Breaking the repeat teen pregnancy cycle

Decision-making preferences and risk factors regarding early adolescent pregnancy in Ghana: stakeholders' and adolescents' perspectives from a vignette-based qualitative study

BACKGROUND

Worldwide, over half of the adolescent pregnancies recorded are unintended. The decision to continue the pregnancy to term or to opt for an abortion is a constant dilemma that is directly or indirectly influenced by stakeholders and also by the wider social environment. This study aimed at understanding the perceived decision-making preferences and determinants of early adolescent pregnancy in the Jamestown area of Accra in Ghana.

METHODS

A vignette-based qualitative study design was used. Eight focus group discussions were carried among various purposively selected groups of participants: parents, teachers, adolescent students who had not been pregnant before, and adolescents who had had at least one pregnancy in the past. The vignette was a hypothetical case of a 15-year-old high school student who had not experienced her menses for the past 6 weeks. The data were analyzed using a thematic analysis approach.

RESULTS

Lack of parent-daughter communication, the taboo on discussing sex-related issues in households and weak financial autonomy were considered to be the main contributing factors to the high early adolescent pregnancy rates in the community. Partner readiness to assume responsibility for the girl and the baby was a key consideration in either continuing the pregnancy to term or opting for an abortion. The father was overwhelmingly considered to be the one to take the final decision regarding the pregnancy outcome. Irrespective of the fact that the respondents were very religious, opting for an abortion was considered acceptable under special circumstances, especially if the pregnant adolescent was doing well in school.

CONCLUSION

Inadequate and inappropriate communication practices around sexuality issues, as well as weak financial autonomy are the major predictors of early adolescent pregnancy in this community. The father is perceived to be the main decision maker regarding a young adolescent's pregnancy outcome. Policy-makers should carefully evaluate the implications of this overwhelming perceived desire for the father to be the final decision-maker regarding adolescent pregnancy outcomes in this community.

Scoping review of risk factors of and interventions for adolescent repeat pregnancies: A public health perspective

BACKGROUND

Adolescent repeat pregnancy is of importance in public health because the birth of a second child to an adolescent mother compounds the adverse medical, educational, socioeconomic and parenting outcomes. Repeat pregnancy in adolescence is not only an international phenomenon but also a local concern as it also occurs in South Africa. The prevalence of adolescent repeat pregnancy in Durban, KwaZulu-Natal, was reported as 17.6% in 2013.

AIM

This review aimed to gather relevant information from national and international sources to inform practice and to provide an understanding of what is known about the risk factors of and the interventions for adolescent repeat pregnancy.

METHODS

A scoping review was undertaken using the Arksey and O'Malley framework. An electronic search was conducted using PubMed, Medline, Science Direct, Ebscohost, Sage and Wiley Online and Google Scholar.

RESULTS

The search identified 3032 citations. After a review of the full text articles, 26 articles met the inclusion criteria. Risk factors pertaining to adolescent repeat pregnancy are categorised according to individual factors, partner relationship factors, family factors, peer factors, and social and community factors. Interventions to reduce adolescent repeat pregnancy have been largely influenced by the ecological framework. Across studies, adolescent mothers who received medical, psychosocial, educational, and family planning support experienced lower rates of repeat pregnancy.

CONCLUSION

A single 'one-size-fits-all' intervention for adolescent repeat pregnancy prevention is unlikely as different strategies were employed by the intervention programmes in this scoping review.

The Role of Teen Mothers' Support Relationships in Maintenance of Contraceptive Use

STUDY OBJECTIVE

To explore interpersonal factors associated with maintaining contraceptive use over time among urban, African American teen mothers.

DESIGN

Longitudinal study, 2011-2015.

SETTING

Six pediatric primary care sites in the same city, all of which primarily serve urban, low-income, African American families.

PARTICIPANTS

Teen mothers accessing health services for their child at one of the six study sites.

INTERVENTIONS

The current study was a secondary data analysis of data that were collected as part of a patient-centered medical home model intervention, that compared a group of teen mothers and their children who were participants in the intervention with mother-child dyads who were enrolled in standard community-based pediatric primary care. Structured interviews were conducted with teen mothers at baseline/enrollment, when their children were, on average, 3 months old, and again 12 months later.

MAIN OUTCOME MEASURES

Maintenance of contraceptive use over time.

RESULTS

Teen mothers who perceived any tangible support from their own mothers were significantly less likely to maintain contraceptive use over time (adjusted odds ratio [AOR] = .27). However, teens who perceived any emotional support from their own mothers were nearly four times more likely to maintain contraceptive use (AOR = 3.74). Teens who lived with their own mothers were more than 5 times more likely to maintain contraceptive use over time (AOR = 5.49).

CONCLUSION

To better understand contraceptive discontinuation and thus to prevent repeat pregnancies among teen mothers, it might be necessary to further examine the role of support relationships in teen mothers' contraceptive decision-making. Secondary pregnancy prevention programs should include key support persons.

Intervention Now to Eliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT): a systematic review of intervention effectiveness and cost-effectiveness, and qualitative and realist synthesis of implementation factors and user engagement

BACKGROUND

The UK has one of the highest rates of teenage pregnancies in Western Europe. One-fifth of these are repeat pregnancies. Unintended conceptions can cause substantial emotional, psychological and educational harm to teenagers, often with enduring implications for life chances. Babies of teenage mothers have increased mortality and are at a significantly increased risk of poverty, educational underachievement and unemployment later in life, with associated costs to society. It is important to identify effective, cost-effective and acceptable interventions.

OBJECTIVES

To identify who is at the greatest risk of repeat unintended pregnancies; which interventions are effective and cost-effective; and what the barriers to and facilitators of the uptake of these interventions are.

DATA SOURCES

We conducted a multistreamed, mixed-methods systematic review informed by service user and provider consultation to examine worldwide peer-reviewed evidence and UK-generated grey literature to find and evaluate interventions to reduce repeat unintended teenage pregnancies. We searched the following electronic databases: MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the Health Technology Assessment Database), EMBASE (Excerpta Medica database), British Nursing Index, Educational Resources Information Center, Sociological Abstracts, Applied Social Sciences Index and Abstracts, BiblioMap (the Evidence for Policy and Practice Information and Co-ordinating Centre register of health promotion and public health research), Social Sciences Citation Index (supported by Web of Knowledge), Research Papers in Economics, EconLit (American Economic Association's electronic bibliography), OpenGrey, Scopus, Scirus, Social Care Online, National Research Register, National Institute for Health Research Clinical Research Network Portfolio and Index to THESES. Searches were conducted in May 2013 and updated in June 2014. In addition, we conducted a systematic search of Google (Google Inc., Mountain View, CA, USA) in January 2014. Database searches were guided by an advisory group of stakeholders.

REVIEW METHODS

To address the topic's complexities, we used a structured, innovative and iterative approach combining methods tailored to each evidence stream. Quantitative data (effectiveness, cost-effectiveness, risk factors and effect modifiers) were synthesised with reference to Cochrane guidelines for evaluating evidence on public health interventions. Qualitative evidence addressing facilitators of and barriers to the uptake of interventions, experience and acceptability of interventions was synthesised thematically. We applied the principles of realist synthesis to uncover theories and mechanisms underpinning interventions (what works, for whom and in what context). Finally, we conducted an overarching narrative of synthesis of evidence and gathered service user feedback.

RESULTS

We identified 8664 documents initially, and 816 in repeat searches. We filtered these to 12 randomised controlled trials (RCTs), four quasi-RCTs, 10 qualitative studies and 53 other quantitative studies published between 1996 and 2012. None of the RCTs was based in the UK. The RCTs evaluated an emergency contraception programme and psychosocial interventions. We found no evidence for effectiveness with regard to condom use, contraceptive use or rates of unprotected sex or use of birth control. Our primary outcome was repeat conception rate: the event rate was 132 of 308 (43%) in the intervention group versus 140 of 289 (48%) for the control goup, with a non-significant risk ratio (RR) of 0.92 [95% confidence interval (CI) 0.78 to 1.08]. Four studies reported subsequent birth rates: 29 of 237 (12%) events for the intervention arm versus 46 out of 224 (21%) for the control arm, with a RR of 0.60 (95% CI 0.39 to 0.93). Many repeat conceptions occurred in the context of poverty, low expectations and aspirations, and negligible opportunities. Service user feedback suggested that there were specific motivations for many repeat conceptions, for example to replace loss or to please a partner. Realist synthesis highlighted that context, motivation, planning for the future and letting young women take control with connectedness and tailoring provide a conceptual framework for future research.

LIMITATIONS

Included studies rarely characterised adolescent pregnancy as intended or unintended, that is interventions to reduce repeat conceptions rarely addressed whether or not pregnancies were intended. Furthermore, interventions were often not clearly defined, had multiple aims and did not indicate which elements were intended to address which aims. Nearly all of the studies were conducted in the USA and focused largely on African American or Hispanic and Latina American populations.

CONCLUSIONS

We found no evidence to indicate that existing interventions to reduce repeat teenage pregnancy were effective; however, subsequent births were reduced by home-based interventions. Qualitative and realist evidence helped to explain gaps in intervention design that should be addressed. More theory-based, rigorously evaluated programmes need to be developed to reduce repeat teenage pregnancy in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003168. Cochrane registration number: i=fertility/0068.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Role of Community Health Workers in Preventing Adolescent Repeat Pregnancies and Births

Intervention by community health workers (CHWs) is believed to prevent repeated childbearing among teenagers. This review investigated the effectiveness of CHWs in reducing repeated pregnancies and births among adolescents aged <20 years, 2 years after the delivery of their first child. Through electronic database and hand searching, experimental and/or observational studies were screened with their results undergoing systematic review and meta-analyses. Subgroup analyses were performed to further assess how study characteristics affected the pooled estimates and heterogeneity. A total of 11 eligible articles, from January 1980 to May 2015, were included. Seven studies evaluated repeated births and eight measured repeated pregnancies. Studies showed relevant disparities in terms of selected methodological aspects and program characteristics. Although most studies (n = 9) were either of "strong" or of "moderate" quality, only two of five finding a significant reduction exhibited a high level of quality as the other three failed to adjust results for confounders. Random effects modeling revealed an overall 30% decrease in repeated adolescent births (odds ratio = .70, confidence interval = .49-.99) among CHW-visited areas relative to nonvisited sites. On the other hand, no significant association was detected in terms of repeated pregnancies (odds ratio = .96, confidence interval = .70-1.28).