The management of teenage pregnancyBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5887 (Published 15 October 2014) Cite this as: BMJ 2014;349:g5887
- Fergus P McCarthy, academic clinical lecturer12,
- Una O’Brien, clinical midwife specialist in teenage pregnancy3,
- Louise C Kenny, professor of obstetrics, consultant obstetrician and gynaecologist, and director1
- 1The Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork University Maternity Hospital, Wilton, Cork, Republic of Ireland
- 2Women’s Health Academic Centre, King’s Health Partners, St Thomas’ Hospital, London
- 3Parentcraft Department, Our Lady of Lourdes Hospital, Maternity Unit, Drogheda, Co Louth, Republic of Ireland
- Correspondence to: F P McCarthy
The United Kingdom continues to have one of the highest rates of teenage pregnancy among member countries of the Organisation for Economic Co-operations and Development
There should be a low threshold for suspicion of pregnancy in teenagers presenting to their general practitioner or emergency department
Teenagers should be engaged in an open, sensitive discussion about pregnancy options, ideally with the support of the family or partner
Early liaison with teenage multidisciplinary team ensures support and continuity of care, which helps to avoid repetition and stress for teenagers and their family
Teenage mothers are at increased risk of adverse pregnancy outcomes, the effects of which seem to be reduced by optimal antenatal care
Long acting reversible contraceptives are the preferred choice after birth to prevent rapid repeat pregnancy
Barrier contraception should be advocated in addition to long acting reversible contraceptive agents to reduce the risk of sexually transmitted infections
Teenage pregnancy refers to pregnancy in women usually within the ages of 13-19, which may be intended or unintended. It remains a major public health concern worldwide. The World Health Organization has estimated that every year approximately 16 million females aged 15-19 and around one million girls aged less than 15 give birth. Complications during pregnancy and childbirth are the second cause of death in 15-19 year old females globally. Furthermore, every year around three million girls undergo unsafe abortions. This review examines key issues related to the care of teenage mothers.
Sources and selection criteria
We searched Medline, Embase, CINAHL, the Cochrane Database of Systematic Reviews, recent conference proceedings, and Clinical Evidence online using the search terms “teenage pregnancy” and “adolescent pregnancy”. We focused on systematic reviews, meta-analyses, and high quality randomised controlled trials published within the past 15 years.
How common is teenage pregnancy?
The United Kingdom continues to have one of the highest rates of teenage pregnancy among member countries of the Organisation for Economic Co-operations and Development.1 This is despite recent decreases in both births and terminations in teenage mothers. Conception rates in women aged 15 to 17 in England in 2012 were 27.7 per 1000 compared with 47.1 per 1000 in 1998. In parallel, rates for termination of pregnancy have also decreased, from 19.8 per 1000 women aged less than 18 in 2007 to 11.7 per 1000 in 2013.2 Teenage pregnancy rates vary considerably worldwide, with the highest in African countries. According to statistics from the United Nations, numbers of births to women aged 15-19 in 2005-10 were as high as 207.1 per 1000 women in Niger and 171.1 per 1000 women in Angola. In developed countries such as South Korea, the Netherlands, and the United Kingdom, the number of births per 1000 women was 2.3, 5.1, and 29.6, respectively.3 4
Interventions to reduce the incidence of teenage pregnancy seem to have had some success, with rates at their lowest in the United Kingdom since records began. This may be, at least in part, a result of the national 10 year strategy adopted by the UK government after the publication of the teenage pregnancy report by the Social Exclusion Unit in 1999. The main aims of the 10 year strategy were to halve the rate of conceptions among under 18s, to set a firmly established downward trend in conception rates in under 16s, to reduce inequality in rates between the 20% of wards with the highest rate of teenage conception and the average wards by at least 25%, and by 2010 to increase to 60% the participation of teenage parents in education, training, and employment to reduce their risk of long term social exclusion.
Who is more likely to be a teenage mother?
The predisposing factors associated with teenage pregnancy are complex and largely of a socioeconomic nature. Latest figures from the UK Office for National Statistics for 2009-11 show that higher levels of conception rates in under 18s are associated with unemployment and child poverty.5 Women from social class V (unskilled) have approximately 10 times the risk of becoming teenage mothers than women from social class I (professional), consistent with the trend of the lower the deprivation rank, the higher the risk of teenage pregnancy. Other groups are also at increased risk. These include ethnic minorities, those living in deprived metropolitan areas (for example, in the United Kingdom the highest conception rates in under 18s were in Manchester and the London borough of Lambeth; ranked as the fourth and 29th most deprived, respectively, out of the 324 English authorities), underachievers in school, and young women with mental health problems.6 A cross sectional study of fertility rates among females aged 15 to 19 years in Ontario, Canada from 1999-2009 found an incidence of 1 in 25 births to women with major mental illness (defined as the presence of a psychotic, bipolar, or major depressive disorder in the five years preceding pregnancy).7
What are the medical considerations in teenage pregnancies?
Teenage pregnancy is associated with considerable socioeconomic deprivation and is associated with increased risks, both to the mother and to the fetus (figure⇓).8 Large retrospective cohort studies have found increased risks of preterm labour (adjusted odds ratio 2.5, 95% confidence interval 1.2 to 5.3), pre-eclampsia (3.7, 1.5 to 9.0), urinary tract infections (2.9, 1.8 to 4.8), eclampsia (3.2, 1.4 to 7.3), anaemia (1.8, 1.6 to 2.1), and complications from sexually transmitted diseases (cohort study demonstrating a prevalence of treatable sexually transmitted infections, including chlamydia, gonorrhoea, syphilis, and trichomonas of up to 39%) in teenage mothers.9 10 Fetal complications that occur more commonly in teenage pregnancies include lower birth weight (mean difference −24 g, 95% confidence interval −40 to −7), infection, growth restriction, and an increased risk of sudden infant death syndrome (odds ratio 1.32, 95% confidence interval 1.18 to 1.47 for under 15s).11 A case-control study in the north west of England found that teenage mothers were at increased risk of preterm birth compared with older mothers (odds ratio 1.21, 95% confidence interval 1.01 to 1.45). This risk was further increased in second time teenage pregnancies (1.93, 1.38 to 2.69).12 Large cohort studies have shown that smoking (36% v 7%) and drug and alcohol misuse (1.1% v 0.2%) are also more common in teenage mothers compared with pregnant women aged 20-35 years of age.9 13
Teenage pregnancy has further long term consequences for mothers and babies. Teenage mothers may have higher risks of negative mental health outcomes, with one prospective cohort study showing that more than half of teenage mothers experienced moderate to severe depression during the first postpartum year.14 None the less, the evidence from case-control and cohort studies is conflicting and further research is warranted.15 16 Teenage mothers are less likely to complete their education and are more likely to be unqualified, in receipt of welfare benefits, and not living independently.17 18 19 A population based cohort study found that independent of socioeconomic background, teenage mothers faced an increased risk of premature death later in life compared with older mothers (rate ratio 1.6, 95% confidence interval 1.4 to 1.9).20 Children of teenage mothers are also disadvantaged. They have a higher infant mortality (a risk of 1.6; 1.4 to 1.7 times greater for infants of mothers under 15 compared with mothers aged 18-19 years) and are less likely to be breast fed (40% v 62% in adult mothers),21 and daughters are more likely to become teenage mothers themselves.18 19 22 23 According to the Centre for Maternal and Child Enquiries perinatal mortality report 2009, the youngest (<20 years) mothers were 1.4 (95% confidence interval 1.2 to 1.6) times more likely to have a stillbirth and 1.2 (1.0 to 1.4) times more likely to have a neonatal death than mothers aged 25-29 years.24 However, the evidence regarding infant mortality is conflicting, with one recent multicentre cross sectional study not finding an increased risk of early neonatal death after adjustment for gestational age at delivery and birth weight.8 25 26 27
What are the social considerations of teenage pregnancy?
Teenage mothers may feel socially isolated by their pregnancy, with one cross sectional study showing approximately 40% of new teenage mothers feeling stigmatised by their pregnancy.28 Those more likely to suffer were unmarried mothers of white race or ethnicity, those with feelings of social isolation, those with aspirations to complete college, and those who were experiencing verbal abuse and family criticism. Studies have also shown an association between sexual abuse in childhood and teenage pregnancy.29 A systematic synthesis of research evidence to identify effective, appropriate, and promising approaches for prevention and support of pregnant teenagers concluded that daycare, education, and career development programmes were promising ways of supporting young parents. Offering holistic support programmes also seems to be appropriate but have not yet been shown to be effective.30
Can teenage pregnancy be prevented?
Teenage pregnancy can be prevented. A systematic review found a small but reliable evidence base that supports the effectiveness and appropriateness of early childhood interventions and youth development programmes for reducing unintended teenage pregnancy. These programmes included promotion of engagement with school through learning support, guidance, and social support; career development; and work experience. The review showed that teenage pregnancy rates were 39% lower among those receiving an intervention than among those receiving standard practice or no intervention (relative risk 0.61, 95% confidence interval 0.48 to 0.77).31 32 Furthermore, a Cochrane review including 41 randomised controlled trials and 95 662 teenagers concluded that a combination of educational and contraceptive interventions seem to reduce unintended pregnancy among teenagers (relative risk in trials of multiple interventions ranged from 0.49 to 0.72).33 These interventions were described as any activity designed to increase adolescents’ knowledge and attitudes about the risk of unintended pregnancies, promote delay in initiation of sexual intercourse, encourage consistent use of birth control methods, and reduce the number of unintended pregnancies.
Who is involved in caring for teenage mothers?
All healthcare professionals should be aware of the possibility of pregnancy in teenagers, and a low threshold for pregnancy testing in any healthcare setting is needed as teenagers may present with a variety of symptoms. These include amenorrhea, abdominal pain, nausea, vomiting, weight changes, urinary problems, irregular periods, or recurrent unexplained presentations to any health professional. A pregnancy test should be performed regardless of a history of sexual activity.34 35
Evidence guiding the management of pregnant teenagers is limited, with most studies focusing on risk factors and pregnancy outcomes. General practitioners have a key role to play in the early detection of teenage pregnancy and encouraging optimal antenatal care. The National Institute for Health and Care Excellence recommends that women under 20 should be offered a named midwife, who should take responsibility for and provide most of the mother’s antenatal care and provide a direct line telephone number.36 Multidisciplinary care is essential and ideally should include the clinical midwife specialist in teenage pregnancy, obstetricians with an interest in teenage pregnancy, and general practitioners. Depending on circumstances, other groups may also be involved in the care of teenage mothers. These include social workers, teenage parenting support groups, breastfeeding teenage groups, lactation consultants, public health nurses, community midwives, family, and foster carers. A randomised trial showed that a community based home visiting programme after birth improved adolescent mothers’ parenting attitudes and continuation at school but did not reduce their odds of repeat pregnancy or depression or achieve coordination with primary care.37
How should teenage mothers be cared for during pregnancy?
Multi-agency care is essential. A cross sectional analysis found that where optimal antenatal care is achieved, pregnancy outcomes seem to improve.38 Pregnancy counselling is essential and pregnant teenagers should be referred as soon as possible to a clinician or clinic where comprehensive pregnancy counselling is available. All options about continuing the pregnancy should be discussed and should include termination of pregnancy, parenthood, adoption, and fostering. These should be discussed in a clear, concise, non-judgmental manner, and it is critical that the teenagers are not excluded from these discussions.
Several key factors are important in the management of teenage pregnancy: diet, lifestyle, sexually transmitted infections, and the involvement of the family.
Emphasis must be placed on good nutrition, and the antenatal use of maternity vitamins should be advocated as teenagers often have poor diets and poor knowledge of appropriate nutrition.39 Non-randomised diet interventions for mothers (education and nutritional support, including dietary recommendations and food substitutions) have been associated with a reduction in the incidence of low birthweight babies among teenage mothers (from 11% to 3%).40 Folic acid should be initiated as soon as possible and pregnancy vitamin supplements recommended.
Avoidance of smoking, alcohol, and drugs
Approximately half of secondary school pupils aged between 11 and 15 have tried smoking, consumed alcohol, or taken drugs at least once in their lives, with 17% doing one or more of these recently.41 Pregnant teenagers should be educated about the risks of smoking, alcohol, and drugs in pregnancy.
Screening for sexually transmitted infections
Young people aged 15-24 years experience the highest rates of sexually transmitted infections, many of which may result in adverse pregnancy outcomes. Of all 16-19 year old women with a diagnosis of a sexually transmitted infection in 2009, at least 11% became re-infected within one year, emphasising the importance of education and barrier methods of contraception.42 This increased risk is probably a combination of unprotected intercourse, less interaction with health services, and multiple relationships. Relevant sexually transmitted infections include chlamydia, gonorrhoea, genital warts, trichomonas, and, more recently, HIV and syphilis. As a result, careful sensitive history taking is essential and appropriate screening and treatment if indicated. There is a lack of evidence to back clear recommendations on who should be screened and when; much depends on local guidelines and individual risk factors.
Cross sectional studies have shown that fathers’ positive involvement in their children’s early life is associated with a range of good outcomes for babies and children.43 Reported benefits of paternal involvement include improved cognitive development, mental health, education and behaviour at school, and peer relationships.44
What are the needs of teenage mothers in the postnatal period?
A key need in the postnatal period includes education to ensure that teenage mothers are competent in caring for their baby before discharge. The involvement of social workers is important to ensure that mothers are aware of financial and educational supports available. Midwifery support is key for practical things involved in caring for babies, and support for breast or bottle feeding. A randomised controlled trial found that postnatal home visiting services by nurse-midwives reduced adverse neonatal events and improved contraception outcomes but did not affect breast feeding or knowledge of and compliance with infant vaccination.45
Adequate contraception is essential for all teenage mothers. Approximately one quarter of teenage mothers have a second child within two years of the first birth.46 Rapid repeat pregnancy is associated with increased morbidity, with a large cohort study showing a twofold increase in adverse pregnancy outcomes, including severe prematurity (relative risk 2.5, 95% confidence interval 1.25 to 4.3) and stillbirth (2.6, 1.3 to 5.3).47 Factors associated with repeat pregnancy include low levels of educational attainment, lack of aspiration, low socioeconomic status, dislike of school, and poor family support. Most teenage mothers report an intention to avoid pregnancy in the near future. As a result, long acting reversible contraceptive agents are advocated as soon as possible after delivery in an effort to break the cycle of unplanned and unwanted pregnancies. These include the intrauterine coil or contraceptive implant, which significantly reduce the rate of rapid repeat pregnancy. Those not using long acting reversible contraceptive agents have up to a 35 times increased risk of rapid repeat pregnancy compared with those using such agents.48 As a result, long acting reversible contraceptive agents should be considered the preferred choice for teenagers seeking contraception.49 50 Barrier contraception should also be advocated to prevent the transmission of sexually transmitted infections.51
Questions for future research
What interventions should be aimed at targeting teenage mothers and ensuring optimal antenatal care and postnatal support?
Are different interventions needed to target specific at risk populations, such as ethnic minority groups that still have high rates of teenage pregnancy?
What interventions would further increase the use of contraception among teenagers?
Tips for non specialists
Have a low threshold for performing a pregnancy test in teenagers presenting to medical services, regardless of presenting symptoms and sexual history
Liaise with midwives and obstetricians with an interest in teenage pregnancy to provide multidisciplinary care and support
Recommend folic acid, pregnancy vitamin supplements, and advise on a healthy diet
Consider screening and treating sexually transmitted infections
Encourage pregnant teenagers to attend regular antenatal clinics specifically directed at teenage mothers, as good antenatal care improves outcomes
Ensure that teenage mothers are reviewed by practitioners as soon as possible after birth and discuss and recommend long acting contraception to avoid rapid repeat pregnancies
Consider contraception in the form of long acting contraceptives, such as intrauterine devices, intrauterine systems, and progestogen only injectable contraceptives or subdermal implants
A patient’s perspective
My name is Kelly. I struggled with postnatal depression and still am. I was 18 when I conceived my son James, and 16 when I had an abortion. So many changes are happening to your body as a teenager and a pregnancy adds a lot of different emotions to that.
On my second pregnancy, myself and John met Mary, the clinical midwife specialist in teenage pregnancy, on our first hospital appointment. She was so welcoming and didn’t judge me. It’s exactly what I needed, because my own mum was still in shock, she couldn’t be there as much as you would like. Who could blame her, her child was having a baby! My mum and dad separated when I was 14.
I had a traumatic labour, then a section. I couldn’t manage the breast feeding as James was in the special care baby unit, and it was hard to bond being apart. My aunt died two days after I gave birth to James, I was so lonely. I grew apart from John my boyfriend. He didn’t understand postnatal depression. I felt like I wasn’t coping as a mother, failing James. I missed my old life so much, my friends, my freedom, my auntie, so I ended up hiding in my room a lot. It was my safe place. I was put on medication, but I needed it.
I’m back with my friends, and have started laughing again. I love James, and his dad is good to him, even though we are not together as a couple. My advice to teenage mums is to go to your GP earlier than I did. He put me in the right direction. Tell someone sooner than I did. I’m lucky I had good support.
I struggled by myself too long, so I now talk at the teenage classes, to help those pregnant mums and dads to be, to understand postnatal depression.
Kelly, Leinster, Republic of Ireland
Additional educational resources
Resources for healthcare professionals
Family Planning Association (www.fpa.org.uk/factsheets/teenagers-sexual-health-behaviour)—Sexual health and behaviour factsheet for teenagers
Social Exclusion Unit (http://dera.ioe.ac.uk/15086/1/teenage-pregnancy.pdf)—Report on teenage pregnancy
Teenage parents: who cares? (http://education.gov.uk/publications/eorderingdownload/teenage%20parents.pdf)—A guide to commissioning and delivering maternity services for young parents
Teenage parents next steps: guidance for local authorities and primary care trusts (www.changeforchildren.co.uk/uploads/Teenage_Pregnancy_Next_Steps_For_LAs_And_PCTs.pdf)—A document that looks at how to improve outcomes for teenage parents
Pregnancy and complex social factors. A model for service provision for pregnant women with complex social factors. (Clinical guideline 110). 2010. (www.nice.org.uk/guidance/cg110/)—Information provided by the National Institute for Health and Care Excellence
Resources for teenagers and their families
NHS Choices. Teenage pregnancy support (www.nhs.uk/conditions/pregnancy-and-baby/pages/teenager-pregnant.aspx#close)—Information on the range of services to support teenage mothers
Care to learn (www.gov.uk/care-to-learn)—A scheme which provides financial aid to mothers under 20 to help with childcare costs while they study
Brook (www.brook.og.uk/index.php/find-a-centre)—Provides services, free and confidential sexual health advice, and contraception to young people under 25
The Young Woman’s Guide to Pregnancy (www.tommys.org/sslpage.aspx?pid=602&nccsm=21&__nccspID=873)—Written specifically for women under 20 and includes the experiences of young mums (available free to 16-19 year olds)
Apps (www.bestbeginnings.org.uk/baby-buddy-phone-app-parentstobe)—Example of an easy to use app available for download, with easily accessible information
Cite this as: BMJ 2014;349:g5887
Contributors: All authors planned and drafted the manuscript, revised the manuscript for critically important intellectual content, and gave final approval of the version to be published. FPMcC is the guarantor.
Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned; externally peer reviewed.