PREDICTORS OF TEENAGE PREGNANCY

The factors associated with teenage pregnancy have been studied extensively although the majority of the studies concentrate on teenage childbearing. It is important to identify these predictors since understanding the associations with teenage pregnancy is beneficial in their prevention. Predictors associated with teenage pregnancy can be divided into individual- and population-level factors. The former include different family- and health-related factors, such as mental health problems. The latter include the traditions and overall health

and welfare characteristics of a country, such as average educational level and possibilities to arrange quality health services.

2.5.1 INDIVIDUAL-LEVEL PREDICTORS

A number of studies have detected that both the low socioeconomic status of the family and low parental low educational achievement are associated with teenage pregnancy.^4–8 A Finnish thesis, published in 1983, investigated the association of family background factors on the risk of teenage abortion.⁷⁷ The study was based on a questionnaire for girls seeking induced abortion and for a control group without a teenage pregnancy. The questionnaire included several questions concerning familial background, sexual education and sexual experience. The questionnaire was performed personally at a follow-up visit 4 weeks after the termination for the abortion group, and during a lesson in hygiene at school for the control group. The results showed that in the control group parents were better educated than those in the abortion group.

Specifically, only 3% of the mothers in the abortion group had achieved a university-level education compared with 21% in the control group. Another Finnish study, published in 2013, made similar findings showing that a mother’s low educational level was independently associated with having an abortion as a teenager.⁶ This study was based on the ‘Finnish 1981 Birth Cohort Study’, where the baseline assessment was conducted in 1989 when the participants were 8 years old. The participants were followed up until 2009, which was when they turned 28 years old. The method combined information from questionnaires conducted during the childhood of the participants and from registers of induced abortions in Finland.

Familial socioeconomic status represents the psychosocial context in which children develop and seem to modify the effect of some other individual-level risk factors, such as self-esteem, risky sexual behaviour and teenage pregnancy.^4,78 In addition to low socioeconomic status, a disrupted family structure has been found to predict teenage pregnancy. In particular, the absence of the father has been shown to be associated with risky sexual behaviour and teenage pregnancy.⁷⁹ However, other studies suggest that this association is not causal but rather reflects other family-related factors influencing the risk of teenage pregnancy.^4,80,81

Studies on psychological background and teenage pregnancy have shown that externalising problems in childhood, such as aggressiveness, hyperactivity and conduct problems, predict teenage pregnancy.4,6,7,82–84

Recently, two longitudinal studies from Sweden and Denmark revealed that girls with attention-deficit/hyperactivity disorder (ADHD) face a significantly higher risk of teenage motherhood than their peers without ADHD.^85,86 This is most likely explained by the related risk-taking behaviours, such as early sexual intercourse or multiple sexual partners, that are associated especially with conduct problems in childhood.^6,7,82,84 The Finnish study, based on

“Finnish 1981 Birth Cohort Study”, showed that having conduct problems at

eight years-of-age associates with becoming a teenage mother or having an induced abortion as a teenager.^6,82

Moreover, it has been shown that psychological development, including cognitive processing and socio-emotional regulation, continues until the late 30s.^9,87 Thus, logical reasoning, behaviour and decision making are still maturing in the teenage years, increasing the likelihood for risky sexual behaviours.^88,89

The findings concerning the association between internalising problems, such as mood disorders or other mental health problems, and teenage pregnancy remain somewhat controversial.^82,90–92 It has been shown that comorbid externalising problems or other confounding factors more likely explain the association than a mood disorders itself.^82,90,93

Daughters of teenage mothers have been shown to become teenage mothers themselves more likely than daughters of older mothers.^4,94,95 This process is referred to as the intergenerational transmission of teenage childbearing.^4,96 The mechanisms of the transmission are partly unknown but daughters of teenage mothers have been identified to face various known risk factors for teenage pregnancy more so than daughters of older mothers.⁹⁶ Further, some unique risks, such as lower levels of parental monitoring, may be involved in the intergenerational transmission of teenage childbearing.⁹⁶ Besides maternal teen motherhood, an older sister’s teenage pregnancy has also been shown to be associated with the risk of teenage pregnancy of the younger daughter.⁹⁴

In addition, some childhood experiences, such as being a bully or a victim of bullying as well as physical and sexual abuse, have been shown to be associated with the risk of teenage pregnancy.^97,98

2.5.2 POPULATION-LEVEL PREDICTORS

At the population level, teenage pregnancy rates have been higher in areas with a lower socioeconomic situation.^8,99 Specifically, repeated teen births in the US cluster in counties with lower socioeconomic conditions.¹² Furthermore, income inequality is associated with teenage pregnancy, since poor teens are likelier to become parents in areas with higher income inequality compared to areas with lower income inequality.¹⁰⁰ A review comparing teenage pregnancy rates and different population-level characteristics of certain countries also indicates that public support for the transition from childhood to adulthood (e.g. low-cost education and unemployment insurance) is associated with decreased teenage pregnancy rates.¹⁰¹ By contrast, cultural traditions, such as the prohibition of premarital sex and dowry payments, increase the risk for teenage pregnancy. In particular, this factor is observed in low-income and lower middle-income countries.¹⁰² In addition, early endogamous marriages and high fertility rates are typical in Roma culture, for example. This contributes to a higher risk for teenage pregnancy.¹⁰³ In Europe, teenage childbirth rates are the highest in

Eastern parts of the continent, such as in Bulgaria and Romania, where the Roma population is highest.¹⁰⁴

The decreasing teenage pregnancy rates have been mainly linked to an increased use of contraception.64,66,105,106 In relation, providing accessible contraceptive services and comprehensive sexuality education has been shown to increase adolescents’ contraceptive use.20,48,67,68 Kirby et al. published a review of 83 studies that measured the effect of curriculum-based sexuality and human immunodeficiency virus (HIV) education programs on sexual behaviour among youth under 25 years old anywhere in the world. They found that many of these programs delayed or reduced sexual activity and/or increased contraceptive use. The programmes were effective in different countries, communities and cultures. The authors identified the 17 most common characteristics for the most effective programmes. These characteristics can be divided into three categories describing the development, the design and teaching strategies, and the implementation of the curricula. Effective programmes are well designed to be implemented in schools where they reach many teenagers, especially when being comprehensive. These programmes can also be implemented in community settings, where they may reach other youths, such as school dropouts.⁶⁷

Thus, comprehensive sexuality education and high-quality contraceptive services are essential in preventing unintended pregnancies, especially among teenagers.