REVIEW
Social issues of teenage
pregnancy
Sinead MC Cook
Sharon T Cameron
Abstract
The UK has the highest rate of teenage pregnancies in Western Europe and
within the UK higher rates are found amongst women who live in areas of
higher deprivation and have other factors such as lower educational
achievement or living in state care homes. Teenage pregnancy can be a pos-
itive event for some young women. However, there are a number of adverse
social outcomes associated with teenage motherhood in the UK, including
being more likely to live in poverty, being unemployed or having lower sal-
aries and educational achievements than their peers. Furthermore, children
of teenage mothers are more likely to become teenage parents themselves.
Strategies to tackle social issues associated with teenage pregnancy need
to involve concurrent interventions, including education, skill building, clin-
ical and social support for teenage mothers and contraception services for
young people and pregnant teenagers.
Keywords adolescent; social class; social problems; teen; teenage
pregnancy
Introduction
The United Nations Children’s Fund (UNICEF) defines teenage
pregnancy as conceiving between the ages of 13e19 years old.
However, in everyday speech the term teenage pregnancy is often
used to describe young women who become pregnant when they
have not yet reached legal adulthood, the age of which varies
across the world. Furthermore, the terms adolescent, young per-
son and child are often used interchangeably with teenager,
despite each having different definitions. The UNICEF definition of
teenage pregnancy will be used for this article. Globally, around 16
million teenage women give birth each year, accounting for around
11% of all births. Over 90% of these deliveries occur in low- and
middle-income countries and more than half occur in seven
countries: Bangladesh, Brazil, the Democratic Republic of Congo,
Ethiopia, India, Nigeria and the United States.
The UK has the highest teenage pregnancy and birth rate in
Western Europe (see Figure 1). Throughout most countries in
Western Europe, the total fertility rate and number of teenage
Sinead M C Cook BSc(hons) MBChB(hons) DTMH DFSRH is a Specialist Trainee 3
in Community Sexual and Reproductive Health, Department of Sexual
Health, Cardiff & Vale University Health Board, Cardiff, UK. Conflicts of
interest: none.
Sharon T Cameron MD MFSRH FRCOG is a Consultant in Sexual and
Reproductive Health, Chalmers Sexual Health Centre, NHS Lothian; and
Reader, Obstetrics and Gynaecology, University of Edinburgh, UK.
Conflicts of interest: STC has received research funding from HRA
Pharma and Pfizer and has been European Scientific Advisory Board
member for Exelgyn.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:9
births has been decreasing and the age at first birth increasing
since the 1970s. In the UK, teenage pregnancy and birth rates
were high compared to the rest of Europe and remained relatively
static until the late 1990s. However, since then, the rate has been
steadily declining. In England and Wales, the under 18 concep-
tion rate reached an all time low level at 27.9 conceptions per
1000 women aged 15e17 years in 2012 since the rate first started
being recorded in 1969 (see Figure 2). The teenage pregnancy
rate in Scotland has shown a similar trend and coincidentally in
2012 had exactly the same rate as England and Wales. Across the
UK the abortion rate for under 18 year olds has also been
decreasing since 2003, from 18.2 to 11.7 per 1000 women under
18 years in 2013. It is important to note that teenage pregnancy
rates only include live births, stillbirths and abortions. Mis-
carriages, which may account for up to 25% of all pregnancies,
are not included. In Northern Ireland, where termination of
pregnancy is illegal except to save the woman’s life or prevent
long term or permanent physical or mental harm to the woman,
statistics are presented in terms of birth rates as opposed to
conception rates; the teenage birth rate in 2012 was 18 per 1000
women under 20 years.
Whilst teenage motherhood can be a positive experience for
some young women, in the UK it is often associated with poor social
and health outcomes for mother and child. These associations
remain after adjusting for pre-existing social, economic, and health
problems. Teenage pregnancy is therefore often both a marker of
social and economic disadvantage at a young age and a cause of
further disadvantage, emotional and physical health problems.
Globally, complications of pregnancy and childbirth are the
second highest cause of death amongst teenagers. Furthermore,
whilst teenage deliveries account for 11% of all births worldwide,
they account for 23% of the overall burden of disease in disability
adjusted life years (DALYs) attributed to pregnancy and childbirth.
Maternal mortality is higher amongst teenagers than women aged
20e24 years worldwide. However, this varies between countries
and globally the risk of teenage maternal mortality is less than for
women aged over 30 years. Box 1 outlines adverse health outcomes
associated with teenage pregnancy. This paper will now focus on
the social issues associated with teenage pregnancy.
Social issues increasing the risks of teenage pregnancy
A number of social factors have been associated with an
increased risk of teenage pregnancy and teenage pregnancy itself
has also been linked to an increased risk of a number of adverse
social outcomes. However, teenage pregnancy rates vary signif-
icantly between different countries, and similarly the social fac-
tors associated with teenage pregnancies also vary. In many
countries with the highest rates of teenage pregnancies, it is
associated with child and adolescent marriage. In these contexts,
teenage childbearing is often an accepted social norm. For
example, in Niger, which has the world’s highest teenage preg-
nancy rate and also has the highest rate of child marriage, 87% of
women are married before they reach 18 years old and 50% will
have had a child by this age.
Within countries, there can be considerable variation in rates
of teenage pregnancy and it’s association with early marriage. In
the Indian subcontinent, the majority of teenage pregnancies
occur amongst married teenagers in rural areas. However, in
243 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW

Teenage birth rates in selected European countries Adverse health outcomes associated with teenage
pregnancy
Bulgaria
Romania
C Young mothers are more likely to suffer from post-partum
depression
Slovakia C Infant mortality is 60% higher
UK C Infants are more likely to have a lower birth weight
Hungary C Infants are more likely to have congenital anomalies in central
Estonia nervous, gastrointestinal and musculoskeletal/integumental
systems
Poland
Ireland Box 1
Portugal urban areas, whilst rates of teenage pregnancy are much lower, a
Czech Republic larger proportion of conceptions are amongst unmarried women.
France A number of risk factors for both early marriage and teenage
Spain pregnancy in rural India have been identified including social
pressure, poverty and low female education and employment
Greece
opportunities.
Germany Most high-income countries have low teenage pregnancy rates
Italy and the majority of pregnancies are amongst unmarried teen-
Sweden agers. In the UK, 96% of teenage conceptions occur amongst
Netherlands unmarried teenagers. Furthermore, the majority of teenage
pregnancies are unplanned. Unplanned pregnancies can often be
Denmark
associated with binge drinking of alcohol amongst teenagers. As
0.0 10.0 20.0 30.0 40.0 50.0 can be seen in Figure 1, some European countries have particu-
Birth rates per 1,000 women aged 15–19 years larly low teenage birth rates compared to others. In the
Netherlands and Scandinavian countries the comparatively lower
Data from Office of National Statistics
rates of teenage births have been attributed to high levels of
http://www.ons.gov.uk/ons/dcp171778_353922.pdf
contraception use, comprehensive sex education and a culture of
Figure 1
openness regarding discussing sexual matters. In other countries

Under 18 Conception Rate: England and Wales

50.0
Rate per 1000 women aged 15–17 years

45.0

40.0

35.0

30.0

25.0

20.0
1994

2004
1987

1989
1990
1991
1992
1993

1995

1997

1998
2000
2001
2002
2003

2005

2007

2009
2010
2011
2012
1988

1996

1998

2006

2008

Year

Data from Office of National Statistics

http://www.ons.gov.uk/ons/dcp171778_353922.pdf

Figure 2

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:9 244 Ó 2015 Elsevier Ltd. All rights reserved.

such as Spain and Italy it has been attributed to socially con-
servative traditional values that stigmatise unmarried teenage
mothers. However, this can be seen as a rather simplified view of
why rates of teenage pregnancies are low in these countries, and
there are likely a number of social factors at play. The different
importance of these factors has been the subject of much debate.
There has correspondingly been much debate as to why the
teenage pregnancy rate and particularly the number of un-
planned pregnancies in the UK are so high. Early coitarche has
been shown to be associated with an increased risk of teenage
pregnancy. When compared to the Netherlands, however,
despite approximately the same numbers of under 16s admitting
to being sexually active (around one third), Dutch teenagers are
much more likely to use reliable contraception from the begin-
ning of their sexual lives. Between 8% and 22% of teenagers in
the UK use no contraception at their first intercourse, and this is
higher for those under 16 years old. Moreover, of those who do
use contraception, many use less reliable methods.
Within the UK, there are a number of groups of teenagers who
have higher rates of teenage pregnancy than others; social factors
that appear to be associated with increased rates of teenage preg-
nancy within the UK are summarised in Box 2. Poverty and social
deprivation are highly associated with teenage pregnancy rates
and the outcomes from teenage pregnancies. Social deprivation is a
composite measure that can include a variety of indicators,
including the teenage woman’s educational level, health and
employment status and their parents’ income and occupation.
Women from areas of higher deprivation have the highest rates of
teenage pregnancies; the differences can be up to ten fold between
the most and least deprived areas. Women who had below average
educational achievement at ages 7 and 16 years old also have a
significantly higher chance of becoming a teenage mother. Young
fathers are also more likely to come from lower socioeconomic
groups and have lower educational achievement. The relationship
of low educational achievement to higher rates of teenage preg-
nancy remains even when adjusted for socioeconomic status.
Teenagers from areas of higher deprivation who become preg-
nant are also more likely to continue with the pregnancy than
undergo termination of pregnancy, with two-thirds of teenage
conceptions being terminated amongst those from affluent areas
compared to only a quarter from the most deprived areas.
Furthermore, the majority of the overall reduction in the teenage
pregnancy rate in the UK has been due to large reductions in
affluent areas, with little reduction in the most deprived areas.
Factors associated with higher rates of teenage preg-
nancy within the UK
C Lower socioeconomic status
C Living in or leaving a care home
C Being involved in crime
C Some ethnic minority groups: Caribbean, Pakistani and
Bangladeshi
C Homelessness
C School excludes, truants and young people underperforming at
school
C Children of teenage mothers
Box 2
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:9
REVIEW
A review of qualitative studies examining teenagers’ opinions
found three major themes relating to increased risk of teenage
motherhood: dislike of school; poor material circumstances and
unhappy childhood; and low expectations and aspirations for the
future; these themes are further expanded in Box 3. While some of
these factors overlap with the factors discussed above, they pro-
vide more personal insights into broad groups such as low
educational attainment and socioeconomic group and how these
factors may be associated with increased rates of teenage births.
For example, some teenage women see having a baby as a way to
change their circumstances and ameliorate the effects of adversity.
Social consequences of teenage pregnancy
Whilst becoming a parent can be a positive and life-enhancing
experience for some teenagers, teenage pregnancy, and particu-
larly teenage childbearing is associated with a number of nega-
tive social outcomes in the UK. However, it is important to
recognise that some of these risks are likely associated with the
previously stated underlying associations with teenage preg-
nancy, such as social deprivation. Also, teenage parents tend to
access less antenatal and maternity services which may nega-
tively impact on social and health outcomes. However, studies
that have attempted to adjust for pre-existing social disadvantage
have found that the teenage childbearing still carries an excess
increased risk of negative outcomes. Teenage mothers have
higher risks of living on lower incomes, lower educational
achievements and difficulties with housing and family conflicts
when compared to their peers. Teenage mothers are also more
Themes from qualitative literature associated with
higher likelihood of becoming a teenage parent within
the UK
C Dislike of school
 Lack of support if experiences difficulties at home or
school
 Difficulties making friends
 Bullying
 Boredom
 Frustration with rules and regulations
 Lack of relevance
C Poor material circumstances and unhappy childhood
 Have to grow up faster
 Violence
 Poor housing
 Frequent moves
 Family conflict and breakdown
 Lack of good role models
C Low expectations and aspirations for the future
 Bad work experiences
 Lack of local opportunities
 Low or no expectations from others
 Need to escape from or change difficult circumstances
 Desire to leave school as soon as possible and get a job
 Having a baby as most attractive option
Box 3
245 Ó 2015 Elsevier Ltd. All rights reserved.

likely to be socially isolated. Young fathers also appear to have
similar educational, economic and employment outcomes to
teenage mothers, but there is much less data on this group.
Children born to teenage mothers are more likely to be born into
poverty and become teenage parents themselves (see Box 4).
Teenage pregnancy strategies in the UK are often attempting
to break the cycle of teenage mothers coming from worse social
situations, which can continue and worsen following becoming a
teenage parent, resulting in their children being brought up in
poor social circumstances and having a higher chance of
becoming a teenage parent themselves. Furthermore, reducing
rates of teenage pregnancy is thought to have the potential to
reduce other social problems, such as increasing female educa-
tion and reducing child poverty.
Teenage pregnancy: a social problem?
This article has discussed social issues that are potential risks
and outcomes associated with teenage pregnancy and parent-
hood in the UK. Considering teenage pregnancy in terms of
negative social outcomes has led to teenage pregnancy being
considered a social problem and strategies to try to reduce
teenage pregnancy rates in the UK being developed. However,
some people have criticised framing teenage pregnancy as a so-
cial problem for a number of reasons. Firstly, associations be-
tween negative social outcomes and teenage pregnancy are likely
not directly causal, but rather a complex chain of circumstances.
Focussing prevention efforts on at risk groups and teenage
mothers can risk blaming individuals and focussing on behaviour
change, while ignoring the wider social situation and focussing
on at risk groups does not appear to reduce teenage pregnancies.
A study of a program titled the ‘Young People’s Development
Programme’, which was an intensive multicomponent young
people development programme that targeted high risk groups of
young people in England, actually found increased rates of
teenage pregnancy compared to the comparison group.
Furthermore, considering pregnant teenagers as problem or risk
groups can increase stereotyping and the stigma felt by teenagers
who are pregnant or parents. A widespread UK stereotype of a
teenage mother is someone receiving state benefits, who is a burden
on society, with poor educational attainment and whose children
have suboptimal life chances. Stigma and stereotyping can increase
the risk of teenage mothers not accessing services and becoming
Negative social outcomes for teenage mothers
C Employment/economic: 22% more likely to be living in poverty by
age 30 than mothers aged over 23 years; less likely to be
employed and if employed more likely to be on lower incomes
than their peers
C Education: 20% more likely to have no qualification by age 30
C Housing: More likely to be living in rented, poor quality housing
and to have to move during pregnancy
C Family: more likely to be lone parents and find themselves in a
family conflict
C Children: children of teenage mothers are more likely to become
teenage parents themselves
Box 4
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:9
REVIEW
more socially isolated. In contexts and areas where teenage child-
bearing is socially accepted there is often more familial and social
support for the mother. Moreover, viewing all teenage pregnancies
as undesirable ignores that some teenagers want to become parents
and find parenthood happy and rewarding.
How to reduce teenage pregnancies and mitigate the negative
social outcomes associated with teenage pregnancy?
There are strategies aiming to reduce teenage pregnancies and
negative social outcomes associated with teenage pregnancy both
across the world and in the UK. In 1999, the UK government
introduced a Teenage Pregnancy Strategy, which set itself a high
target to reduce the rate of teenage pregnancies in England and
Wales by 50%. It also aimed to increase the proportion of teenage
parents in education, employment and training to reduce their risk
of long-term social exclusion. The goal to halve the rate of teenage
pregnancies was not met; the actual decrease in teenage pregnancy
between 1998 and 2010 was 13.3% in England and Wales. The
strategy included health promotion campaigns, improving health
services and school sex education. It was discontinued in 2010 but
reducing teenage pregnancy rates is still on the policy agenda as a
devolved issue in all four nations in the UK. For example, in En-
gland the under 18 conception rate is one of three key sexual health
indicators in the Public Health Outcomes Framework 2013e2016
and is also used as a measure of progress on child poverty.
Primary prevention of teenage pregnancy and supporting
teenagers who become pregnant
Reducing rates of teenage pregnancy and improving outcomes for
teenage parents and their children requires a comprehensive
strategy with multiple elements. Previously, attention only
focussed on improving sex education and access to sexual and
reproductive health services. Whilst these are vital elements, they
are not sufficient on their own for reducing teenage pregnancies in
the UK. This evidence has generated increased interest in in-
terventions that target wider social determinants, such as
addressing economic inequalities and improving education and
employment opportunities in areas of high deprivation. Pro-
grammes that involve concurrent interventions, including educa-
tion, skill building and contraception can reduce rates of
unintended pregnancies. Furthermore, broad childhood in-
terventions and youth development programmes that target aca-
demic and social skills, particularly those that encourage
involvement of the young people’s parents and family, can also
reduce rates. Child and youth development programmes that seem
to be particularly successful combine the following elements:
 Learning support for those who are struggling academically
 Relationship skills development
 Parental involvement
 Work experience opportunities, volunteering, and out of
school activities
 Support for those experiencing family breakdown and
conflict
As well as focussing on primary prevention of teenage preg-
nancy, it is important to provide support for teenage mothers and
reduce rapid repeat pregnancies (pregnancies occurring soon
after childbirth). A short inter-pregnancy interval (1 year or less)
has been shown to be an independent risk factor for both adverse
246 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
obstetric outcomes such as preterm birth and neonatal death and
negative social outcomes. Programmes that appear to be most
successful at reducing rapid repeat pregnancies integrate clinical
and social services and include home visits and easily accessible
and youth-friendly contraceptive, antenatal and postnatal ser-
vices. These services should also provide easy access to the most
effective long acting reversible contraceptives (LARCs), such as
subdermal implants and intrauterine methods.
It is particularly important to address social exclusion associated
with teenage motherhood, through improving access to health ser-
vices, providing educational support, further education and training,
income support and housing assistance. There are a number of
programmes in the UK, including the CAN (Classes & Advice
Network) parenting scheme that is a network of parenting classes
focussed in areas of high deprivation and the Care to Learn pro-
gramme that provides support for teenage mothers who want to
continue or further their education.
How can the obstetrician & gynaecologist contribute?
Whilst many of the interventions required are broad and out with the
immediate clinical setting, there are many ways in which the indi-
vidual clinician can contribute to reducing negative social outcomes
associated with teenage pregnancy. Firstly, it is important to
remember to discuss contraception and sexual health opportunisti-
cally when consulting with young people. LARCs should be pro-
moted to all women who are keen to prevent pregnancy and
particularly to teenagers and they should be made aware of how to
access emergency contraception if required. It is important to build
appropriate consultation skills and allow extra time for consulta-
tions with teenagers. Improving access and availability of youth-
orientated contraception services may help to reduce teenage preg-
nancies. During any contraceptive consultation, it is also important
to offer sexually transmitted infection (STI) screening, and advise
using double protection i.e. contraception and condoms, due to the
high prevalence of STIs in under 25 year olds in the UK. Opportu-
nities should be sought to discuss these topics without a parent
present whenever possible. Provision of clear, non judgemental in-
formation about abortion and how to access abortion services may
also avoid late presentation for termination of pregnancy.
Whenever consulting with teenagers, it is import to consider risk
assessment, potential abuse and child protection issues. Compe-
tence to make independent decisions for contraceptive use (Fraser
competence) should be assessed and documented for young people
under the age of 16 years old (or under 18 years old in state care) (see
Box 5).
All services need to ensure they are friendly and accessible to
young people. Health workers should try to make teenagers feel
comfortable and welcome to relieve embarrassment or feelings of
stigmatisation. Accessibility includes physical location and tim-
ings. The ability to have out-of-hours appointments during eve-
nings and weekends and to be able to either drop-in or make
fixed appointments is very important for teenagers. Some hos-
pitals have dedicated young people’s sexual and reproductive
health and/or maternity services. Services need to be universal
and inclusive, but there are some particularly socially disad-
vantaged groups and groups that have difficultly accessing ser-
vices that may need additional tailored support. These groups
include teenage mothers and also other young people who are:
 Living in deprived areas
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:9
 From a minority ethnic group, refugees, asylum seekers
and people recently arrived in the UK
 Looked after or leaving care
 Excluded from school or do not attend regularly or have
poor educational attainment
 Unemployed or not in education or training
 Homeless
 Living with mental health problems
 Living with physical or learning disabilities
 Living with HIV/AIDS
 Substance misusers (including alcohol misusers)
 Criminal offenders
Contraception discussions and plans for future contraception
should occur with all young women who present when pregnant,
whether they opt to continue with the pregnancy or for termi-
nation. In general, if possible, young women should leave the
hospital following delivery or termination with their chosen
contraceptive or if not with a clear plan for accessing their cho-
sen method of contraception.
Finally, when consulting with teenage mothers there needs to
be strong links with relevant external agencies as many of the
social issues discussed above cannot be dealt with by the health
care sector alone. In many areas of the UK there is the oppor-
tunity to refer pregnant teenagers to the Family Nurse Partner-
ship (FNP). This is a preventative programme that supports
teenage mothers from pregnancy until their children are two
years old. It aims to improve social outcomes for teenage
mothers and their children. Studies in both the UK and the USA
have shown that the programme improved rates of smoking
cessation, breastfeeding, antenatal appointment attendance, self
esteem and return to education or employment.
Guidelines for provision of contraception to under 16s
Department of health guidance: “a doctor or health profession is able
to provide contraception, sexual or reproductive health advice and
treatment, without parental knowledge or consent, to a young per-
son aged under 16, provided that:
C She/he understands the advice provided and its implications
C Her/his physical or mental health would otherwise be likely to suffer
and so provision of advice or treatment is in their best interest.”
In addition, it is good practice to follow the criteria set out by Lord
Fraser in 1985, commonly known as Fraser guidelines:
C “The young person understands the health professional’s advice
C The health professional cannot persuade the young person to
inform his or her parents or allow the doctor to inform the parents
that he or she is seeking contraceptive advice
C The young person is very likely to begin or continue having in-
tercourse with or without contraceptive treatment
C Unless he or she receives contraceptive advice or treatment, the
young person’s physical or mental health or both are likely to suffer
C The young person’s best interests require the health professional
to give contraceptive advice, treatment or both without parental
consent”
Box 5
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 REVIEW

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Practice points
FURTHER READING C Despite declining over recent years, teenage pregnancy rates in
Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit.
the UK are still the highest in Western Europe
Contraceptive choices for young people. 2010. http://www.fsrh.org/ C Social deprivation is associated with higher rates of teenage
pdfs/ceuGuidanceYoungPeople2010.pdf (last accessed 15 Feb 2015).
pregnancy in the UK, therefore it is important to be aware of an
Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit.
increased likelihood of social issues when interacting with preg-
Postnatal sexual and reproductive health. 2009. http://www.fsrh.org/
nant teenagers
pdfs/Ceuguidancepostnatal09.pdf (last accessed 15 Feb 2015). C Teenage pregnancy is associated with negative stereotypes and
Harden A, Brunton G, Fletcher A, Oakley A. Teenage pregnancy and social
stigma which can impact on young pregnant women’s use of
disadvantage: systematic review integrating controlled trials and
services and increase social isolation
qualitative studies. BMJ 2009; 399: 1182e5. C A multidisciplinary approach should be used for clinical and social
Lee E, Clements S, Ingham R, Stone N. A matter of choice? Explaining
support for teenage mothers
national variation in teenage abortion and motherhood. York: Joseph C It is essential that contraception, antenatal and postnatal services
Rowntree Foundation, 2004.
are young person friendly
NICE Guidelines: PH51 Contraceptive services with a focus on young C Contraception should be discussed with all pregnant teenagers
people up to the age of 25. National Institute for Health and Care
and a contraceptive plan made to contribute to reduce the risk of
Excellence. 2014. http://www.nice.org.uk/guidance/ph51/chapter/
rapid repeat pregnancies
about-this-guidance (last accessed 5 Feb 2015).
Nove A, Matthews Z, Neal S, Camacho AV. Maternal mortality in adoles-
cents compared with women of other ages: evidence from 144
countries. Lancet Glob Health 2014; 2: e155e64.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:9 248 Ó 2015 Elsevier Ltd. All rights reserved.