Teenage pregnancy: whose problem is it?

Abstract

Background. The UK has the highest rates of teenage conception in Europe. Teenage conception has been identified in medical literature as a problem for society and teenagers. However, little attempt has been made to see it from the perspective of the teenagers themselves.

Objective. To explore teenage women's attitudes to sexual health, contraception and pregnancy.

Methods. Ethnographic qualitative study based on in-depth interviews and participant observation. The study took place in young mothers' groups, young persons' clinics and general practices in Bristol. Subjects were 34 young women between the ages of 16 and 20, sampled purposefully in two groups to include young mothers and never-pregnant young women from advantaged and disadvantaged socioeconomic backgrounds.

Results. The two groups did not differ in their use of contraception at first intercourse. Young women from more socioeconomically advantaged backgrounds felt that motherhood would not be acceptable to them, but were more tolerant to others who became young mothers. The pregnant/ young mothers revealed more difficulties getting access to reliable contraceptive services, and dissatisfaction with sex education in schools. The pregnant/young mothers found abortion to be less acceptable than the more socially advantaged group. Both groups reported sexual behaviour that involved risks of becoming pregnant, but the more socially advantaged group were more likely to use emergency contraception.

Conclusions. The study demonstrates the importance of taking the views of young people into account when planning both sex education and the provision of contraceptive services.

Jewell D, Tacchi J and Donovan J. Teenage pregnancy: whose problem is it? Family Practice 2000; 17: 522–528.

Introduction

The UK is widely quoted as having the highest rates of teenage conception in Europe.^1,2 In England and Wales during 1996 (the last year for which routine data are currently available), there were 44 000 live births to women below the age of 20 years, representing approximately 7% of all live births. The live birth rate was 29.8 per 1000 women aged 15–19 years, compared with 65.4 per 1000 for women aged 20–44 years.³ Reduction of conceptions among women below the age of 16 years was identified as a specific target in the Health of the Nation.⁴ Without solid empirical evidence as to how such a reduction should be achieved, much of the debate and published research has focused on sex education in schools⁵ and the problems of access to suitable services.⁶ However, the danger of assuming a clear link between improved knowledge and access to services on the one hand and behavioural change on the other is well known.⁷

Teenage pregnancy is commonly identified in the medical literature as a problem for society and teenagers that requires intervention. A systematic review of the medical literature, for example, reports medical, financial and social problems for mothers and their children following teenage pregnancy, and suggests that sex education and access to services should be improved and linked.⁸ An association has been found, however, between socioeconomic deprivation and teenage pregnancy^9–11 and it is likely that at least some of the increased risks are attributable to this, rather than the pregnancy itself.

Absent from much of the moral, political and medical debate that surrounds teenage pregnancy is the perspective of teenagers and young people. A small number of studies have suggested that, while teenage pregnancy may be considered to be a problem for society, it may be less so for the teenagers themselves.^12–14 If this is true, interventions designed by society and health services to reduce teenage conceptions may not be successful. Improved targeting of resources and policies requires that interventions be acceptable to young people.

To this end, we carried out a study using qualitative research methods to explore whether pregnant teenagers differed from non-pregnant teenagers in terms of their attitudes towards health, sex and pregnancy, including their knowledge and use of contraception and health services, and their perceptions of society's view of teenage mothers.

Methods

In order to explore the views and opinions of young women, an ethnographic approach was taken.^15,16 Such research has a long history in social anthropology.^17–19 It enables the researcher to explore and understand the lives and perspectives of those being researched by observing them in their social environments and participating in informal discussions. The primary researcher (J.T.) carried out participant observation with young women over a period of 18 months and supplemented this with in-depth interviews with these women and others to collect data.

Sampling

Women were recruited purposefully to ensure that the sample included a range of social circumstances (e.g. ‘disadvantaged’, i.e. living in an area with relatively high levels of poverty and unemployment, poor and mainly rented housing and with limited personal and family financial resources; and ‘advantaged’, i.e. living in areas with relatively low levels of poverty and unemployment, mostly owner-occupied housing and with mostly good personal and family financial resources), ages (within the range 16–20 years) and sexual experiences (those who had had sexual intercourse and those who had not; those under 16 years and those over 16 years at first intercourse). Informants were identified through young mothers' groups, GP surgeries, young people's sexual health clinics and introductions by other young women (see below).

Participant observation was carried out in four settings: (i) A young mother’s group in a disadvantaged inner city area (group A). This group was for ‘older’ women aged 16–25 years. J.T. visited the group every week for 2 months and then occasionally over an 18 month period. (ii) A young mothers' group on a large disadvantaged estate on the outskirts of the city (group B). This group was for younger women aged 13–19 years. J.T. visited the group every week over an 18 month period. (iii) A young mothers' peer education project. J.T. attended this regularly over a 12 month period. (iv) A young mothers' video project. J.T. attended regular meetings over a 13 month period from the conception of the video to its first screening.

J.T. was introduced to groups A and B as a researcher investigating young women's views of teenage pregnancy. She attended meetings and took part in arranged group activities such as Indian cooking, self-defence and parenting classes to get to know the women, even doing the washing up to gain their trust. Much of the time was taken up with general informal conversation, with J.T. sometimes able to steer the conversation towards issues around teenage pregnancy. Formal sessions on topics such as healthy eating, managing budgets, parenting and toilet training provided information on the perspectives and experiences of the young mothers that would have been inaccessible through interviews alone. Some sessions were thus explicitly relevant to the study and others provided more informal data relating to the young women's lives, views and interactions.

The peer education project was designed to give school-aged children an insight into what it was like to be a young parent, and the video project was linked to it. Both projects provided the study with insights into the ways in which the young mothers felt they were perceived by society and how they perceived themselves and other young mothers. Much of the discussion at meetings was about negative and positive experiences of teenage pregnancy and young motherhood and what sorts of information should be presented to school children.

In-depth interviews were carried out with 12 members of the young mothers' groups, and other young women interviewed were identified as follows:

GP surgeries.

Three GP surgeries were identified to include areas of high and low socioeconomic characteristics, and 10 informants were recruited by GPs. Two informants were pregnant, eight were not; three were ‘advantaged’ and seven ‘disadvantaged’. Six women were interviewed once and four twice.

Young people's sexual health clinics.

Nine women were recruited from two clinics, one in the centre of the city serving a wide-ranging population and the other in a socioeconomically disadvantaged area; eight were ‘advantaged’ and one was ‘disadvantaged’.

Introductions by other young women (snowball sampling).

Two young mothers were introduced to the researcher as friends of members of the young mothers' groups; one young woman was introduced to the researcher during a visit to a youth club.

Data management and analysis

Detailed fieldnotes were kept of discussions and findings after the participant observation.^15,16 In-depth interviews were guided by a checklist of topics including the family background of the young woman, friends and boyfriends, sexual health and relationships, contraceptive use, career plans and, where appropriate, pregnancies and children. Interviews were audio tape-recorded and fully transcribed. Transcripts and fieldnotes were scrutinized and coded using descriptive codes (such as education, family background, contraceptive use) and more interpretive thematic codes (such as control over fertility, the importance of love, attitudes to abortion). The coding frame was developed by J.T. after all three authors had independently coded two transcripts and discussed the differences that arose (primarily differences of wording rather than thematic differences). The coding frame was used by J.T. with some flexibility to incorporate any new themes that arose as the research progressed.

Descriptive accounts of groups of four or five interviews and their accompanying fieldnotes were then produced. Finally, all the data were drawn together around the major themes, set within the context of these young people's sexual and emotional relationships and social circumstances. In the section that follows, we describe the major themes of importance to those providing health services for young people. The extracts from interviews provide examples of recurring themes elicited from analysis of fieldnotes written throughout the 18 months of fieldwork and transcripts of over 40 in-depth interviews.

The study was approved by the Local Research Ethics Committees based in each of the three National Health Service trusts in Bristol.

Results

Thirty-four women were interviewed during the study. Their characteristics are presented in Table 1. Their ages ranged from 16 to 22 years; the reported age of first intercourse ranged from 12 years to three who had not yet had sex. Although the numbers are small, it is clear that the young mothers tended to have had their first sexual intercourse at an earlier age than the non-pregnant women. In terms of the use (or not) of contraception at the first intercourse, the pattern was similar for both the young mothers and the non-pregnant women, although more of the non-pregnant women had used emergency contraception at some time. The majority of informants were socioeconomically ‘disadvantaged’ although 10 ‘advantaged’ non-pregnant women were also interviewed.

The main themes from the interviews and participant observation are described below, focusing on aspects relevant to those involved with the provision of services for young people and teenage mothers: attitudes towards teenage pregnancy, sex and love in relationships, and knowledge and behaviour in relation to contraception.

Attitudes towards teenage pregnancy

There were clear differences between those from advantaged backgrounds and those from and disadvantaged backgrounds in terms of their attitudes towards abortion and teenage pregnancy. Much of the difference could be accounted for by the ways in which the young women saw their future, with the advantaged women putting much greater emphasis on the importance of having a career, university, money and personal development. The disadvantaged women felt that the best age for starting a family was between 17 and 25 years, whereas the advantaged women felt it should be rather later, in their late twenties or early thirties. The groups revealed striking differences in attitudes to teenage pregnancy in general. Although early motherhood was less acceptable as an option for advantaged women, their attitude towards those who become young mothers was often tolerant:

“Bloody brave I think. Because I know I couldn’t, me personally … I just don’t know how they cope, because I know I couldn’t.” (non-pregnant, aged 18 years, at university, advantaged background)

Although they recognized that it would not be an easy choice, all of the advantaged group said they would be likely to opt for an abortion if they became pregnant in their teens:

“I have quite often thought about it because I do love children and can’t wait to have children so, but I think if I got pregnant now, I would be very stuck to make the decision, but I don’t really want children now because I have got so much ahead of me, so I probably would end up having an abortion.” (non-pregnant, aged 17 years, in sixth form, advantaged background)

Some of the young mothers had considered abortion but felt unable to go through with it:

“I don’t really like it [abortion] but … I couldn’t go out and demonstrate against it or anything because I know people have, and I know the reasons why and I mean I nearly did one as well. I just sat down and thought I know I haven’t got a good enough reason to go ahead with it [the abortion]—so I didn’t.” (young mother, first pregnant at 17 whilst at college, disadvantaged background)

Other young mothers had concealed their pregnancy in its early stages to avoid even having to consider the option of termination:

“No, it wasn’t really an option and I just thought that if I leave it for as long as possible then I’m not gonna be able to have one anyway, so the thought won’t even come into my head.”(young mother, pregnant at 17 and 18, disadvantaged background)

Among the young mothers there were often conflicting views about the experience of becoming pregnant so early. While they clearly loved their children, there were also considerable regrets:

“Oh, she's gorgeous and the age difference between us, like when she's my age, I’ll just be hitting my 30s.’ But “I wish I’d never [become pregnant] … If I knew then what I know now, it would have been different because … the money—I was working before her … I had a lot more friends … I was out all the time … but now I just sit in every night and I haven’t got no money.” (young mother, pregnant at 15, disadvantaged background)

The young mothers felt under some pressure to demonstrate that they were capable and good mothers, despite their young age and often used expensive children's clothing or expensive pushchairs as a means of demonstrating this:

“I used to go to the [clothes shop in neighbouring city] and things like that and buy clothes and the cheapest thing in there would be about £10 per sock sort of thing … and I used to leave all his labels out, so people could see where I bought his clothes from. So they thought I’d be looking after him properly if he had decent clothes on.”(young mother, pregnant at 17 and 18, disadvantaged background)

Yet they often used derogative and stereotypical terms to describe other teenage mothers. Other mothers were variously described as selfish, of having become pregnant ‘on purpose’ in order to get housing or benefits—the kinds of accusation that the young mothers involved in the research worked hard to distance themselves from. Other young mothers were portrayed as ‘bad’ mothers in an effort discursively to position themselves as ‘good’ mothers:

“She still puts herself first and that’s something I find really hard, I think ‘Oh God, how could you do that? How could you … possibly put yourself before your little girl?’” (young mother, pregnant at 17 and 18, disadvantaged background)

Sex and love in relationships

The sexual relationship and how the women felt about their sexual partners affected their contraceptive use. Within relationships that were seen as long term, careful contraception was not always maintained, although many realized in retrospect that they had been ‘naïve’:

“Younger girls are meeting up with older boys and they talk you round it and ‘Oh no you won’t blah blah blah’ … and then, ‘Oh if you love me, you’ll let me not wear nothing [condom]’ and all that and I think, ‘Oh yeah—I really do love him’ blah blah … but you don’t know what it is. You think you love this person and they are wonderful and things, but …” (young mother, aged 17 years, disadvantaged background)

The young mothers often talked about how becoming a parent had made them more mature and responsible, and also changed their view of what love was and what they wanted from a relationship. Love was now seen as a more developed emotion and a stable basis upon which to build a relationship and family, whereas sex was more transient:

“Sex is just for enjoyment, isn't it? … it's there for when you want a bit of pleasure. Sex and love is different. I mean love is like when someone is there, isn’t it?” (young mother, aged 20 years, disadvantaged background)

Emotional attachments (often referred to as love) were used to explain risk-taking behaviour among some of the young women.

“I was with him for so long. I idolized him, I thought the world of him. I would have done anything, anything. Which I did … At the time I thought it was love because he would do anything for me and it was vice versa with me … But it wasn’t, it was more lust.”(young mother, aged 17, disadvantaged background)

Knowledge and behaviour in relation to contraception

Many of the young women were struggling to find contraception to suit them. In general the more disadvantaged group had less knowledge about contraception and some used injectable contraception because they felt unable to control their fertility adequately using other methods. Many reported taking the contraceptive pill, but sometimes inadequately:

“The pill—I wasn’t told that you had to take it at the same time every day. I wasn’t told that if you missed one that it wouldn’t work if you took two the next day. I was just given it … and even though it like explains everything in the leaflet, you don’t read it … You don’t know the importance of it. You just think ‘Oh, yeah’ and you just take this pill every day and you think, you know, you’re doing the right thing.” (young mother, pregnant at 17 and 18, disadvantaged background)

A major source of information for all women was other young women, but again, the information was often inadequate:

“It seems to be word of mouth and from my experience it has always been like that … I mean basically, people don’t really know much about smear tests and, you know, all these things and the morning after pill and stuff like that and there's a lot of, really, just lack of information, I think, about it all.” (non-pregnant, sexually active, aged 16, advantaged background)

Parents are a source of information for some of the young women. However, they are not always well informed or able to deal with the issues involved:

“I consider myself to be, um, quite well informed and on top of it. I think my parents are much less aware and … I wish that they could be targeted more … I think they find it a little bit more difficult to cope … which I find quite frustrating because … I actually don’t tell them things which I would like them to just be aware of …” (non-pregnant, sexually active, aged 16 years, advantaged background)

Five of the young mothers had two children (four of these second children were described as ‘unplanned’) and several had pregnancy ‘scares’ during the study. There was a widespread lack of confidence in contraception among the disadvantaged young mothers. Although there appeared to be greater levels of control over fertility among the non-pregnant women, their accounts suggested that there was little difference between them in terms of ever having taken risks with unprotected sex. The crucial difference lay in the nature, length and responses to such risky behaviour: more advantaged women tended to take emergency contraception after unprotected sex; more disadvantaged women tended to wait and see if they were pregnant:

“Afterwards you think ‘Oh, dear! Oh, no.’ Sort of, I like pootled off and … got the morning-after pill … It was with one of my friends from around the campus, I went with [her] because she needed to get it as well … two weeks into term and we just thought ‘Oh no’!” (non-pregnant, aged 18 years, at university, advantaged background)

“Before I had my daughter, I thought I was pregnant a couple of times before … And I thought ‘Oh, no I’m late, I’m late on like—oh, no’ and, like, I would come on, like, even later, you know, and thought ‘Thank God!’ I was, like, was wiping sweat off my head when I come on. I was just begging to see a period, like, all the time … so it was a bit petrifying.” (young mother, first pregnant at 15, disadvantaged background)

The advantaged woman above also indicated that she would employ the ‘wait-and-see’ policy, but only if she felt reasonably sure she would be safe:

“One of them was, sort of, at the end of my period so I thought I was vaguely OK with that one, um, … and the other two were, sort of, about a week after my period. So I thought again, ‘I’m gonna be, hopefully OK’. But, sort of, waiting for the 3 weeks thinking ‘Please, hurry up, hurry up’.” (non-pregnant, age 18, at university, advantaged background)

The participant observation with young mothers' groups provided additional data describing the attitudes of the women to contraception and sex education. They tended to become sexually active young, and as they were already ‘practising’ sex, felt that sex education was too late, too biological and did not explain enough about contraception or the emotions involved in sexual relationships and pregnancy. The women supported the concept of ‘peer education’—wanting information from someone with personal experience. Sometimes they did not use contraception for months or years before becoming pregnant, even if they had ‘scares’. Several were taken to GPs when their parents became aware that they were sexually active, but they often used the contraception ineffectively and were sometimes unhappy at having it prescribed for them. A young mother who was 13 when she first conceived did not think at the time that it was physically possible for her to become pregnant and had not even considered using contraception at that time. In retrospect, many realized that their behaviour was inappropriate, but felt they were poorly informed about contraception and health. In contrast, the more advantaged women were generally more knowledgeable about health services and were better able to gain access to them and to obtain and use contraception as they wanted. The young mothers talked about the problems they had in obtaining contraceptive advice and services that suited them, often recounting negative meetings with service providers and other obstacles to obtaining contraceptives and contraceptive advice:

“Well, I did try to have the coil fitted but she said to me, ‘You didn’t have your baby naturally’, and I said, ‘I did’. She said, ‘You didn’t’—I said, ‘I was there! I did!’ She said, ‘Well, I can’t fit this’, she said ‘You are so small’.”

“I’d probably go to [clinic name] for family planning or something but I’m so lazy, I don’t get there … If I had a car I would be … then I will definitely sort out a contraceptive.” (young mother, pregnant at 15, disadvantaged background)

In contrast, those from advantaged backgrounds appeared to take such things in their stride, using their friendship networks to ease their first experience of obtaining contraceptives and emergency contraception:

“I was going to go to the family planning clinic and she [friend] said, ‘No, I’ve been to [clinic name] and they are really really nice and I will take you along’, so she took me down there. And then I took [another friend], so it’s kind of a [word of mouth].” (non-pregnant, aged 18 years, at university, advantaged background)

Discussion

We have identified differing attitudes towards early pregnancy, abortion and ‘teenage mothers' between the two groups. Early pregnancy and young motherhood were generally more acceptable to the disadvantaged women than those with advantaged backgrounds. Abortion and the use of emergency contraception were both more acceptable to advantaged women. Although risky behaviour was similar among all the women, those with advantaged backgrounds were more able to access reliable contraceptive services. Interestingly, women from advantaged backgrounds were more tolerant towards young mothers. These results reinforce earlier work by Phoenix,^13,20 who found that young mothers use discourses to stigmatize other young mothers as a way of distancing themselves from such negative associations. This study confirms previous findings that teenagers experience difficulty gaining access to contraceptive services, and this is compounded by perceived deficiencies in their sex education.²¹ Health practitioners were often seen as unsympathetic to and dismissive of their needs. As Hutchinson points out,²² many sexually active young people “receive few positive messages on managing their sexuality”, and simply warning them about the dangers of pregnancy and sexually transmitted disease may make them feel “outside the law and unable to take responsibility for themselves”.

How differences in attitude translate into use of contraception is less clear. There was no absolute distinction, in terms of using or not using contraception, between the two groups, except possibly in the use of emergency contraception. However, the disadvantaged young women were less able to access sexual health services and to maintain contraceptive use. They were more likely to miss appointments or stop using a prescribed form of contraception without advice from a health practitioner. Cooper et al.²³ identified the key issues in terms of obtaining contraception to be confidentiality and anonymity; doctors were perceived to be judgmental and to have too little time for satisfactory consultations.

This research also indicates the importance of considering emotional relationships in sexual behaviour and motherhood, which are found to be crucial to an understanding of sexual and contraceptive behaviour. For all of the women, but more markedly among the disadvantaged women, emotional states and relationships were more central to their lives than a concern for their own sexual health, which was seen as lying outside of these immediate and felt concerns. Sexuality carries its own rationalities, which do not necessarily prioritize safe sexual behaviour.²⁴

The strength of this study has been our opportunity to explore young women's emotional lives and to gain an insight into experiences of young women and young mothers from their own perspectives—a perspective missing from the vast majority of existing work on this subject.¹² Participant observation is a central component of ethnographic fieldwork and it allowed J.T. to engage with these young women over time, to develop research relationships and to get to know them in their own social environment as well as in the more ‘official’ interview setting. The young women's relationships and domestic life were often informally discussed in the observed young mothers' groups, allowing insights into their everyday lives. J.T. was able to befriend the women by sharing her own experiences as a young mother (she was pregnant as a teenager and now has teenage children of her own). We strongly believe that this had a very positive impact on the research, allowing J.T. to explore shared experiences that might have been inaccessible to others.

It is important to point out, however, that we were unable to identify any groups of advantaged pregnant teenagers to observe and so we cannot be conclusive about the effects of socioeconomic disadvantage and teenage pregnancy. Our findings (comparing interviews with advantaged and disadvantaged women) suggest that advantaged women more readily tend to avoid pregnancy by use of emergency contraception or abortion.

This study adds a timely dimension to previous work. It reinforces suggestions that, in order to reduce unplanned pregnancy and encourage safer sexual practices, it is necessary to have a more holistic understanding of the place and role of sex, contraception and pregnancy in young women's lives.^25,26 It reinforces the view that the approach most likely to be successful will require involvement of young people, both in sex education⁵ and in the planning of contraceptive services. Overall, what is needed is a shift away from blaming young women for teenage pregnancy towards greater understanding of their perspective on sexual health and relationships.

We would like to thank the women whose interviews form the basis of this research, together with Young Mothers' Groups, the Brook Advisory Centre and the general practices who allowed their patients to be interviewed. This study was funded by a grant from the South West Research and Development Directorate.

References