© International Epidemiological Association 2002 Printed in Great Britain
POINT–COUNTERPOINT
Too much too young? Teenage pregnancy
is not a public health problem
Debbie A Lawlor and Mary Shaw
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 con-
solidation 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 pro-
cess 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 requir-
ing targeted interventions.3–6 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
Department of Social Medicine, University of Bristol, Canynge Hall,
Whiteladies Road, Bristol BS8 2PR, UK.
552
International Journal of Epidemiology 2002;31:552–554
A crucial question relates to whether the adverse outcomes
experienced by (some) mothers and children of teenage preg-
nancies 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 socioeco-
nomic 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 sep-
arating 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 teen-
age 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 preg-
nancy 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 preg-
nancies 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’ preg-
nancy is detrimental to either baby or mother has not been
established.
It is important to consider whether labelling teenage preg-
nancy 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 expo-
nentially 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 asso-
ciated 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
TEENAGE PREGNANCIES 553
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 do
we 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. TheHealth 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.
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.
9 Fergusson DM, Woodward LJ. Maternal age and educational and
psychosocial outcomes in early adulthood. J Child Psychol Psychiatry
1999;40:479–89.
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.
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.
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.
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.
15 Geronimus AT. What teen mothers know. Human Nature 1996;7:323–52.
554 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
16 Geronimus AT. The weathering hypothesis and the health of African-
American women and infants: Evidence and speculations. Ethn Dis
1992;2:207–21.
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.
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.
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.
22 Hanna B. Negotiating motherhood: the struggles of teenage mothers.
Journal of Advanced Nursing 2001;34:456–64.
23 Goldenberg RL, Klerman LV. Adolescent pregnancy—another look.
N Engl J Med 1995;332:1161–62.
© International Epidemiological Association 2002 Printed in Great Britain
Too much too young? Teenage pregnancy
is a public health, not a clinical, problem
Gabriel Scally
The argument as to whether teenage pregnancy is a public
health problem or not entirely depends on the definition of a
‘public health problem’. In the absence of any working definition,
Lawlor and Shaw concentrate on the biological outcomes of
full-term pregnancies amongst teenagers. There is some legitimacy
in their proposition that the adverse maternal outcomes, from
a narrow medical perspective, do not constitute a major public
health problem. They do not, however, deal with the much
more important issues of the educational and social effects of
early motherhood. It is surely a palpably good thing for it to be
socially, culturally and economically unacceptable that so many
teenagers disrupt their lives through the consequences of
an unwanted pregnancy. The conclusion of the authors of the
Effective Healthcare Bulletin that ‘Teenage pregnancy is associated
with increased risk of poor social, economic and health out-
comes for both mother and child’, places health outcomes third
behind social and economic outcomes.1
The reason why teenage pregnancy is an important public
health issue is because integrated action across several sectors
is needed to help young women avoid unwanted pregnancy
and to deal with the consequences of pregnancy whether it is
wanted or not. That the health sector has an important role in
Regional Director of Public Health, South West Region, England.
24 Orr ST, Miller CA, James SA, Babones S. Unintended pregnancy and
preterm birth. Paediatr Perinat Epidemiol 2000;14:309–13.
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.
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.
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.
International Journal of Epidemiology 2002;31:554–555
this must surely be undeniable. There is not only the com-
plexity of providing sexual health services for young people
but also the organization of maternity services for teenagers
who decide to continue with a pregnancy and the provision of
termination services for those who do not. The strategy laid out
in the Social Exclusion Unit’s report goes far beyond issues of
health service provision and sets out to tackle issues including
education, housing, social security benefits and self esteem.2
The reason why teenage pregnancy is regarded alongside
cardiovascular disease, cancer and mental health is precisely
because similarly broad-based action is needed in all of these
areas. The problems of obesity, smoking, poor diet, and social
isolation cannot be considered solely as medical issues if we
want to prevent disease rather than treat the consequences of
it. That is not to say that there are not potential difficulties
in singling out teenage pregnancy as a key issue in the sexual
health field. The most serious issue is the way in which the
setting of targets for teenage pregnancy can distort priorities
within the sexual health field. The establishment of a target for
the reduction in the rate of pregnancies to under 16s in the
‘Health of the Nation’ strategy encouraged some Health Author-
ities to reduce sexual health services for older groups despite the
highest rate of unwanted pregnancy, judged by the termination
rate, occurring amongst women in their twenties.

Lawlor and Shaw are incorrect to say that health risks arising
from pregnancies to older women are disregarded. The growth
of assisted, and particularly multiple, conception is seen as an
important issue. The rise in age at first pregnancy has magnified
widespread concern about the ineffective operation of antenatal
screening and has led to a major initiative to improve the system
in the UK.
The effort to medicalize public health goes back a long way.
John Ryle was one of the most prominent advocates of substitu-
ting disease based social medicine for public health. He sought
to substitute ‘inspiration more from the field of clinical experi-
ence’ for what he perceived to be an over-emphasis on the
environment.3 Lawlor and Shaw have followed the same
tempting, but flawed logic. This leads them to conclude that
because the consequences of unwanted teenage pregnancy
cannot be quantified as being substantial in terms of disease then
it cannot be a public health issue.
Perhaps the most disturbing element of Lawlor and Shaw’s
paper is the misconstruing of what Tony Blair wrote in his
Foreword to the Social Exclusion Unit’s Teenage Pregnancy
© International Epidemiological Association 2002 Printed in Great Britain
Teen pregnancy is not a public health crisis in
the United States. It is time we made it one
Janet Rich-Edwards
Strictly speaking, Lawlor and Shaw are correct. After adjusting
for family background, race/ethnicity, socioeconomic position,
educational success, and future prospects, many US studies
show that teen mothers are as likely as older mothers to bear
and raise healthy, successful children.1–6 After adjusting for
being born to Texas oil barons and educated at Andover and
Yale (throw in effect modification by paternal occupation), might
you or I be the leader of the free world? Sure. The sanitary
appeal of our modelling exercises can blind us to the sheer com-
mon sense of crude numbers. Teen parenthood is still associated
with infant mortality, childhood illness, welfare dependence,
academic failure, juvenile crime, and teen parenthood in gen-
erations to follow.7,8
This is not to deny the importance of research into the causes
and effects of teen pregnancy. Indeed, it is testimony to the
increasing strength of epidemiological methods that maternal
age can be stripped from its tight association with economic and
social risks, yielding the conclusion that teen pregnancy (at least
for the 98% of teen pregnancies that occur after age 14 in the
US)9 poses little, if any, inherent biological risk in the developed
Department of Ambulatory Care and Prevention, Harvard Medical School and
Harvard Pilgrim Health Care.
TEENAGE PREGNANCIES 555
report.2 He did not write that teenage pregnancy was shameful,
what he wrote was that the UK’s record in respect of the rate of
teenage pregnancy was shameful. These are completely differ-
ent things. The idea of teenage pregnancy being shameful is
surely a concept that’s time has long passed, whereas a recog-
nition that we as a society have a shameful record in the poverty,
educational failure and social exclusion of teenage mothers is an
important step in doing something to rectify that situation.
Unless of course you care only for perinatal mortality rates and
not about disrupted young lives.
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 Social Exclusion Unit. Teenage Pregnancy. London: The Stationery
Office, 1999.
3 Ryle J. Changing Disciplines. Oxford: Oxford University Press, 1948.
International Journal of Epidemiology 2002;31:555–556
world. Such studies implicate poverty, not maternal age, as the
real threat to maternal and infant welfare. It is not just the
disadvantaged, but the ‘discouraged among the disadvantaged’
who become teen mothers.10 Poverty causes teen pregnancy.
Simply put, girls with prospects do not have babies.
But does premature parenthood cause future poverty?
Remarkably, with appropriate control for economic background
and educational attainment prior to pregnancy, it appears that
the life trajectories of teen mothers are little altered by becom-
ing mothers in their teens.5,11 Circumstances were not about to
improve for these young women, even if they had postponed
pregnancy into their twenties. In the words of one Boston teen,
‘Why should you wait? Who’s coming?‘12 Under these circum-
stances, it would make little, if any, difference to US public
health if teen mothers were to wait a few years. Indeed, where
cumulative exposure to poverty and stress degrades maternal
health capital, risks of poor pregnancy outcome may actually
rise with maternal age.13 Arline Geronimus has argued that in
the face of such powerful weathering forces, it makes sense for
disadvantaged women to bear their children in their teens.14
These data indict a society in which many youth face pros-
pects so bleak that the conventional credentials of adulthood, a
high school degree and a job, are rendered nearly worthless.
556 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Where there is no opportunity, there is no cost to early parent-
hood. However, there is a corollary: increase opportunity, and
the cost of early parenthood rises. Teens appear to be rational
beings who, given the motivation and the means, will exploit oppor-
tunity by delaying parenthood long enough to gain a social and
economic foothold. Hence the success of some teen pregnancy
prevention and parenting programmes, which provide both
motivation and means to escape poverty and delay parent-
hood.15,16 Teens may also be motivated by real or perceived
changes in the economy: some have argued that the decline
in the US teen pregnancy rate over the last decade was a by-
product of economic expansion.17
So where is the public health crisis? If there is a real health
cost of teen pregnancy, we are hard put to measure it. Our best
estimates remain fraught with confounding and selection bias.
However, common sense tells us that there is large and elastic
margin of teens who can correctly self-select themselves out of
a future of poverty and ill health, given a chance to enhance
personal and job skills, and with full access to contraception and
abortion services. These constitute the means to escape poverty
and early parenthood. The motivation to delay parenthood springs
from real local opportunities. We must create environments in
which educational attainment matters, jobs have living wages,
and it simply makes sense to avoid premature parenthood. We
need to make teen pregnancy a real public health crisis.
What is the alternative? To dismiss the needs of today’s and
tomorrow’s teen mothers because their counterfactuals would
not have amounted to much? The crude data demonstrate that
teen mothers need opportunities and tools to escape poverty;
the adjusted data show us that self-selection will prevent teen
pregnancy where such opportunities and tools exist. The equal-
izing power of our adjusted statistical models can be beguiling.
Let us not forget that the real world is not a level playing field,
that equal opportunity remains a polite national fiction, and
that statistics alone will not loosen the sickly embrace of poverty
and teen pregnancy.
References
1 Gueorguieva RV, Carter RL, Ariet M, Roth J, Mahan CS, Resnick MB.
Effect of teenage pregnancy on educational disabilities in kinder-
garten. Am J Epidemiol 2001;154:212–20.
2 Scholl TO, Hediger ML, Huang J, Johnson FE, Smith W, Ances GI.
Young maternal age and parity. Influences on pregnancy outcome.
Ann Epidemiol 1992;2:565–75.
3 Reichman NE, Pagnini DL. Maternal age and birth outcomes: data
from New Jersey. Fam Plann Perspect 1997;29:268–72.
4 Makinson C. The health consequences of teenage fertility. Fam Plann
Perspect 1985;17:132–39.
5 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.
6 Rothenberg PB, Varga PE. The relationship between age of mother
and child health development. Am J Public Health 1981;8:810–17.
7 Committee on Adolescence, American Academy of Pediatrics.
Adolescent pregnancy—current trends and issues: 1998. Pediatrics
1999;103:516–20.
8 Maynart RA (ed.). Kids Having Kids. A Robin Hood Foundation Special
Report on the Costs of Adolescent Childbearing. New York, NY: The Robin
Hood Foundation, 1996.
9 National Center for Health Statistics. Vital and
Health Statistics, 1998.
Vol. 1: Natality. Rockville, MD: National Center for Health Statistics.
Table 1–13.
10 Luker K. Dubious Conception. The Politics of Teenage Pregnancy.
Cambridge, MA: Harvard University Press, 1996.
11 Hoffman SD. Teenage childbearing is not so bad after all ... or is it?
A review of the new literature. Fam Plann Perspect 1998;30:236–43.
12 Dodson L. Don’t Call Us Out of Name: The Untold Lives of Women and Girls
in poor America. Boston: Beacon Press, 1998, p. 97.
13 Geronimus AT. The weathering hypothesis and the health of African-
American women and infants: evidence and speculation. Ethn Dis
1992;2:207–21.
14 Geronimus AT. What teen mothers know. Human Nature 1996;7:
323–52.
15 Kirby D.
Emerging Answers: Research Findings on Programs to Reduce Teen
Pregnancy. Washington, DC: The National Campaign to Prevent Teen
Pregnancy. May 2001.
16 Roth J, Brooks-Gunn J, Murray L, Foster M. Promoting healthy
adolescents: synthesis of youth development program evaluations.
Journal of Research on Adolescence1998;8:423–29.
17 The Alan Guttmacher Institute. The Guttmacher Report on
Public Policy.
New York: The Alan Guttmacher Institute, October 1998; pp. 6–8.
© International Epidemiological Association 2002 Printed in Great Britain
Too much too young? In Nepal more a case
of too little, too young
Sally Smith
It is critical that as public health specialists we identify carefully
and more exactly where the problem lies with teenage preg-
nancy. Is the age of the mother the critical factor determining
the subsequent health of mother and baby? Or are the ‘other
confounding factors’ referred to in some of the research studies
in fact the real problems?
Lawlor and Shaw refer to studies that make more serious
efforts to control for these confounding factors, concluding that
increased risks are predominantly caused by ‘social, economic
and behavioural factors that predispose some young women
to pregnancy’. They indicate that cultural factors may also play
a part. To what extent do the poor outcomes of teenage preg-
nancy reflect the attitude of a society towards teenage pregnancy?
And 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?
To look at these questions in the light of 16 years of repro-
ductive health work in Nepal is not just fascinating but vital; for
many young women they represent life and death issues over
which they have no control.
A simple place to start is to state that 43% of girls in the hill
areas of Nepal marry in their teens (between 15 and 19 years of
age).1 There is strong cultural and family pressure to produce a
son within a year; the status of the young woman within her
new family is dictated predominantly by this one factor. From
the Nepalese perspective early pregnancy is a highly successful
outcome; an extended family network cares for the baby, thus
mitigating some of the problems associated with immaturity of
the young mother.
Pregnancy outside of marriage, however, is a catastrophe. The
girl becomes unmarriageable unless a hasty marriage can be
arranged (which is not always culturally acceptable), her future is
destroyed and she becomes a social outcast. The baby may be
aborted (often at considerable risk to the life of the mother)
adopted (rarely) or die. An unmarried teenage girl would not
normally have the option to keep her baby and remain sup-
ported by her family. Some of these girls, in desperation, commit
suicide or run away to avoid shame, in which case the baby may
be born in the open and abandoned by the mother.
The simple answer to the question ‘is teenage pregnancy a
public health problem?’ in Nepal, would initially seem to be: No.
It is, as elsewhere, unwanted and socially unacceptable preg-
nancy, which is the problem.
On deeper examination however the situation may not be as
simple as that. When one looks at the maternal and infant
mortality rates for Nepal compared to England and Wales they
are hugely different. The maternal mortality rate per 100 000
Director Saknya HIV/AIDS Prevention Education Unit, United Missions to
Nepal (until 1999).
557
International Journal of Epidemiology 2002;31:557–558
live births was 539 in Nepal in 1996, whereas in England and
Wales it was 6.4; the infant mortality rate per 1000 live births
was 78.5 in the period 1992–1996 in Nepal, whereas in England
and Wales it was 6.2 in 1994.1,2 One may be drawn to conclude
that age at first pregnancy in Nepal, even in the ‘socially accept-
able’ group of married teenagers, may actually be a factor in
high maternal and infant mortality rates. Let us ask the question
again: ‘To what extent would delaying the age of marriage, and
the age of first birth, have an impact on the outcomes of
pregnancy and the health of both mothers and babies in Nepal?’
Some of the factors to consider are:
Nutrition
In the hills of Nepal the diet may be extremely limited (50%
of the population receive less than adequate calorific intake).1
Young girls are usually last in line for food; they receive less
food, of lower nutritional value, than their brothers. Once
married, the daughter-in-law is the least important member
of the family and certainly receives least food. The incidence of
anaemia in pregnancy (63%),1 low birthweight (25.4% births
less than 2500 g)1 and cephalopelvic disproportion are signifi-
cant. Delaying age of marriage and first birth would have an
effect on the nutritional and maturational problems faced by
very young mothers, simply giving her longer to develop and
grow, even if all other factors remained the same.
Education
Increasing numbers of Nepali girls are attending school and
having the opportunity to receive high school education (female
enrolment in high school as per cent of male enrolment is 28%).1
In the cities more females are attending college and have the
chance to enter paid employment. Women who have a second-
ary schooling are less likely to give birth during adolescence,
and the survival rate of children increases with years of high
schooling received by the mother. On average women with
seven more years of education marry four years later and have
2.2 fewer children than those with no education.3 In countries
where women are subjected to multiple pregnancies over many
years her later years of childbearing may also be high risk. To
decrease her overall number of reproductive years, and the
overall number of children, increases the survival and health of
the smaller number she does have, as well as the health of the
mother herself.
Increased income-earning skills
If young women are given the opportunity to gain skills with
which they can earn an income, then they provide increased
558 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
family income for food and medicines. Since poverty is almost
certainly a key factor in health and child survival—and it is well
known that mothers will use their own income to pay for food
and medicines that their children need—then to delay marriage
and childbearing until the woman has income-earning skills
will increase her overall health and that of her children.
A direct spin-off from education, income-generating power,
and literacy, are the increased levels of ‘empowerment’ experi-
enced by women. Women with literacy, education and even small
amounts of their own money have a confidence and bargaining
power unknown to those without it. A woman’s reproductive
health decisions are often controlled by her male partner—to
empower a young woman may in itself be one of the most
powerful factors in improving reproductive health. A woman
able to: avail herself of family planning services, understand
the messages and make informed choices about their use, limit
her family size, negotiate safe sex and condom use to prevent
infection with sexually transmitted diseases, and decide to take
her child to the health centre and have her immunized, is in
a powerful position to influence her health, and that of her
children. Literacy, education and income do not guarantee a
woman any of these freedoms, but they increase her chances of
gaining them.
© International Epidemiological Association 2002 Printed in Great Britain
What a difference a year makes?
Too little too late
Debbie A Lawlor and Mary Shaw
‘… if we could successfully intervene and change a woman’s age at
first birth and nothing else about her up to that point‘?1
Scally argues that we do not deal with the much more import-
ant issues of the educational and social effects of early mother-
hood and focus on a narrow medical definition of public health.
We would argue that we deal primarily with the detrimental
effects, for mother and child, of social deprivation. However, we
do not feel that these problems are the preserve of one particular
age group. We agree with Scally, Rich-Edwards and Smith that
some teenage mothers in the UK, US and Nepal have blighted
lives, but we do not believe that labelling a woman who chooses
to have a baby under the age of twenty as a public health prob-
lem actually helps the mother or her child. We believe that the
underlying problem lies in society’s attitudes towards young
people and specifically in attitudes towards women’s repro-
ductive lives.
Department of Social Medicine, University of Bristol, Canynge Hall,
Whiteladies Road, Bristol BS8 2PR, UK.
In conclusion therefore I would say that in Nepal it is not so
much a case of ‘too much too young’, but the opposite, ‘too little
too young’: too little food, too little education, too little finance
and too little choice. This is what makes teenage pregnancy a
problem. Active efforts to delay marriage and age of first preg-
nancy alone would make significant differences to the health of
mothers and babies in Nepal. When active attempts are made to
address the ‘too littles’ then we will begin to see real improve-
ments in the health status of mothers and their children.
Acknowledgements
Thanks to Saknya Unit staff, in particular Dr A Furber for
commenting on an earlier draft of this counterpoint.
References
1 Country
Profile. Nepal. http//w3.whosea.org/cntryhealth/nepal/index.
htm (accessed February 2002).
2 Macfarlane A, Mugford M, Henderson J, Furtado A, Stevens J, Dunn
A. Birth Counts: Statistics of Pregnancy and Childbirth. Vol. 2. Tables.
London: The Stationery Office, 2000.
3 Childbearing. Safe Motherhood Fact Sheet. http://www.safemotherhood.
org/ facts and figures/adolescentsexuality.htm (accessed February 2002).
International Journal of Epidemiology 2002;31:558–559
It seems that we are all agreed that there are no inherent
health or medical problems associated with becoming pregnant
and having a child before the age of twenty. Therefore, if society
were such that a 16-year-old could begin her family at that
age, and then say in her mid-twenties, return to education or a
chosen career path, without prejudice and undue uphill struggle,
there would be no problem. Referring to very different contexts
Rich-Edwards and Smith suggest that if young women are pro-
vided with education, income-earning potential and empower-
ment then an additional benefit will be that early motherhood
will be delayed. But we would argue that opportunities, support
and services should be available to women regardless of their age
and regardless of whether or not they have children. Provision
should suit and support the reality of women’s lives, rather than
limit their opportunities and choices unless they organize their
reproduction in a socially acceptable way. Changing society’s
attitude towards young women and their reproductive choices
may facilitate better opportunities and support, labelling them
as a public health problem is unlikely to.2 Understanding that
an unwanted pregnancy is NOT the same as an unwanted
child or a child automatically doomed to fail in society is also

important. Labelling any aspect of teenage pregnancy as
shameful is unlikely to be beneficial. Concerted efforts to reduce
poverty and inequalities—a clear public health threat—for
women and men of all ages is clearly where public health policy
should be focused.3
TEENAGE PREGNANCIES 559
References
1 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.
2 Lawlor D, Shaw M, Johns S. Teenage pregnancy is not a public health
problem. BMJ 2001;323:1428.
3 Mitchell R, Dorling D, Shaw M. Inequalities in Life and Death: What If
Britain Were More Equal? Bristol: The Policy Press, 2000.