Ellen Knox, Perinatal Institute May
The West Midlands has
the highest teenage pregnancy rate in the UK, which
in turn has the highest rate in Western Europe.
As a result the Social Exclusion Unit were asked
to develop a strategy to reduce teenage pregnancy
rates. They identified two main goals:
- To halve the rate of teenage conceptions
among the under 18s by 2010.
- To reduce the long term risk of social exclusion
by getting more teenage parents into education,
training or employment.
As health care professionals largely involved
with the care of teenagers who are already pregnant
we are still in a position to improve their care.
It is first important to review the evidence for
the risks they face.
Many adverse outcomes have been associated with
teenage pregnancy including: premature delivery (1,2),
small for gestational age infants (1),
low birthweight infants (1,3),
increased neonatal mortality (4),
and pregnancy induced hypertension (2,5).
However, the evidence for some is more robust than
for others. In addition, many studies do not adjust
for the confounding variables of socio-economic status
and adverse lifestyle factors that are more prevalent
in this group and can independently affect outcome
It is therefore not clear from the literature whether
teenagers are at increased risk of adverse outcome
because of biological immaturity, a combination of
gynaecological immaturity and the fact that they
may not have reached her growth potential and there
may be nutritional competition between fetus and
mother. Indeed prepregnancy weight and weight gain
during pregnancy appears to have more of an impact
on pregnancy outcome in the teenage than the adult
In an attempt to adjust for biological immaturity,
a cohort study in Sweden examined outcomes from women
having first live singleton births in the teenage
period and second consecutive births after age 20
At first birth the risk of prematurity increased
with decreasing maternal age. At second birth the
risk of prematurity decreased for all age groups
but the greatest reduction was amongst those who
had been <17 at first birth. As the investigators
had previously found teenage pregnancy to increase
the risk of adverse social situations, they concluded
that the reduced risk of premature delivery in the
second pregnancy was secondary to relative biological
However, a Scottish cohort study examined first
and second births within the teenage years adjusting
for smoking status and socio-economic deprivation
They found no increased risk of adverse outcome in
first pregnancies but an increase in prematurity
and stillbirth during second pregnancies. Although
this examined population first and second births
rather than consecutive births within the same woman,
the study concluded that background factors in the
first pregnancy were the cause of adverse outcome.
Conflicting results were found in a study in
Utah, which adjusted for marital status, educational
attainment and antenatal care provision (1).
They found increased risks of low birthweight, prematurity
and small for gestational age infants amongst teenage
mothers. However, after adjusting for smoking status
the only significant difference was an increased
risk of low birthweight amongst younger teenagers
Increased risks of neonatal and postneonatal
mortality have been described amongst teenage births
However this was almost entirely accounted for by
the high rates of prematurity within the group.
In conclusion, the literature is in general
agreement with an increased risk of premature birth,
especially amongst those in the very young (aged
13-16) age group (1,11).
This may represent the intrinsic risk of biological
immaturity although this has yet to be proven. Other
adverse outcomes may result partly from infant prematurity
or the background socio-economic risk factors. Regardless
of the effect of adjustment for background factors,
the fact remains they are more prevalent in teenage
This was highlighted in the last Confidential
Enquiry into Maternal Deaths 1997-99 (12).
There were 14 deaths of mothers aged< 18, 5 of
which were < 16. 13/14 were socially excluded,
50% had disclosed domestic violence (compared to
12% of the entire cohort of mothers who died) and
50% were poor attenders at antenatal clinic (compared
to 20% of the total cohort who were poor attenders
or booked late). In addition, 4 women were homeless
at the time of death despite the fact that 3 were <16
and under the care of social services at the time.
Other related risks
The prevalence of sexually transmitted diseases
is increasing and is a particular problem in the
teenage age group. The incidence of gonorrhoea increased
35% between 1997-99 in the United Kingdom and the
group in the female population most at risk were
aged 16-19 (13).
A recent study in the United States revealed 1 in
5 teenagers to have an undiagnosed STD (14).
In addition 1 in 8 teenagers attending a family planning
clinic in Nottingham had an STD.
"In a single act of unprotected intercourse
with an infected partner, a teenage girl has a
1% risk of contracting HIV, a 30% chance of contracting
genital herpes and a 50% chance of contracting
This must be accessible and the advice delivered
in an appropriate manner. Contrary to popular belief,
many teenagers do seek advice. In a recent case controlled
study, of 240 teenagers who conceived, 94% had consulted
a health care professional in the year prior to conceiving
71% had consulted specifically about contraception
and 50% had been prescribed the oral contraceptive
pill. Those who had conceived were far more likely
to have consulted than those (controls) who had not.
There is some evidence that teenage mothers
are more likely to suffer from postnatal depression
than older mothers (17).
In addition, one study reported a 37-54% reduction
in milk production 6 months after childbirth in adolescents
compared to older mothers (18).
There were some differences in breastfeeding behaviour
between the two groups which may have contributed
to the result, but it appears that teenagers may
need extra support with breastfeeding.
Whilst there is no evidence to date of medical
interventions that can specifically improve pregnancy
outcome, we must ensure that teenage mothers receive
supportive care and are directed towards the social
support they need. Smoking cessation should be targeted
and attendance at antenatal clinic encouraged. In
addition post natal contraception can help prevent
second teenage pregnancy and sexually transmitted
There are many initiatives already in the West
Midlands area addressing these issues. We await the
results of the research being conducted in Coventry
and Walsall examining the antenatal and postnatal
experiences of young women who became pregnant under
the age of twenty. This will be released shortly
and will provide a valuable insight into how services
can be improved.
In addition, the midwifery project, “Teenage
pregnancy-improving service delivery” aims to optimise
maternity and community links within the West Midlands.
This is a 12 month project run jointly by the West
Midlands Perinatal Institute (Cynthia Folarin, Public
Health Specialist) and the Regional Teenage Pregnancy
Coordinator (Alice Cruttwell). It aims to map the
current delivery of maternity care offered to pregnant
teenagers identifying any gaps that exist, increase
early entry into prenatal care, identify first point
of contact and identify the need for teenage pregnancy
specific maternity services. In addition it will
work towards the development of minimum standards
of practice and a resource pack for professionals.
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of young maternal age with adverse reproductive outcomes
NEJM 1995; 332: 1113, Abstract
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