Persisting teen age births , a global challenge

Introduction: Teen age births, though have reduced, are still common, with a lot of impact on mothers’, babies’, families’, communities’, nations’ health, world at large. Impact can echo throughout girl’s life, carry over to next generations. It has been revealed that globally unmarried adolescents have less access to family planning than general population and sex during adolescence is common with lack of awareness of sequlae in girls, specially in South East Asia. Objectives: To know about teen age births, effects, global challenges in prevention of teen age births, their sequlae. Methodology: Simple review about various studies, health providers views was done by different search engines like Uptodate, Pubmed, Ermed Consortium, Cochrane Library, Delnet, MedIND and self experiences were added. Results: Racial/ethnic geographic disparities in teen births persist, both within, across Countries, States, Districts, Communities, some with low rates and others with high. United States of America (USA) reported much higher teen age births compared to other developed countries though declined after 1991 dramatically between 2007 and 2016 as per published research using National Survey of Family Growth (NSFG) and Youth Risk Behaviour Survey in USA. Change was influenced primarily by increase in contraceptive use, to lesser degree declines in sexual activity. It was also revealed that in all countries, unmarried adolescents appeared to have less access to family planning than general population of. USA Teenage pregnancy has been reported to be associated with number of adverse health outcomes for mother, baby as well as social economic disadvantages for individuals, their future families even next generations. Existing literature suggested that the persistence of teen age births and many other aspects of girls lives reflected range of cultural, socio-economic factors. Conclusion: There is need of Improving adolescents awareness about sexuality, reproduction, sequlae. Access to contraceptives as per need, including emergency conception are essential. Public youth policies must consider the differences in stories of adolescents. Policies programs’ must go around their lives.


Introduction
Globally many programs have been advocated, specially designed for diverse populations and settings for prevention of teen age births. Still teen-age births continue to be common. The reasons are many, some simple and others complex. The problem is global, be it developing or developed countries. Research in many nations measuring the socio-economic consequences of teen age births, revealed that magnitude was more complicated than it might have appeared and was likely to differ across time periods in different countries. Policies and Countries cultural contexts seemed to surely matter and varied over the times and space [1]. Gaps seem wide and need research, some greater and some smaller.

Objectives
To know about teen age births, effects and global challenges in prevention of teen age births and their sequlae.

Methodology
Simple review of various studies was done by various search engines like Uptodate, Pubmed, Ermed Consortium, Cochrane Library, Delnet, MedIND. Health providers views were also looked into. Self experiences were added. There were no inclusion or exclusion criteria of studies reviewed. Whatever literature could be accessed was looked into.

Frequency and Causes
Existing literature suggested that persistence of adolescent fertility reflected a range of cultural and socio-economic factors. Researchers reported that less favorable socioeconomic conditions, low education and low income of the teens family, seemed to contribute to high teen age births [2]. Our experience says that teen age births are not uncommon in high income families and in girls with higher education too. The problem is global. In a study teens in Child Welfare Centers were at higher risk of pregnancy and birth than other groups [3]. Racial/ethnic and geographic disparities in teen age birth rates have also persisted [4], Bierut [5], estimated that teenage pregnancy rate in US was as much as nine times higher than in other developed countries. In 2011, in the United States of America [U.S.A.], there were 31.3 births per 1,000 adolescent girls [6]. Lindberg [7] reported that birth rates among adolescents declined dramatically between 2007 and 2016 in the U.S.A. Studies also revealed the important contribution of contraceptive use in declining adolescent fertility in U.S.A. between 1991 to 2016. The teen age birth rates in the USA dropped by 9 percent compared to the previous years. Experts believed the record low births for teens will continue to have a long-term trend. Published research using the US National Survey of Family Growth (NSFG) and the youth risk behavior survey found that declines in rates of pregnancy and births after 1991 were influenced primarily by increase in contraceptive use. But to some there was some decline in sexual activity too. Researchers found considerable increase in condom use and declines in contraceptive nonuse between the 1990s and 2000s [8]. In their recent study of NSFG data, researchers documented increase in use of hormonal methods among adolescent girls, but no change in sexual activity between 2007-2012 [7]. So sexual activity and contraceptive use among adolescents continue to be the focus of policy debates for understanding their relative roles in declines and no decline in rates of pregnancies and births among adolescents. This can provide information about policies, contraceptive advocacy, increase in use of any method or dual methods. In a study long-Acting Reversible Contraception (LARC) and withdrawal, were the primary proximal determinant of declines in adolescent pregnancy and birth rates in the USA between 2007 to 2014 compared with their previous study examining change in pregnancy risk between 2007-2012 and the study identified the same in other studies too [9]. In a study about assessment of family planning services availability and readiness in 10 African countries, it was revealed that in all the countries, unmarried adolescents appeared Page: 40 www.raftpubs.com to have less access to family planning than the general population [10]. Geographic differences in teen births persisted, both within and across States with low as well as high teen age birth rates. Around 15% of all births in Latin America and the Caribbean (LAC) were in adolescent girls with an adolescent fertility rate of 65 per 1000 in 2014 [11]. Still the U.S. teen pregnancy rate was substantially higher than in other industrialized nations. Basch [12] reported that the drop-in teen-age births was due to increase in access to sex education, delay in initial sexual intercourse, and increase in contraceptive use. However, researchers also reported that the girls born to teen mothers were 66% more likely to become teen mothers. Ditsela and Dyk [13] did an exploratory study on the risk and protective factors associated with adolescent pregnancy and found a correlation between the parenting style in the girl's home and teenage pregnancy. The findings suggested that adolescent pregnancy was more common is girls who grew up with authoritarian or permissive parents. In contrast, adolescents who perceived their parents to be more responsive, communicative and who allowed them go with their works were less likely to get pregnant as teenagers. Some parents resisted talking with their teenagers about strategies to prevent pregnancies [14]. Research has also shown that when nonpregnant and pregnant teenagers were compared those who were pregnant tended to have an external locus of control which was defined as "the continuum between internal and external ownership of one's power and actions". These findings suggested that high self-esteem and internal locus of control, the belief that their actions determined their life events, could act as protective factors [15]. When reasons were looked into, it was revealed that many factors contributed to a teen's risk of becoming pregnant. Family history and home life seemed to have impact on teenage girls. Media also affected. In a study teenage girls who watched the MTV shows often were shown to have an increased probability of engaging in sex, however frequent viewing was associated with a decreased probability of having engaged in recent sex for girls and also those girls whose fathers often communicated about sex with them while growing up [16]. Rodriguez-Vignol [17], reported that lower rates of adolescent pregnancies in some countries with high rates of adolescent sexuality were driven by increased access to contraception and abortion. Socio-economic inequalities in access remained problematic [18]. There are many other reasons like having sex without knowledge of consequences getting exploited by peers, friends, employers, relatives.

Effects
Teenage pregnancy has been reported to be associated with a number of adverse health outcomes for the mother, baby as well as social and economic disadvantages for individuals and families communities and world as a whole. The impacts of teenage pregnancy are many, affecting the health of the mother, baby, family, community and nation at large. It can echo throughout a girl's entire life and carry over to the next generation too. Teen age births affect adolescents physical and mental health, education as well as economic status. Many of these young mothers faced challenges that affected their lives as well as lives of their children, including being single parents, not earning their school diplomas and living in poverty [12,15]. Cavazos-Rehg, et al [19], found that 16% of the girls in their study, who were sexually active would be pleased, 11% a little pleased, 5% very pleased if they became pregnant. Research showed that being a teen parent could be stressful due to education disruption, being unprepared for parenthood, disruption in their life plans, and sudden monetary burden, realization that the teen will have a lifelong connection with the other parent or ending the relationship with the other parent [20]. Researchers have also suggested that it may be helpful for mental health practitioners to ask the teenage mother if the pregnancy was wanted and intended, since this information could be a predictor of favorable adjustment to parenting and not a harbinger of future difficulties, encouraging parents to develop a Page: 41 www.raftpubs.com Pregnancy and birth were significant contributors to high school dropout rates among girls. Only about 50% of teen mothers received a high school diploma by 22 years of age, whereas 90% of women who did not give birth during adolescence graduated [21]. The children of teenage mothers were more likely to have lower school achievements and more dropouts of high school. They had more health problems and faced unemployment as young adults. In 2010, teen pregnancies and births accounted for at least 9.4 billion$ costs to U.S. tax payers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers. These effects continued for the teen mothers and their children even after adjusting for those factors that increased the teenagers risk for pregnancy, such as growing up in poverty, having parents with low levels of education, growing up in a single-parent family, and having poor performance in school [22]. Nguyen and colleagues [23] analysed data of 60096 primiparous women aged 15-49 years who gave birth between 2010-16 from the fourth National Family Health Survey (NFHS-4) 2015-16. They examined whether first pregnancy in adolescents was associated with higher child undernutrition compared with first pregnancy after adolescence and if so, whether biological, social, and programmatic factors explained this intergenerational risk. The five hypothesised mechanisms, maternal nutritional status, education and power, access to health services, child feeding practices, and living conditions were used with some concerns about the study. Despite the concerns the study provided evidence that teenage pregnancy was associated with higher undernutrition risks and that children born to teenage mothers were 0.25 SD shorter for their age and 5 percentage points more likely to be stunted compared with those born to adult mothers. Although the study provided evidence for a vicious cycle of undernutrition, issues related to unequal gender norms and girls' lack of ability in making choices regarding marriage, family planning, or general health cannot be ignored. The effects also included social isolation, low academic achievement, nutritional depletion, low income-earning potential, and lifelong poverty. East etal [20]. also studied the consequences of adolescents' pregnancy wontedness, and regrets for their and their children's well-being. In their study 76% of adolescents reported that they wanted their pregnancy "very much" while pregnant, and this decreased to 26% at one year postpartum. In another study only 5% of teens responded that they did not want pregnancy while pregnant. However, this increased to 33% at 1 year [7,24].
Analysis by some researchers revealed teen age births effects were quite consistently negative, although less than in previous research, precisely as an omitted variable analysis would suggest. The average difference in economic well-being between a teen mother and her (nonteen mother) sister was about one-third, whereas in earlier studies, the impact was typically between 40 and 50% [22]. Too often, teens do not seek adequate medical care during pregnancy, which can result in various complications, some fatal too. Owing to denial and fear of rejection by family, pregnant teenage mothers tended to skip antenatal care and many do not register pregnancy at all. The more common complications that may occur during teen pregnancy include anaemia, hypertensive disorders, a term/ preterm prelabour rupture of membrane, preterm births. Teen pregnancy may impact the baby's growth and development over time with low birth weight being more common. Experts site delays in intellectual and motor development, and more ongoing medical and behavioural issues in babies born to teen age mothers. Ongoing medical care is crucial to prevent complications during pregnancy birth and the mother's wellbeing in future [25]. Most of the adolescent mothers are characterized as having poor family structure, lack of social support and elevated rates of stress which all raise the risk of postpartum depression. However, mental health Page: 42 www.raftpubs.com counsellors, as well as other school and community resources could help [22]. Ghulam et al [26]. also reported that married adolescent girls were less likely to use contraceptives, and have poor birth spacing, increased risks for low birthweight offsprings, with long term effects on morbidity and mortality. Dehl [27] reported that there was high suicide rate among young women, particularly married girls in India. Teen mothers may be doing poorly, but the teen birth is far from the sole cause. The impacts may have become more negative, a result that is consistent with a trend towards a less general safety net and a less hospitable labour market for less-skilled and less-educated girls. The results are more fragile than is widely understood. Teen age pregnancy and childbearing bring substantial social and economic costs through immediate and longterm impacts on teen parents and their children. The associated loss of productivity and negative impacts on development at the national level are known [28]. In the study by Nguyen et al [23], of 60.096 women in the sample, 14 107 (25%) first gave birth during adolescence. Children born to such mothers had lower scores for height and weight than children born to adult mothers. Compared with adult mothers, adolescent mothers were shorter, more likely to be underweight and anaemic, less likely to have access to health services, and had poorer complementary feeding practices. Adolescent mothers also had less education, less bargaining power and lived in poorer household with poorer sanitation. In the path analysis, these intermediate factors predicted child anthropometry, with the strongest links with mother's education (18%), socioeconomic status (13%), and weight (15%).

Discussion
Although reasons for some declines in teen age births are not totally clear, evidence suggested more teens were abstaining from sex and more teens who were sexually active were using birth control methods than in previous years and these were the major reasons which affected teen age births. A variety of diverse programs, including sexuality education programs, youth development programs, abstinence education programs and clinic-based programs go on globally. In addition to evidence-based prevention programs, teens needed access to youth-friendly contraceptives, reproductive health services and support from parents and other trusted adults, who could play an important role in helping teens make healthy choices about relationships, sex, and birth control. Efforts at the community level that addressed social and economic factors associated with teen pregnancy also played critical role in addressing racial/ethnic and geographical disparities observed in teen births in the US. Bausch [11] listed six factors schools needed to consider in their programs and policies for teens and families, State-of-the-art, evidence-based sex education that gave students' knowledge, attitude, skills, and motivation to avoid pregnancy, Youth development activities that build on students assets and enhanced their self identities , future aspirations and enhancement of school connectedness, link students to reproductive health services, either clinics or in community, also to mental health and social services which provided parents education .Theses activities help them have skills to share their values with their children and teach them to avoid pregnancy. Cavazos-Rehg etal [19]. suggested educating students, prior to pregnancy about the potential loss of educational and financial opportunities will do better for them. If an adolescent became pregnant, lack of social support seemed to be a preventive factor for depression as well as contributor to whether or not the mother continued her education. Temin [28] have led policy-makers to identify teen age births as an important area for intervention. to ensure the ambition of the Sustainable Development Goals to leave no-one behind is achieved. In particular, greater focus on younger adolescents is important, as they faced greater health disadvantages for both mother and infant [29][30][31]. and may require specific approaches and strategies to address pregnancies [31]. Reducing adolescent pregnancies will also potentially contribute more widely to the SDGs through reducing the cycle of deprivation, as well as positively Page: 43 www.raftpubs.com impacting on the goals focussing on poverty, hunger, quality education, gender equality and decent work and economic growth [33][34][35][36][37]. Education is seen as a key component of multisectoral approaches to reducing adolescent births. Attempts to increase school enrolment through conditional cash transfers have had some success in Colombia and Peru. Both have improved school enrolment and there was some indication of reduced adolescent pregnancy [38]. Adolescents needed sexuality education that provided information and skills to protect them and avoid adverse health and social outcomes. Family life education to young girls is likely to change the scenario. The social and cultural aspects of adolescent pregnancy underlined the importance of a holistic approach to sexuality education that addressed social and cultural norms including gender inequality and relationship dynamics [39]. A study within the five countries was done with wide variations in approaches to adolescent sexuality education. While Colombia has adopted many of the principles of comprehensive sexuality education (CSE), Peru and the Dominican Republic continue to focus on a much narrower curriculum [40]. Adolescents needed to be able to obtain contraceptive information and services, including emergency contraception. The present article based on review focuses on the fact that public youth policies must consider the differences in the life stories of adolescent girls, help and guide them in prevention of pregnancy and its squeal. Present review had no criteria for including studies, reviews, opinion and may be called limitations by some but for study this was inclusive work.