Childbirth and induced abortion as a teenager : Associations with contraceptive services and long-term health outcomes

(1)

Department of Obstetrics and Gynaecology University of Helsinki

Finland

CHILDBIRTH AND INDUCED ABORTION AS A TEENAGER: ASSOCIATIONS WITH

CONTRACEPTIVE SERVICES AND LONG-TERM HEALTH OUTCOMES

Eerika Jalanko

ACADEMIC DISSERTATION

To be publicly discussed, with the permission of the Medical faculty of the University of Helsinki, in the Seth Wichmann auditorium of the Women’s Hospital

on the 11th of February 2022, at 12 noon Helsinki 2022

(2)

Department of Obstetrics & Gynaecology University of Helsinki, Finland

Physician in-chief, Helsinki University Hospital, Finland

and

Research Professor Mika Gissler, PhD

THL Finnish Institute for Health and Welfare, Information Services Department, Finland

Research Centre for Child Psychiatry, University of Turku, Finland

Academic Primary Health Care Centre, Stockholm Department of Molecular Medicine and Surgery, Karolinska Institutet, Sweden

Reviewed by: Docent Dan Apter, MD, PhD University of Helsinki, Finland

Chief Physician, VL Medi Clinical Research Center, Finland

and

Docent Lena Marions, MD, PhD

Institution of Clinical Science and Education Department of Obstetrics and Gynaecology Karolinska Institutet, Sweden

Official opponent: Professor Riittakerttu Kaltiala, MD, PhD Faculty of Medicine and Health Technology, Tampere University, Finland

Department of Adolescent Psychiatry, Tampere University Hospital, Finland

The Faculty of medicine uses the Urkund system (plagiarism recognition) to examine all doctoral dissertations.

Cover design by Nico Vehmas ISBN 978-951-51-7786-5 ISBN 978-951-51-7787-2 (PDF) Unigrafia, Helsinki 2022

(3)

To my family

(4)

ABSTRACT

Teenage pregnancy rates have declined globally during recent decades.

However, data on induced abortion rates, particularly those of teenagers, are incomplete in many countries. This is usually due to a lack of reliable national registers on induced abortions. In addition, age-specific rates of induced abortions are usually not available in areas with restrictive abortion laws.

The declining trend in teenage pregnancy has been mainly linked to the increased use of contraception in developed countries. Specifically, increased use of the long-acting reversible contraceptives (LARC), referring to intrauterine devices (IUD) and implants, is associated with lower teenage pregnancy rates. However, the high costs of contraception are one of the most important barriers limiting access to effective contraception among teenagers.

The provision of free-of-charge contraceptives, especially that of LARC methods, has been shown to be associated with decreased teenage pregnancy rates.

In addition to removing financial barriers, comprehensive sexuality education and the provision of youth-friendly services with proper counselling on different contraceptive methods likely increase the contraceptive use among teenagers.

Investing in youth-friendly contraceptive services is essential since the majority of teenage pregnancies are unintended. Furthermore, teenage pregnancy has been shown to be associated with several adverse outcomes at both the individual and societal levels. However, research on the long-term consequences following teenage pregnancy in regard to the outcome of the pregnancy, childbirth or induced abortion, is lacking. In addition, studies concerning the combined association of socioeconomic status and different contraceptive services with teenage pregnancy rates have not been published.

This thesis investigates the association of different municipality-level characteristics and contraceptive delivery models with teenage pregnancy rates and long-term risk of psychiatric morbidity and premature death following teenage pregnancy. The research consists of three articles (I–III).

The first article (I) evaluates the combined association of regional, socioeconomic (educational level and need for social assistance) and contraceptive service (provision of free-of-charge contraception, non- prescription emergency contraception [EC] and availability of adolescent-only clinics) variables with the rates of teenage childbirth and induced abortion in the 100 largest municipalities in Finland. The data include the annual teenage childbirth and induced abortion rates of the municipalities from 2000 to 2018.

The following variables were significantly associated with both lower rates of teenage childbirth and teenage induced abortion when adjusted for all the other variables used in the model: the provision of free-of-charge contraception (rate ratio [RR] 0.82; 95% confidence interval [CI] 0.73–0.92

(8)

of the municipality (RR 0.94; 95% CI 0.94–0.95 and RR 0.94; 95% CI 0.93–

0.94, respectively).

The second article (II) examines the risk of psychiatric morbidity following teenage childbirth or teenage induced abortion in Finland during a maximum of 28 years follow-up time. The comparison group consisted of peers without a history of teenage pregnancy. The incidence of psychiatric diagnoses remained higher during the entire follow-up period among women with a history of teenage childbirth compared to women without a teenage pregnancy. In contrast, after a teenage induced abortion, the incidence increased only five years post-abortion. The overall risk of psychiatric morbidity during the follow-up time was increased among women with a history of teenage pregnancy regardless of the outcome, childbirth or induced abortion, when compared to peers without one (adjusted IRR [aIRR] 1.2; 95%

CI 1.2–1.3 and aIRR 1.3; 95% CI 1.2–1.3, respectively).

The third article (III) investigates the risk of premature death after teenage childbirth or teenage induced abortion compared to peers without a history of teenage pregnancy during a maximum of 25 years follow-up time. The incidence of premature death was higher among women with a history of teenage pregnancy regardless of the outcome when compared to women without a teenage pregnancy. When analysed according to different causes of death, among women with a history of induced abortion the increased risk of premature death was seen only due to suicide and injury, poisoning and other external causes when compared to peers without a teenage pregnancy (adjusted mortality rate ratio [aMRR] 2.0; 95% CI 1.4–2.9 and aMRR 1.5; 95%

CI 1.1–1.9). In contrast, among women with a history of teenage childbirth, this risk was not increased after adjustment for age at the beginning of the pregnancy, residential area and highest achieved educational level.

Specifically, the highest achieved educational level was found to associate with the risk of psychiatric morbidity and premature death among women with a history of teenage pregnancy regardless of the outcome.

In conclusion, the provision of free-of-charge contraception and high educational level were associated with both lower rates of teenage childbirth and teenage induced abortion at the municipality level. Women with a history of teenage pregnancy faced an increased risk for psychiatric morbidity and premature death, and this risk persisted into adulthood. However, the data lacked information on familial socioeconomic background, which is known to have a strong association with both the risk of teenage pregnancy and psychiatric morbidity later in life.

Thus, according to the results in this thesis and previous studies, the increased risk for psychiatric morbidity and premature death among women with a history of teenage pregnancy is likely due to a more complex entity rather than the age at first pregnancy itself. Therefore, youth-friendly contraceptive services with proper counselling and schooling should be

(9)

provided to all teenagers to prevent unintended pregnancies and adverse outcomes.

(10)

FINNISH SUMMARY, TIIVISTELMÄ

Teiniraskauksien esiintyvyys on laskenut maailmanlaajuisesti viimeisten vuosikymmenten aikana.

Lisääntynyt ehkäisyn käyttö ja erityisesti pitkävaikutteisten ehkäisymenetelmien (kierukat ja kapselit) tarjoaminen nuorille maksutta on yhteydessä matalampaan teiniraskauksien esiintyvyyteen.

Pitkittäistutkimuksia erilaisten ehkäisypalveluiden yhteydestä teiniraskauksien esiintyvyyteen valikoitumattomassa aineistossa ei kuitenkaan ole saatavilla.

Panostaminen nuorten ehkäisypalveluihin on ensiarvoisen tärkeää, sillä teiniraskauksiin liittyy monia negatiivisia ilmiöitä niin yksilön kuin yhteiskunnankin kannalta. Tutkimustietoa teiniraskauteen kytkeytyvien terveysriskien ja sosiaalisen huono-osaisuuden esiintyvyydestä nuoren myöhemmässä elämässä on kuitenkin saatavilla vain vähän. Teini-ikäisen raskaus on usein ei-toivottu, ja merkittävä osa teiniraskauksista päättyykin raskaudenkeskeytykseen. Luotettavaa tietoa teini-ikäisten raskaudenkeskeytyksistä ei kuitenkaan monissa maissa ole saatavilla.

Tämän väitöskirjatutkimuksen tavoitteena oli selvittää teiniraskauden kokeneiden naisten psykiatrisen sairastuvuuden ja ennenaikaisen kuolleisuuden riskiä pitkällä aikavälillä, sekä kuntien ehkäisypalveluiden ja sosioekonomisen tilanteen yhteyttä teiniraskauksien esiintyvyyteen Suomessa. Hyödynsimme kaikissa väitöskirjan osatöissä Suomen luotettavia rekistereitä, ja ensimmäisessä työssä toteutimme lisäksi kyselyn Suomen 100 suurimpaan kuntaan niiden tarjoamien ehkäisypalveluiden kartoittamiseksi.

Ensimmäisessä osatyössä havaitsimme, että seuraavat tekijät olivat yhteydessä teini-ikäisten matalampiin synnytys- ja raskaudenkeskeytyslukuihin: maksuttoman ehkäisyn tarjoaminen (RR 0.82;

95% CI 0.73 – 0.92 ja RR 0.87; 95% CI 0.79 – 0.96), ja kunnan korkeampi koulutusaste (RR 0.94; 95% CI 0.94 – 0.95 and RR 0.94; 95% CI 0.93 – 0.94).

Toisessa ja kolmannessa osatyössä tutkimme teiniraskauden kokeneiden naisten psykiatrisen sairastuvuuden ja ennenaikaisen kuolleisuuden riskiä pitkällä, yli 25 vuoden, aikavälillä teiniraskauden jälkeen. Naisilla, jotka olivat kokeneet teiniraskauden, oli suurempi psykiatrisen sairastuvuuden ja ennenaikaisen kuolleisuuden riski verrattuna naisiin, jotka eivät olleet kokeneet teiniraskautta. Riski oli kohonnut riippumatta siitä, päättyikö teiniraskaus synnytykseen vai raskaudenkeskeytykseen. Teiniraskauden kokeneilla nuorilla on usein ongelmia myös muilla elämän osa-alueilla, ja teiniraskaus on yksi osa tätä ongelmakenttää. Tämän väitöskirjatutkimuksen ja aiemman kirjallisuuden perusteella kohonnut psykiatrisen sairastuvuuden

(11)

ja ennenaikaisen kuolleisuuden riski liittyy ennemminkin tähän kokonaisuuteen kuin ikään raskauden alkaessa.

Yhteenvetona tutkimustulostemme perusteella maksuton ehkäisy ja korkeampi koulutusaste ovat yhteydessä matalampiin teiniraskauslukuihin Suomessa. Näiden lisäksi laadukas seksuaalikasvatus osana peruskoulujen opetussuunnitelmaa, yksilöllinen ehkäisyneuvonta sekä ehkäisypalveluiden hyvä saatavuus ovat olennaisia elementtejä järjestettäessä nuorten terveyspalveluita. Näin pystyttäisiin mahdollisimman tehokkaasti ehkäisemään ei-toivottuja raskauksia ja niihin liittyviä negatiivisia ilmiöitä.

(12)

AAP American Academy of Pediatrics

ACOG The American College of Obstetrics and Gynecology ADHD Attention-deficit/hyperactivity disorder AIC Akaike Information Criterion aIRR Adjusted incidence rate ratio

aMRR Adjusted mortality rate ratio BDI Beck’s Depression Inventory BMI Body mass index

CDC Centers for Disease Control and Prevention CHC Combined hormonal contraceptives

CI Confidence interval

Cu-IUD Copper intra-uterine device

EBCOG European Board and College of Obstetrics and Gynaecology

EC Emergency contraception

EPDS Edinburgh Postnatal Depression Scale FSRH The Faculty of Sexual and Reproductive Healthcare HIV Human immunodeficiency virus

ICD International Classification of Diseases IRR Incidence rate ratio

IUD Intra-uterine device

LARC Long-acting reversible contraception LNG-IUD Levonorgestrel-releasing intrauterine device MCS Mental Component Summary

MEC Medical Eligibility Criteria MRR Mortality rate ratio NS Non-significant

NSFG National Survey of Family Growth OLS Ordinary least squares

RR Rate ratio

SARC Short-acting reversible contraception

SD Standard deviation

STI Sexually transmitted infection

UK United Kingdom

UN United Nations

UNFPA United Nations Population Fund

UNICEF United Nations International Children’s Emergency Fund

US United States

Valvira National Supervisory Authority for Welfare and Health VIF Variance inflation factor

WHO World Health Organization

(13)

LIST OF ORIGINAL PUBLICATIONS

This thesis is based on the following publications:

I Jalanko E, Gyllenberg F, Krstic N, Gissler M, Heikinheimo O Municipal contraceptive services, socioeconomic status and teenage pregnancy in Finland: A longitudinal study. BMJ Open 2021.17;11(2):e043092.

doi: 10.1136/bmjopen-2020-043092

II Jalanko E, Leppälahti S, Heikinheimo O, Gissler M

The risk of psychiatric morbidity following teenage induced abortion and childbirth:

A longitudinal study from Finland. Journal of Adolescent Health 2020. 66(3):345-351.

doi: 10.1016/j.jadohealth.2019.08.027

III Jalanko E, Leppälahti S, Heikinheimo O, Gissler M

Increased risk of premature death following teenage abortion and childbirth –

A longitudinal cohort study. European Journal of Public Health 2017. 27(5):845-849.

doi: 10.1093/eurpub/ckx065

The publications are referred to in the text by their Roman numerals. The original publications are reproduced with the permission of the copyright holders.

(14)

1 INTRODUCTION

Teenage pregnancy is a global concern affecting mostly the developing parts of the world.¹ Motherhood or pregnancy as a teenager can be viewed as a human right issue, particularly in developing countries. For example, preventing teenagers’ access to sexual health and contraceptive services is against their right to health. Furthermore, pregnant girls are often forced to leave school thus denying them their right to education.

Teenage pregnancies are usually unintended^2,3 and associated with other hardships these girls face in their lives. For example, a poor socioeconomic background and low educational level of the parents are associated with a higher risk of getting pregnant as a teenager.^4–8 Additionally, changes in hormonal levels and the dopaminergic system in the brain during the teenage years affect to emotions and behaviour. These physiological changes combined with a possibly vulnerable background increases the risk for imprudent behaviour, such as risky sexual behaviour.^9,10

Concerning the situation following teenage pregnancy, women with a history of teenage pregnancy face an increased risk for adverse obstetrical outcomes¹¹ as well as socioeconomic and educational disadvantages.^12,13 Furthermore, teenage motherhood is shown to be associated with increased risk of psychiatric morbidity and even premature death.^13–17 The majority of the research suggests that these disadvantages are likely due to the worse background of pregnant teenagers and not the age at pregnancy itself.^13–15 Studies evaluating associations of different factors with teenage pregnancy typically lack information on teenage induced abortions and concentrate only on teenage mothers. A few studies have been able to also examine teenage induced abortions and their relation to socioeconomic and educational outcomes, showing that undergoing an induced abortion instead of giving birth as a teenager might mitigate some of the adverse outcomes.^13,18,19 However, studies on the long-term consequences following a teenage pregnancy according to the outcome of the pregnancy, childbirth or induced abortion, are lacking.

Although the majority of vulnerable teenagers at increased risk of teenage pregnancy and related concerns live in developing countries, teenagers in developed areas also face barriers to proper contraceptive services and sexuality education. Financial barriers are one of the most important factors preventing teenagers’ access to effective contraception. The provision of free- of-charge contraception, particularly that of long-acting reversible contraceptives (LARC), has been shown to be associated with lower teenage pregnancy rates.^20–22 In addition to reducing financial barriers to contraception, teenagers find proper counselling on different contraceptive methods as an important part of contraceptive services.^23,24 Thus, the provision of youth-friendly contraceptive services would likely improve

(15)

teenagers’ sexual health and decrease teenage pregnancy rates. However, studies investigating the association of different socioeconomic and contraceptive service factors with teenage pregnancy are lacking.

The present thesis evaluates the combined association of socioeconomic and contraceptive service variables with teenage pregnancy rates at the municipality level in Finland as well as the long-term risk of psychiatric morbidity and premature death among women with a history of teenage pregnancy. The outcomes in all studies were investigated according to the outcome of the teenage pregnancy - childbirth or induced abortion.

(16)

2 REVIEW OF THE LITERATURE

2.1 DEFINITIONS OF TEENAGE, ADOLESCENCE AND TEENAGE PREGNANCY

Adolescence is a unique developmental period from childhood to adulthood encompassing both biological changes and societal transitions. The World Health Organization (WHO) defines adolescence as the period between 10 to 19 years of age.²⁵ Teenage (ages 13 to 19 years)²⁶ can be seen as a part of adolescence among other commonly used age definitions that span with the developmental periods of childhood, adolescence and adulthood (Figure 1).

Figure 1 Commonly used age definitions for terms describing childhood, adolescence and adulthood.

In many countries, legal adulthood is defined as starting at the age of 18 years.

However, developmental maturing to adulthood and transitioning to assimilate the adult responsibilities typically appear later.²⁷ Initially, the laws were enacted to protect vulnerable adolescents from harm, such as child marriage and child labor.²⁸ At the same time, adult legal privileges, such as voting, are used to ensure civic engagement and social participation for adolescents. Additionally, laws in many countries enable adolescents to access health services before 18 years of age without parental consent.

This is extremely important especially concerning sexual health and contraception.

Thus, enacting laws of adult privileges based on developmental aspect would serve

0 5 10 15 20 25 30

Children Teenagers Adolescents Young people Youth Adults

13 –19 0 –18

10 –19

15 –25 10 –24

18 Æ

(17)

adolescents best.²⁷ Adolescence is a dynamic phase in brain development and the social environment should provide ample resources such that adolescents can reach their full potential, unique for this period of life.^28,29

In this thesis, the term teenage pregnancy refers to pregnancies of girls under 20 years of age. Furthermore, teenage pregnancy encompasses both teenage induced abortions and teenage childbirths, which are examined separately. Miscarriages or ectopic pregnancies are not included in teenage pregnancies here since they are not included in the registers used in this thesis.

2.2 TEENAGE PREGNANCY AS A GLOBAL CONCERN

Adolescence is a critical period of life with rapid brain development. One’s social environment and the opportunities provided during one’s teenage years crucially affect one’s capabilities to develop essential life skills, such as independence, completion of education and employment. Becoming pregnant as a teenager diminishes the possibilities of adopting these skills.^28,30 Globally, the majority of teenage pregnancies occurs in the least developed areas with poor opportunities for education and employment.¹ In these societies, teenage pregnancy is often intertwined with additional concerns, such as sexual violence and child marriage.³¹ Although child marriage is against human rights, it is still practised broadly, mostly in Sub-Saharan Africa and South Asia. The highest incidence of child marriage is seen in the Central African Republic, where approximately 68% of women are married before age 18.³² Child brides often become pregnant as teenagers and 90% of teenage births in developing countries occur among married girls.³³ Teenage pregnancies have serious consequences for both the teenagers and their children especially in low-income countries.³¹ Complications from pregnancy and childbirth is the leading cause of death among girls aged 15 – 19 years old globally.³⁴ Teenage mothers have also been shown to be at higher risk for eclampsia regardless of whether living in a developing or a developed region.^11,35–37 However, the incidence has been shown to be higher in low- and middle-income countries.³⁸ Further, babies of teenage mothers are more likely to be delivered preterm and have low birth weight than those of older mothers.^35,39,40

In addition to health consequences, pregnancy and childbirth during teenage years increase the risk for several social and economic hardships in life. For example, both married and unmarried pregnant teenagers especially in low- or middle-income countries experience isolation or violence by their family, partners and peers, contributing to physical and psychological consequences.^41,42 Furthermore, early childbearing is associated with school drop-out and a lower educational level, which compromises a girl’s possibilities for future education and employment.13,14,43–45

Alternatively, in many developing countries marriage and childbearing as a teenager might be the best option for young girls due to poor education and employment possibilities.⁴⁶

Attitudes towards teenage sexuality as well as cultural norms strongly affect accessibility to sexuality education and effective contraceptives. This is an enormous challenge when organising sexuality education especially in low- and middle-income

(18)

countries but also in developed areas. Additionally, teenagers may avoid seeking contraceptive services due to fear of judgement and social stigma. Thus, many teenagers across the world do not know how to use contraceptives or where to obtain them. Many also have misconceptions about contraception.⁴⁷ Other barriers to contraceptive use among teenagers globally include financial constraints and lack of youth-friendly services.20–22,47,48

WHO, the United Nations (UN), the United Nations International Children’s Emergency Fund (UNICEF) and the United Nations Population Fund (UNFPA) have launched programmes to enhance teenagers’ sexual rights and reduce teenage pregnancies in developing countries. For example, the Global Programme to End Child Marriage launched in 2016 by UNICEF and UNFPA, helps adolescent girls to avoid marriage and childbearing in the 12 countries with highest rates of child marriage.⁴⁹ WHO published guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries in 2011. These guidelines cover six areas and recommendations for action as shown in Table 1.⁴⁷

(19)

Table 1 WHO guidelines for preventing early pregnancy and poor reproductive

outcomes among adolescents in developing countries and recommendations for action.⁴⁷

DOMAIN ACTION RECOMMENDATIONS

Preventing early marriage Effective legal prohibition Keep girls in school

Engage community leaders to change norms

Preventing early pregnancy Engage community leaders to put forth efforts in preventing early pregnancy in culturally acceptable ways

Sexuality education at school Provision of contraceptives

Increasing contraceptive use Enable legal and community support for contraceptive provision

Adolescent-friendly contraceptive services Reduce financial barriers to contraception Education on sexuality and contraceptive use Reducing coerced sex Enforce laws to punish perpetrators of coerced sex

Promote community norms not to tolerate coerced sex Engage men to reconsider gender norms

Empower girls to resist unwanted sex by building their self- esteem, life skills and social networks

Reducing unsafe abortion Provide access to safe abortion where legal

Enable access to post-abortion care and contraceptive services

Improve family and community support for access Education on the dangers of unsafe abortion Increasing the use of skilled

antenatal, childbirth and postpartum care

Enable access to skilled antenatal, childbirth and postpartum care

Education on birth and emergency preparedness Education on the risks of abandoning skilled care

Although the majority of teenage pregnancies and related concerns occurs in developing countries, many teenagers in high-income areas also face barriers to high- quality sexuality education and effective contraceptives. Further, sexuality education and access to contraception varies between countries and even within a country. For example, in many Catholic countries, contraception is not accepted, whereas in some countries, contraceptives are provided free of charge. Thus, cultural norms and aspects strongly affect girls’ sexual rights, and this should be recognised when analysing teenage pregnancy and contraception in different areas.

The data of the present research have been obtained from Finland, which has high- quality and comprehensive health services. Thus, the main focus of this thesis lies in teenage pregnancies and contraceptive services in developed countries.

(20)

2.3 INCIDENCE

Data on teenage pregnancy rates, including both childbirths and induced abortions, are incomplete in many countries.⁵⁰ This is partly due to a lack of reliable data on teenage induced abortions.^50,51 Furthermore, the number of induced abortions in countries with incomplete data is often underestimated, and age-specific rates of induced abortions are usually not available in countries with restrictive abortion laws.^50,52

The highest rates of teenage childbirths take place in developing countries, especially in Sub-Saharan Africa.^50,53 Conversely, the incidence of teenage pregnancy is among the lowest worldwide in the Nordic countries (8.0–11.1 induced abortions and 2.5–5.3 childbirths per 1000 girls aged 15 to 19 years in 2018), including Finland (6.5 induced abortions and 4.1 childbirths per 1000 girls aged 15 to 19 years in 2019).^54–57 Majority of the teenage childbirths in Finland occur among girls aged 18 to 19 years of age (Figure 7). Figure 2 shows the average incidence of childbirths for 15- to 19-year-old girls globally between 2015 and 2020 published by the UN.⁵⁸ Figure 3 shows the teenage childbirth and induced abortion rates in the Nordic countries from 1974 to 2019 and Figure 4 the childbirth and induced abortions rates among girls aged 13 to 17 years in Finland from 1990 to 2020.^57,59

(21)

21

Figure 2Adolescent birth rates globally between 2015 and 2020.58

(22)

Figure 3 Teenage induced abortions and live births in the Nordic countries.⁵⁷ 1974 1980 1985 1990 1995 2000 2005 2010 2015 2019 0

20 40 60 80

Year

Teenage induced abortions, n / 1000 15 to 19 year-olds

Finland Denmark

Iceland Norway Sweden Teenage induced abortions in the Nordic countries, n / 1000 15 to 19 year-olds

1974 1980 1985 1990 1995 2000 2005 2010 2015 2019 0

20 40 60 80

Year

Teenage live births in the Nordic countries, n / 1000 15 to 19 year-olds

Denmark Finland Iceland Norway Sweden

Teenage live births, n / 1000 15 to 19 year-olds

(23)

Figure 4 Induced abortions and childbirths among 13- to 17-year-old girls in Finland.⁵⁹

In Europe, the highest rates of teenage pregnancy have been reported in eastern parts of the continent.⁵⁰ Further, teenage pregnancy rates in England and Wales used to be at relatively high levels, but the incidence has decreased during recent years, being 32.1 conceptions per 1000 girls aged 15 to 19 years in 2018.⁶⁰ The most recent rates of both teenage induced abortions and childbirths are not available from England and Wales but 48% of the conceptions in this age group resulted in induced abortion in 2018.⁶⁰

According to the latest figures, teenage pregnancy rates have decreased steadily in the United States (US), being 16.6 childbirths per 1000 girls aged 15 to 19 years old in 2019 and 5.8 induced abortions in 2018. However, there is a large variation between the individual states.^12,61–63

The declining rates of teenage pregnancy in developed countries have been linked to an increasing availability and use of contraceptives.^56,64–66 Furthermore, high-quality sexuality education provided at schools reflects the downward trend in teenage pregnancy rates.^48,67–69 On the contrary, restrictive abortion laws do not reduce the number of abortions.⁷⁰

2.4 LEGALITY OF INDUCED ABORTION

Globally, abortion legislation varies from illegal on all grounds to freely available in early pregnancy. The laws differ greatly between developed and developing regions.^52,71 Overall, 59% of women of reproductive age live in regions with laws allowing induced abortion on request or on broad social grounds including most countries in Europe, Canada, the US and the Russian Federation.⁷¹ In Asia, the majority of women live under liberal abortion laws

1990 1995 2000 2005 2010 2015 2020

0 2 4 6 8 10

Year

Pregnancy rates, n/1000 aged 13-17 year-olds

Induced abortions Childbirths

(24)

since abortion is broadly legal in China and India, which are the most populous countries of the region.⁷¹ On the contrary, globally 27% of women live in countries where induced abortion is prohibited altogether or permitted only to save the woman’s life. These include most countries in Africa and South America as well as several countries in Asia, such as Iraq, Laos and the Philippines.⁷¹ However, restricting access to abortion does not prevent women from seeking it but rather increases the number of unsafe procedures.^52,72

Based on WHO’s definition, the safety of abortion can be classified into three categories: safe, less safe and least safe, of which the latter two together make up all unsafe abortions.^73,74 It is estimated that 45% of all induced abortions worldwide are unsafe and that 97% of these take place in developing countries.⁷² Further, in countries with highly restrictive abortion laws, only 25% of induced abortions are safe, whereas 87% of abortions are safe in countries where abortion is available on request.⁷²

When considering teenagers, cost and concern over privacy are the major barriers to seeking abortion even in countries with liberal abortion laws and safe abortion services.^52,75 Additionally, some countries require parental consent for adolescents seeking induced abortion.⁵² This leads to an increased risk of late abortions with higher risks for complications. Further, teenagers typically seek post-abortion care later than older women, which may lead to long-term health concerns.⁷⁵

2.4.1 ABORTION LEGISLATION IN FINLAND

In Finland, induced abortion for social reasons became legal in 1970 but the legislation has not changed remarkably since then. The act on termination of pregnancy allows an induced abortion for social reasons, including age < 17 or

40 years and 4 deliveries, up to 12th gestational weeks with referral of one or two physicians. At 20 gestational weeks, an induced abortion for social reasons can be performed with the consent of the National Supervisory Authority for Welfare and Health (Valvira). In addition, an induced abortion is allowed at 24 gestational weeks due to foetal defect and with no gestational limitation if the pregnancy is a risk to the woman’s health or life. Parents’

permission is not required for minors.⁷⁶

2.5 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

(25)

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

(26)

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

(27)

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.

2.6 CONTRACEPTION SERVICES FOR TEENAGERS

Although increased use of contraception has been found to be associated with reduced rates of teenage pregnancy, improved contraceptive methods alone do not lead to a decrease in teenage pregnancies. Sexual health for teenagers can be improved by combining adequate contraceptive methods with the following components:

1. sexuality education 2. proper counselling

3. youth-friendly contraceptive services^107–109

2.6.1 UNIQUE NEEDS

When organising sexuality education, counselling and contraceptive services, the unique needs of adolescents must be considered. Knowledge of the different developmental phases of adolescence aids in understanding the importance of the related unique needs.¹⁰⁹

Pubertal maturation typically begins at the age range of 9 years to 12 years by increasing the secretion of adrenal androgens, gonadal steroids and growth hormones. These hormonal changes not only cause physical changes but also

(28)

changes in behaviour and emotions.^9,10 In addition, the remodelling of the dopaminergic system in the brain increases reward-seeking and risk-taking behaviours during puberty. Risk-taking declines in the late adolescent years, when the capacity for self-regulation improves. These changes increase the vulnerability to reckless behaviour, including risky sexual behaviour, in the teenage years.⁸⁹

Early sexual activity is more common when physical development starts early, but the regulation of emotions and cognitive thinking remains immature. Sexual decision-making and pregnancy prevention at this time are particularly challenging.¹⁰⁹

Sexual debut occurs in the middle adolescence, that is, teens aged 15 years to 17 years.¹⁰⁹ A Finnish study, published in 2015, examined risk factors in relation to young women’s sexual behavior.¹¹⁰ It was based on a questionnaire and part of the HPV (human papilloma virus)-study. The female participants (n = 3558) were 22 years old when the questionnaire was completed. The median age for sexual debut was 16 years. Early sexual debut was associated with non-use of contraception still at the age of 22: 23% of women with early sexual debut (under 14 years of age) did not use contraception in their last intercourse compared with 11% of women with sexual debut at 17 years or older.

According to the School Health Promotion Study of Finland in 2019, 40%

to 55% of teenagers have had sexual intercourse by 18 years of age depending on whether they studied at upper secondary school or at vocational school (Figure 5). The School Health Promotion Study surveys the health and school work of Finnish pupils and students. The anonymous and voluntary classroom-administered questionnaire has been carried out every other year in all schools in Finland since 1996. Some questions in the questionnaire have changed over time, but the question about age at first sexual intercourse has been asked in comprehensive schools and upper secondary schools since 1996 and in vocational schools since 2008.¹¹¹ The responses show that the number of teenagers having had sexual intercourse by 15 or by 18 years of age has slightly decreased from 2000 to 2019 (Figure 5).¹¹² In other Western countries, the age of sexual debut is rather similar.¹⁰⁷

(29)

Figure 5 Experience of sexual intercourse among teenagers in Finland.¹¹²

During middle adolescence, the ability to plan in advance and consider the future consequences of current decisions is only beginning to develop.^9,109 Thus, contraceptive adherence is challenging, and concrete information and support in using contraception during this time is needed.¹⁰⁹

Late adolescents and young adults can realise the long-term implications of their actions but still remain more impulsive than adults and face a significant risk of unintended pregnancy.¹⁰⁹ Although the physiological and psychosocial developments in adolescence are driven by biological changes, the developmental transition to adulthood, especially in late adolescence, is partly culturally defined. For example, practicing to achieve a long-term goal requires motivation and a desire to survive through difficulties, and these motivations are shaped by social experiences.⁹

Based on the developmental phases of childhood and adolescence, the WHO published ‘Standards for sexuality education in Europe’ in 2008.¹¹³ It was developed as a response to the need for sexuality education standards in Europe. In the document, sexuality education is considered in a broad and holistic way, which includes more than just prevention of STIs and unwanted pregnancies. In addition to the physical and emotional aspects of sexuality,

2000 2005 2010 2015 2020

0 20 40 60 80

Year

Percentage of students having had a sexual intercourse

Experience of sexual intercourse, as % of students in 8th and 9th grade of comprehensive school (15 to 16 year-olds)

Experience of sexual intercourse, as % of students in 1st and 2nd year of vocational school (17 to 18 year-olds). Data available from 2008.

Experience of sexual intercourse, as % of students in 1st and 2nd year of upper secondary school (17 to 18 year-olds)

Experience of sexual intercourse at different learning institutions in Finland from 2000 to 2019

(30)

this broad definition of sexuality education refers to feelings of safety and security, for example. Thus, starting sexuality education already before the age of four is understandable. It should be age- or development-appropriate and should never be scary or judgmental. The document divides childhood and adolescence into different age groups according to what should be taught at a certain age. These age groups are based on developmental phases, as discussed earlier. Additionally, ‘Standards for sexuality education in Europe’ introduces the seven characteristics of delivering sexuality education. It provides good information and support when starting sexuality education or broadening existing programmes.

2.6.2 CONTRACEPTIVE USE AMONG TEENAGERS

According to data from the UN, the use of contraceptives among married women or women in a union aged 15 to 49 years has increased from 1990 to 2019 worldwide.¹¹⁴ Based on these data, Kantorovà et al. published regional and global estimates and predictions for contraceptive use among teenagers aged 15 to 19 years in the period from 1990 to 2030. They showed that contraceptive use also increased among teenagers from 1990 to 2019 worldwide, especially among married girls.¹¹⁵

There is a large variation in contraceptive use between married and unmarried girls. However, it is important to consider that unmarried teenagers may under-report their contraceptive use. This probably derives from the fear of getting stigmatised due to their sexual behaviour.¹¹⁵ Figure 6 presents the percentage of all teenage girls and married girls or girls in a union using modern contraceptive methods in 2019 in different areas of the world.

(31)

Figure 6 Median percentage of all girls and married girls or girls in a union, aged 15 to 19 years, using modern contraceptive methods by region in 2019.¹¹⁵Data on

unmarried girls are not available for Western Asia and Northern Africa, and Central Asia and Southern Asia.

In the Nordic countries in 2015, the hormonal contraceptive use among teenagers aged 13 to 19 years was rather high, specifically, approximately 40%

in Sweden and Norway, and 50% in Denmark.⁶⁴ The data are based on registers of redeemed prescriptions in each country. There are not estimations of contraceptive use among teenagers in Finland and Iceland since personal identification data are not recorded for non-reimbursable contraceptive sales in these countries.

According to the School Health Promotion Study of Finland in 2019, 17%

of students in 8^th or 9^th grades of comprehensive school (15- to 16-year-olds) did not use contraception the last time they had sexual intercourse.

Respectively, 7% of students in the 1^st and 2^nd grades of upper secondary school (17- to 18-year-olds) and 11% of students in the 1^st and 2^nd grades of vocational school (17- to 18-year-olds) reported not having used any contraception the last time they had sexual intercourse.¹¹⁶

0 10 20 30 40 50 60 70

All girls Married girls Unmarried girls

(32)

2.6.3 CONTRACEPTIVE METHODS FOR TEENAGERS

The Finnish evidence-based clinical practice guideline, “Käypä hoito”, as well as WHO and the Faculty of Sexual and Reproductive Healthcare (FSRH), indicates that age alone is not a contraindication to any contraceptive method.^117–119 Thus, all reversible contraceptive methods are suitable for teenagers.^118–121 WHO, the Centers for Disease Control and Prevention (CDC) and FSRH provide guidance for safe contraceptive use in women with certain medical conditions.118,122,123 These guidelines are presented in the form of Medical Eligibility Criteria (MEC), where potential contraindications are classified from categories 1 to 4, the latter indicating absolute contraindication. Additionally, WHO and the CDC have published Selective Practice Recommendations for Contraceptive Use that recommend which exams to perform prior to starting contraception for a patient.^120,124 A medical history should be taken to find out possible contraindications for certain contraceptive methods (e.g. smoking and migraines). Blood pressure and body mass index (BMI) should be measured before providing combined hormonal contraceptives (CHC). A pelvic examination is not necessary except when inserting an IUD or when the patient has symptoms. Pap smears and bloodwork are not recommended routinely. Tests for sexually transmitted infections (STIs) should be performed when needed.107,118,121

Effectiveness is one of the most important characteristics of the contraceptive method.^121,125 WHO has developed a tiered system to describe different contraceptive methods according to the effectiveness of the methods, where tier 1 refers to a more effective method and tier 3 to a less effective method.¹²⁶ Besides contraception, contraceptives also have non-contraceptive benefits that should be considered when providing contraception for a patient.

Table 2 presents the different reversible contraceptive methods according to the tiered effectiveness system, and the non-contraceptive benefits of each method.

(33)

Table 2 Reversible contraceptive methods according to effectiveness and their non- contraceptive benefits.¹²⁶

Effectiveness Contraceptive method Non-contraceptive benefits107,109,121

Tier 1 (do not depend on the user)

LARC:

Hormonal IUD Copper IUD Implant

Possible reduction in menstrual bleeding (hormonal IUD and implant)

Tier 2 (depend on consistent use)

Short-acting reversible contraceptives (SARC):

CHC (pills, patch, vaginal ring)

Progestin-only pills

Possible reduction in menstrual bleeding, improvement in cycle regulation and acne (CHC)

Tier 3 (depend on user during sexual activity or immediately after)

Condom, spermicide, natural family planning, emergency contraception (EC)

Prevents STIs (condom)

Given that the contraceptive efficacy of LARC methods is excellent, they are highly recommended for teenagers.¹⁰⁶ LNG-IUDs also significantly reduce the amount of menstrual bleeding although spotting during the first months of use is typical.¹²⁷ Other side effects for LNG-IUDs are increased risk for acne and benign ovarian cysts but these hormonal side effects typically settle over time.¹²⁸ Cu-IUD does not have hormonal side effects, but it typically increases menstrual bleeding.^129,130

The continuation rate of LARC methods among teenagers has been shown to be high in several studies. A systematic review published in 2017 summarised the 12-month continuation rate to be 74% for IUDs and 84% for implants among individuals under 25 years of age.¹³¹ A Finnish study, published in 2020, examined the 2-year discontinuation rates of LARC methods in Vantaa when offered free of charge for first-time users.¹³² The results showed that among women aged 15 to 19 years, the proportion discontinuing the use of LNG-IUD was 25% after 1 year of insertion and 33%

after 2 years of insertion. The discontinuation proportions for implant in the same age group were 18% and 36%. In addition to high continuation rates, LARC methods do not require daily or weekly remembering. Thus, many international societies, such as the American College of Obstetrics and Gynecology (ACOG), American Academy of Pediatrics (AAP), European Board and College of Obstetrics and Gynaecology (EBCOG) and FSRH recommend LARC methods as first-line contraception for adolescents.119,133134,135

Although LARC methods are widely recommended as the first-line option for adolescents, oral contraceptive (OC) pills continue to be the most popular hormonal contraceptives among adolescents.¹²¹ Since all SARC methods

(34)

depend on consistent use, teenagers should be encouraged to use methods that increase adherence, such as technology reminders or regular schedule.^121,136

Regardless of the chosen contraceptive method, teenagers should be encouraged for dual method use, that is, using condom in addition to the more effective method. Double contraception combining LARC methods and condoms to better reduce both the risk for unintended pregnancy and STIs would be the best option for teenagers not in a stable relationship.^107,121

Teenagers should also be aware of EC and how to use it. There are three methods of EC available in most countries: copper IUD, oral levonorgestrel and oral ulipristal acetate.¹³⁷ Further, low-dose mifepristone as EC is available in Russia, China and Vietnam.¹³⁸ Cu-IUD is the most effective method of EC, and it can be inserted five days after sexual intercourse.¹³⁹ Of the two available pills used as EC, ulipristal acetate is more effective than levonorgestrel.^140,141 The main mechanism of action for both ulipristal acetate and levonorgestrel involves delaying or inhibiting ovulation. Ulipristal acetate appears to be effective also shortly before ovulation when levonorgestrel is no longer effective.¹⁴² In addition to these methods, LNG-IUD as EC has recently been shown to be non-inferior to Cu-IUD. However, only Cu-IUD is the only IUD approved for EC.^143,144

2.6.4 SEXUALITY EDUCATION

Declining teenage pregnancy rates have been linked to an increased use of contraception.^64,66,105 In addition, teenagers must have proper knowledge of sexuality, reproduction and different contraceptive methods to achieve successful contraceptive use. Providing comprehensive sexuality education increases teenagers’ contraceptive use^67,68, although the direct impact of sexuality education on teenage pregnancies is difficult to investigate.¹⁴⁵ However, in Finland, the high-quality mandatory sexuality education provided at all schools properly reflects the declining trend in teenage pregnancies.^69,146,147 Especially induced abortion rates among teenagers started to increase in the 1990s, after a fairly steep decline from 1980s (Figure 2). Meanwhile, the use of OCs increased only minimally in the 1990s, whereas it apparently increased in the 1980s. Additionally, the use of OCs among teenagers even decreased in the capital area since 1993 although adolescent sexual activity increased especially at the end of the 1990s.^148,149 The increase in teenage abortion rates and the stable OC use in the 1990s may partially be due to the varying quantities and qualities of sexual education in schools.

Health education was not a compulsory subject at that time, and local authorities were able to decide their school curricula more freely starting in the mid-1990s.¹⁴⁸ However, the basic education act 453/2001 was enacted in June 2001 and legislated health education as a compulsory subject in comprehensive schools to be started in each municipality not later than 2004.

Thereafter, both teenage childbirths and induced abortions started to decrease again (Figure 2).^69,146,147

(35)

2.6.5 PROPER COUNSELLING

Although sexuality education improves teenagers’ contraceptive use, individual counselling by educated health care providers is essential so that each teenager can find the most suitable contraception for their needs. In Finland and most parts of Europe, sexuality education is integrated as a compulsory subject in the school curriculum, providing a good base of knowledge in reproductive health and contraception for teenagers, as discussed earlier. By contrast, in the US, the availability and quality of sexuality education for teenagers differ between states, highlighting the importance of individual counselling. Thus, ACOG has published a recommendation on counselling about contraception for adolescents.¹⁵⁰

Effective counselling techniques, including concepts such as the ‘5 Ps’¹⁵¹ (Table 3) and GATHER¹⁵² (Table 4), and motivational interviewing can be useful to structure the counselling and to explore possible ambivalence towards contraception.136,150–152

Table 3 Sexual history questions to ask patients (the ´5 Ps´).

1. PARTNERS Sexual activity at the moment

How many partners the teenager has had Gender of the partners

2. PRACTICES Type of sexual contact to estimate the risk for STIs

3. PROTECTION FROM STIs Use of STI protection

4. PAST HISTORY OF STIs Has the teenager or the current partner been diagnosed with STI

5. PREVENTION OF PREGNANCY Use of contraception

Concern or desire of getting pregnant Need for information on birth control

Table 4 The GATHER approach to counselling about contraception.

GREET Greet her

ASK Ask about her life

TELL Tell her about contraceptive methods

HELP Help her to make the decision about the most suitable contraceptive method

EXPLAIN Explain about the chosen contraceptive method in detail RETURN Return for advice or more information is encouraged

Childbirth and induced abortion as a teenager : Associations with contraceptive services and long-term health outcomes