Teenage pregnancy has become one of the most important topics for population policies from different perspectives: talking about the volume of adolescent population, its growth and reproduction, as well as the biopsychosocial risk involved in teenage motherhood. Adolescent population in Mexico represents almost a fifth of the country’s population. It is an opportunity for social and economic development to ensure the sustainable growth of the nation. However, to achieve this growth, it is essential that the population is prepared both in an academic and humanist way.[1] However, several researches and policies created to improve the reproductive health of adolescents, forget that early motherhood in our country is the result of a complex economic, social and cultural context. The objective of this study was to evaluate the effects of primary prevention interventions in the prevention of unwanted pregnancies in adolescents. Conclusion. Strategies must be real, not only on paper and in speeches. Results should be directly reflected in the adolescent population. Strategies should be inclusive with adolescents and wide in context. Mexico does have a document which serves as basis to reduce the number of unwanted pregnancies in adolescents, but it is crucial that people participate, together with governmental institutions, in the implementation of this strategy; otherwise it is just going to stay as another good treaty.
Keywords: unwanted pregnancy, pregnancy prevention, adolescence, sexual and reproductive health.
Teenage pregnancy or adolescent pregnancy is the one that occurs in an adolescent woman: between early adolescence or puberty (the beginning of the fertile age) and late adolescence. The WHO establishes adolescence between the ages of 10 and 19 years old.[2] In Mexico, teenage pregnancy has become one of the fundamental issues of population policies. From different perspectives, there is a discussion about the volume of adolescent population, its growth and reproduction, as well as the biopsychosocial risk involved in adolescent motherhood.[3] Besides, it represents a high medical risk, involving also socioeconomic and emotional difficulties for the mother and her son, which is known as the "failure syndrome" .[4]
Risk factors associated with teenage pregnancy are arranged in the individual, family and social dimensions.[5] In the individual dimension, factors with the highest risk are, among others: perception of invulnerability, low self-esteem, low academic aspirations, impulsivity, drug use, sexually permissive friendships, a low education level of women, low level of knowledge about contraceptive methods and its use, less planning of the first intercourse and an earlier sexual debut.
Another perspective is the demographic perspective[3] which states that there are different reasons that affect the current situation of adolescent pregnancy, among them are: (I) the high proportion of young people between 10 and 19 years old that in Mexico represent 18.5% of the total population and go up to 22.3 million in 2015;1 (II) 18.6% of total births are to women between 10 and 19 years old;6 (III) 50% of adolescents between 15 and 19 years old are sexually active; (IV) there is an annual increase of 10% of women sexually active from 12 to 19 years old; (V) 25% of sexually experienced teens get pregnant and 60% of these gestations happens 6 months after the sexual debut; (VI) 35% of teenage mothers are single mothers and 50% of single mothers are teenagers; (VII) between 60% and 70% of these pregnancies are unintended pregnancies, and (VIII) having evidence that pregnancy at an early age may represent a biopsychosocial risk for the mother and the newborn, as well as an increased maternal mortality, helps understanding the psychosocial effects of this phenomenon.[7]
The adolescent population of Mexico represents almost a fifth of all the population in the country, which should mean an opportunity for social and economic development to ensure the sustainable growth of the nation. However, to accomplish this assumption, it is essential that the population get both an academic and humanistic formation.[8] Though, several researches and policies aimed at improving the reproductive health of adolescents forget that early motherhood in our country happens because of a complex economic, social and cultural context.
The objective of this study was to evaluate the effects of primary prevention interventions in the prevention of unintended pregnancies in adolescents. The importance of this issue encouraged the development of this research that could be a basis for future studies in order to determine some factors that influence pregnancy in adolescence and show that this situation has been wrongly tackled by the government from a preventive perspective.
Unintended pregnancy among adolescents represents an important public health challenge for both developed and developing countries. To tackle this problem, many prevention strategies have been applied in different countries, such as health education, skill development and providing better access to contraceptive methods. However, there is uncertainty regarding the effects of these measures, therefore it is necessary to examine the scope they have had.[9]
The United Nations Children's Fund (UNICEF) reported, in 2010, that 18% of the world’s population were between 10 and 19 years old, 19% of teenage girls in developing countries have been pregnant before 18 years old.[10] Of the seven million teen births to mothers under 18 years old, two million are under 15 years old.
According to the WHO, about 16 million girls aged between 15-19 give birth each year, representing about 11% of all births, 95% of them occurring in developing countries. According to the World Bank,[11] Latin America and the Caribbean have the highest rates of teenage pregnancy (72 births per 1,000 women between the ages of 15 and 19 years old), followed by Sub-Saharan Africa and South Asia (with 108 and 73 births, respectively). Although rates are decreasing worldwide, this process has been extremely slow in Latin America, apparently because of the inequality conditions in that region. A worrying fact is that the region of Latin America and the Caribbean is the only region where births to mothers under 15 years old, increased.[10] To this, UNICEF adds that 22% of adolescent girls in Latin America and the Caribbean begin to be sexually active before the age of 15 years old, the highest percentage among different regions. Within this region, Nicaragua, Dominican Republic and Guatemala registered the highest adolescent fertility rates in 2010, with more than a 100 births per 1,000 women aged between 15 and 19 years old; while Peru, Haiti and Trinidad and Tobago had the lowest rates, with less than 50 births per 1,000 women in the same age range.[11] Teenage pregnancy is getting worse in many countries, which shows the need to firmly deal with this problem.
The National Population Council estimates that in Mexico almost one in five persons is between 10 and 19 years old. This group has almost doubled its number since 1970, year in which the population aged 10-19 was only 11.4% of the country’s total population. According to the 2009 National Survey of Demographic Dynamics (NSDD), Mexico is in an intermediate position between Latin America and the Caribbean, with 69.5 births per thousand women between the ages of 15 and 19 years old.
Teenage pregnancy in Mexico is becoming more and more important due to two factors: 1) Among women of childbearing age, adolescents aged 15 to 19 are the largest group, currently representing 17% of the total. At the other end of reproductive life, women between 45 and 49 years old represent about 11%12 2) In the last 40 years, the fertility of adolescent girls has decreased, but in a much lower proportion than in other age groups. According to official surveys between 1974 and 2009, women aged 15 to 19 reduced their fertility rate by 47% (from 131 to 69.5 children per 1,000 women). Instead, women between 35 and 39 years old reduced their fertility by 77%, and women between 40 and 49 years old by 88% .13,14
It should be added that there are varying proportions of teenage mothers among the states of the country. In terms of fertility, ENADID 2014 states that the national average of births to women aged 15 to 19 was 77.02 births per 1,000 women. The states of Coahuila, Nayarit, Zacatecas, Oaxaca, Chiapas, Durango, Chihuahua, Michoacán, Campeche, Guerrero, Veracruz, Guanajuato had higher rates than the national one; while Quintana Roo, Nayarit, Chiapas, Durango, Baja California Sur, Coahuila, Chihuahua and Jalisco had rates higher than 75 per 1,000 women.15
The decrease of adolescent fertility can partly be explained by the fact that the opportunities to access higher levels of education or access appropriate jobs that allow them to continue studying, have not increased. Additionally, the increase of sexually active teenagers and the lack of regular use of contraception methods have been important factors in the observed trends. According to ENADID 2009, the percentage of women between 15 and 19 years old that were sexually active went from 11.9% to 15.2% in 22 years.16 Based on other sources such as the Mexican Youth Survey, the percentage of adolescents from 15 to 19 years old that has had sexual intercourse increased from 22.3% in 2000 to 27.2% in 2005 and to 33.6% in 2010. Meanwhile, the ENSANUT 2012 also shows increases in the percentage of sexually active teenagers, from 18% in 2000 to 26% in 2012 for men; and from 16% to 21% for women.
Among the population aged 12 to 19, the average age of sexual debut at a national level is 15.5 years old (15.3 years old for men and 15.7 years old for women).
WHO reports that prevention strategies of teenage pregnancy must have a holistic approach in order to give adolescents the best opportunity to develop both personally and socially. The strategies by themselves are not effective, but combining them to improve access to education and contraception methods, reduces unintended pregnancies in adolescents.[17]
Strategies to prevent unintended pregnancies include any activity (health education or counseling, health education plus skills development, health education on contraceptive methods, education on contraceptive methods and its distribution, religious groups or individual counseling) designed to: improve knowledge and attitudes of adolescents regarding the risks of unwanted pregnancies; promote delaying the sexual debut; promote the constant use of methods of birth control and reduce unintended pregnancies.[9]
Several countries have announced multisectoral strategies with high-level political support, some of the most emblematic examples are:
United States: The Presidential Teen Pregnancy Prevention Initiative is based on funding community organizations, governmental organizations or schools to implement strategies based on evidence that has been proven to be effective.[18] A strength of this effort is the emphasis on monitoring and evaluating the strategies, which allows expanding the evidence that supports them and the learning about effective programmatic factors.[19] This strategy is considered a role model for having succeeded in reducing adolescent fertility rate from 47.7 births per 1,000 women aged 15 to 19 in 2000 to 26.6 births in 2013.[20]
United Kingdom: the Teenage Pregnancy Strategy began in 2000 with the goal of reducing the rate of teenage pregnancy by half for 2010. The strategy included an action plan of 30 points in four areas: 1) financial funds at a national, regional and local levels, labeled for this strategy; 2) improvements in prevention based on a comprehensive sexual education of higher quality and an access to friendly contraceptive services; 3) a national media campaign addressed to teenagers, their mothers and fathers; 4) social support for adolescent mothers and fathers to return to school or work. The achievements were overwhelming, the rate of teenage pregnancies of teens under 18 years old decreased 41% by 2012, going from 46 pregnancies per 1,000 women aged 15 to 17 to 27.7 pregnancies.[21],[22]
Peru: the Multisectoral Plan to Prevent Teenage Pregnancy involves the ministries of health, women, education, justice and labor. The plan states that these institutions should be coordinated to carry out strategies based on evidence in the field of each institution.[23] One strength of the program is that it includes long-term strategies (2012-2021).
Honduras: the National Strategy for Adolescent Pregnancy Prevention is based on six core ideas: 1) strategies based on family, community and education sectors; 2) provision of quality health services for adolescents at an out-patient and in-patient level; 3) development of the skills of human resources to respond to the health needs of adolescents; 4) generation of strategic information; 5) strategic partnerships between the government, the private sector, civil society and international cooperation organizations, as well as with the community, the families and the media; and 6) high-level political coordination headed by the Secretary of State (Ministry of the Interior) and a technical committee formed by the Ministry of Health with representatives from the Departments of State, aid agencies, representatives of nongovernmental organizations, training schools, medical and nursing societies, organized groups of adolescents, faith-based organizations and others linked to this topic.
Sierra Leone: the national strategy to reduce teenage pregnancy (2013-2015), "Let Girls Be Girls, not Mothers", based on five pillars linked with: 1) the regulatory environment; 2) access to Sexual and Reproductive Health (SSH) services; 3) comprehensive sexual information and education; 4) empowerment of adolescents in their communities; and 5) establishment of mechanisms for coordination, monitoring and evaluation.[24]
Chile: this country has implemented strategies based on home visits to the adolescent population considering that this visits allow a comprehensive approach, from the health, educational, emotional and instrumental perspectives.[25]
However, there are no reports on the progress these strategies have had so far in Latin America.
The history of contraceptive programs in the public sector exists since the enactment of the General Law of Population in 1974, the amendment of the Article 4 of the Constitution and the Article 25 of the Health Code in 1973, which guaranteed the people’s right to exercise in a free, responsible and informed manner, the decision on when and how many children to have. In 1977, the National Population Council (CONAPO) designed the first National and Regional Population Policy that stated the objective of reducing the population growth rate, and the first National Family Planning Program (1976-1982). In 1977, CONAPO created the National Program for Sexual Education, with the design of materials on this topic.[26]
The first steps of the programs to deal with adolescents were taken in the ‘80s. In 1981, the IMSS created the Department of Sexual Counseling and Education for Adolescents. In 1984, the Secretariat of Health trained personnel of primary health care in Mexico City and other big cities of the country so they could provide sexual and family planning counseling to adolescents. In 1993, the Declaration of Monterrey, served as a basis to initiate a comprehensive health care program for adolescents, emphasizing on their reproductive health. The Action Program of the International Conference on Population and Development in Cairo,1994, asked for the protection and promotion of the adolescents’ right to education, information and SSR through programs and services in a context based on rights.[26]
Despite the efforts that have been made along these 40 years, the impact on the specific rate of adolescent fertility has increased along with the growth of this group of the population, which calls into question what different national and international regulations claim, so adolescents can exercise their sexual and reproductive rights in a free and responsible way.
Strategies that have shown little or no efficacy include the community models of peer education and juvenile centers. [27]
The failure of these strategies is due to problems in the methodological design of the strategies for peer educators. Other problems have been identified which are related to the involvement of adolescents in the development of these programs. For example, there no diagnosis of needs; adolescents do not get involved in the design of peer strategies; the roles, the expectations and the limits of the participation of adolescents and of those who manage the programs, is not clear; there is a problem with the selection of peers, as there is no study of adolescents’ social networks, and usually those who participate are self-nominated and become collaborators of more than one program at a time; there is a differentiated participation of men and women depending on the context; there are low retention rates and a lack of incentives, including economic ones, to remain in the programs; non-existent follow-up after initial training; and finally, there is no differentiation between the information coming from adult professionals and the information provided by adolescent peers.[26]
For years, state governments, institutions providing care to adolescents and some Civil Society Organizations have established isolated strategies, sometimes without the appropriate approach, to try to reduce teenage pregnancies, having no desired results or having little follow-up. The reality is that the number of teenage pregnancies continues to rise in large part of the country. For that, the Government announced on January 23, 2015 the SPTP as a presidential decree, and instructed to carry out the lines of action it includes.[28]
The SPTP is an interinstitutional organized response, headed by the federal government, to respond to unintended pregnancies at an early age. In it participate institutions like the National Population Council, the National Institute for Women, National Institute of Youth, the Secretariat of Health, Mexican Social Security Institute, Institute for Health and Social Security for State Workers, System of Family Development, Committee on the Development of Indigenous People, Secretariat of Public Education, Secretariat of Social Development, all of them engaged with the same objective: reducing the number of teenage pregnancies in Mexico, with absolute respect for sexual and reproductive rights . With the firm conviction of following this same line of action until 2030. Those organizations are integrated in an Interinstitutional Group for the Prevention of Teenage Pregnancy (GPTP), committed to replicate the same strategy in each state of the country.[26]
The SPTP has a very broad conceptual approach that shows a comprehensive solution, not just a health care one, taking into account demographic, social, economic, educational, cultural aspects. It uses an ecological framework and puts the old fragmented systems aside. There are eight core ideas that support the transversal operation of this strategy: 1) Inter-sectoral approach, 2) Citizenship and sexual and reproductive rights, 3) Gender perspective, 4) Course of life and life project 5) Co-responsibility, 6) Youth Participation, 7) Research and scientific evidence and 8) Evaluation and accountability, all of them try to ensure the functionality and integration of all institutions in this strategy. The SPTP, together with the political organization of Mexico, outlined building consensus among different levels of government based on coordination, cooperation and communication, in a scenario of sustainability.
The measurement of the impact of this strategy is designed with three types of indicators which will be annually monitored, and two nominal cuts will be done, one in 2018 and the other at the end of 2030.26 This makes difficult to define, at this time, the direct impact the strategy has so far in the proposed indicators. At more than a year after it was decreed, 19 SGPTP (State Groups for the Prevention of Teenage Pregnancies) have been formed. The specific pregnancy rate, according to NSDD, in 2014, was of 78.5[29]; since the implementation of the SPTP, in 2015, the Specific Adolescent Fertility Rate (SAFR) closed at 76.9.[30]
The impact that such a national strategy has had cannot only be measured in numbers; there has also been progress in this area since it is the first time that a national strategy is carried out with this approach. It is also the first time that institutions of national presence come together to carry out this type of activities in a coordinated manner. It is the first time that this topic is included in the federal public agenda. If this goal is achieved, it will be an unprecedented event to which an exclusive budget will be allocated for these strategies.[30]
Teenage pregnancy is an urgent public health problem in growth, which not only has a health approach, but also limits the maximum development of a teenager and endangers the fulfillment of his/her life plan. To give adolescents the opportunity of a better development, it is essential to create comprehensive strategies that prevent that an early pregnancy becomes the only path in their lives, but instead, that it be the last path they may choose, always respecting their sexual and reproductive rights. These strategies must be real and not only on paper and in speeches, the results should be reflected directly in the adolescent population. Strategies should be inclusive with adolescents and comprehensive regarding their context. Even though Mexico has implemented a document which supports the basis for the eradication of pregnancy in teenagers under 15 years old and for the reduction in the number of unintended pregnancies in adolescents, it is crucial that people watch and participate, together with governmental institutions, in implementing this strategy; otherwise, it will only be another good attempt.
[1]Consejo Nacional de Población. [Homepage in internet].CONAPO; c2015. [Consultado 8 de marzo 2016]. Disponible en: http://www.conapo.gob.mx/es/CONAPO/Proyecciones_Datos
[2]Organización Mundial de la Salud [Homepage in internet]. OMS; c2016. [Consultado 12 de marzo 2016]. Disponible en: http://www.who.int/mediacentre/factsheets/fs364/es/
[3]Menkes C, Suárez L. Sexualidad y embarazo adolescente en México. Proyecciones de población 2003; 9: 131.
[4]Alarcón RI, Coello J, Cabrera J, Monier G. Influence factors in adolescence pregnancy. Rev. Cub. de Enf. 2009; 25 (2):1927.
[5]Bernardita W, Póo FA, Vásquez O, Muñoz S, Vallejos C. Identificación de factores de riesgo y factores protectores del embarazo en adolescentes de la novena región. Rev Chil Obstet Ginecol 2007; 72 (2):7681
[6]Instituto Nacional de Estadistica y Geografia. [Homepage in internet]. INEGI. 2015 [Consultado 8 de marzo 2016]. Disponible en: .http://www.inegi.org.mx/sistemas/olap/Proyectos/bd/continuas/natalidad/nacimientos.asp ?s=est&c=23699&proy=nat_nac
[7]Valdés A, Essien J, Bardales J, Saavedra M, Mitac D. Embarazo en la adolescencia. Incidencia, riesgos y complicaciones. Hospital Ginecoobstétrico. 2001; 388.
[8]Diaz V. El embarazo de las adolescentes en México. Gac Méd Méx, 2003; 139: 2327.
[9]Chioma Oringanje. [Homepage in internet].c2015. Disponible en. http://insects.arizona.edu/chiomaoringanje
[10]Fondo de Población de las Naciones Unidad (2013). Estado de la población mundial 2013. Maternidad en la niñez, enfrentar el reto del embarazo adolescente. Nueva York: Fondo de Población de las Naciones Unidas.
[11]Azevedo JP, Favara M. Haddock SE. et al. Embarazo Adolescente y Oportunidades en América Latina y el Caribe sobre maternidad temprana, pobreza y logros económicos. Banco Mundial–LAC. 2012: 2542.
[12]Consejo Nacional de Población. [Homepage in internet].CONAPO; 2014. [Consultado 19 de febrero 2016]. Disponible en: http://www.conapo.gob.mx/es/CONAPO/Proyecciones
[13]Encuesta Nacional de la Dinámica Demográfica 2009. [Homepage in internet].CONAPO; c2009. [Consultado 19 de febrero 2016]. Disponible en: http://www.conapo.gob.mx/en/CONAPO/ENADID_2009
[14]Consejo Nacional de Población. Proyecciones del CONAPO 2010–2050 en 2013 [Homepage in internet].CONAPO; c2013. [Consultado 19 de febrero 2016]. Disponible en: http://www.conapo.gob.mx/es/CONAPO/Proyecciones
[15]Encuesta Nacional de la Dinámica Demográfica 2014. [Homepage in internet].CONAPO; c2014. [Consultado 19 de febrero 2016]. Disponible en:http://www.inegi.org.mx/est/contenidos/proyectos/encuestas/hogares/especiales/enadid/enadid2014/
[16]Consejo Nacional de Población (2010), “La situación actual de los jóvenes en México, Serie de Documentos Técnicos”, México, DF (2010), pág. 86.
[17]Biblioteca de Salud Reproductiva de la OMS [Homepage in internet].OMS; c2015. [Consultado 19 de febrero 2016]. Disponible en: :http://apps.who.int/rhl/adolescent/cd005215_ramoss_com/es/
[18]Kappeler E, Feldman A. Historical context for the creation of the Office of Adolescent. Health and the Teen Pregnancy Prevention Program. Journal of Adolescent Health. 2014; 54.(3):S3–S9.
[19]Farb F. From Mission to Measures: Performance Measure Development for a Teen Pregnancy Prevention Program. Journal of Adolescent Health. 2014; 54.(3): 15–20.
[20]Department of Health and Human Services Office of Adolescent Health. Trends in Teen Pregnancy and childbearing, [Homepage in internet].USA; 2014. [Consultado 19 de febrero 2016]. Disponible en: : Web, 2014. http://www.hhs.gov/ash/oah/adolescent–health–topics/reproductive–health/teen–pregnancy/trends.html
[21]University of Bradfordshire, Teenage Pregnancy Knowledge Exchange, [Homepage in internet].USA; c2014. [Consultado 19 de febrero 2016]. Disponible en: http://www.beds.ac.uk/howtoapply/departments/healthsciences/teenage–pregnancy–knowledge–exchange
[22]Villa L. Svanemyr J. Ensuring Youth´s Right to Participation and Promotion of Youth Leadership in the Development of Sexual and Reproductive Health Policies and Programs. Journal of Adolescent Health 2010; 1928.
[23]Perú, Ministerio de Salud, Plan Multisectorial para la Prevención del Embarazo en Adolescentes 2012–202, [Homepage in internet].UNFPA/AECID c2011. [Consultado 19 de febrero 2016]. Disponible en: http://www.unfpa.org.pe/publicaciones/publicacionesperu/MINSA–Plan–Multisectorial–PEA–2012–2021.pdf
[24]Let girls be girls!: National Strategy for the Reduction of Teenage Pregnancy (2013–2015), [Homepage in internet]. República de Sierra Leona, 2015. [Consultado 19 de febrero 2016]. Disponible en: https://www.k4health.org/toolkits/youthpolicy/let–girls–be–girls–not–mothers–national–strategy–reduction–teenage–pregnancy
[25]Bernardita W, Berger C, Aracena M. Una perspectiva integradora del embarazo en adolescentes: La visita domiciliaria como estrategia de prevención. Rev Chil de Psico .2001; 10(1): 2134
[26]Estrategia Nacional para la Prevención de Embarazo en Adolescentes.. [Homepage in internet].CONAPO; c2015; [Consultado 19 de febrero 2016]. Disponible en: http://www.conapo.gob.mx/work/models/CONAPO/Resource/2441/1/images/ENAPEA_V10.pdf
[27]Zuurmond MA, Geary RS, Ross DA. The effectiveness of youth centers in increasing the use of sexual and reproductive health services: A systematic review. Studies in Family Planning 2012; 43(3): 239–254.
[28]Gobierno de México. 2015. http://www.gob.mx/conapo/articulos/estrategianacionalparalaprevenciondelembarazoenadolescentesenapea
[29]Sistema de Registros de Nacimientos SINAC [Homepage in internet].DGE; c2015; [Consultado 27 de febrero 2016]. Disponible en: http://www.dgis.salud.gob.mx/contenidos/basesdedatos/bdc_nacimientos.html
[30] Coalicion por la salud de las Mujeres [Homepage in internet].CIMANoticias; c2016; [Consultado 09 de mayo 2016]. Disponible en: http://www.cimacnoticias.com.mx/node/69380
[a]Centro Nacional de Equidad de Género y Salud Reproductiva. Ciudad de México, Mexico.
[b]Área Académica de Medicina del Instituto de Ciencias de la Salud de la Universidad Autónoma del Estado de Hidalgo. Pachuca Hidalgo. Mexico.
[*]Corresponding author:
José Alejandro González Espíndola
Centro Nacional de Equidad de Género y Salud Reproductiva
Homero No. 213
Polanco
Ciudad de México, México
age241088@hotmail.com,
Cell phone number: 7751240969