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Teenage pregnancy is not a public health problem
- Debbie A Lawlor, Sarah Johns, Mary Shaw (5 September 2001)
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Focus On Identifying The Teenagers At Risk Of Adverse Pregnancy Outcomes
- Aubrey Cunnington (16 September 2001)
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Debbie A Lawlor, Lecturer in Epidemiology and Public Health Medicine Department of Social Medicine, University of Bristol, Sarah Johns, Mary Shaw
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Dear Editor We read Smith et al's paper (BMJ 1 September 2001) with interest and agree with their interpretation of their own and others' results that first teenage births are not associated with adverse outcomes and that studies that do report an association between teenage births and adverse outcomes are most likely the result of confounding factors. However, we disagree with their conclusion that the strength of the association between second teenage pregnancy and risk of preterm delivery and still birth, found in their study, indicates causation. The most likely explanation for this association is a combination of inadequate control for socio-economic position, which the authors concede, and differences in the interval between pregnancies among teenage compared to older mothers. Differences in pregnancy spacing cannot be rejected as an explanation, as the authors attempt, without assessing its impact within this study. Comparing the strength of their associations to those of one study of between pregnancy interval and adverse outcomes conducted in the US and using different confounding factors in the analysis is inadequate. Further, Smith et al. do not consider the possible impact of differences in antenatal and delivery care between pregnant teenagers and older women in any of their analyses. It is increasingly common for women to delay their first birth until they are in their 30s - indeed the mean age of first birth for married women in England and Wales was 29.3 in 1999. This is despite the increased risk of chromosomal abnormalities and complications of pregnancy in this age group. Furthermore, it is not often recognised that maternal mortality increases exponentially with mother's age [1]. Women having babies in their 30s and 40s are not labelled a 'public health problem', and neither are women who have problems conceiving, even though their babies have an increased risk of perinatal death [2]. Smith et al. refer to the age group 20-29 as 'older mothers', but limiting the upper age limit to 29 severely restricts their sample. More importantly we feel that health professionals should not accept without challenge the common perception that 'teenage pregnancy is an important public health problem' in the way that these authors do. There is no biological reason to suggest that having a baby before the age of 20 is associated with ill-health. Indeed, it has been proposed that the teenage maternal mortality rate for England and Wales is lower than the rate for mothers in their twenties [3]. This so called 'public health problem' is really a reflection of what is considered to be - in this time and place - socially, culturally and economically acceptable. The Social Exclusion Unit's report on teenage pregnancy set two main goals: Halving the conception rate of the under-18s and setting a firmly established downward trend in the rate for under-16s by 2010; Achieving a reduction in the risk of long-term social exclusion of teenage parents and their children. We would argue that the first of these is inappropriate, as women of any age should be given the right and support to chose when to have a baby. The second is clearly what a civilised society should be aiming to achieve, and yet most action is likely to be geared towards achieving the first goal. For example, a Primary Care Group in Bristol bid and was successful in receiving funds from the local health authority's 'Inequalities Budget' to undertake work towards achieving the first of these targets only [4]. Teenage pregnancy is not a public health problem - the accumulative effect of social and economic exclusion on the health of mothers and their babies, whatever their age, is. Dr Debbie A Lawlor
Sarah Johns
Dr Mary Shaw
References 1. Loudon, I. Death in Childbirth: an International Study of Maternal Care and Maternal Mortality 1800 - 1950. Oxford, Clarendon Press: 1992. 2. Draper, E.S, Kurinczuk, J.J, Abrams, K.R, and Clarke, M. Assessment of Separate Contributions to Perinatal Mortality of Infertility History and Treatment; a Case-Control Analysis. Lancet 1999;353:1746-1749 3. Makinson, C. The Health Consequences of Teenage Fertility. Family Planning Perspectives 1985;17:132-139. 4. Velleman G, Williams E. The role of the primary care group in promoting health. In Scriven A, Orme J (eds). Health promotion, professional perspectives. New York, Palgrave in association with The Open University: 2001:43-51. |
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Aubrey Cunnington, SHO Accident and Emergency King's College Hospital, London, UK
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Focus On Identifying Teenagers At Risk of Adverse Pregnancy Outcomes EDITOR-Smith and Pell are to be commended on producing a study filling an important gap in the literature on teenage pregnancy (1). Previous studies have not controlled for many of the important confounders, which both increase a teenage girl’s risk of becoming pregnant and increase the risk of an adverse outcome of pregnancy (2). This study shows that when these factors are controlled for, first pregnancies to teenagers are at no greater risk of adverse outcomes than adults. Unfortunately I feel that their report of increased risk of prematurity associated with second teenage birth is misleading. They state that their cross-sectional study removes the bias of the natural protection of a second birth on adverse outcomes. However they do not state that they have excluded individuals from being included in both the first and second pregnancy groups. They have taken a sample from a six- year period and so it is highly likely that some mothers have been sampled twice. There is no control for previous pre-term birth, one of the strongest risk factors for premature birth in a subsequent pregnancy (3). In addition 15-19 year olds having a second teenage pregnancy are highly likely to constitute a rather special group. Some will have had their first pregnancy at a very young age and may be victims of abuse or have behavioural or psychological problems. Their precise circumstances will not be well represented by the use of the Carstairs deprivation index. Household and personal deprivation are more important than postcode as predictors of the risk of a teenager becoming pregnant in areas of above average deprivation (4). In the light of these objections I am not convinced the reason for more second teenage births being premature is a purely biological one. However what remains incontrovertible is that, in absolute terms, second teenage births do remain high risk for adverse outcomes. The challenge set by politicians has been to cut teenage pregnancy rates (5) but it is more important to cut out the adverse effects of teenage pregnancy. To achieve this requires the identification of those most at risk of pregnancy or repeat pregnancy. The success of interventions should be judged by this standard rather than the reduction in numbers of pregnancies. Reaching the most disadvantaged who may have the worst outcomes will be a considerable challenge. Aubrey Cunnington 1. Smith GCS, Pell JP. Teenage pregnancy and risk of adverse perinatal outcomes associated with first and second births: population based retrospective cohort study. BMJ 2001: 323; 476-9. 2. Cunnington AJ. What’s so bad about teenage pregnancy? The Journal of Family Planning and Reproductive Healthcare 2001: 27 (1); 36-41. 3. Ancel P-Y, Saurel-Cubizolles M-J, Carlo Di Renzo G et al. Very and moderate pre-term births: are the risk factors different? Br J Obstet Gynaecol 1999: 106; 1162-70. 4. Sloggett A, Joshi H. Deprivation indicators as predictors of life events 1981-1992 based on the UK ONS longitudinal study. J Epidemiol Community Health 1998; 52 :228-33. 5. Aggleton P, Oliver C, Rivers K. Reducing the rate of teenage conceptions. The implications of research into young people, sex, sexuality and relationships. Health Education Authority 1998. |
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