The Obstetrician & Gynaecologist 2007;9:3:153-158
doi: 10.1576/toag.9.3.153.27334
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
Management of teenage pregnancy
Richard P Horgan, MRCOG MRCPI, Clinical Research Fellow1 and
Louise Clare Kenny, PhD MRCOG, Senior Lecturer/Consultant Obstetrician and Gynaecologist2
1. Cork University Maternity Hospital Wilton, Cork, Republic of Ireland Email: richard.horgan{at}ucc.ie (corresponding author)
2. Cork University Maternity Hospital Republic of Ireland
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Abstract
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Key content:- The United Kingdom has the highest teenage pregnancy rate in Western Europe.
- Risk factors include socioeconomic deprivation, low educational achievement and having teenage parents.
- Adverse outcomes associated with teenage pregnancy include premature delivery, infants being small for gestational age, low birthweight and increased neonatal mortality.
- Associated risks include high rates of sexually transmitted infections, alcohol and substance misuse, smoking and poor diet.
- Attendance at antenatal care is generally poor and teenagers may present late, therefore, it is important to tailor care to their individual needs.
Learning objectives:
- To learn about current guidance and policies.
- To know about the risk factors for teenage pregnancy, adverse outcomes and associated risks.
- To learn about the management of teenage pregnancy with particular reference to prevention.
Ethical issues:
- When is it necessary to obtain parental consent for termination of pregnancy or to prescribe contraception in girls aged less than 16 years of age?
- Why do some teenagers see pregnancy as a positive life event?
Please cite this article as: Horgan RP, Kenny LC. Management of teenage pregnancy. The Obstetrician & Gynaecologist 2007;9:153–158.
Keywords adolescents / management / pregnancy / teenage
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Introduction
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The United Kingdom has the highest rate of teenage pregnancy in Western Europe. This has been associated with a range of adverse outcomes, particularly preterm birth, especially in the 13–16 year age group. These risks are likely to reflect a complex interplay between sociodemographic variables, gynaecological immaturity and the growth and nutritional status of the mother. This review summarises the challenges presented by adolescent and teenage pregnancy and outlines key points to be considered in its management.
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Current guidelines and policies
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While there is copious data in the literature on teenage pregnancy, many of the studies are somewhat dated. Furthermore, many originate in the USA and caution is required when extrapolating this data to the UK situation. The Royal College of Obstetricians and Gynaecologists does not have any specific guidance on teenage pregnancy. However, in the guideline on routine antenatal care,1 teenage pregnancy is considered to be an area that may need additional input. The Cochrane Library has a protocol for a review on ‘Interventions for preventing unintended pregnancies among adolescents’2 but no specific review on the management of teenage pregnancy has yet been published. The National Institute for Health and Clinical Excellence (NICE) has recently published a guideline, Preventing Sexually Transmitted Infections and Reducing Under 18 Conceptions.3
The national target of halving the rate of conception in under 18-year-olds by 2010 is a joint Public Service Agreement between the Department of Health and the Department for Education and Skills (DfES). This is part of a broader government strategy for improving sexual health in the UK. While specific guidelines for the management of teenage pregnancy are not currently available, the Department of Health has published guidance for doctors and other health professionals on providing contraceptive advice or treatment to someone aged under 16 years without parental consent.4
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Factors contributing to teenage conception
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In recent years the rate of teenage conception has fallen steadily in the USA and Europe. In 2004 the conception rate in England was 41.5 per 1000 girls aged 15–17 years, representing an overall decline of 11.1% since 1998. However, the UK still has the highest rate of teenage pregnancy in Western Europe, while the USA possesses the highest rate in the world at 43.0 per 1000. (See Figures 1 and 2).
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Figure 1
Live birth rate for women aged 15–19 years, 1973–1996.34 (Adapted with kind permission from the Social Exclusion Unit)
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Figure 2
Births per 1 000 women aged 15–19 years, 1998.34 (Adapted with kind permission from the Social Exclusion Unit)
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It is important to recognise that teenage pregnancy can be a positive life choice for some young women, particularly those from certain ethnic or social groups. In some South Asian ethnic groups in the UK, rates of teenage pregnancy within marriage are high. Ethnicity and culture play a role and are an important consideration for healthcare professionals and for statistical purposes.
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Risk factors for teenage pregnancy
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The higher rates of teenage pregnancy tend to be concentrated in inner cities and are linked to poverty. Multiple socioeconomic risk factors have been identified and are shown in Box 1.
Social deprivation
Teenagers from unskilled manual backgrounds (social class V) are 10 times more likely to become teenage mothers than those from professional backgrounds (social class I). Teenagers from socially deprived areas are up to six times more likely to become pregnant than teenagers from other areas and are much less likely to opt for a termination.
Low educational achievement
Young people scoring below average on measures of educational achievement at ages 7 and 16 years have been found to be at significantly increased risk of becoming teenage parents, especially those whose performance declines between these ages. Wellings et al.5 surveyed over 11000 males and females aged 16–44 years across the UK. They found that 29% of sexually active young women who left school at 16 years of age without any qualifications had a child before the age of 18 years, compared with 14% of those who left at 16 with qualifications and 1% of those who left at age 17 years or over.
Teenage parents
There is evidence that women who were themselves children of teenage mothers are more likely to have a teenage pregnancy compared with those born to older mothers and the offspring are at risk for becoming teenaged mothers or fathers themselves.6
Socioeconomic deprivation
The strong association between teenage pregnancy and socioeconomic deprivation was highlighted in the report of the 1997–1999 Confidential Enquiry into Maternal and Child Health.7 There were 14 deaths of mothers aged <18 years, 5 of whom were <16 years old. Thirteen out of 14 were socially excluded, 50% had disclosed domestic violence (compared with 12% of the entire cohort of mothers who died) and 50% were poor attenders at antenatal clinic (compared with 20% of the total cohort who were poor attenders or booked late). In addition, four of the women were homeless at the time of death, despite three of them being under 16 years of age and under the care of social services at the time. The correlation between deprivation and maternal deaths was also seen in the subsequent report, 2000–2002.8 Teenage pregnancy has also been associated with an increased prevalence of domestic violence. However, a recent review of 15 studies has failed to clarify whether there is a causal link between maltreatment or violence and adolescent pregnancy or whether there is an increased risk of domestic violence to pregnant teenagers.9
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The impact of teenage pregnancy
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Many adverse outcomes have been associated with teenage pregnancy including premature delivery, infants being small for gestational age, low birthweight and increased neonatal mortality, anaemia and pregnancy-induced hypertension.10–13 In the long term the offspring of adolescents have poorer cognitive development, lower educational attainment, more frequent criminal activity and a higher risk of abuse, neglect and behavioural problems during childhood.14
Despite the magnitude of the problem, it is unknown whether the poor outcomes of teenage pregnancy are partly attributable to the biological challenges presented by young maternal age or whether they are solely the consequence of sociodemographic factors. The biological risks may have been exaggerated in previous studies as a result of inadequate controls for sociodemographic risk factors. Sociodemographic variables associated with teenage pregnancy undoubtedly increase the risk of adverse outcomes. However, recent studies have demonstrated that the relative risk remains significantly elevated for both younger and older teenage mothers after adjustment for marital status, level of education and adequacy of prenatal care.15
Gynaecological immaturity
The high risk of adverse pregnancy outcome in the adolescent has been attributed to gynaecological immaturity and the growth and nutritional status of the mother. Gynaecological immaturity undoubtedly predisposes adolescent girls to poor pregnancy outcome in that the rates of spontaneous miscarriage and of very preterm birth (<32 weeks of gestation) are highest in girls aged 13–15 years. However, maternal growth and nutritional status during pregnancy also appear to play a potentially modifiable role. Many adolescent girls retain the potential to grow while pregnant. Data from a study from Camden, New Jersey,16 one of the poorest cities in the USA, has shown that almost 50% of adolescents continue to grow while pregnant. This growth is associated with larger pregnancy weight gains, increased fat stores and greater postpartum weight retention than in non-growing adolescents and mature women. Paradoxically, in spite of the changes typically associated with increased fetal size (larger pregnancy weight gains, increased fat stores), the offspring are smaller in growing than non-growing adolescents. This significant reduction in fetal growth rate is attributed to a competition for nutrients between the maternal body and the gravid uterus. Clearly, there is a complex interplay between socioeconomic and biological factors that influences the outcome of teenage pregnancy (Box 2).
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Risks associated with teenage pregnancy
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Sexually transmitted infections
The prevalence of sexually transmitted infections (STIs) is increasing and presents a particular problem in teenagers. The incidence of gonorrhoea increased by 35% between 1997 and 1999 in the UK and those most at risk in the female population were aged 16–19 years.17 A recent study in the USA revealed that 1 in 5 teenagers have an undiagnosed STI.18 In addition, 1 in 8 teenagers attending a family planning clinic in Nottingham, in the UK, had an STI.19
Alcohol and substance misuse and smoking
These are common in adolescents. A UK survey of alcohol, tobacco and illicit drug use in teenagers aged 15 and 16 years reported that 36% smoked cigarettes and that levels of smoking were higher in girls than boys.20 Furthermore, girls who have had a teenage pregnancy are more likely to have smoked than those who have not conceived as teenagers.21 Interestingly, while the incidence of teenage pregnancy is declining in the UK, the proportion of teenage girls smoking has remained unchanged and in some areas is increasing.22 This is an important clinical problem as smoking compounds the potential for adverse outcomes of adolescent pregnancy, particularly intrauterine growth restriction . The birthweight-for-gestational-age curves of smoking adolescents show a marked fall-off in weight from 36 weeks of gestation. Furthermore, at least 10% of adolescent smokers have pregnancies affected by severe early onset (before 32 weeks of gestation) fetal growth restriction.23
Smoking during pregnancy is also known to be associated with an increased risk of placental abruption, preterm premature rupture of membranes, preterm birth, stillbirth and sudden infant death syndrome. Research has shown that prenatal exposure to tobacco smoke is a risk factor for respiratory infections, asthma, allergy, childhood cancer and adverse neurobehavioural development.24 The Centers for Disease Control and Prevention (CDCs) in the USA analysed state-specific trends in maternal smoking during 1990–2002.25 This report indicated that participating areas observed a significant decline in maternal smoking during the surveillance period while 10 states reported recent increases in smoking by pregnant teens. The widespread public health message to abstain during pregnancy has helped decrease maternal smoking. To reduce prevalence further, implementation of additional interventions is required.
Poor diet
Teenagers may have poor eating habits and neglect to take their vitamin supplements. They are less likely than older women to be of adequate prepregnancy weight or to gain an adequate amount of weight during pregnancy.26 Low weight gain increases the risk of having a low birthweight baby. This is frequently compounded by adverse social circumstances.
Postnatal depression and difficulties with breastfeeding
There is some evidence that teenage mothers are more likely to suffer from postnatal depression than older mothers.27 In addition, one study reported a 37–54% reduction in milk production 6 months after childbirth in adolescents compared with older mothers.28 There were some differences in breastfeeding behaviour between the two groups that may have contributed to the result but it appears that teenagers need extra support with breastfeeding.
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Management
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General measures
While there is no evidence, to date, of medical interventions that can specifically improve pregnancy outcome, we must ensure that teenage mothers receive supportive care and are directed towards the social support they need. Smoking cessation should be targeted and attendance at an antenatal clinic encouraged. In addition, effective postnatal counselling, particularly regarding contraception, can help prevent subsequent pregnancies and STIs.
Termination of pregnancy and adoption
Teenage pregnancy is often viewed as unplanned and unwanted. However, the reality is more complex. Although approximately 40% of teenagers in the UK terminate their pregnancies, the majority choose to continue. Over 25% will become pregnant again during their teenage years, including 18% of those who terminate their first pregnancy. These figures suggest that many teenagers become pregnant by design rather than by accident. Nevertheless, termination is very commonly performed in these circumstances. Teenagers are more likely to have later terminations, are more likely to resort to unskilled practitioners and dangerous methods and, when complications do arise, they are more likely to present late.29
While termination and adoption are options that are available and should be presented to the pregnant teenager, the reality is that most girls choose to continue with their pregnancies and keep their infants. It is, therefore, imperative that every effort is made to encourage pregnant teenagers to access antenatal care and that the care they subsequently receive is tailored to the unique needs of this age group. The healthcare professional must be aware of the potential complications and the opportunities for intervention that exist.
Antenatal care
Adolescents should be encouraged to attend for antenatal care from an early stage as attendance is frequently poor. Gestational age should be confirmed with early ultrasound wherever possible, although many teenagers present late. This is an opportunity to offer advice on nutrition and adverse habits such as smoking and alcohol use. Social support is important and many teenagers may benefit from an early referral to a specialist midwife or social worker. Information regarding antenatal care and labour should be provided in a format that is accessible and easily understood. Caregivers should be sensitive to the potential challenges presented by written information, as a significant number of teenagers have literacy difficulties.
Care during labour and delivery
Where age is the only risk factor, management is usually the same as for other labouring women. However, in very young adolescents there is an increased likelihood of obstructed labour because of a small, immature pelvis.
Postnatal management
The postnatal period provides an opportunity for counselling and education from the obstetrician, midwife, general practitioner, health visitor and social worker. Teenage mothers are more likely to have unhealthy habits that place the infant at greater risk of inadequate growth, infection and chemical dependence. Below the age of 20 years, the younger the mother, the greater the risk of her infant dying during the first year of life. Infant feeding, growth and safety need to be observed. Having her first child during adolescence makes a woman more likely to have more children overall. Women in this group are also less likely to receive child support from the biological fathers: over 50% of children of adolescent mothers never live with their biological father.30 They are less likely to complete their education and establish the independence and financial security that enable them to provide for themselves and their children without outside assistance. There are, therefore, some areas that need special attention, particularly discussion regarding financial issues, returning to school and contraceptive advice.
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Prevention of teenage pregnancy
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There are many different kinds of teenage pregnancy prevention programmes. Studies in pregnancy prevention have attempted to address the many facets of adolescent sexual activity, contraceptive use and pregnancy. Kirby31 has identified five main categories of teenage pregnancy prevention programmes: education, improving access to contraception, education for parents and their families, multi-component prevention and youth development.
Primary prevention focuses on sexual education in schools. However, evaluation studies of specific interventions, as well as reviews and meta-analyses of the effects of current strategies, show discrepant evidence of effectiveness.32,33
Contraception
Secondary prevention is directed at teenagers who are already sexually active, through the use and provision of contraception. Condoms are the most widely used contraceptive in adolescence but teenagers are relatively poor users of both barrier and hormonal contraceptives. The combined use of condoms plus the contraceptive pill (‘double Dutch’) is probably the most effective option.34 Use of the combined pill in a vaginal ring or in patch form may help to improve compliance. Long-acting contraception is not widely used and may help to reduce teenage pregnancy but it does not protect against STIs. Emergency contraception should not be used as an alternative for a regular form of contraception and it does not protect against STIs, but it has the potential to prevent most unplanned adolescent pregnancies. However, difficulties in accessing emergency contraception can be caused by lack of knowledge of the method, difficulties in finding a provider and cost. It is available over the counter at pharmacies but adolescents under the age of 16 years require a prescription.
Increasing the availability of contraceptive clinic services for young women is associated with reduced pregnancy rates. The role of the general practitioner is paramount: over 70% of consultations for contraception in the UK occur in general practice. In the UK, 91% of teenagers who become pregnant have had at least one visit to their general practitioner within the previous year – 71.3% of them specifically for contraceptive advice.35 Location of services is also very important. According to adolescents, there are several factors that determine whether they use the services or not. These include: confidentiality, a non-judgmental approach, accessibility and whether they are treated by a male or female clinician. Contraceptive services should be easily accessible, confidential, cheap or free and safe. They also benefit from having close links with associated services such as STI clinics, smoking cessation programmes, substance abuse clinics, social services, maternity hospitals and termination services.
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Conclusion
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Teenage pregnancy is common in the UK. Teenagers are at risk of a range of adverse pregnancy outcomes, particularly preterm birth. The reasons for this are complex and it is most likely that they reflect a combination of adverse socioeconomic pressures and gynaecological and biological immaturity. While there is no evidence to date of medical interventions that can specifically improve pregnancy outcome, the obstetrician providing care for women in this age group should be aware of the potential challenges. Antenatal care should be tailored to the individual needs of this group, particularly with regard to encouraging early and regular attendance, smoking cessation programmes, counselling regarding the risk of STIs and future contraception.
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References
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- National Collaborating Centre for Women's and Children's Health. Antenatal Care: Routine Care for the Healthy Pregnant Woman. Clinical Guideline. NCCWCH: RCOG Press; 2003. [www.rcog.org.uk/resources/Public/pdf/Antenatal_Care.pdf].
- Ehiri JE, Meremikwu A, Meremikwu M. Interventions for preventing unintended pregnancies among adolescents. (Protocol). In: Cochrane Database of Systematic Reviews, 2005. Art. No.: CD005215 doi:10.1002/14651858.CD005215. [www.mrw.interscience.wiley.com/ cochrane/clsysrev/articles/CD005215/frame.html].
- National Institute for Health and Clinical Excellence. Preventing Sexually Transmitted Infections and Reducing Under 18 Conceptions: Guidance. Public Health Intervention Guidance 3. London: NICE; 2007. [http://guidance.nice.org.uk/PHI3].
- Department of Health. Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health, London: DOH; 2004. [www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4086960].
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- Confidential Enquiry into Maternal and Child Health, Why Mothers Die 2000–2002. The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom 2004
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- Olausson PO, Cnattingius S, Haglund B. Does the increased risk of preterm delivery in teenagers persist in pregnancies after the teenage period? BJOG 2001;108:721–5. doi:10.1111/j.1471-0528.2001.00182.x[Medline]
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Abstract
Introduction
