The studies constituting this thesis were constructed to identify associations of contraceptive services as well as socioeconomic and health factors with teenage pregnancies in Finland in two different settings: first, the association of different contraceptive services and socioeconomic factors with teenage pregnancy rates at the municipality level, and second, the risk for psychiatric morbidity and premature death after teenage pregnancy during a long follow-up period. This provides important information for health care workers and policymakers when organising health services for teenagers.
6.1 SOCIOECONOMIC STATUS AND TEENAGE PREGNANCY (STUDIES II AND III)
Globally, teenage childbirths concentrate on areas with low socioeconomic status.1,50 However, reliable data on abortion rates are not available in many countries, especially in those with restricted abortion laws. Statistical models have been developed to estimate the abortion rates and intendedness of pregnancy across the world. However, recent estimations on induced abortion rates and intendedness of pregnancy globally, especially among teenagers, are not available.
Maslowsky et al. showed that in the US, teenage childbirths, specifically repeated ones, cluster in areas with lower socioeconomic status, including higher poverty and unemployment rates as well as lower high school graduation rates. In addition, the counties with highest rates of repeat teenage childbirths had the lowest number of publicly funded family planning clinics per capita.12 However, there were significantly more visits to these clinics in counties with higher rates of repeat teenage childbirths. These findings reflect the inequality in access to contraceptive services, especially among teenagers.
Study I of the present research also showed similar municipality-level findings regarding the association of teenage pregnancy rates and educational level in Finland. Both the rates of teenage childbirth and teenage induced abortion were higher in municipalities with lower education levels. However, in contrast to the previous literature, there was no association between the number of social assistance recipients of the municipalities and teenage pregnancy rates. This may be partly because in Finland there are no such large differences in economic conditions between the areas when compared to the US, for example.
At the individual level, especially teenage mothers achieve a lower socioeconomic status later in life compared to women who became mothers at more mature age.13,14,44,45 Research on socioeconomic conditions among women with a history of teenage induced abortion is more sparse. Two
longitudinal studies from Finland and New Zealand found that women who chose an induced abortion instead of giving birth as a teenager achieved a higher educational level in young adulthood.13,18
The findings of the present research support these results regarding educational level. Studies II and III showed that women with a history of teenage pregnancy achieved a lower educational level during the entire follow-up period compared to those without teenage pregnancy: 25% of women with previous teenage pregnancy had a high educational level, whereas 56% of women without teenage pregnancy had a high educational level. Among women with a history of teenage pregnancy, those who underwent an induced abortion achieved a higher educational level compared to those who gave birth (34% vs 17%).
The association between teenage pregnancy and socioeconomic situation can be considered from two angles: before and after the pregnancy. It has been shown that poor socioeconomic background, including low parental educational level, increases the risk of teenage pregnancy.4–8 The results of School Health Promotion Study in Finland showed differences in adolescents’
sexual behaviour whether studying in vocational school or in upper secondary school: students in upper secondary school had sexual debut later and used contraception more often than their peers in vocational school.112 Additionally, poor school performance already at the age of eight is in association with increased risk of getting pregnant as a teenager.6
When concerning situation after teenage pregnancy, it has been shown that teenage mothers achieve a lower socioeconomic situation later in life compared to older mothers or women without a teenage pregnancy.13,14,18,44,45
The findings concerning the effect of socioeconomic background on the socioeconomic achievements among teenage mothers in young adulthood are somewhat controversial. Two studies from the UK and New Zealand showed that teenage mothers had a lower educational level in young adulthood regardless of the background.14,45 In contrast, the study from New Zealand found that lower economic status among teenage mothers was explained by the familial background factors although educational level remained lower despite socioeconomic background.14 Furthermore, Gorry et al. investigated the socioeconomic achievements of teenage mothers in the US according to the socioeconomic status of their residential area. The study found that teenage mothers from higher-income counties achieved a lower socioeconomic status in young adulthood compared to their peers without a teenage childbirth. However, no adverse outcomes were found among teenage mothers from lower-income counties. Conversely, some teenage mothers from poor socioeconomic conditions seemed to obtain a higher educational level than they would without teenage childbirth. However, these results were not statistically significant.197
Concerning socioeconomic achievements following teenage induced abortion, two studies from Finland and New Zealand showed worse outcomes for teenage mothers compared to individuals who underwent an induced
abortion.13,18 Moreover, the study from New Zealand found no difference in the educational level achieved among women with a history of teenage induced abortion compared to women with no such history.18
Overall, women with a history of teenage pregnancy achieve a lower socioeconomic status in young adulthood. The findings in the present research add to this knowledge showing that the difference in educational achievements also remains in later life. However, background factors were not considered in this study. The somewhat controversial results in different studies reflect the complex associations of socioeconomic factors and teenage pregnancy.
Furthermore, previous studies have been fairly small and had a short follow-up period. Cultural and regional differences as well as different educational possibilities also likely explain part of the controversial findings.
6.2 CONTRACEPTIVE SERVICES AND TEENAGE PREGNANCY (STUDY I)
The association of contraceptive services and teenage pregnancy rates at the municipality level were investigated in study I. Availability of free-of-charge contraception, non-prescription EC and access to an adolescent-only clinic were used as variables to describe the contraceptive services of the municipalities.
6.2.1 FREE-OF-CHARGE CONTRACEPTION AND TEENAGE PREGNANCY
The results of study I showed that providing free-of-charge contraception is associated with lower rates of both teenage childbirth and teenage induced abortion. Previous studies have specifically shown an association of free-of-charge LARC methods and lower teenage pregnancy rates.20,22 The Contraceptive CHOICE Project, a prospective cohort study in Missouri (US) during 2007–2010, found a significant decrease in both teenage induced abortion and teenage childbirth rates when providing all contraceptives at no cost. The association was especially strong for LARC methods.20 However, the study design in the CHOICE Project did not include a comparison group;
rather, the CHOICE population was compared to national levels of induced abortions.157
In line with the CHOICE results, a Finnish study published in 2018 found that providing free-of-charge LARC methods decreased teenage induced abortion rates in Vantaa, Finland. A similar decrease was not seen in the neighbouring municipality, Espoo, which did not provide free-of-charge contraception and served as a control.22 The results of the present research support these findings by showing that provision of all contraceptive methods at no cost is associated with lower teenage pregnancy rates in an unselected population.
6.2.2 NON-PRESCRIPTION EC AND TEENAGE PREGNANCY
Two studies from the UK and the US, published in 2011 and 2016, did not find a significant association between OTC EC and teenage pregnancy rates.198,199 Our results were somewhat contradictory to those studies. Provision of non-prescription EC was associated with lower rates of teenage induced abortions and childbirths. However, this association was significant only when non-prescription EC was available without age restrictions, that is, from 2015 onwards. Actual use of EC did not increase in Finland after 2015.200 Thus, the association may be due to other factors, such as the increased use of LARC among adolescents.200 Instead, EC use increased in 2002200 when it became available without prescription for 15 years old and above, and school pupils were well aware of how to use EC.201
6.2.3 ADOLESCENT-ONLY CLINICS AND TEENAGE PREGNANCY The centralisation of adolescent contraceptive services within an adolescent-only clinic did not associate significantly with lower teenage pregnancy rates in study I. However, there were only seven municipalities that had centralised adolescent contraceptive services within an adolescent clinic. This may partly explain the finding. Further, in 2010 nurses got a possibility to begin oral contraceptives for teenagers aged 15 years or older and IUDs for teenagers aged 18 years or older when used for contraception.202 It has been also shown that teenagers give high priority to flexible operating hours and convenient locations, such as within school health care, regarding contraceptive services.48,165 Thus, centralisation of the services within an adolescent-only clinic might not be such an important factor for teenagers seeking contraceptive services.
6.2.4 YOUTH-FRIENDLY SERVICES
Accessibility is one of the most important factors concerning youth-friendly health services, including sexual health services.166,173 According to the WHO’s recommendation, accessibility refers to free-of-charge or affordable services, convenient locations and operating hours, as well as clear information on the available services.166 Although LARC methods have been shown to be most effective in preventing teenage pregnancy, the results in the present research also support the previous findings that the provision of both LARC and SARC methods free of charge for teenagers is associated with lower teenage pregnancy rates.20,22,106
In addition to removing the financial barrier of teenagers’ access to contraception, it is important to provide proper and individual counselling on reproductive health and contraception. Counselling should be based on effective counselling techniques, such as the GATHER process and the 5 Ps.151,152 Furthermore, discussion about different contraceptive methods
should be started with the most effective ones first, namely LARC methods.203 Providing all contraceptive methods free of charge for teenagers and using these effective counselling methods are likely to improve teenagers’ sexual health and decrease teenage pregnancy rates as well. However, to ensure teenagers’ awareness of the available sexual health services, it is important to provide the information in the most suitable way for teenagers. In developed countries, evidence-based information should be available through the internet, social media and different technical applications. Additionally, education on sexual and reproductive health should be a mandatory subject in the school curriculum with clear information about available services.
Information on sexual health services should also cover the availability of induced abortion. School-based sexuality education plays a remarkable role when improving adolescents’ sexual health since it reaches all pupils, especially when integrated as a compulsory subject in the curriculum.
6.3 LONG-TERM LIFE OUTCOMES FOLLOWING TEENAGE PREGNANCY (STUDIES II AND III)
6.3.1 PSYCHIATRIC MORBIDITY (STUDY II)
Majority of the previous research on psychiatric morbidity after a teenage pregnancy includes only teenagers who have given birth. Concerning an induced abortion and mental health problems, the previous literature concentrates mostly on adult women. These studies have showed no increased risk for mental health issues following induced abortion.186–190 A longitudinal study from Finland, published in 2016, revealed similar findings among teenagers. The Finnish study found a higher incidence of psychiatric morbidity at the age of 25 among young women with a history of teenage induced abortion compared to peers without a teenage pregnancy. However, the psychiatric morbidity was higher already prior to the induced abortion.13 In line with this, a small survey from the US showed no increased risk for depression or low self-esteem at one and five years after teenage induced abortion compared to peers without induced abortion. However, the strongest risk factor for post-abortion depression and low self-esteem was existing depression already before the pregnancy.185
Study II showed the risk of psychiatric morbidity to be higher among women with a history of teenage induced abortion compared to women with no teenage pregnancy although the women with a psychiatric diagnosis before pregnancy were removed from the data. This higher risk persisted into adulthood. These findings support the results from previous studies since the risk started to increase only five years after a teenage induced abortion. This suggests that it is not the abortion itself but other factors that explain the higher incidence of psychiatric morbidity later in life.
By contrast, the incidence of psychiatric diagnoses was higher among women with a history of teenage childbirth during the first five years postpartum when compared to peers without teenage pregnancy. The previous literature has shown that the increased risk is most likely due to the disadvantaged background and social hardships teenage mothers face prior to pregnancy.13,14,184 The somewhat contradictory findings in study II might be due to the lack of detailed information about the socioeconomic situation of the participants and their family prior to pregnancy. In addition, the data included only the most severe psychiatric diagnoses before the year 1998 since psychiatric diagnoses given at outpatient clinics were not registered in the national registries before that time.
6.3.2 PREMATURE DEATH (STUDY III)
Despite the studies concerning socioeconomic factors and psychiatric morbidity among women with a prior teenage pregnancy, research on premature death following teenage pregnancy is scarce. Two longitudinal studies from Sweden and the UK found an increased risk of premature death among women with a history of teenage childbirth independent of socioeconomic background.16,17 The risk was most pronounced for deaths associated with lifestyle factors, including accidental death, suicide, cervical cancer and lung cancer. In addition, the studies were not able to adjust the outcomes for previous mental health problems. Thus, the increased risk of premature death found in these studies was most likely due to factors other than the age at first childbirth per se. A recent Finnish study did not find an increased risk of premature death before the age of 25 among teenage mothers compared to peers without teenage pregnancy.13 In contrast, the Finnish study showed an increased risk of premature death among women with a history of teenage induced abortion. However, there were only seven deaths in the cohort and six of them were due to accident or suicide. In addition, all of these women were diagnosed with depression prior to the abortion. Thus, the increased risk found in the previous Finnish study was also most likely explained by factors other than the teenage induced abortion itself.
The results of study III of the present thesis support the previous findings showing that women with a history of teenage pregnancy face an increased risk of premature death regardless of the outcome of the pregnancy, induced abortion or childbirth. However, after adjustment for the highest education level achieved, the risk remained significantly increased only due to suicide among women with a history of teenage induced abortion. In contrast, among women with a history of teenage childbirth, the risk of death was increased after adjustment only due to diseases of the circulatory system. The lower risk of premature death due to risk-taking behaviour among women with a history of teenage childbirth compared to women with a teenage induced abortion might partly be result from the protective effect of motherhood itself.17 As a
shortcoming of the study, the data lacked information on socioeconomic situation and risk-taking behaviour prior to pregnancy.
Altogether, the risk of psychiatric morbidity and premature death was higher among women with a history of teenage pregnancy compared to peers with no such history. The findings add to the current knowledge that these risks persist into adulthood. However, adjustment for the highest achieved educational level decreased these associations. Additionally, it has been shown that lower educational level is associated with premature mortality.204–206
Lower education level and increased risk for psychiatric morbidity and premature death among women with a history of teenage pregnancy are most likely due to a more complicated phenomenon including several background factors, as discussed earlier in this thesis. However, the findings in the present research show that the gap in education level continues into adulthood. Thus, pregnant teenagers, especially the ones giving birth, should be encouraged and supported to continue their education.
The incidence of mood disorders increases during adolescence, especially among girls.207 This increased risk together with disadvantaged socioeconomic background and other possible hardships may contribute to mental health issues and risk-taking or even suicidal behaviours, especially if getting pregnant as a teenager. Therefore, to prevent these adverse outcomes, it would be essential to identify pregnant teenagers with risk factors for mental health problems or risk-taking behaviour as early as possible. In Finland, teenagers continuing their pregnancy meet health care providers and social workers regularly during the pregnancy and after the childbirth. Thus, possible mental health issues or need for additional support is easier to identify than for teenagers who choose an induced abortion. Nevertheless, it is important for health care workers to be alert to risk factors for mental health problems when consulting all pregnant teenagers, irrespective of whether they choose to continue the pregnancy or not.
6.4 STRENGTHS AND LIMITATIONS
All studies in this thesis were register-based studies that have both strengths and limitations. The data on rates of teenage induced abortions and childbirths were obtained from the reliable and valid Finnish health registers covering practically all teenage childbirths and induced abortions both in the selected municipalities (study I) and nationally (studies II and III).191,193,208
The register-based study design is not affected by recall or selection bias except for the information on provided contraceptive services in municipalities that were assessed in the survey. However, all municipalities in study I responded to the survey. The associating factors were investigated separately for pregnancies ending in induced abortion and childbirth in all studies.
Furthermore, the follow-up periods in all studies were 19–26 years, allowing
the investigation of different associations with teenage pregnancies over a long time period.
However, the limitations of these studies are also acknowledged. First, although several variables associated with teenage pregnancy rates were examined in study I, other factors may have also affected the rates, such as possible changes in teenagers’ substance use. Second, the socioeconomic variables used in study I were defined at the municipality level, which is a fairly crude measure of the situation. Third, policies concerning EC came into force in all municipalities at the same time. Thus, there was not a comparison group of municipalities not offering the service in the same year. In studies II and III, the data lacked information on parental socioeconomic situation before the teenage pregnancy. Furthermore, only the most severe psychiatric diagnoses were included in these data, since psychiatric diagnoses given at outpatient clinics were not registered before 1998.
6.5 IMPLICATIONS AND FUTURE ASPECTS
The results of the present thesis show that providing all contraceptive methods for free for teenagers is associated with both reduced rates of teenage induced abortions and teenage childbirths. The provision of free-of-charge
The results of the present thesis show that providing all contraceptive methods for free for teenagers is associated with both reduced rates of teenage induced abortions and teenage childbirths. The provision of free-of-charge