Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies

Study characteristics and quality

Ten controlled trials^w1-w10 and five qualitative studies^w11-w15 met our inclusion criteria. Six controlled trials were judged to be of sufficient methodological quality to provide reliable evidence about the impact of interventions on teenage pregnancy rates.^{w1-w3 w6 w7 w9} All these trials were conducted in the US and targeted disadvantaged groups of children and young people (tables 2⇓ and 3⇓).

Each of the methodologically sound controlled trials evaluated one of two intervention types: (a) an early childhood intervention, or (b) a youth development programme. Three studies evaluated early childhood interventions that aimed to promote cognitive and social development through preschool education, parent training, and social skills training.^{w2 w3 w7} Two of these studies—the Perry Preschool Program^w2 and the Abecedarian Project^w3—evaluated the long term effects of preschool education and parenting support interventions; the third—the Seattle Social Development Project—evaluated the long term effects of a school based social skills development intervention for children and their parents.^w7

A further three studies evaluated youth development programmes that aimed to promote self esteem, positive aspirations, and a sense of purpose through vocational, educational, volunteering, and life skills work.^{w1 w6 w10} Two of these studies—Teen Outreach^w1 and the Quantum Opportunities Program^w6—evaluated after school programmes based on the principle of “serve and learn,” in which community service is combined with student learning and educational support; the third—the Children’s Aid Society Carrera-Model Program—evaluated a comprehensive academic and social development intervention delivered in youth centres, which included work experience, careers advice, academic support, sex education, arts workshops, sports, and other activities.^w10

In each trial, the control group received no intervention or standard education. The four controlled trials that were deemed not to be of sufficient quality also evaluated youth development programmes in the US.^{w4 w5 w8 w9}All five qualitative studies were judged to be of medium or high quality.^w11-w15 These studies included participants from a range of areas throughout the UK and used individual interviews, focus groups, and self completion questionnaires to collect data (table 4⇓). Four studies focused on, or included, the views of young parents,^{w11 w12 w14 w15} but only two of these studies included the views of young fathers as well as young mothers.^{w14 w15}

Quantitative studies of the effects of interventions on teenage pregnancy rates

Of the six controlled trials deemed to be of sufficient methodological quality, four measured pregnancy rates reported by young women,^{w1 w2 w7 w10} three measured partner pregnancy rates reported by young men,^{w1 w7 w10} and two measured birth rates reported by young men and young women separately^w3 or together.^w6 The four controlled trials measuring pregnancy rates reported by young women or young men^{w1 w2 w7 w10} were included in two random effects meta-analyses: one that assessed the effects of interventions on teenage pregnancies reported by young women and a second that measured the effects of interventions on teenage pregnancies reported by young men. The findings of the two controlled trials that measured birth rates^{w3 w6} were not subject to meta-analysis, but their findings are summarised after each meta-analysis. Tests revealed no statistical heterogeneity between the studies, suggesting that it would be appropriate to pool the effect sizes. However, effect sizes for youth development interventions and early childhood education interventions were pooled separately in recognition of the differences between these two types of intervention.

The pooled effect size from the first meta-analysis showed that early childhood interventions and youth development programmes reduced teenage pregnancy rates among young women (RR 0.61, 95% CI 0.48 to 0.77; fig 1⇓). The effect of an early childhood intervention on birth rates reported by young women was similar in the study by Campbell and colleagues^w3 (0.56, 0.42 to 0.75).

Fig 1 Forest plot showing the effect of youth development programmes and early childhood interventions on pregnancy rates reported by young women

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The effect of these interventions on pregnancies reported by young men is less clear (fig 2⇓). The pooled effect size from the second meta-analysis showed that young men who had received an early childhood or youth development intervention reported fewer partner pregnancies than those who had not, but this result was not statistically significant (RR 0.59, 95% CI 0.34 to 1.02).

Fig 2 Forest plot showing the effect of youth development programmes and early childhood interventions on pregnancy rates reported by young men

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Hahn and colleagues^w6 evaluated a youth development programme and measured birth rates reported by both young women and young men. The intervention reduced the birth rate by 36%, although this result was of borderline statistical significance (RR 0.64, 95% CI 0.40 to 1.03).

Qualitative studies of the views and experiences of young people

Three major themes relating to teenage pregnancy emerged from the findings of the five qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations and aspirations for the future (fig 3⇓).

Fig 3 Thematic analysis of young people’s views on the role of education; training; employment and careers; and financial circumstances in teenage pregnancy

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Dislike of school was a key aspect of young parents’ accounts of their lives before becoming parents and of young people identified as “at risk” of becoming teenage parents (for example, “Still be at school? I’d rather have a baby than that. I just didn’t like school, it was hard, it was horrible”^w14). The reasons young people gave for disliking school varied (fig 3). Some related to the subject matter taught in school, which was seen as boring or irrelevant, especially for young women who had difficult or unhappy home lives and caring responsibilities (for example, “what on earth is this going to do for me?”^w15). Other reasons related to insufficient or inappropriate support when falling behind with school work or experiencing bullying by teachers and peers (for example, “I got bullied so I just stopped going”^w12). Some young people were frustrated with the inflexibility of “institutional life,” with all its rules and regulations (for example, “You can’t sit with your friends, which I found the best way of learning”^w11).

Young parents reported unhappiness, rather than poverty in itself, as the most significant aspect of their childhood experiences that related to becoming a parent, although unhappiness went hand in hand with adversity and material disadvantage in their accounts. Common experiences included family conflict and breakdown, sometimes caused by violence, which could lead to living in care (fig 3). Young fathers reported violent fathers and a lack of suitable role models. Young parents noted how they had to “grow up faster” in order to survive, and also reported a lack of confidence, low self esteem, and high anxiety levels.^w11 Some young women saw having a baby at an early age as a way to change their circumstances and ameliorate the effects of adversity. It is important to note, however, that not all the teenage mothers who participated in these studies had grown up unhappy or experienced personal adversity. Regardless of circumstances, some women had wanted to have a baby when they were young and looked forward to still being young when their children were older.

There were differences in the expectations and aspirations of young people who had, or wanted to have, a baby early in life and young people who had or wanted to have a baby later in life. For example, mothers who had children when they were teenagers wanted to leave school as soon as possible and get a job. In contrast, those who became pregnant later in life expected to go to university and travel. Both young mothers and young fathers believed that few opportunities were open to them apart from poorly paid, temporary work in jobs that they disliked (for example, “There are so many jobs out there that I didn’t even know existed . . . I probably could have done something but I just didn’t even think of these high paid jobs I could have done”^w14). Young mothers described how having a baby was a more attractive option than entering the workforce, further education, or training. Young men’s lack of ambition was compounded by the low expectations their parents and peers held for them. Young people who wanted children later in life had long term plans and a more positive outlook for the future, and they described how participating in out of school activities such as sports, music, and arts improved their self esteem and motivation.

Do current interventions address the needs and concerns reported by young people?

The themes in our synthesis of qualitative studies suggest areas that should be addressed in preventive interventions, but measures to target these areas have not all been soundly evaluated for their effect on teenage pregnancy rates (table 5⇓).

Youth development programmes and early childhood interventions both go some way to addressing young people’s dislike of school. Two of the three youth development programmes in the controlled trials we reviewed included components designed to promote young people’s academic achievement, such as tutoring and homework assistance,^{w6 w10} whereas the third aimed to improve young people’s interpersonal skills so they could develop good relationships with their peers and others.^w1 One early childhood intervention both taught children conflict resolution skills and trained parents to create a home environment supportive of learning.^w7 We did not find any research that had tested the impact on teenage pregnancy rates of interventions designed to change the school culture and environment, such as antibullying strategies, teacher training, or involving young people in making decisions about what happens in the school.

All the youth development programmes aimed to prevent teenage pregnancy by broadening young people’s expectations and aspirations for the future. These programmes offered young people work experience in their local communities, careers advice, group work to stimulate active reflection, and discussion of future careers and employment opportunities. Two of the three soundly evaluated youth development programmes also provided out of school sports or arts activities.^{w6 w10}