Article Text
PDF
Abstract
Objectives This study aims to investigate the incidence, associated factors and interventions to address teen pregnancy involvement (TPI) among African, Caribbean and Black (ACB) adolescents in North America.
Design We conducted a scoping review of the literature, guided by the social-ecological model.
Data sources Studies were retrieved from databases such as Ovid Medline, Ovid Embase, CINAHL, CAB Direct and Google Scholar and imported into COVIDENCE for screening.
Eligibility criteria The Joanna Briggs Institute scoping reviews protocol guided the establishment of eligibility criteria. Included studies focused on rates, associated factors and interventions related to TPI among ACB boys and girls aged 10–19 in North America. The publication time frame was restricted to 2010–2023, encompassing both peer-reviewed and non-peer-reviewed studies with diverse settings.
Data extraction and synthesis Data were extracted from 32 articles using a form developed by the principal author, focusing on variables aligned with the research question.
Results The scoping review revealed a dearth of knowledge in Canadian and other North American literature on TPI in ACB adolescents. Despite an overall decline in teen pregnancy rates, disparities persist, with interventions such as postpartum prescription of long-acting birth control and teen mentorship programmes proving effective.
Conclusion The findings highlight the need for increased awareness, research and recognition of male involvement in adolescent pregnancies. Addressing gaps in housing, employment, healthcare, sexual health education and health systems policies for marginalised populations is crucial to mitigating TPI among ACB adolescents.
Impact The review underscores the urgent need for more knowledge from other North American countries, particularly those with growing ACB migrant populations.
- adolescent
- health equity
- mental health
- public health
- reproductive medicine
- systematic review
Data availability statement
Data for this scoping review were obtained from publicly available literature sources and databases. All cited references are accessible through their respective publication channels.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
STRENGTHS AND LIMITATIONS OF THIS STUDY
Employing a scoping review design, the study comprehensively mapped and synthesised evidence on teen pregnancy among African, Caribbean and Black (ACB) adolescent boys and girls, allowing for the identification of key concepts, strengths, limitations and sources of evidence.
Exploring male involvement in teen pregnancy outcomes, the study uniquely distinguishes itself from most research, which often overlooks males in the teen pregnancy discourse, adding depth and breadth to the understanding of factors contributing to teen pregnancy.
The rigour of our study’s processes in including expert opinions and the feedback of an advisory board including medical practitioners, teen parents and teenagers themselves significantly adds value to its reliability and authenticity
This scoping review on teen pregnancy among ACB adolescents acknowledges limitations, including diverse study designs, and despite an intent to explore all North American countries, a majoity our findings resulted from US studies. Thus, caution must be taken in generalizing the study's findings to ACB teens in other geographic settings.
Introduction
Primary and recurrent occurrences of teenage pregnancy pose significant public health challenges due to their association with adverse socioeconomic,1 psychological2 and medical outcomes3 for both adolescent mothers and their children. In the USA, an estimated 15.4 out of every 1000 girls aged 15–19 experience pregnancy in 2020 and 9 out of 10 births occurred outside the marriage.4 Research finds that teen pregnancy involvement (TPI) rates disproportionately impact African, Caribbean and Black (ACB) adolescent boys and girls. Factors including age, race, geographical location and socioeconomic conditions contribute to substantial variations in teenage birth rates across the USA. In 2018, the birth rates for Black and Hispanic teenagers were more than twice as high as those for White teenagers.5 Though a paucity of research exists in the literature, several studies have highlighted the lack of attention that has been given to understand the factors associated with these disparities and acknowledge the simplification of interpretation this leads to, making this a prevalent gap in the literature.6 7 This gap is exacerbated by the fact that most studies that investigate TPI in predominantly White continents, such as North America come from the USA, and mostly focus solely on adolescent girls, providing a limited overview of TPI among the ACB population.8 An illustrative example is the absence of current evidence on teen pregnancy incidence or prevalence rates in Canada, where the last available data dates back to 2006, severely hampering possibilities for intervention in this crucial area.9 Within this context, a critical research question emerges: What is known from existing literature on the incidence, prevalence, associated factors and interventions to mitigate TPI rates among ACB adolescent boys and girls in North America? Incorporating these questions in our inquiry underscores the urgency of addressing this research gap; and will guide our choice of what approaches to take in uncovering this public health concern. This query serves as a compass, guiding the exploration of factors influencing teen pregnancy within the unique socio-cultural context of ACB teenagers, encompassing cultural views on sexuality, community expectations, traditional gender roles and the interplay of variables including peer networks, healthcare inequities and access to education.6 7
Background
Studies highlight conflicting views of the impact of teen pregnancy. While most studies note detrimental health and socioeconomic consequences for involved teens, such as later presentation for antenatal care, increased incidences of birth complications such as preterm delivery, low birth weight, rapid-repeat teen pregnancies, teen parents’ or child’s death, postpartum depression, poverty, low-income jobs, financial dependency, decreased self-esteem and lower education levels for teen moms.10–12 Some other studies demonstrate that some of these detrimental outcomes were more so related to social factors and not necessarily age.10 Nonetheless, as adolescence remains a time for physical and psychological development, teens who are underdeveloped per se, that is, lack both the psychological and physical acumen/maturity to undertake pregnancy, may be at increased risk, causing a public health concern.13
Teen pregnancy rates have been decreasing over the past 10 years14; however, racial disparities remain, especially among ACB adolescents.6 12 In 2008, teen pregnancy rates of African- American adolescents were three times (121.6 pregnancies/1000 teenagers) that of non-Hispanic white teenagers (44.8 pregnancies/1000 teenagers).15 In 2010, although there was an overall decline in teen pregnancy rates, the pregnancy rates of black teens (51.4/1000 adolescents) were still twice as much of non-Hispanic white teens (23.6),14 and these differences remain consistent as of a recent study in 2018 (27.2 for black teens vs 13.2 for non-Hispanic white teens).16 As such, black teens remain at an increased risk of unintended pregnancy and its associated health outcomes.17
Despite the concerns about teen pregnancy and its associated adverse outcomes among ACB adolescents, less than a handful of literature reviews and no scoping review to this day provide an up-to-date overview of TPI among the ACB population especially in North America. To address this prominent gap, the current study aims to identify all available evidence and any additional knowledge gaps related to the incidence, associated factors and interventions to mitigate rates of TPI among ACB adolescent males and females in North America.
Theoretical framework
Guided by McLeroy et al’s18 work, the current study adopts a social-ecological model (SEM) to conceptualise health behaviour. According to SEM, health and its outcomes can be understood in terms of complex multilayered interactions between the individual and the environment they are embedded. These interactions occur in five main levels moving from the individual to societal factors: On the individual level, health is understood by looking at the individual’s biological, psychological and personal history (eg, gender, age, medical history, history of drug abuse, sexual preferences and desire for pregnancy). At the relationship level, we consider how the individual’s immediate social relationships/interactions guide their behaviour (eg, peer influence, child–parental relationships, neighbourhood and romantic partners). At the community level, we examine the immediate socioeconomic, institutional, organisational or neighbourhood structures, the individual is influenced by (eg, socioeconomic status, schools, workplaces and access to healthcare resources). Finally, at the societal level, the effects of social, cultural and racial norms, as well as socio-political policies/law are considered (eg, policies around birth control, employment opportunities). By adopting the SEM in this scoping review as a guiding framework, it enables an in-depth exploration of the complexity of factors (individual, community, societal and policy) influencing TPI of ACB adolescents in North America.
Objectives
To investigate the incidence, associated factors and interventions to address TPI among ACB adolescents in North-America.
The review
Aim
The review aimed to expand the scope of TPI rates, associated factors and relevant interventions among ACB adolescents. The review focused on the concept of TPI which counteracts the exclusion of male involvement, a typical occurrence in the discourse regarding teen pregnancy wherein the sole focus is on girls. Considering that teen pregnancy is a global health issue, we broadened this review to include studies from North American countries including Canada.
Concept
This review focused on the concept of TPI. This concept extended beyond the concept of teen pregnancy by acknowledging the involvement of boys in the outcomes of pregnancy. A majority of literature pertaining to teen pregnancy and pregnancy prevention programmes mostly focused on girls alone,8 which is problematic; this scoping review aimed to identify all available evidence also inclusive of male involvement in the outcomes of teen pregnancy.
Methods
Design: This study is a scoping review aimed at mapping the literature and synthesising all available evidence related to teen pregnancy among ACB adolescent boys and girls. In our study, the choice of a scoping review methodology was grounded in the need to thoroughly explore the under-researched area of teen pregnancy among ACB adolescents. Scoping reviews, known for their efficacy in identifying key concepts, strengths, limitations and diverse sources of evidence, align with our goal of informing practice, policy-making and gaining a comprehensive understanding of this nuanced subject.19 This approach allowed us to delve into the socio-cultural factors shaping experiences and outcomes, contributing valuable insights to the existing knowledge base. Scoping reviews also identify gaps in a research area, which provides opportunities for future research. To increase the reliability and level of confidence in the study processes as well as to obtain public opinion on the study, an advisory board consisting of ACB healthcare providers, parents and teenagers was convened to guide the study analyses, processes and results and to provide expert advice and feedback.20
Search methods: With a broad focus of the study on the incidence, associated factors and interventions related to TPI, a scoping review was deemed to be most appropriate to analyse all available evidence. A search of PROSPERO and relevant registries revealed no ongoing literature review on this topic. Thus, the present review has been registered on open science framework. A review protocol was first developed using the Joanna Briggs Institute methodology21 and the results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.22
Inclusion criteria: Studies that had participants who were ACB adolescent boys and girls aged between 10 and 19 were included. Studies that had a sample of both adolescent boys and/or girls were included. Peer-reviewed studies of all research designs and non-peer-reviewed literature from 2010 to 2023 were included to account for all available evidence. All types of settings such as health clinics, schools and support groups were included to allow for a variable sample. A total of five pertinent health literature databases were searched: Ovid Medline, Ovid Embase, CINAHL, CAB Direct and Google Scholar.) In consultation with a reference librarian, a search strategy was developed based on a combination of relevant keywords, MeSH terms and subject headings (see an example with CINAHL search, provided in online supplemental appendix A - supplemental material 1). The search was first conducted on CINAHL, and subsequently replicated and modified for other databases.
Supplemental material
Exclusion criteria: Since there are many different intersecting areas of adolescent sexual and reproductive health, such as sexually transmitted infections (STIs), unsafe abortions and unwanted pregnancies,23 studies whose primary outcome was not teen pregnancy were excluded. Studies published before 2010 were excluded to limit outdated evidence. Studies conducted outside North America were excluded. Finally, studies that included a mixture of races and had a sample that comprised less than 50% of ACB participants were excluded, except such studies that presented separate findings for each race such that specific information on the ACB sample could be easily identified. Similarly, studies involving different age groups (eg, young adults and youths) were excluded if their data analyses and results were not done separately for the different age groups, and the results for our desired age range could not be easily gleaned out.
Study selection: Articles retrieved from the database search were imported into Covidence, which is a software that supports article screening and full-text reviews.24 A team of four independent reviewers conducted a two-step screening process for the retrieved articles. Initially, the title and abstract of the records were screened, leading to the removal of ineligible articles. Subsequently, the full text of the remaining articles underwent a thorough review based on predetermined inclusion and exclusion criteria. Eligible studies from this process were then included in the final analysis of the results. Additionally, the PRISMA-ScR flow chart for scoping reviews and meta-analysis was used as the preferred reporting tool for the results and items identified in the articles.
Quality appraisal: The quality of evidence in this scoping review was assessed methodologically. Our methodological approach involved a thorough quality assessment for both qualitative and quantitative studies to ensure robust and valid findings. For quantitative studies, we focused on internal validity aspects such as study design and blinding, while also considering external validity factors like population characteristics and cultural nuances. In the case of qualitative studies, we employed a nuanced assessment, considering factors such as credibility, dependability and transferability. Credibility was ensured by aligning researchers’ interpretations with participants’ perspectives while dependability was maintained through a logical research process. Transferability considerations gauged the relevance of findings to different contexts. To avoid the risk of bias in data selection, inclusion, exclusion and extraction, study articles and titles were screened independently by two or more reviewers. Likewise, full-text citations were critically assessed by two independent reviewers for inclusion and notes were written under history in COVIDENCE with rationales for articles that were excluded. In cases where there were disagreements or conflicts about an article(s) by two reviewers, the conflict was resolved by a third reviewer. Further, discrepancies after full-text reviews were resolved through discussions with other reviewers. This thorough process of inclusion and exclusion was to ensure that all extracted studies were valid and that there was consistency in the review process. Further, the use of the advisory board to provide feedback and critical thoughts on study findings promotes the quality and reliability of the study.20 25
Data extraction and synthesis: Following the full-text review, a data extraction form was developed by the principal author and categorised into variables corresponding to the research question such as concept, participants, study methods, associated barriers and facilitators, interventions, implications, strengths, and limitations of the study (see online supplemental appendix B - supplementary material 2). Four independent reviewers completed a thorough review of the 32 articles to extract and capture the data into the form based on the variables. If there was ambiguity or conflict regarding the extracted data, the review authors held a discussion and subsequently refined the extracted data based on the decision made.
Supplemental material
The study methodology and results were aligned with the PRISMA-ScR checklist (see online supplemental appendix C - supplementary material 3). The processes of screening and selection of relevant studies are presented in online supplemental figure 1. Using the SEM, the associated factors and barriers are summarised in a concept diagram. The interventions were summarised by themes based on the targeted risk factor or behaviour being promoted. Finally, on data analysis, the implications and significance of the results as well as any identified knowledge gaps are discussed and reported.
Supplemental material
Supplemental material
Scoping review limitations: While scoping reviews provide a comprehensive overview, potential limitations arise due to the diverse inclusion of study designs. Our review on teen pregnancy among ACB adolescents included various research methodologies, potentially impacting the consistency of methodological rigour. The broad inclusion of settings and North American countries introduced contextual variability, impacting the generalisability of findings. The expansive age range (10–19 years) acknowledged adolescence’s diversity but may lead to heterogeneity in experiences and outcomes. To address these concerns, we employed rigorous quality appraisal and involved an advisory board for diverse perspectives. Despite these efforts, readers should recognise the trade-offs in scoping reviews between inclusivity and potential variations in study quality.
Patient and public involvement
None.
Results
Characteristics of the identified articles
A total of 2083 articles produced from the search were imported into Covidence (see PRISMA diagram). After the removal of 1070 duplicate records by Covidence, 1013 articles were eligible for abstract screening. Of the 1013 records, articles included samples in countries across North America, such as Canada, the USA, Mexico, Grenada and the Dominican Republic. From the 1013 articles, 934 records were excluded, and 79 studies were eligible for a full-text review. Each included study was USA based. Of the 79 articles, 32 records were included, and 47 records were excluded for data extraction. 15 articles were excluded because the study population comprised less than 50% ACB participants. Nine studies did not have teen pregnancy as a primary outcome. Eight studies were excluded as they were published before 2010. In eight studies, complete information was not provided and was, therefore, excluded. In six studies, the age range of the population was not between 10 and 19 years . Finally, one paper was excluded because the study was incomplete. Finally, 31 articles were included in this scoping review.
The results of the study are summarised in online supplemental table 1. Also, associated factors on TPI by individual, relationship, community and public policy levels are presented in table 1. Of the 32 articles, 17 articles were published in the last 7 years (2015–2023), inclusive of one editorial6 and two conference oral presentation abstracts.26 27 Fifteen (15) articles were published between 2010 and 2015. The different studies’ methodologies and years of publication are presented in online supplemental figures 2 and 3, respectively (see online supplemental materials 6 and 7). All 32 articles were published in the USA, revealing a significant gap in Canadian literature and other North American countries. The majority of studies focused on assessing intervention efficacy1 17 27–34 and factors associated with teen pregnancy including race, behaviour, social and structural factors,6 23 35–40 indicating a strong emphasis on practical applications and understanding causative factors. The relationship between risky sexual behaviour and teen pregnancy was also frequently studied.41–44 One article primarily emphasised the influence of male teens on teen pregnancy rates.45 A good number of studies also assessed the association between socioeconomic status and teen pregnancy.7 46–48 In addition, information was provided specific to the subsets of adolescents in foster care49 and girls within the juvenile justice system.36 A statistical analysis to show the association and prevalence of teen pregnancy was also included.7 50
Supplemental material
Supplemental material
Supplemental material
Associated factors on TPI among African, Caribbean and Black adolescent boys and girls
Of the 32 articles, there are 23 quantitative, 2 qualitative, 3 reviews and 4 non-peer-reviewed literature made up of 2 quantitative and 2 editorials (online supplemental figure 3). The inclusion of various study types (quantitative, qualitative, reviews and non-peer-reviewed) and the application of different theoretical frameworks showcase the multidimensional approach researchers adopt to explore teen pregnancy. Some studies employed a theoretical framework for the research. Salihu et al 1 used an ecological framework, Mustanski et al 44 used problem behaviour therapy and developmental theory. Killebrew et al 37 used social learning theory, Hoskins and Simons42 used the social-contextual model, Rosenbaum et al 39 used the theory of gender and power. The quantitative studies had a range of sample sizes among the 23 studies: the smallest study had 51 participants, and the largest had 66 069. The mean sample size is 7231.4. The qualitative sample size ranged from 24 to 48 participants with the median size of 36 participants. Most of the available literature studied teen pregnancy with an entirely female sample. Only one study assessed an entirely male sample.45 Four assessed a mixed-sex sample with greater than 50% female participants.15 34 38 44 Three studies assessed a population that was 50% female and 50% male.29 40 51 The 32 studies included teens aged 10–19 years.
TPI rates
Teen pregnancy has declined dramatically over the past decade. Considering that each study assessed a different patient population, rates of teen pregnancy varied dramatically. Between 22 and 34.3 teen girls/1000 pregnant women give birth annually in the USA.17 30 50–52 Some populations are disproportionately affected by teen pregnancy, with the teen birth rate in Chicago 57% higher than the national average.45 Teens in foster care have a 37% increased likelihood of teen pregnancy compared with teens not in the system.49 Teens who engage in high-risk behaviours almost double their chance of experiencing teen pregnancy between the ages of 16–18.44 Teens residing in rural areas exhibit a 4% higher likelihood of experiencing planned pregnancies.48 ACB teens are disproportionately affected by teen pregnancy with birth rates 2–3 times that of white teens.7 15 29 On average, incidents of teen pregnancy ranged from 1.9 to 93.5 per 1000 births for ACB teens.49 50 Variability in teen pregnancy rates among different populations (eg, ACB teens, those in foster care and living in rural areas) underscores the importance of tailoring interventions to address specific risk factors associated with diverse subgroups. Between 16.3% and 47.5% of participants in various studies reported experiencing a pregnancy at some point throughout their lives.36–38 40 42 In one study, 37.8% of participants reported initiating sexual intercourse before the age of 13.36 However, since most studies did not report age of initiation of sexual intercourse no conclusion about early initiation of intercourse as a risk factor for teen pregnancy can be made. The lack of reporting on the age of initiation of sexual intercourse across studies hinders a comprehensive understanding of early initiation as a potential risk factor. In studying teen pregnancy rates, it is important to consider the impact of reoccurrent pregnancy with no gap or minimum gap. In this review, about 10.5%–50% of teen parents become pregnant again within a 2-year period.27 32 The prevalence of reoccurrent pregnancy with no gap or minimum gap among teen parents highlights the need for targeted interventions addressing reproductive health and contraception education. Three studies provided rates of teen pregnancy in response to an intervention and found no statistical significance.28 31 41 According to the findings presented above, teen pregnancy remains a prevalent issue that must be addressed.
Factors associated with TPI
Several factors were identified as facilitators of TPI among ACB adolescent boys and girls at the various levels of the SEM. Using concept diagrams, we summarised these findings in online supplemental figure 4A. Facilitators of teen pregnancy are factors that facilitate or predispose ACB teens to pregnancy involvement. At an individual level, there are a multitude of factors that place teens at risk. Mental illness,31 36 substance abuse,36 37 40 43 47 age,36 40 inadequate or incorrect use of birth control,27 45 religious beliefs,40 desire for pregnancy,27 47 a lack of sex education27 30 43 and socioeconomic status and poverty1 6 7 38 50 are all risk factors for teen pregnancy. Mental illness can include instability in response to trauma, depression, anxiety or eating disorders.31 36 Substance abuse linked to pregnancy is typically related to use of drugs before engaging in sexual intercourse as teens are more likely to take risks and not use birth control.37 40 43 47 An increase in rates of teen pregnancy is seen as teens age and begin to engage in more frequent sexual activity.36 40 Teen pregnancy is associated with teens using barrier contraception, such as condoms, in replacement of a long-acting contraception method such as oral contraception or an intrauterine device.27 45 Various religions commonly promote practising abstinence and do not equip teens with the information and resources for engaging in sexual activity, this leads to teen pregnancy when teens are not prepared or knowledgeable about safe sex practices.40 Similarly, a lack of sex education puts teens in a vulnerable position to teen pregnancy.30 43 Some studies examining teen sexuality found that teens who were concerned40 or trying to decipher their sexuality,47 were more likely to become pregnant. At the individual level, teens who had negative experiences and attitudes towards pregnancy prevention strategies (eg, contraception), such as experiencing side effects with their contraceptives, were at risk of teen pregnancy and were less likely to continue using contraception.17 Another study found that teens who had been non-compliant with their immediate postpartum care were more likely to experience a rapid repeat pregnancy within 2 years of a prior birth.27
Supplemental material
At a relationship level, a history of domestic or intimate partner abuse,36 49 51 high-risk sexual activity,37 41 44 relationships with an older male partner or cohabiting,39 peer pressure or peers engaging in high-risk activities,37 42 43 47 family members encouraging pregnancy,43 45 50 no adult mentorship,1 32 neighbourhood influence15 29 53 and reproductive coercion34 are all facilitators of teen pregnancy. A history of abuse by a family member or partner is a precursor for teen pregnancy, even if the abuse experienced is not sexual.36 41 49 High-risk sexual activity includes having multiple partners, not using birth control and using substances during or before intercourse.1 34 41 44 An age gap between teen partners is associated with an increase in teen pregnancy because the older partner is typically more prepared to engage in sex and the younger partner is increasingly vulnerable to pressure or reproductive coercion.39 Cohabitating with a partner can force teen girls to stay in an unhealthy relationship if they are financially dependent on their partner. Peer pressure and hanging out with peers that engage in high-risk activities such as substance abuse and sexual activity is also a risk factor for teen pregnancy since it normalises this behaviour for teens.37 42 43 47 Instances of family pressure to enter into motherhood or cases wherein family members were ambivalent about reproduction sometimes encouraged teen pregnancy which can cause teens to take more risks if they believe their pregnancy would be accepted and even desired by family members.43 45 50 For example, in Woodhams et al’s,45 a male participant explained, ‘Like I know … my [mom] don’t care, ‘cause I supposed to have a baby anyways… my [mom] want the baby.’ (p.89). A lack of positive adult mentorship can also lead to teen pregnancy if youth do not have positive role models available.1 32 Also, cases of broken families wherein there were absentee parents, particularly, dads, were associated with incidences of teen pregnancy.43 47 51 Neighbourhoods can contribute to teen pregnancy if teen pregnancy, substance abuse or violence are prominent and normalised within a community.15 29 54
At a community level, socioeconomic status and poverty1 6 7 38 50 and access to reproductive healthcare services25 32 48 are the largest facilitating factors of teen pregnancy. Socioeconomic status or poverty can contribute to teen pregnancy because teens have less resources and access to opportunities and are more likely to view pregnancy positively as a higher ranking in their social status. Access to reproductive healthcare services is key to access to birth control, abortion services and preventative healthcare. Without these resources, teens are very susceptible to teen pregnancy and STIs. Further, one integrative review47 found that certain societal messages and expectations regarding pregnancy within African American communities led young girls to desiring pregnancy and bearing multiple children at early ages in a bid to affirm their childbearing capabilities.47 No facilitators of teen pregnancy at a public policy level were identified.
Sequel to the facilitators, several factors were identified as barriers to TPI among ACB adolescent boys and girls at the various levels of the SEM. Using concept diagrams, we summarised these findings in online supplemental figure 4B. Barriers to teen pregnancy are factors that are protective or preventive against teen pregnancy. At an individual level, alcohol use was not linked to teen pregnancy rates.36 Alcohol use can increase chances of teen pregnancy if teens engage in intercourse while drinking. However, the studies included in this review did not show a correlation between teen pregnancy and alcohol use. Contraception use is a very beneficial barrier to teen pregnancy.27 31 41 45 Long-acting contraception methods are far more effective than barrier methods, but both are effective in preventing teen pregnancy. Focus on the future and goal setting is shown to prevent teen pregnancy.38 If teens feel empowered and supported by community members, they are less likely to engage in risky sexual behaviour or to attempt to conceive a pregnancy. Religious beliefs can assist teenagers in preventing teen pregnancy in some cases.40 If religions teach abstinence practices and teens practice abstinence, this is an effective way to prevent pregnancy. However, sex education and corresponding knowledge about sex and risks are very effective in preventing teen pregnancy.27 30 44 It is essential that all teens are equipped with the necessary information to prevent teen pregnancy.
Supplemental material
At a relationship level, a supportive neighbourhood environment,16 34 38 40 42 family concern and effective parenting,16 35 40 42 43 47 50 51 relational stability,1 17 49 and adult mentorship32 49 were the most effective at preventing teen pregnancy. A supportive neighbourhood environment is important to foster a community of support and active participation. A supportive neighbourhood prevents teens from engaging in high-risk activities such as substance abuse and provides teens with the opportunity to participate in community activities. Effective parenting and adult mentorship are key in assisting teens in making positive decisions. Relational stability increases the chances of safe and consensual sex practices.
At a community level, access to reproductive healthcare1 5 30 46 48 50 and living in an urban area7 48 were protective against teen pregnancy. Access to reproductive healthcare is essential to provide teens with the means and information to practice safe sex. Living in an urban area is correlated with increased access to reproductive healthcare services and a decreased desire for pregnancy.
The analysis reveals a comprehensive exploration of teen pregnancy facilitators and barriers across multiple levels of the SEM, emphasising the interconnectedness of individual, relationship, community and societal factors. At a public policy level, affordable housing policies were influential in preventing teen pregnancy by providing teens with opportunities to be financially independent of coercive or unhealthy partners.39 Increased economic and educational opportunities for youth are also instrumental in preventing teen pregnancy.7
Male involvement
This scoping review identified male involvement in teen pregnancy as a significant literature gap, highlighting the need for more research to understand and address the role of male adolescents in the context of teen pregnancy prevention. Of the 32 studies available, only 1 study studied an exclusively male population.45 Woodhams et al 45 revealed that the way male teens view the responsibility of preventing pregnancy and perceived risk level is key factors in facilitating teen pregnancy. To elaborate, ACB male teens report using barrier contraception in casual relationships and at the beginning of long-term relationships. However, as the relationship progresses or becomes monogamous, the method of preventing pregnancy changes to a female-directed approach (typically long-acting contraception). Gray et al 36 studied an exclusively female population but provided insight into factors associated with the history of TPI from the perception of these girls who included their sex partners. It was found in other studies that male teen, particularly ACB male teens, are perceived by their female partners to desire teen pregnancy.43 Therefore, desire of a pregnancy is associated with the male involvement in teen pregnancy.
Of the eight studies that reported a mixed-gender sample with greater than 38% male participants, five reported findings specific to male involvement in teen pregnancy. One study recognised that the baby simulation intervention, where middle school students take care of a baby simulator, was significantly less effective on males than females.34 In particular, it had the opposite effect on ACB males, increasing their sexual activity.34 Mustanski et al 44 noted that there is potentially a higher risk of substance use and risky sexual behaviour among males than females. However, it is important to note that risky sexual behaviour also varies with age and as age increases, so do the percentage of females engaging in risky sexual behaviour.44 Kogan et al 38 found no difference in responsiveness to a supportive community-based intervention between male and female participants. The authors speculate that this difference may be attributable to the lack of research on ways to support teens through development, instead of minimising risk factors.38 Dallas51 found that male teens who have entered teen parenthood need the same resources and sex education available to them as female teens. Thomas Farrell et al 40 report the acceptance of a heteronormative culture as a risk factor for both male and female queer teens who are hiding their sexuality, increasing their chances of risky sexual behaviour. Barbee et al 55 suggest that a positive attitude towards early premarital pregnancy is associated with male gender.
Interventions to reduce
Several interventions were found to be effective in reducing TPI among ACB adolescent boys and girls who underscore the importance of multifaceted approaches in reducing teen pregnancy rates. Damle et al 27 and Frarey et al 28 showed that prescribing teens a long-acting birth control in the immediate postpartum period is very effective in preventing rapid repeat pregnancy. In addition, Summers et al 47 discussed that many teen pregnancy interventions specific to the ACB population are understudied, and those that are effective were the interventions that included parents of teenagers or addressed substance use. Another study identified that more pregnancy prevention programmes need to focus on high-risk geographical areas involving ACB minorities.50 Interventions tailored to specific geographical locations and societal expectations demonstrate the importance of context-specific strategies in addressing teen pregnancy. Teen mentorship programmes have been shown to encourage teens to finish their education and achieve employment.32 The Federal healthy start programme by Salihu et al 1 provided ‘sex education, family planning, drug and prevention education, and communication and negotiation skills acquisition’ (p. 153). This programme was successful in decreasing rates of teen pregnancy. Another programme showed a 50% reduction in rapid teen pregnancy through the introduction of a home-care parenting intervention where teens had increased access to birth control.31 Somers34 evaluated an intervention programme aimed at increasing self-efficacy to resist sexual pressure and personal intention to avoid adolescent pregnancy. The Moving to Opportunity programme offers affordable housing to at-risk youth and may decrease rates of teen pregnancy by providing a safe environment.29 The 2gether project decreased teen pregnancy through a multimedia platform and contraception counselling.17 The CHOICE programme also used contraceptive counselling for youth experiencing health disparities.46 The baby simulator intervention proved to be an effective educational initiative, however, there was no way to measure its long-term impact on teen pregnancy rates.34 Another study showed that community mobilisation and sustainability can engage neighbourhoods and result in overall positive health outcomes, it is possible that this would have a long-term impact on teen pregnancy rates.16 Overall, the provision of informed and non-judgemental sex education was a very effective intervention in preventing teen pregnancy.30 37 45 50 Important to note were studies which had highlighted abstinence education in relation to teen pregnancy rates. While one systematic review noted effectiveness of some abstinence-based intervention programmes in reducing teen pregnancy rates,30 another study examining the association of state-mandated abstinence-only sexuality education (AOSE) with rates of adolescent HIV infection and teenage pregnancy, found that US states with more restrictive AOSE policies, and with greater proportions of at-risk populations (ie, adolescents who live below the federal poverty level and attended schools with >50% of an African American population), had higher adolescent HIV and teen pregnancy rates.26 The controversy surrounding the effectiveness of abstinence-based education programmes emphasises the ongoing debate within the literature, suggesting the need for nuanced approaches that consider diverse perspectives. The various interventions identified by the studies are categorised into themes and presented in table 2 and online supplemental figure 5.
Supplemental material
Themes emanating from intervention studies
Discussion
Overview of findings
The results derived from the analysed studies emphasise the ongoing issue of teenage pregnancy, notwithstanding an overall decrease in the past 10 years. The prevalence rates displayed considerable differences across various demographic groups, underscoring the requirement for customised interventions. The discrepancies in teenage pregnancy occurrences among ACB teenagers, individuals in foster care and those living in rural areas underscore the significance of tackling distinct risk elements within diverse subcategories. The recurrence of pregnancies with no intervening gap or minimum period presents a significant obstacle, accentuating the essential need for precise interventions concentrated on reproductive health and contraception education.
The SEM furnishes a thorough framework for comprehending the diverse elements that contribute to teenage pregnancy. Factors at the individual level, encompassing mental health issues, substance misuse, age and suboptimal contraceptive practices, illustrate the intricate web of influences. Facilitators at the relationship level, such as domestic violence, engaging in high-risk sexual behaviours and peer influence, further compound vulnerability. Factors at the community and societal levels, such as socioeconomic status, accessibility to reproductive healthcare and societal norms, assume crucial roles. Identifying these facilitators facilitates the design of interventions that acknowledge the interplay of factors across multiple levels.
Research gap
This extensive scoping review has led to the discovery of gaps and other very crucial issues that were not highlighted in existing literature. The gap in the literature reveals that there are no published articles and no noted rates of TPI in both boys and girls in disproportionate and marginalised populations specifically among ACB adolescents in Canada. In addition to the gap of no published articles on TPI among ACB in North America, the literature was silent on the significant role that male involvement played in teen pregnancy. This, however, is concerning since the pregnant teen needs the sympathy, support (emotional, financial, spiritual), love and presence of the male responsible for her pregnancy which inevitably could also guarantee her access to reproductive healthcare and antenatal services.
The results of the scoping review which were all published in the USA between 2010 and 2023, leave a huge gap in Canadian literature which is concerning considering that teen pregnancy remains a critical health and sociocultural issue that needs to be addressed.17 The most frequently studied relationship in the selected articles is between teen risky sexual behaviour and teenage pregnancy.41 Guided by the SEM, at the individual, relationship, community and public policy levels, the findings indicate complex intersectional and multiple factors that predispose teens from these selected marginalised populations to teen pregnancies.6 32 These associated factors resulting from existing social inequities include risky sexual behaviours, misuse or disuse of drugs including contraceptive methods and pills, lack of information/sex education, religious beliefs, peer influence, neighbourhood pressure, poverty, low socioeconomic status and a lack of and limited access to contraceptive and reproductive health services.6 32 45 49
The interventions towards teen pregnancy prevention are vast and can stem from the individual, relationship, community and policy levels. Studies reviewed have identified social inequities in the settings where most of these marginalised groups live and this is a major barrier to most of the interventions that may be effective in preventing teen pregnancies among ACB adolescents in Canada. As such, the individual teen could be empowered to set achievable goals geared towards a focus on the future.38 This intervention is possible through family and supportive community mentorship and educational programmes focused on reproductive health and sex education27 Parents should develop a healthy, comfortable conversation around sex with their teens or establish collaborations with school-based programmes that embrace this conversation around sex to educate their teenagers on risky sexual behaviours.30
Educational programmes should be developed that are age appropriate and all inclusive (girls and boys) to address issues of sex education and should be included in educational curriculums.35 It is also essential that after school programmes are established and encouraged to keep teenagers occupied with developmental programmes and consistent building of self-esteem through these projects.30 Thus, community members can organise sustainable career awareness and facilitate jobs for teenagers through community projects.16 Through these projects, there could be the creation of safe neighbourhoods for teens who should feel safe in these environments. Religious and state mandate organisations can also promote teenage pregnancy prevention through teachings on abstinence, responsible sex behaviours and parenting, harmful and/or discriminatory sexuality education policies26 and issues of faith with sexuality at teen ages.47 In addition, there is an urgent need for policies to be enacted to address difficulties in accessing teen pregnancy health centres, and inequitable distribution of social amenities such housing, education and health centres.6 The long-acting reversible contraception (LARC) has been identified as a very effective methodology for teens and as such, should be encouraged for use by teenagers.31 41 Further, programmes and policies should be enacted which support male involvement and equal responsibility.51 Thus, teenage pregnancy should be addressed and seen as an issue for both girls and boys and not an issue for only girls. These policies should encourage the use of professional help and more advocacy on issues bordering neglect of pregnant teens girls by their male partners.45 These interventions are applicable media through which TPI could be addressed.
This scoping review highlights important evidence to fill gaps related to teen pregnancy involvement among ACB adolescent in other North American Countries, outside of the USA, particularly,in Canada, which shares multiple borders with the USA. Of note, are the study’s recommendations which are applicable to other North American countries. These recommendations include the importance of (1) examining male involvement with equal responsibilities in teen pregnancies; (2) policies which should be enacted, implemented and sustained in marginalised populations who support and promote equity in housing, education, health and employment opportunities for teens and (3) most importantly, it is prudent to conduct further research on TPI among ACB adolescents boy and girls within other geographical settings in order to fully understand the immensity of this problem and to develop context-specific tools and strategies towards addressing the problem of TPI among ACB adolescents.
Strengths
To our knowledge, our study is the first of its kind to contribute significant evidence on the scope of TPI among ACB adolescent boys and girls in North America. Our study also had an emphasis on examining male involvement, thus, our results provide unique evidence related to male involvement in the outcomes of pregnancy among ACB adolescent boys and girls. In addition, the study followed a very rigorous process of accessing, evaluating and extracting retrieved evidence. The authors are confident that they observed adequate and thorough scrutiny in assessing each article to ensure accuracy of extracted data and its relevance to meeting the review’s goals. Each individual study was thoroughly checked by two or more authors, against the study’s inclusion and exclusion criteria, and its strengths and limitations were noted. Weekly meetings and conversations were held during the entire review process to discuss the review’s progress and any issues arising. The inclusion of an advisory board in our study processes was a huge plus and benefit to our study as it enhanced our validity and transferability.
Limitations
While we set out to conduct a scoping review of TPI in North America, our study results stemmed primarily from analyses of evidence from the USA. While this limits the generalisability of our study’s findings to ACB adolescent boys and girls, in other countries outside the USA, it also intensely highlights the need for more research and data on TPI, particularly for visible minorities, to be generated within other predominantly white countries in North America. In addition, it is important to note and appreciate the diversity and heterogeneity that exist within the African/Black culture. Thus, interventions generated from this review ought to be implemented with caution for all ACB teen populations. Given this prior knowledge, we ensured that our advisory board consisted of persons with diverse African/Black heritage and/or culture or nationality.
While scoping reviews offer a comprehensive overview, our examination of teen pregnancy among ACB adolescents is limited by the diverse inclusion of study designs, potentially impacting methodological consistency. We aimed to encompass North American countries; however, our search yielded studies exclusively conducted in the USA. The inclusive age range recognises adolescence’s diversity but may result in heterogeneous experiences. Despite rigorous quality appraisal and advisory board involvement, readers should acknowledge trade-offs between inclusivity and potential variations in study quality inherent in scoping reviews.
The majority of the included studies did not provide information on the age of initiation of sexual intercourse. Therefore, drawing conclusions about early initiation of intercourse as a potential risk factor for teen pregnancy is impeded by the lack of reported data on this aspect across the studies.
Nursing implications
In nursing practice, the identification of factors influencing TPI will help increase nurses’ knowledge regarding pregnancy risk factors. Nurses can screen for these factors and address them as needed during therapeutic interactions with teens.47 This will be an effective medium for identifying high-risk and vulnerable teens for better tailored interventions to these teens and hence, increase efficacy in preventing teen pregnancy.7 Additionally, nursing administration needs to ensure that there is the promotion of easy access to teen contraception by prioritising reproductive healthcare in appointments.6 48 That notwithstanding, there should be the consistent administration of short-term/long-term) follow-up surveys to teen patients on pregnancy involvement.30
For nursing research, the review findings have demonstrated that there is the need for future nursing research to focus on key areas in teen pregnancy prevention such as social and contextual factors that increase risk of teen pregnancy, parental involvement and or peers in counselling, training of adult mentors, supporting adult teen mentoring, enrolling teens before childbirth, areas of building on racial congruence between research team and participants, and find more effective ways of reducing unintended pregnancies.32 42 46 In line with this, in nursing education, emphasis needs to be placed on equipping nurses with the requisite skills to enable them to build therapeutic relationships that create a safe, welcoming and friendly environment so that teens can feel comfortable discussing their fears and reproductive concerns with them.15 Nurses should also be trained to give age-appropriate sex education to teens and reduce racial disparities in the provision of care to teens.46
Further, for policy and knowledge translation regarding TPI, the research findings have highlighted the urgency in enacting, implementing and sustaining equitable distribution and the promotion of easy access to reproductive health services for at-risk groups (blacks, people with low socioeconomic status).53 Findings that have also been identified to be effective in mitigating TPI such as sex education in school curriculums need to be made compulsory for all elementary, junior and senior high schools.43 There should also be the integration of mental health and social work into primary care setting and these programmes can be tailored to unique family needs.31 To seek the views of the public on the study, an advisory board was formed to appraise the study findings through a discussion forum via Zoom.
Patient and public opinion
An advisory board is a group of people with expertise, opinion or experiences in a phenomenon of interest who are recruited for purposes of research to solicit feedback on research procedures, develop research partnerships/opportunities in knowledge development.20 Specifically, for studies involving minority groups such as in TPI involving ACB’s, an advisory board is necessary to provide expert advice, current knowledge, guidance and critical thinking that increases the reliability of study processes and level of confidence in the study’s findings/recommendations.20 25 The advisory board for this scoping review was recruited through a snowball sampling method and grouped into two teams: (1) Medical practitioners made up of two registered nurses, a clinical doctor, public health specialist, paediatrician, midwife, pharmacist and a nurse educator who have had clinical experiences working with teenagers; (2) Teenagers from grade 10 to university level between the ages of 14 and 19 years. Their thoughts, which were in congruence with the study’s findings were grouped under five themes towards curbing TPI: societal/relationship level and male involvement, health practice, policy level and future research. These are summarised in table 3.
Advisory board/public opinion’s feedback on study
Conclusion
TPI among ACB teens in North America is a crucial public health concern that is largely influenced by the social determinants of health. Though teen pregnancy has dire consequences on the health of the teen, their families and the larger community, very little is known about the various dimensions and outcomes of male involvement in teenage pregnancies, especially in North America. In nursing, a scoping review such as this, will guide and provide direction for future research towards reducing the incidence of teenage pregnancy involvement among ACB in North America.
This comprehensive scoping review has unveiled critical gaps and issues overlooked in existing literature, particularly regarding teen pregnancy among ACB adolescents. Notably, the absence of published articles and documented rates in Canada for both genders within these marginalised populations underscores the urgent need for targeted research and interventions. The silence on the substantial role of male involvement in teen pregnancy is a concerning oversight, as recognising the importance of the male partner’s support is crucial for the holistic well-being of pregnant teens. The identified interventions spanning individual, relationship, community and policy levels offer a pathway to address social inequities hindering effective strategies in marginalised settings. Tailored programmes focusing on family and community mentorship, comprehensive sex education and after-school initiatives can empower individual teens, fostering a sense of safety and belonging in their environments.
Terminology
Abstinence education: Educational programmes promoting abstaining from sexual activity until marriage, often part of sex education initiatives.
Advisory board: A group of individuals, often experts or stakeholders, providing guidance, feedback and validation for research findings and recommendations.
Antenatal care: Medical care provided to pregnant individuals before childbirth, focusing on monitoring and promoting the health of both the pregnant person and the unborn child.
Abstinence Only Sexuality Education (AOSE): Educational programmes that exclusively promote abstinence from sexual activity until marriage.
Heteronormative culture: A cultural perspective that assumes and promotes heterosexuality as the norm, marginalising non-heterosexual orientations.
Informed and non-judgemental sex education: Educational programmes that provide comprehensive and unbiased information about sexual health and practices.
LARC: long-acting reversible contraception
Low birth weight: A newborn weighing less than 2500 g (5 pounds, 8 ounces) at birth.
Teen Pregnancy Involvement (TPI): Refers to adolescents’ engagement in pregnancy, encompassing both boys and girls.
Preterm delivery: Giving birth before completing the full term of pregnancy, which is generally around 37 weeks.
Scoping review: A research methodology designed to map the existing literature, identify key concepts and provide a comprehensive overview of a specific topic. Scoping reviews are known for their inclusivity and exploration of diverse evidence sources.
Socio-Ecological Model: A theoretical framework that examines how individuals' behaviours and health outcomes are influenced by a combination of personal, interpersonal, community and societal factors.
Rapid-repeat teen pregnancies: Successive pregnancies occurring in quick succession during adolescence.
Data availability statement
Data for this scoping review were obtained from publicly available literature sources and databases. All cited references are accessible through their respective publication channels.
Ethics statements
Patient consent for publication
Acknowledgments
We would like to acknowledge UBC Librarian and Library Research Commons team member—Katherine Miller and Elham Esfandiari, for their assistance in refining the search strategy. Particularly, Katherine Miller, who had repeated meetings with team members to refine their searches in the various databases. We would like to express our gratitude to the advisory board consisting of African, Caribbean and Black healthcare providers, parents and teenagers. Their expert advice and feedback were instrumental in guiding our study analyses, processes and results. Their valuable contributions significantly enhanced the quality of our research.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors EO conceived the idea for the scoping review and designed the protocol. EO performed supervisory roles and also contributed to the writing and editing of the manuscript to ensure intellectual content. EO is the study's guarantor. EB contributed to the writing and editing of the manuscript, particularly, the discussion section. EM contributed to the writing and editing of the manuscript, particularly, the results section. SA and SS contributed to writing and editing of introduction and theoretical framework. HG contributed to writing of the methodology. ES provided expert review and written contributions to the manuscript. All authors contributed to data acquisition, writing the original draft, reviewing and approving the final version for submission, based on the International Committee of Medical Journal Editors (ICMJE) guidelines for authorship.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.