SUBSEQUENT LIFE OUTCOMES FOLLOWING TEENAGE

The association of teenage childbearing with disadvantages at the individual and societal levels later in life has been broadly addressed in the literature.^13–

15,18,44,45,180 However, girls becoming mothers as teenagers often face challenges in life even before pregnancy. Thus, it is difficult to determine the causality of teenage motherhood and adverse outcomes later in life as discussed earlier in this thesis. It has been suggested that choosing an induced abortion instead of giving birth as a teenager might mitigate some of these adverse outcomes,^13,18 but research on teenage abortion and later life outcomes remain sparse. In addition, follow-up periods in studies concerning outcomes after teenage pregnancy usually end in young adulthood, and research on long-term outcomes is lacking.

2.7.1 SOSIOECONOMIC STATUS

A substantial number of studies have shown that teenage mothers face more socioeconomic struggles later in life compared to older mothers or women without a history of teenage pregnancy. Two longitudinal studies from the United Kingdom (UK) and New Zealand found lower educational achievement and lower income levels among teenage mothers compared to older mothers.^14,44

Hobcraft et al. present similar findings showing that young mothers (under 23 years of age at the time of childbirth) were 40% more likely to have a low household income and twice as likely to have no qualifications at the age of 33 compared to older mothers.⁴⁵ A Finnish birth cohort study from 2016 revealed that young women who had undergone childbirth at less than 18 years of age were more likely to receive income support and to achieve only a low educational level by the age of 25 compared to their peers without a teenage pregnancy.¹³ Further, in this Finnish study, the outcomes for women with a history of induced abortion were also investigated. The study found that the risk of being welfare dependent or having achieved only a low educational level by the age of 25 was significantly lower for women who had had an induced abortion at less than 18 years of age compared to women who gave birth at less than 18 years of age.¹³ Fergusson et al. present similar findings concerning educational achievement among women with a previous teenage abortion vs.

women who became mothers as teenagers.¹⁸ However, the lower economic situation among teenage mothers was explained by certain family and social characteristics being present prior to pregnancy.¹⁸ In the US, teenage childbirths, especially repeated ones, also cluster in counties with lower socioeconomic conditions. These counties are more reliant on publicly funded family planning clinics although they have fewer of them per capita.¹²

Although there is a considerable number of studies available on the consequences of teenage motherhood, far fewer studies have focused on the

predictors or consequences of teenage fatherhood. A systematic review on teenage fatherhood published in 2019 concluded that the majority of the research is outdated and has focused on the predictors of teenage fatherhood or the consequences of the child instead of the subsequent life outcomes of teenage fathers.¹⁸¹ However, nine studies included in the review had investigated the socioeconomic situation of teenage fathers after becoming a father and up to 10 years later, and six of them were published after the year 2000. Two of these six studies controlled the outcomes for prior socioeconomic situation. The results of these two studies were somewhat controversial. Fletcher and Wolfe (2012) found that teenage fathers achieved a lower educational level but were more likely to have full employment at the age of 22 when compared to their non-father peers.¹⁸² Instead, Assini-Meytin and Green (2015) found no difference in educational achievement among teenage fathers compared to their non-father peers but that teenage fathers were more likely to be unemployed later in life than men without a teenage fatherhood.¹⁸³ However, the discrepancies between the results of these studies might be due to the timing of when the outcomes were measured. Fletcher and Wolfe investigated socioeconomic outcomes at the age of 22, whereas Assini-Meytin and Green were able to use a longer follow-up period, examining the outcomes at the ages of 32 and 42.

2.7.2 PSYCHIATRIC MORBIDITY AND PREMATURE DEATH

There is a growing body of research investigating mental health among pregnant teenagers and during the first postpartum year. This literature focuses principally on depressive symptoms, and depression during pregnancy and the first postpartum year seems to be more common among teenage mothers compared to older mothers.¹⁸⁰ However, a study from Pittsburgh, US, published in 2016, suggests that there is no difference in depressive symptoms among pregnant teenagers compared to their non-pregnant peers.¹⁸⁴ Nonetheless, it is important to note that the outcomes are mostly based on the use of different screening measures, such as Beck’s Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS), and not on rigorous clinician-rated diagnostic interviews.¹⁸⁰

When considering mental health problems in young adulthood after a teenage pregnancy, two longitudinal studies from the US and New Zealand show that teenage mothers have more mental health issues than their peers with no pregnancies.^14,15 However, this is likely due to the poorer backgrounds and social hardships these girls had already experienced prior to pregnancy.^14,15 A longitudinal study from Finland concluded similar findings showing that teenage mothers were more likely to have psychiatric disorders one year after the childbirth and at the age of 25 when compared to young women with no pregnancies. However, the risk had already been higher before the pregnancy.¹³

The Finnish study also examined psychiatric disorders following an induced abortion and found no difference in the risk for mental health issues at the age of 25 among teenage mothers compared to women who had chosen an induced abortion. Similarly, the risk of psychiatric disorders was also higher prior to pregnancy among teenagers undergoing an induced abortion.¹³ Warren et al. documented similar findings.¹⁸⁵ These results are in line with research concerning mental health following an induced abortion among adult women. It has been established that adult women undergoing an induced abortion face no increased risk for psychiatric disorders later in life.^186–190 Table 6 presents a summary of selected studies on adulthood psychological outcomes following a teenage pregnancy vs comparison groups. The focus lies on studies published after the year 2000 and with a follow-up period longer than one year after the pregnancy.

In addition to mental health issues, teenage mothers have an increased risk for premature death especially due to a health-damaging lifestyle.^16,17 Two longitudinal studies from the UK and Sweden revealed that teenage mothers faced an increased risk for dying of suicide compared to older mothers regardless of socioeconomic background.^16,17 In addition, an elevated risk of dying from cervical cancer among teenage mothers was identified in both of these studies. In the Swedish study, deaths due to violence and ischemic heart diseases were more common among women with a history of teenage childbirth compared to older mothers. Instead, the study from the UK found an increased risk of dying from lung cancer among teenage mothers compared to older mothers or women without any children. The Finnish longitudinal study also investigated the risk of premature death before age 25 among women who had undergone an induced abortion.¹³ The study found an increased risk of dying prematurely among women with a history of teenage induced abortion compared to young women without teenage pregnancies.

However, all the deaths took place several years after the induced abortion, and all women who died of suicide or accidents were diagnosed with depression prior to pregnancy.¹³ Altogether, the Finnish study as well as the studies from Sweden and the UK concluded that the increased risk of premature death following a teenage pregnancy was not an effect of age at first pregnancy itself but rather due to other lifestyle factors.^13,16,17 Despite these findings, studies investigating the long-term consequences after a teenage childbirth or an induced abortion in the same setting, are lacking.

43

Table 6Adulthood psychological outcomes following a teenage pregnancy vs comparison groups. StudyDesignPsychological outcomes Early motherhood and subsequent life outcomes (Boden et al. 2008)A longitudinal study based on interviews comparing the socioeconomic and mental health outcomes of teenage mothers (< 18 years n = 22, < 21 years n = 64) and their peers with no teen pregnancy (n = 429) at the age of 25 years

Childbirth < 18 and childbirth < 21 vs no teen childbirth: Major depression NS Anxiety disorder NS Suicidal ideation NS Suicide attempt NS Substance dependence NS, after adjustment Is underage abortion associated with adverse outcomes in early adulthood? A longitudinal birth cohort study up to 25 years of age (Leppälahti et al. 2016)

A longitudinal register-based study comparing the socioeconomic and mental health outcomes of women with a previous teenage pregnancy (induced abortion < 18, n = 1041 or childbirth < 18, n = 395) and peers without a teenage pregnancy (< 20 years, n = 27 605) at the age of 25. They also investigated the outcomes before and after the pregnancy.

Teenage abortion and teenage childbirth vs no teen pregnancy (adjusted OR, 95% CI): Any psychiatric disorder 1.5; 1.3–1.8 and NS Psychoactive substance use disorder 1.9; 1.4–2.6 and NS Mood disorder 1.4; 1.1–1.7 and NS Teenage abortion and teenage childbirth vs no teen pregnancy (unadjusted OR, 95% CI): Any psychiatric disorder before pregnancy 1.8; 1.5–2.1 and 2.9, 2.3–3.7 Any psychiatric disorder after pregnancy 2.1; 1.7–2.5 and 1.9, 1.5–2.6 Psychoactive substance use disorder before pregnancy 4.3; 2.8–6.6 and 4.1, 2.1–8.1

Review of the literature 44

Psychoactive substance use disorder after pregnanc 4.0; 3.1–5.3 and 2.8, 1.7–4.6 Mood disorder before pregnancy 2.0; 1.6–2.6 and 2.9, 2.0–4.1 Mood disorder after pregnancy 2.0; 1.6–2.4 and 2.2, 1.6–3.0 Teen motherhood and long-term health consequences (Patel et al. 2012)

A longitudinal study based on interviews comparing the physical and mental health outcomes of teenage mothers (< 18 years, n = 1310), women with a prior teenage pregnancy but no motherhood (< 18 years, n = 467), women with unprotected sex as teenagers but no pregnancy (< 18 years, n = 238) and all other women i.e. women with no teenage pregnancy nor unprotected sex as teenagers (n = 2691) at the age of 40 years

Teenage motherhood < 18 vs all other women (adjusted OLS regression, p): Mental Component Summary (MCS) -1.065, p<0. Teen pregnancy only < 18 vs all other women (adjusted OLS regression, p): MCS -1.379, p < 0.05 Unprotected sex as teenagers < 18 but no pregnancy vs all other women: MCS NS Do depression and low self-esteem follow abortion among adolescents? Evidence from a national study (Warren et al. 2010)

A longitudinal study based on interviews comparing the depression and low self-esteem of women with a teenage induced abortion (< 18 years, n = 69) and women with teenage pregnancy but no induced abortion (< 18 years, n = 220) at 1 and 5 years after the induced abortion

Teenage induced abortion vs teenage pregnancy, induced abortion: (adjusted OR, 95% CI): Depression 1 year later 0.8; 0.3–2.1 Depression 5 years later 0.7; 0.2–2.0 Low self-esteem 1 year later 1.3; 0.7–2.7 Low self-esteem 5 years later 0.9; 0.3–2.4 NS = non-significant MCS = mental component summary OLS = ordinary least squares

Table 6Adulthood psychological outcomes following a teenage pregnancy vs comparison groups.(continued from previous page)