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The Adolescent Girl
Sultan C (ed): Pediatric and Adolescent Gynecology. Evidence- Based Clinical Practice. 2nd, revised and extended
edition. Endocr Dev. Basel, Karger, 2012, vol 22, pp 302–331
Teenage Pregnancy
Ramiro Molina Cartes ⭈ Electra Gonzalez Araya
Centro de Medicina Reproductiva y Desarrollo Integral de la Adolescencia (CEMERA), Facultad de Medicina,
Universidad de Chile, Santiago, Chile
Abstract
Teen pregnancy is a social problem not resolved in developing and some developed countries.
Adolescent fecundity has become the most exact bio-demographic and health indicator of develop-
ment. In developing countries that are expected to follow the sexual behaviour patterns of devel-
oped countries, without offering the levels of education and services for adolescents, the
consequences will be adolescent fecundity and STI prevalence increase. The ignorance about sexu-
ality and reproduction both in parents, teachers and adolescents increases the early initiation of
coital relations and of unwanted pregnancies. Extreme poverty and being the son or daughter of an
adolescent mother are risk factors of repeating the early pregnancy model. The application of pre-
dictive risk criteria in pregnant adolescents to facilitate the rational use of Health Services to dimin-
ish the maternal and perinatal mortality is discussed as well as the social factors associated with
adolescent pregnancy as socioeconomic levels, structure – types and characteristics of the family,
early leaving school, schooling after delivery, female employment, lack of sexual education, parental
and family attitudes in different periods of adolescent pregnancy, adolescent decisions on preg-
nancy and children, unstable partner relationship and adoption as an option. Social consequences
are analyzed as: incomplete education, more numerous families, difficulties in maternal role, aban-
donment by the partner, fewer possibilities of having a stable, qualified and well-paid job, greater
difficulty in improving their socioeconomic level and less probability of social advancement, lack of
protection of the recognition of the child. Finally, based on evidence, some measures that can reduce
adverse consequences on adolescent mothers, fathers and their children are suggested.
Copyright © 2012 S. Karger AG, Basel
Adolescent Sexuality and Fecundity
Adolescent fecundity is the reflection of the initiation of unprotected sex in adoles-
cents. Therefore, a knowledge of these behaviors, their related factors and changes
in time will contribute to the understanding of this behavior and, therefore, to a
search for intervention alternatives based on education and protection of the
youths.
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Teenage Pregnancy 303
Magnitude of the Problem and Analysis of the International Situation
The information provided by UNFPA is analyzed according to region in table 1. The
10 countries with the higher fecundity rates between 15 and 19 years of age have been
recorded, as have those with the lower rates. A summary is given of the average use
of contraceptives in each 5- country subgroup. In regions with less than 20 countries,
each country in the region is tabulated.
In Africa, the countries with the lower adolescent fecundity rates have a higher
prevalence of use of contraceptives (4 and 5 times more). Similarly, the 5 countries
with the lower fecundity rates have a difference of more than 10 points with their
counterparts that have fecundity rates of over 39 per thousand.
The Latin America and Caribbean region has a somewhat similar profile, with the
exception of the 5 countries with lower adolescent fecundity rates evincing a lower
frequency in use of contraceptives. This can be influenced by the fact that the region
has a concentration of countries with very similar rates of fecundity and others with
exceptionally low contraceptive use rates like Haiti and Trinidad and Tobago. It is also
a fact that clandestine abortions in these two countries are a factor that is very dif-
ficult to weigh in terms of adolescent fecundity.
In Asia there is a very close relationship between lower Adolescent Fecundity rates
and greater use of contraceptives, with the exception of the 5 countries with lower
rates ranging from 42 to 71 per 1,000.
Europe has the lowest rates of adolescent fecundity and the highest prevalence of
contraceptive use. In this region, the influence of legalized abortion is an important
factor in adolescent fecundity.
North America gives similar rates of contraceptive use but very different fecundity
rates. It is probable that this has been affected by political and structural factors in the
area of healthcare for adolescents, sex education at school and coordination with the
Health sector.
In Oceania, the relationships between both variables are extremely clear in the
four countries analyzed.
The Region of former USSR countries shows that the countries with fecundity rates
below 29 have only 6 more points in terms of prevalence of use. It is quite possible
that the legalization of abortion in this region is the explanation for the low fecundity
rates among adolescents.
Finally, the highest rate of adolescent fecundity (222 per 1,000) is seen in the
Democratic Republic of the Congo in Africa, with 21% of prevalence of use; the low-
est is seen in the Democratic People’s Republic of Korea (1 per 1,000), with 69% of
prevalence of the use of contraceptives.
Until a decade ago, infant mortality was an excellent health indicator that reflected
the levels of poverty or development of countries. Nonetheless, the introduction of
better health care, immunizations, modern medicine with a wider scope of action
and the improvement of nutrition patterns in various developing countries have had
a very important impact on infant mortality.
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304 Cartes · Araya
Table 1. Higher and lower adolescent fecundity and prevalence of contraceptive use by regions and countries
Region/country Higher adolescent fecundity rate Region/country Lower adolescent fecundity rate
fecundity rate contraceptive
use prevalence
fecundity rate contraceptive use
prevalence
Africa Africa
Congo RD 222 21 Burundi 55 20
Liberia 219 6 Botswana 52 44
Niger 196 11 11.2 Mauritius 41 76 43.2
Guinea- Bissau 189 10 Rwanda 40 17
Mali 179 8 Egypt 39 59
Chad 164 3 Swaziland 33 46
Sierra Leone 160 5 Morocco 19 63
Uganda 152 24 11.6 Tunisia 7 63 55.6
Guinea 149 9 Algeria 7 61
Mozambique 149 17 Libyan Arab
Jamahiriya
345
Latin America and Caribbean Latin America and Caribbean
Nicaragua 113 72 Costa Rica 71 80
Dominican Republic 108 61 Colombia 65 78
Guatemala 107 43 62.2 México 65 71 74.0
Honduras 93 65 Uruguay 61 77
Venezuela 90 70 Chile 60 64
Brasil 89 77 Perú 60 71
Panamá 83 – Argentina 57 65
El Salvador 81 67 71.5 Cuba 47 73 55.8
Ecuador 83 73 Haiti 46 32
Jamaica 78 69
Trinidad and Tobago
35 38
Asia Asia
Bangladesh 125 58 Israel 14 68
Nepal 115 48 Malaysia 13 55
Afghanistan 113 19 42.6 Kuwait 13 52 57.2
Laos People’s DR 72 32 Oman 10 24
India 62 56 China 8 87
Palestinian
occupied territory
79 50 Singapur 5 62
Yemen 71 23 Hong Kong 5 84
Timor- Leste RD 54 10 34.8 Republic of Korea 4 81 70.0
Philippines 47 51 Japan 3 54
Cambodia 42 40 Democratic
Republic of Korea
169
Europe Europe
Bulgaria 40 42 Finland 9 77
Romania 32 70 Spain 9 66
Serbia 25 41 61.4 Greece 9 76 72.6
United Kingdom 24 84 Germany 9 70
Estonia 21 70 Norway 8 74
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Teenage Pregnancy 305
Adolescent fecundity has become the most exact biodemographic and health indi-
cator of development levels in many countries.
On comparing five countries of the Latin American and Caribbean Region with
the 6 developed countries with lower infant mortality rates in 2008 and their evolu-
tion since 1995, there is a 10- point difference between Sweden and Uruguay, a 2- point
difference with Cuba and 4 points with Chile. These differences do not reflect differ-
ences in development.
Nonetheless, when comparing the adolescent fecundity rates between Sweden and
Uruguay there is a difference of 56 points, 42 with Cuba and 55 with Chile.
Adolescent fecundity gives an almost unequivocal reflection of the differences bet w-
een developed and developing countries. This reflection also means that the solution is not
circumscribed to contraception in adolescents, but that there are many actions to be taken
that affect adolescent fecundity apart from poverty and underdevelopment (fig. 1, 2).
Initiation of Sexual Relations in Adolescents
In comparative studies on adolescent sexuality in different countries in Latin America
over the past years, women have had coital experience in figures that vary between
Region/country Higher adolescent fecundity rate Region/country Lower adolescent fecundity rate
fecundity rate contraceptive
use prevalence
fecundity rate contraceptive use
prevalence
Macedonia 21 14 Slovenia 7 74
Slovakia 20 24 Belgium 7 78
Bosnia and
Herzegovina
20 36 39.6 France 7 71 72.2
Hungary 19 77 Denmark 6 78
Lithuania 19 47 Italy 6 60
Northern America Northern America
USA 42 73 Canada 15 74
Oceania Oceania
Papua New Guinea 51 26 New Zealand 23 74
Melanesia 48 28 Australia 14 71
Countries with economies in transition of the former USSR Countries with economies in transition of the former USSR
Uzbekistan 34 65 Azerbaijan 29 55
Moldavia 32 68 Russian Federation 28 73
Kazakhstan 31 51 55.3 Tajikistan 28 38 61.5
Kyrgyzstan 31 48 Ukraine 28 68
Armenia 30 53 Belarus 22 73
Georgia 30 47 Turkmenistan 16 62
United Nations for populations Activity. The State of World population. 1995 and 2008. www.unfpa.org
Table 1. Continued
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306 Cartes · Araya
9 and 50% in females and 15 and 65% in males, depending on the characteristics of
the adolescents. In the 1985– 1987 National US Survey, some 80% of male adolescents
had had their first sexual experience before the age of 20, as was the case with 75% of
females of the same age group (table 2).
As can be seen in practically all the countries with comparative DHS surveys,
there is a fall in the age of the first sexual relation and an increase in contraceptive
111412
1617
557666757101213
344455 6
–55
–50
–17
–25
–24
–40
–20
–43
–33
–17
–17
–14
–60
–50
–40
–30
–20
–10
0
10
20
Infant mortality
1995
Infant mortality
2008
% Decreasing
Cuba
Chile
Costa Rica
Trinidad&Tobago
Uruguay
Sweden
Finland
France
Germany
Canada
UK
USA
Fig. 1. Infant mortality rates in selected countries: 1995 and 2008. United Nations for populations
activity. The state of world population, 1995 and 2008. www.unfpa.org.
93
60
92
56 60
13 913 13
27 33
64
27
35 39
60 61
579915
24
42
–24
–42
–49
72
–66
–22
–31–31
–44
–27
–34
–80
–60
–40
–20
0
20
40
60
80
100
Fec rate 1995 Fec rate 2008 % Decreasing
Costa Rica
Trinidad&Tobago
Cuba
Chile
Uruguay
Sweden
France
Finland
Germany
Canada
UK
USA
Fig. 2. Fecundity rates of 15- to 19- year- olds in selected countries 1995– 2008. United Nations for
populations Activity. The state of world population, 1995 and 2008. www.unfpa.org.
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Teenage Pregnancy 307
Table 2. Principal indicators of sexual and reproductive behavior in selected countries in the region and its comparison
with developed countries
Country and years Fecundity rate
15– 19
Mean age
for 1st child
Mead age at
1st marriage
Age of first
sexual relations
% contraceptive
use at 1st sexual
relation*
% current
contracep-
tive use**
Bolivia 1989
2003
99
84
20.6
20.9
20.0
20.8
18.5
18.7
6.8
17.2
30.3
58.4
Brazil 19 1986
1996
74
86
22.4
22.2
21.1
21.0
20.3
18.8
49.2
59.6
66.2
76.7
Colombia 1986
2005
73
90
21.6
21.6
20.8
21.8
19.6
17.9
20.9
48.7
64.8
78.2
Guatemala 1987
98/99
134
117
19.7
20.2
18.5
19.2
18.4
18.6
3.3
11.0
23.2
38.2
Haiti 94/95
2000
76
86
21.9
21.9
20.5
20.6
18.7
18.0
8.3
7.0
18.0
28.1
Nicaragua 97/98
2001
130
119
19.8
19.6
18.3
18.1
18.2
17.8
23.0
20.8
60.3
68.6
Peru 1986
2002
100
116
21.2
20.5
19.3
19.0
18.9
18.2
15.0
30.9
49.8
69.8
Dominican
Republic
1986
2002
100
116
21.2
20.5
19.3
19.0
18.9
18.2
15.0
30.9
49.8
69.8
Chile 2006 54.0 19.5 17.6 36.5*** 71.5
Sweden 1996 7.8 17.1 78 *** 93.5
France 1995 10.0 18.0 89.7*** 82.1
Canada 1995 24.5 17.3 86.8
Great Britain 1995 28.3 17.5 79.0*** 95.9
USA 1996 54.4 17.2 75.3*** 80.0&
Bolivia to Dominican Republic: ORC Macro. 2000 Measure DHS STAT compiler http://www.measuredhs.com
Chile: Fourth National Survey of the National Youth Institute 2006. http://www.INJUV.gov.cl/index2.html
Sweden to USA: The Alan Guttmacher Institute. Darroch J, Frost J, Susheela Sing and study team. Teenage Sexual and repro-
ductive Behaviour in Developed Countries. Can More Progress Be Made? Ocasional report No. 3, November, 2001. New
York, Washington.
* Contraceptive use before the first birth.
**Use among married women.
*** Use with first sexual relation and use among currently sexually active adolescents and youngsters.
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308 Cartes · Araya
use at the initiation of sexual relations, but it is very inferior to the situation in devel-
oped countries. The use of contraceptives in adolescents in those countries was not
available, so there is only information on Chile and the developed countries. In
Chile, the prevalence of use in adolescents and youngsters is below that of Developed
Countries.
If developing countries are expected to follow the sexual behavior patterns of
developed countries, without offering the levels of education and services for adoles-
cents given in the more developed countries, the consequences will be very serious
both in of adolescent fecundity and prevalence of STI and in conjugal infertility and
gynaecological pathologies in adulthood. Heavy investment should be made in sexual
and reproductive health programmes for adolescents and public policies should be
given priority in those countries.
Conditioning Factors in the Initiation of Adolescent Sex Relations
It has been shown that higher levels of instruction and education, the existence
of sex education programmes, higher self- esteem in adolescents, the existence of
life projects, better educated parents, improved family communications, the bet-
ter perception that the adolescent has of her/his parents’ relationship as a couple,
and a better use of leisure time are associated with the postponement of sex among
adolescents, and with the use of contraceptive methods when they become sexually
active. There is no doubt whatsoever that ignorance about sexuality and reproduc-
tion both in parents, teachers and adolescents increases the possibility of an early
initiation of coital relations and of unwanted pregnancies. Extreme poverty and
being the son or daughter of an adolescent mother are risk factors of repeating the
early pregnancy model.
Focusing on Pregnant Adolescent Risk
Introduction
There are doubts regarding the criteria of selection and management of pregnant
adolescents. Some consider that any pregnancy in single women of under the age of
19 is a high obstetric and perinatal risk. Others do not agree with this criterion and
consider that not all pregnant adolescents are at risk, but find it difficult to apply cri-
teria that allow for their classification according to risk factors.
The application of predictive risk criteria in pregnant adolescents would facilitate
the rational use of health services in accordance with their own organization and the
reality of the resources available. Those systems with adequate structures between
the different levels of complexity of the health care system would find that an instru-
ment of this kind would be easy to apply and validate, by means of the variables of
each reality. Those systems that do not have upgrades in terms of levels of complex-
ity or those that only offer preferential health care to a given level would also find an
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Teenage Pregnancy 309
instrument of this kind useful, as it would adequately derive those adolescents that
are beyond their resolution capacity.
This section of the chapter is based on the results of a research study supported by
Project M 1662 or the Department of Technical Research of the University of Chile
and by Project AMR 132895 of the Pan- American Health Office.
The study determined the factors of predictive risk of an obstetric or perinatal
pathology in a population of single pregnant adolescents. The specific objective of
this was to design a risk pattern to facilitate the attention given to adolescents in a
maternal programme based on levels of complexity.
Materials and Methods
A group of 652 pregnant adolescents from low income families and treated by a mul-
tiprofessional health care team at the Centre of Reproductive Medicine and Integral
Development of the Adolescent was studied prospectively. Prenatal control included
attention to adolescents, their partners, their families and the newborn child. All the
deliveries and newborn babies were treated at the Obstetric and Perinatal Residence
of the Department of Obstetrics and Gynecology of the Clinical University Hospital.
The same technical standards were applied in each case. There were no home deliver-
ies in this cohort under study.
The information collected in preprinted cards covered social aspects, prenatal
obstetric control, prenatal and postnatal nutritional assessment, care during labor,
delivery and puerperium care up to 3 or 5 days in hospital. Care of the newborn baby
until discharged from the Maternity Unit.
In the case of the analysis of information, pathologies during pregnancy, delivery,
intrahospital puerperium period and the newborn were considered dependent vari-
ables. In the puerperium, the variables were not significant and were not taken into
consideration in the final analysis. The record of the pathology used the International
Classification of Diseases (ICD IX ,1975 review). The first diagnosis pathologies are
shown in table 3.
Variables based on the newborn baby took into account a separate analysis for
babies of 2,449 g or under at birth and an Apgar of less that 7 at 5 min. Nonetheless,
it was not possible to include these criteria in the final analysis, because the number
of children with these characteristics was 49 and 24 cases respectively, so that the
distribution according to categories and independent variables did not have statistical
significance, given the small numbers.
The following factors were defined as independent variables: psychosocial, biolog-
ical and medical attention and nutritional care with readings of weight, size, weight/
size ratio, brachial perimeter, tricipital skin fold and body mass index at the begin-
ning and end of the prenatal and post delivery control.
In the preliminary bifactorial analysis, 19 independent variables were selected. For
each of the three periods the sensibility and specificity of the set of selected variables
was calculated.
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310 Cartes · Araya
Results
Of the variables analyzed, 11 refer to the personal characteristics of the adolescent, 4
to indicators of health care and gestational morbidity and 4 to the progenitor of the
pregnancy and to the family of the adolescent.
Table 3. Distribution of pathology diagnosed during pregnancy, delivery and
newborn baby (dependent variables)
Related pathologies by periods n %
Pregnancy 652
No pathology 364 55.8
Evidence of pathology 288 44.2
Obstetric 77.4
Infectious and parasitic 8.7
Urogenital 4.5
Cardio respiratory and digestive 3.5
Nutrition 2.1
Neurological and Psychiatric 2.1
Other diagnoses 1.7
Total 100.0
Delivery 652
No pathology 407 62.4
Evidence of pathology 245 37.6
Bearing- down detention 26.9
Fetal- pelvic disproportion 22.9
Problems related to placenta and cord 19.2
Pregnancy- induced hypertensive syndrome 15.1
Fetal distress 11.4
Lesion of soft parts 2.8
Other diagnoses 1.7
Total 100.0
Newborn 652
No pathology 413 63.3
Evidence of pathology 239 36.7
Jaundice 28.5
Infections and sepsis 15.9
Asphyxia and RSD 11.7
Hemolytic Illness and Rh and Cl group 10.9
Polyglobulia 9.2
Obstetric trauma 8.4
Small for gestational age (SGA) 7.5
Cord- related problems 4.2
Other diagnoses 3.3
Total 100.0
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Teenage Pregnancy 311
Table 4. Selected variables as risk factors at pregnancy, delivery and newborn periods
Variable/category Pregnancy Delivery New Born
Age group RR CL RR CL RR Cl
11– 14 years 1.22 0.94– 1.58 1.29 0.99– 1.69 0.79 0.54– 1.17
15– 16 years 1.11 0.92– 1.33 0.94 0.76– 1.16 1.03 0.84– 1.27
17– 19 years (reference) 1 1 1
Parental filiations
Recognized by both parents
(reference)
111
Recognized but not legally 0.89 0.71– 1.12 0.95 0.75– 1.21 0.90 0.69– 1.17
Not recognized or orphan 0.78 0.50– 1.21 0.79 0.48– 1.30 0.78 0.46– 1.32
Instruction level
3rd, 4th or University
(reference)
111
1st– 2nd secondary school 1.31 0.92– 1.84 0.98 0.70– 1.35 1.05 0.76– 1.45
5th– 8th Primary School 1.26 0.91– 1.75 0.99 0.73– 1.34 0.89 0.65
1st– 4th Primary School 1.73 * 1.21– 2.46 0.97 0.67– 1.42 0.82 0.54– 1.23
Adolescent attitude at beginning of pregnancy
Positive (reference) 1 1 1
Negative 1.34 0.89– 2.30 1.18 0.75– 1.85 1.01 0.66– 1.56
Indifferent 1.11 * 1.21– 3.69 1.32 0.68– 2.53 1.49 0.84– 2.65
Adolescent attitude at the end of pregnancy
Positive 1 1 1
Negative 1.08 0.78– 1.49 1.11 0.78– 1.57 1.04 0.71– 1.52
Indifferent 1.32 * 1.00– 1.74 1.10 0.77– 1.58 0.96 0.63– 1.45
Order within the family
5th– 8th (reference) 1 1 1
2nd– 4th 0.98 0.77– 1.25 0.96 0.73– 1.26 1.10 0.87– 1.40
1st 1.03 0.80 1.11 0.84– 1.47 1.14 0.84– 1.56
Pregnancy sexual condition
Voluntary (reference) 1 1 1
Seduction 1.13 0.73– 1.72 0.85 0.46– 1.58 0.88 0.48– 1.63
Rape 1.25 0.88– 1.77 1.80 * 1.38– 2.35 1.12 0.70– 1.77
Age of menarche
9– 11 years 1.36 0.90– 2.06 1.26 0.82– 1.96 1.09 0.69– 1.71
12– 14 years 1.20 0.82– 1.76 1.21 0.81– 1.81 1.14 0.76– 1.70
15– 17 years 1 1 1
Gynecological age
1 year 1.14 0.78– 1.66 1.20 0.80– 1.81 1.00 0.66– 1.51
2 years 0.78 0.54– 1.14 1.15 0.82– 1.61 0.70 0.46– 1.05
3 years 0.95 0.72– 1.26 0.84 0.61– 1.17 0.72 0.52– 0.98
4 years 0.87 0.65– 1.16 0.90 0.65– 1.23 0.74 0.54– 1.01
5 years 0.92 0.70– 1.21 1.01 0.75– 1.36 0.75 0.56– 1.02
6 years and + (reference) 1 1 1
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312 Cartes · Araya
Table 4 shows that the significant personal characteristics, associated with the risk
of morbidity in pregnancy (RR > of 1 and p < 0.05) were: indifferent attitude at the
onset of pregnancy and at the end of pregnancy and school level ranging between 1st
and 4th grade.
The variables associated with risk of morbidity at delivery were: pregnancy result-
ing from rape and a nutritional level described as having lost weight or overweight
according to brachial perimeter and estimation of muscle mass. The variables associ-
ated with morbidity at delivery were: a height of 1.50 or under and obesity.
Table 5 shows that the risk of pregnancy pathology is associated with the condition
of 10 or more prenatal controls. The precocity of the initiation of prenatal control
is also a risk factor in the newborn baby. These results are confusing, since in this
experience early prenatal control is conditions greater risk of detection of pathology.
This result occurs in models in which prenatal control is routine. As expected, there
is a higher risk of delivery pathology and for the newborn baby in the antecedent of
pregnancy and delivery pathology.
Table 6 analyses the characteristics of the progenitor of the pregnancy and the fam-
ily of the adolescent. We can see that the only significant variable related to a higher
risk of morbidity is being a student or being a member of the military service associ-
ated with a higher risk of pregnancy morbidity. There are no significant differences in
the rest of the groups with or without evidence of pathology.
All these variables (17 during pregnancy, 18 at delivery and 19 in the newborn)
were included in the multifactorial analysis, the results of which are summarized in
table 7. The risk variables during pregnancy are the same as those described for stu-
dent partner or military service and the attitude of the adolescent at the onset of preg-
nancy. In this last variable, the positive attitude is expressed as protective (β– 0.90),
so the negative attitude needed to appear as reciprocal to consider the risk. Two new
variables appear, a significant one is the age of menarche. The more advanced the age
of menarche the lower the risk of pathology (β – 0.15). The age of menarche should be
approximately 11 years.
Variable/category Pregnancy Delivery New Born
Height
1.35– 1.50 m 1.34 0.94– 1.91 1.39 0.95– 2.01 2.16 * 1.29– 3.64
1.51– 1.60 m 1.04 0.74– 1.46 1.06 0.74– 1.51 1.93 * 1.18– 1.61
1.61 m and + (reference) 1 1 1
Nutritional state (brachial perimeter)
Normal (reference) 1 1 1
Thinness 1.14 0.89– 1.45 1.32 * 1.04– 1.67 1.70 * 1.11– 2.60
Obesity 1.13 0.60– 2.12 1.74 * 1.14– 2.67 1.70 * 1.11– 2.60
Table 4. Continued
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Teenage Pregnancy 313
Table 5. Quality of medical care and current obstetric pathology related to risk of morbidity
Variable/category Pregnancy Delivery New Born
RR CL RR CL RR Cl
Prenatal visits
1– 3 1 1 1
4– 6 1.13 0.84– 1.53 1.26 0.91– 1.75 1.14 0.82– 1.60
7– 9 1.29 0.97–1.72 1.24 0.90– 1.72 1.20 0.86– 1.67
10 and + 1.37 * 1.00– 1.86 1.35 0.96– 1.92 1.31 0.92– 1.88
Gestational age at first control
7– 15 weeks 0.93 0.63– 1.37 1.07 0.71– 1.63 1.55 * 1.01– 2.38
16– 20 weeks 1.03 0.72– 1.47 1.17 0.81– 1.72 1.75 * 1.17– 2.61
21– 25 weeks 1.09 0.76– 1.54 1.20 0.82– 1.77 1.57 * 1.04– 2.37
26– 30 weeks 1.03 0.72– 1.48 1.18 0.80– 1.74 1.40 0.92– 2.15
31– 40 (reference) 1 1 1
Current pregnancy pathology
No – 1 1
Yes – 1.36 * 1.13– 1.65 1.40 * 1.15– 1.71
Current delivery pathology – – 1.58 * 1.30– 1.92
Table 6. Partner and adolescent’s family characteristics related to risk of morbidity
Variable/category Pregnancy Delivery New Born
RR Cl RR Cl RR Cl
Partner activity
Stable labor (reference) 1 1 1
Occasional labor 1.20 0.92– 1.57 0.86 0.65– 1.14 1.31 0.98– 1.74
Student/army service 1.53 * 1.20– 1.96 1.07 0.83– 1.39 1.30 0.97– 1.73
No activity 1.05 0.76– 1.46 1.14 0.85– 1.53 1.20 0.85– 1.69
Partner attitude
Positive 1 1 1
Negative 1.05 0.87– 1.27 0.95 0.76– 1.19 0.81 0.64– 1.02
Indifferent 0.71 0.45– 1.12 1.31 0.94– 1.82 0.61 0.35– 1.05
Family attitude beginning prenatal control
Positive 1 1 1
Negative 0.99 0.80– 1.21 0.97 0.78– 1.21 0.75 0.60– 0.93
Indifferent 0.77 0.45– 1.30 1.01 0.63– 1.61 0.75 0.44– 1.26
Family attitude at end prenatal control
Positive 1 1 1
Negative 1.09 0.91– 1.31 0.94 0.77– 1.16 1.00 0.81– 1.25
Indifferent 0.91 0.56– 1.49 1.22 0.82– 1.81 1.13 0.71– 1.80
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The other variable of significance is the nutritional state as measured by the
brachial circumference before 20 weeks of pregnancy. Information shows that the
larger the brachial circumference the lesser the risk of pathology during pregnancy.
Nonetheless, thinness should be recorded as a factor of predictive risk. These four
variables reached a specificity of 74.5%:
Table 7. Predictive risk variables for pregnancy: delivery and newborn in pregnant adolescents
Variable Category Beta SE χ2p R Comments
Pregnancy1
Partner activity student/army
service
occasional work
0.978
0.467
0.257
0.277
14.51
2.86
0.0001
0.090
0.157
0.041
increases the risk
increases the risk
Age of menarche older menarche age (– ) 0.159 0.078 4.08 0.0043 (– ) 0.0064 lower age is the risk
Brachial muscle
area at 20 weeks
large brachial area (– ) 0.0004 0.0002 3.56 0.059 (– ) 0.055 small brachial area is the risk;
thinness is the risk
Adolescent
attitude
beginning
pregnancy
positive attitude (– ) 0.904 0.553 2.67 0.102 (– ) 0.036 indifferent or negative attitude
is the risk factor
Delivery2
Pregnancy
sexual situation
seduction and rape 0.855 0.185 13.54 0.0036 0.122 in the analysis, infinite risk
appears when the name of the
partner is unknown
Stature the higher stature (– ) 0.034 0.019 2.91 0.088 (– ) 0.097 the risk is the lower stature
Newborn3
Stature the higher stature (– ) 0.053 0.020 6.78 0.009 (–)0.097 stature 1.50 m or less is the
risk
Secondary
education level
1– 2 years middle 0.481 0.231 4.35 0.037 0.068 conflict of pregnant student
Partner activity student and army
service
0.384 0.230 2.80 0.094 0.040 high risk of abandonment
Delivery
pathology
existence of
pathology
0.419 0.218 3.69 0.055 0.058 existence of pathology
1 Sensibility: 50.3; specificity: 74.5; correct: 63.9; false (+): 39.3; false(– ): 34.3.
2 Sensibility: 53.8; specificity: 60.2; correct: 57.5; false(+): 49.7; false(– ): 36.5.
3 Sensibility: 60.8; specificity: 55.0; correct: 57.5; false(+): 49.7; false(– ): 34.8.
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Teenage Pregnancy 315
For the delivery, the model selected two variables for predicting risk of morbid-
ity. Rape once again appears as a strong risk factor. It should be noted that in a more
detailed analysis of this variable, when the aggressor is unknown to the victim, risk
becomes infinite, which rarely occurs in medicine, because it becomes a certainty.
The other variable was stature. Tallness is protective (β – 0.034). Small stature is a
risk factor. The specificity of these two variables reached 60.2%.
The model selected four variables for the risk of morbidity in the newborn. Stature,
which once again is a protection against morbidity; higher stature (β – 0.05). Smaller
stature is recorded as a risk factor.
The model selected a new variable, which is 1st and 2nd year secondary education.
Once again the activity of the partner – student or in the military service – appears
as a risk factor, a variable that is repeated in pregnancy. Delivery pathology is also a
risk factor, although it is a late predictive factor. The specificity of these four variables
reached 55%.
In short, the model selected a total of 10 variables, with four corresponding to preg-
nancy, two to delivery and four for the newborn baby. Of the latter, delivery pathol-
ogy is discarded as it is a late risk predictive factor in primary and secondary levels of
healthcare. There are two variables that are repeated as predictive risk factors; activity
of the partner, for pregnancy and the newborn baby, and stature at delivery and in the
newborn baby.
In order to design a predictive risk model to be applied at different levels of com-
plexity, predictive risk factors were reorganized according to their p value, as can be
seen in table 8.
To these factors, we can add two additional factors that were not significant in the
study, but which do imply risk from a clinical point of view. These variables are: age 16
or under and being unmarried in the case of some regions or countries. Another risk
factor to be considered is the apparition or existence of a prior obstetric or pregnancy
related pathology, which follows the same clinical criteria applied to adult pregnant
women.
Table 8. Predictive risk factors regarding p value
Variable Category p value
Partner activity student/army service/occasional labor repeated p value
Stature 1.50 m or less repeated p values
Pregnancy sexual condition seduction or rape 0.0036
Instruction level two years of median level 0.0370
Age of menarche 11 years old or less 0.0430
Brachial muscular area thinness 0.059
Adolescent attitude at beginning of
pregnancy
indifferent or negative 0.102
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Comments
After the publication of the Aubry and Nesbitt report, a series of experiments were
carried out in order to apply quantitative criteria in the determination of obstetric and
perinatal risk, which are very well summarized in the WHO 1977 publication. The
Collaborative Perinatal Study carried out by the US Department of Health Education
and Welfare, whose results were published in 1972, has also been an important con-
tribution to the determination of risk factors. The methodology for group compari-
son of the latter study allows for the consideration of each factor on its own, without
discriminating the relative weighting of each factor. This makes is difficult to apply
findings to the selection of pregnant women using predictive risks. Other models use
known or supposed risks and make unifactorial analyses to determine projections for
population groups but without being able to determine individual risks.
The results of this study are based on the record of facts and conditions of a pop-
ulation of similar characteristics and treated in a same healthcare system. 77% of
pathologies during pregnancy had an obstetric cause, with a predominance of preg-
nancy hypertension syndrome (28.6%), urinary tract infections (23.2%), symptoms
or threat of premature labor (19.6%), and anemia (15.9%).
98% of pathologies during delivery had obstetric causes. In the Newborn’s first
5 days of life, the most important pathology was icteric syndrome requiring photo-
therapy (29%), followed by infections and sepsis (16%), and asphyxia and respiratory
distress syndrome (12%). Hemolytic disease and Rh incompatibility (11%) was con-
sidered when it required treatment.
With this information, we can conclude that the pregnant adolescent population
group is a high risk group during pregnancy. The variable attitude of the adolescent
towards the baby was eliminated because it was a late factor as it is asked at the end
of the pregnancy when many other events have already occurred. The pregnancy
and delivery pathology variables do not correspond to pregnancy so they were also
disregarded.
As for delivery itself, no variable was eliminated. Three variables were eliminated
in the newborn period: filiation of the adolescent, attitude of the partner on learning
that the adolescent is pregnant, and attitude of the parents at the beginning of preg-
nancy. This criterion was adopted because inconsistencies were found when match-
ing these factors with other variables.
We were surprised that age was not selected because it was not statistically signifi-
cant although it is a clear risk variable from a clinical point of view. 85% of girls under
14 develop pathologies in any of the three periods. This phenomenon is explained
because it is a continuous variable that considers year- to- year differences and for this
reason differences are scarce. When this variable becomes important and is com-
pared with adult pregnant women, it shows high levels of significance. Nonetheless,
this criterion was not used to change the methodology of the multifactorial analy-
sis designed. In this study, the pathology- free control group was also made up by
adolescents. It is best to take this factor into consideration in every model as it has
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Teenage Pregnancy 317
an indisputable clinical application. Furthermore, there are other extremely high risk
variables that are associated with younger ages as is the case of sexual abuse.
The model finally selected 10 predictive risk variables of which two are repeated in
some of the periods analyzed, which gives them greater predictive strength. The deliv-
ery pathology factor is a late factor in terms of predictive variables and is used routinely
in the clinical context. There are only 7 predictive risk variables left. These are dis-
tributed in the three periods. But, in the applicative model they should be considered
together and selected in accordance with a criterion that associated them with more
than a period and with their level of signification, as expressed in table 8. On analyzing
these 7 variables, we see that four are already known or used as risk factors: low stature,
age of menarche, malnutrition or thinness and attitude regarding pregnancy.
Similarly, sexual abuse is an extremely high predictive risk, which is well known for
its association with unwanted pregnancy and unaccepted children. But, for those coun-
tries that do not consider legal abortion, in these cases the factor becomes the highest
obstetric and perinatal risk of those analyzed in this study. It was the only factor that
reaches statistical infinite risk in the regression analysis when it is associated with an
unknown aggressor. Education level as a risk factor is associated with lower education
level, which is a confusing variable in the lower socioeconomic level. In this study risk
is associated with two years of secondary school, which corresponds to a total of 9– 10
years of schooling. This is explained by the serious problem posed by an unwanted
pregnancy in an adolescent that attends school that results from a relationship with a
sporadic partner, delay in informing the pregnancy, delated medical consultation or the
existence of a pathology that cannot be hidden, sudden interruption of life plans and
serious family disruptions. Apparently, in our society, pregnancy in adolescents with
little schooling is associated with a social medium that has a greater cultural acceptance
of the phenomenon and therefore there is an earlier medical control and greater accep-
tance of routine preventive measures. This factor should be considered in the context of
each reality in accordance with the levels of instruction of the population treated.
A unifactorial analysis showed that the early initiation of prenatal control and
the larger number of prenatal controls were a factor or greater risk. This finding is
confusing, as the groups under study had adequate coverage of prenatal control, and
the early control detected more pathology and is an indicator of a group presenting
pathology. The same happens with the larger number of visits that is concentrated on
the pathology bearing group with a higher frequency of appointments. This indicator
should be carefully assessed when group comparison is carried out in an environment
of high quality prenatal control.
Four of the variables selected present negative beta readings, which indicate that the
risk is lower in the measure that the quality of the variable improves. So, to older age
of menarche, there is less risk of pregnancy pathology; the same occurs with a larger
brachial muscle area and with a positive attitude of the adolescent at the onset of preg-
nancy; a taller stature also reduces the risk of delivery pathologies. In these cases, the
reciprocal category has been taken as a risk factor in terms of its practical application.
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In this context, a proposal is submitted based on a classification of pregnant ado-
lescents according to predictive risk to apply criteria or quality and intensity of medi-
cal care and make the best use of the resources available.
This model takes into consideration some factors which are the already given clin-
ical management. Each local reality can adapt these factors according to the system,
organization and availability of resources of maternal- infant healthcare.
Nonetheless, it will also be necessary to validate these findings to prove
that those with higher risk are really those that are shown by the model. This
validation will not influence intervention with adequate health services, as we
are not measuring mortality or preventable morbidity, but expected morbidity
complications.
In the case of this experience, the proposed scheme was applied and validated in
northern Santiago and was classified into three groups. Experience showed that only
2 were necessary. Only 45% of pregnant adolescents had to be referred to the second-
ary level for their prenatal control.
It is finally necessary to consider the indicators of sensibility and specificity which
have a discreet performance as they are working with an at risk population that is
discriminated in terms of risk. This phenomenon can result in strong pressure on
the more complex levels of healthcare if predictive risk factors are indiscriminately
increased to select the population to be attended at this level.
Adolescent characteristics Predictive risk classification Guideline of attendance
* Pregnancy pathology pregnant adolescent of
high or median obstetric
and perinatal risk
they enter to the system for the
primary health care system and are
referred immediately to second level
of complexity care; application of
local clinical guidelines
* Pregnancy as consequence
of sexual abuse
*Partner: student/army
service/occasional labor
*Stature of 1.50 m or less
*Age of menarche: 11 years
old or less
Thinness
* Two years of secondary
school level
pregnant adolescent of
undetectable risk
medical care attendance at primary
level of complexity; greater number
of visits and close coordination with
second level of complexity for
adequate references
*Single, without partner
*More than 17 years old
*Indifferent or negative
attitude at the beginning of
pregnancy
* All pregnant adolescents
until the age accepted by
the local programme
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Teenage Pregnancy 319
Conclusions
Pregnant adolescents behave with different levels of risk in accordance with a series of
association variables that can be measured and analyzed in their relative importance
according to a model that takes into account the set of multivaried analysis factors.
Nonetheless, risk prediction faces the problem that the entire population of preg-
nant adolescents is at appreciable risk and for this reason the sensibility and specific-
ity of the indicators is not too high.
Pregnant adolescents can be classified into two groups in accordance with their
predictive risks:
a High- risk adolescents: Pregnancy pathologies or pregnancy- related pathologies.
Pregnancy resulting from sexual abuse.
b Student partner, partner in the military service or occasional worker, stature of
under 1.50 m. Age of menarche 11 or less and thin.
c Unpredictable risk: the rest of the adolescents, and all those in the age group
determined by the programme.
These groups should be given healthcare of a different intensity and quality accord-
ing to the resources of materno- infant care and at different levels of complexity.
Social Factors Associated with Adolescent Pregnancy
Adolescent pregnancy is a phenomenon that appears in all social groups, but its
characteristics, causes and consequences differ from one social group to another. It
is possible that in higher socio- cultural sectors this event is kept anonymous and its
outcome is solved by decisions made within the family. While in the poorer sectors,
the medical and social implications of this phenomenon are more acute.
Changes in the Family Structure
There is an increasing number of adolescents living in monoparental families, in other
words in the absence of one of the parents, generally the father. In these families, it is
frequent for the mother to have to provide for the children, thus having to delegate
the care of the children to third parties or simply having to leave them on their own.
This situation becomes more acute in the poorer sectors. Families with female heads
of household have a higher probability of being poor than bi- parent families.
Changes in the Exercise of Fecundity and Sexuality
Another important change is the increase of children born out of wedlock. The risk of
a newborn child being illegitimate varies according to the age of the mother, and chil-
dren born of adolescent mothers have two times more possibilities of being monopa-
rental children. The following are observed regarding these changes:
(a) Marriage age has become older. In the past it was common for women to
marry young and for maternity to occur within marriage, or if the woman became
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320 Cartes · Araya
pregnant before the wedding, it was brought forward to make the unborn child
legitimate.
(b) Sexual activity in adolescents has increased. This change in adolescent sexual
behavior may be considerably influenced by the impact of mass communications
media, especially television. This medium contributes to the acquisition of knowl-
edge of adolescents and influences their behaviors in many areas, but especially in
the realm of sexual behavior. If there are not regular and proven sex education pro-
grammes, there is no criticism to communications media and they become sources
of learning. There are increasing implicit and explicit sexual messages in television
programmes. Sexual references are present in almost every type of programme and
sex is shown as romantic and desirable, especially when it is illicit. There is frequent
reference to coital relations among unmarried couples or linked to prostitution and
violence, but they are rarely portrayed within a context of love, warmth, stability, and
commitment within or outside marriage.
But this change in sexual behavior has not been accompanied by an increase in the
use of methods to prevent pregnancy, which has resulted in an increase of pregnan-
cies among unmarried women and children born out of wedlock.
Adolescent pregnancy is often unplanned and has undesired social consequences
on the life of adolescents such as school desertion, social rejection, illegal abortion,
negligence, abuse or abandonment in the life of the children.
Changes in Female Employment Patterns and Status
There is an increasing number of women who join the work force. This increase in
women who work outside the home brings a fundamental change in their activities
and the orientation of their life projects. These changes are linked to changes in the
social, cultural, ideological and economic conditions of society. Although the incor-
poration of women in the workforce outside the home has been specially related to
those activities in which they are more skilled than men; they increasingly cover
activities that were carried out by men. For this reason, a greater number of adoles-
cents today have mothers that work outside the home.
The incorporation of women into the workforce, the implementation of elements
that make domestic work easier, the participation of other family members, and the
reduction of the time that women spend on household tasks create more indepen-
dence of the woman vis- à- vis her partners, especially in the middle and upper classes.
These factor make women perceive their roles and status in a very different way from
the women of earlier generations, and influence the development of adolescents.
Restrictions to the Delivery Sex Information to Adolescents
Adolescent sexuality features lack of orientation and is immersed in an erotizing con-
text. Day- to- day culture stimulates early sex initiation and the exercise of genitality,
but it does not educate about its consequences and does not give adolescents the right
to clear and timely information. Sex is equal to risk. On the other hand, adolescents
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Teenage Pregnancy 321
have more freedom and less restrictions in their daily life. There are more occasions
for sexual relations but not enough information, knowledge and access to contracep-
tive methods, and there is an occurrence of unpredicted and unprotected sexual rela-
tions and there is no awareness of the risk of pregnancy and acquisition of STI.
But, information is not enough; information should be complete and should pro-
vide spaces for an overt discussion of the subject to internalize new concepts and atti-
tudes. Furthermore, it is not necessary for adolescents to know about sex, they must
put this knowledge into practice.
Socioeconomic Level
Between 64 and 86% of adolescents who get pregnant come from low socio- economic
sectors. These groups are characterized by presenting other risk factors such as pro-
miscuity problems, overcrowding at home, lack of social welfare systems, employment
instability of the head of the household and of other family members. This determines
income that is irregular and insufficient to satisfy the basic needs of the family.
In low socioeconomic levels principally, in addition to what has been described
above, adolescent pregnancy is associated with lack of life projects and of profes-
sional, vocational, labor and family projects. They feel undervalued not only by their
families, but by society as well, and have low levels of self- esteem so that the only
status that gives them value as persons is maternity, which then becomes an objective
of life.
These adolescents present unsatisfied needs of affection that lead them to look
for the satisfaction of these needs in their partners. They also present deficient lev-
els of communication and/or conflictive emotional relations with their parents and
other family members, and to some degree or other belong to groups that are at risk.
The families are characterized by lack of proper schooling in the parents, and family
members have unsatisfied needs of affection.
Sometimes, with a certain frequency, there exist histories of adolescent pregnancy
among close family members such as mothers, sister or grandmother. In these fami-
lies, we can also see a high degree of undervaluation of the female and a certain degree
of social marginality. An important sociocultural factor that favors adolescent preg-
nancy is that there are communities that condemn adolescent sexuality but accept
early pregnancy like something natural or magical.
Early School Desertion
An important proportion of pregnant adolescents had deserted the school system
because of bad grades, repetition or lack of academic motivation. Although education
is seen as an excellent medium of social mobility, this does not seem to be the case
with adolescents.
It is possible that the education system is not taking into account the real educa-
tional needs of adolescents in the poorer sectors, applying educational models that
match the reality of middle and high income level adolescents.
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Another reason could be their early incorporation into the labor market, but most
of them have been left at home looking after their younger siblings or simply devoted
to household chores instead of their mothers, who have had to become the family
breadwinners.
Personal Characteristics of Their Environment
Adolescent pregnancy can have indisputably adverse consequences from a psycholog-
ical, family, social and legal point of view for both mother and child. The adolescent
might see that her possibilities of further studies, employment and of having a family
are reduced. On the other hand, she is not prepared to provide the care required by a
child. And if she is not prepared from a psychological and social point of view, she is
also limited economically because she is not economically independent and lacks the
financial means to cover the expenses of raising a child.
A pregnant adolescent can face the following alternatives:
(a) Keep the baby and raise it with the support of her partner, in a formal or infor-
mal relationship.
(b) Keep the baby and raise it with the support of her family.
(c) Keep the baby as a single mother.
(d) Give the baby for adoption.
(e) Interrupt the pregnancy.
These are all extremely complex decisions, and each will depend on circumstances
and pressures, and on the option available to each of the mothers.
Biodemographic Characteristics of Pregnant Adolescents Based on Information
Gathered in Chile and on a Study by CEMERA
Age
Age distribution of adolescents according to age at pregnancy
Chile 1993–2003
419,569 live- born infants have accumulated in these 11 years. This corresponds to
a rate of 60.9 per 1,000 women between 11 and 19 years of age. The ratio for 11- to
15- year- olds was 5.5 per 1,000. 90% of live- born babies occur between the ages of 16
and 19 and 10% between 11 and 15.
Age n %
11 years 17 0.004
12 years 218 0.05
13 years 1.953 0.47
14 years 9.451 2.3
15 years 28.994 6.9
16–19 years 378.936 90.3
11–19 years 419.569 100
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Teenage Pregnancy 323
Schooling
Diverse studies show that the average number of school years reached by pregnant
adolescents varied between 6 and 8 years of primary education. Those that manage to
complete some years of secondary education vary between 10 and 44%. This is illus-
trated by a follow- up study carried out by CEMERA.
Distribution of adolescents according to level of schooling reached at the begin-
ning of the pregnancy:
Median schooling is between 5th to 8th grade primary school. Although the
schooling level of this group is not deficient when compared with the population of
this age group, it was found that the last grade completed corresponded to an age that
was lightly higher than the expected age for this level.
Activity
Pregnant adolescents leave school early and join the labor world early and in dis-
advantageous conditions. Most stay at home caring for younger siblings and doing
household chores instead of their mothers, especially when the latter are the bread-
winners of the family.
Distribution of adolescents according to activity when becoming pregnant:
More than half of the adolescents were studying when they became pregnant,
a third had left school and did nothing and 12% had become a member of the
workforce.
The continuation of the school education of pregnant adolescents will be one of
the great difficulties that they will have to face in the immediate future. Most of them
can never go back to school. Pregnancy and maternity are still one of the main causes
of school desertion in this period. In a follow- up study of 651 pregnant adolescents
controlled at CEMERA, 55% were studying when they became pregnant and only
69% stayed on at school after giving birth.
Schooling n %
1–4 primary 83 12.8
5–8 primary 308 47.3
1–2 secondary 180 27.7
3–5 secondary 80 12.2
Total 651 100.0
Status when becoming pregnant n %
Student 363 55.8
Worker 81 12.4
Housewife 202 31.8
Total 651 100.0
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324 Cartes · Araya
There are personal, family and social barriers for continuing to study. They feel
that they have no right to this, the feel that they cannot overcome social pressures,
and they do not feel supported or encouraged by their families and society. Their
families, especially families from the poorer sectors, might believe that she wasted her
only chance to study and the scarce family economic resources are now focused on
raising the new member who has just been born.
Another aspect is the change in the educational requirements of these students.
They urgently need to finish their formal education and need training to join the
workforce. There is also a need for crèches or nursery schools in the school system or
connected to it in order to make the raising of the child easier. Most of them do not
have a relative that can take on this responsibility.
Chile has an alternative educational programme for these mothers and pregnant
adolescents. This will be discussed in another chapter.
Prenatal Control Is Later than in Adult Pregnant Women
Pregnant adolescents tend to start their prenatal control later than their adult coun-
terparts with the corresponding maternal and perinatal risk. One of the reasons
for this is the belated awareness of the pregnancy. She holds on to the idea that it
is simply a late menstruation and that it will soon work out. Current pregnancy
tests and facilities have contributed to reduce the importance of this factor. On the
other hand, there is a natural tendency to hide this pregnancy because of fear of
parental reaction, or because they do not want to hurt them make them sad or
disillusioned.
Unplanned Pregnancy
The risk of pregnancy in the first 6 months of unprotected sex is very high. Most of
these pregnancies are unplanned, unexpected and initially unwanted. They start their
sex lives without contraceptive protection. The reasons for this behavior are:
– Misinformation regarding the risks of pregnancy.
– Fear of the collateral e ects of contraceptive methods created by myths and false
beliefs spread by family and peers.
– Lack of support from the male.
– Unexpected and unplanned sex.
– Lack of cognitive skills to understand the consequences of early maternity or
paternity.
– Delay in looking for information on the initiation of sexual activity.
– Double messages regarding the use of contraceptives and being sexually active in
our society.
– Adolescents from low socioeconomic groups can perceive that they have little to
lose with an early pregnancy because there is nothing that will make their social
mobility possible and for this reason, they will make no e ort to avoid pregnancy,
– No access to sex orientation and contraception services.
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Teenage Pregnancy 325
Unstable Partner Relationship
In addition to being a person with whom there is an important affective relationship,
the progenitor of this pregnancy is generally another adolescent or young adult who
has enormous difficulty in taking on the responsibility of paternity. Pregnancy occurs
in a context that is significantly important to them in terms of affection, in spite of
the fact that their relationship as a couple is unstable and immature. Pregnancy often
changes the relationship of the couple, ending it.
It is more frequent to see adolescents that become pregnant as the result of spo-
radic sexual relations without affective links that are the result of an impulse. For
many adolescents, the fact of acting impulsively seems to reduce their guilt with fam-
ily and society for having broken social rules.
It is also important to point out that a proportion of adolescent pregnancies is the
result of rape and that this is generally intrafamily rape. In these groups, both the
adolescents and their families tend to reject the unborn child.
Initial Attitude of Rejection
A follow- up study carried out by CEMERA adolescent attitudes in three different
periods of pregnancy, as observed in the following table.
Attitude of the adolescent at three periods of pregnancy:
Unexpected pregnancy is frequently initially accepted by the adolescent, her partner
and her family. Pregnancy is a very critical period for the future mother and this can
generate high levels of anxiety in her. Nonetheless, most of them accept the pregnancy
and the idea of the child, although this does not happen with their partner and families,
whose acceptance comes later and to a lesser degree. Great care should be taken with
the percentage of adolescents that continue to reject their pregnancy and the child.
Adoption as an Option for Single Pregnant Adolescents
Although adolescent maternity reduces the opportunities and optimum results for
the adolescent mother and her child, they rarely consider adoption as an option, espe-
cially when the child is born of an affective relationship, and is not always considered
when pregnancy results from rape. It is important to take into account the following
reasons:
(a) Social sanctions against adoption, this social disapproval can also go together
with the adolescent’s belief that her duty and responsibility is to keep the child, even
Attitude When she knows she is pregnant At the onset of control At the end of control
n% n%n%
Positive 39 6 507 77.9 549 84.3
Indifferent 21 3.2 68 10.4 57 8.8
Negative 591 90.8 76 11.7 45 6.9
Total 651 100.0 651 100.0 651 100.0
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326 Cartes · Araya
though she perceives her inability to do this. This is frequently reinforced by her sig-
nificant figures and the professionals with whom she interacts.
(b) Little knowledge of adoption on the part of the adolescent, her family and pro-
fessionals involved.
(c) Fear of anticipation of future sorrow, not only of the adolescent but also of her
family.
(d) Lack of support of the professionals that give her overt orientation regarding
this option.
Family Characteristics
The families of pregnant adolescents are usually defined as severely dysfunctional
families both in terms of organization and composition, they are also defined as dis-
organized in they way in which they structure their family activities, in which they
state their standards and share responsibilities.
In terms of structure, they are frequently single parent families with a high propor-
tion of female heads of families owing to separation, paternal desertion, widowhood
or because they are girls born out of wedlock.
There are often different ways of family structure in successive stages of the vital
cycle of the family, which can produce enormous instability in the family’s composi-
tion and organization, with the corresponding lack of role fulfillment. The natural
history of the process generally begins with the marriage or initial living together of
the mother, when a given number of children are born; this is followed by paternal
desertion and by the mother becoming the head of the family. But in the long or short
term, the mother has a new partner, and this male is expected to assume a pater-
nal and supportive role. Nonetheless, the stability of this new relationship is usually
rather fragile as it is based more on the need for survival of the family group, and ends
in separation. The mother is once again alone and responsible for all her children,
which have now increased in number and needs.
There are frequently negative substitute parental figures like stepfathers or mother’s
lover and/or alcoholic, drug addicted and or violent fathers, grandfathers, or brothers.
In general, they are families that have unsatisfied affection needs and deficient
communication especially regarding sexual issues.
Parental and Family Reaction to an Adolescent Pregnancy
The above mentioned follow- up study measured parental attitudes to the pregnancy
of an adolescent daughter, as appears in the following table:
Attitude On learning about pregnancy At the end of pregnancy
n% n%
Positive 144 23.7 368 56.5
Indifferent 28 4.6 81 12.4
Negative 436 71.7 202 31.1
Total 608 100.0 651 100.0
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Teenage Pregnancy 327
Parental reaction to the news of the pregnancy of their adolescent daughter covers
a range of responses which go from a high percentage of initial disapproval which can
be expressed in terms of disgust, anger, verbal aggression, physical aggression and
making her leave home.
But in the measure that the pregnancy advances, among a large number of parents
the initial negative attitude changes to acceptance and resignation. But the percent-
age of parents that do not change their negative initial attitude is still worrying, as it
reflects lack of support and understanding of the daughter at such critical moments.
Evidence shows hat the news of the adolescent’s pregnancy generates mixed feelings
of anxiety, anger and pain in parents and tutors, and especially in mothers, but they
must accepts the fact and get ready to receive the arrival of this grandchild into the
family despite their feelings. After the birth of the baby of an adolescent mother, there
may be conflictive situations within the family related to the rights and duties of rear-
ing a child. Conflictive situations of this kind can have an adverse effect on the nor-
mal development of the child.
Social Consequences for the Adolescent Mother
Incomplete Education
The laws that protect the continuity of the education of pregnant schoolgirls are an
efficient tool to encourage them to finish their education. But, school maternity gen-
erates rejection among the parents of other schoolchildren. Advanced pregnancy
makes attending school more difficult and becomes even more difficult after the birth
of the baby.
More Numerous Families
Women who become mothers at an earlier age have less schooling and more possibil-
ities of having more children in the future with shorter intervals between each child.
The education level achieved by the adolescent mother is strongly associated with her
reproductive behavior, on the once side and to her level of awareness about health.
Difficulties in Fulfilling Their Maternal Role
These adolescent mothers have greater difficulty in raising their children. Raising
a child is a difficult task even for an adult mother. Successful maternity requires
a combination of skills and understanding that cannot be compared to any other
responsibility in our lives. It also requires a degree of maturity which is often beyond
the grasp of adolescents. This is more evident in those girls who must raise their
children practically on their own, without the support of their partner, and without
being able to provide for the needs of the children. Insufficient economic resources,
acute stress, lack of support from the father of the child, lack of ability and training
in maternity and personal problems or needs that prevent them from fulfilling the
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328 Cartes · Araya
needs of the dependent child are some of the factors that can contribute to these
shortcomings.
Possibility of Being Abandoned by the Partner
Pregnancy frequently changes the affective relationship with the partner who has
fathered the child, and in many cases marks the end of this relationship. On telling
her partner that she is pregnant, he is generally frightened by this responsibility, as
paternity was not within his short- term plans. Diverse studies show that the male
reacts negatively in half of the cases, withdrawing or denying his paternity, which
indicates that these children will be raised without the affective and economic sup-
port of their fathers.
The future probability of these mothers increases when they have a higher degree
of schooling, when they are members of a less poorer sector, when they live indepen-
dently with the father of their baby, and when the father gives economic support for
the upkeep of the child.
Fewer Possibilities of Having a Stable, Qualified and Well- Paid Job
Adolescent mothers are more exposed to suffer from chronic underemployment and
insufficient income. The mothers and their children have a higher probability of depend-
ing on public assistance systems and remaining under the care of their families for a lon-
ger time than those women who postpone their maternity until their second decade. As
should be expected, the employment participation of adolescent mothers increases with
time, but the type of work they gain is related to their limited education and training.
Long- term follow- up studies indicate that they have limited labor opportunities.
Greater Difficulty in Improving Their Socioeconomic Level and Less Probability of
Social Advancement
The future of the pregnant adolescent is strongly marked by her economic status, by
the fact that he partner has left her and the education she attains. Those adolescents
that are abandoned by their partners enter the labor market later, in economic dis-
tress and with lack of training. But if they had a better education and had more train-
ing, they could have better employment opportunities and contribute more to the
family income and thus increase their autonomy in family decisions, which would go
in benefit of the welfare of their child.
Among the poor, early maternity is associated with the perpetuation of socioeco-
nomic disadvantages and the inequity that women have to face at school and at work.
Lack of Protection of the Recognition of the Child
In many countries, the Civil Code covers diverse ways to establish the recognition of
a child, but two are the most used: (a) the father recognizes his paternity by means of
a recorded public deed or by registering the child with the Civil Registry Office, and
(b) the mechanism for a mother to sue for paternity before a court of law. The alleged
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Teenage Pregnancy 329
father is summoned to court and he must admit or deny his paternity. Once the father
has admitted his paternity, the nonmatrimonial filiation link is established, together
with the right and duties of each parent. But if the father denies his paternity, the case
is closed and he can never be summoned to court for the same case. Other legislations
admit paternity investigations through filiation testing such as ADN tests.
There is a strong association between adolescent pregnancy and recognition of the
child born out of wedlock with the new filiation rules, owing to the high percentage
of children born of adolescent mothers. Children of unwed mothers are greatly dis-
criminated. This situation, in addition to being unjust, has a direct effect on that enor-
mous proportion of mothers that accept responsibility for their children. Adolescent
mothers face situations of legal lack of support, and this situating becomes even more
difficult in the case of unwed mothers, when the law places them and their children
in a detrimental position.
As regards alimony, the legislation has no procedural mechanisms to facilitate it. It
is usual from mothers to give up on their demands owing to legal complication and
the subsequent bill for food. This situation affects both children born within and out-
side wedlock and many legislations allow for the grandparents to be made liable for
the costs in the case that the parents are unable to fulfill their duties.
In many legislations, there is a progressive acknowledgement of advantages for
the child, which includes inheritance rights, social security benefits and the right to
support from the father. It guarantees social protection for the child and can help her/
him to develop a more positive self image. The interest and support of the father –
regardless of the fact that he is married or not to the mother – is of enormous impor-
tance to the child and its development.
Measures That Can Reduce Adverse Consequences on Adolescent Mothers and Their
Children
Adolescent mothers and fathers should be guided to make their own decisions regard-
ing their child.
When They Decide to Keep the Child
When they decide to keep the child, they should be given guidance to use all the
resources available in the community to fulfill their parental responsibilities.
(a) Family placement: in some specific cases, it might be necessary for the child
to be placed with a family that has registered as temporary caregivers with the public
system for these ends.
(b) Provide facilities for the day care of the child: crèches, day care centers and
others that help the adolescent mother’s reinsertion into the school system or her
incorporation into the labor market.
(c) Alternative school programmes that can help the pregnant adolescent and
mother to stay at school and help her to improve her scholastic achievements, together
with caring for her child.
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330 Cartes · Araya
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them for a better paid job.
(e) Give attention for the partner of the adolescent, especially if he is an adoles-
cent. He should be taken as a subject that requires service. The adolescent father can
face emotional problems that are similar to those of the adolescent mother. Paternity
might generate in him conflicts and possible guilt feelings that might prevent his
adjustment. He might benefit from discussing his conflicts and his responsibilities
towards the child and mother.
(f) Inform the adolescent mother of the advantages of recognition of paternity,
which include inheritance rights from the father, social security benefits, and right to
paternal support.
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discipline techniques that are appropriate for the child.
(h) Speedy access to effective contraceptive methods in order to prevent repeated
and unwanted pregnancies.
When the Adolescent Mother Decides to Give Her Child for Adoption
When they decide to keep the child, she should feel that this is a responsible act to give
the child a life that she cannot or does not want to give it. She should think of adoption
as a responsible act of her maternity. She should receive guidance from a professional or
institution that is well aware of the adoption process and can help her with it.
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Bibliography of Social Factors Related to Adolescent Pregnancies
Ramiro Molina Cartes
Centro de Medicina Reproductiva y Desarrollo Integral de la Adolescencia (CEMERA), Facultad de Medicina,
Universidad de Chile
8380455 Santiago (Chile )
E- Mail ramiromolina@med.uchile.cl
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