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International Journal of Nursing Practice 2014; ••: ••–••
CLINICAL PAPER
A global perspective on adolescent pregnancy Nola Holness RN PhD-C ARNP CNM PhD Student, College of Nursing and Health Sciences, Florida International University, Miami, Florida, USA
Accepted for publication August 2013 Holness N. International Journal of Nursing Practice 2014; 00: 00–00 A global perspective on adolescent pregnancy Adolescent pregnancy is an international dilemma affecting not just the adolescent and her infant, but entire societies. Of almost 300 million female adolescents worldwide, 16 million give birth yearly, accounting for 11% of all births worldwide. The Millennium Development Goal # 5 incorporates reducing adolescent births worldwide. The purpose of this paper is a comprehensive critique of findings on a global perspective on adolescent pregnancy and evaluation of strategies to reduce this international concern. In Latin America and the Caribbean, unmet need for family planning made little change in 20 years. In Dutch and Scandinavian countries, there are national sex education programmes and family planning clinics run by nurse midwives with direct authority to prescribe contraceptives. In Japan, strong conservative norms exist about premarital sex. In the UK, a lack of consistent targeted sex education, delay in access to contraception and contraceptive use failure are associated with high teen pregnancy rates. In the United States, 750 000 teen pregnancies occur yearly, costing $9 billion per year. Health disparities exist: Whites had 11, Blacks had 32 and Hispanics had 41 per 1000 births. Programmes to reduce teen pregnancy should incorporate family, contraception and abstinence education, and sustained commitment of media, businesses, religious and civic organizations. Key words: adolescent, global, pregnancy.
INTRODUCTION Adolescent pregnancy, a national and international dilemma, is costly, not just to the adolescent and her infant, but to society at large. Of the 300 million adolescents worldwide, 11% of all births are to 16 million women aged 15–19 years. Adolescents account for 23% of all worldwide disability and diseases caused by pregnancy and childbirth.1 Outlined in the United Nation’s Millennium Goal # 5 is the concern that adolescent pregnancy carries the highest mortality and morbidity which increases with each subsequent pregnancy.2 The purpose of this paper is to review Millennium Development Goal # 5, analyse the global impact of adolescent pregnancy, assess international and national trends of adolescent pregCorrespondence: Nola Holness, 8801 S. W. 9th Court, Pembroke Pines, FL 33025, USA. Email: [email protected] Work Address: 1611 N.W 12 Avenue, Miami, FL. doi:10.1111/ijn.12278
nancy, and provide a comprehensive review and critique of strategies to prevent or reduce adolescent pregnancy.
MILLENNIUM DEVELOPMENT GOAL # 5 In 2000, world leaders met and accepted the eight millennium goals as developed by the United Nations.2 These eight goals address global issues to ‘eradicate extreme poverty and hunger; achieve universal primary education; promote gender equality and empower women; reduce child mortality rates; improve maternal health; combat HIV/AIDS, malaria and other diseases; ensure environmental sustainability; and develop a global partnership for development’. The focus of this discussion is Millennium Goal # 5: to improve maternal health. There are two targets associated with this goal: (i) to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio, addressing proportion of births attended by skilled © 2014 Wiley Publishing Asia Pty Ltd
2
N Holness
health personnel; and (ii) to achieve, by 2015, universal access to reproductive health, focusing on contraceptive and unmet need for family planning as well as antenatal coverage.
GLOBAL IMPACT OF ADOLESCENT PREGNANCY As of 2008, there has been a 34% decline in maternal mortality rates. Universal access to prenatal care has increased internationally; in developing countries, there has been an increase to 81% in 2009 compared with 64% in 1990. In developed regions, the percentage of women using contraceptives in 1990 was 68 and in 2010, 72. In developing regions, contraceptive use was 52 in 1990 and 62 in 2010. The unmet need for family planning remains high in some regions. For example, in Sub-Saharan Africa, 27% had an unmet need in 1990 and 25% still have an unmet need in 2010. In the Caribbean, 20% had an unmet need for family planning in 1990, and 17% in 2010. Overall, for the developing regions, 16% had unmet need for family planning in 1990 and 12% in 2010.2 The United Nations2 reported that adolescent pregnancy remains a problem for many regions. Not much change has occurred in some regions. In Sub-Saharan Africa, per 1000 adolescent women, 126 in 1990 and 120 in 2009 gave birth. In the Caribbean, adolescent pregnancy rate was 80 in 1990 and 69 in 2009. Overall, in developed countries, there were 34/1000 births in 1990 and 23 in 2009. For developing regions, the sum was 64/100 births in 1990 and 52 in 2009.2 Annually, in the United States, there are nearly one million adolescent pregnancies with a national cost of $7–15 billion yearly.3 After two decades of decline, adolescent birth rates increased in 2007; then declined in 2009, nevertheless; the United States remains the developed country with the highest rate of adolescent pregnancy.4
RISKS ASSOCIATED WITH ADOLESCENT PREGNANCY Adolescent pregnancy has associated risks of low birthweight infants (less than 2500 g), neonatal deaths from acute infections, sudden infant death syndrome and maternal mortality. Other medical complications include anaemia, malaria, HIV, sexually transmitted infections (STIs), post-partum haemorrhage, mental disorder (mainly depression), poor maternal weight gain, prematurity (births at less than 37 weeks) and pregnancy-induced © 2014 Wiley Publishing Asia Pty Ltd
hypertension, These rates are two to three times higher than those for adult women. Social issues related to adolescent pregnancies include poverty, unmarried status, low educational levels, smoking, drug use, inadequate prenatal care and school dropout.1,5 Between 30 and 50% of adolescent mothers who have a first birth before age 18 years will have a second child within 12 to 24 months. One fifth of adolescent births in the United States in 2004 were repeat births. Significant health disparities exist among racial and ethnic pregnant adolescent groups. In 2009, Whites had 11, Blacks had 32 and Hispanics had 41 births per 1000 females.6 Multiple risks are associated with adolescent pregnancy including unsafe abortions, of which 2.5 million worldwide occur yearly. Maternal deaths are four times higher if the mother is 16 years or less. Another risk is of obstetric fistula, of which 65% develop this as adolescents. Stillbirths and death occurring in the first week of birth have a 50% higher incidence for adolescent moms. Scoring lower in math and reading, repeating a school grade or high school dropout, poor health as an infant, being the victim of abuse and neglect, placement in foster home, incarcerated, unemployed or underemployed, giving birth as teenager are some of the risks for the offspring of an adolescent mother.3 In the United States, cost associated with adolescent pregnancy are: school dropouts costing $260 billion over lifetime; $20 billion yearly for income maintenance, health care and nutrition for adolescent-led families; $16 billion for public assistance programmes; and $1 million for failing to prevent adolescent offsprings becoming career criminals.7
INTERNATIONAL AND NATIONAL TRENDS OF ADOLESCENT PREGNANCY According to Treffers et al.,8 earlier age at menarche, delay of marriage, inadequate contraception and poverty are influences for an adolescent pregnancy. Other influences are increased importance of education, increased motivation for higher levels of education and training, and goals other than motherhood for young women.9 Of note, the socioeconomic, political and cultural characteristics of the individual countries have an influence on trends in adolescent pregnancy.9 In socialist and communist countries, around the mid-20th century, young age at marriage increased childbearing trends, whereas in the United
Adolescent pregnancy
States, low income among minority families was a strong predictor of early sexual activity, pregnancy and childbearing.9 There are varying beliefs worldwide on adolescent pregnancy. In Canada, the belief is that childbearing belongs in adulthood; adolescents should complete their education, become employed and independent from their parents, and engage in stable relationships.10 In the United Kingdom, lack of sex education, peer pressure, pressure from older partner, delay in access to contraception, poor relation with available services and contraceptive use failure are highlighted trends of adolescent pregnancy.11 Furthermore, studies from the United Kingdom investigated the transition of the adolescent to motherhood on a ‘social death’ continuum. The constructs that had an impact on the adolescent’s transition included: moral decision-making (pregnancy seen as right or wrong), sexuality (her passion vs. her commitment to purity), youth (how experienced or inexperienced is the adolescent), motherhood (whether she is prepared or unprepared) and marriage (whether or not the pregnancy occurred in wedlock).12 In Dutch and Scandinavian countries, adolescent pregnancy is not socially accepted and best avoided. Sex education and family planning clinics are run by certified nurse midwives with direct authority to prescribe oral contraceptives. Hotline services are available for consultation, collaboration occurred between schools and family planning clinics, and adolescents have easy access to contraception.11 In Japan, where there are strong conservative norms about premarital sex and no national sex education programme, there are very low adolescent birth rates.11 In the Caribbean, innovative strategies were employed to reduce adolescent pregnancy. In Honduras, work was done with adolescents in the informal sector providing community-based educational and social programmes, food supplementation, basic health education on sexuality, reproductive health, substance abuse, counselling, and youth empowerment and control.7 In Trinidad and Tobago, life skill training programmes were initiated to prepare adolescents for the workplace and society. Selfawareness, parenting, nutrition, sex education, drug abuse, sports and recreation, basic literacy, community service, micro-entrepreneurship and immediate employment were skills addressed.7 Jamaica and Guyana accounted for 20% of all adolescent births in the Caribbean in the 1990s. Pregnancy was the main reason girls
3
did not finish school.13 In Jamaica, the Women Centre of Jamaica Foundation conducted classroom education on skills and job training to support adolescent mothers returning to school. There was a reported reduction in adolescent repeat pregnancy of 45% for participants of this programme.13
STRATEGIES TO REDUCE/PREVENT ADOLESCENT PREGNANCIES Burt7 encouraged investments in adolescents. In the United States, one in every seven persons is an adolescent who need to develop to become responsible adults.7 Huberman14 outlined that individuals and agencies having an impact on the adolescent include involved parents, service groups, faith communities, adolescent peers, media, business leaders, educational institutions, elected officials and health-care providers. It must be emphasized, according to Cockey,15 that a one-size solution does not fit all. Strategies for success can be accessed from individuals, parents, peers, health professionals and community. For the individual adolescent to prevent a pregnancy or prevent a repeat pregnancy, her risk, resilience, selfesteem and internal vs. external locus of control must be assessed.7 Resilience, negative life events, stressful situations, protective factors, self-esteem, personal bonds, mentoring and a caring adult in her life are influences on the adolescent to cope within her sociocultural environment.16–18 Abstinence as an option should be explored as virginity pledging was associated with delayed sexual initiation for pledgers; however, pledging did not affect sexual safety when adolescents were no longer abstinent.19 Of note, how adolescents view virginity and abstinence differed based on their sexual experiences.19 Parents and peers are significant influences on the adolescent sexual behaviours. The family structure, whether intact or dysfunctional, will impact the adolescent’s highrisk behaviours, including sexual activities.7 There is a need for an increased role of parents to foster communication with adolescents, creating stable relationships. There is the need to provide adolescents with facts, develop close relationship with the father of baby, encourage positive influences on maternal attachment behaviours, and have as social influences the parents to deter antisocial behaviours and peer-led interventions to facilitate peers helping peers.11,20 © 2014 Wiley Publishing Asia Pty Ltd
4
N Holness
HEALTH PROFESSIONAL AND COMMUNITY PROGRAMMES Neighbourhood conditions, facilities, and local institutions of school and church are important agencies in reducing adolescent pregnancy.7 According to Cockey,15 the adolescent pregnant prevention programmes that worked had parent and adult involvement, stressed abstinence and personal responsibility, had clear strategies for the future, with media, business, religious and civic organizations involvement, and sustained commitment.15 Other qualities for success are early intervention, long time frame, intensive personal involvement, school involvement, and programmes that are not changed with political or monetary influences.7 It is vital to promote health education; therapeutic communication; learning; assessing physiologic and psychological needs; encouraging adolescents to ‘look out for me’; STI prevention; family planning; well woman gynaecology; prenatal care; balanced diet; folic acid; and no smoking, alcohol or drug use.15,21 Religious influences have an effect, with adolescents from religious families found to have less risky sexual behaviours when there is a cohesive family environment and positive peer network.22 At the national level, here in the United States, the Centers for Disease Control and Prevention is working to reduce adolescent pregnancy, and is linked with national organizations including Title X programmes (reproductive services) and state-based adolescent pregnancy prevention coalitions.23,24
THE MESSAGE The media message should target men and women with the same message. Schadewald stated that abstinence needs to be ‘sexy’ as a media message to adolescents.15 The conflicting message to adolescents from the media is that sex and risky behaviours make them popular, smarter and attractive. It is important to have adolescents see pregnancy as an impediment or threat to their goals.15 Donna Shalala, speaking about adolescents, as quoted by Cockey,15 stated: ‘Postpone sexual activity, stay in school, prepare to work . . . are the right things to do’ and Bill Clinton said: ‘Work to instill a sense of personal responsibility, self-respect, and sense of possibility’.15 Currently, one media message of television is the reality show MTV’s 16 and Pregnant. This hour-long documentary series focuses on the challenging subject of adolescent pregnancy, following a 5–7 month period in the life of the pregnant or parenting adolescent. She navigates © 2014 Wiley Publishing Asia Pty Ltd
the bumpy terrain of adolescence, growing pains, rebellion and coming of age, all while dealing with being pregnant or parenting.25
CONCLUSION There are 300 million adolescents worldwide, with 16 million becoming pregnant yearly. Adolescents have the highest maternal mortality rates which increase with each pregnancy. There is the need to break the cycle of adolescent pregnancy. More after school activities, fear of AIDS, easier access to contraceptives, counselling from peers and less adolescent sexual activities are factors posited for the decline in rates. Nevertheless, even with the decline, adolescent birth rates in the United States are the highest for developed countries. Health education, job opportunities, abstinence, personal responsibility and access to contraceptives are some strategies to reduce adolescent pregnancy. Adolescent pregnancy remains a costly challenge for nurses and all health-care professionals. According to Rosenbaum,26 more than $200 million is spent annually on abstinence programmes in the United States. Yet the research findings indicate conflicting results regarding the success of these programmes, with reduction in rates for some studies and no decrease in sexual activity for others. Health-care providers need knowledge and skills to care for these multicultural vulnerable adolescent mothers. Cassata and Dallas27 explored the attitudes of nurses caring for low-income adolescent clients in Chicago, IL. Nurses can experience cultural conflicts and lack knowledge and skills to care for multicultural vulnerable adolescent mothers.27 Collaborative research is needed to determine internal and external factors affecting these alarming adolescent pregnancy and birth rates, and identify interventions and policies to stem the tide of this international and national dilemma of unplanned adolescent pregnancy especially among underserved minority populations.
REFERENCES 1 World Health Organization. Adolescent Pregnancy, 2009. Available from URL: http://www.who.int/mediacentre/ factsheets/fs364/en/. Accessed 15 May 2012. 2 United Nations. The Millennium Development Goals Report, 2012, 2012. Available from URL: http://www.un.org/ millenniumgoals/pdf/MDG%20Report%202012.pdf. Accessed 16 August 2012.
Adolescent pregnancy
3 Healthy People 2020. Family Planning, 2012. Available from URL: http://healthypeople.gov/2020/topicsobjectives 2020/overview.aspx?topicid=13. Accessed 17 March 2014. 4 Guttmacher Institute. U.S. Teenage Pregnancies, Births and Abortions: National and State Trends by Race and Ethnicity, 2010. Available from URL: http://www.guttmacher.org/ pubs/USTPtrends.pdf. Accessed 12 May 2012. 5 Klein J, the American Academy of Pediatrics Committee on Adolescence. Adolescent pregnancy: Current trends and issues. Pediatrics 2005; 116: 281–286. doi: 10.1542/ peds.2005-0999. 6 Sangalang B, Barth R, Painter J. First-birth outcomes and timing of second births: A statewide case management program for adolescent mothers. Health and Social Work 2006; 31: 54–64. doi: 10.1093/hsw/31.1.54. 7 Burt M. Reason to invest in adolescents. Journal of Adolescent Health 2002; 31: 136–152. 8 Treffers P, Olukoya A, Ferguson B, Liljestrand J. Care for adolescent pregnancy and childbirth. International Journal of Gynecology and Obstetrics 2001; 75: 111–121. 9 Singh S, Darroch J. Adolescent Pregnancy and Childbearing: Levels and Trends in Developed Countries, 1999. Available from URL: http://www.guttmacher.org/pubs/journals/ 3201400.html. Accessed 15 May 2012. 10 Boonstra H. Teen pregnancy: Trends and lessons learned. The Guttmacher Report on Public Policy 2002; 5: 7–10. 11 Amu O, Appiah K. Teenage pregnancy in the United Kingdom: Are we doing enough. The European Journal of Contraception and Reproductive Health Care 2006; 11: 314– 318. doi: 10.1080/13625180600929028. 12 Whitehead E. Teenage pregnancy: On the road to social death. International Journal of Nursing Studies 2001; 38: 437– 446. 13 Drayton V, Montgomery S, Modeste N, Frye-Anderson B, McNeil P. The impact of the Women’s Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies. West Indian Medical Journal 2000; 49: 316–326. 14 Huberman B. State wide teen pregnancy prevention organizations: Recommendations and lessons learned. Advocates for Youth, 2008. Available from URL: http://www .advocatesforyouth.org/statetppmanual/1069?task=view, Accessed 12 May 2012.
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15 Cockey C. Preventing teen pregnancy. Lifeline 1999; 3: 32–40. 16 Rutter M. Resilience in the face of adversity: Protective factors and resistance to psychiatric disorder. British Journal of Psychiatry 1985; 147: 589–611. 17 Werner E. The children of Kauai: Resiliency and recovery in adolescence and adulthood. Journal of Adolescent Health 1992; 13: 262–268. 18 Van Breda A. Resilience theory: A literature review. Pretoria, South Africa: South African Military Health Service, 2001. Available from URL: www.vanbreda.org/adrian/ resilience/resilience9.pdf. Accessed 10 August 2011. 19 Martino S, Elliott M, Collins R, Kanouse D, Berry S. Virginity pledgers among the willing: Delays in first intercourse and consistency of condom use. Journal of Adolescent Health 2008; 43: 341–348. 20 Cook EC, Buehler C, Henson R. Parents and peers as social influences to deter antisocial behaviors. Journal of Youth and Adolescence 2009; 38: 1240–1252. 21 Broussard A, Broussard B. Teaching pregnant teens, lessons learned. Nursing for Women’s Health 2010; 14: 106–111. 22 Manlove J, Logan C, Moore K, Ikramullah E. Pathways from family religiosity to adolescent sexual activity and contraceptive use. Perspectives on Sexual and Reproductive Health 2008; 40: 105–117. doi: 10. 1363/4010508. 23 Centers for Diseases Control and Prevention. NCHS Data on Teen Births in U.S., 2012. Available from URL: http://www .cdc.gov/reproductivehealth/AdolescentReproHealth/ index.htm. Accessed 15 May 2012. 24 U. S. Department of Health and Human Services. Title X Family Planning, 2011. Available from URL: http://www .hhs.gov/opa/title-x-family-planning/. Accessed 10 May 2012. 25 MTV. MTV’s 16 and pregnant, 2012. Available from URL: http://www.mtv.com/shows/16_and_pregnant/season _4/series.jhtml. Accessed 10 May 2012. 26 Rosenbaum J. Patient teenagers: A comparison of the sexual behavior of virginity pledgers and matched non-pledgers. Pediatrics 2009; 123: e110–e120. doi: 10.1542/peds.20080407. 27 Cassata L, Dallas C. Nurses’ attitudes and childbearing adolescents: Bridging the cultural chasm. ABNF Journal 2005; 16: 71–76.
© 2014 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2014; ••: ••–••
CLINICAL PAPER
A global perspective on adolescent pregnancy Nola Holness RN PhD-C ARNP CNM PhD Student, College of Nursing and Health Sciences, Florida International University, Miami, Florida, USA
Accepted for publication August 2013 Holness N. International Journal of Nursing Practice 2014; 00: 00–00 A global perspective on adolescent pregnancy Adolescent pregnancy is an international dilemma affecting not just the adolescent and her infant, but entire societies. Of almost 300 million female adolescents worldwide, 16 million give birth yearly, accounting for 11% of all births worldwide. The Millennium Development Goal # 5 incorporates reducing adolescent births worldwide. The purpose of this paper is a comprehensive critique of findings on a global perspective on adolescent pregnancy and evaluation of strategies to reduce this international concern. In Latin America and the Caribbean, unmet need for family planning made little change in 20 years. In Dutch and Scandinavian countries, there are national sex education programmes and family planning clinics run by nurse midwives with direct authority to prescribe contraceptives. In Japan, strong conservative norms exist about premarital sex. In the UK, a lack of consistent targeted sex education, delay in access to contraception and contraceptive use failure are associated with high teen pregnancy rates. In the United States, 750 000 teen pregnancies occur yearly, costing $9 billion per year. Health disparities exist: Whites had 11, Blacks had 32 and Hispanics had 41 per 1000 births. Programmes to reduce teen pregnancy should incorporate family, contraception and abstinence education, and sustained commitment of media, businesses, religious and civic organizations. Key words: adolescent, global, pregnancy.
INTRODUCTION Adolescent pregnancy, a national and international dilemma, is costly, not just to the adolescent and her infant, but to society at large. Of the 300 million adolescents worldwide, 11% of all births are to 16 million women aged 15–19 years. Adolescents account for 23% of all worldwide disability and diseases caused by pregnancy and childbirth.1 Outlined in the United Nation’s Millennium Goal # 5 is the concern that adolescent pregnancy carries the highest mortality and morbidity which increases with each subsequent pregnancy.2 The purpose of this paper is to review Millennium Development Goal # 5, analyse the global impact of adolescent pregnancy, assess international and national trends of adolescent pregCorrespondence: Nola Holness, 8801 S. W. 9th Court, Pembroke Pines, FL 33025, USA. Email: [email protected] Work Address: 1611 N.W 12 Avenue, Miami, FL. doi:10.1111/ijn.12278
nancy, and provide a comprehensive review and critique of strategies to prevent or reduce adolescent pregnancy.
MILLENNIUM DEVELOPMENT GOAL # 5 In 2000, world leaders met and accepted the eight millennium goals as developed by the United Nations.2 These eight goals address global issues to ‘eradicate extreme poverty and hunger; achieve universal primary education; promote gender equality and empower women; reduce child mortality rates; improve maternal health; combat HIV/AIDS, malaria and other diseases; ensure environmental sustainability; and develop a global partnership for development’. The focus of this discussion is Millennium Goal # 5: to improve maternal health. There are two targets associated with this goal: (i) to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio, addressing proportion of births attended by skilled © 2014 Wiley Publishing Asia Pty Ltd
2
N Holness
health personnel; and (ii) to achieve, by 2015, universal access to reproductive health, focusing on contraceptive and unmet need for family planning as well as antenatal coverage.
GLOBAL IMPACT OF ADOLESCENT PREGNANCY As of 2008, there has been a 34% decline in maternal mortality rates. Universal access to prenatal care has increased internationally; in developing countries, there has been an increase to 81% in 2009 compared with 64% in 1990. In developed regions, the percentage of women using contraceptives in 1990 was 68 and in 2010, 72. In developing regions, contraceptive use was 52 in 1990 and 62 in 2010. The unmet need for family planning remains high in some regions. For example, in Sub-Saharan Africa, 27% had an unmet need in 1990 and 25% still have an unmet need in 2010. In the Caribbean, 20% had an unmet need for family planning in 1990, and 17% in 2010. Overall, for the developing regions, 16% had unmet need for family planning in 1990 and 12% in 2010.2 The United Nations2 reported that adolescent pregnancy remains a problem for many regions. Not much change has occurred in some regions. In Sub-Saharan Africa, per 1000 adolescent women, 126 in 1990 and 120 in 2009 gave birth. In the Caribbean, adolescent pregnancy rate was 80 in 1990 and 69 in 2009. Overall, in developed countries, there were 34/1000 births in 1990 and 23 in 2009. For developing regions, the sum was 64/100 births in 1990 and 52 in 2009.2 Annually, in the United States, there are nearly one million adolescent pregnancies with a national cost of $7–15 billion yearly.3 After two decades of decline, adolescent birth rates increased in 2007; then declined in 2009, nevertheless; the United States remains the developed country with the highest rate of adolescent pregnancy.4
RISKS ASSOCIATED WITH ADOLESCENT PREGNANCY Adolescent pregnancy has associated risks of low birthweight infants (less than 2500 g), neonatal deaths from acute infections, sudden infant death syndrome and maternal mortality. Other medical complications include anaemia, malaria, HIV, sexually transmitted infections (STIs), post-partum haemorrhage, mental disorder (mainly depression), poor maternal weight gain, prematurity (births at less than 37 weeks) and pregnancy-induced © 2014 Wiley Publishing Asia Pty Ltd
hypertension, These rates are two to three times higher than those for adult women. Social issues related to adolescent pregnancies include poverty, unmarried status, low educational levels, smoking, drug use, inadequate prenatal care and school dropout.1,5 Between 30 and 50% of adolescent mothers who have a first birth before age 18 years will have a second child within 12 to 24 months. One fifth of adolescent births in the United States in 2004 were repeat births. Significant health disparities exist among racial and ethnic pregnant adolescent groups. In 2009, Whites had 11, Blacks had 32 and Hispanics had 41 births per 1000 females.6 Multiple risks are associated with adolescent pregnancy including unsafe abortions, of which 2.5 million worldwide occur yearly. Maternal deaths are four times higher if the mother is 16 years or less. Another risk is of obstetric fistula, of which 65% develop this as adolescents. Stillbirths and death occurring in the first week of birth have a 50% higher incidence for adolescent moms. Scoring lower in math and reading, repeating a school grade or high school dropout, poor health as an infant, being the victim of abuse and neglect, placement in foster home, incarcerated, unemployed or underemployed, giving birth as teenager are some of the risks for the offspring of an adolescent mother.3 In the United States, cost associated with adolescent pregnancy are: school dropouts costing $260 billion over lifetime; $20 billion yearly for income maintenance, health care and nutrition for adolescent-led families; $16 billion for public assistance programmes; and $1 million for failing to prevent adolescent offsprings becoming career criminals.7
INTERNATIONAL AND NATIONAL TRENDS OF ADOLESCENT PREGNANCY According to Treffers et al.,8 earlier age at menarche, delay of marriage, inadequate contraception and poverty are influences for an adolescent pregnancy. Other influences are increased importance of education, increased motivation for higher levels of education and training, and goals other than motherhood for young women.9 Of note, the socioeconomic, political and cultural characteristics of the individual countries have an influence on trends in adolescent pregnancy.9 In socialist and communist countries, around the mid-20th century, young age at marriage increased childbearing trends, whereas in the United
Adolescent pregnancy
States, low income among minority families was a strong predictor of early sexual activity, pregnancy and childbearing.9 There are varying beliefs worldwide on adolescent pregnancy. In Canada, the belief is that childbearing belongs in adulthood; adolescents should complete their education, become employed and independent from their parents, and engage in stable relationships.10 In the United Kingdom, lack of sex education, peer pressure, pressure from older partner, delay in access to contraception, poor relation with available services and contraceptive use failure are highlighted trends of adolescent pregnancy.11 Furthermore, studies from the United Kingdom investigated the transition of the adolescent to motherhood on a ‘social death’ continuum. The constructs that had an impact on the adolescent’s transition included: moral decision-making (pregnancy seen as right or wrong), sexuality (her passion vs. her commitment to purity), youth (how experienced or inexperienced is the adolescent), motherhood (whether she is prepared or unprepared) and marriage (whether or not the pregnancy occurred in wedlock).12 In Dutch and Scandinavian countries, adolescent pregnancy is not socially accepted and best avoided. Sex education and family planning clinics are run by certified nurse midwives with direct authority to prescribe oral contraceptives. Hotline services are available for consultation, collaboration occurred between schools and family planning clinics, and adolescents have easy access to contraception.11 In Japan, where there are strong conservative norms about premarital sex and no national sex education programme, there are very low adolescent birth rates.11 In the Caribbean, innovative strategies were employed to reduce adolescent pregnancy. In Honduras, work was done with adolescents in the informal sector providing community-based educational and social programmes, food supplementation, basic health education on sexuality, reproductive health, substance abuse, counselling, and youth empowerment and control.7 In Trinidad and Tobago, life skill training programmes were initiated to prepare adolescents for the workplace and society. Selfawareness, parenting, nutrition, sex education, drug abuse, sports and recreation, basic literacy, community service, micro-entrepreneurship and immediate employment were skills addressed.7 Jamaica and Guyana accounted for 20% of all adolescent births in the Caribbean in the 1990s. Pregnancy was the main reason girls
3
did not finish school.13 In Jamaica, the Women Centre of Jamaica Foundation conducted classroom education on skills and job training to support adolescent mothers returning to school. There was a reported reduction in adolescent repeat pregnancy of 45% for participants of this programme.13
STRATEGIES TO REDUCE/PREVENT ADOLESCENT PREGNANCIES Burt7 encouraged investments in adolescents. In the United States, one in every seven persons is an adolescent who need to develop to become responsible adults.7 Huberman14 outlined that individuals and agencies having an impact on the adolescent include involved parents, service groups, faith communities, adolescent peers, media, business leaders, educational institutions, elected officials and health-care providers. It must be emphasized, according to Cockey,15 that a one-size solution does not fit all. Strategies for success can be accessed from individuals, parents, peers, health professionals and community. For the individual adolescent to prevent a pregnancy or prevent a repeat pregnancy, her risk, resilience, selfesteem and internal vs. external locus of control must be assessed.7 Resilience, negative life events, stressful situations, protective factors, self-esteem, personal bonds, mentoring and a caring adult in her life are influences on the adolescent to cope within her sociocultural environment.16–18 Abstinence as an option should be explored as virginity pledging was associated with delayed sexual initiation for pledgers; however, pledging did not affect sexual safety when adolescents were no longer abstinent.19 Of note, how adolescents view virginity and abstinence differed based on their sexual experiences.19 Parents and peers are significant influences on the adolescent sexual behaviours. The family structure, whether intact or dysfunctional, will impact the adolescent’s highrisk behaviours, including sexual activities.7 There is a need for an increased role of parents to foster communication with adolescents, creating stable relationships. There is the need to provide adolescents with facts, develop close relationship with the father of baby, encourage positive influences on maternal attachment behaviours, and have as social influences the parents to deter antisocial behaviours and peer-led interventions to facilitate peers helping peers.11,20 © 2014 Wiley Publishing Asia Pty Ltd
4
N Holness
HEALTH PROFESSIONAL AND COMMUNITY PROGRAMMES Neighbourhood conditions, facilities, and local institutions of school and church are important agencies in reducing adolescent pregnancy.7 According to Cockey,15 the adolescent pregnant prevention programmes that worked had parent and adult involvement, stressed abstinence and personal responsibility, had clear strategies for the future, with media, business, religious and civic organizations involvement, and sustained commitment.15 Other qualities for success are early intervention, long time frame, intensive personal involvement, school involvement, and programmes that are not changed with political or monetary influences.7 It is vital to promote health education; therapeutic communication; learning; assessing physiologic and psychological needs; encouraging adolescents to ‘look out for me’; STI prevention; family planning; well woman gynaecology; prenatal care; balanced diet; folic acid; and no smoking, alcohol or drug use.15,21 Religious influences have an effect, with adolescents from religious families found to have less risky sexual behaviours when there is a cohesive family environment and positive peer network.22 At the national level, here in the United States, the Centers for Disease Control and Prevention is working to reduce adolescent pregnancy, and is linked with national organizations including Title X programmes (reproductive services) and state-based adolescent pregnancy prevention coalitions.23,24
THE MESSAGE The media message should target men and women with the same message. Schadewald stated that abstinence needs to be ‘sexy’ as a media message to adolescents.15 The conflicting message to adolescents from the media is that sex and risky behaviours make them popular, smarter and attractive. It is important to have adolescents see pregnancy as an impediment or threat to their goals.15 Donna Shalala, speaking about adolescents, as quoted by Cockey,15 stated: ‘Postpone sexual activity, stay in school, prepare to work . . . are the right things to do’ and Bill Clinton said: ‘Work to instill a sense of personal responsibility, self-respect, and sense of possibility’.15 Currently, one media message of television is the reality show MTV’s 16 and Pregnant. This hour-long documentary series focuses on the challenging subject of adolescent pregnancy, following a 5–7 month period in the life of the pregnant or parenting adolescent. She navigates © 2014 Wiley Publishing Asia Pty Ltd
the bumpy terrain of adolescence, growing pains, rebellion and coming of age, all while dealing with being pregnant or parenting.25
CONCLUSION There are 300 million adolescents worldwide, with 16 million becoming pregnant yearly. Adolescents have the highest maternal mortality rates which increase with each pregnancy. There is the need to break the cycle of adolescent pregnancy. More after school activities, fear of AIDS, easier access to contraceptives, counselling from peers and less adolescent sexual activities are factors posited for the decline in rates. Nevertheless, even with the decline, adolescent birth rates in the United States are the highest for developed countries. Health education, job opportunities, abstinence, personal responsibility and access to contraceptives are some strategies to reduce adolescent pregnancy. Adolescent pregnancy remains a costly challenge for nurses and all health-care professionals. According to Rosenbaum,26 more than $200 million is spent annually on abstinence programmes in the United States. Yet the research findings indicate conflicting results regarding the success of these programmes, with reduction in rates for some studies and no decrease in sexual activity for others. Health-care providers need knowledge and skills to care for these multicultural vulnerable adolescent mothers. Cassata and Dallas27 explored the attitudes of nurses caring for low-income adolescent clients in Chicago, IL. Nurses can experience cultural conflicts and lack knowledge and skills to care for multicultural vulnerable adolescent mothers.27 Collaborative research is needed to determine internal and external factors affecting these alarming adolescent pregnancy and birth rates, and identify interventions and policies to stem the tide of this international and national dilemma of unplanned adolescent pregnancy especially among underserved minority populations.
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