Adolescent or teenage pregnancy is defined as a young female under the age of 20 becoming pregnant (World Health Organisation [WHO], 2014; United Nations Children’s Fund [UNICEF], 2008).
Teenage pregnancy is part of multiple inequalities in health; the WHO (2017) defines health inequality as ‘differences in the health condition and/or in the distribution between different population groups’.
The health risks for the mother involve may be physical, such as pre-eclampsia, obstructed labour due to undeveloped pelvis, anaemia, urinary infections and eating disorders (Cantlay, 2015), social and psychological such as social exclusion, poverty, discontinuation of studies, substance abuse, and the likelihood of postnatal depression. Pregnant teenagers are also more likely to access antenatal care at a late stage of the pregnancy (Public Health England [PHE], 2016; Royal College of Midwives [RCM], 2015a), which is key to reduce adverse maternal and baby outcomes.
Additionally, babies born to teenage mothers are at a higher risk of low birthweight, premature birth, a 30% higher risk of stillbirth and a 45% higher risk of infant mortality, they are also 30% less likely to be breastfed compared to the babies of older women (PHE, 2016; RCM, 2015a).
The poster will focus on the risks that a teenage mother may encounter, followed by a critique supported by various sociological and behavioural theories that explain the problem. The midwives’ role is also discussed within this context.
A Public Health Concern:
The issue in the United Kingdom is due to the high incidence of teenage pregnancy amongst Europe and the risks associated with it (Department of Health [DoH], 2010), in addition, it is estimated to cost the NHS 63 million a year (Cantlay, 2015).
Despite the last national data available showing a decline in the rate of teenage pregnancy, if compared to the previous years; the under-18 conception rate fell from 24.3 conceptions per 1000 women aged 15 to 17 in 2013 to 22.8 in 2014 (Office for National Statistics [ONS], 2017a), there is no recent data from 2016-2017 to state that there has been a clear reduction in the teenage pregnancy rate or that the current Public Health programmes are achieving this priority. The United Kingdom had one of the highest rates amongst West Europe in 2015 at a rate of 6.4 per 1000 livebirths for women under 18 compared to other countries such as 0.8 in Denmark and 1.1 in the Netherlands (ONS, 2017b).
Therefore, teen pregnancy remains as Public Health concern in England with the priority to achieve the same rates as the rest of the European countries (Ma, 2016).
Many national publications are focused on prevention of teenage pregnancy, however, other than a recent Public Health England report published in 2016, very little is mentioned regarding the strategies that must be created to support the teenagers who want to or are becoming mothers for other reasons (Knowsley, 2014; DoH, 2011; DoH, 2010). Thus, this report intends to explain teenage pregnancy holistically and the midwifery role.
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Poster description and intervention:
The image shows a teenager plagued by many issues and worries yet unable to express them. One such problem is social exclusion which presents a major problem for pregnant teenagers. It may be the result of bullying in school, poverty or unstable financial situations or even mental illnesses such as depression, which are prevalent in teenagers (PHE, 2016; RCM, 2015a). Other common problems include drug abuse and STD’s. As the chances of a teen having an STD are high (RCM, 2015a) healthcare professionals must ask related questions at antenatal appointments.
The ‘Teen Mom’ logo is included as it originated from a famous TV show about teenage pregnancy, this was done to make it recognisable to teenagers who are more familiar with the media world, as well as clearly stating that this poster is aimed at teenagers, since the pregnant girl’s age might not be apparent.
To make the poster more persuasive and relevant and to encourage youth proactivity, social media logos have been also included to promote support seeking.
At the bottom left corner of the poster, the question ‘need someone to talk?’ is proposed, followed by ‘We listen!’, which suggests that midwives are more used to giving out information than listening to what the pregnant young women may have to say. The statement does not, however, specify that the intervention is intended to provide counselling and promote health using an educational approach.
Counselling is a form of psychosocial therapy (Hough, 2014), which midwives also use as a part of their skills.
It involves listening and supporting the teenager to find the best solutions for them. However, it does not attempt to solve all the problems and should be done in a confidential environment, free of judgement against the teenager and without the counsellor attempting to use generalised techniques for a unique situation or individual to solve the problem (NHS Choices, 2014; Hough, 2014).
At the same time, the poster indicates some (but not all) the risks that the teenager may grapple with. The purpose of the poster is to make the teenager aware of her vulnerable status and to seek the appropriate support available.
As stated per the educational approach; the teenager who is self-aware about their risks takes responsibility for their actions and of the life of their unborn child and will be more likely to seek help (DoH, 2010; Leishman and Moir, 2007). At the same time, young fathers should be encouraged to take part in the education process. However, the inclusion of the father is dependent on the situation and must be taken on a case-by-case basis.
Ultimately, health promotion encourages healthy lifestyles and the access to the healthcare system (Naidoo and Wills, 2000). The aim is to prevent the health and psychosocial risks associated with teenage pregnancy in the models described above.
Theoretical framework and critical analysis:
Firstly, we must consider that there are some sexual risk factors that could lead to pregnancy in teenage girls, such as lower economic status, substance misuse, lack of communication with the family or partner, dysfunctional families, lack of supervision, peer pressure or media influence (Langille, 2007; Leishman, 2007). Having identified these, there are different groups in society that are more likely to become pregnant at a young age. To analyse these, various theories will be used and explained primarily in the context of the United Kingdom.
Teenage pregnancy can be explained by a Sociological Theory from the different perspectives and Behaviour Theories.
The Sociological Theory is useful in this issue as allows for the explanation of a phenomenon which one does not have control or experience over (Barry, 2012). It enables researchers to analyse and understand why these pregnancies might happen, especially in vulnerable groups of the society. At the same time, the cultural relativism approach uses culture as the main context to explain specific phenomena (Howson, 2009).
Currently, there is no recorded data available on teenage mothers who give birth per ethnic group in the United Kingdom (Aspinall and Hashem, 2010). However, there are independent sources and an article which found data from the Labour Force Survey, which proves that teenage pregnancy is more common in ethnic minority groups in the United Kingdom, such as Caribbean, Pakistani and Bangladeshi compared to white. This may be due to cultural/religion reasons as most Pakistani and Bangladeshi were found to have babies inside marriages at a teenage age (Berthoud, 2001), these facts come together with the evidence that a socioeconomic disadvantaged background influences the decisions in childbearing (McCall et al.,2015; Coyne and D’Onofrio, 2012).
On the other hand, the social conflict theory was developed by Karl Marx during the 19th century. Marx focused on society by its economic structure, which is viewed as a place of inequalities that generate conflicts between the most vulnerable group of society and a highest social class (Ritzer and Stepnisky, 2014).
Conflict is manifested in different ways in society and it is useful to explain how nowadays it is influenced by the media. Stereotyping messages are spread in TV that can affect how society and professionals view teenage pregnancy. The poster, therefore, makes a reference to shows such as ‘Teen Mom’ and ‘16 and Pregnant’, where young mothers’ lives are glamourized and teen pregnancy is often shown as a route to fame or stardom. This can lead to conflict in society as a way of promoting teenage pregnancy.
In the United Kingdom, teenage pregnancy has a cost to society for childcare and increased public services (PHE, 2016), which can also create conflict. ‘Media myths’ about teenage mothers are recognised and encouraged in the country (Anwar and Stanistreet, 2014) stating that girls are attracted by the financial benefits of having a baby and that they would ‘enjoy a glamourous life’. However, there is evidence that teenage mothers are more likely to live in poorer conditions and deprived areas, more likely to suffer from negative outcomes; social, economic and educational (PHE, 2016; Corlyon, 2011). So how does living under childcare benefits create a glamourous lifestyle?
Stereotypes involve the determination of distinctive characteristics in a particular group of society that can be shameful or negative and is most prevalent in the interaction between teenagers and adults (Anwar and Stanistreet, 2014; Hatzenbuehler, 2013 Devlin, 2006). A ‘stereotype image’ is not shown in the poster (for example; a problematic teenager in a deprived area with a drug problem) as this would perpetuate the stereotype that all pregnant young mothers are like this.
Midwives must keep in mind that many of the issues described previously are common in the teenager. However, even a teenage mother fits the stereotype, her problems should not, in any way, interfere with her access to proper care and treatment. Otherwise, it is considered to be discrimination on the stereotypes or labels and is ‘problematic’.
Another theory that explains why some of these teenagers become conflictive is the problem behaviour theory by Richard Jessor developed in 1978, these ‘problematic’ behaviours are due to their influencing relationships and environment since social relationships in teenagers are particularly important (Coyne and D’Onofrio, 2012; Crowther and Jessor, 1978).
Therefore, a teenager deprived of a proper parenting/upbringing style is more likely to have suffered neglect and abuse, which is then manifested in conflict behaviour (for example, a sexual risk behaviour) as a form of rebellion against the family (Romano, 2006; Crowther and Jessor, 1978).
This theory might explain pregnancy in vulnerable teenagers, who do not have a big support network, hence, they require more support from professionals. The poster is aimed at this particular group although, it may not be clearly represented.
Since the teenagers who are pregnant form a heterogeneous group of people in society, who can have diverse characteristics and different experiences, this theory does not justify all cases of teenage pregnancy. The ‘stereotypical’ view of the conflictive teenager in a deprived area might not be applicable for many of them. Therefore, other studies with particular ‘positive’ views have aroused from this topic.
From these studies done in the United Kingdom, it was found that some teenagers wanted to become mothers and took it as a role they were proud of (Anwar and Stanistreet, 2014; Arai, 2009, Cater, 2006). Some of the teenagers interviewed in the qualitative studies state that having a baby helped them to find jobs and it was viewed as normal to be parents at a young age in their particular society (Anwar and Stanistreet, 2014; Cater, 2006). For some, it was also a way to improve their socioeconomic status and become independent (Coyne and D’Onofrio, 2012; Cater, 2006).
Thus, it is deduced that not all teenage pregnancies are unwanted or unplanned and may be a positive experience. However, the adverse outcomes for the mother and baby in the present and future must be taken into account at all times when having interventions with the teenager (PHE, 2016; DoH, 2010).
From these studies, it is also noticed that most were done in areas of poverty and lower incomes, which again challenges the fact that vulnerable teenagers require more support as their own experience may be more important than the outcomes described.
The Midwives’ Role:
Midwives play an important role for the teenage mother in the antenatal clinic. The identification of sexual, social and psychological problems at the booking history is key when trying to help with a teenage mother’s individual needs (PHE, 2016; RCM, 2015a)
It is specifically recommended that the midwives should discuss the mental health wellbeing of the young mother at every visit since these groups are at risk of suffering depression (RCM, 2015a; Leishman, 2007).
There are services that midwives must make use of and refer to, as they have been shown to improve outcomes in the teenage mothers and their partners, including helping them to seek for job and education and domestic violence prevention, like the Family Nurse Partnership Programme (PHE, 2016). Midwives can also give the Healthy Start vitamins and vouchers as all under 18’s and low incomes qualify for it, which is one of the ways to promote a healthy diet since teenagers are very likely to have eating disorders and a poor diet (PHE, 2016).
Some teenagers might also be at risk of serious harm or it is suspected that the teenager has suffered sexual exploitation, in which case, the midwife must refer to the Safeguarding specialist team (PHE, 2016). Midwives must consider this as a probability always as it is not uncommon for a pregnant teen to have suffered some kind of abuse (PHE, 2016; RCM, 2015a; Saewyc, 2004).
On the other hand, referrals might still not resolve all the problems that the teenager is experiencing and there are things often missed at the antenatal appointments. This might be due to lack of time and training around the particular problems of the teenager, which are only one of the few issues among the multiple challenges that midwifery is currently experiencing in the United Kingdom (RCM, 2015b).
In this case, it is particularly important to create a non-judgemental and open-minded environment, which are elements of a women-centred midwifery care and the Code of Conduct (NMC, 2015; Tharpe, 2013), as discussed previously, this group is particularly vulnerable to the stereotypes and labels (Anwar and Stanistreet, 2014; Devlin, 2006).
There are recent studies that demonstrate how these labels affect midwifery care; for example, in breastfeeding as it was found that midwives’ do not promote or empower teenage mothers to breastfeed, despite most mothers expressing an interest in breastfeeding their infants (Hunter, 2014).
Therefore, the teenager will be more likely to express her concerns if she does not fear being judged and midwives’ will be at the same time able to understand the uniqueness of the situation more accurately.
Midwives’ caring for teenage girls must be aware of the psychosocial implications that this pregnancy has; not just for the mother but also for the baby and later in life. Care must also not focus exclusively on the ‘high risk’ category due to the health risks. The ‘high risk’ language often medicalizes care and means that midwives deny a women-centred care, where the opinions and experience of the girl, in this case, are at the core (RCM, 2015c).
Conclusion:
Teenagers have unique issues that differ from other groups of people, these differences are part of multiple health inequalities that involve mental health and social factors. A pregnancy for a young girl, therefore, involves a higher risk associated with all of her holistic dimensions (health, social and psychological).
These health inequalities are encouraged by stereotypes and labels, which might be making the issue bigger rather than if an open-minded and non-judgemental health service was provided.
Actions supporting teenage mothers and fathers should be more specific, focusing on particular problems such as the personal experiences of the teenagers and how they vary. Individual and midwifery care is required, especially in deprived areas.
There are many current services available. However, midwifery care still experiences challenges and the care in the antenatal clinic requires improvement in order to understand the situation of the teenager