research paper about early pregnancy in the philippines

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• Published: 06 November 2018

Trends in repeated pregnancy among adolescents in the Philippines from 1993 to 2013

• Joemer C. Maravilla   ORCID: orcid.org/0000-0001-5794-9565 1 , 2 ,
• Kim S. Betts 1 , 2 &
• Rosa Alati 1 , 2 , 3  

Reproductive Health volume  15 , Article number:  184 ( 2018 ) Cite this article

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The extent of repeated pregnancy (RP) and repeated birth (RB) among adolescents aged 15–19 is still unknown in the Philippines despite the health and socio-economic consequences. This study aims to investigate the RP and RB prevalence trends in the Philippines from 1993 to 2013.

A total of 7091 women aged 15–24 who experienced at least one pregnancy were captured in the Philippine demographic health surveys from 1993 to 2013. Annual RP and RB prevalence per age group in three and five categories were calculated and stratified by region, type of residence and wealth index. Cochran–Armitage tests and multivariate logistic regression were applied to determine trend estimates.

Compared to women aged 19–21 years and 22–24 years, for which decreasing patterns were found, RP ([Adjusted Odds ratio (AOR =0.96; 95%Confidence interval (CI) =0.82–1.11) and RB (AOR = 0.90; CI = 0.73–1.10) trends among 15–18 year olds showed negligible reduction over the 20 years. From a baseline prevalence of 20.39% in 1993, the prevalence of RP among adolescents had only reduced to 18.06% by 2013. Moreover, the prevalence of RB showed a negligible decline from 8.49% in 1993 to 7.80% in 2013. Although RP and RB prevalence were generally found more elevated in poorer communities, no differences in trends were noted across wealth quintiles.

For two decades, the Philippines has shown a constant and considerably high RP prevalence. Further investigation, not only in the Philippines but also in other developing countries, is necessary to enable development of secondary prevention programs.

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Plain English summary

Despite high and stable levels of adolescent fertility in the Philippines, no specific research has been conducted to specifically measure the trend and magnitude of repeated adolescent pregnancy, which is defined as an adolescent who has had at least two pregnancies. Repeated pregnancy, therefore needs to be investigated as it reflects not only the reproductive health of adolescent mothers but also disparities in service delivery of health, education and welfare support to adolescents after their first pregnancy.

We used the Philippine Demographic and Health Surveys to sample 7091 women aged 15–24 who experienced at least one pregnancy. Annual RP and RB prevalence per age group in three and five categories were calculated and stratified by region, type of residence and wealth quintile. Trends were statistically analysed using Cochran–Armitage tests and multivariate logistic regression.

While a decline was observed in 19–21 and 22–24 year olds, we found a constant prevalence of one in every five in 15–18 years old from 1993 to 2013. This trend was evident across all regions, types of residence and socio-economic status. Our analysis also found that those from the poorest wealth quintile demonstrated a heightened risk of repeated pregnancy compared to other quintiles. The non-decreasing prevalence trend of repeated pregnancy among adolescents indicated the need for secondary prevention programs particularly for the poorest households. Epidemiological investigations are also necessary to explore the causes and impact of repeated pregnancy on maternal, child and neonatal health, not only in the Philippines, but also among other low- and middle-income countries.

Introduction

The adolescent pregnancy epidemic in the Philippines has been acknowledged as one of the worst in the Western Pacific Region [ 1 ] with a recent prevalence of 13.6% among 15–19 year olds. The Philippines is the only country in this region with no significant decline in adolescent fertility in the past decades [ 2 ] from 56 per 1000 in 1973 to 57 per 1000 in 2013 [ 2 , 3 ]. In order to address this entrenched public health issue, preventive policies and programs have been implemented [ 4 , 5 ], and epidemiological studies have been developed to provide evidence of the current sexual health and behaviour of Filipino adolescents [ 6 ]. However, these measures have put little emphasis on the more serious problem of repeated adolescent pregnancies.

Repeated adolescent pregnancy, which is defined as a subsequent pregnancy among adolescents aged 10–19 years [ 7 ] is known to affect around 18% of adolescent mothers in the USA [ 7 ], Europe [ 8 ], and Australia [ 9 ]. Despite the evident chance of repeated adolescent pregnancy especially within 2 years postpartum [ 10 ], current research is unable to clearly establish its magnitude in developing countries such as the Philippines, nor how the trends have changed across time [ 11 , 12 , 13 ]. Although a World Health Organization (WHO) multi-country report [ 14 ] discussed the relationship between age and parity among Filipino adolescents, this study did not assess the prevalence of multi parity as its primary measure.

As a marker for adolescent reproductive health, repeated pregnancy reflects health disparities particularly among the disadvantaged adolescent population. Repeated pregnancy also indicates poor distribution and unequal access to reproductive health services [ 15 ] and inadequate service capacity of individual localities. It relates to low educational attainment, limited employment opportunities and poverty among adolescent mothers [ 15 , 16 ]. It has been shown that repeated adolescent pregnancy leads to an increase in national health and welfare expenditure as a consequence of the long-term dependency of adolescents and their families on government assistance [ 15 , 17 ].

An increasing trend of adolescent sexual activity [ 3 ] ongoing poor compliance with modern contraceptives [ 2 , 18 ] and inadequate use of family planning services all suggest that repeated adolescent pregnancy is highly prevalent in the Philippines [ 12 ]. Analysis of existing nationally representative data can be helpful in evaluating the extent of this public health problem. In this study, we aim to determine the prevalence of repeated pregnancies and births among adolescents and young adults from a series of national surveys conducted between 1993 and 2013. Moreover, we intend to analyze the trend of repeated pregnancies and births by age groupings and potential macro-level confounders across two decades, with resulting trends perhaps reflecting the effectiveness of existing policies and programs in addressing this under-recognized adolescent health problem.

Population and sample

This study used the Philippine Demographic and Health Survey (DHS) from 1993, 1998, 2003, 2008, and 2013 which are cross-sectional surveys conducted every 5 years. This nationally representative survey involved a multi-stage sampling design up to the household level with enumeration areas distributed by region and type of residence using the most recent national census as its sampling frame. All women in the selected households which includes adolescents aged 15–19 years and young adults aged 20–24 years were interviewed using the Individual Woman’s Questionnaire. This survey therefore excludes adolescents aged below 15 years. As shown in Appendix , the majority of the survey sample belonged to these age brackets which we will refer to as adolescents for the succeeding parts of this paper.

Outcome and socio-geographic measures

Repeated adolescent pregnancy/birth.

An adolescent aged 15–19 years was considered as having experienced repeated pregnancy (RP) if she had experienced at least two pregnancies, including current pregnancies, which either resulted in a live birth and/or pregnancy loss. A case of repeated birth (RB) was defined as an adolescent with at least two live births. These definitions were adapted from related review papers [ 8 ] and the Centers for Disease Control and Prevention [ 7 ].

Survey year was considered as a continuous variable in the analysis to measure the trend because of equal intervals between survey years. Thus, each unit increase in year variable translates to an actual five-year increase.

Respondents were categorized by age into three and five groups. The three age groups include “15–18” which considers the legal age of consent (18) in the Philippines, “19–21” as the transition period, and “22–24” as young adults [ 19 ]. In sensitivity analysis we further subdivided age into five groups (i.e. “15–16”, “17–18”, “19–20”, “21–22”, and “22–24”) to analyze in detail the trends per age.

Socio-geographic variables

Region refers to the three main island groups: Luzon, Visayas, and Mindanao. We disaggregated and compared all estimates by region since each island group has unique geographical and cultural characteristics. Further disaggregation per administrative region was not pursued, as the number of administrative regions had increased during the 1998. Type of residence was either rural or urban area where the respondent resided at the time of the survey. Based on their household’s wealth score, adolescents were grouped into the household wealth quintiles “richest”, “richer”, “middle”, “poorer”, and “poorest” class.

We calculated the mean, standard deviation and prevalence rate of RP and RB per year per age group. RP prevalence was calculated by dividing the number of adolescents with RP and the number of adolescents who experienced at least one pregnancy (including those currently pregnant) multiplied by 100. RB prevalence on the other hand was calculated by dividing the number of adolescents with RB and the number of adolescents who experienced at least one livebirth multiplied by 100. Deformalized survey weights were applied while calculating the prevalence.

We used the ptrendi package in Stata13 to perform Cochran–Armitage tests to determine the prevalence trend per age group using the chi-square statistic and meeting the assumptions of an additive model. Cochran–Armitage test is a modified Pearson’s chi-square test which assesses the association between binary (i.e. RP and RB) and ordinal (i.e. year and age) categories. Multivariate logistic regression analysis with interaction effects for age (i.e. age groups using both three and five categories) and year was conducted while using repeated pregnancy and birth as binary outcome variables (i.e. yes or no). We measured the trend between two consecutive survey years to identify which periods had significant changes in prevalence. In addition, we analyzed trends using year and socio-geographic (i.e. region, type of residence, and wealth index) interaction per age group. For the purpose of this analysis, we used the three category age group as this was the only categorization which allowed a sufficient number of cases.

Among women aged 15–24 years with at least one pregnancy ( n  = 7091), a large proportion (53.3%) were found among the 22–24 year olds. Despite the small proportion of adolescents captured by the surveys, the proportion of 15–18 year olds reported in the survey has increased over time from 7.64% ( n  = 107) in 1993 to 15.55% ( n  = 213) in 2013 ( see Table  1 ).

Trend analysis per age group

Cochran–Armitage tests showed an overall decrease in the trend of RP (Chi2 = 127.60; p  < 0.001) across 20 years among the 15–24 years old from a weighted RP prevalence (WtPrev RP ) of 58.12% in 1993 to 40.58% in 2013. There was also a general RB (Chi2 = 100.90; p  < 0.001) reduction from weighted RB prevalence (WtPrev RB ) of 51.25% to 35.66%. However, within age groupings this decline was not observed among 15–18 years olds. In Fig.  1 , we only found a slight decrease in RP prevalence from 20.39% in 1993 to 18.06% in 2013. RB prevalence also presented a minimal change with 0.69 decline among 15–18 and 0.80 decline among 17–18 years olds in this 20-year period ( see Fig.  2 ). Further observations among 17–18 years olds showed a similar RP trend from 22.26 to 18.52%.

Prevalence trends of adolescents with repeated pregnancy in the Philippines from 1993 to 2013 by age group. Caption: This figure presents the weighted prevalence of repeated pregnancy using age groups with ( a ) three and ( b ) five categories. Groups using the three categories include 15–18 years old, 19–21 years old and 22–24 years old while the five categories including 15–16 years old, 17–18 years old, 19–20 years old, 21–22 years old and 23–24 years old, as represented by each line on the graphs. The x-axis is the survey year arranged in chronological order while the y-axis the weighted prevalence

Prevalence trends of adolescents with repeated birth in the Philippines from 1993 to 2013 by age group. Caption: This figure presents the weighted prevalence of repeated birth using age groups with ( a ) three and ( b ) five categories. Groups using the three categories include 15–18 years old, 19–21 years old and 22–24 years old while the five categories including 15–16 years old, 17–18 years old, 19–20 years old, 21–22 years old and 23–24 years old, as represented by each line on the graphs. The x-axis is the survey year arranged in chronological order while the y-axis the weighted prevalence

Similar results were found in the regression analysis. The RP trend among 15–18 year olds remained virtually unchanged across all surveys from 1993 to 2013 [Odds ratio (OR) =0.93; 95% Confidence interval (CI) =0.81–1.07]. There was a similar pattern of RB trend in this age group (OR = 0.87; CI = 0.72–1.06) following an apparent increase in prevalence from 1993 to 1998 (OR = 3.29; CI = 1.25–8.62). On the other hand, the older age groups showed a significant decline both for RP and RB with unadjusted ORs ranging from 0.83 to 0.87 ( see Table  2 ). Analyses using five age categories showed no significant difference in the trends previously described. Trends among 15–16 and 17–18 year old adolescents remained unchanged, whereas a decreasing trend was apparent for those aged 19–20, 21–22 and 23–24.

Adjustments for regions, types of residence and wealth quintile suggested that the trends were not confounded by these factors across all age groups. Interestingly, wealth index was strongly associated with RP and RB as adolescents from the poorest quintile had shown higher odds in reference to richest quintile (OR RP  = 5.41, CI = 4.31–6.78; OR RB  = 5.36, CI = 4.17–6.89). Calculation of weighted prevalence confirmed this association with a WtPrev RP of 59.60% and WtPrev RB of 52.50%.

Change of prevalence between two consecutive survey years was also analyzed using the three age categories. We found that there was a decrease in RP prevalence among 15–18 from 1998 to 2003 (OR = 0.52; CI = 0.28–0.99), and among 22–24 from 1993 to 1998 (OR = 0.77; CI = 0.61–0.97) and 2003–2008 (OR = 0.71; CI = 0.58–0.88). A drop in RB prevalence was also found among 15–18 from 1998 to 2003 (OR = 0.32; OR = 0.13–0.81); and among 22–24 from 1993 to 1998 (OR = 0.74; CI = 0.58–0.93).

Trend per socio-geographic variable per age group

The constant RP trend among 15–18 and the decreasing RP trend among 22–24 were found in all regions, types of residence and wealth quintiles ( see Table  3 ) . On the other hand, the decline of RP decline among 19–21 was only consistent across regions and types of residence. Only the poorer households showed a 20-year reduction when compared to the other four quintiles.

A similar pattern was observed for RB trend among those aged between 15 and 18 and 22–24. Unlike RP, the trend for RB among 19–21 year olds was inconsistent across the three socio-geographic variables. The decreasing trend was only found in Visayas and Mindanao region, rural communities, and poor wealth quintiles (see Fig.  3 ) .

Prevalence trend of repeated pregnancies and births among adolescents per socio-geographic variable in each age group. Caption: This figure presents the trend of the weighted prevalence of repeated pregnancies and births in each of the socio-graphic variable using the three age categories: 15–18 years old, 19–21 years old and 22–24 years old. The left column presents the weighted prevalence of repeated pregnancy while the right column presents repeated birth. In each graph, the x-axis is the survey year arranged in chronological order while the y-axis the weighted prevalence. The color of each line represents a category of each socio-geographic variable as shown at the bottom of the graph

In each age group, we also conducted adjusted Wald tests to measure the difference of trend estimates between the categories of each socio-geographic variable. No differences were observed for 15–18. For 19–21, differences were only found between the RP trend estimates of poorest and poorer quintiles, and between the RB trend estimates rural and urban communities. For 22–24, differences between the trend estimates of poorest and richest, and between poorer and richest were found both for RP and RB.

Discussions

Despite the declining trends of RP and RB in older age groups, the prevalence among adolescents younger than 18 years showed no decrease across 20 years of data, remaining stable across all regions, types of residence, and wealth quintiles. The prevalence was high with approximately one in every five adolescents aged 15–18 years with a history of pregnancy experiencing RP while one in every ten of those who had a livebirth experienced RB.

While the decreasing RP and RB trend among young adults can likely be attributed to their improved contraceptive use [ 20 ] and awareness of and participation in family planning (FP) strategies [ 3 , 21 ]. The unchanged trend among adolescents may result from the unique socio-cultural characteristics and FP policies in the Philippines, wherein adolescents are prevented from accessing FP services, even after their first pregnancy. One of the possible explanations for this finding is that the strong influence of the Catholic church at the local level may have affected the health seeking behavior and the implementation of reproductive health programs among adolescents [ 22 , 23 ].

Unclear and restricted health and health-related policies for adolescent mothers may also play a role. The initial adolescent health policy in the Philippines [ 24 ], which aimed to reduce unwanted pregnancies and provide adolescent-friendly health services, did not include strategies for dealing with the prevention of secondary pregnancies [ 25 , 26 ]. This may have led to adolescents being discouraged to access essential health information and use birth control methods [ 23 , 27 ].

Despite emphasizing the importance of health promotion and behavioral change, a recently introduced national law (Responsible Parenthood and Reproductive Health Act of 2012 or RH Law) and framework [ 4 ], did not embrace specific programmatic actions to address RP. The RH Law still prevents minors (i.e. below 18 years old) from accessing modern methods of contraception without parental consent and does not exempt adolescent mothers and adolescents who experienced miscarriage [ 28 ]. This policy restriction has already been found as a deterrent for adolescents to access contraceptives and counselling services in a review of evidence from 16 developing countries [ 29 ]. This study suggests that despite the availability of contraception, most of these developing countries retain barriers and restrictions towards the use of birth control methods, particularly among unmarried adolescents. In the context of this social and political environment, the RP/RB trends showed in this paper can be expected to continue for several years to come not only in the Philippines but also in other developing countries.

The role and reach of secondary prevention programs must be clarified due to the limited access to appropriate postnatal services (e.g. contraception, counselling, and educational support) for adolescent mothers. Health workers may also need to be trained to address the unique psychosocial characteristics and support the challenging developmental transition of very young mothers by enhancing adolescents’ readiness and decision-making abilities to delay another pregnancy and/or use modern family planning methods. Given the high rate of unmet need for modern contraception among married adolescents [ 21 ], policy initiatives/reforms such as providing exemption on contraception to adolescent mothers may be needed to achieve a reduction in the trend seen in this paper.

Our findings also suggest that prevention programs aimed at those from the poorest quintile may be warranted due to the high RP/RB prevalence among this group. In the Philippines and other low- and middle-income countries (LMICs), attempts to reach out to households from the poorest sector have been undertaken through the Conditional Cash Transfer (CCT) Program [ 30 , 31 ]. For example, the CCT program in Mexico has been found to indirectly reduce adolescent pregnancy and increase contraceptive use among adolescents and young adults [ 31 ]. The potential of cash incentive schemes can also be used as an opportunity to monitor and provide prevention programs to adolescent mothers, particularly within 24 months after their first pregnancy [ 10 ].

Our study uniquely explores the status of repeated pregnancy and birth in LMICs in the Asia-pacific Region. Most published reports on this topic are primarily from the USA, Europe, and Australia [ 32 ]. Of the few reports identified from LMICs, many used birth order (i.e. 2nd order or higher) and a different denominator (i.e. total number of adolescents) in the computation of prevalence. Despite the availability of possible data sources among LMICs [ 33 ], few studies have attempted to look specifically at the distribution of adolescents and young adults with RP/RB. Most of the reports available may include vital statistics which is limited to those only with livebirths and does not necessarily account for previous unsuccessful pregnancies.

By placing RP as an issue of crucial importance to the public health especially of LMICs, our paper makes a significant contribution to the literature calling for improvement of sexual and reproductive health of adolescents. The Global Strategy for Adolescent Health for 2030 recognized childbirth and pregnancy complications as one of the two leading causes of death among 15–19 year old girls [ 34 ]—addressing RP would help to reduce this. The absence of a reduction in RP trend over 20 years that we identified, signals the need for secondary prevention programs in line with WHO recommendations [ 35 ].

This study finds strength in our use of nationally-representative individual datasets instead of aggregate estimates. This prevents the risk of producing results affected by the ecological fallacy, particularly in the analysis of year-age interaction. Furthermore, we were able to perform more thorough analyses such as the adjustment of trend estimates for confounders (i.e. wealth quintile, region, and type of residence).

Limitations

Our study also has limitations. Recall bias and under-reporting are likely to produce bias in any surveys covering information of a sensitive nature. Insufficient record validation is common across the DHS surveys from all countries. However, the DHS’ survey procedure enables cross-checking through repeated questions during the interview to reduce the effect of this validation issue. Additionally, our findings may not be comparable to longitudinal studies from developed countries that defined RP as an adolescent who became pregnant within 12–24 months of her first pregnancy/ delivery.

Future research

In addition to cross-sectional analyses that measure RP prevalence, epidemiological investigations are needed to explore the causes and outcomes of RP. Studies conducted in LMICs may identify different associations and dynamics due to the psychosocial and cultural characteristics of and attitudes towards adolescent mothers in these countries. This type of study not only directs the development of specialized perinatal care, and psychosocial and welfare support but also places priority on those adolescents with RP.

A multi-country analysis would also be beneficial in obtaining a broader RP status especially in countries with similar characteristics. This would help international organizations to implement immediate action for RP in a global approach and prioritize countries with a high RP burden. Additionally, projection of RP prevalence at least until 2030 using country-level determinants such as contraceptive prevalence, poverty, literacy, and maternal-child mortality rates, may facilitate target setting for this potential adolescent reproductive health indicator.

There is a constant trend of one in every five adolescent mothers in the Philippines experiencing repeated pregnancy from 1993 to 2013 (across all regions, type of residence, and socio-economic status). These findings indicate the need for secondary prevention programs, particularly among the poorest households. Epidemiological investigations are also necessary to explore the causes and impacts of repeated pregnancy on maternal, child, and neonatal health in the Philippines and other low- and middle-income countries.

Abbreviations

Conditional Cash Transfer

95% Confidence Interval

Demographic and Health Survey

Family planning

Low- and middle-income countries

Repeated birth

Repeated Pregnancy

World Health Organization

Weighted RB prevalence

Weighted RP prevalence

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Acknowledgements

We also acknowledge the Demographic and Health Surveys Program for allowing us to access the all Philippine DHS datasets. This study was presented at the 15th World Congress on Public Health, Australia, April 3–7, 2017.

This study was supported by the University of Queensland International Scholarship.

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The datasets analyzed during the current study are not publicly available but can be requested from the DHS Program data managers.

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JM conceptualized the study design, prepared the datasets, conducted the analysis, and drafted and revised the manuscript. KB conceptualized the study design, conducted the analysis, and revised the manuscript. RA conceptualized the study design, supervised the data analysis, and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

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Maravilla, J.C., Betts, K.S. & Alati, R. Trends in repeated pregnancy among adolescents in the Philippines from 1993 to 2013. Reprod Health 15 , 184 (2018). https://doi.org/10.1186/s12978-018-0630-4

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Received : 25 September 2017

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Published : 06 November 2018

DOI : https://doi.org/10.1186/s12978-018-0630-4

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Education, earnings and health effects of teenage pregnancy in the Philippines

This paper examines the effect of teenage pregnancy (early childbearing) on education and lifetime earnings using data from national surveys. It finds that the discounted lifetime wage earnings foregone by a cohort of teenage women 18-19 years resulting from early childbearing is estimated between 24 billion pesos and 42 billion pesos with mean of 33 billion pesos, representing from 0.8% to 1.4% of GDP with mean of 1.1%.

Teenage Pregnancy in the Philippines: Trends, Correlates and Data Sources

Josefina natividad.

Results from cumulative years of the National Demographic and Health Survey and the latest result of the 2011 Family Health Survey, shows that teenage pregnancy in the Philippines, measured as the proportion of women who have begun childbearing in their teen years, has been steadily rising over a 35-year period. These teenage mothers are predominantly poor, reside in rural areas and have low educational attainment. However, this paper observes a trend of increasing proportions of teenagers who are not poor, who have better education and are residents of urban areas, who have begun childbearing in their teens. Among the factors that could help explain this trend are the younger age at menarche, premarital sexual activity at a young age, the rise in cohabiting unions in this age group and the possible decrease in the stigma of out-of-wedlock pregnancy.

Key words: teenage pregnancy, early childbearing, age at menarche

Women’s age-specific fertility rates [*] follow a characteristic pattern. Soon after menarche, the fertility rate starts at a low level, peaks at ages 20-29, then declines until it stops completely following menopause. The optimal ages for successful pregnancy are in the peak reproductive years. At either end of the reproductive spectrum, that is at the youngest (below 20) and the oldest (40 and above) ages, there is a higher risk of adverse pregnancy outcomes. Studies have shown that at age 35 and over, and especially at 45 and over, women are more likely to experience gestational diabetes, placenta previa, breech presentation and operative vaginal delivery than younger women aged 20-29. Other observed complications that are more prevalent among older mothers compared to mothers in their twenties are preeclampsia, gestational hypertension, cesarean delivery, abruptio placenta and preterm delivery. 1

Similarly, when the woman is at the younger extreme of the reproductive age spectrum, below 20 years, pregnancy carries the same elevated risk of adverse outcomes. 2 Many studies consistently show that teenage mothers are at increased risk of pre-term delivery and low birth weight. 3-6 From a large data base of births in the Latin American Center for Perinatology and Human Development in Uruguay, it was found that after adjusting for major confounding factors, women age 15 and younger were at increased risk for maternal death, early neonatal death and anemia compared with women age 20-24. Furthermore, women aged less than 20 had higher risk for postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, low birth weight, pre-term delivery and small for gestational age infants. 7 The same elevated risks for teenage pregnancies, independent of known major confounders like low socioeconomic status, inadequate prenatal care and inadequate weight gain during pregnancy were documented using data from the 1995-2000 nationally linked birth/infant death data set of the United States compiled by the National Center for Health Statistics and the Centers for Disease Control and Prevention. 8 In developing countries where no large data bases exist, evidence from smaller samples show similar results indicating that the risks are not specifically linked to the level of development of a country’s health care system and the availability of appropriate maternal care for very young pregnant women, 4 but are specific to the age group and its accompanying implication of biological immaturity for childbearing. The risks follow an age gradient; they are generally higher at the younger end of the teenage years and diminish toward the latter teen years.

Teenage pregnancy carries other significant non-health risks which are specific to this stage in the life course. 9

For example, when a teenager bears a child and consequently either marries formally or enters into a consensual union, she puts herself at risk of not finishing her education 10-11

and of limiting her chances of realizing her full potential by being burdened with child care when she herself is still, almost a child. If the teenager remains unmarried following a pregnancy, she risks social stigma from having an out-of-wedlock pregnancy and of having to bear its negative consequences. 12

At the aggregate level, a high teenage pregnancy rate contributes to high population growth as teenage mothers will have considerably longer exposure to the risk of pregnancy than those who enter into marital unions at a later age.

Teenage pregnancy has two aspects, and both could occur concurrently within the same country, whether developed or developing. On the one hand, high teenage pregnancy rates may result from the culturally sanctioned practice of early marriage and early marital childbearing, and on the other, from premarital intercourse and unintended pregnancy. Research evidence points to a shift in behaviors among young people in patterns of sexual activity such that early childbearing is becoming more a consequence of early intercourse. This is more often true in urban than in rural areas. 13 Additionally, a downward trend in the age at menarche in both developed and developing countries has been reported in a number of studies. 14-16 Zabin and Kiragu (1998) in their review report a connection between age of onset of sexual activity or age at first birth and age at menarche resulting in earlier onset of childbearing for the current generation of teenagers compared with earlier cohorts. 17

Because of the increased risks to both mother and child of too early childbearing, there is a need to understand the situation on teenage pregnancy in any country in order to design appropriate interventions. But obtaining reliable and valid data for analysis is not always easy, especially in a developing country.

This paper consists of two parts: the first discusses data sources for the study of teenage pregnancy in general; the second part presents trends in teenage pregnancy in the Philippines, some correlates and an analysis of the drivers for the observed trend using a specific data source. We will use data from the National Demographic and Health Survey (NDHS) conducted in the Philippines at 5-year intervals since 1968. The NDHS surveys are part of the DHS program of surveys that are highly regarded for methodological soundness and rigor in the design and conduct of data collection. With a common research design and questionnaire adopted throughout all the surveys in the series, NDHS data lends itself well to the analysis of long term trends in teenage pregnancy in the Philippines.

Data for the study of levels, trends, determinants and consequences of teenage pregnancy are usually derived from varied sources and using a wide range of data collection methods. Studies on the consequences of early childbearing, particularly the risk of adverse outcomes normally use hospital-based records, using either prospective or retrospective designs. For example, completed charts on births occurring in a hospital over a given period can be the source of information for studying pregnancy outcomes, as these will normally contain basic demographic information: the mother’s age, the pregnancy order as predictor variables and factors like maternal complications, placental complications, medications administered in hospital and neonatal outcomes as outcome indicators. 2 The advantage of these data sets is that they provide reliable and valid reports on the pregnancy outcomes under study using medically accepted diagnostic criteria and are not based on the teenage mother’s self-report. The main disadvantage is possible misclassification by age if there is reason for the mother to conceal her true age. If such a bias exists, it is likely to be higher in the younger adolescent than the older adolescent years as it may be less socially acceptable to have a birth at age 12 or 13 than at 18 or 19. Background variables on the mother that can serve as explanatory factors may also be limited; some will record education but socioeconomic status is normally not included in hospital records. As a data source for determining the total number of teenage pregnancies, hospital-based records are not reliable as these cover only hospital-based births. In most developing countries, majority of births occur in non-hospital settings.

To determine the level of teenage pregnancy in a given country, one potential data source is the Vital Registration System, which collects vital statistics such as births, death and marriages in the population. Usually, the national government requires that these vital events are officially reported through birth registration, death registration and marriage registration. In the Philippines, recording these events is the main duty of Local Civil Registrars. In some developed countries, there is a separate perinatal statistics collection system based on data collected by midwives and other health practitioners for each live and still birth which takes place in hospital and for home births. 18 The vital registration system is an ideal way to capture the level of teenage pregnancy year-on-year because it is a continuing record of births as they occur. Unfortunately, most vital registration systems especially in developing countries are hobbled by problems of underreporting and incompleteness. For example, it is estimated that in 2000, the level of completeness of birth registration in the Philippines was 78 percent, i.e., only 78 per cent of 5-year-olds at the time of the survey have been registered in the birth registry (have a birth certificate, whether or not it was physically with the household at the time of the survey) [†] . There is also a marked disparity among regions in the Philippines in the completeness of birth registration, with the Autonomous Region of Muslim Mindanao registering the lowest level of completeness of birth registration.

Even when vital registry data effectively capture all births in its reporting system, the type of information contained in birth registration forms will still be unable to answer many questions that will help understand fertility and its determinants better. Sample surveys fill in this gap. The most commonly accepted alternative source of data for estimating teenage pregnancy and investigating its correlates are nationally representative surveys of women in the reproductive years (15-49), extracting the relevant data for women aged 15-19 in the sample. Respondent to these surveys are the women themselves.

There have been a number of recent publications from the World Health Organization, USAID and other international groups providing guidelines for the conduct of ethical research when the subjects are children and adolescents. Among the recommendations are procedures for securing informed consent from parents/guardians when the subject is a minor [‡] . The recommended practice respects country-specific customs and traditions and may waive the requirement for written parental consent and accept alternative procedures for documenting consent that are appropriate to the local setting. 22-23 In the field of survey research on fertility at all ages including the teenage years, the Demographic and Health Surveys (DHS) program funded by USAID and implemented by ORC- Macro has been the gold standard.

DHS data are publicly available and easily downloadable hence are commonly used in many cross-country comparisons. In the Philippines, the National Demographic and Health Survey (NDHS) seriesis the major data source on long-term trends in teenage pregnancy and its determinants. The surveys are undertaken in the Philippines by the National Statistics Office in collaboration with the Department of Health and ORC Macro. 24-25 The sample of women in the reproductive years is representative at the national and regional levels. The NDHS follows a standard protocol for obtaining informed consent from survey respondents.

In the succeeding analysis of teenage pregnancy in the Philippines, we use mainly the NDHS survey results from various survey dates. For the long term trend in the age-specific fertility rate at ages 15-19, we use NDHS data from 1973 to 2008. For the analysis of determinants we refer to the survey results from 1993 to 2008 NDHS. Other data sources on correlates of teenage pregnancy cited in this paper are the Young Adult Fertility and Sexuality surveys of 1994 (YAFS 2) and 2002 (YAFS 3) and the 2011 Family Health Survey (FHS). YAFS is a series of surveys on young adults aged 15-24 gathering information on sexual and non-sexual risk behaviors and its correlates while the 2011 FHS is the latest round of what used to be known as the Family Planning Survey (FPS) series, also covering women age 15-49 as does the NDHS, but mostly focused in scope on family planning. Since 2006, the FPS has incorporated a complete birth history for measuring fertility and infant child mortality and a special module to collect information for estimating maternal mortality.

Survey data from both the NDHS Series and the 2011 FHS supports findings of other studies from other countries about the elevated risk of early neonatal deaths among teenage mothers (Table 1).

Click here to download Table 1

Table 1. Neonatal and infant mortality rate for the 10-year period preceding the survey

Neonatal and infant mortality tend to be higher at both ends of the reproductive spectrum, i.e., the youngest (less than 20) and the oldest (aged 45-49) age groups. Teenage mothers also compare poorly with mothers from the older age groups in a number of reproductive health indicators. For one, they tend to have the shortest birth intervals (Figure 1) of all age groups. Taking into account the fact that their bodies are not yet ready for the physical demands of childbearing, having closely spaced births exposes young mothers to further health risks.

Still, having closely spaced births is not necessarily a matter of choice for these young mothers as implied by the finding from the 2003 and 2008 NDHS and the 2011 FHS that currently married women aged less than 20 have the highest unmet need for contraception (Figure 2). For example, in the 2011 FHS, 37 percent of currently married 15-19 year olds had an unmet need for contraception, mostly for spacing of births, compared to 19 percent for all currently married women. This is an indication that adolescent mothers are an underserved segment of reproductive health programs and services.

Click here to download Figure 1

Figure 1. Median number of months since preceding birth

Click here to download Figure 2

Figure 2. Percent of women with unmet need for family planning

The WHO reports that about 16 million adolescent girls aged 15-19 give birth each year, roughly 11% of all births worldwide. Almost 95% of these births occur in developing countries. The adolescent fertility rate worldwide was estimated to be 55.3 per thousand for the 2000-2005 period, meaning that on average about 5.5% of adolescents give birth each year. In the Philippines, according to the latest Vital Statistics Report released by the National Statistics Office, in 2008 a total 1,784,316 births were registered; of these 10.4%, (186,527 births) were born to mothers under 20 years of age. Total registered births in 2008 increased by 2% from the previous year’s 1,749,878 births while births to teenage mothers increased by 7.6 %, from 173,282 in 2007. Assuming the same level of underreporting for teenage births as for total births, a comparison of the percent increase of total births and births to teenage mothers suggests that fertility has a faster pace in the youngest reproductive ages.

To get further insight into how the fertility at the youngest reproductive age group compares with that of later years, Figure 3 shows the long-term trend in fertility rates at three age groups, the youngest (15-19), the peak reproductive years (25-29) and the oldest reproductive group (45-49) over a 35-year period.

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Figure 3. Age-specific fertility rates for women aged 15-19, 25-29 and 45-49, 1973 to 2008 NDHS

Over this period, there has been a dramatic decrease in the fertility rate at the largest and the oldest reproductive age groups, accounting in large measure for the decline in the total fertility rate [§] [**] of the Philippines from 6.0 children in 1973 to 3.3 in 2008. In 1973, there were 302 births per thousand women aged 25-29; by 2008 this has dropped considerably to 172. Similarly, in 1973, there were 28 births per thousand women aged 45-49 dropping dramatically to only 6 births per thousand women in 2008. But, amidst these declining rates in the reproductive ages above 20, the 35-year trend indicates that the fertility rate in the 15-19 age group has remained virtually unchanged, from 56 births per thousand women in 1973 to 54 in 2008.

Compared with the rest of the world, the Philippines’ adolescent fertility rate is within the average range. Compared with its neighbors in Southeast Asia, it is also mid-range, at the same level as Indonesia, but higher than Thailand and Vietnam (Figure 4). Despite anecdotal reports to the contrary, the adolescent fertility rate has not changed significantly in four decades.

The age-specific fertility rate (ASFR) for women 15-19 is a measure of the incidence of fertility; it is the rate of births relative to the person years of exposure to the risk of childbearing within the given age group. It is highly possible for one woman to contribute more than one birth to the numerator as the reference period is usually about five years before the survey date. Therefore, for purposes of gauging the level of early childbearing in the population, the ASFR is not a good measure.

In place of the ASFR at 15-19, a more appropriate gauge of early childbearing is the proportion of women in the age group who are pregnant/who have become mothers. 12,26,27 Unlike the ASFR, in this measure a woman can only be counted once. The proportion of women who have already given birth at a certain age is a measure of the timing of first birth and is an indicator of how early child bearing has begun in the population.

Source: World Health Organization ( http://apps.who.int/gho/data/view.main.310?lang=en accessed 15 April 2013)

Click here to download Figure 4

Figure 4. Adolescent Fertility Rate in Selected Southeast Asian Countries

Figure 5 presents the trend in the proportion who have begun childbearing at 15-19 over a 15-year period based on the 1993-2008 NDHS. The measure is further broken down into a younger (15-17) and older group (18-19).

Figure 4 shows that the proportion of 15-19 year olds who have begun childbearing has been steadily rising, from about 7 percent in 1998 to 10 percent in 2008. The increase is steeper among the older teens (18-19) but there is a 100 percent increase among the younger teens, from 2 per hundred in 1993 to 4 per hundred in 2008. Overall, the picture presented in this figure is that the proportion of teenagers who have who have begun childbearing is higher in 2008 than in 1993. Thus by this measure, we can conclude that indeed more women are getting pregnant or have become mothers in their teens nowadays than in the past and that the picture depicted by the age-specific fertility rate is a misleading one when describing the trend in teenage pregnancy.

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Figure 5. Percent who have begun childbearing, 1993-2008 NDHS

The question to ask now is, “Does early childbearing occur equally in all segments of the young female population or does it occur more often in some subgroups than others?” Three factors are usually cited as sources of variability in teenage pregnancy rates in any population. Across countries, teenage pregnancy tends to be more prevalent in rural areas, among women with low education and among the poor.

To investigate the situation in the Philippines, the next set of figures presents the same longitudinal trend broken down by rural-urban residence, educational attainment and socioeconomic status (as measured by the wealth index [††] ). Those who had no formal schooling are excluded in the analysis because they comprise a very small proportion of the sample population

In terms of residence, Figure 6 shows that the percent who have begun childbearing at 15-19 is generally higher in rural than in urban areas but the percent change from 1993 to 2008 is higher in the urban (62.5 percent) than in the rural (40.4 percent). In both areas the proportions who have become mothers has been steadily increasing in the 15-year reference period.

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Figure 6. Percent who have begun childbearing by rural-urban residence, 1993 to 2008 NDHS

By educational attainment (Figure 7) there is a clear education gradient in early childbearing but while teenagers with elementary level schooling have the highest proportions who have become mothers, the trend shows no consistent pattern of increase through the years. The rise in early childbearing is more pronounced among those with high school and college education where the trend shows a persistent upward climb for each survey round. The upsurge is especially pronounced among those with college education with the increase in early childbearing from 1993 to 2008, a striking 290 percent change.

Figure 8 compares early childbearing across the wealth quintiles with the first quintile representing the poorest 20% of the women (based on the status of their household) and the fifth quintile the richest 20%. Only two data points are compared because only the 2003 and 2008 NDHS rounds had available information to compute the wealth index. The results indicate a gradient of difference by socioeconomic status similar to that observed with educational attainment, which is to be expected as these two variables are highly correlated, i.e., those with the lowest education will tend to be among the poorest. Overall, early childbearing is most prevalent among women in the poorest (first and second) quintiles. Comparing the 2003 and 2008 data it appears that the prevalence of early childbearing did not change much for women from a high prevalence level in the two lowest quintiles (in fact it decreased among the poorest teenagers) but definitely increased for the higher quintiles (3 rd , 4 th and 5 th ).

Click here to download Figure 7

Figure 7. Percent who have begun childbearing by educational attainment, 1993-2008 NDHS

Click here to download Figure 8

Figure 8. Percent who have begun childbearing by wealth quintile, 2003 and 2008 NDHS

The comparison of differences in early childbearing across residence, education and socioeconomic status of the adolescent suggest a changing pattern in early childbearing. Not only has the percentage who have become mothers in their teens been increasing, but the composition of these teenage mothers has been changing. The transition has moved from being mostly rural, poor and with the lowest educational attainment toward an increasing proportion of urban residents, better educated and those from the middle to the richest socioeconomic groups have likewise commenced childbearing in the teenage years.

What could be driving this trend of early childbearing among all groups in society? As stated earlier, this could be a result of early marriage or of premarital sexual activity leading to pregnancy or to both. To investigate which of these two factors could account for the change, we compare the 1993 to 2008 marital status of teenagers categorized as never married, married, living together and separated. Married refers to those who are formally in a marital union, living together refers to those who are in a consensual union and have not formally married.

Click here to download Figure 9

Figure 9. Marital status of women aged 15-19, 1993 to 2008 NDHS

Figure 9 shows that from the 1993 NDHS, 92 percent of teenagers were never married. This proportion has consistently declined through the years and in the 2008 NDHS, only 89 percent of teenagers were never married. If early marriage was driving the trend toward higher prevalence of early childbearing, the proportion married should correspondingly increase with the decline in the proportion never married. Figure 9 show that the proportion who are married has been declining. What is steadily on the rise is the proportion in a consensual union. This suggests that it is early premarital sexual activity that is the driver for the trend toward the increasing prevalence of early childbearing in the Philippines. Pregnancy resulting from premarital sexual activity often leads to the decision to begin cohabitation but not necessarily to a formalized marital union. Corroborating evidence for this shift toward non-marital fertility among teenage women is found in the vital statistics report of the National Statistics Office which states that in 2008 “Majority (79.2 %) of babies born to women under 20 (years) of age were illegitimate.” [‡‡] Illegitimate means that the mother and father were not formally married at the time the birth was registered. The trend toward non-marital fertility is by no means limited to the youngest women. The Vital Statistics Report for 2008 further states that of the total births registered in 2008, 37.5 percent were born out of wedlock and 40 percent of illegitimate births were born to mothers in the age group 20-24.

Evidence for early premarital sexual activity is further supported by findings from two surveys on a national representative sample of young people aged 15-24 in the Philippines, the Young Adult Fertility and Sexuality Study done in 1994 (YAFS 2) and in 2002 (YAFS 3). In YAFS 2, 8 percent of 15-19 year olds reported ever having engaged in premarital sex; this increased in 2002 to 12 percent. Only 24 percent used contraception during their first premarital sexual activity. 28 Since YAFS was conducted more than a decade ago, presumptive changes in prevalent sexual behaviors and practices of young people may have undoubtedly contributed to the increasing proportion of teenage girls becoming mothers at a very early age.

Another contributory factor to the increasing prevalence of early childbearing is the decreasing age at menarche, a development that is consistently reported in the literature as occurring in countries that have experienced significant improvements in living conditions and the nutritional status of female children. Table 2 presents the reported age at menarche by women in the various reproductive age groups.

Click here to download Table2

Table 2. Percent distribution of age at menarche by age at time of the survey, 2008 NDHS

Table 2 indicates that the reported age at menarche has been declining across successive cohorts of women. For example, among the 15-19 year olds, the reported age at menarche peaks at age 12 (31%) while among the 45-49 year olds the peak is at 15 and above (30.7%). This trend in consistent with that reported in the literature about the deceasing trends in the age at menarche in other developed and developing countries. 29

Overall, the findings in this paper from the analysis of the Philippines’ National Demographic and Health Survey series over a number of years, together with findings from the Family Health Survey, corroborates that more teenagers now are getting pregnant compared to earlier cohorts. A confluence of factors have come together to make this happen: a trend toward younger age at menarche, changing norms and practices with regard premarital sexual activity among the youth and increasing acceptance of premarital sex coupled with less societal pressure to legitimize out-of-wedlock pregnancies. Although there are differences amongst groups, the increasing prevalence of early childbearing is observed in all socioeconomic classes, all levels of education and in both urban and rural settings.

Teenage pregnancy exposes both mother and child to many health and other risks, both and there is need to further study how to mitigate its effects or how to reverse the trend. Any interventions should be cognizant of the following factors:

1. While early childbearing has increased among the non-poor, the better educated and residents of urban areas, teenage pregnancy is still unacceptably higher among the poor, those with lower education and rural residents. Interventions designed to help reverse the trend should be tailored to the circumstances leading to early pregnancy that may be specific to these subgroups.

2. The timing of school-based interventions such as sexuality education should be mindful of the finding that teenage pregnancy is highest among those with the least education, specifically those with elementary or lower educational attainment. Thus age-appropriate sexuality education should begin in the pre-adolescent years before teenagers leave school. The high unmet need for contraception among currently cohabiting or married teens, requires specific services and family planning programs for this group. Teenage mothers have the lowest birth intervals (median of less than 24 months) and expose themselves and any more babies to greater risks if a subsequent pregnancy is not prevented. The fact that there is high unmet need for contraception in this age group indicates that there is a desire to space births longer but for some reason the expressed desire is not matched by the corresponding action of using contraception for birth spacing (Figure 2). Further studies should investigate barriers to the use of contraception among currently married teenagers as no direct answers are available from either the NDHS or the FHS.

3. Hospital-based prospective and retrospective studies to study the adverse outcomes of early pregnancy and childbirth on the mother and her baby compared to other age groups are needed to better understand the specific health risks in the Philippine setting. Findings of these studies will be an important input for intervention programs not only for the teenagers themselves, but also for health providers who will be involved in the delivery of services for this age group.

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*The age-specific fertility rate is the number of births per thousand women of a given age or age group. An age-specific fertility rate is generally computed as a ratio. The numerator is the number of live births to women in a particular age group during a period of time, and the denominator is an estimate of the number of person-years lived by women in that same age group during the same period of time. It is expressed as births per 1,000 women.

Source: http://www.un.org/esa/population/publications/WFR2009_Web/ Data/Meta_Data/ASFR.pdf. Retrieved 7 May 2013

[†] http://www.indexmundi.com/facts/indicators/SP.REG.BRTH.RU.ZS/ compare?country=ph#country=pg:pe:ph:th. Retrieved 11 April 2013.

[‡] [‡] The practice of securing written informed consent for surveys is a matter of ongoing debate in the social science survey community as the practice has been shown to affect participation rates and may compromise the validity of the research findings Please cite references number 20 and 21 here.

[**] The total fertility rate is a basic indicator of the level of fertility. It is calculated by summing age-specific fertility rates over all reproductive ages. It may be interpreted as the expected number of children a woman who survives to the end of the reproductive age span will have during her lifetime if she experiences the given age-specific rates.

Source: http://data.un.org/Glossary.aspx?q=total+fertility+rate. Retrieved 7 May 2013

[††] The wealth index is a composite measure of a household's cumulative living standard. It is calculated using easy-to-collect data on a household’s ownership of selected assets, such as televisions and bicycles; materials used for housing construction; and types of water access and sanitation facilities. It divides households into five quintiles, with quintile 1 representing the poorest 20 % and quintile 5 the richest 20%.

(Measure DHS. http://www.measuredhs.com/ topics/Wealth-Index.cfm Accessed 15 April 2013).

[‡‡] http://www.census.gov.ph/article/registered-live-births-increased-20-percent-20082012-08-16-1700

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Early motherhood: a qualitative study exploring the experiences of African Australian teenage mothers in greater Melbourne, Australia

• Mimmie Claudine Ngum Chi Watts 1 ,
• Pranee Liamputtong 2 &
• Celia Mcmichael 3  

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Motherhood is a significant and important aspect of life for many women around the globe. For women in communities where motherhood is highly desired, motherhood is considered crucial to the woman’s identity. Teenage motherhood, occurring at a critical developmental stage of teenagers’ lives, has been identified as having adverse social and health consequences. This research aimed to solicit the lived experiences of African Australian young refugee women who have experienced early motherhood in Australia.

This qualitative research used in-depth interviews. The research methods and analysis were informed by intersectionality theory, phenomenology and a cultural competency framework. Sixteen African born refugee young women who had experienced teenage pregnancy and early motherhood in Greater Melbourne, Australia took part in this research. Interviews were audio recorded, transcribed and data analysed using thematic content analysis. Ethics approval for this research was granted by Victoria University Human Research Ethics committee.

Motherhood brings increased responsibilities, social recognition, and a sense of purpose for young mothers. Despite the positive aspects of motherhood, participants faced challenges that affected their lives. Most often, the challenges included coping with increased responsibilities following the birth of the baby, managing the competing demands of schooling, work and taking care of a baby in a site of settlement. The young mothers indicated they received good support from their mothers, siblings and close friends, but rarely from the father of their baby and the wider community. Participants felt that teenage mothers are frowned upon by their wider ethnic communities, which left them with feelings of shame and embarrassment, despite the personal perceived benefits of achieving motherhood.

Conclusions

We propose that service providers and policy makers support the role of the young mothers’ own mother, sisters, their grandmothers and aunts following early motherhood. Such support from significant females will help facilitate young mothers’ re-engagement with education, work and other aspects of life. For young migrant mothers, this is particularly important in order to facilitate settlement in a new country and reduce the risk of subsequent mistimed pregnancies. Service providers need to expand their knowledge and awareness of the specific needs of refugee teen mothers living in ‘new settings’.

Peer Review reports

Globally, teenage pregnancy remains a public health concern. Worldwide, sixteen million girls give birth during adolescence annually with an estimated three million having unsafe abortions. Most adolescent pregnancies occur in developing countries, and teenagers living in socio-economically disadvantaged settings in developed countries are at higher risk of teenage pregnancy as compared to the broader population [ 1 ]. The adolescent period is considered a critical time in the young person’s life. Initiation of sexual activities, and for many a marriage, occur during this period. The early onset of sexual intercourse and menarche and the delay in marriage means the period of adolescent is now longer than ever, which increases the risk of unplanned pregnancy and early motherhood. During the teenage years, young people who are faced with early motherhood may experience conflict between their new position as mothers and their adolescent needs [ 1 , 2 ]. The experiences of early motherhood are contextual, influenced by culture and the society within which the teenager/woman lives [ 1 – 6 ].

In Australia, teenage birth rates fell from 22.1 live births per thousand women in 1992 to just over 15.5 births per 1000 women in 2010 [ 7 ]. Teenagers living in low socioeconomic areas have higher birth rates [ 8 ]. The consequences of early pregnancy and births to teenagers - including events leading up to these pregnancies - have been highlighted in the research literature [ 9 ]. Teenagers most at risk of unplanned pregnancies are those from low socio-economic status, families with a history of teenage pregnancies, those who have experienced abuse, and those without a father figure. Disconnections from school or leaving school early are also risk factors for and consequences of early pregnancy and birth. Some of the health risks to the baby include still birth, low birth weight, risk of dying in the first few months of life, and these risks increase with younger maternal age. For the mother, risks of fistula and maternal death, particularly in poor settings, are real. Some of the social problems include school dropout which leads to reduced educational opportunity and low skills acquisition [ 10 ]. However, a growing body of research has questioned the evidence that teen childbearing largely has negative consequences for teen mothers and their babies, and have highlighted the importance of understanding the views and experiences of teen parents [ 11 , 12 ]. Regardless, after the birth of the baby, mothering and motherhood become a reality.

Motherhood is an important part of many women’s lives, particularly in societies where traditional gender roles persist. In many African societies, motherhood is central to the social and cultural system [ 13 ]. Motherhood and childbearing among Sub-Saharan African women is regarded as a normal duty within a woman’s life [ 14 – 16 ]. In many parts of Africa, motherhood is seen as an essential role, with family and social life orientated towards children with early onset of childbearing and large families preferred [ 10 ]. From an early age, there is a positive orientation towards motherhood [ 1 , 13 ]. The importance of motherhood may continue post-migration and settlement [ 14 , 17 ]. Yet motherhood in the context of migration is often substantially different: young immigrant women experience the dual transitions of becoming a mother while also adjusting to everyday life in a site of settlement, often without extended networks of social support [ 6 , 18 ].

Early positive orientation towards motherhood has been associated with teenage pregnancy (TP) [ 4 , 19 ]. Girls are made to feel that motherhood is a prerogative in their lives as women and central to female gender roles [ 4 ]. Australia is home to over 280,000 persons with African ancestry [ 20 ]. However, experiences of teen pregnancy and early motherhood among African Australians following migration are under-examined and inadequately understood. This paper aims to highlight the experiences and challenges of African Australian teenage mothers who are living in Greater Melbourne. It discusses their experiences of teenage motherhood, and critically examines how young teenage mothers - who are mainly single - navigate early motherhood.

In this paper, we use the terms teenager, young woman/woman and adolescent. Teenagers (13–19 years of age) are a subset of the adolescent period (10–19 years of age) [ 16 ]. All 16 young women who participated in this study were teenagers at the time of their first pregnancy; at the time of interview not all participants were still teenagers, but all were still young women below the age of 30 years.

Theoretical framework

In this paper, we situate our finding within intersectionality theory which recognises the multiple intersections in a woman’s life, including race, gender, skin tone, accent, education level, migration status, language and other life situations [ 21 – 23 ]. Intersectionality theory considers the multiple dimensions within which teenagers exist, including gender, age, developmental stage, socioeconomic status, ethnicity, minority group status and migration experience (e.g. refugee). For the teenagers and young women who participated in this research, the above dimensions were a central part of their identities. Thus, intersectionality theory goes beyond the boundaries of race and gender to include other social categories such as migration status, religion, sexual orientation, educational attainment, language and many other categories that play and/or influence the individual’s life situation. Intersectionality theorists argue that to be able to understand the world of minority women, it is critical to move beyond the boundaries of gender and race. For Sub-Saharan African (SSA) women, culture, marriage, and child bearing remain important. Marriage and childbearing almost often define a woman’s position within the family and her community [ 13 , 14 ]. Using the single axes of either race or gender will not present a complete picture of the individual’s experiences and cannot fully answer questions about the woman’s existence [ 21 , 22 ]. To understand the position and the experiences of the teenage mothers in this study, their cultural heritage, the community associations and the lives or journeys they have experienced should be considered.

Intersectionality theory uses a multiple axes approach: it considers multiple complexities and dimensions, and the many identities that an individual woman may possess [ 23 ]. Each aspect of a person’s identity influences their decision making. For African teenage mothers who are at the same time refugees, from low socioeconomic background and with low levels of education, these multiple identities need to be understood when examining experiences of early pregnancy and early motherhood among this cohort of migrants. While intersectionality has been critiqued as being too open [ 24 ], we posit that as a framework it captures the nuances and differences that are central to individual lives [ 21 , 22 ], including the young women in our study.

Qualitative research is widely used in the health sciences and is regarded as the most appropriate method when exploring people’s life experiences or phenomena that are sensitive or socially complex [ 25 , 26 ]. This study utilised in-depth interviewing methods, and the study drew upon both phenomenology and cultural competence frameworks to inform the research methods and analytical approach. Phenomenology was particularly suited for this study as it is concerned with the study of human existence and how humans understand and perceive their own behaviours [ 27 ]. Phenomenology allows the researcher to uncover hidden aspects of people’s lives that would not emerge during ‘normal’ conversations, or that people would not typically reveal to people outside their own social or cultural circles ([ 27 , 26 ]).

In-depth interviews were chosen as the primary data collection method as their structured nature allows the interviewee to ‘tell their story in the deepest and richest way possible during the interview process’ ([ 28 ] p. 388). Participants were eligible to participate in the study if they were: (i) of African descent; (ii) had migrated to Australia under the Australian Humanitarian scheme, or were sponsored by someone who had migrated under the humanitarian scheme; and, (iii) had experienced teenage pregnancy (TP) or early motherhood. Participants were included from different African ethnic and cultural groups, different socio-economic situations, and from different settings within greater Melbourne.

Purposive sampling was used to reach this hard to reach population as it allowed the researcher to interview those who had experienced teenage pregnancy. Initially, invitations were sent out to potential participants through formal (church notice board) and informal (friends and community members) networks. Potential participants were invited to contact the researcher and set up a convenient interview time. This method was not successful in recruiting African women who had experienced TP. Another researcher in the UK has also reported very low response rates when recruiting black African families using information flyers and the internet, and subsequently used snowball recruitment techniques via formal and informal social networks [ 29 ]. Accordingly, in this study snowballing methods were ultimately used to identify potential participants who met the eligibility criteria. People who heard about and were interested in the research referred potential information-rich participants [ 26 ]. Potential participants were provided with a plain English language statement about the research. It was only after this process that interviews were set up with participants. This allowed the participants opportunity to consent to participate, or to opt out or cancel the interview if they did not want to proceed.

In-depth interviews were conducted with sixteen African Australian teenage mothers, or women who had experienced teenage pregnancy, and who had a refugee background (see Table  1 ). Pseudonyms were assigned to all participants to ensure confidentiality [ 25 ]. Interviews were digitally recorded and transcribed verbatim. The data were entered into NVivo (qualitative data analysis program) and analysed using thematic analysis [ 26 ]. Data were read for understanding several times. An inductive analysis and exploratory approach was applied during this process. Coding, sorting and organising data are an integral part of thematic analysis [ 30 ]. The data were searched systematically for re-occurring words, which later became code words: these code words were then grouped to form themes. The NVivo software was used in conjunction with manual coding during the data analysis to help with the management of the data.

Ethics approval for this research was granted by the Victoria University Human Research Ethics Committee. Data collection took place between February 2010 and August 2011.

Characteristics of the teenage mothers

The sixteen young women in this study had all migrated to Australia from Sub-Saharan Africa via Australia’s humanitarian program and fourteen had subsequently experienced teenage pregnancy. One arrived pregnant but was unaware of her pregnancy and one had both pregnancies overseas (in transit country) prior to arrival. At the time of interview, participants ranged in age from 17 to 30 years (one participant did not provide her age but was in her late teens to early twenties). All women were Conclusionsunemployed except one who had a casual job at a supermarket. Of the sixteen participants, ten were from Sudan, three from Liberia, and one each from Burundi, Ethiopia and Sierra Leone. All women, but for two, had lived in a transit country following flight from their country of origin, with some living in so-called transit situations for up to seven years. All participants spoke at least two languages and/or dialects. All women had a religious affiliation: fifteen were Christian and one a Muslim.

Cultural influences

Regardless of whether the pregnancy was planned or unplanned, all the teen mothers in our study decided to proceed with their pregnancy. A few indicated that knowledge of others’ experiences of crude abortions in refugee camps was a deterrent to aborting the baby. Cultural and religious attitudes and practices further influenced the decision to carry the baby to term, despite the challenges of single/teenage motherhood. Chelsea, a young Muslim woman, discusses her fear of abortion, the fate that awaits a woman if she dies due to an abortion, and the implications of abortion for the family:

In the camp, one girl, she was pregnant and she was a Muslim girl and she got pregnant by a Christian boy and then the Christian boy denied the pregnancy and then she went and drank something to get an abortion and then she died. So that one make many people scared in the camp. Everyone would say, “I’m not going to do abortion anymore”. And then when she died, like a Muslim, you do abortion no one will touch you. They have to get someone to take you away; they (Muslim) can’t even bury you. No one will come next to you (the body). So it was so sad. Her family members crying, “There’s no one to bury her” from the Muslim community. (Chelsea)

However, women also spoke of more positive reasons for proceeding with pregnancy. Kayla, for example, was 19 years at the time of interview and was pregnant. She said ‘ I thought if I got pregnant our life would be better . . . that’s why in my second relationship I said, “I just want to get pregnant. I don’t care from whom but I just want a baby”. The ‘cultural socialization’ for some of these teen mothers was that motherhood was just part of life whether planned or unplanned.

Becoming a mother

Among these young women, becoming a mother was largely a positive experience, despite the associated challenges. They were generally happy to have a baby of their own and felt that their lives had changed for the better since becoming a mother, even when everyday life was difficult. Motherhood was perceived to be a connection and an avenue for their parents to accept a partner they would otherwise not accept. According to Candida:

I thought if I get pregnant and have a baby together with him, mum will not be able to do anything about it and we will be together because of the baby.

Motherhood, however, also brought some mixed feelings and experiences. Pregnancy at any age can be physically exhausting, and for young women who are often ‘alone’ or with little support, and physiologically and emotionally still developing, pregnancy can be challenging. Having someone to lean on irrespective of their age can bring feelings of joy to these young women. For Alimatou, a mother to a two year-old boy and expecting a second baby, support was provided by her son. Below Alimatou shares her joys and sorrows of motherhood as a pregnant young mother:

In a way, sometimes it’s good, sometimes not good … sometimes when something happens and we are in the apartment he says, ‘Sorry, Mum.’ Then when I’m tired, like when I’m sleeping, I’ll send him and he’ll go and bring something so that I don’t have to go and bring them. ( Alimatou)

For some young women, motherhood brought with it a sense of maturity, elevated responsibility and purpose. They began to regard themselves as adult and more mature. Becoming a mother meant they had to behave like responsible adults. Motherhood offered them an immediate family structure, and gave them a person they could truly love. For some, it brought an increased sense of self-worth. For Francisca, motherhood did not only bring joy, she felt more grown up and ‘ahead’ of her peers:

Now I’m like a woman. I’m sort of a girl and a woman. I’m an older girl, not young girls that are getting new stuff. I’m not one of them … Because I had a baby and comparing to the girls who haven’t had a baby. ( Francisca)

While there was a sense of purpose and maturity that came with motherhood, these mothers acknowledged the many difficulties they faced as young mothers.

Challenges of motherhood

Despite the positive elements of motherhood, challenges emerged that affected various aspects of the young women’s life. Most often, these challenges stemmed from coping with the responsibilities of looking after a baby and young child, particularly when also attending school and/or seeking employment:

Yeah, is very hard to take care of the kids and still go to school or look for job, and you don’t have someone to look after you and your baby. It’s very hard. (Daniela)

Some women felt regret in relation to having a baby while still at school, particularly when they were unable to complete their school education which then led to difficulties in finding work. This difficulty was noted particularly among those with limited social support networks, as they had no one to help at home or lend a hand in the absence of biological parents following migration:

It is not easy to have a baby. It’s very hard, it is better to go to school and get a job first. Once the baby comes, it is very hard, you can’t do anything, especially when you do not have someone to help you it is very hard. (Ayuba)

Those with an older child found the tasks of motherhood even more demanding. Meeting the needs of the older child and a new-born, continuing their own education, and socialising with their friends were reportedly very difficult for these teen mothers. Feelings of exhaustion were not uncommon, making it difficult for the young mother to re-engage with or enter the work force, or to pursue training or education. These challenges were more evident when the young mother was expecting another child, often with limited resources and support. Below Jessica, aged 17, with a young daughter and expecting her second child spoke of how hard everyday life had become. Jessica compared her current situation with the time she only had Rosy to parent. Jessica, who did not have her biological parents in Australia, highlighted the daily life challenges she faced coupled with the physiological changes expecting mothers have to deal with:

It’s very difficult. Before it was easy for me before I just had Rosy. Because she couldn’t walk, I couldn’t take her to the shop, I can’t go to school and I can’t do all my stuff. But now I don’t do anything because if I take her to the child-care I come back home and I’m just tired. I think when the baby is born it will be more difficult because I don’t have a car because he [her boyfriend] took my car and I don’t even have a car and that’s why everything is getting more difficult. It will be very hard for me to go back to school now. Everything is not going to be easy like it used to be. But I am happy with my kids. (Jessica)

Post-partum social support for the teenager

Experiences of stress and regret that came with teen motherhood were associated with inadequate social support before and after the baby’s birth. There was a widespread sense of loss of social life and inadequate social support. Among these women with African backgrounds, the lack of social support in a site of settlement emerged as a common difficulty that had an impact upon their experiences of early motherhood, everyday life, and plans for their future. However, some support was available to assist them to meet the demands and challenges of early motherhood.

Family support

The challenge that many migrants face in sites of settlement is the lack of extended family, social and cultural networks [ 6 , 14 ]. Family and friends are considered a source of support, and for teenagers this is significant in how they will reintegrate with education, employment and social life. Some of the young mothers in this study migrated alone, some with extended family member and family friends. Most young mothers received some support from their parents and guardians (i.e. people who sponsored the young women to come to Australia, or who were caring for them when the pregnancy occurred). The extent of support that the women received from these people depended on the relationship they had before the pregnancy and birth of the baby. Where the relationship between parents or guardians and teens had been good, they were likely to receive support. Teenagers who lived with at least one biological parent or a first degree relative received the most help and support with the baby as compared to those who did not live with their parents or relatives. The young mothers who lived with guardians said they would have had better support if their biological mothers were present:

Is not good thing [to be pregnant out of wedlock] but she’s [uncle’s wife] not good since I get pregnant. She kicked me out of house. Now she doesn’t talk to me, even if she finds me in the street she doesn’t say hi to me. It’s not good. So it’s better to have your mum. Even if your mum is angry with you it’s not going to be like this. She’s going to calm down a little. (Daniella)

Mothers were reportedly at the fore when it came to supporting the teen mothers, even if they had been unhappy or disappointed about their daughter’s pregnancy. Those participants who had the support of their mothers indicated that their mothers had a sense of responsibility towards them. Their own mothers’ acts of love towards the young mothers and their baby were highly valued and acknowledged. The support of participants’ mothers and families was evident in some interviews. The interview with Chelsea took place at her home, and Chelsea’s mother had the baby on her back (as is the practice for African mothers) while Chelsea went about her interview and other duties. When the baby cried, her sister who was about 12 years-old at the time, carried the baby and cuddled her. It was evident that Chelsea had support from both her mother and sibling. Chelsea said her sister had learnt from her not to have a baby while still at school or out of wedlock, although she continued to help her with the baby. In other interviews, female siblings were evidently helpful and supportive of their sister and her baby. Several young mothers received help from their sisters in taking care of the baby so they could attend to school work or go out and socialise.

The level of support received by young mothers substantially influenced their intentions and capacity to re-engage with education and work. Teenagers who received more support from their family, especially from their mothers, were more likely to return or want to return to school. Chelsea, for example, had the support of her mother and went back to school when her baby was aged four months:

[My mum] asked me ‘Are you going to keep the baby?’ and I was like, ‘Yes.’ My mum was upset because of my schooling and stuff and then I talked to my mum and we had a fight for some time … so she says I have to go to school . . . As soon as February, when school started I went back to school, because I wanted. I wanted to do something for myself in the future that’s good. I want to become a nurse. (Chelsea)

Those young women who had their fathers in Australia did not feel strongly about getting their support. For most of these teenagers, their fathers were partially or completely absent from their own lives, which often brought feelings of loss. Almost all teenagers came from single parent homes or their fathers were reportedly in Africa or elsewhere, often married to other wives:

Dad, he’s in the USA. It’s very strange, we’re trying to be close to him but his mind is always somewhere else. I’m not sure if he wants to have children and a family even at his age. He left when my brother was about one year and my younger brother is 15, turning 16, so it’s like we haven’t seen him for 15 years. It’s feeling like I’m sad. (Kayla)

Support was not only lacking from absent biological fathers; step-fathers who were present were said to provide limited support for the step-daughters and their children. Bikutsi, who had two miscarriages, felt unsupported and unloved by the ‘fathers’ in her life, including her step-father and biological father. Indeed, she attributed some of the struggles in her own life (and those of her mother) to the inadequate support of the fathers.

Support from friends

Participants received mixed levels of support from friends, and the level of support largely depended on the type of friendship before the pregnancy. Loyal friends were said to support the mothers during the pregnancy and after the baby’s birth:

Some [friends] are very close, like this one who is here now, she visits daily. Even before I had the baby she encourages me. The others are now very distant from me. I think because I was pregnant. (Veronica)

During the interview with Veronica, her friend was present and helped out with the baby. They seemed very close and, according to Veronica, becoming pregnant strengthened the relationship between the two friends. This supportive scenario between friends was not the same for others, who felt isolated, sometimes because their friends were young mothers themselves:

I have one best friend and she has a baby as well, how can she support me? She has to look after her baby so she didn’t have time to support me. So I decided to keep to myself. (Chelsea)

For some young mothers, long travel distances and the inability to commute easily was a barrier to getting support from friends:

Yeah I have one [friend] but she lives very far. She lives in the other side of the city. I do not drive, so it’s very hard to get there. (Ayuba)

Support from the baby’s father

The fathers of the babies were often absent during and after the pregnancy. For the few fathers who were around, the amount of support provided - financial, emotional or physical - to the teenage mother and the baby was generally described as inadequate. When present, the a few fathers were reportedly inclined to try to access the social security benefits available to the mother rather than support her with the child:

He would pretend that he loved me, but he didn’t love me and he didn’t love my child. It’s very hard to find a good person because when they know you have a baby, they don’t care about you. They love to come around if you have money and ask if you have money and then they just go away with the money. If they know you have a kid, it sends them packing. (Stephanie)

For some teen mothers, a perceived lack of support from the father was due to the fact that the relationship had broken down before the baby’s birth. As Veronica said:

We are not getting married, yes [we are] in a relationship; no, not serious, just between the baby … Because I don’t love the boy … because my mind is not to love the boy … My heart is not there … I am young and I want to continue my education.

Support from the wider community

In Melbourne, members of the wider African community generally frown upon unmarried teenage mothers, leaving the teenagers with feelings of shame and embarrassment. Young mothers are perceived to set bad examples to other teenagers, and give a bad reputation to the community and their families. Hence, teenage mothers were perceived to be bad role models for other younger girls. In accordance with this perception, the lack of support given to these mothers by members of their community was evident. None of the participants in this research said they had received support for the baby via their community. Community attitudes towards them left with feelings of embarrassment. Veronica noted:

I was embarrassed; I was embarrassed with everyone [in the community]. My mother was angry with me, because I could not go to school. She felt bad, because I am pregnant in street [unmarried] and it is a big problem in the community.

According to the participants, an African family is situated within the wider community, and they share in their children’s feelings of shame and embarrassment that emerge through wider community disapproval. A daughter’s teen pregnancy out of marriage reflects badly on the parents, and places their parental responsibilities/duties in question by the wider community. Interdependency post migration remained an anchor point for many African migrants and their families. Thus any community perceptions and attitudes towards individuals were taken seriously. Those young mothers without significant social bonds expressed feelings of exclusion and rejection. Francisca who moved to Melbourne from another city without sharing her pregnancy status with anyone recounted:

Because I haven’t got any friends that connect with me, like really best friend, I can’t just talk to all the girls that sit with me and I don’t know really well and haven’t met them. (Francisca)

Stephanie shared similar feelings of isolation and a lack of ties with her ‘friends’:

If I go and tell my friend something about me, maybe they communicate it to other people I’m better keeping it to myself. (Stephanie)

Friendships were limited for many of these young women because of their migration statuses and interrupted lives. Together with other barriers, integration into the wider community was difficult for them; becoming pregnant and negative community perceptions of teen mothers increased young women’s risk of isolation.

Discussion and conclusion

The study provides insight into young African migrant women’s experiences of teen pregnancy and early motherhood, with particular focus here on their experiences of social support. The paper is based on qualitative research – i.e. in-depth interviews with sixteen African Australian women with refugee backgrounds who experienced teen pregnancy - and the findings cannot be taken as representative of the experiences of all refugee and African young women in Melbourne, Australia. However, the paper does provide insight into the intersecting identities that shape teen pregnancy and early motherhood in a site of settlement.

For African Australians with refugee background living in Melbourne, teenage motherhood brings both joy and regret [ 14 ]. This finding supports the increasing body of research that indicates teen childbearing should not be viewed solely through a ‘risk prevention’ lens that emphasises negative consequences for teen mothers and their babies [ 11 , 12 ]. Our research indicates that motherhood brought happiness for many of the young women and an increased sense of meaning, despite the associated challenges of early parenting [ 14 ]. There was an associated sense of maturity and responsibility. Many young mothers developed a personal sense of stability, identity, purpose and responsibility following early motherhood, a finding similar to other studies of teenage pregnancy and parenthood (see [ 1 , 6 , 14 ]). The respect awarded mothers in Africa may be seen as a reason for this strong sense of identity and purpose following motherhood [ 1 ]. In this study, positive experiences of motherhood were associated with good social support which contributed to feelings of acceptance and optimism for teenage mums (see also [ 1 ]). For some, teen pregnancy and early motherhood brought them closer to their families (particularly mothers and female siblings) and they valued having a child whom they loved and who loved them back [ 1 , 4 ]. Other studies have reported that pregnancy and motherhood can strengthen relationships and seal the woman’s place in a relationship, marriage and within the community [ 1 , 6 , 14 ]. Indeed in some societies, particularly when political instability is common, women become bearers of nationhood [ 3 ]. Thus, society, culture and the context within which motherhood occurs shapes and influences the motherhood experiences.

Nonetheless, in this study, all the young mothers indicated that pregnancy and early parenthood had come at a time when they were also confronting the ongoing challenges of settlement in Australia as well as the transitions and challenges of adolescence and early adulthood. Our findings demonstrate the conflicting role of motherhood to the self despite inherent benefits to the self, family and broader society [ 6 , 14 ]. Other studies have documented the conflicting experiences (joy and challenges) of motherhood, particularly among adolescent mothers who experience tensions between their needs as both mothers and as adolescents [ 2 ]. For participants in this study, they negotiated the competing demands and challenges of pregnancy and parenthood as well as adolescence and early adulthood, while also confronting settlement in a new country which brings its own challenges in relation to housing, language acquisition, education, social connections and workforce participation. Becoming a young mother in a new country is therefore complex, and theoretical frameworks that can engage with the multiple axes through which early motherhood is shaped and experienced best support understanding and analysis of these experiences.

In this study, intersectionality theory provided a framework whereby the complex and diverse experiences of early motherhood could be understood, as it supported analysis of the participants’ lives across multiple axes [ 31 ]. Indeed, we contend that analysis of the experiences and perspectives of young mothers must highlight the many dimensions and intersections of their lives. By using intersectionality theory, it was evident that many factors in these young mothers’ lives contributed to their early motherhood experiences. Race, age, gender, migration experience, the family environment, socioeconomic status, educational background, and social networks prior to pregnancy contributed to a complex web of intersecting experiences that then shaped teen pregnancy and early motherhood (see also [ 23 ]). Based on her research with Southeast Asian immigrant women/mothers in Australia, Liamputtong [ 6 ] argues that ‘women had other interpersonal identities that are also salient to them and impact on their mothering roles’. In this study, an array of interpersonal identities influenced how young mothers experience early motherhood. While there is a large body of literature that highlights the disadvantages of teenage pregnancy and early motherhood, intersectionality theory provides a broad framework via which the diverse contexts, experiences, drivers and outcomes of teen pregnancy and early motherhood can be considered: in this study the focus has been Sub-Saharan migrants living in Australia who experience teen pregnancy [ 13 ].

However, while acknowledging the diverse and intersecting axes that shape and define personal experiences, this paper has focused on young mother’s experiences and accounts of social support networks. The level of difficulty and regret that came with motherhood were associated with the level of social support and acceptance teenage mothers received before and after the baby’s birth. Research indicates that family support is critical to teen mothers and it has been found to have a positive impact on parenting experiences, behaviours and practices [ 32 ]. Among many participants, despite initial negative reactions – particularly from mothers - when first confronted with the news of the pregnancy, interpersonal support was forthcoming from mothers and sisters (and some female friends). Yet most spoke of a lack of support from extended family members and their own immediate communities, and this appeared to affect teen mothers’ everyday lives and futures by amplifying the disadvantages they already face. Further, the family of young mothers also came under scrutiny by the broader community, which contributed to heightened feelings of shame and disapproval. Both the fathers of the young mothers and the fathers to the babies were described as providing inadequate or even no support, often cited as being absent.

As this research found, being a teenage mother can be difficult and many participants spoke of having inadequate social support. Early motherhood was often marred by a sense of loss, particularly not being able to complete their school education and obtain a good job (see also [ 1 , 2 ]). But with the right people and support, teenager mothers were able to engage in mainstream society.

Being a refugee and settling in Australia comes with many challenges, and teenage pregnancy can amplify the challenges of settlement including education, employment, housing and development of social networks [ 12 , 33 ]. Yet for many participants, having a child brought a sense of purpose, family, attachment and identity. In this study, intersectionality theory has provided an important framework for examining the ‘multiple identities’ that shape pregnancy decisions and lived experiences of early motherhood among young African women living in Melbourne with refugee backgrounds [ 34 ]. For example, as young migrants from Africa with refugee backgrounds, settlement in Australia can be a highly challenging process that is often characterised by disrupted and fluid family and social networks: motherhood emerges as a lived experience that can provide stability, permanency and love. Other studies of migration and protracted refugee situations have documented that teenagers with refugee backgrounds have limited control over their lives and futures, and motherhood remains one of the few things they feel they can control [ 4 , 19 ]. And in her study of South East Asian immigrants, Liamputtong [ 6 ] argues that motherhood gives young women a sense of purpose and belonging and fulfils a moral and cultural responsibility. Further, these young women come from cultures where ingrained gender roles and practices support early orientation towards motherhood and childbearing, and motherhood is regarded as a female duty and responsibility. Hence, while early motherhood has many complexities and disadvantages for young women in a site of settlement, paradoxically, it can also be fulfilling.

Implications for service providers and policy makers

Motherhood at any age is complex, but more so for teen mothers and migrants who are developing and trying to negotiate their emerging position as adults in a site of settlement. For young women with refugee backgrounds, lack of extended family and social support networks (including the absence of biological parents) confers significant disadvantage. In this study, young mothers highlighted the important supportive role of their own mothers in particular (where available), yet many spoke of inadequate wider social support and disapproval of family and community members. Research indicates that social connectedness promotes better psychosocial outcomes for young parents, and better settlement and well-being outcomes for refugee youth [ 12 ]. Social support, both from significant people in a woman’s life and from health professionals, has been found to increase the mother’s self-confidence and assurance in her role as a mother [ 14 , 18 ]. Accordingly, adequate social support for migrant/refugee teen mothers is critical, including because it has a positive impact on their ability and decisions to re-engage in education and in the workforce, thereby reducing the risk of continuing social disadvantage for mother and child. Services and teen parenting programs for young people with refugee backgrounds should recognize and facilitate the important supportive role of extended family and community networks, including mothers, siblings, guardians, friends, the father of the child, and the father (s) of the young mother.

It is important that at least one biological parent, particularly the mother, is present during and soon after the birth of the baby. This provides long-term benefits for mother and child, particularly for the mother’s re-engagement in school or work. Importantly, immigration regulations should be considered, particularly the substantial costs associated with temporary visitor visas, so that African parents/family can visit and provide much needed support for their daughters when experiencing early motherhood.

Service providers should also consider the broader context within which early, unplanned, or mistimed pregnancies and motherhood occur among teenage mothers, including those with refugee backgrounds. Despite policy commitments to delivering appropriate services to disadvantaged community, there are few examples of programs to support young mothers from refugee or culturally diverse backgrounds [ 12 ]. Initiatives and services are required that support young people to become parents while also maintaining broader settlement and life goals. Services must have increased awareness about migrant and refugee communities, and the particular challenges and needs of teen mothers, their children and families.

Given access to appropriate support, people with refugee backgrounds can make significant contributions to their new countries of settlement and lead satisfying personal and family lives. For women with refugee backgrounds, early motherhood can be challenging, particularly where there is inadequate or limited social support, and this has an impact upon their aspirations and imagined futures. Yet, in line with the emerging research that highlights the positive aspects of teen pregnancy and early motherhood, this study suggests that African young mothers with refugee backgrounds often value motherhood. Programs and policies should seek to increase and nurture social support networks while also building on the evident resilience and resourcefulness of these young women.

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Ngum Chi Watts, M.C., Liamputtong, P. & Mcmichael, C. Early motherhood: a qualitative study exploring the experiences of African Australian teenage mothers in greater Melbourne, Australia. BMC Public Health 15 , 873 (2015). https://doi.org/10.1186/s12889-015-2215-2

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Trends in repeated pregnancy among adolescents in the Philippines from 1993 to 2013

Joemer c. maravilla.

1 School of Public Health, The University of Queensland, Herston, QLD Australia

2 Institute for Social Science Research, The University of Queensland, Indooroopilly, QLD Australia

Kim S. Betts

3 Centre for Youth Substance Abuse Research, The University of Queensland, Herston, QLD Australia

Associated Data

The datasets analyzed during the current study are not publicly available but can be requested from the DHS Program data managers.

The extent of repeated pregnancy (RP) and repeated birth (RB) among adolescents aged 15–19 is still unknown in the Philippines despite the health and socio-economic consequences. This study aims to investigate the RP and RB prevalence trends in the Philippines from 1993 to 2013.

A total of 7091 women aged 15–24 who experienced at least one pregnancy were captured in the Philippine demographic health surveys from 1993 to 2013. Annual RP and RB prevalence per age group in three and five categories were calculated and stratified by region, type of residence and wealth index. Cochran–Armitage tests and multivariate logistic regression were applied to determine trend estimates.

Compared to women aged 19–21 years and 22–24 years, for which decreasing patterns were found, RP ([Adjusted Odds ratio (AOR =0.96; 95%Confidence interval (CI) =0.82–1.11) and RB (AOR = 0.90; CI = 0.73–1.10) trends among 15–18 year olds showed negligible reduction over the 20 years. From a baseline prevalence of 20.39% in 1993, the prevalence of RP among adolescents had only reduced to 18.06% by 2013. Moreover, the prevalence of RB showed a negligible decline from 8.49% in 1993 to 7.80% in 2013. Although RP and RB prevalence were generally found more elevated in poorer communities, no differences in trends were noted across wealth quintiles.

For two decades, the Philippines has shown a constant and considerably high RP prevalence. Further investigation, not only in the Philippines but also in other developing countries, is necessary to enable development of secondary prevention programs.

Plain English summary

Despite high and stable levels of adolescent fertility in the Philippines, no specific research has been conducted to specifically measure the trend and magnitude of repeated adolescent pregnancy, which is defined as an adolescent who has had at least two pregnancies. Repeated pregnancy, therefore needs to be investigated as it reflects not only the reproductive health of adolescent mothers but also disparities in service delivery of health, education and welfare support to adolescents after their first pregnancy.

We used the Philippine Demographic and Health Surveys to sample 7091 women aged 15–24 who experienced at least one pregnancy. Annual RP and RB prevalence per age group in three and five categories were calculated and stratified by region, type of residence and wealth quintile. Trends were statistically analysed using Cochran–Armitage tests and multivariate logistic regression.

While a decline was observed in 19–21 and 22–24 year olds, we found a constant prevalence of one in every five in 15–18 years old from 1993 to 2013. This trend was evident across all regions, types of residence and socio-economic status. Our analysis also found that those from the poorest wealth quintile demonstrated a heightened risk of repeated pregnancy compared to other quintiles. The non-decreasing prevalence trend of repeated pregnancy among adolescents indicated the need for secondary prevention programs particularly for the poorest households. Epidemiological investigations are also necessary to explore the causes and impact of repeated pregnancy on maternal, child and neonatal health, not only in the Philippines, but also among other low- and middle-income countries.

Introduction

The adolescent pregnancy epidemic in the Philippines has been acknowledged as one of the worst in the Western Pacific Region [ 1 ] with a recent prevalence of 13.6% among 15–19 year olds. The Philippines is the only country in this region with no significant decline in adolescent fertility in the past decades [ 2 ] from 56 per 1000 in 1973 to 57 per 1000 in 2013 [ 2 , 3 ]. In order to address this entrenched public health issue, preventive policies and programs have been implemented [ 4 , 5 ], and epidemiological studies have been developed to provide evidence of the current sexual health and behaviour of Filipino adolescents [ 6 ]. However, these measures have put little emphasis on the more serious problem of repeated adolescent pregnancies.

Repeated adolescent pregnancy, which is defined as a subsequent pregnancy among adolescents aged 10–19 years [ 7 ] is known to affect around 18% of adolescent mothers in the USA [ 7 ], Europe [ 8 ], and Australia [ 9 ]. Despite the evident chance of repeated adolescent pregnancy especially within 2 years postpartum [ 10 ], current research is unable to clearly establish its magnitude in developing countries such as the Philippines, nor how the trends have changed across time [ 11 – 13 ]. Although a World Health Organization (WHO) multi-country report [ 14 ] discussed the relationship between age and parity among Filipino adolescents, this study did not assess the prevalence of multi parity as its primary measure.

As a marker for adolescent reproductive health, repeated pregnancy reflects health disparities particularly among the disadvantaged adolescent population. Repeated pregnancy also indicates poor distribution and unequal access to reproductive health services [ 15 ] and inadequate service capacity of individual localities. It relates to low educational attainment, limited employment opportunities and poverty among adolescent mothers [ 15 , 16 ]. It has been shown that repeated adolescent pregnancy leads to an increase in national health and welfare expenditure as a consequence of the long-term dependency of adolescents and their families on government assistance [ 15 , 17 ].

An increasing trend of adolescent sexual activity [ 3 ] ongoing poor compliance with modern contraceptives [ 2 , 18 ] and inadequate use of family planning services all suggest that repeated adolescent pregnancy is highly prevalent in the Philippines [ 12 ]. Analysis of existing nationally representative data can be helpful in evaluating the extent of this public health problem. In this study, we aim to determine the prevalence of repeated pregnancies and births among adolescents and young adults from a series of national surveys conducted between 1993 and 2013. Moreover, we intend to analyze the trend of repeated pregnancies and births by age groupings and potential macro-level confounders across two decades, with resulting trends perhaps reflecting the effectiveness of existing policies and programs in addressing this under-recognized adolescent health problem.

Population and sample

This study used the Philippine Demographic and Health Survey (DHS) from 1993, 1998, 2003, 2008, and 2013 which are cross-sectional surveys conducted every 5 years. This nationally representative survey involved a multi-stage sampling design up to the household level with enumeration areas distributed by region and type of residence using the most recent national census as its sampling frame. All women in the selected households which includes adolescents aged 15–19 years and young adults aged 20–24 years were interviewed using the Individual Woman’s Questionnaire. This survey therefore excludes adolescents aged below 15 years. As shown in Appendix , the majority of the survey sample belonged to these age brackets which we will refer to as adolescents for the succeeding parts of this paper.

Outcome and socio-geographic measures

Repeated adolescent pregnancy/birth.

An adolescent aged 15–19 years was considered as having experienced repeated pregnancy (RP) if she had experienced at least two pregnancies, including current pregnancies, which either resulted in a live birth and/or pregnancy loss. A case of repeated birth (RB) was defined as an adolescent with at least two live births. These definitions were adapted from related review papers [ 8 ] and the Centers for Disease Control and Prevention [ 7 ].

Survey year was considered as a continuous variable in the analysis to measure the trend because of equal intervals between survey years. Thus, each unit increase in year variable translates to an actual five-year increase.

Respondents were categorized by age into three and five groups. The three age groups include “15–18” which considers the legal age of consent (18) in the Philippines, “19–21” as the transition period, and “22–24” as young adults [ 19 ]. In sensitivity analysis we further subdivided age into five groups (i.e. “15–16”, “17–18”, “19–20”, “21–22”, and “22–24”) to analyze in detail the trends per age.

Socio-geographic variables

Region refers to the three main island groups: Luzon, Visayas, and Mindanao. We disaggregated and compared all estimates by region since each island group has unique geographical and cultural characteristics. Further disaggregation per administrative region was not pursued, as the number of administrative regions had increased during the 1998. Type of residence was either rural or urban area where the respondent resided at the time of the survey. Based on their household’s wealth score, adolescents were grouped into the household wealth quintiles “richest”, “richer”, “middle”, “poorer”, and “poorest” class.

We calculated the mean, standard deviation and prevalence rate of RP and RB per year per age group. RP prevalence was calculated by dividing the number of adolescents with RP and the number of adolescents who experienced at least one pregnancy (including those currently pregnant) multiplied by 100. RB prevalence on the other hand was calculated by dividing the number of adolescents with RB and the number of adolescents who experienced at least one livebirth multiplied by 100. Deformalized survey weights were applied while calculating the prevalence.

We used the ptrendi package in Stata13 to perform Cochran–Armitage tests to determine the prevalence trend per age group using the chi-square statistic and meeting the assumptions of an additive model. Cochran–Armitage test is a modified Pearson’s chi-square test which assesses the association between binary (i.e. RP and RB) and ordinal (i.e. year and age) categories. Multivariate logistic regression analysis with interaction effects for age (i.e. age groups using both three and five categories) and year was conducted while using repeated pregnancy and birth as binary outcome variables (i.e. yes or no). We measured the trend between two consecutive survey years to identify which periods had significant changes in prevalence. In addition, we analyzed trends using year and socio-geographic (i.e. region, type of residence, and wealth index) interaction per age group. For the purpose of this analysis, we used the three category age group as this was the only categorization which allowed a sufficient number of cases.

Among women aged 15–24 years with at least one pregnancy ( n  = 7091), a large proportion (53.3%) were found among the 22–24 year olds. Despite the small proportion of adolescents captured by the surveys, the proportion of 15–18 year olds reported in the survey has increased over time from 7.64% ( n  = 107) in 1993 to 15.55% ( n  = 213) in 2013 ( see Table  1 ).

Characteristics of the respondents

Abbreviations: n -Number of respondents

a Birth pertains to livebirth; b Adolescents with at least 1 pregnancy

Data captured in bold are highly significant

Trend analysis per age group

Cochran–Armitage tests showed an overall decrease in the trend of RP (Chi2 = 127.60; p  < 0.001) across 20 years among the 15–24 years old from a weighted RP prevalence (WtPrev RP ) of 58.12% in 1993 to 40.58% in 2013. There was also a general RB (Chi2 = 100.90; p  < 0.001) reduction from weighted RB prevalence (WtPrev RB ) of 51.25% to 35.66%. However, within age groupings this decline was not observed among 15–18 years olds. In Fig.  1 , we only found a slight decrease in RP prevalence from 20.39% in 1993 to 18.06% in 2013. RB prevalence also presented a minimal change with 0.69 decline among 15–18 and 0.80 decline among 17–18 years olds in this 20-year period ( see Fig.  2 ). Further observations among 17–18 years olds showed a similar RP trend from 22.26 to 18.52%.

Prevalence trends of adolescents with repeated pregnancy in the Philippines from 1993 to 2013 by age group. Caption: This figure presents the weighted prevalence of repeated pregnancy using age groups with ( a ) three and ( b ) five categories. Groups using the three categories include 15–18 years old, 19–21 years old and 22–24 years old while the five categories including 15–16 years old, 17–18 years old, 19–20 years old, 21–22 years old and 23–24 years old, as represented by each line on the graphs. The x-axis is the survey year arranged in chronological order while the y-axis the weighted prevalence

Prevalence trends of adolescents with repeated birth in the Philippines from 1993 to 2013 by age group. Caption: This figure presents the weighted prevalence of repeated birth using age groups with ( a ) three and ( b ) five categories. Groups using the three categories include 15–18 years old, 19–21 years old and 22–24 years old while the five categories including 15–16 years old, 17–18 years old, 19–20 years old, 21–22 years old and 23–24 years old, as represented by each line on the graphs. The x-axis is the survey year arranged in chronological order while the y-axis the weighted prevalence

Similar results were found in the regression analysis. The RP trend among 15–18 year olds remained virtually unchanged across all surveys from 1993 to 2013 [Odds ratio (OR) =0.93; 95% Confidence interval (CI) =0.81–1.07]. There was a similar pattern of RB trend in this age group (OR = 0.87; CI = 0.72–1.06) following an apparent increase in prevalence from 1993 to 1998 (OR = 3.29; CI = 1.25–8.62). On the other hand, the older age groups showed a significant decline both for RP and RB with unadjusted ORs ranging from 0.83 to 0.87 ( see Table  2 ). Analyses using five age categories showed no significant difference in the trends previously described. Trends among 15–16 and 17–18 year old adolescents remained unchanged, whereas a decreasing trend was apparent for those aged 19–20, 21–22 and 23–24.

Trend analysis of repeated pregnancy and birth adolescents from 1993 to 2013 per age group

Abbreviations: OR-Odds ratio; CI-95% Confidence Interval

a Significant during Cochran test at 0.001 level; b Adjusted for region, type of residence and wealth quintile

Adjustments for regions, types of residence and wealth quintile suggested that the trends were not confounded by these factors across all age groups. Interestingly, wealth index was strongly associated with RP and RB as adolescents from the poorest quintile had shown higher odds in reference to richest quintile (OR RP  = 5.41, CI = 4.31–6.78; OR RB  = 5.36, CI = 4.17–6.89). Calculation of weighted prevalence confirmed this association with a WtPrev RP of 59.60% and WtPrev RB of 52.50%.

Change of prevalence between two consecutive survey years was also analyzed using the three age categories. We found that there was a decrease in RP prevalence among 15–18 from 1998 to 2003 (OR = 0.52; CI = 0.28–0.99), and among 22–24 from 1993 to 1998 (OR = 0.77; CI = 0.61–0.97) and 2003–2008 (OR = 0.71; CI = 0.58–0.88). A drop in RB prevalence was also found among 15–18 from 1998 to 2003 (OR = 0.32; OR = 0.13–0.81); and among 22–24 from 1993 to 1998 (OR = 0.74; CI = 0.58–0.93).

Trend per socio-geographic variable per age group

The constant RP trend among 15–18 and the decreasing RP trend among 22–24 were found in all regions, types of residence and wealth quintiles ( see Table  3 ) . On the other hand, the decline of RP decline among 19–21 was only consistent across regions and types of residence. Only the poorer households showed a 20-year reduction when compared to the other four quintiles.

Trend analysis of repeated pregnancy and birth among adolescents per socio-geographic variable in each age group

Abbreviations: OR-Odds ratio; CI-95% Confidence Interval; p- p value; F-F statistic; NC-No cases; NA-Not applicable; OR-Odds ratio

A similar pattern was observed for RB trend among those aged between 15 and 18 and 22–24. Unlike RP, the trend for RB among 19–21 year olds was inconsistent across the three socio-geographic variables. The decreasing trend was only found in Visayas and Mindanao region, rural communities, and poor wealth quintiles (see Fig.  3 ) .

Prevalence trend of repeated pregnancies and births among adolescents per socio-geographic variable in each age group. Caption: This figure presents the trend of the weighted prevalence of repeated pregnancies and births in each of the socio-graphic variable using the three age categories: 15–18 years old, 19–21 years old and 22–24 years old. The left column presents the weighted prevalence of repeated pregnancy while the right column presents repeated birth. In each graph, the x-axis is the survey year arranged in chronological order while the y-axis the weighted prevalence. The color of each line represents a category of each socio-geographic variable as shown at the bottom of the graph

In each age group, we also conducted adjusted Wald tests to measure the difference of trend estimates between the categories of each socio-geographic variable. No differences were observed for 15–18. For 19–21, differences were only found between the RP trend estimates of poorest and poorer quintiles, and between the RB trend estimates rural and urban communities. For 22–24, differences between the trend estimates of poorest and richest, and between poorer and richest were found both for RP and RB.

Discussions

Despite the declining trends of RP and RB in older age groups, the prevalence among adolescents younger than 18 years showed no decrease across 20 years of data, remaining stable across all regions, types of residence, and wealth quintiles. The prevalence was high with approximately one in every five adolescents aged 15–18 years with a history of pregnancy experiencing RP while one in every ten of those who had a livebirth experienced RB.

While the decreasing RP and RB trend among young adults can likely be attributed to their improved contraceptive use [ 20 ] and awareness of and participation in family planning (FP) strategies [ 3 , 21 ]. The unchanged trend among adolescents may result from the unique socio-cultural characteristics and FP policies in the Philippines, wherein adolescents are prevented from accessing FP services, even after their first pregnancy. One of the possible explanations for this finding is that the strong influence of the Catholic church at the local level may have affected the health seeking behavior and the implementation of reproductive health programs among adolescents [ 22 , 23 ].

Unclear and restricted health and health-related policies for adolescent mothers may also play a role. The initial adolescent health policy in the Philippines [ 24 ], which aimed to reduce unwanted pregnancies and provide adolescent-friendly health services, did not include strategies for dealing with the prevention of secondary pregnancies [ 25 , 26 ]. This may have led to adolescents being discouraged to access essential health information and use birth control methods [ 23 , 27 ].

Despite emphasizing the importance of health promotion and behavioral change, a recently introduced national law (Responsible Parenthood and Reproductive Health Act of 2012 or RH Law) and framework [ 4 ], did not embrace specific programmatic actions to address RP. The RH Law still prevents minors (i.e. below 18 years old) from accessing modern methods of contraception without parental consent and does not exempt adolescent mothers and adolescents who experienced miscarriage [ 28 ]. This policy restriction has already been found as a deterrent for adolescents to access contraceptives and counselling services in a review of evidence from 16 developing countries [ 29 ]. This study suggests that despite the availability of contraception, most of these developing countries retain barriers and restrictions towards the use of birth control methods, particularly among unmarried adolescents. In the context of this social and political environment, the RP/RB trends showed in this paper can be expected to continue for several years to come not only in the Philippines but also in other developing countries.

The role and reach of secondary prevention programs must be clarified due to the limited access to appropriate postnatal services (e.g. contraception, counselling, and educational support) for adolescent mothers. Health workers may also need to be trained to address the unique psychosocial characteristics and support the challenging developmental transition of very young mothers by enhancing adolescents’ readiness and decision-making abilities to delay another pregnancy and/or use modern family planning methods. Given the high rate of unmet need for modern contraception among married adolescents [ 21 ], policy initiatives/reforms such as providing exemption on contraception to adolescent mothers may be needed to achieve a reduction in the trend seen in this paper.

Our findings also suggest that prevention programs aimed at those from the poorest quintile may be warranted due to the high RP/RB prevalence among this group. In the Philippines and other low- and middle-income countries (LMICs), attempts to reach out to households from the poorest sector have been undertaken through the Conditional Cash Transfer (CCT) Program [ 30 , 31 ]. For example, the CCT program in Mexico has been found to indirectly reduce adolescent pregnancy and increase contraceptive use among adolescents and young adults [ 31 ]. The potential of cash incentive schemes can also be used as an opportunity to monitor and provide prevention programs to adolescent mothers, particularly within 24 months after their first pregnancy [ 10 ].

Our study uniquely explores the status of repeated pregnancy and birth in LMICs in the Asia-pacific Region. Most published reports on this topic are primarily from the USA, Europe, and Australia [ 32 ]. Of the few reports identified from LMICs, many used birth order (i.e. 2nd order or higher) and a different denominator (i.e. total number of adolescents) in the computation of prevalence. Despite the availability of possible data sources among LMICs [ 33 ], few studies have attempted to look specifically at the distribution of adolescents and young adults with RP/RB. Most of the reports available may include vital statistics which is limited to those only with livebirths and does not necessarily account for previous unsuccessful pregnancies.

By placing RP as an issue of crucial importance to the public health especially of LMICs, our paper makes a significant contribution to the literature calling for improvement of sexual and reproductive health of adolescents. The Global Strategy for Adolescent Health for 2030 recognized childbirth and pregnancy complications as one of the two leading causes of death among 15–19 year old girls [ 34 ]—addressing RP would help to reduce this. The absence of a reduction in RP trend over 20 years that we identified, signals the need for secondary prevention programs in line with WHO recommendations [ 35 ].

This study finds strength in our use of nationally-representative individual datasets instead of aggregate estimates. This prevents the risk of producing results affected by the ecological fallacy, particularly in the analysis of year-age interaction. Furthermore, we were able to perform more thorough analyses such as the adjustment of trend estimates for confounders (i.e. wealth quintile, region, and type of residence).

Limitations

Our study also has limitations. Recall bias and under-reporting are likely to produce bias in any surveys covering information of a sensitive nature. Insufficient record validation is common across the DHS surveys from all countries. However, the DHS’ survey procedure enables cross-checking through repeated questions during the interview to reduce the effect of this validation issue. Additionally, our findings may not be comparable to longitudinal studies from developed countries that defined RP as an adolescent who became pregnant within 12–24 months of her first pregnancy/ delivery.

Future research

In addition to cross-sectional analyses that measure RP prevalence, epidemiological investigations are needed to explore the causes and outcomes of RP. Studies conducted in LMICs may identify different associations and dynamics due to the psychosocial and cultural characteristics of and attitudes towards adolescent mothers in these countries. This type of study not only directs the development of specialized perinatal care, and psychosocial and welfare support but also places priority on those adolescents with RP.

A multi-country analysis would also be beneficial in obtaining a broader RP status especially in countries with similar characteristics. This would help international organizations to implement immediate action for RP in a global approach and prioritize countries with a high RP burden. Additionally, projection of RP prevalence at least until 2030 using country-level determinants such as contraceptive prevalence, poverty, literacy, and maternal-child mortality rates, may facilitate target setting for this potential adolescent reproductive health indicator.

There is a constant trend of one in every five adolescent mothers in the Philippines experiencing repeated pregnancy from 1993 to 2013 (across all regions, type of residence, and socio-economic status). These findings indicate the need for secondary prevention programs, particularly among the poorest households. Epidemiological investigations are also necessary to explore the causes and impacts of repeated pregnancy on maternal, child, and neonatal health in the Philippines and other low- and middle-income countries.

Acknowledgements

We also acknowledge the Demographic and Health Surveys Program for allowing us to access the all Philippine DHS datasets. This study was presented at the 15th World Congress on Public Health, Australia, April 3–7, 2017.

This study was supported by the University of Queensland International Scholarship.

Availability of data and materials

Abbreviations.

Characteristics of National Demographic and Health Survey (NDHS) Philippines from 1993 to 2013

Authors’ contributions

JM conceptualized the study design, prepared the datasets, conducted the analysis, and drafted and revised the manuscript. KB conceptualized the study design, conducted the analysis, and revised the manuscript. RA conceptualized the study design, supervised the data analysis, and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Ethics approval and consent to participate

This study underwent an expedited review and was approved by the University of Queensland – School of Public Health Ethics Committee on April 11 2016.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests. The authors have no financial relationships relevant to this article to disclose.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Joemer C. Maravilla, Email: [email protected] .

Kim S. Betts, Email: [email protected] .

Rosa Alati, Email: [email protected] .

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