Journal of Adolescent Health 67 (2020) 239e244

www.jahonline.org

Original article

Association Between First Depressive Episode in the Same Year as

Sexual Debut and Teenage Pregnancy
Yassaman Vafai, Ph.D. *, Marie E. Thoma, Ph.D., and Julia R. Steinberg, Ph.D.
Maternal and Child Health Program, Department of Family Science, University of Maryland School of Public Health, College Park, Maryland

Article history: Received August 21, 2019; Accepted February 3, 2020

Keywords: Depression onset; Sexual experience; Teenage pregnancy; Adolescence health

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: This study aimed to examine whether the timing of depression onset relative to age at
sexual debut is associated with teenage pregnancy.
Adolescent girls who
Methods: Using data from 1,025 adolescent girls who reported having had sex in the National Co- experience depression
morbidity SurveydAdolescent Supplement, we applied cox proportional hazards models to test onset in the same year as
whether depression onset before first sex, at the same age as first sex, or after first sex compared with their sexual debut were at
no depression onset was associated with experiencing a first teenage pregnancy. We examined the an increased risk for
unadjusted risk by depression status as well as risk adjusted for adolescents’ race/ethnicity, marital teenage pregnancy. The
status, poverty level, whether the adolescent lived in a metropolitan area, living status, age at first findings indicate that not
sex, parental education, and age of mother when the adolescent was born. only the presence but also
Results: In both unadjusted and adjusted models, we found that adolescents with depression the timing of depression
onset at the same age as having initiated sex were at an increased risk of experiencing a teenage matters and emphasize
pregnancy (unadjusted hazard ratio [HR] ¼ 2.5, 95% confidence interval [CI]: 1.08e5.96; adjusted the need for integrating
HR ¼ 2.7, 95% CI: 1.15e6.34) compared with those with no depression onset. Moreover, compared mental health and sexual
with those with no depression onset, the risk of pregnancy for girls experiencing depression onset and reproductive health.
before first sex also increased but was not significant (adjusted HR ¼ 1.5, 95% CI: .82e2.76).
Conclusions: Timing of first depressive episode relative to age at first sexual intercourse plays a
critical role in determining the risk of teenage pregnancy. Timely diagnosis and treatment of
depression may not only help adolescents’ mental well-being but may also help them prevent
teenage pregnancy.
Ó 2020 Society for Adolescent Health and Medicine. All rights reserved.

For many women in the U.S., adolescence marks the initiation
of sexual intercourse [1], which may place them at risk for
teenage pregnancy. In 2013, the rate of teenage pregnancy
among girls aged 15e19 years was 43 pregnancies per 1,000
Conflicts of interest: The authors do not report any potential conflicts of
interest.
* Address correspondence to: Yassaman Vafai, Ph.D., Maternal and Child
Health Program, Department of Family Science, University of Maryland School of
Public Health, 1142 School of Public Health, 2242 Valley Dr, College Park, MD
20742.
E-mail address: yvafai@umd.edu (Y. Vafai).
adolescent girls, a 36% decrease from 2008 [2]. Despite this
decline, the U.S. has one of the highest teenage pregnancy rates
among developed countries [3,4]. Three fourths of teenage
pregnancies are unintended, meaning they occurred earlier in
life than the person wanted, or the person did not want any
children at all. Teenage pregnancy is associated with adverse
outcomes such as lower educational attainment and lower
employment opportunities in teen mothers [5e9] and preterm
birth and low birthweight in their children [10,11]. Therefore,
understanding factors associated with teenage pregnancy may
help in preventing these factors and their consequences. To that

1054-139X/Ó 2020 Society for Adolescent Health and Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2020.02.001
240 Y. Vafai et al. / Journal of Adolescent Health 67 (2020) 239e244
end, a more thorough understanding of the association between
depression, a common mental health experience among
adolescent girls, and teen pregnancy is warranted.
Previous studies have found that depression is associated
with contraceptive behaviors such as nonuse or inconsistent
use of contraception in adolescent girls and teenage pregnancy
[12e16]. However, no research has examined whether the timing
of depression at or around the time of sexual debut may place
teens at higher risk for subsequent teenage pregnancy. A better
understanding of how timing of depression onset relative to first
sexual experience is associated with teenage pregnancy is
important for clinical practice and public health interventions
aimed at preventing teenage pregnancy. Among recently sexu-
ally active teens, timely screening and treatment of depression in
addition to contraceptive counseling may help mitigate the risk
of pregnancy. The objective of this study, therefore, was to
examine the association between a first depressive episode
occurring before, at, or after age at first sex and the likelihood of
having a first teenage pregnancy among a nationally represen-
tative sample of sexually active adolescent girls aged 13e18 years
at the time of the survey.
Methods
Data source and study population
Data were drawn from the National Comorbidity Surveyd
Adolescent Supplement (NCS-A), a nationally representative
cross-sectional study of 10,123 adolescents (n ¼ 5,170 female)
aged 13e18 years in the U.S This study was designed to estimate
the lifetime and current prevalence of DSM-IV disorders, onset
age, course of development, and comorbidity of DSM-IV
disorders and associated risk and protective factors. The data
were collected in-person and use diagnostic interviews, which
are based on the modified version of the World Health Organi-
zation Composite International Diagnostic Interview (CIDI), a
fully structured diagnostic interview designed for use by trained
interviewers [17]. A detailed description of the measures and
study design of NCS-A is published elsewhere [18,19]. Briefly,
between February 2001 and January 2004, adolescents from
household and school-based samples were interviewed by
professional interviewers using computer-assisted personal
interviews. Access to and use of the data was approved by the
Interuniversity Consortium for Political and Social Research and
the University of Maryland, College Park’s Institutional Review
Board. Because the focus of this study is teenage pregnancy, our
study population was restricted to female participants who
reported ever having sex (n ¼ 1,139). We excluded girls who
reported having sex before age 11 years (n ¼ 8) because these
may not have been consensual [20] and those missing on cova-
riates (n ¼ 106) leaving 1,025 in the analytic sample.
Measures
Outcome: First teenage pregnancy. We defined whether a first
teenage pregnancy occurred using the following questions from
the survey: (1) have you ever given birth to a child; and (2) have
you ever had a miscarriage, stillbirth, or abortion. If adolescents
reported they had a child, or miscarriage, stillbirth, or abortion,
then they were coded as having had a teenage pregnancy. If they
reported not having a child, miscarriage, stillbirth or abortion,
then they were coded as not having a teenage pregnancy. We also
computed the age at adolescent’s first pregnancy for those who
had been pregnant at least once using responses to the following
questions: (1) how old were you when you had your first child;
and (2) how old were you (the first time you had a miscarriage,
stillbirth or abortion). For those who had been pregnant only
once, this age was used as the age at first pregnancy. For those
who had been pregnant more than once, the youngest age at
pregnancy was used as the age at first pregnancy.
Exposure: timing of first depressive episode. Age at interview, age
at first sex, and age at first minor and major depressive episodes
were reported by adolescents. Using this information, we oper-
ationalized the timing of a first depressive episode relative to
participants’ age at sexual debut into a four-level variable: (1) no
depressive episode onset; (2) depressive episode onset before
age at first sex; (3) depressive episode onset at the same age as
first sex; and (4) depressive episode onset after first sex but by
the end of study (age at interview or age at first pregnancy).
Covariates. Based on the literature, we included the following
baseline characteristics, which have been shown to be associated
with depression or teenage pregnancy [16,21]: race/ethnicity,
marital status, regional residency, living status, age at first sex;
participants’ parental education, and participants’ mothers’ age
at the time of giving birth to the adolescent participants.
Analyses
We compared pregnant and nonpregnant participants on
baseline covariates and timing of depression onset using chi-
square tests for categorical variables. To examine the relation-
ship between the timing of first depressive episode and the risk
of first teenage pregnancy, we conducted survival analysis using
Cox proportional hazards models. We reconstructed time to
pregnancy from first sex based on information on adolescents’
age at first sexual intercourse and age at first pregnancy (in
years). Age at first sexual intercourse was considered the study
origin for all participants, and time was measured from age at
first sex to the age at first pregnancy for those who became
pregnant. For those who were never pregnant, we right censored
adolescents at their age at interview (when the study period
ended). Individuals who had age at first sex at the same age as
the end of their study period were given a value of .01 years in
the study. Unadjusted and adjusted hazard ratios (aHRs) and 95%
confidence intervals (CIs) between the timing of first depressive
episode and first teenage pregnancy were estimated using Cox
proportional hazards models.
To account for the national representativeness of our sample,
we incorporated the sampling weights and the cluster and strata
variables to correctly calculate weighted sample size in the
bivariate analyses (proportion estimates) and the appropriate
standard error estimates in the regression models [19,22]. All
analyses were conducted in STATA 14.
Results
Of 1,025 adolescent girls who reported ever having had sexual
intercourse (our analytic sample), 13% (unweighted n ¼ 141)
experienced a first pregnancy during the study period. The total
time at risk from the age at sexual debut to the first teenage
pregnancy was 1,324.276 person-years, with the median at risk
time of 1 year (range: <1 to 6 years). Table 1 presents the
 Y. Vafai et al. / Journal of Adolescent Health 67 (2020) 239e244 241

Table 1
Baseline characteristics of the sample by pregnancy outcome (n ¼ 1,025)

Teenagers characteristics Overalla (n ¼ 1,025) Pregnancy statusa p value

Pregnant (n ¼ 141) Censored (n ¼ 884)

Unweighted (n) Weighted (%) Weighted (%) Weighted (%)

Depression onset status .038

No onset before pregnancy or end of study 717 70.3 59.3 71.9
Onset before first sex 216 23.0 27.4 22.6
Onset at first sex 55 4.4 9.9 3.6
Onset after first sex at or before pregnancy 37 2.3 3.4 2.1
or end of study
Current age, mean (SD) 1,025 16.2 (.11) 16.6 (.16) 16.1 (.12) .014
Race/ethnicity .005
White, non-Hispanic 559 65.9 50.7 68.1
Black, non-Hispanic 228 19.2 27.7 17.9
Hispanic 191 12.4 17.8 11.6
Others 47 2.6 3.8 2.4
Marital status <.001
Married/cohabiting 46 3.6 14.5 2.1
Never married 979 96.4 85.5 97.9
Poverty index ratio .002
<1.5 178 14.4 30.6 12.1
1.5 to 3.0 229 22.8 18.6 23.4
3.0 to 6.0 308 32.0 25.2 33.0
>6.0 310 30.8 25.6 31.5
Residential region .830
Metropolitan 454 49.0 48.2 49.1
Rural 247 16.1 14.6 16.3
Other 324 34.9 37.2 34.6
Living status <.001
Living with two biological parents 561 55.1 4.4 56.6
Living with two nonbiological parents 10 2.5 .1 2.9
Living with one biological and one 251 23.1 16.9 24.0
nonbiological parents
Living with a single parent 173 16.7 33.2 14.3
Other 30 2.7 5.3 2.3
Age at first sex, mean (SD) 1,025 14.9 (.1) 14.5 (.2) 14.9 (.1) .023
Age at first pregnancy, mean (SD) 141 15.5 (.2) 15.5 (.2) -
Age at depression onset, mean (SD) 313 11.9 (.3) 11.5 (.6) 12.0 (.3) .459
Parental characteristics
Education .391
Less than high school 168 13.4 18.1 12.7
High school graduate 380 39.2 44.6 38.4
Some college 233 23.3 18.4 24.0
College graduate or more 243 24.1 19.2 24.9
Mother’s age at time adolescents were born .977
19 197 20.1 20.5 20.0
>19 828 79.9 79.5 80.0

Chi-square tests were used to test whether there were differences in pregnancy status by race/ethnicity, marital status, poverty index ratio, residential regions, living
status, parental education, and maternal age at birth of the participants. Student’s t tests were used to test the differences in pregnancy status by age at first sex, age at
depression onset, and age at first pregnancy.
a
Survey weights were applied for the calculation of overall percentages, chi-square statistics, and differences in pregnant and nonpregnant groups.

baseline characteristics of the entire sample and differences by
pregnancy status. The majority of the participants did not have a
depressive episode (70%), whereas 23% had their first depressive
episode before age at first sex, 4.4% had a first depressive episode
at age at first sex, and 2.3% had their first depressive episode after
age at their first sexual intercourse. For those who had a first
depressive episode during the study period (n ¼ 308), the mean
age at first depressive episode was 11.9 (standard deviation
[SD] ¼ .3). Pregnant adolescent girls were more likely to have a
first depressive episode before, during, and after age at first sex
compared with those with no pregnancy, with the largest dif-
ference for first depressive episode occurring at age at first sex
(9.9% for pregnant vs. 3.6% for never pregnant; p ¼ .038).
The participants’ mean age at the time of the interview was
16.2 (SD ¼ .11). The majority of participants (66%) identified as
white non-Hispanic and were never married (96%). Forty-nine
percent resided in metropolitan areas, 55% reported living with
their two biological parents, and 32% were in the third poverty
index ratio category. Approximately 53% of teenagers had par-
ents with a high school degree or less, and 20% reported being
born to a teenage mother. Participants’ average age at sexual
initiation was 14.9 (SD ¼ .1), ranging from 11 to 18 years.
Adolescent girls with an experience of first pregnancy were
more likely to be from a black non-Hispanic or Hispanic back-
ground (45.5% vs. 29.6%; p ¼ .005), were more likely to be married
(14.5% vs. 2.1%; p < .001), to be living with a single parent (33.2%
vs. 14.3%; p < .001), and to be in the lowest poverty index ratio
(30.6% vs. 12.1%; p ¼ .002) compared with their nonpregnant
counterparts. Among participants with an experience of first
pregnancy, the mean age at first pregnancy was 15.5 (SD ¼ .2).
242 Y. Vafai et al. / Journal of Adolescent Health 67 (2020) 239e244

Table 2
Bivariate analysis between timing of first depressive episode and covariates (n ¼ 1,025)

Teenager characteristics First depressive episode timinga p value

No Onset before Onset at Onset after

onset (%) first sex (%) first sex (%) first sex (%)

Total unweighted (n) 717 216 55 37

Race/ethnicity .108
White, non-Hispanic 65.8 70.2 62.2 31.1
Black, non-Hispanic 20.4 11.3 20.6 56.8
Hispanic 11.3 15.7 14.3 8.48
Others 2.4 2.8 3.0 3.6
Marital status .491
Married/cohabiting 3.6 4.6 .5 1.9
Never married 96.5 95.4 99.5 98.1
Poverty index ratio .458
<1.5 14.9 11.0 26.5 10.4
1.5 to 3.0 24.1 19.3 14.5 33.8
3.0 to 6.0 31.6 35.1 22.2 26.9
>6.0 29.2 34.6 36.8 29.0
Residential region .116
Metropolitan 48.5 54.9 26.3 49.2
Rural 18.3 10.1 14.8 9.6
Other 33.2 35.0 59.0 41.2
Living status .034
Living with two biological parents 60.2 39.5 49.4 62.8
Living with two nonbiological parents 1.1 7.6 0 0
Living with one biological and one 21.0 30.6 21.7 14.8
nonbiological parents
Living with a single parent 15.7 19.7 18.7 15.3
Other 2.0 2.6 10.2 7.2
Age at first sex, mean (SD) 15.7 (.2) 15.3 (.3) 15.1 (.3) 15.8 (.4) .215
Parental characteristics
Education .124
Less than high school 14.4 9.5 14.6 19.4
High school graduate 42.3 33.0 24.5 31.9
Some college 19.3 32.4 39.3 24.6
College graduate or more 24.0 25.1 21.6 24.1
Mother’s age at time adolescents were born .064
19 17.5 30.6 7.7 19.0
>19 82.5 69.5 92.3 81.0

Chi-square tests were used to test whether there were differences in first depressive episode timing by race/ethnicity, marital status, poverty index ratio, residential
regions, living status, parental education, and maternal age at birth of the participants. Student’s t tests were used to test the differences in first depressive episode
timing by age at first sex.
a
Survey weights were applied for the calculation of percentages, chi-square statistics, and differences in depression groups.

Table 2 shows the differences in baseline characteristics by Discussion

depression categories. There was only a marginal difference be-
tween the four depression groups with respect to the age of the
mothers of the adolescents at the time the mothers gave birth to
their daughters (p ¼ .064). Adolescents who had depression
onset before first sex (30.6%) were marginally more likely to have
a teenage mother than adolescents who had depression onset at
first sex (7.7%) or after first sex (19.0%) or no depression onset
(17.5%) during the study period.
The results of the crude and the adjusted Cox proportional
hazard models for all covariates are illustrated in Table 3. In the
unadjusted models, participants whose first depressive episode
was in the same year as their first sexual intercourse had 2.5
times higher hazards of becoming pregnant compared with
those with no depressive episode onset (95% CI: 1.08e5.96;
p ¼ .034). In the model adjusted for all covariates, the hazard
of first teenage pregnancy remained higher for girls with
depression onset at the age of first sexual intercourse (aHR ¼ 2.7,
95% CI: 1.15e6.34) compared with adolescents who were never
depressed. Compared with those with no depression, the risk of
pregnancy for girls who experienced depression onset before
sexual debut also increased, but it was not statistically significant
(aHR ¼ 1.5, 95% CI: .82e2.76).
Using a nationally representative sample of sexually active
adolescent girls and conducting survival analysis, which ac-
counts for the time to event, we investigated the association
between the timing of depression onset relative to first sexual
intercourse and first pregnancy. Compared with those with no
depression onset, girls who experienced depression onset in
the same year as their sexual debut were at an increased risk
for first pregnancy during the study period after adjusting for
adolescents’ race/ethnicity, marital status, poverty level,
whether the adolescent lived in a metropolitan area, living
status, age at first sex, parental education, and age of mother
when adolescent was born. Although we did not directly test
the mechanism through which depression onset in the same
year as sexual debut may have led to an increased pregnancy
risk, two pathways can be speculated. First, experiencing
depressive symptoms around the time of sexual debut may
have led girls to nonuse or inconsistent use of contraceptive
methods during sex as shown by previous research [12e15].
This could be because of lack of motivation and self-efficacy
[23]. Alternatively, unprotected sex may have been used as a
tool to cope with the negative emotions caused by depressive
 Y. Vafai et al. / Journal of Adolescent Health 67 (2020) 239e244 243

Table 3 This study offers a unique contribution to the existing body of

The unadjusted and adjusted HRs and the 95% CIs for the association between literature on adolescent health. Although previous studies have
timing of first depressive episode and first teenage pregnancy (n ¼ 1,025)
considered adolescents’ depression status at any point in time
Variables Unadjusted HR Adjusted HR before occurrence of first pregnancy and adjusted for age at first
(95% CI) (95% CI)
sex in the regression model [16,27e29], our study is the first to
Timing of depression onset incorporate age at first sex in the operationalization of the
Onset before first sex 1.4 (.84e2.49) 1.5 (.82e2.76)
exposure by defining the timing of depression onset before, at, or
Onset at first sex 2.5 (1.08e5.96) 2.7 (1.15e6.34)
Onset after first sex before first 1.0 (.38e2.70) 1.1 (.36e3.53)
after age at first sex. This measure may better elucidate the
pregnancy or end of the study complex relationship between mental health, sexual risk
No onset before first pregnancy or 1.0 1.0 behaviors, and the risk of pregnancy in adolescence. Unlike pre-
end of the study (ref) vious studies, we explicitly model the timing of these events using
Race/ethnicity
Cox proportional hazards models, which accounts for censoring of
Black, non-Hispanic 1.9 (1.21e2.83) 1.7 (1.01e2.98)
Hispanic 1.9 (1.30e2.83) 1.6 (1.01e2.98) individuals who have not yet experienced the event of interest
Others 1.6 (.55e4.85) 1.3 (.42e4.28) (i.e., first pregnancy during adolescence). Previous studies have
White, non-Hispanic (ref) 1.0 1.0 used logistic regression, which limits inferences about the risk of
Marital status
pregnancy because it assumes a fixed period in estimating the
Never married .3 (.18e.57) .3 (.12e.65)
Married/cohabiting (ref) 1.0 1.0
odds of the event rather than appropriately accounting for
Poverty index ratio censoring of individuals who may not have experienced the event
<1.5 2.3 (1.31e4.18) 1.6 (.86e3.08) during the study period but may in the future. This method,
1.5 to 3.0 .9 (.44e1.79) .8 (.38e1.49) therefore, produces a more specific measure of the association
3.0 to 6.0 .8 (.44e1.60) .8 (.38e1.54)
between depression and teenage pregnancy with respect to
>6.0 (ref) 1.0 1.0
Residential region sexual debut that accounts for the relative timing of these events.
Rural .8 (.51e1.40) 1.2 (.70e2.02) These findings provide further evidence that mental health is
Other .9 (.62e1.39) 1.1 (.71e1.57) associated with adolescents’ sexual and reproductive health
Metropolitan (ref) 1.0 1.0
behaviors. Therefore, integrating mental health and sexual and
Living status
Living with two nonbiological .1 (.01e.89) .1 (.01e1.01)
reproductive health services and programs for adolescents
parents is warranted. More specifically, practices, programs, or
Living with one biological and .8 (.51e1.41) .8 (.42e1.44) interventions aimed at preventing teenage pregnancy or
one nonbiological parents addressing the sexual and reproductive health needs of adoles-
Living with a single parent 2.08 (1.40e3.08) 1.7 (1.02e2.73)
cents should not only consider timely screening and treatment of
Other 1.9 (.62e5.67) 1.3 (.40e4.41)
Living with two biological 1.0 1.0 adolescent girls for depression but also provide contraceptive
parents (ref) services tailored to specific needs of each person. Likewise,
Age at first sex 1.0 (.83e1.20) 1.1 (.86e1.31) clinical practice and public health programs that address
Parental education depression among adolescent girls should consider their sexual
Less than high school 1.5 (.59e3.64) 1.0 (.33e2.57)
High school graduate 1.4 (.58e3.31) 1.2 (.46e3.15)
and reproductive health needs.
Some college 1.0 (.32e2.96) .7 (.21e2.39) Although this study represents a more comprehensive anal-
College graduate or higher (ref) 1.0 1.0 ysis of the relationship between depression and teenage preg-
Mother’s age at time adolescents nancy, it also comes with limitations. First, we only knew age in
were born
years at depression onset and age in years at first sex. Therefore,
19 1.1 (.61e2.09) 1.1 (.56e2.01)
>19 (ref) 1.0 1.0 for those who had depression onset at the same age as their first
sex, we only know that depression and sexual debut occurred
The regression model was adjusted for all baseline characteristics including race
concurrently within the same year. Similarly, for those who
and ethnicity, marital status, poverty index ratio, residential region, living situ-
ation, age at first sex, parental education, and teen’s mothers’ age at the time of experienced pregnancy in the same year as sexual debut and
giving birth to the participants. depression onset, it is possible that depression onset occurred as
CI ¼ confidence interval; HR ¼ hazard ratio; ref ¼ reference group. a result of pregnancy. However, more detailed information on
the month of depression onset, sexual debut, and pregnancy as
well as pregnancy intention was not available in the dataset.
mood [24]. These findings are in line with other research Despite this limitation, we were able to differentiate that the
demonstrating depressive symptoms are associated with window of risk for first teenage pregnancy was highest when
decreased motivation to use contraception, less contraceptive depression onset occurred at or around the time of sexual
self-efficacy, and adolescent girls’ nonuse or inconsistent use initiation, rather than before or after sexual debut. Second, in
of contraception [12e15,23,24], all of which are associated this study, we operationalized teenage pregnancy based on
with teenage pregnancy. participants’ self-reported age at which first childbirth and/or
The present study used data from the NCS-A, which is the first miscarriage, stillbirth, or abortion occurred, rather than at
only available nationally representative dataset with rich infor- the time of conception. This may have led to slight differences in
mation on DSM-IV disorders including major and minor the timing of events based on the gestational age of the preg-
depressive disorders and their onset. The use of the CIDI nancy. However, because we categorized the timing of events
depression diagnosis instrument in this survey eliminated limi- broadly within 1 year, we think this limitation would be
tations that depression screening tools may carry. Depressive minimized.
symptoms’ screening instruments have only a limited validity in Although in this study we were able to determine when a first
predicting DSM-IV depressive disorders, whereas CIDI is a depressive episode occurred relative to first sex, for the adoles-
validated depression diagnostic instrument [25,26]. cents whose depression onset was before the age at first sex, we
244 Y. Vafai et al. / Journal of Adolescent Health 67 (2020) 239e244
do not know whether they were still experiencing depression at
the time of first sex, as the depression may have been treated or
resolved. Thus, this group represents a potentially mixed group
of active and resolved depression, which may be why we
observed an attenuated nonsignificant association; however,
the magnitude of association was still stronger compared with
the group with no depression. Further delineation of whether the
depression was resolved or active at the time of sexual debut was
not available in the study.
Our study comprised of 20% of all adolescent girls in the NCS-A
who reported ever having had sex, which is smaller than that
reported in the National Survey of Family Growth in the similar
time frame (42%) [30]. Given the limitations associated with self-
report data, teens who may have only had nonconsensual sex
may be less likely to report having had sex or age at first sex. In
addition, miscarriages or abortions may have been under-
reported, which could have affected the true rate of pregnancy in
this study. However, the percentage of sexually active girls in our
study who experienced pregnancy (13%) is only slightly lower
than the nationally reported percentage of pregnancy between
2001 and 2004 (15.7%e16.7%) among girls aged 15e19 years who
reported ever having sex [2]. Therefore, it is unlikely that the
potential underreporting of miscarriage or abortions has affected
the findings of this study.
Finally, the response rate for the NCS-A is about 75% [19].
Moreover, the average age at first sex in our study (14.9 years) is
lower than that of the general population (15.5 years) reported in
other nationally representative studies [31]. Therefore, the
characteristics of the 25% nonresponses may have been different
than those of the participants affecting the generalizability of the
findings.
To better understand the relationship between depression
and teenage pregnancy with respect to age at sexual debut,
future studies should assess the elements of the psychosocial
mechanismsdsuch as motivation, self-efficacy, and self-
assertiveness to use contraception, pregnancy ambivalence, or
depression coping strategiesdthrough which experiencing
depression around the time sex may affect the risk of teenage
pregnancy. Furthermore, future studies should examine whether
experiencing multiple depressive episodes over time and the
timing of these episodes relative to first sex versus a single
episode would have an effect on the risk of pregnancy during
adolescence. In fact, approximately half of adolescents experi-
encing a first depressive episode experience a recurrence of
depression within the next year [32].
In conclusion, our findings highlight that not only the pres-
ence of depression during adolescence but experiencing
depression at the same age at sexual debut is associated with a
higher risk for first teenage pregnancy. A better integration of
mental health and reproductive health programs and practices
for adolescents may not only improve mental well-being but also
prevent teenage pregnancy.
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