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Topic:
pregnancy in adolescence
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Pregnancy in Adolescence
The birth rate for teenagers 15–19 years is rising for the first time since 1991. The adolescent birth
rate had been dropping steadily since a high of 61.8 births per 1,000 in 1991 to a low of 40.5 births
per 1,000 in 2005. But between 2005 and 2006 there was a 3% increase in births to adolescents.
According to data from the National Vital Statistics Reports, 435,427 births occurred to mothers
aged 15–19 in 2006, correlating to a birth rate of 41.9 live births per 1,000 women in this age
group.1 Thus, adolescent pregnancy continues to have major medical, social, and economic
impact in the United States, with an adolescent birth rate ranking the highest of developed
countries.2 Overall, 47.8% of high school students reported having ever engaged in sexual
intercourse, with 7.1% stating that their age at first intercourse occurred before the age of 13,
according to 2007 data from the CDC.3

Recent research has shown that adolescent pregnancy is not simply the result of a girl's failure to
obtain and use contraception, but is instead inexorably linked to many social, cultural, educational,
and economic factors influencing adolescent risk-taking behaviors. The negative medical and social
consequences of adolescent pregnancy are considerable, and programs to reduce the incidence
and ramifications of adolescent pregnancy must be multidimensional in their approach to
adolescent pregnancy prevention.

REASONS ADOLESCENTS BECOME PREGNANT

It is well-documented that there are many negative consequences of adolescent childbearing,

including lower educational attainment, poverty, limited career opportunities, lack of access to
prenatal care, low birth weight/preterm delivery, family conflict, and depression.13 For years it has
been assumed by the medical community that individual adolescents did not desire pregnancy, and
that it was accidental when it did occur. Based on these assumptions, prevention programs focused
efforts toward provision of contraception, anticipating that if adolescents did not desire pregnancy
they would be motivated to use contraception. Many of these programs have had minimal impact,
and this may be because at least some adolescents do not perceive pregnancy as an unwanted
situation. New research is showing that many teens have mixed feelings about the possibility of
pregnancy.14, 15One must assess adolescent perceptions about adolescent pregnancy with a
special focus on the role of ambivalence toward adolescent childbearing and the social factors
influencing adolescents' feelings and choices.
Some adolescents do not use contraception because they are not motivated to prevent pregnancy;
they either “want to become pregnant” or “do not care” if they become pregnant.13 Of pregnant
teens in a racially and ethnically diverse sample, 17.5% stated that they wanted to get pregnant.16 A
study of 584 girls in a urban high school in Los Angeles found that girls who perceived positive
consequences associated with adolescent pregnancy were more likely to be Latina, non-United
States natives, have low expected educational attainment, had low parental monitoring, had good
communication with parents, and wished to have many children.13

Other girls desire pregnancy or are ambivalent about pregnancy if they think their male partner
wants them to become pregnant.17 A study of 13–18 year olds in Minnesota documented the range
of positive, negative, and ambivalent feelings girls have toward pregnancy and showed that
perceived partner desire for pregnancy, limited future expectations, and lack of school engagement
were significantly associated with positive pregnancy feelings.17 Interestingly, those who most
wanted to avoid pregnancy were more likely to be using hormonal methods of birth control, and
those who wanted or were ambivalent about pregnancy were more likely to use condoms or no
method at all.

Parents have strong influence with regard to adolescent pregnancy. It is well-known that lack of
parental involvement and lack of parental monitoring of adolescent activities are risk factors for
adolescent pregnancy. A prospective study of minority adolescents showed that those who had low
parental monitoring were 2.5-times more likely to become pregnant and have a documented
pregnancy test at 6 month follow-up.18 Adolescents are less likely to initiate sexual activity and less
likely to become pregnant if they perceive that their mothers disapprove of them having sexual
intercourse, and if they were satisfied with their relationship with their mothers.19

Other factors contributing to adolescent pregnancy include developmentally normal factors such
as the inability to think abstractly and plan ahead, adolescent feelings of invulnerability, and societal
attitudes about sexuality that ascribe less blame to sexual activity when it occurs spontaneously
without planning than when contraception and sexual activity are planned.

GIRLS AT GREATEST RISK FOR PREGNANCY

Adolescents who are having unprotected sexual intercourse or who are not using effective
contraception are obviously at high risk for becoming pregnant. Much research and study has
focused on identifying biological, psychological, and social characteristics of girls who are most
likely to be at risk for adolescent pregnancy. Some of those risk factors and associations are listed
(Table 1).
Table 1. Maternal characteristics associated with inconsistent contraceptive use and conception
during adolescence16

Sociodemographic
Young age
Non-white race and Hispanic ethnicity
Poverty and socioeconomic deprivation
Not living with parents: living alone, with friends, with boyfriends, or relatives other than parents
Being married
Being parous
Psychosocial characteristics
Dropping out of school
Inadequate family support
Depression
Longstanding romantic relationship
Older boyfriend
Substance use

CONTRACEPTION
Although an increasing percentage of adolescents are using condoms, the use of oral contraceptive
pills is decreasing, thus placing many at higher risk for adolescent pregnancy. In a 2001 high school
survey of sexually active teenagers, 58% reported using a condom at last intercourse, an increase
from 46.2% in 1991; black adolescents were most likely to report condom use.

Birth control pill use is decreasing, with only 18.2% of students in traditional high schools (and only
14.1% of students in alternative high schools) reporting using birth control pills at last intercourse
in 2001, a decrease from 20.8% one decade earlier.5 Birth control pill use varied by race, and white
 students (23.4%) were significantly more likely than Hispanic (9.6%) and black (7.9%) students to
report birth control pill use.5 Figure 5 shows the trend of increasing oral contraceptive use and
decreasing condom use with advancing grade.5 It has been suggested, however, that the use of
longer-acting hormonal birth control methods are one reason that the adolescent pregnancy rates
in the United States are decreasing.25 Table 2 shows sexual habits among adolescents by gender
and race.

Fig. 5. Percent of sexually active students using

condoms or birth control pills by grade.

Table 2. Sexual Habits of Adolescents in 2001

Ever had sex (%) Condom Pill ≥4 partners (%) Sex before age 13
Black male 68.8 72.7 07.8 38.7 25.7
Black female 53.4 60.7 07.8 15.6 07.6
White male 45.1 63.8 19.3 12.8 06.2
White female 41.3 51.0 26.7 11.1 03.3
Hispanic male 53.0 59.1 08.7 20.6 11.4
Hispanic female 44.0 47.6 10.4 09.5 04.1

(Data from Grunbaum JA, Kann L, Kinchen SA, et al: Youth risk behavior surveillance—United
States, 2001. MMWR Surveill Summ 51(4):1–62, 2002.)

Unfortunately, adolescents delay seeking medical contraceptive services by approximately 17

months after the onset of sexual activity.26 Adolescent girls are fertile; 50% of adolescents become
pregnant within the first 6 months of sexual activity, well before the typical onset of medical
contraceptive use.27 Unfortunately, younger adolescents are less likely to use effective
contraception (hormonal methods) than older adolescents.

Compliance and correct daily use of medication is poor, even for adults with chronic and severe
medical conditions;28 adolescents are particularly at risk for poor compliance with oral
contraceptives. Typical failure rates of oral contraceptives among adolescents are between 9% and
18%.28Continuation rates for adolescents' oral contraceptive use at the end of a year are low; more
than one quarter of those who stop using the pills become pregnant in the next year. Logically, it is
somewhat surprising that so many adolescents stop using oral contraceptives, given their multiple
noncontraceptive benefits including decreased acne, predictable cycles, and less dysmenorrhea,
among others. We know that those sexually active girls who use effective contraception are
different from those who do not. They are typically older, are in more stable relationships, have
higher academic achievement, and higher educational goals than teens who do not use
contraception.11 These data suggest that for prevention programs to be successful, knowledge of
sexuality and contraception must be taught before the high school years. Teens must actively
desire to prevent conception, and positive alternatives to pregnancy need to be stressed to help
motivate adolescents to avoid pregnancy. Helping adolescents postpone sexual involvement until
they are developmentally capable of effectively using contraception will also result in lower
pregnancy rates.

New dosing regimens and contraceptive delivery systems have become available, which may have
a positive impact on compliance. The Quick Start method of beginning oral contraceptive pills has
been studied in adolescents and has shown that instructing adolescents to start their pill pack the
same day as their visit, regardless of where they are in the menstrual cycle, enhanced compliance
at 3 months compared with beginning the pills with the onset of the next menstrual period. 28 Long-
acting drug delivery systems include the levonorgestrel intrauterine contraceptive system (Mirena
IUS,) depot medroxyprogesterone acetate (Depo Provera) and Implanon, a 3 year progestin only
rod system. Other recent advances in contraceptive hormone delivery systems which appeal to
teens include birth control patches, and the vaginal ring. Patches may seem particularly appealing,
especially to young teens, and data may ultimately show enhanced compliance in adolescents.
Emergency contraception has become widely available, but its specific impact on adolescent
pregnancy rates is not well known.