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Friday, March 13, 2020

Abortion

From Wikipedia, the free encyclopedia

Abortion
Other namesInduced miscarriage, termination of pregnancy
SpecialtyObstetrics and gynecology
ICD-10-PCSO04
ICD-9-CM779.6
MeSHD000028
MedlinePlus007382

Abortion is the ending of a pregnancy by removal or expulsion of an embryo or fetus before it can survive outside the uterus. An abortion that occurs without intervention is known as a miscarriage or spontaneous abortion. When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced miscarriage". The unmodified word abortion generally refers to an induced abortion. A similar procedure after the fetus has potential to survive outside the womb is known as a "late termination of pregnancy" or less accurately as a "late term abortion".

When properly done, abortion is one of the safest procedures in medicine, but unsafe abortion is a major cause of maternal death, especially in the developing world. Making safe abortion legal and accessible reduces maternal deaths. It is safer than childbirth, which has a 14 times higher risk of death in the United States. Modern methods use medication or surgery for abortions. The drug mifepristone in combination with prostaglandin appears to be as safe and effective as surgery during the first and second trimester of pregnancy. The most common surgical technique involves dilating the cervix and using a suction device. Birth control, such as the pill or intrauterine devices, can be used immediately following abortion. When performed legally and safely on a woman who desires it, induced abortions do not increase the risk of long-term mental or physical problems. In contrast, unsafe abortions (those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities) cause 47,000 deaths and 5 million hospital admissions each year. The World Health Organization recommends safe and legal abortions be available to all women.

Around 56 million abortions are performed each year in the world, with about 45% done unsafely. Abortion rates changed little between 2003 and 2008, before which they decreased for at least two decades as access to family planning and birth control increased. As of 2018, 37% of the world's women had access to legal abortions without limits as to reason. Countries that permit abortions have different limits on how late in pregnancy abortion is allowed.

Historically, abortions have been attempted using herbal medicines, sharp tools, forceful massage, or through other traditional methods. Abortion laws and cultural or religious views of abortions are different around the world. In some areas abortion is legal only in specific cases such as rape, problems with the fetus, poverty, risk to a woman's health, or incest. There is debate over the moral, ethical, and legal issues of abortion. Those who oppose abortion often argue that an embryo or fetus is a human with a right to life, and they may compare abortion to murder. Those who support the legality of abortion often hold that it is part of a woman's right to make decisions about her own body. Others favor legal and accessible abortion as a public health measure.

Types

Induced

An induced abortion may be classified as therapeutic (done in response to a health condition of the women or fetus) or elective (chosen for other reasons).

Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion. Most abortions result from unintended pregnancies. In the United Kingdom, 1 to 2% of abortions are done due to genetic problems in the fetus. A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses. Specific procedures may also be selected due to legality, regional availability, and doctor or a woman's personal preference.

Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; to prevent harm to the woman's physical or mental health; to terminate a pregnancy where indications are that the child will have a significantly increased chance of mortality or morbidity; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy. An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons. Confusion sometimes arises over the term "elective" because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.

Spontaneous

Miscarriage, also known as spontaneous abortion, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation. A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is a "premature birth" or a "preterm birth". When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn". Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.

Only 30% to 50% of conceptions progress past the first trimester. The vast majority of those that do not progress are lost before the woman is aware of the conception, and many pregnancies are lost before medical practitioners can detect an embryo. Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman. 80% of these spontaneous abortions happen in the first trimester.

The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus, accounting for at least 50% of sampled early pregnancy losses. Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus. Advancing maternal age and a woman's history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.

Methods

 
 
Practice of Induced Abortion Methods
Induced Miscarr.
Gestational age may determine which abortion methods are practiced.

Medical

Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486) in the 1980s.

The most common early first-trimester medical abortion regimens use mifepristone in combination with misoprostol (or sometimes another prostaglandin analog, gemeprost) up to 10 weeks (70 days) gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone. Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone. This regimen is effective in the second trimester. Medical abortion regimens involving mifepristone followed by misoprostol in the cheek between 24 and 48 hours later are effective when performed before 70 days' gestation.

In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue. Early medical abortion regimens using mifepristone, followed 24–48 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age; from 9 to 10 weeks efficacy decreases modestly to 94%. If medical abortion fails, surgical abortion must be used to complete the procedure.

Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain, France, Switzerland, and the Nordic countries. In the United States, the percentage of early medical abortions performed in non-hospital facilities is 31% as of 2014.

Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second-trimester abortions in Canada, most of Europe, China and India, in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.

Surgical

A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization).
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump

Up to 15 weeks' gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion. Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump. These techniques can both be used very early in pregnancy. MVA can be used up to 14 weeks but is more often used earlier in the U.S. EVA can be used later.

MVA, also known as "mini-suction" and "menstrual extraction" or EVA can be used in very early pregnancy when cervical dilation may not be required. Dilation and curettage (D&C) refers to opening the cervix (dilation) and removing tissue (curettage) via suction or sharp instruments. D&C is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. The World Health Organization recommends sharp curettage only when suction aspiration is unavailable.

Dilation and evacuation (D&E), used after 12 to 16 weeks, consists of opening the cervix and emptying the uterus using surgical instruments and suction. D&E is performed vaginally and does not require an incision. Intact dilation and extraction(D&X) refers to a variant of D&E sometimes used after 18 to 20 weeks when removal of an intact fetus improves surgical safety or for other reasons.

Abortion may also be performed surgically by hysterotomy or gravid hysterectomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and can be used during later stages of pregnancy. Gravid hysterectomy refers to removal of the whole uterus while still containing the pregnancy. Hysterotomy and hysterectomy are associated with much higher rates of maternal morbidity and mortality than D&E or induction abortion.

First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia.

Labor induction abortion

In places lacking the necessary medical skill for dilation and extraction, or where preferred by practitioners, an abortion can be induced by first inducing labor and then inducing fetal demise if necessary. This is sometimes called "induced miscarriage". This procedure may be performed from 13 weeks gestation to the third trimester. Although it is very uncommon in the United States, more than 80% of induced abortions throughout the second trimester are labor-induced abortions in Sweden and other nearby countries.

Only limited data are available comparing this method with dilation and extraction. Unlike D&E, labor-induced abortions after 18 weeks may be complicated by the occurrence of brief fetal survival, which may be legally characterized as live birth. For this reason, labor-induced abortion is legally risky in the United States.

Other methods

Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine. Among these are: tansy, pennyroyal, black cohosh, and the now-extinct silphium.

In 1978 one woman in Colorado died and another was seriously injured when they attempted to procure an abortion by taking pennyroyal oil. Because the indiscriminant use of herbs as abortifacients can cause serious—even lethal—side effects, such as multiple organ failure, such use is not recommended by physicians.

Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage. In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage. One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.

Reported methods of unsafe, self-induced abortion include misuse of misoprostol and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These and other methods to terminate pregnancy may be called "induced miscarriage". Such methods are rarely used in countries where surgical abortion is legal and available.

Safety

An abortion flyer in South Africa

The health risks of abortion depend principally upon whether the procedure is performed safely or unsafely. The World Health Organization defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities. Legal abortions performed in the developed world are among the safest procedures in medicine. In the United States as of 2012, abortion was estimated to be about 14 times safer for women than childbirth. CDC estimated in 2019 that US pregnancy-related mortality was 17.2 maternal deaths per 100,000 live births, while the US abortion mortality rate is 0.7 maternal deaths per 100,000 procedures. In the UK, guidelines of the Royal College of Obstetricians and Gynaecologists state that "Women should be advised that abortion is generally safer than continuing a pregnancy to term." Worldwide, on average, abortion is safer than carrying a pregnancy to term. A 2007 study reported that "26% of all pregnancies worldwide are terminated by induced abortion," whereas "deaths from improperly performed [abortion] procedures constitute 13% of maternal mortality globally." In Indonesia in 2000 it was estimated that 2 million pregnancies ended in abortion, 4.5 million pregnancies were carried to term, and 14-16 percent of maternal deaths resulted from abortion.

In the US from 2000 to 2009, abortion had a lower mortality rate than plastic surgery, and a similar or lower mortality rate than running a marathon. Five years after seeking abortion services, women who gave birth after being denied an abortion reported worse health than women who had either first or second trimester abortions. The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth. Outpatient abortion is as safe from 64 to 70 days' gestation as it before 63 days.

There is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 10 weeks gestation. Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion.

Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. Complications, which are rare, can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate. Infections account for one-third of abortion-related deaths in the United States. The rate of complications of vacuum aspiration abortion in the first trimester is similar regardless of whether the procedure is performed in a hospital, surgical center, or office. Preventive antibiotics (such as doxycycline or metronidazole) are typically given before abortion procedures, as they are believed to substantially reduce the risk of postoperative uterine infection; however, antibiotics are not routinely given with abortion pills. The rate of failed procedures does not appear to vary significantly depending on whether the abortion is performed by a doctor or a mid-level practitioner.

Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen. The risk of death from abortion approaches roughly half the risk of death from childbirth the farther along a woman is in pregnancy; from 1 in a million before 9 weeks gestation to nearly 1 in 10 thousand at 21 weeks or more (as measured from the last menstrual period).

Some purported risks of abortion are promoted primarily by anti-abortion groups, but lack scientific support. For example, the question of a link between induced abortion and breast cancer has been investigated extensively. Major medical and scientific bodies (including the World Health Organization, National Cancer Institute, American Cancer Society, Royal College of OBGYN and American Congress of OBGYN) have concluded that abortion does not cause breast cancer.

In the past even illegality has not automatically meant that the abortions were unsafe. Referring to the U.S., historian Linda Gordon states: "In fact, illegal abortions in this country have an impressive safety record." According to Rickie Solinger,
A related myth, promulgated by a broad spectrum of people concerned about abortion and public policy, is that before legalization abortionists were dirty and dangerous back-alley butchers.... [T]he historical evidence does not support such claims.
Authors Jerome Bates and Edward Zawadzki describe the case of an illegal abortionist in the eastern U.S. in the early 20th century who was proud of having successfully completed 13,844 abortions without any fatality. In 1870s New York City the famous abortionist/midwife Madame Restell (Anna Trow Lohman) appears to have lost very few women among her more than 100,000 patients—a lower mortality rate than the childbirth mortality rate at the time. In 1936 the prominent professor of obstetrics and gynecology Frederick J. Taussig wrote that a cause of increasing mortality during the years of illegality in the U.S. was that
With each decade of the past fifty years the actual and proportionate frequency of this accident [perforation of the uterus] has increased, due, first, to the increase in the number of instrumentally induced abortions; second, to the proportionate increase in abortions handled by doctors as against those handled by midwives; and, third, to the prevailing tendency to use instruments instead of the finger in emptying the uterus.

Mental health

Current evidence finds no relationship between most induced abortions and mental-health problems other than those expected for any unwanted pregnancy. A report by the American Psychological Association concluded that a woman's first abortion is not a threat to mental health when carried out in the first trimester, with such women no more likely to have mental-health problems than those carrying an unwanted pregnancy to term; the mental-health outcome of a woman's second or greater abortion is less certain. Some older reviews concluded that abortion was associated with an increased risk of psychological problems; however, they did not use an appropriate control group.

Although some studies show negative mental-health outcomes in women who choose abortions after the first trimester because of fetal abnormalities, more rigorous research would be needed to show this conclusively. Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", but this is not recognized by medical or psychological professionals in the United States.

A long term-study among US women found that about 99% of women felt that they made the right decision five years after they had an abortion. Relief was the primary emotion with few women feeling sadness or guilt. Social stigma was a main factor predicting negative emotions and regret years later.

Unsafe abortion

Soviet poster circa 1925, warning against midwives performing abortions. Title translation: ""Miscarriages induced by either grandma or self-taught midwives not only maim the woman, they also often lead to death."

Women seeking an abortion may use unsafe methods, especially when abortion is legally restricted. They may attempt self-induced abortion or seek the help of a person without proper medical training or facilities. This can lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.

Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries. Unsafe abortions are believed to result in millions of injuries. Estimates of deaths vary according to methodology, and have ranged from 37,000 to 70,000 in the past decade; deaths from unsafe abortion account for around 13% of all maternal deaths. The World Health Organization believes that mortality has fallen since the 1990s. To reduce the number of unsafe abortions, public health organizations have generally advocated emphasizing the legalization of abortion, training of medical personnel, and ensuring access to reproductive-health services. In response, opponents of abortion point out that abortion bans in no way affect prenatal care for women who choose to carry their fetus to term. The Dublin Declaration on Maternal Health, signed in 2012, notes, "the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women."

A major factor in whether abortions are performed safely or not is the legal standing of abortion. Countries with restrictive abortion laws have higher rates of unsafe abortion and similar overall abortion rates compared to those where abortion is legal and available. For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications, with abortion-related deaths dropping by more than 90%. Similar reductions in maternal mortality have been observed after other countries have liberalized their abortion laws, such as Romania and Nepal. A 2011 study concluded that in the United States, some state-level anti-abortion laws are correlated with lower rates of abortion in that state. The analysis, however, did not take into account travel to other states without such laws to obtain an abortion. In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by up to 75% (from 20 million to 5 million annually) if modern family planning and maternal health services were readily available globally. Rates of such abortions may be difficult to measure because they can be reported variously as miscarriage, "induced miscarriage", "menstrual regulation", "mini-abortion", and "regulation of a delayed/suspended menstruation".

Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits, while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria. While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year. Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide, though this varies by region. Secondary infertility caused by an unsafe abortion affects an estimated 24 million women. The rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008. Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon.

Live birth

In 2019, a US Senate Bill entitled the "Born-Alive Abortion Survivors Protection Act" raised the issue of live birth after abortion. The bill would mandate that medical providers resuscitate neonates delivered showing signs of life during an abortion process. During the debate around this issue, US Republicans falsely alleged that medical providers "execute" live-born babies. Existing US laws would punish execution as homicide. Furthermore, US abortion experts refute the claim that a "born-alive" fetus is a common event and reject laws that would mandate resuscitation against the wishes of the parents.

Only 1.3% of abortions occur after 21 weeks of pregnancy in the US. Although it is very uncommon, women undergoing surgical abortion after this gestational age sometimes give birth to a fetus that may survive briefly. The periviable period is considered to be between 20 and 25 weeks gestation. Long-term survival is possible after 22 weeks. However, odds of long-term survival between 22 and 23 weeks are 2–3 percent and odds of survival between 23 and 24 weeks are 20 percent. "Intact survival", which means survival of a neonate without subsequent damage to organs such as the brain or bowel is 1% at 22 weeks and 13% at 23 weeks. Survival odds increase with increasing gestational age.

If medical staff observe signs of life, they may be required to provide care: emergency medical care if the child has a good chance of survival and palliative care if not. Induced fetal demise before termination of pregnancy after 20–21 weeks gestation is recommended by some sources to avoid this and to comply with the US Partial Birth Abortion Ban. Induced fetal demise does not improve the safety of an abortion procedure and may incur risks to the health of the woman having the abortion.

Incidence

There are two commonly used methods of measuring the incidence of abortion:
  • Abortion rate – number of abortions per 1000 women between 15 and 44 years of age
  • Abortion percentage – number of abortions out of 100 known pregnancies (pregnancies include live births, abortions and miscarriages)
In many places, where abortion is illegal or carries a heavy social stigma, medical reporting of abortion is not reliable. For this reason, estimates of the incidence of abortion must be made without determining certainty related to standard error.

The number of abortions performed worldwide seems to have remained stable in recent years, with 41.6 million having been performed in 2003 and 43.8 million having been performed in 2008. The abortion rate worldwide was 28 per 1000 women, though it was 24 per 1000 women for developed countries and 29 per 1000 women for developing countries. The same 2012 study indicated that in 2008, the estimated abortion percentage of known pregnancies was at 21% worldwide, with 26% in developed countries and 20% in developing countries.

On average, the incidence of abortion is similar in countries with restrictive abortion laws and those with more liberal access to abortion. However, restrictive abortion laws are associated with increases in the percentage of abortions performed unsafely. The unsafe abortion rate in developing countries is partly attributable to lack of access to modern contraceptives; according to the Guttmacher Institute, providing access to contraceptives would result in about 14.5 million fewer unsafe abortions and 38,000 fewer deaths from unsafe abortion annually worldwide.

The rate of legal, induced abortion varies extensively worldwide. According to the report of employees of Guttmacher Institute it ranged from 7 per 1000 women (Germany and Switzerland) to 30 per 1000 women (Estonia) in countries with complete statistics in 2008. The proportion of pregnancies that ended in induced abortion ranged from about 10% (Israel, the Netherlands and Switzerland) to 30% (Estonia) in the same group, though it might be as high as 36% in Hungary and Romania, whose statistics were deemed incomplete.

An American study in 2002 concluded that about half of women having abortions were using a form of contraception at the time of becoming pregnant. Inconsistent use was reported by half of those using condoms and three-quarters of those using the birth control pill; 42% of those using condoms reported failure through slipping or breakage. The Guttmacher Institute estimated that "most abortions in the United States are obtained by minority women" because minority women "have much higher rates of unintended pregnancy".

The abortion rate may also be expressed as the average number of abortions a woman has during her reproductive years; this is referred to as total abortion rate (TAR).

Gestational age and method

Histogram of abortions by gestational age in England and Wales during 2004. (top) Abortion in the United States by gestational age, 2004. (bottom)
 
Abortion rates also vary depending on the stage of pregnancy and the method practiced. In 2003, the Centers for Disease Control and Prevention (CDC) reported that 26% of reported legal induced abortions in the United States were known to have been obtained at less than 6 weeks' gestation, 18% at 7 weeks, 15% at 8 weeks, 18% at 9 through 10 weeks, 10% at 11 through 12 weeks, 6% at 13 through 15 weeks, 4% at 16 through 20 weeks and 1% at more than 21 weeks. 91% of these were classified as having been done by "curettage" (suction-aspiration, dilation and curettage, dilation and evacuation), 8% by "medical" means (mifepristone), >1% by "intrauterine instillation" (saline or prostaglandin), and 1% by "other" (including hysterotomy and hysterectomy). According to the CDC, due to data collection difficulties the data must be viewed as tentative and some fetal deaths reported beyond 20 weeks may be natural deaths erroneously classified as abortions if the removal of the dead fetus is accomplished by the same procedure as an induced abortion.

The Guttmacher Institute estimated there were 2,200 intact dilation and extraction procedures in the US during 2000; this accounts for <0 .2="" abortions="" class="reference" id="cite_ref-169" number="" of="" performed="" sup="" that="" the="" total="" year.="">[168]
Similarly, in England and Wales in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 and 19 weeks, and 2% at or over 20 weeks. 64% of those reported were by vacuum aspiration, 6% by D&E, and 30% were medical. There are more second trimester abortions in developing countries such as China, India and Vietnam than in developed countries.

Motivation

Personal

A bar chart depicting selected data from a 1998 AGI meta-study on the reasons women stated for having an abortion.

The reasons why women have abortions are diverse and vary across the world. Some of the reasons may include an inability to afford a child, domestic violence, lack of support, feeling they are too young, and the wish to complete education or advance a career. Additional reasons include not being willing to raise a child conceived as a result of rape or incest.

Societal

Some abortions are undergone as the result of societal pressures. These might include the preference for children of a specific sex or race, disapproval of single or early motherhood, stigmatization of people with disabilities, insufficient economic support for families, lack of access to or rejection of contraceptive methods, or efforts toward population control (such as China's one-child policy). These factors can sometimes result in compulsory abortion or sex-selective abortion.

Maternal and fetal health

An additional factor is maternal health which was listed as the main reason by about a third of women in 3 of 27 countries and about 7% of women in a further 7 of these 27 countries.

In the U.S., the Supreme Court decisions in Roe v. Wade and Doe v. Bolton: "ruled that the state's interest in the life of the fetus became compelling only at the point of viability, defined as the point at which the fetus can survive independently of its mother. Even after the point of viability, the state cannot favor the life of the fetus over the life or health of the pregnant woman. Under the right of privacy, physicians must be free to use their "medical judgment for the preservation of the life or health of the mother." On the same day that the Court decided Roe, it also decided Doe v. Bolton, in which the Court defined health very broadly: "The medical judgment may be exercised in the light of all factors—physical, emotional, psychological, familial, and the woman's age—relevant to the well-being of the patient. All these factors may relate to health. This allows the attending physician the room he needs to make his best medical judgment."
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Public opinion shifted in America following television personality Sherri Finkbine's discovery during her fifth month of pregnancy that she had been exposed to thalidomide. Unable to obtain a legal abortion in the United States, she traveled to Sweden. From 1962 to 1965, an outbreak of German measles left 15,000 babies with severe birth defects. In 1967, the American Medical Association publicly supported liberalization of abortion laws. A National Opinion Research Center poll in 1965 showed 73% supported abortion when the mother's life was at risk, 57% when birth defects were present and 59% for pregnancies resulting from rape or incest.

Cancer

The rate of cancer during pregnancy is 0.02–1%, and in many cases, cancer of the mother leads to consideration of abortion to protect the life of the mother, or in response to the potential damage that may occur to the fetus during treatment. This is particularly true for cervical cancer, the most common type of which occurs in 1 of every 2,000–13,000 pregnancies, for which initiation of treatment "cannot co-exist with preservation of fetal life (unless neoadjuvant chemotherapy is chosen)". Very early stage cervical cancers (I and IIa) may be treated by radical hysterectomy and pelvic lymph node dissection, radiation therapy, or both, while later stages are treated by radiotherapy. Chemotherapy may be used simultaneously. Treatment of breast cancer during pregnancy also involves fetal considerations, because lumpectomy is discouraged in favor of modified radical mastectomy unless late-term pregnancy allows follow-up radiation therapy to be administered after the birth.

Exposure to a single chemotherapy drug is estimated to cause a 7.5–17% risk of teratogenic effects on the fetus, with higher risks for multiple drug treatments. Treatment with more than 40 Gy of radiation usually causes spontaneous abortion. Exposure to much lower doses during the first trimester, especially 8 to 15 weeks of development, can cause intellectual disability or microcephaly, and exposure at this or subsequent stages can cause reduced intrauterine growth and birth weight. Exposures above 0.005–0.025 Gy cause a dose-dependent reduction in IQ. It is possible to greatly reduce exposure to radiation with abdominal shielding, depending on how far the area to be irradiated is from the fetus.

The process of birth itself may also put the mother at risk. "Vaginal delivery may result in dissemination of neoplastic cells into lymphovascular channels, haemorrhage, cervical laceration and implantation of malignant cells in the episiotomy site, while abdominal delivery may delay the initiation of non-surgical treatment."

History and religion

Bas-relief at Angkor Wat, Cambodia, c. 1150, depicting a demon inducing an abortion by pounding the abdomen of a pregnant woman with a pestle.
 
"French Periodical Pills". An example of a clandestine advertisement published in a January 1845 edition of the Boston Daily Times.
 
Since ancient times abortions have been done using a number of methods, including herbal medicines, sharp tools, with force, or through other traditional methods. Induced abortion has long history and can be traced back to civilizations as varied as China under Shennong (c. 2700 BCE), Ancient Egypt with its Ebers Papyrus (c. 1550 BCE), and the Roman Empire in the time of Juvenal (c. 200 CE). One of the earliest known artistic representations of abortion is in a bas relief at Angkor Wat (c. 1150). Found in a series of friezes that represent judgment after death in Hindu and Buddhist culture, it depicts the technique of abdominal abortion.

Some medical scholars and abortion opponents have suggested that the Hippocratic Oath forbade Ancient Greek physicians from performing abortions; other scholars disagree with this interpretation, and state that the medical texts of Hippocratic Corpus contain descriptions of abortive techniques right alongside the Oath. The physician Scribonius Largus wrote in 43 CE that the Hippocratic Oath prohibits abortion, as did Soranus, although apparently not all doctors adhered to it strictly at the time. According to Soranus' 1st or 2nd century CE work Gynaecology, one party of medical practitioners banished all abortives as required by the Hippocratic Oath; the other party—to which he belonged—was willing to prescribe abortions, but only for the sake of the mother's health. Aristotle, in his treatise on government Politics (350 BCE), condemns infanticide as a means of population control. He preferred abortion in such cases, with the restriction "[that it] must be practised on it before it has developed sensation and life; for the line between lawful and unlawful abortion will be marked by the fact of having sensation and being alive".

In Christianity, Pope Sixtus V (1585–90) was the first Pope before 1869 to declare that abortion is homicide regardless of the stage of pregnancy; and his pronouncement of 1588 was reversed three years later by his successor. Through most of its history the Catholic Church was divided on whether it believed that early abortion was murder, and it did not begin vigorously opposing abortion until the 19th century. Several historians have written that prior to the 19th century most Catholic authors did not regard termination of pregnancy before "quickening" or "ensoulment" as an abortion. From 1750, excommunication became the punishment for abortions. Statements made in 1992 in the Catechism of the Catholic Church, the codified summary of the Church's teachings, opposed abortion.

A 1995 survey reported that Catholic women are as likely as the general population to terminate a pregnancy, Protestants are less likely to do so, and Evangelical Christians are the least likely to do so. Islamic tradition has traditionally permitted abortion until a point in time when Muslims believe the soul enters the fetus, considered by various theologians to be at conception, 40 days after conception, 120 days after conception, or quickening. However, abortion is largely heavily restricted or forbidden in areas of high Islamic faith such as the Middle East and North Africa.

In Europe and North America, abortion techniques advanced starting in the 17th century. However, conservatism by most physicians with regards to sexual matters prevented the wide expansion of safe abortion techniques. Other medical practitioners in addition to some physicians advertised their services, and they were not widely regulated until the 19th century, when the practice (sometimes called restellism) was banned in both the United States and the United Kingdom. Church groups as well as physicians were highly influential in anti-abortion movements. In the US, according to some sources, abortion was more dangerous than childbirth until about 1930 when incremental improvements in abortion procedures relative to childbirth made abortion safer. However, other sources maintain that in the 19th century early abortions under the hygienic conditions in which midwives usually worked were relatively safe. In addition, some commentators have written that, despite improved medical procedures, the period from the 1930s until legalization also saw more zealous enforcement of anti-abortion laws, and concomitantly an increasing control of abortion providers by organized crime.

Soviet Russia (1919), Iceland (1935) and Sweden (1938) were among the first countries to legalize certain or all forms of abortion. In 1935 Nazi Germany, a law was passed permitting abortions for those deemed "hereditarily ill", while women considered of German stock were specifically prohibited from having abortions. Beginning in the second half of the twentieth century, abortion was legalized in a greater number of countries.

Society and culture

Abortion debate

Induced abortion has long been the source of considerable debate. Ethical, moral, philosophical, biological, religious and legal issues surrounding abortion are related to value systems. Opinions of abortion may be about fetal rights, governmental authority, and women's rights

In both public and private debate, arguments presented in favor of or against abortion access focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion. The World Medical Association Declaration on Therapeutic Abortion notes, "circumstances bringing the interests of a mother into conflict with the interests of her unborn child create a dilemma and raise the question as to whether or not the pregnancy should be deliberately terminated." Abortion debates, especially pertaining to abortion laws, are often spearheaded by groups advocating one of these two positions. Anti-abortion groups who favor greater legal restrictions on abortion, including complete prohibition, most often describe themselves as "pro-life" while abortion rights groups who are against such legal restrictions describe themselves as "pro-choice". Generally, the former position argues that a human fetus is a human person with a right to live, making abortion morally the same as murder. The latter position argues that a woman has certain reproductive rights, especially the right to decide whether or not to carry a pregnancy to term.

Modern abortion law

International status of abortion law
UN 2013 report on abortion law.
  Legal on request
  Legal for maternal life, health, mental health, rape and/or fetal defects, and also for socioeconomic factors
  Illegal with exception for maternal life, health, mental health and/or rape, and also for fetal defects
  Illegal with exception for maternal life, health and/or mental health, and also for rape
  Illegal with exception for maternal life, health, and/or mental health
  Illegal with exception for maternal life
  Illegal with no exceptions
  No information

Current laws pertaining to abortion are diverse. Religious, moral, and cultural factors continue to influence abortion laws throughout the world. The right to life, the right to liberty, the right to security of person, and the right to reproductive health are major issues of human rights that sometimes constitute the basis for the existence or absence of abortion laws.

In jurisdictions where abortion is legal, certain requirements must often be met before a woman may obtain a safe, legal abortion (an abortion performed without the woman's consent is considered feticide). These requirements usually depend on the age of the fetus, often using a trimester-based system to regulate the window of legality, or as in the U.S., on a doctor's evaluation of the fetus' viability. Some jurisdictions require a waiting period before the procedure, prescribe the distribution of information on fetal development, or require that parents be contacted if their minor daughter requests an abortion. Other jurisdictions may require that a woman obtain the consent of the fetus' father before aborting the fetus, that abortion providers inform women of health risks of the procedure—sometimes including "risks" not supported by the medical literature—and that multiple medical authorities certify that the abortion is either medically or socially necessary. Many restrictions are waived in emergency situations. China, which has ended their one-child policy, and now has a two child policy, has at times incorporated mandatory abortions as part of their population control strategy.

Other jurisdictions ban abortion almost entirely. Many, but not all, of these allow legal abortions in a variety of circumstances. These circumstances vary based on jurisdiction, but may include whether the pregnancy is a result of rape or incest, the fetus' development is impaired, the woman's physical or mental well-being is endangered, or socioeconomic considerations make childbirth a hardship. In countries where abortion is banned entirely, such as Nicaragua, medical authorities have recorded rises in maternal death directly and indirectly due to pregnancy as well as deaths due to doctors' fears of prosecution if they treat other gynecological emergencies. Some countries, such as Bangladesh, that nominally ban abortion, may also support clinics that perform abortions under the guise of menstrual hygiene. This is also a terminology in traditional medicine. In places where abortion is illegal or carries heavy social stigma, pregnant women may engage in medical tourism and travel to countries where they can terminate their pregnancies. Women without the means to travel can resort to providers of illegal abortions or attempt to perform an abortion by themselves.

The organization Women on Waves, has been providing education about medical abortions since 1999. The NGO created a mobile medical clinic inside a shipping container, which then travels on rented ships to countries with restrictive abortion laws. Because the ships are registered in the Netherlands, Dutch law prevails when the ship is in international waters. While in port, the organization provides free workshops and education; while in international waters, medical personnel are legally able to prescribe medical abortion drugs and counseling.

Sex-selective abortion

Sonography and amniocentesis allow parents to determine sex before childbirth. The development of this technology has led to sex-selective abortion, or the termination of a fetus based on sex. The selective termination of a female fetus is most common.

Sex-selective abortion is partially responsible for the noticeable disparities between the birth rates of male and female children in some countries. The preference for male children is reported in many areas of Asia, and abortion used to limit female births has been reported in Taiwan, South Korea, India, and China. This deviation from the standard birth rates of males and females occurs despite the fact that the country in question may have officially banned sex-selective abortion or even sex-screening. In China, a historical preference for a male child has been exacerbated by the one-child policy, which was enacted in 1979.

Many countries have taken legislative steps to reduce the incidence of sex-selective abortion. At the International Conference on Population and Development in 1994 over 180 states agreed to eliminate "all forms of discrimination against the girl child and the root causes of son preference", conditions also condemned by a PACE resolution in 2011. The World Health Organization and UNICEF, along with other United Nations agencies, have found that measures to reduce access to abortion are much less effective at reducing sex-selective abortions than measures to reduce gender inequality.

Anti-abortion violence

In a number of cases, abortion providers and these facilities have been subjected to various forms of violence, including murder, attempted murder, kidnapping, stalking, assault, arson, and bombing. Anti-abortion violence is classified by both governmental and scholarly sources as terrorism. In the U.S. and Canada, over 8,000 incidents of violence, trespassing, and death threats have been recorded by providers since 1977, including over 200 bombings/arsons and hundreds of assaults. The majority of abortion opponents have not been involved in violent acts. 

In the United States, four physicians who performed abortions have been murdered: David Gunn (1993), John Britton (1994), Barnett Slepian (1998), and George Tiller (2009). Also murdered, in the U.S. and Australia, have been other personnel at abortion clinics, including receptionists and security guards such as James Barrett, Shannon Lowney, Lee Ann Nichols, and Robert Sanderson. Woundings (e.g., Garson Romalis) and attempted murders have also taken place in the United States and Canada. Hundreds of bombings, arsons, acid attacks, invasions, and incidents of vandalism against abortion providers have occurred. Notable perpetrators of anti-abortion violence include Eric Robert Rudolph, Scott Roeder, Shelley Shannon, and Paul Jennings Hill, the first person to be executed in the United States for murdering an abortion provider.

Legal protection of access to abortion has been brought into some countries where abortion is legal. These laws typically seek to protect abortion clinics from obstruction, vandalism, picketing, and other actions, or to protect women and employees of such facilities from threats and harassment. 

Far more common than physical violence is psychological pressure. In 2003, Chris Danze organized anti-abortion organizations throughout Texas to prevent the construction of a Planned Parenthood facility in Austin. The organizations released the personal information online, of those involved with construction, sending them up to 1200 phone calls a day and contacting their churches. Some protestors record women entering clinics on camera.

Other animals

Spontaneous abortion occurs in various animals. For example, in sheep it may be caused by stress or physical exertion, such as crowding through doors or being chased by dogs. In cows, abortion may be caused by contagious disease, such as brucellosis or Campylobacter, but can often be controlled by vaccination. Eating pine needles can also induce abortions in cows. Several plants, including broomweed, skunk cabbage, poison hemlock, and tree tobacco, are known to cause fetal deformities and abortion in cattle and in sheep and goats. In horses, a fetus may be aborted or resorbed if it has lethal white syndrome (congenital intestinal aganglionosis). Foal embryos that are homozygous for the dominant white gene (WW) are theorized to also be aborted or resorbed before birth. In many species of sharks and rays, stress-induced abortions occur frequently on capture.

Viral infection can cause abortion in dogs. Cats can experience spontaneous abortion for many reasons, including hormonal imbalance. A combined abortion and spaying is performed on pregnant cats, especially in Trap-Neuter-Return programs, to prevent unwanted kittens from being born. Female rodents may terminate a pregnancy when exposed to the smell of a male not responsible for the pregnancy, known as the Bruce effect.

Abortion may also be induced in animals, in the context of animal husbandry. For example, abortion may be induced in mares that have been mated improperly, or that have been purchased by owners who did not realize the mares were pregnant, or that are pregnant with twin foals. Feticide can occur in horses and zebras due to male harassment of pregnant mares or forced copulation, although the frequency in the wild has been questioned. Male gray langur monkeys may attack females following male takeover, causing miscarriage.

Teenage pregnancy

From Wikipedia, the free encyclopedia
 
Teenage pregnancy
Other namesTeen pregnancy, adolescent pregnancy
Preventing Teen Pregnancy in the US-CDC Vital Signs-April 2011.pdf
A US government poster on teen pregnancy. Over 1,100 teenagers, mostly aged 18 or 19, give birth every day in the United States.
SpecialtyObstetrics
SymptomsPregnancy under the age of 20
Complications
Prevention
Frequency23 million per year (developed world)
DeathsLeading cause of death (15 to 19 year old females)

Teenage pregnancy, also known as adolescent pregnancy, is pregnancy in a female under the age of 20. Pregnancy can occur with sexual intercourse after the start of ovulation, which can be before the first menstrual period (menarche) but usually occurs after the onset of periods. In well-nourished females, the first period usually takes place around the age of 12 or 13.

Pregnant teenagers face many of the same pregnancy related issues as other women. There are additional concerns for those under the age of 15 as they are less likely to be physically developed to sustain a healthy pregnancy or to give birth. For girls aged 15–19, risks are associated more with socioeconomic factors than with the biological effects of age. Risks of low birth weight, premature labor, anemia, and pre-eclampsia are connected to biological age, being observed in teen births even after controlling for other risk factors (such as accessing prenatal care etc.).

Teenage pregnancies are associated with social issues, including lower educational levels and poverty. Teenage pregnancy in developed countries is usually outside of marriage and is often associated with a social stigma. Teenage pregnancy in developing countries often occurs within marriage and half are planned. However, in these societies, early pregnancy may combine with malnutrition and poor health care to cause medical problems. When used in combination, educational interventions and access to birth control can reduce unintended teenage pregnancies.

In 2015 about 47 females per 1,000 had children well under the age of 20. Rates are higher in Africa and lower in Asia. In the developing world about 2.5 million females under the age of 16 and 16 million females 15 to 19 year old have children each year. Another 3.9 million have abortions. It is more common in rural than urban areas. Worldwide, complications related to pregnancy are the most common cause of death among females 15 to 19 year old.

Definition

Teenage pregnancy rate in the United States by age group in 2013.
 
The age of the mother is determined by the easily verified date when the pregnancy ends, not by the estimated date of conception. Consequently, the statistics do not include pregnancies that began at age 19, but that ended on or after the woman's 20th birthday. Similarly, statistics on the mother's marital status are determined by whether she is married at the end of the pregnancy, not at the time of conception.

Effects

According to the United Nations Population Fund (UNFPA), "Pregnancies among girls less than 18 years of age have irreparable consequences. It violates the rights of girls, with life-threatening consequences in terms of sexual and reproductive health, and poses high development costs for communities, particularly in perpetuating the cycle of poverty." Health consequences include not yet being physically ready for pregnancy and childbirth leading to complications and malnutrition as the majority of adolescents tend to come from lower-income households. The risk of maternal death for girls under age 15 in low and middle income countries is higher than for women in their twenties. Teenage pregnancy also affects girls' education and income potential as many are forced to drop out of school which ultimately threatens future opportunities and economic prospects.

Several studies have examined the socioeconomic, medical, and psychological impact of pregnancy and parenthood in teens. Life outcomes for teenage mothers and their children vary; other factors, such as poverty or social support, may be more important than the age of the mother at the birth. Many solutions to counteract the more negative findings have been proposed. Teenage parents who can rely on family and community support, social services and child-care support are more likely to continue their education and get higher paying jobs as they progress with their education.

A holistic approach is required in order to address teenage pregnancy. This means not focusing on changing the behaviour of girls but addressing the underlying reasons of adolescent pregnancy such as poverty, gender inequality, social pressures and coercion. This approach should include "providing age-appropriate comprehensive sexuality education for all young people, investing in girls' education, preventing child marriage, sexual violence and coercion, building gender-equitable societies by empowering girls and engaging men and boys and ensuring adolescents' access to sexual and reproductive health information as well as services that welcome them and facilitate their choices".

In the United States one third of high school students reported being sexually active. In 2011–2013, 79% of females reported using birth control. Teenage pregnancy puts young women at risk for health issues, economic, social and financial issues.

Teenager

Being a young mother in a first world country can affect one's education. Teen mothers are more likely to drop out of high school. One study in 2001 found that women that gave birth during their teens completed secondary-level schooling 10–12% as often and pursued post-secondary education 14–29% as often as women who waited until age 30. Young motherhood in an industrialized country can affect employment and social class. Teenage women who are pregnant or mothers are seven times more likely to commit suicide than other teenagers.

According to the National Campaign to Prevent Teen Pregnancy, nearly 1 in 4 teen mothers will experience another pregnancy within two years of having their first. Pregnancy and giving birth significantly increases the chance that these mothers will become high school dropouts and as many as half have to go on welfare. Many teen parents do not have the intellectual or emotional maturity that is needed to provide for another life. Often, these pregnancies are hidden for months resulting in a lack of adequate prenatal care and dangerous outcomes for the babies. Factors that determine which mothers are more likely to have a closely spaced repeat birth include marriage and education: the likelihood decreases with the level of education of the young woman – or her parents – and increases if she gets married.

Child

Early motherhood can affect the psychosocial development of the infant. The children of teen mothers are more likely to be born prematurely with a low birth weight, predisposing them to many other lifelong conditions. Children of teen mothers are at higher risk of intellectual, language, and socio-emotional delays. Developmental disabilities and behavioral issues are increased in children born to teen mothers. One study suggested that adolescent mothers are less likely to stimulate their infant through affectionate behaviors such as touch, smiling, and verbal communication, or to be sensitive and accepting toward his or her needs. Another found that those who had more social support were less likely to show anger toward their children or to rely upon punishment.

Poor academic performance in the children of teenage mothers has also been noted, with many of the children being held back a grade level, scoring lower on standardized tests, and/or failing to graduate from secondary school. Daughters born to adolescent parents are more likely to become teen mothers themselves. Sons born to teenage mothers are three times more likely to serve time in prison.

Medical

Maternal and prenatal health is of particular concern among teens who are pregnant or parenting. The worldwide incidence of premature birth and low birth weight is higher among adolescent mothers. In a rural hospital in West Bengal, teenage mothers between 15 and 19 years old were more likely to have anemia, preterm delivery, and a baby with a lower birth weight than mothers between 20 and 24 years old.

Research indicates that pregnant teens are less likely to receive prenatal care, often seeking it in the third trimester, if at all. The Guttmacher Institute reports that one-third of pregnant teens receive insufficient prenatal care and that their children are more likely to have health issues in childhood or be hospitalized than those born to older women.

In the case for Latinas and teenage pregnancy, there are barriers that prevent them from receiving any health care. That is because the Latino population is the least insured group in the Unites States.
 
Young mothers who are given high-quality maternity care have significantly healthier babies than those who do not. Many of the health-issues associated with teenage mothers appear to result from lack of access to adequate medical care.

Many pregnant teens are at risk of nutritional deficiencies from poor eating habits common in adolescence, including attempts to lose weight through dieting, skipping meals, food faddism, snacking, and consumption of fast food.

Inadequate nutrition during pregnancy is an even more marked problem among teenagers in developing countries. Complications of pregnancy result in the deaths of an estimated 70,000 teen girls in developing countries each year. Young mothers and their babies are also at greater risk of contracting HIV. The World Health Organization estimates that the risk of death following pregnancy is twice as high for girls aged 15–19 than for women aged 20–24. The maternal mortality rate can be up to five times higher for girls aged 10–14 than for women aged 20–24. Illegal abortion also holds many risks for teenage girls in areas such as sub-Saharan Africa.

Risks for medical complications are greater for girls aged under 15, as an underdeveloped pelvis can lead to difficulties in childbirth. Obstructed labour is normally dealt with by caesarean section in industrialized nations; however, in developing regions where medical services might be unavailable, it can lead to eclampsia, obstetric fistula, infant mortality, or maternal death. For mothers who are older than fifteen, age in itself is not a risk factor, and poor outcomes are associated more with socioeconomic factors rather than with biology.

Economics

The lifetime opportunity cost caused by teenage pregnancy in different countries varies from 1% to 30% of the annual GDP (30% being the figure in Uganda). In the United States, teenage pregnancy costs taxpayers between $9.4 and $28 billion each year, due to factors such as foster care and lost tax revenue. The estimated increase in economic productivity from ending teenage pregnancy in Brazil and India would be over $3.5 billion and $7.7 billion respectively.

Less than one third of teenage mothers receive any form of child support, vastly increasing the likelihood of turning to the government for assistance. The correlation between earlier childbearing and failure to complete high school reduces career opportunities for many young women. One study found that, in 1988, 60% of teenage mothers were impoverished at the time of giving birth. Additional research found that nearly 50% of all adolescent mothers sought social assistance within the first five years of their child's life. A study of 100 teenaged mothers in the UK found that only 11% received a salary, while the remaining 89% were unemployed. Most British teenage mothers live in poverty, with nearly half in the bottom fifth of the income distribution.

Risk factors

Culture

Rates of teenage pregnancies are higher in societies where it is traditional for girls to marry young and where they are encouraged to bear children as soon as they are able. For example, in some sub-Saharan African countries, early pregnancy is often seen as a blessing because it is proof of the young woman's fertility. Countries where teenage marriages are common experience higher levels of teenage pregnancies. In the Indian subcontinent, early marriage and pregnancy is more common in traditional rural communities than in cities. Many teenagers are not taught about methods of birth control and how to deal with peers who pressure them into having sex before they are ready. Many pregnant teenagers do not have any cognition of the central facts of sexuality.

Economic incentives also influence the decision to have children. In societies where children are set to work at an early age, it is economically attractive to have many children.

In societies where adolescent marriage is less common, such as many developed countries, young age at first intercourse and lack of use of contraceptive methods (or their inconsistent and/or incorrect use; the use of a method with a high failure rate is also a problem) may be factors in teen pregnancy. Most teenage pregnancies in the developed world appear to be unplanned. Many Western countries have instituted sex education programs, the main objective of which is to reduce unplanned pregnancies and STIs. Countries with low levels of teenagers giving birth accept sexual relationships among teenagers and provide comprehensive and balanced information about sexuality.

Other family members

Teen pregnancy and motherhood can influence younger siblings. One study found that the younger sisters of teen mothers were less likely to emphasize the importance of education and employment and more likely to accept human sexual behavior, parenting, and marriage at younger ages. Younger brothers, too, were found to be more tolerant of non-marital and early births, in addition to being more susceptible to high-risk behaviors. If the younger sisters of teenage parents babysit the children, they have an increased probability of getting pregnant themselves. Once an older daughter has a child, parents often become more accepting as time goes by. A study from Norway in 2011 found that the probability of a younger sister having a teenage pregnancy went from 1:5 to 2:5 if the elder sister had a baby as a teenager.

Sexuality

In most countries, most males experience sexual intercourse for the first time before their 20th birthday. Males in Western developed countries have sex for the first time sooner than in undeveloped and culturally conservative countries such as sub-Saharan Africa and much of Asia.

In a 2005 Kaiser Family Foundation study of US teenagers, 29% of teens reported feeling pressure to have sex, 33% of sexually active teens reported "being in a relationship where they felt things were moving too fast sexually", and 24% had "done something sexual they didn’t really want to do". Several polls have indicated peer pressure as a factor in encouraging both girls and boys to have sex. The increased sexual activity among adolescents is manifested in increased teenage pregnancies and an increase in sexually transmitted diseases.

Role of drug and alcohol use

Inhibition-reducing drugs and alcohol may possibly encourage unintended sexual activity. If so, it is unknown if the drugs themselves directly influence teenagers to engage in riskier behavior, or whether teenagers who engage in drug use are more likely to engage in sex. Correlation does not imply causation. The drugs with the strongest evidence linking them to teenage pregnancy are alcohol, cannabis, "ecstasy" and other substituted amphetamines. The drugs with the least evidence to support a link to early pregnancy are opioids, such as heroin, morphine, and oxycodone, of which a well-known effect is the significant reduction of libido – it appears that teenage opioid users have significantly reduced rates of conception compared to their non-using, and alcohol, "ecstasy", cannabis, and amphetamine using peers.

Early puberty

Girls who mature early (precocious puberty) are more likely to engage in sexual intercourse at a younger age, which in turn puts them at greater risk of teenage pregnancy.

Lack of contraception

Adolescents may lack knowledge of, or access to, conventional methods of preventing pregnancy, as they may be too embarrassed or frightened to seek such information. Contraception for teenagers presents a huge challenge for the clinician. In 1998, the government of the UK set a target to halve the under-18 pregnancy rate by 2010. The Teenage Pregnancy Strategy (TPS) was established to achieve this. The pregnancy rate in this group, although falling, rose slightly in 2007, to 41.7 per 1,000 women. Young women often think of contraception either as 'the pill' or condoms and have little knowledge about other methods. They are heavily influenced by negative, second-hand stories about methods of contraception from their friends and the media. Prejudices are extremely difficult to overcome. Over concern about side-effects, for example weight gain and acne, often affect choice. Missing up to three pills a month is common, and in this age group the figure is likely to be higher. Restarting after the pill-free week, having to hide pills, drug interactions and difficulty getting repeat prescriptions can all lead to method failure.

In the US, according to the 2002 National Survey of Family Growth, sexually active adolescent women wishing to avoid pregnancy were less likely than older women to use contraceptives (18% of 15–19-year-olds used no contraceptives, versus 10.7% for women aged 15–44). More than 80% of teen pregnancies are unintended. Over half of unintended pregnancies were to women not using contraceptives, most of the rest are due to inconsistent or incorrect use. 23% of sexually active young women in a 1996 Seventeen magazine poll admitted to having had unprotected sex with a partner who did not use a condom, while 70% of girls in a 1997 PARADE poll claimed it was embarrassing to buy birth control or request information from a doctor.

The National Longitudinal Study of Adolescent Health surveyed 1027 students in the US in grades 7–12 in 1995 to compare the use of contraceptives among Whites, Blacks, and Hispanics. The results were that 36.2% of Hispanics said they never used contraception during intercourse which is a high rate compared to 23.3% of Black teens and 17.0% of White teens who also did not use contraceptives during intercourse

In a 2012 study, over 1,000 females were surveyed to find out factors contributing to not using contraception. Of those surveyed, almost half had been involved in unprotected sex within the previous three months. These women gave three main reasons for not using contraceptives: trouble obtaining birth control (the most frequent reason), lack of intention to have sex, and the misconception that they "could not get pregnant".

In a study for the Guttmacher Institute, researchers found that from a comparative perspective, however, teenage pregnancy rates in the US are less nuanced than one might initially assume. "Since timing and levels of sexual activity are quite similar across [Sweden, France, Canada, Great Britain, and the US], the high U.S. rates arise primarily because of less, and possibly less-effective, contraceptive use by sexually active teenagers." Thus, the cause for the discrepancy between rich nations can be traced largely to contraceptive-based issues.

Among teens in the UK seeking an abortion, a study found that the rate of contraceptive use was roughly the same for teens as for older women.

In other cases, contraception is used, but proves to be inadequate. Inexperienced adolescents may use condoms incorrectly, forget to take oral contraceptives, or fail to use the contraceptives they had previously chosen. Contraceptive failure rates are higher for teenagers, particularly poor ones, than for older users. Long-acting contraceptives such as intrauterine devices, subcutaneous contraceptive implants, and contraceptive injections (such as Depo-Provera and combined injectable contraceptive), which prevent pregnancy for months or years at a time, are more effective in women who have trouble remembering to take pills or using barrier methods consistently.

According to Encyclopedia of Women's Health, published in 2004, there has been an increased effort to provide contraception to adolescents via family planning services and school-based health, such as HIV prevention education.

Sexual abuse

Studies from South Africa have found that 11–20% of pregnancies in teenagers are a direct result of rape, while about 60% of teenage mothers had unwanted sexual experiences preceding their pregnancy. Before age 15, a majority of first-intercourse experiences among females are reported to be non-voluntary; the Guttmacher Institute found that 60% of girls who had sex before age 15 were coerced by males who on average were six years their senior. One in five teenage fathers admitted to forcing girls to have sex with them.

Multiple studies have indicated a strong link between early childhood sexual abuse and subsequent teenage pregnancy in industrialized countries. Up to 70% of women who gave birth in their teens were molested as young girls; by contrast, 25% of women who did not give birth as teens were molested.

In some countries, sexual intercourse between a minor and an adult is not considered consensual under the law because a minor is believed to lack the maturity and competence to make an informed decision to engage in fully consensual sex with an adult. In those countries, sex with a minor is therefore considered statutory rape. In most European countries, by contrast, once an adolescent has reached the age of consent, he or she can legally have sexual relations with adults because it is held that in general (although certain limitations may still apply), reaching the age of consent enables a juvenile to consent to sex with any partner who has also reached that age. Therefore, the definition of statutory rape is limited to sex with a person under the minimum age of consent. What constitutes statutory rape ultimately differs by jurisdiction.

Dating violence

Studies have indicated that adolescent girls are often in abusive relationships at the time of their conceiving. They have also reported that knowledge of their pregnancy has often intensified violent and controlling behaviors on part of their boyfriends. Girls under age 18 are twice as likely to be beaten by their child's father than women over age 18. A UK study found that 70% of women who gave birth in their teens had experienced adolescent domestic violence. Similar results have been found in studies in the US. A Washington State study found 70% of teenage mothers had been beaten by their boyfriends, 51% had experienced attempts of birth control sabotage within the last year, and 21% experienced school or work sabotage.

In a study of 379 pregnant or parenting teens and 95 teenage girls without children, 62% of girls aged 11–15 and 56% of girls aged 16–19 reported experiencing domestic violence at the hands of their partners. Moreover, 51% of the girls reported experiencing at least one instance where their boyfriend attempted to sabotage their efforts to use birth control.

Socioeconomic factors

A young poverty-stricken girl clutches her child. Frontispiece illustration from Street Arabs and Gutter Snipes by George Carter Needham, Boston, 1884.

Teenage pregnancy has been defined predominantly within the research field and among social agencies as a social problem. Poverty is associated with increased rates of teenage pregnancy. Economically poor countries such as Niger and Bangladesh have far more teenage mothers compared with economically rich countries such as Switzerland and Japan.

In the UK, around half of all pregnancies to under 18 are concentrated among the 30% most deprived population, with only 14% occurring among the 30% least deprived. For example, in Italy, the teenage birth rate in the well-off central regions is only 3.3 per 1,000, while in the poorer Mezzogiorno it is 10.0 per 1,000. Similarly, in the US, sociologist Mike A. Males noted that teenage birth rates closely mapped poverty rates in California:

County Poverty rate Birth rate*
Marin County 5% 5
Tulare County (Caucasians) 18% 50
Tulare County (Hispanics) 40% 100
* per 1,000 women aged 15–19

Teen pregnancy cost the US over $9.1 billion in 2004, including $1.9 billion for health care, $2.3 billion for child welfare, $2.1 billion for incarceration, and $2.9 billion in lower tax revenue.

There is little evidence to support the common belief that teenage mothers become pregnant to get benefits, welfare, and council housing. Most knew little about housing or financial aid before they got pregnant and what they thought they knew often turned out to be wrong.

Childhood environment

Women exposed to abuse, domestic violence, and family strife in childhood are more likely to become pregnant as teenagers, and the risk of becoming pregnant as a teenager increases with the number of adverse childhood experiences. According to a 2004 study, one-third of teenage pregnancies could be prevented by eliminating exposure to abuse, violence, and family strife. The researchers note that "family dysfunction has enduring and unfavorable health consequences for women during the adolescent years, the childbearing years, and beyond." When the family environment does not include adverse childhood experiences, becoming pregnant as an adolescent does not appear to raise the likelihood of long-term, negative psychosocial consequences. Studies have also found that boys raised in homes with a battered mother, or who experienced physical violence directly, were significantly more likely to impregnate a girl.

Studies have also found that girls whose fathers left the family early in their lives had the highest rates of early sexual activity and adolescent pregnancy. Girls whose fathers left them at a later age had a lower rate of early sexual activity, and the lowest rates are found in girls whose fathers were present throughout their childhood. Even when the researchers took into account other factors that could have contributed to early sexual activity and pregnancy, such as behavioral problems and life adversity, early father-absent girls were still about five times more likely in the US and three times more likely in New Zealand to become pregnant as adolescents than were father-present girls.

Low educational expectations have been pinpointed as a risk factor. A girl is also more likely to become a teenage parent if her mother or older sister gave birth in her teens. A majority of respondents in a 1988 Joint Center for Political and Economic Studies survey attributed the occurrence of adolescent pregnancy to a breakdown of communication between parents and child and also to inadequate parental supervision.

Foster care youth are more likely than their peers to become pregnant as teenagers. The National Casey Alumni Study, which surveyed foster care alumni from 23 communities across the US, found the birth rate for girls in foster care was more than double the rate of their peers outside the foster care system. A University of Chicago study of youth transitioning out of foster care in Illinois, Iowa, and Wisconsin found that nearly half of the females had been pregnant by age 19. The Utah Department of Human Services found that girls who had left the foster care system between 1999 and 2004 had a birth rate nearly three times the rate for girls in the general population.

Media influence

A study conducted in 2006 found that adolescents who were more exposed to sexuality in the media were also more likely to engage in sexual activity themselves. According to Time, "teens exposed to the most sexual content on TV are twice as likely as teens watching less of this material to become pregnant before they reach age 20".

Prevention

Comprehensive sex education and access to birth control appear to reduce unplanned teenage pregnancy. It is unclear which type of intervention is most effective.

In the US free access to a long acting form of reversible birth control along with education decreased the rates of teen pregnancies by around 80% and the rate of abortions by more than 75%. Currently there are four federal programs aimed at preventing teenage pregnancy: Teen Pregnancy Prevention (TPP), Personal Responsibility Education Program (PREP), Title V Sexual Risk Avoidance Education, and Sexual Risk Avoidance Education.

Education

The Dutch approach to preventing teenage pregnancy has often been seen as a model by other countries. The curriculum focuses on values, attitudes, communication and negotiation skills, as well as biological aspects of reproduction. The media has encouraged open dialogue and the health-care system guarantees confidentiality and a non-judgmental approach.

Abstinence only education

Ad promoting abstinence in Ghana for prevention of unplanned pregnancy and HIV/AIDS (2005)

Some schools provide abstinence-only sex education. Evidence does not support the effectiveness of abstinence-only sex education. It has been found to be ineffective in decreasing HIV risk in the developed world, and does not decrease rates of unplanned pregnancy when compared to comprehensive sex education. It does not decrease the sexual activity rates of students, when compared to students who undertake comprehensive sexual education classes.

Public policy

Canada

In 2018, Québec's Institut national de santé publique (INSPQ) began implementing adjustments to the Protocole de contraception du Québec (Québec Contraception Protocol). The new protocol allows registered nurses to prescribe hormonal birth control, an IUD or emergency birth control to women, as long as they comply with prescribed standards in the Prescription infirmière : Guide explicatif conjoint, and are properly trained in providing contraceptives. In 2020, Québec will offer online training to registered nurses, provided by the Ordre des infirmières et infirmiers du Québec (OIIQ). Nurses that do not have training in the areas of sexually transmitted and blood borne infections may have to take additional online courses provided by the INSPQ.

United States

US statistics in April 2015

In the US, one policy initiative that has been used to increase rates of contraceptive use is Title X. Title X of the Family Planning Services and Population Research Act of 1970 (Pub.L. 91–572) provides family planning services for those who do not qualify for Medicaid by distributing "funding to a network of public, private, and nonprofit entities [to provide] services on a sliding scale based on income." Studies indicate that, internationally, success in reducing teen pregnancy rates is directly correlated with the kind of access that Title X provides: “What appears crucial to success is that adolescents know where they can go to obtain information and services, can get there easily and are assured of receiving confidential, nonjudgmental care, and that these services and contraceptive supplies are free or cost very little.” In addressing high rates of unplanned teen pregnancies, scholars agree that the problem must be confronted from both the biological and cultural contexts.

On September 30, 2010, the US Department of Health and Human Services approved $155 million in new funding for comprehensive sex education programs designed to prevent teenage pregnancy. The money is being awarded "to states, non-profit organizations, school districts, universities and others. These grants will support the replication of teen pregnancy prevention programs that have been shown to be effective through rigorous research as well as the testing of new, innovative approaches to combating teen pregnancy." Of the total of $150 million, $55 million is funded by Affordable Care Act through the Personal Responsibility Education Program, which requires states receiving funding to incorporate lessons about both abstinence and contraception.

Developing countries

In the developing world, programs of reproductive health aimed at teenagers are often small scale and not centrally coordinated, although some countries such as Sri Lanka have a systematic policy framework for teaching about sex within schools. Non-governmental agencies such as the International Planned Parenthood Federation and Marie Stopes International provide contraceptive advice for young women worldwide. Laws against child marriage have reduced but not eliminated the practice. Improved female literacy and educational prospects have led to an increase in the age at first birth in areas such as Iran, Indonesia, and the Indian state of Kerala.

Other

A team of researchers and educators in California have published a list of "best practices" in the prevention of teen pregnancy, which includes, in addition to the previously mentioned concepts, working to "instill a belief in a successful future", male involvement in the prevention process, and designing interventions that are culturally relevant.

Prevalence

Adolescent birth rate in women aged 10-19 years as of 2016
 
In reporting teenage pregnancy rates, the number of pregnancies per 1,000 females aged 15 to 19 when the pregnancy ends is generally used.

Worldwide, teenage pregnancy rates range from 143 per 1,000 in some sub-Saharan African countries to 2.9 per 1,000 in South Korea. In the US, 82% of pregnancies in those between 15 and 19 are unplanned. Among OECD developed countries, the US, the UK and New Zealand have the highest level of teenage pregnancy, while Japan and South Korea have the lowest in 2001. According to the UNFPA, “In every region of the world – including high-income countries – girls who are poor, poorly educated or living in rural areas are at greater risk of becoming pregnant than those who are wealthier, well-educated or urban. This is true on a global level, as well: 95 per cent of the world’s births to adolescents (aged 15–19) take place in developing countries. Every year, some 3 million girls in this age bracket resort to unsafe abortions, risking their lives and health.”

According to a 2001 UNICEF survey, in 10 out of 12 developed nations with available data, more than two thirds of young people have had sexual intercourse while still in their teens. In Denmark, Finland, Germany, Iceland, Norway, the UK and the US, the proportion is over 80%. In Australia, the UK and the US, approximately 25% of 15-year-olds and 50% of 17-year-olds have had sex. According to the Encyclopedia of Women's Health, published in 2004, approximately 15 million girls under the age of 20 in the world have a child each year. Estimates were that 20–60% of these pregnancies in developing countries are mistimed or unwanted.

Save the Children found that, annually, 13 million children are born to women aged under 20 worldwide, more than 90% in developing countries. Complications of pregnancy and childbirth are the leading cause of mortality among women aged 15–19 in such areas.

Sub-Saharan Africa

The highest rate of teenage pregnancy in the world is in sub-Saharan Africa, where women tend to marry at an early age. In Niger, for example, 87% of women surveyed were married and 53% had given birth to a child before the age of 18.

India

In the Indian subcontinent, early marriage sometimes results in adolescent pregnancy, particularly in rural regions where the rate is much higher than it is in urbanized areas. Latest data suggests that teen pregnancy in India is high with 62 pregnant teens out of every 1,000 women. India is fast approaching to be the most populous country in the world by 2050 and increasing teenage pregnancy, an important factor for the population rise, is likely to aggravate the problems.

Asia

The rates of early marriage and pregnancy in some Asian countries are high. In recent years, the rates have decreased sharply in Indonesia and Malaysia, although it remains relatively high in the former. However, in the industrialized Asian nations such as South Korea and Singapore, teenage birth rates remain among the lowest in the world.

Australia

In 2015, the birth rate among teenage women in Australia was 11.9 births per 1,000 women. The rate has fallen from 55.5 births per 1,000 women in 1971, probably due to ease of access to effective birth control, rather than any decrease in sexual activity.

Europe

The overall trend in Europe since 1970 has been a decreasing total fertility rate, an increase in the age at which women experience their first birth, and a decrease in the number of births among teenagers. Most continental Western European countries have very low teenage birth rates. This is varyingly attributed to good sex education and high levels of contraceptive use (in the case of the Netherlands and Scandinavia), traditional values and social stigmatization (in the case of Spain and Italy) or both (in the case of Switzerland).

On the other hand, the teen birth rate is very high in Bulgaria and Romania. As of 2015, Bulgaria had a birth rate of 37/1.000 women aged 15–19, and Romania of 34. The teen birth rate of these two countries is even higher than that of underdeveloped countries like Burundi and Rwanda. Many of the teen births occur in Roma populations, who have an occurrence of teenage pregnancies well above the local average.

United Kingdom

The teen pregnancy rate in England and Wales was 23.3 per 1,000 women aged 15 to 17. There were 5,740 pregnancies in girls aged under 18 in the three months to June 2014, data from the Office for National Statistics shows. This compares with 6,279 in the same period in 2013 and 7,083 for the June quarter the year before that. Historically, the UK has had one of the highest teenage pregnancy and abortion rates in Western Europe. 

There are no comparable rates for conceptions across Europe, but the under-18 birth rate suggests England is closing the gap. The under-18 birth rate in 2012 in England and Wales was 9.2, compared with an EU average of 6.9. However, the UK birth rate has fallen by almost a third (32.3%) since 2004 compared with a fall of 15.6% in the EU. In 2004, the UK rate was 13.6 births per 1,000 women aged 15–17 compared with an EU average rate of 7.7. 

A spokeswoman for the British Pregnancy Advisory Service said: "Contrary to popular perception, this data shows that the teenage pregnancy rate is falling dramatically in England and Wales. While the UK has historically had a high teenage conception rate, it is now at its lowest level on record and not significantly out of step with other European countries.

"We have seen a huge decline in the number of babies born to teenage mothers over the last decade, in part due to the improvements we've seen in contraception advice and services for younger women, with straightforward access to abortion services when their chosen method lets them down. But it also reflects broader societal shifts, with younger women quite rightly expecting and able to pursue educational and professional ambitions."

United States

US teen pregnancy rate 15 to 19 year olds (per 1,000), including black, Hispanic, and white populations.
 
In 2001, the teenage birth rate in the US was the highest in the developed world, and the teenage abortion rate is also high. In 2005 in the US, the majority (57%) of teen pregnancies resulted in a live birth, 27% ended in an induced abortion, and 16% in a fetal loss. The US teenage pregnancy rate was at a high in the 1950s and has decreased since then, although there has been an increase in births out of wedlock. The teenage pregnancy rate decreased significantly in the 1990s; this decline manifested across all racial groups, although teenagers of African-American and Hispanic descent retain a higher rate, in comparison to that of European-Americans and Asian-Americans. The Guttmacher Institute attributed about 25% of the decline to abstinence and 75% to the effective use of contraceptives. While in 2006 the US teen birth rate rose for the first time in fourteen years, it reached a historic low in 2010: 34.3 births per 1,000 women aged 15–19.

The Latina teenage pregnancy rate is 75% higher pregnancy rate than the national average.

The latest data from the US shows that the states with the highest teenage birthrate are Mississippi, New Mexico and Arkansas while the states with the lowest teenage birthrate are New Hampshire, Massachusetts and Vermont.

Canada

The Canadian teenage birth trended towards a steady decline for both younger (15–17) and older (18–19) teens in the period between 1992 and 2002; however, teen pregnancy has been on the rise since 2013.

Teenage fatherhood

In some cases, the father of the child is the husband of the teenage girl. The conception may occur within wedlock, or the pregnancy itself may precipitate the marriage (the so-called shotgun wedding). In countries such as India, the majority of teenage births occur within marriage.

In other countries, such as the US and Ireland, the majority of teenage mothers are not married to the father of their children. In the UK, half of all teenagers with children are lone parents, 40% are cohabitating as a couple and 10% are married. Teenage parents are frequently in a romantic relationship at the time of birth, but many adolescent fathers do not stay with the mother and this often disrupts their relationship with the child. US surveys tend to under-report the prevalence of teen fatherhood. In many cases, "teenage father" may be a misnomer. Studies by the Population Reference Bureau and the National Center for Health Statistics found that about two-thirds of births to teenage girls in the US are fathered by adult men aged over 20. The Guttmacher Institute reports that over 40% of mothers aged 15–17 had sexual partners three to five years older and almost one in five had partners six or more years older. A 1990 study of births to California teens reported that the younger the mother, the greater the age gap with her male partner. In the UK 72% of jointly registered births to women aged under 20, the father is over 20, with almost 1 in 4 being over 25.

History

Teenage pregnancy (with conceptions normally involving girls between age 16 and 19), was far more normal in previous centuries, and common in developed countries in the 20th century. Among Norwegian women born in the early 1950s, nearly a quarter became teenage mothers by the early 1970s. However, the rates have steadily declined throughout the developed world since that 20th century peak. Among those born in Norway in the late 1970s, less than 10% became teenage mothers, and rates have fallen since then.

Society and culture

Politics

Some politicians condemn pregnancy in unmarried teenagers as a drain on taxpayers, if the mothers and children receive welfare payments and social housing from the government.

Marie Curie

From Wikipedia, the free encyclopedia https://en.wikipedia.org/wiki/Marie_Curie Marie Curie Curie, c.  1920 Born Maria Salomea...