6.2 Teenage pregnancy
Teenage mothers vary considerably in their circumstances, behaviour and well-being, although numerous studies have found that early child-bearing is predicted by early school failure, early behavioural problems, family dysfunction and poverty (Moore, Sugland, Blumenthal, Glei and Snyder 1995). Young women from disadvantaged backgrounds with low aspirations appear to be particularly vulnerable, and raising female aspirations from a very young age has a direct effect on their reducing chances of becoming a teenage mother (Cheesbrough, Ingham and Massey 2002). Because of these underlying problems, and because of motherhood itself, teenage mothers experience greater social and economic problems than older, two-parent families.
Teenage parenthood is both an outcome and a risk factor for other negative outcomes. Teenage pregnancy is also associated with other risk factors, including sexual abuse, rape, the risk of HIV/AIDS and other sexually transmitted diseases; and a wide range of other high-risk behaviours including drug abuse. However, the likelihood is that the increased risk is causally related not to early pregnancy, but to prior adverse circumstances and personal characteristics.
Research suggests that teenage pregnancy is important more as a marker of pre-existing problems than of the problems directly caused by the timing of birth per se(Kalil and Kunz 2001). Many of the difficulties faced by teenage mothers are a function of their disadvantaged backgrounds rather than the difficulty of bringing up a child at a young age. Simply changing a woman’s age at first birth would not necessarily change these prior conditions (Hoffman, Foster and Furstenberg Jr 1993, Hotz et al 1999). Other factors, especially family and individual characteristics that are difficult to measure contribute to the poorer than average outcomes of teenage mothers. The effects of teenage pregnancy alone may be over-emphasised if these factors are overlooked.
A number of reviews have been undertaken on the evidence on preventing and reducing unintended teenage pregnancies (see for example Cheesbrough et al 2002, Corcoran, O'Dell Miller and Bultman 1997, DiCenso, Guyatt and Willan 1999, Kane and Wellings 1999, Kirby 2001, Kirby and Coyle 1997, NHS Centre for Reviews and Dissemination 1997). A wide range of programmes has been used, differing in approach, components, duration, intensity and target population. Addressing both sexual and non-sexual risk factors is seen as critical in reducing levels of unintended teenage conceptions. Some aspects of behaviour can be addressed through risk-reduction interventions, but other less direct influences, such as socio-economic disadvantage and educational aspirations and levels, may be less tractable.
The most recent systematic reviews have concluded that the studies are not methodologically strong. Many suffer from the lack of a control group and the lack of pre-and post-intervention data. Nevertheless some interventions have been found to be effective in preventing teenage pregnancies. A strong conclusion of the meta-analyses is the failure of abstinence–only programmes to delay the initiation of sexual intercourse or the level of sexual activity amongst teenagers (Cheesbrough et al 2002, DiCenso et al 1999, Kirby 2001, Tepperman, Davila, McClendon and Werner 1998). A review of twenty randomised control trails found that sex education programmes do not increase sexual activity (DiCenso et al 1999). This finding is confirmed by a methodical review of teenage pregnancy and interventions in the USA, Canada, Australia and New Zealand (Cheesbrough et al 2002). It found that sex education can increase the use of contraceptives amongst sexually active teenagers and that intensive community-based education and contraceptive services can reduce the rate of teenage conceptions.
A meta-analysis of programmes designed to prevent teenage pregnancy found that effective programmes reduced the risk of pregnancy, reduced unprotected intercourse and increased the frequency of contraceptive use, but did not fundamentally alter adolescent sexual behaviour (Tepperman et al 1998). They did not delay initiation of intercourse, reduce the frequency of intercourse or influence teenagers to use contraception when they were starting intercourse. Programmes that did succeed in preventing and reducing teenage pregnancy actively encouraged the correct use of contraception, provided non-judgemental access to contraceptives, discussed how to avoid pregnancy or sexual activity, discussed alternatives to sexual activity, and life options and choices within a context of age-specific interventions. A recent meta-analysis of evaluations of teenage pregnancy programmes in the USA and Canada updating previous work suggests sex education and improved access to contraceptives can reduce sexual risk-taking, pregnancy and childbearing among teenagers (Kirby 2001).
International comparisons reveal great variation in pregnancies in young women. A recent large-scale investigation examined the reasons for the wide variation in teenage pregnancy and birth rates among five developed countries: Canada, France, Great Britain, Sweden and the USA (Darroch, Singh and Frost 2001a, b, Singh, Darroch and Frost 2001). Although all five countries have a high per capita income and are highly developed and industrialised, they differ in many ways that have a potential impact on rates of teenage sexual behaviour. They differ in the extent of social and economic inequality, health care systems, the provision of services to teenagers and in societal attitudes to teenage sexual activity. Despite recent declines in rates of teenage pregnancy in the USA, the rate is currently two to four times that of the four other developed countries studied. The study found that variation in sexual behaviour is not an important contributor to explaining the differences in pregnancy levels between the countries studied.
However, differences in the use and effectiveness of contraception are likely to contribute substantially to differences in pregnancy rates. Differences in societal attitudes to teenage sexuality may influence the incidence of contraception. Contraceptive services and supplies are available to teenagers free or at low cost in all of the countries studied except the USA, and efforts are made to facilitate easy access to these services. There may also be differences in teenagers’ attitudes to and knowledge of contraception, the level of confidentiality and parental support or opposition.
Even so, sexual activity and contraceptive use are themselves influenced by a large number of social, economic and cultural factors. Comparatively widespread disadvantage in the USA may help explain why USA teenagers have higher birthrates and pregnancy rates than those in other developed countries (Singh et al 2001). Although Cheesbrough et al (2002) do not draw causal inferences, they note that both New Zealand and the USA experienced growing inequality and rates of teenage pregnancy in the 1980s.
Falling rates of teenage pregnancy in the industrialised world over the past 25 years suggests widespread underlying causes, including the increased importance of education, increased educational aspirations and widening horizons for young women beyond motherhood and family formation (Singh and Darroch 2000).
The emerging view is that risk reduction measures which address sexual behaviour, and which are designed to improve sexual knowledge or the social skills required to implement that knowledge, can be effective in reducing unintended teenage pregnancies, although they may not reduce the level of sexual activity. Non-sexual risk factors, including economic and social disadvantage and poor educational achievement may be more difficult to address, but are important policy targets because they shape the incentives of teenagers to become pregnant.
