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Factors associated with teenage pregnancy in South Asia: a

systematic review
Acharya Dev Raj1, Bhattarai Rabi2, Poobalan Amudha3, van Teijlingen Edwin R4, Chapman
Glyn5

1. MSc, MA, Project Assistant, Epidemiology Group, School of Medicine and Dentistry, Section of
Population Health, University of Aberdeen, Scotland, UK.
2. MSc, Institute of Applied Health Sciences, Department of Public Health, School of Medicine
and Dentistry, University of Aberdeen, Scotland, UK.
3. MBBS, Teaching Fellow, Section of Population Health, School of Medicine and Dentistry,
University of Aberdeen, Scotland, UK.
4. PhD, MEd, MA (Hons) Professor, Maternal & Perinatal Health Research, School of Health &
Social Care, Bournemouth University, England, UK.
5. MGenMed, MPH, Clinical Tutor & Honorary Public Health Lecturer, College of Life Sciences
and Medicine, Suttie Centre for Teaching and Learning, University of Aberdeen, Scotland,
UK.

Abstract

Background: South Asia has a large proportion of young people in the world and teenage
pregnancy has emerged as one of the major public health problem among them. The objective
of this study is to systematically review to identify the risk factors associated with teenage
pregnancy in South Asian countries.
Methods: We systematically searched MEDLINE, EMBASE and CINAHL database (1996 to April
2007) and web-based information. Inclusion criteria were the English-language papers available
in the UK and describing teenage pregnancy in South Asia.
Results: Out of the seven countries in South Asia, most of the studies were related to Nepal,
Bangladesh, India and Sri Lanka. Socio-economic factors, low educational attainment, cultural
and family structure were all consistently identified as risk factors for teenage pregnancy.
Majority of teenage girls are reported with basic knowledge on sexual health however, very few
of them have used the knowledge into practice. Both social and medical consequences of
teenage pregnancies are reported consistently along the most of the studies. Utilization of
health services, which is a protective factor, remains low and consistent. However, teenagers
agreed to delay the indexed pregnancy if they would know its consequences.
Conclusions: In South Asia, many risk factors are a part of socio-economic and cultural
influences. This systematic review is limited by the amount and the quality of papers published
on factors associated with teenage pregnancy. In particular, future research in South Asian
countries is needed with standardised measures and methodologies to gain an insight into
observed variations in pregnancy rates.

Keywords: Teenage pregnancy, factors, South Asia, young people

Corresponding author:
D. R. Acharya, Epidemiology Group, Section of
Population Health, Institute of Applied Health
Science, Foresterhill, University of Aberdeen,
Aberdeen AB25 2ZD, UK. Tel.: +44 01224 552968;
Fax +44 01224 550925; E-mail:
[email protected], [email protected]

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Introduction

T
eenage pregnancy is a public health the attitudes of teenagers could be different
concern both in developed and from other parts of Asia. The objective of
developing world 1 , 2 , 3 . Globally 15 this systematic review is to identify young
million women under the age of 20 give people’s knowledge, attitude and behaviour,
birth, representing up to one-fifth of all risk factors, utilisation of health services and
births 4 and 529,000 women die due to consequences associated with teenage
pregnancy and child birth related pregnancy in South Asia.
complication every year 5 . The risk of death
due to pregnancy-related causes is double Materials and methods
among women aged 15-19 compared to The methodology of this review draws
women in their twenties 6 . Young women are from methods developed by NHS Centre for
also at risk of unwanted pregnancies, Reviews and Dissemination 22 . Three
sexually transmitted infections (STIs) and electronic bibliographic databases, MEDLINE,
unsatisfactory or coerced early sexual EMBASE, and CINAHL were searched
relationships 7 , 8 . systematically for the period 1996 to April,
In the developing world, one-third to 2007. Mesh terms and key words for young
one-half of women become mothers before people, teenage pregnancy and South Asia
the age of 20 and pregnancy related were combined with the Cochrane
complications have become the leading Collaboration strategy for identifying primary
causes of death among them 9 , 10 . South Asian studies. English-language papers available in
countries (India, Pakistan, Sri Lanka, Nepal, the UK and describing teenage pregnancy in
Maldives, Bhutan and Bangladesh) have high South Asia were retrieved and reviewed. The
proportions of teenage pregnancies, since MEDLINE search strategy was adapted for
early marriage is common and there is a searching other databases. Reference lists of
social expectation to have a child soon after all articles were checked to identify further
marriage 11 , 12 , 13 . A study showed that nearly relevant studies. Due to resource constrains
60% of all girls are married by the age of 18 searching of the grey literature and hand
years and one fourth are married by the age searching was not done.
of 15 years in South Asia 14 . Primary studies of any study design
Within South Asia, the recorded that looked at knowledge, attitudes,
teenage pregnancy rate is highest in consequences, risk factors and behaviour
Bangladesh 35% followed by Nepal 21% and associated with teenage pregnancy in South
India 21% 15 . Teenage pregnancy can have Asia were included. The term ‘factor’ does
significant effect on the level of education of not imply causality but only associations for
women, their employment opportunities and the purpose of this review. All identified
marital stability and it increases their abstracts were checked against the inclusion
economic and social dependency on family and exclusion criteria agreed a priori,
and neighbours 16 . Although teenagers independently by two reviewers. Any studies
represent a large proportion of population in with pregnancy (conception) as an outcome
the developing countries, still relatively measure were included; studies that only
little is known about their sexual knowledge used proxy outcome measures of pregnancy,
and experience and the risk associated with such as reproductive health or childbearing
the teenage pregnancy 17 , 18 , 19 . In recent (parenthood), were excluded. Any queries
years reviews have been conducted on about inclusion were discussed between
teenage pregnancies in developing countries reviewers or referred to a third reviewer if
or in ethnic minorities 20 , 21 but none of them necessary.
have specifically focused on South Asian Full texts of all the potentially
teenagers. This is a gap as there are cultural eligible reviews were obtained and critically
variations and differences and consequently appraised. A data extraction form was
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developed and piloted. One reviewer become pregnant (p<0.001) than Buddhist
extracted data from identified studies and teenagers. Structural and social inequalities,
this was checked by the second reviewer. poverty and gender all made young people
Discrepancies were resolved by consensus or extremely vulnerable to teenage
arbitration. The following data were pregnancy28,32.
recorded: author; year of publication; type The likelihood of teenage pregnancy
of study; location; setting(s); age group; and childbearing seemed to be associated
sample size and methodology. All the with the level of education29. However, very
included studies were assessed for few studies have concentrated on education
methodological quality using assessment and teenage pregnancies. Sharma et al.,27 in
checklist 23 , 24 , 25 , however studies were not 2001 showed that among teenage mothers 13
rated or excluded on the basis of the overall (19%) were significantly less likely to have
quality rating. studied beyond primary school education
compared to among the mothers who were in
Results their twenties 4 (6%). This needs to be
Details of the search and study interpreted with caution as the numbers
selection results are shown on the flow chart reported are very low, however such
in Figure 1. A total of ten studies met all differences were also noted by Shrestha31 in
criteria and have been reviewed and a retrospective study (p<0.005) which had a
included in this paper. bigger sample size. Early age at marriage is
culturally acceptable in South Asian culture,
Overview of studies which seems to add the risk of teenage
Of the ten included articles, three pregnancy27. It is also taken as a licence or
studied the sexual health knowledge, social expectation for a woman to enter into
attitude and behaviour, nine studies looked reproductive life and to become pregnant
at risk factors of teenage pregnancy, three immediately after marriage. With mean age
discussed the utilisation of health services of marriage of 15.9 years in rural Nepal,
and nine studies examined the consequences some girls who married before the onset of
of teenage pregnancy. Of those studies, menarche fell pregnant once they were
three were conducted in Nepal, four in India, fertile31.
two in Sri Lanka and one in Bangladesh. Each Low involvement of teenage girls in
study has included more than one outcome decision making also contributed to early
and varied according to the settings such as; pregnancy. Most adolescent marriages (80%)
location, target group, method of data were arranged by parents without the girl’s
collection and analysis. The studies also consent31. A higher proportion of adolescent
varied according to the methodological pregnant women (67%) were found to be part
quality (Table 1). of an extended family, of which just over
half (51%) claimed that the authority over
Risk factors for teenage pregnancies in South conception remains with their husband27 in
Asia spite of the teenagers’ desire to make their
Socio-economic status, educational own decisions. The study also noted that
attainment, cultural factor and family teenage pregnant women seem to be more
structure were all identified as risk factors likely to have had love marriage (against the
for teenage pregnancies in South wishes of parents/family). Consequently, this
Asia 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 . Using a leads to negligence of family members
retrospective questionnaire, Shrestha31 towards care and guidance in teenage
demonstrated that the incidence of teenage pregnancies. In addition, teenage girls are
pregnancies is significantly higher in the also less likely to visit health service clinics
lower social classes (52%) than in the higher without their husband’s permission34. These
social classes (26%). This study also found family structures and social norms have
that Hindu teenagers are more likely to
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forced teenagers to give birth before they pregnancy26,28,29,30,31,33,34, 35 . Apart from

are emotionally or physically ready32. medical consequences, there are many
adverse social consequences identified
Sexual health knowledge, attitude and within this review. Lower access to higher
behaviour education, high divorce rates, premature
Different studies have reported that death of women, population growth, weak
the most teenage girls are aware of at least and unhealthy children and single
one contraception method and their source motherhood are all negative consequence of
for such information is friends and teenage pregnancy29,31,32,34.
peers27,29,31 However, very few had ever Sharma et al.,33 identified that the
used any of contraception; as a result risk of pregnancy complications was 2.5
considerable numbers of teenage mothers times higher among pregnant teenagers
reported unplanned (47%) and undesired compared to mothers in their twenties. A
(34%) pregnancies31. Possible reason for such significant number of teenage mothers had
outcome according to Goonewardena et al.,29 Vitamin A and iodine deficiency, which
in 2005 is that the majority of teenage girls results in night blindness and formation of
are unaware of the process of conception Goitre33,35. A north India study has also
and dangers of unplanned pregnancy before shown that the prevalence of anaemia is high
the onset of pregnancy. These authors noted 69 (46%) among teenage mothers, which
that teenage mothers would have delayed occurs due to low intake of dietary iron35.
the index pregnancy if they had known its The likelihood of PIH (13%) and pre-
consequences before hand. eclampsia (5%) was significantly higher
(p<0.001 and p=0.03) among pregnant
Utilisation of health services teenagers compared to the women in their
Only three studies looked at the twenties (3% and 1% respectively) in a Sri
utilisation of health services29,30,33. A Lankan study29. Of those studies investigating
significant proportion (p=0.02) of teenagers the link between teenage pregnancy and still
(17-19 years) had a low uptake of antenatal birth, Khandait et al.,28 found an association
care compared to adult mothers29. Socio- 3% (p<0.05) compared to the mothers at 20-
economic deprivation remains significantly 29 age years group (2%). Other two studies
important, reflecting differential access to have also reported similar type of results; 18
health services among teenage mothers29,30. (3%) by Shrestha 31(2002) and 3 (2%) by
A Nepalese study indicated that the Weerasekera30 (1997) in terms of teenage
frequency of antenatal check up among pregnancy and still birth. There seem to be
teenage pregnant women is poor (p<0.02) inconsistent evidence between birth weight
compared to the mothers in their twenties33. and teenage pregnancy. The mean birth
The possible reason given by the latter weight was found higher (2.81kg) among
author for lower uptake of antenatal care teenagers33; the high birth weight could be
facilities by pregnant teenagers is lack of because of the fact that the study sample
physical and mental maturity. size was very small. However, another study
showed that the incidence of low birth
Consequences of teenage pregnancy weight was statistically significant 34%
Most of the studies, nine out of ten, (p<0.0001) among teenage mothers
have examined the relationship between compared to the mothers in their twenties30.
teenage pregnancy and its consequences. Two studies reported higher pre-term
The studies found that pre-term delivery, delivery among teenage mothers compared
still birth, fetal distress, birth asphyxia, to older women. Shrestha 31 reported 3% in
anaemia, low birth weight, pregnancy- teenage mothers compared to 1% in mature
induced hypertension (PIH) and spontaneous mothers and Goonewardene et al.,29 in 2005
abortion were most frequently encountered reported 19% in teenagers compared to 11%
complications during teenage in older mothers, which was marginally
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significant (p = 0.06). A small hospital-based deciding about the continuation of pregnancy

study found that fetal distress (6%) and birth could be linked to the need to enhance
asphyxia (2%) was commonly reported among young people’s awareness, self efficacy and
pregnant teenagers33. There are conflicting autonomy to enable informed decision-
findings regarding the link between making and reduce unsafe and unwanted
spontaneous abortion and teenage pregnancies 39 .
31
pregnancy. Shrestha has reported that Many studies suggest that teenagers
spontaneous abortion was similar 15 (3%) have basic knowledge about contraception;
among teenage mothers and mothers in their mostly related to information about condom
twenties. However, Ganatra et al.,34 in 2002 use. However, their use was limited and
noted that such likeliness is very low 3 (2%) unrelated to lowering teenage pregnancy
among teenage mothers and very high among rates. The studies were not able to explain
matured mothers 166 (14%). why young people were inconsistent
contraceptive users, even though they have
Discussion relatively high level of contraceptive
Low socio-economic status, limited knowledge. Jejeebhoy et al., clearly notified
education, cultural factors and extended that much of such knowledge remains
family structure all appeared to be related superficial and ridden with myths,
to teenage pregnancy. Being socially misperceptions and a sense of
discriminated against and economically poor, invulnerability 40 . In addition, gender power
young women become victims of gender bias imbalance make risky behaviours acceptable,
and tend to have little decision-making encourage secrecy and fear of disclosure,
power. On the other hand, most of the South and inhibit negotiation among partners.
Asian parents think that youngsters lack of Health service utilisation by
experience to choose their partners, and teenagers has been poorly studied in South
that their daughter might be ‘’spoiled’’ Asia. Those very few studies show that the
(rape or unacceptable relationship), hence utilisation of health services is directly linked
family structure has a strong effect on early to socio-economic deprivation. Socio-cultural
child bearing. traditions, gender relations, availability and
Education could play a significant role access to health facilities and low health
in developing self-confidence, increasing age sector infrastructure are all barriers to
at first sexual intercourse and delaying access health care services in South Asia. A
marriage 36 . However, it also provides an large study undertaken in India found that
opportunity for pre-marital sexual activity. service delivery has not been youth-friendly
Such activity may create risks of unwanted to their unique needs and is ambiguity in the
pregnancy if it is combined with a lack of extent of service delivery 41 .
knowledge about the body and The consequences of teenage
37 , 38
contraception . Compulsory sex education pregnancies mentioned in this review paper
can help to empower the girls, which is the are similar to those described in previous
most effective strategy to prepare them for studies 42 , 43 , 44 , 45 , 46 . One report have
late marriage, planned and delayed emphasized that parents must be apprised of
pregnancy and better motherhood. The legal the need to involve children in marriage-
age of marriage for most South Asian related decisions. They must also be made
countries is 18 years, however many girls aware of the physical and mental health
marry before this age. Marriage law in South dangers of early marriage 47 . Women’s
Asia is unenforceable and might have limited education could be an important predictor to
effectiveness; it is also not in tune with help boost teenagers’ confidence to prepare
cultural and social norms. Moreover, them mentally and physically to access
teenagers get less psychological and social sexual health services. Caltabiano et al., in
support on sexual health education from 2008 have also notified that combination of
their family members. The issue of husband sex education programme along with
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reproductive health services could prevent languages), publication type (studies have
reproductive health problems of young been reported in grey literature) or not being
married couples 48 . Teenage girls need indexed in electronic international
information about local health services, and bibliographic databases.
at the same time they also want to be Thirdly, the included studies used a
assured that the confidentiality is variety of study designs, content and size
maintained at each step. and were of varying quality. This diverse
Although they have reasonable nature of studies made it difficult to explore
knowledge of contraceptive method, it is not variations between countries or between age
translated to behaviour. Our review shows groups, and to interpret and summarise key
that teenagers are not very familiar with findings. Some studies examined factors
consequences of teenage pregnancies. For associated with teenage pregnancy in
example, teenagers would have delayed the deprived inner-city areas, while some others
index pregnancy if they had known about its were conducted in hospital setting making
consequences. These factors should be taken the exploration of potential socio-economic
into consideration by teenage sexual health differences not possible.
policy makers and programme directors. In particular, future research in South
Thus, more practical, innovative, interesting Asian countries is needed with standardised
and effective human right-based measures and methodologies. It will help to
interventions should be designed, so that gain insight into observed variations in
teenagers could get direct benefit by pregnancy rates and ensure that new public
acquiring knowledge. health and sexual health interventions are
There are relatively fewer studies better designed and implemented. Funders
conducted in relation to teenage pregnancy of future research should also consider
in South Asia, although they comprise a supporting longitudinal studies to be able to
significant proportion of the total explore changes over time.
population. Firstly, this systematic review is
limited by the amount and the quality of
papers published focusing on factors
associated with teenage pregnancy carried
out in South Asia. One study has reported
that Hindu religion is associated with high
teenage pregnancy; however it did not
describe what major factors contributed to
create such scenario. More research is
needed to explore the impact of religion on
the risk of teenage pregnancy.
Secondly, most studies reporting
factors associated with teenage pregnancy
are related to Nepal, Bangladesh, India and
Sri Lanka. None of those studies were
conducted in Pakistan, the Maldives or
Bhutan, reducing the generalisability of
findings to the whole of South Asia. One
possible explanation for the lack of studies
from the latter countries is that teenage
pregnancy is not perceived as a public health
problem; hence not the focus of research.
Another reason could be bias in our search
strategy and databases, e.g. due to language
(perhaps studies have been reported in local
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Figure 1: Flow chart of the identification of studies

Possible references
identified from databases
N=111
Papers not relevant/duplicates and
not meeting inclusion criteria N=72

Selected papers for full

appraisal N=39

Papers not relevant to the objective

of the study N=14

Full Papers studied and

critically appraised
N=25

Duplicate/Not related to South Asian

countries N=15

Papers included for

final review N=10

Key: N is the number of studies included at each level

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Table 1: Basic characteristics of included studies

Authors and Study design Sample size & sampling Type of Mode of information Location & Outcome measured
Year methodology study collection setting
Rashid 2006 Survey N=153 Convenience sampling Quantitative In-depth interviews, case Urban slum Risk factors and
& qualitative studies, observation, community, behaviour of married
discussion Bangledesh teenage girls

Brennan et al. Survey N= 19,300 Sampling method is Quantitative Survey with structure Urban and Risk factors &
2005 not clearly mentioned questionnaire Rural consequence of
community, teenage pregnancy
India
Goonewarden Prospective N =620 Quantitative Interview with pre-tested Hospital Attitude/behaviour,
e & cohort study 13-16 years = 95 questionnaire to the setting, Sri risk factors,
Deeyagaha 17-19 years = 250 participants Lanka consequences,
Waduge 2005 20-24 years = 275. utilisation of health
All the nulliparous mothers services mode of
aged less than 24 years in delivery
study period were included

Pathak et al. Survey N=151 Study area (village) Quantitative Pre-tested semi-structured Rural Prevalence of Iron,
2003 were randomly selected, and and questionnaire, clinical Community, Vit. A, & Iodine
all APM* were included in the experimental examination, and instrument India deficiencies among
study from selected village study assessment teenage pregnant
mothers and its
consequences
Sharma et al. Case-control N=140 Quantitative One to one interview with pre- Urban and Risk factors,
2002 study 13-19 years=70 tested questionnaire rural/Hospital knowledge &
20-29 years=70 setting, Nepal behaviours of
purposive & random teenage pregnant
woman
Shrestha 2002 Retrospective N =1,150 Quantitative Interview with pre-tested Rural Risk factors,
exploratory Below 19 yr=575, & qualitative structured questionnaires to community, knowledge, attitude,
study and 20 and above=575 the participants, key Nepal behaviour &
survey Two-stage cluster sampling informants consequence of
technique used teenage pregnancy

Ganatra & Survey N= 226 Married adolescents ≤ Quantitative Interview with structured Rural Risk factors, attitude,
Hirve 2002 20 years, 43 never married & qualitative questionnaire, group community, behaviour &
and separated ≤ 20 and 1491 discussion, key informants, India consequence of
married women >20 years, and in-depth interviews and teenage pregnancy
Clustered sampling use of hospital record

Sharma et al. Case-control N=140 Quantitative Interview with pre-tested Hospital Risk factors,
2001 study Adolescent =70 structured questionnaire and setting, Nepal consequences,
20-29 years=70 hospital delivery record utilisation of health
All primigravida adolescent services & mode of
were included in index group delivery
and control group were chosen
randomly

Khandait et Hospital N=46,443 Quantitative Observed the hospital records Hospital Risk factors &
al. 2000 record survey Sampling method is not clearly record consequence of
(retrospective mentioned setting, India teenage pregnancy
analysis)
Weerasekera Hospital Adolescent N=1600 Quantitative Information were recorded on Hospital Risk factors,
1997 record survey Over 20 yr N=14699 pre-designed data collection record utilisation of health
Sampling method was not forms setting, Sri services &
clearly mentioned Lanka consequences
teenage pregnancy
* APM= Adolescent Pregnant Mothers

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