Too much too young? Teenage pregnancy is not a public health problem

Debbie A Lawlor and Mary Shaw

Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.

CAPULET
But saying o'er what I have said before:
My child is yet a stranger in the world;
She hath not seen the change of fourteen years,
Let two more summers wither in their pride,
Ere we may think her ripe to be a bride.

PARIS
Younger than she are happy mothers made.

CAPULET
And too soon marr'd are those so early made.

Romeo and Juliet Act I Scene II. William Shakespeare, (c. 1594)

Debates about the appropriate age at which a woman should become a mother are not new, but it is only in recent decades that, in Britain at least, teenage pregnancy has become labelled alongside cardiovascular disease, cancer and mental health as a major public health problem.1 In this paper we will argue that teenage pregnancy should not be conceptualized as a public health problem and suggest that this label is rather a reflection of what is considered to be—in this time and place—socially, culturally and economically acceptable.

The management of reproduction and childbirth has, in most countries and most cultures, been the province of women, but the rise of western biomedicine in the 18th century and its consolidation in the 19th led to the medicalization of pregnancy.2 This process was important not only in terms of shifting gender roles in medical care, but because it signalled a shift of power relations by which women's bodies and the reproductive process came to be seen as legitimate subjects for social control. This is exemplified in the development of public health policies during the 1990s, in Britain and the US, which have included teenage pregnancy as a national public health problem requiring targeted interventions.3ndash;6 The concern of both countries relates to their rates of teenage pregnancy being higher than those in other developed countries.5,6 However, the idea that teenage pregnancy constitutes a health problem is expressed in policy documents in many developed countries, regardless of whether they have a relatively high rate. For example, the Nordic Resolution on Adolescent Sexual Health Rights counts as a measure of public health success the fact that ‘the number of teenage pregnancies in Nordic countries are among the lowest in the world'.7

A crucial question relates to whether the adverse outcomes experienced by (some) mothers and children of teenage pregnancies are causally related to the age of the mother, or whether there are other factors which lead to the adverse outcomes experienced by teenage mothers and their children. Several studies have found that teenage pregnancy is associated with adverse outcomes for both mother and baby. These include low birthweight, prematurity, increased perinatal and infant mortality and poorer long-term cognitive development and educational achievement for both mother and child.8,9 However, studies which have aimed to address the underlying causes of these adverse outcomes—by controlling for additional factors—have produced conflicting results. Some suggest that adverse outcomes remain even after controlling for maternal socioeconomic position and other confounding factors,8 some find that age has no effect,10–12 whereas other studies report that once maternal socioeconomic position and smoking are taken into account young age is actually associated with better outcomes.13–16

These contradictory findings probably reflect the small size of some studies, residual confounding, and the difficulty of separating effects that may be related to maternal age from effects that are appropriately regarded as confounding. For example, poor parenting skills may reflect the ignorance of young age but may also occur at any age among women who have restricted access to information and education. Larger studies and those employing methods specifically designed to adequately control for confounding factors (for example using sibling comparisons)17 suggest that young age is not an important determinant of pregnancy outcome or of the future health of the mother.10,11 A recent systematic review of the medical consequences of teenage pregnancy concluded that ‘Critical appraisal suggested that increased risks of these outcomes [anaemia, pregnancy-induced hypertension, low birthweight, prematurity, intra-uterine growth retardation and neonatal mortality] were predominantly caused by the social, economic, and behavioural factors that predispose some young women to pregnancy.’18 Moreover, Cunnington asserts from this review that most teenage pregnancies are low risk—a point which is omitted from much research and from policy documents and statements.

In addition, and this is perhaps more the case than with other public health issues, it is problematic to transpose the findings of studies across different populations (or indeed different times). For example, black American teenage mothers are no less likely to breastfeed than are older mothers, whereas fewer white teenage mothers breastfeed;17 in one study low birthweight was found to be associated with teenage pregnancy amongst white but not black mothers.13 Good pregnancy outcomes have been found amongst teenage mothers (age 15–19 years) from an ultraorthodox Jewish community living in Jerusalem amongst whom marriage and pregnancy at a young age is encouraged and the women strongly supported within the community.19 Attitudes towards young mothers (and towards lone mothers, these groups often overlapping) shift in relation to prevailing moral values, and also to some extent reflect economic conditions.20,21 The experiences of teenage mothers may, to an extent, be a sign of the prevailing values of health care professionals and society more generally.22 Hence poor outcomes in one population, even with adequate control for confounding factors, may reflect the attitudes of that particular society towards teenage pregnancy and motherhood. It has been suggested that the findings of poor perinatal outcomes amongst teenage mothers in one study conducted in Utah, despite control for a range of socioeconomic factors,8 may be explained by the very low prevalence of teenage pregnancy in Utah: ‘Thus being a teenage mother in Utah is unusual, even under optimal circumstances.’23

It has been suggested that a large proportion of teenage pregnancies are unintended and that many may be the result of abuse.6 But surely unintended pregnancy or pregnancy that is the result of abuse is something that should concern health professionals regardless of the age of the mother? In the US it is estimated that one-third of all pregnancies that result in live births are unintended.24 This is clearly not something that affects only teenage mothers and whether ‘unintended’ pregnancy is detrimental to either baby or mother has not been established.

It is important to consider whether labelling teenage pregnancy as a public health problem affords any benefit to mothers or children. What public health impact would we achieve ‘... if we could successfully intervene and change a woman's age at first birth and nothing else about her up to that point‘?25

In the developed world it is increasingly common for women to delay their first birth until they are in their thirties—indeed the mean age of first birth for married women in England and Wales was 29.3 in 1999.26 Across Western Europe the age of first-time mothers is at an all time high, which demographers attribute to social and economic factors such as female and male wages and career planning on the part of women.27 This trend is despite the increased risk of chromosomal abnormalities and complications of pregnancy in the 30+ age group.28 Furthermore, it is not often recognized that maternal mortality increases exponentially with mother's age.29 Women having babies in their thirties and forties are not labelled a ‘public health problem’, and neither are women who receive (or more usually, can pay for) infertility treatment, even though their babies have an increased risk of perinatal death.30 The ‘risks’ that are seen as pertinent vary with the age of the mother—any health risks to older women may be disregarded by public policy makers as older mothers are more likely to be educated, economically self-reliant and from a higher socioeconomic class. Interestingly, it has been argued that for older women the poorer medical outcomes associated with older maternal age may be disregarded because of the better social outcomes for children of older women.31

There is no convincing evidence that teenage pregnancy is a public health problem and it is difficult to identify a biologically plausible reason for adverse outcomes of young maternal age, as Cunnington says: ‘It makes little biological sense for young women to be able to reproduce at an age that puts their children at risk.’18 For policy makers the labelling of teenage pregnancy as a public health problem reflects social, cultural and economic imperatives. Researchers and health practitioners should think more carefully about why something is labelled a public health problem, together with the social and moral context in which it occurs and in which they practice.

British Prime Minister Tony Blair's preface to the Social Exclusion Unit's report on teenage pregnancy5 indicates the strength of negative feelings:

While the rate of teenage pregnancies has remained high here, throughout most of the rest of Western Europe it fell rapidly. As a country, we can’t afford to continue to ignore this shameful record.

We do not agree that teenage pregnancy is shameful, nor dowe believe that teenage pregnancy is (or is best conceptualized as) a public health problem; however, we do believe that the accumulative effect of social and economic exclusion on the health of mothers and their babies, whatever their age, is.

References

1 Dickson R, Fullerton D, Eastwood A, Sheldon T, Sharp F. Preventing and reducing the adverse effects of unintended teenage pregnancy. Effective Health Care Bulletin 1997;3.

2 Oakley A. Doctor knows best. In: Black N, Boswell N, Gray A, Murphy S, Popay J (eds). Health & Disease—A Reader. Milton Keynes: Open University Press, 1984.

3 Alan Guttmacher Institute. 11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States. New York: Alan Guttmacher Institute, 1976.

4 Department of Health. The Health of the Nation: A Strategy for Health in England. London: The Stationery Office, 1992.

5 Social Exclusion Unit. Teenage Pregnancy. London: The Stationery Office, 1999.

6 Felice ME, Feinstein RA, Fisher MM et al. Adolescent pregnancy—current trends and issues: 1998 American Academy of Pediatrics Committee on Adolescence, 1998–1999. Pediatrics 1999;103:516–20.[Abstract/Free Full Text]

7 Foreningen Sex & Samfund. The Nordic Resolution on Adolescent's Sexual Health Rights. http://www.sexogsamfund.dk/. 1999. 27–9–2001. (Accessed 5 November 2001).

8 Fraser AM, Brockert JE, Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995;332:1113–17.[Abstract/Free Full Text]

9 Fergusson DM, Woodward LJ. Maternal age and educational and psychosocial outcomes in early adulthood. J Child Psychol Psychiatry 1999;40:479–89.[CrossRef][ISI][Medline]

10 Gueorguieva RV, Carter RL, Ariet M, Roth J, Mahan CS, Resnick MB. Effect of teenage pregnancy on educational disabilities in kindergarten. Am J Epidemiol 2001;154:212–20.[Abstract/Free Full Text]

11 Scholl TO, Hediger ML, Huang J, Johnson FE, Smith W, Ances IG. Young maternal age and parity. Influences on pregnancy outcome. Ann Epidemiol 1992;2:565–75.[Medline]

12 Lee MC, Suhng LA, Lu TH, Chou MC. Association of parental characteristics with adverse outcomes of adolescent pregnancy. Fam Pract 1998;15:336–42.[Abstract/Free Full Text]

13 Reichman NE, Pagnini DL. Maternal age and birth outcomes: data from New Jersey. Fam Plann Perspect 1997;29:268–72, 295.

14 Makinson C. The health consequences of teenage fertility. Fam Plann Perspect 1985;17:132–39.[ISI][Medline]

15 Geronimus AT. What teen mothers know. Human Nature 1996;7:323–52.[ISI]

16 Geronimus AT. The weathering hypothesis and the health of African-American women and infants: Evidence and speculations. Ethn Dis 1992;2:207–21.[Medline]

17 Geronimus AT, Korenman S. Maternal youth or family background? On the health disadvantages of infants with teenage mothers. Am J Epidemiol 1993;137:213–25.[Abstract]

18 Cunnington A. What's so bad about teenage pregnancy? The Journal of Family Planning and Reproductive Health Care 2001;27:36–41.

19 Gale R, Seidman DS, Dollberg S, Armon Y, Stevenson DK. Is teenage pregnancy a neonatal risk factor? J Adolesc Health Care 1989;10:404–08.[Medline]

20 Carabine J. Constituting sexuality through social policy: the case of lone motherhood 1834 and today. Social & Legal Studies 2001;10: 291–314.

21 Bullen E, Kenway J, Hay V. New Labour, social exclusion and educational risk management: the case of ‘gymslip’ mums. British Educational Research Journal 2000;26:441–56.[ISI]

22 Hanna B. Negotiating motherhood: the struggles of teenage mothers. Journal of Advanced Nursing 2001;34:456–64.[CrossRef][ISI][Medline]

23 Goldenberg RL, Klerman LV. Adolescent pregnancy—another look. N Engl J Med 1995;332:1161–62.[Free Full Text]

24 Orr ST, Miller CA, James SA, Babones S. Unintended pregnancy and preterm birth. Paediatr Perinat Epidemiol 2000;14:309–13.[CrossRef][ISI][Medline]

25 Hoffman SD. Teenage childbearing is not so bad after all ... or is it? A review of the new literature. Fam Plann Perspect 1998;30:236–39, 243.

26 Office for National Statistics. Birth Statistics 1999 England & Wales. FM1 No. 28. London: The Stationery Office, 2000.

27 Gustafsson S. Optimal age at motherhood. Theoretical and empirical considerations on postponement of maternity in Europe. Journal of Population Economics 2001;34:456–64.

28 Nybo Andersen AM, Wohlfahrt J, Christens P, Olsen J, Melbye M. Maternal age and fetal loss: population based register linkage study. BMJ 2000;320:1708–12.[Abstract/Free Full Text]

29 Loudon I. Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800–1950. Oxford: Clarendon Press, 1992.

30 Draper ES, Kurinczuk JJ, Abrams KR, Clarke M. Assessment of separate contributions to perinatal mortality of infertility history and treatment: a case-control analysis. Lancet 1999;353:1746–49.[CrossRef][ISI][Medline]

31 Stein Z, Susser M. The risks of having children in later life. Social advantage may make up for biological disadvantage. BMJ 2000;320: 1681–82.[Free Full Text]