Inhibitors and Facilitators of Unwanted Adolescent Pregnancy in Iran and the World: A Review

Introduction

Adolescents account for approximately 1.2 billion of the world's population (1). Adolescence is a transitional stage from childhood to adulthood. According to some international organizations, adolescents are the young people aged between 10 and 19 years (2). Adolescence is an important period for the formation of personal identity and sexual orientation (3). Numerous unhealthy and high-risk behaviors occur in adolescence, resulting in short- and long-term undesirable consequences for adolescents, their families, and society (4). Some of the high-risk behaviors during adolescence include smoking, alcohol consumption, and unsafe sexual relations (5). New emotions emerge during adolescence; friends and peers become more significant, and the interest in the opposite sex heightens during this period (6-8).

More than half of the youth in the world begin their sexual activity during adolescence (9). According to the World Health Organization (WHO) statistics, about 16 million adolescent girls aged 15 to 19 years and 1 million teenage girls less than 15 years of age become pregnant worldwide annually (10). According to the same organization in 2016, annually almost 21 million teenage girls aged 15 to 19 years become pregnant in developing countries, about 49% of which are unintended (11). Mulugeta et al. (2014) showed that 30.8% of adolescent girls in Kenya had sex before marriage, one quarter (24.4%) of whom had unwanted pregnancy, 89% had abortion experience, and 11% had childbirth (12). The fertility rate for adolescents in China was 9 per 1000 births in 2012. Annually, more than 10 million self-induced abortions occur in China, 20-30% of which are among unmarried teenage girls (13).

Unwanted adolescent pregnancy is associated with negative individual, economic, and social effects (14). Pregnancy and childbirth impose physiological strains to the mother's body, which in turn, may lead to disease development or increased predisposition to various disorders and complications, such as anemia, preeclampsia, low birth weight, neonatal malformations, dystocia, cesarean section, increased maternal and child mortality, and abortion (15). Unwanted adolescent pregnancy undermines emotional mother-child bond and increases aggressive behavior towards adolescents (16). Adolescent pregnancies give rise to undesirable social outcomes in the domains of education, job development, poverty rate, and social exclusion (17, 18); they also impose a significant financial burden to societies, such that about $10.9 million per year is spent for this issue (19).

Another issue in adolescence is the change in psychological needs; in fact, adolescence is one of the most challenging periods in terms of mental health (20). According to Erikson's theory of psychosocial development, adolescents from the age of 12 years suffer from a psychosocial crisis termed as "identity versus confusion", which if remained unrecognized and unsatisfied, might play a role in the occurrence of unwanted pregnancy (6).

Given that adolescents are the most vulnerable age group to high-risk behaviors, any disorder or inadequate physical and mental health can contribute to slow progression of the community. On the other hand, adolescent health impairments may have negative long-term consequences for the health of the entire community (21). Therefore, recognizing the reasons for exposure of adolescents to the risk of unwanted pregnancy and the factors leading to facilitating or preventing unwanted adolescent pregnancy can help reduce the rate of unwanted pregnancy. Counseling with adolescents regarding unwanted pregnancy, as well as may predispose health care providers for more effective and expeditious action in this area. Therefore, this review was conducted to explore the inhibitors and facilitators of unwanted adolescent pregnancy in Iran and the world.

Methods

In this narrative review, all the authors searched the Google Scholar, PubMed, Elsevier, Scopus, ProQuest, Irandoc, Scientific Information Database (SID), and Magiran databases using the keywords of "pregnancy", "unwanted", and "adolescent" in both Persian and English and in the form of possible combinations to retrieve the relevant articles published from 2000 to 2016. In addition to articles, the WHO publications regarding unwanted adolescent pregnancy were also reviewed.

After the search, all the replicates were first excluded, and then the titles and abstracts of the articles were scanned. Next, the full text of the remaining articles was read to omit the unrelated articles. The relevant articles (both quantitative and qualitative articles) were included in the process. The remaining articles that met the inclusion criteria were chosen and confirmed qualitatively by all the authors. The main inclusion criteria were documentations related to unwanted pregnancy and

adolescents in English or Persian and accessibility of full text of the articles. In general, our search rendered 1453 articles, and eventually 29 articles and documents were selected based on the inclusion criteria. Figure 1 illustrates the article selection procedure.

Results

According to the findings of the review, the factors associated with unwanted adolescent pregnancy were expressed in two main categories of inhibitors and facilitators (Table 1).

Table 1. A review of studies in Iran and across the globe

Inhibitors

1- Abstinence

Abstinence is sexual inhibition due to moral, religious, legal, and health reasons, which is considered as one of the inhibitors of high-risk sexual relations and their associated outcomes (22). The findings of a study by Stanger-Hall et al. (2011) across 48 states in the USA showed that the abstinence education alone, as a governmental policy, was ineffective in adolescent pregnancy prevention and suggested including sex and sexual diseases education into the high school biology courses to lower the rate of adolescent pregnancy. Abstinence education along with education on sexual activity and sexually transmitted diseases had a greater effect on reducing fertility and birth rates compared to the abstinence education alone (22). The results of a study by Cabezón et al. (2005) demonstrated that the risk of unwanted adolescent pregnancy had diminished following sex education by focusing on abstinence (23).

2- Religious beliefs

Religious beliefs are of the key factors inhibiting high-risk sexual activity and its consequences. McCree et al. (2003) reported that religious adolescents had a higher self-efficacy in their relationships. These adolescents began to have sex in older ages and chose only one sexual partner. Moreover, these adolescents refused high-risk sexual relationships and had a more positive attitude toward the use of contraceptive methods (24). Manlove et al. (2006) indicated that parental religious activities were related to later timing of sexual initiation, suggesting an important dimension of family that can improve reproductive health outcomes in children. However, they reported no relationship between family religiosity and improved contraceptives use (25).

3- Adolescent employment program

One of the inhibitors of high-risk behaviors and pregnancy is the employment of adolescents. The results of Novella et al. (2015) highlighted that employment programs and the focus on professional skills training for adolescent girls aged 16-19 had a positive effect on reducing fertility rate and improving their occupational status (26). The results of Amoran et al. (2012) showed that employment in an organization protects adolescents against pregnancy when they are increasingly exposed to early pregnancy (27).

4- Parent-adolescent relationship  

Effective parent-adolescent relationship is one of the factors inhibiting unwanted adolescent pregnancy. Parental rules and control can enhance knowledge and resistance in adolescents at times of pressure for having sex. The study by Lederman et al. (2008) underscored the important role of the Parent-Adolescent Relationship Education (PARE) program in diminishing adolescent pregnancies. Strengthening family bonds and increasing sex education contributed to preventing unwanted pregnancy (28). The results of Moni et al. (2013) in a study on unmarried teenage girls in India presented that lack of parental control, family conflicts, and poor intra-family relationships were significant predictors of unmarried adolescent pregnancy (29).

Facilitators

1- Pornography on the Internet and media

Increased Internet access and watching romantic and pornographic movies are some of the causes of unwanted adolescent pregnancy. Nguyen et al. (2016) showed that the use of Internet was significantly associated with the incidence of pregnancy in adolescents (30). Meddinus et al. (2007) found that pornography (misleading sexually explicit images) is one of the factors influencing adolescent pregnancy (31). In a study by Thobejane in 2015 on adolescent pregnancy, it was found that about 80% of adolescents blamed the media for their pregnancy as they spent most of their time watching pornographic movies (32). Chandra et al. (2008) found that exposure to sexual contents on television predicted teen pregnancy. Further, adolescents exposed to high levels of sexual content on television (90th percentile) were twice as likely to experience pregnancy in the subsequent 3 years, compared to teens with lower levels of exposure (10th percentile) (33).

2- Peer pressure

During adolescence, friends and peers become more significant as part of the identity of adolescents is formed in the peer group. Thus, peer pressure is one of the factors affecting adolescent unwanted pregnancy. Thobejane in 2015 examined the factors influencing adolescent pregnancy in South Africa, they revealed that many adolescents are affected by their peers in the early reproductive age (32). Gyan et al. (2013) examined 55 students from Ghana and found peer pressure as one of the main causes of adolescent pregnancy (34). Osaikhuwuomwan et al. (2013) pinpointed that peer pressure in 71.8% of cases was the reason for unwanted adolescent pregnancy (35).

3- Lack of knowledge and information

The lack of awareness of adolescents regarding their reproductive system, sexual health, and contraceptive methods could result in unwanted pregnancy and its related consequences. Lack of adequate knowledge and information on contraceptive methods and physiology of pregnancy were some of the causes of unwanted adolescent pregnancy.

3-1- Contraceptive methods

Costa et al. (2013) stated that limited awareness and negative attitude of adolescents towards the use of contraceptives pose them to a higher risk of pregnancy (36). Richter et al. (2015) reported that misconceptions about contraception are still evident in many adolescents. They also reported that adolescents' awareness regarding contraceptive methods was low (37). Mushwana et al. (2015) determined the factors affecting adolescent pregnancy in South Africa. In a study of 147 teenage girls, they noted that there is a shortage of health services (6). Ramathuba et al. (2012) expressed that many adolescents have no information on contraceptive methods, intrauterine contraceptive devices, and female condoms. Fear of parental reaction to the use of contraceptives, poor contraception education, and lack of counseling in this regard were identified as the main causes of non-use of contraceptives (38).

3-2- Physiology of pregnancy

Mushwana et al. (2015) reported that about 61% of cases found insufficient sexual information to be the reason for heightened pregnancy rates (6). Richter et al. (2015) ascribed that limited knowledge of adolescents was associated with unwanted pregnancy, and misconceptions about sex are still evident in many adolescents. Their results also showed that adolescents had meager knowledge on
the physiology of pregnancy and contraception and that they were misled easily by their sexual
partners (37).

4- Drug and alcohol abuse

The rate of abusing drugs, alcohol, tobacco, marijuana, or other substances was higher in adolescents with unwanted pregnancy. In a study by Francisco et al (2016), the prevalence rates of smoking and alcohol consumption were respectively 21.2% and 41.5% in adolescents with unwanted pregnancy; 57.4% of them used cigarettes and 77.5% consumed alcohol at home. About 80.3% of adolescents with unwanted pregnancy had friends who smoked and 90.6% had friends who consumed alcoholic beverages. The friends who smoke or use alcoholic drinks are pivotal risk factors for substance abuse in adolescents with unwanted pregnancies (39). Salas-Wright et al. (2015) exhibited that pregnant adolescents had significantly more experience of abusing drugs, such as hashish, and alcohol (40). Panova et al. (2016) found a direct relationship between alcohol consumption and adolescent pregnancy and reported that pregnant adolescents preferred to consume stronger alcoholic beverages (41).

5- Violence

Violence during sexual intercourse was one of the facilitators of unwanted adolescent pregnancy. Christofides et al. (2014) stated that unwanted pregnancy was more evident in teenage girls experiencing physical violence (42). Anand et al. (2016) found that the first sexual intercourse of some adolescents occurs by force and coercion and then adolescents voluntarily enter sex activities (43).

6- Fashion in clothing

Mashau et al. (2011) stated that increased rate of premarital sex is one of the causes of elevated rate of unwanted adolescent pregnancy, and adherence to fashion in clothing is one of the effective factors in premarital sex (44).

7- Family structure

Poor family structure plays a facilitating role in unwanted adolescent pregnancy. Single-parent families with broken or damaged structure experience numerous challenges. In these families, poor support and inadequate supervision lead the teenager to high-risk behaviors, such as unsafe sexual behavior (45, 46). Izugbara in 2015 showed that there is often more access to health services and emergency health services in families where adolescents live with both parents; as a result, the rate of unwanted adolescent pregnancy in these families is lower. In addition, the age and gender of heads of families are effective factors in unwanted adolescent pregnancy. This phenomenon is less likely to be observed in households where a woman is the head of the family. Moreover, the prevalence of unwanted pregnancy in adolescent girls from families with older heads is lower compared to younger families (47). Winters et al. (2012) demonstrated that adolescent pregnancies were more common in single-parent families compared to adolescents living with both parents (48).

8- Economic and income status

Poverty and low income are direct and indirect facilitators of unwanted adolescent pregnancy. Lambani et al. (2015) argued that poverty is responsible for 80% of unwanted adolescent pregnancies (49). Akella et al. (2015) drew a direct relationship between teenage pregnancy and poverty (50). In a cohort study by Faisal-Cury et al. (2017) in Sao Paulo, Brazil, the results showed that pregnancy in low-income girls was associated with low educational levels (51).

Discussion

The present review was conducted to explore the inhibitors and facilitators of unwanted pregnancy in Iran and across the globe. In sum, the results of studies on inhibitors suggested that parental behaviors and lifestyle, parent-adolescent relationship, and reinforced family interactions in the field of sexual education lead to increased adolescent contraception knowledge and improvement of resistance against pressure to sex (28). Adolescent pregnancy was often linked with unemployment and low income. The pregnant adolescents have lower education because of school dropout, which increases the likelihood of poverty.

 Adolescent mothers usually belong to poor families, and their children are more likely to become pregnant when they become adolescents, and their children will also be poor in the future, and this cycle of poverty will be repeated in future generations (52). Religious beliefs are one of the most important factors preventing social deviation. However, religion forms identities and affects values and relationships. Religion prohibits any premarital sex and lays down specific moral rules for abstinence (24, 25). Adolescent girls and boys may be exposed to harms such as unwanted pregnancy, sexually transmitted diseases, and sexual assault; thus, religions prohibit any premarital sex (22). In the present age, the gap between maturity and marriage has broadened with lowered puberty age and increased age of marriage. Within this period, sexuality is potent, thereby increasing the likelihood of premarital sex (9). The incidence of sexual relations among adolescents and premarital sex give rise to challenges such as unwanted pregnancy (5, 9, 24).

Abstinence plays a major role in preventing unwanted adolescent pregnancy. Abstinence is the power of sexual inhibition. Abstinence prevents high-risk sexual relationships due to moral, religious, legal, and health reasons, resulting in lower adolescent pregnancies (22). Job training in adolescents is another significant factor in preventing unwanted adolescent pregnancy. The focus on professional skills training for adolescent girls has positive effects for reducing reproduction rate (26, 27).

Some facilitators of unwanted adolescent pregnancy include screening pornography on the Internet and media, peer pressure, lack of knowledge and information regarding contraception and the physiology of pregnancy, drug and alcohol abuse, violence, and fashion in clothing.

Pornography on the Internet and media is one of the facilitators of unwanted adolescent pregnancy.

Recent advances in information technology have changed the attitudes of adolescents toward sexuality. Most of the sexual messages are exchanged using information technology, through text or video messages and social networks, which put adolescents at risk of early sexual activity and unwanted pregnancy. Nowadays, the available portable electronic devices allow adolescents to have prompt and easy access to any information. Moreover, the increase in access to the Internet by adolescents has increased the opportunities for learning about sexual issues and has led to the growth of unrealistic sexual values and beliefs, as well as increased sexually aggressive behaviors and sexual violence (53, 54). Adolescents are able to listen to music, watch TV, and have online chat simultaneously. Uncontrolled surfing on the Internet facilitates screening of online pornography. The Internet, therefore, imposes serious harms to adolescent lifestyles, as some adolescents bombarded by pornography tend to experience and practice these movements in their real life (44). The adolescents using pornography have lower levels of social and emotional integration and are more prone towards delinquency and behavioral problems; further, symptoms of depression are more prevalent among them. The overuse of the Internet has isolated people from societies, real communication, and social interactions; this problem has dominated the lives of individuals, leading to loneliness and eventually depression (54).

Peer pressure is another facilitators of unwanted adolescent pregnancy. During adolescence, friends and peers become more significant. Part of the adolescent identity is formed in peer groups. Peer groups influence adolescents in areas such as smoking, alcohol abuse, and unsafe sexual relationships. In peer groups, adolescents who have no premarital sex are thought to be stupid, spoiled, and disgusting; therefore, as soon as possible, the adolescents seek sexual intercourse that poses them at risk of unwanted pregnancy (7, 55, 56).

Insufficient knowledge is another facilitator of unwanted adolescent pregnancy. If adolescents become aware of their reproductive system, sexual health, and contraceptive methods, they can prevent unwanted pregnancy and sexually transmitted diseases (22). In adolescence, physical and mental changes lead to curiosity about sexual intercourse. Drug and alcohol abuse in adolescents predispose them toward unwanted pregnancy. The adolescents abusing drugs, alcohol, tobacco, marijuana, or other substances are at higher risk of unwanted pregnancy (57). Girls addicted to heroin usually become prostitutes to pay for their substances, which exposes them to unwanted pregnancy (52).

The strength of this study was examining the results of various studies (both qualitative and quantitative), and the limitation of this study was the lack of access to studies in other languages (except for Persian and English).

Implications for Practice

The findings of this review revealed that more studies were conducted to investigate facilitators of unwanted adolescent pregnancy in comparison to inhibitors. The lack of sufficient knowledge and information in adolescents plays a major role in unwanted adolescent pregnancy. However, a definitive judgment on the contribution of each factor to unwanted adolescent pregnancy requires further detailed studies. The results of this review are applicable in policymaking, planning, and formulating strategies and programs to empower and change the behaviors of adolescents and strengthen the inhibitors and prevent the facilitators of unwanted adolescent pregnancy. Additionally, these findings might be used in the area of the attitude and method of controlling the challenges of reproductive and sexual health of adolescents in accordance with the existing culture. We recommend performing a more extensive review without restricting the language in search of studies related to this issue to determine the contribution of each factor to unwanted adolescent pregnancy.

Acknowledgments

This article was derived from a research project approved by the Obstetrics and Reproductive Health Research Center with the ethical code of IR.SBMU.PHNM.1396.795. Hereby, the authors appreciate the cooperation and assistance of the officials of school of Nursing and Midwifery, library and computer ward at Shahid Beheshti University of Medical Sciences, as well as the Obstetrics and Reproductive Health Research Center.

Conflict of interest

The authors declare no conflicts of interest.