct 7(4):CD005215. doi: 10.1002/14651858.CD005215.pub2.