Is a woman’s first pregnancy outcome related to her years of schooling? An assessment of women’s adolescent pregnancy outcomes and subsequent educational attainment in Ghana

Childbearing during adolescence (between ages 10 and 19) is associated with lower educational attainment while the reverse has been shown for adolescent girls who do not get pregnant or choose to terminate the pregnancy when they do. In this study, the relationship between women’s first adolescent pregnancy outcomes, that is, pregnancies ending in a live birth, induced abortion, spontaneous abortion or no pregnancy, and their current years of schooling was examined. This relationship was also observed across the 20–29, 30–39 and 40–49 year age groups.

The 2007 Ghana Maternal Health Survey dataset was used for the study. The total sample consisted of 8186 women between ages 20 and 49.

Results showed that just over one-half of the women had no pregnancy below age 20; while about 40% of those who were pregnant as teenagers gave birth. Women’s years of schooling also ranged from 0 to 18. Those who had pregnancy outcomes as induced abortions had the most years of schooling and those who had live births had the fewest. These teenage mothers exhibited educational levels similar to those who had spontaneous abortions (miscarriages and stillbirths). When the age at which women had their first pregnancy was included in the analysis, then those who had no pregnancies had similar educational levels as those who had given birth. Also, women between ages 30 and 39 had results that contradicted those of all women.

Interventions to help keep young girls in school must emphasize their delaying pregnancy and childbearing for as long as possible.

The cultural attitudes and practices pertaining to fertility among most sub-Saharan Africans, and Ghanaians in particular, depict a pronatalist stance [1‐3]. This is made even more evident as despite the fact that fertility trends in Ghana over the past three decades indicate a substantial transition from 6.4 to 4.2 births, there has been a stall since 2003 [4] at levels nearly double the replacement value. There are variations in fertility rates across the country and this may be attributable to socio-economic differentials more than geographic ones [2]. One socio-economic indicator that has had a complex effect on fertility in Ghana is formal education [5]. A longstanding relationship exists between the educational attainment of women and their fertility, where generally, higher educational attainment is associated with lower fertility [5‐10].

From the literature we understand that women with low educational levels tend to report higher parities, since they start bearing children earlier [6, 7, 11, 12]. In most sub-Saharan countries,¹ including Ghana, when teenage pregnancies arise, young girls tend to discontinue their education in order to give birth. However, the relationship between pregnancy and schooling also exists in the opposite direction; thus, young girls may be dropping out of school prior to the pregnancy [13]. Reasons for the incidence of school dropouts include their poor academic performance, a lack of funds to continue schooling and family problems, to name a few [4]. There is a negative association between educational aspirations and academic performance, and teenage pregnancy. Those who perform poorly in school and have no aspirations are more likely to experience a teenage pregnancy [14]. They may either drop out before or after the pregnancy. All these established relationships ultimately help us to understand the bi-directional nature of the phenomenon. Findings from the most recent Ghana Demographic and Health Survey (GDHS) show the majority of women (ages 15 to 24) cited financial constraints as their reason for not completing school (38.7%). Only 1.5% of the women mentioned a pregnancy as their reason for dropping out, while 9% stopped school for family reasons or to get married [4]. A qualitative study conducted with young girls in Accra share similar sentiments [15], and this suggests that young women may currently not be dropping out of school due to pregnancy as before.

Much has been written about sub-Saharan African women’s fertility and educational attainment, and studies have gone further to examine other pregnancy outcomes in relation to women’s educational attainment as well [3, 5‐9, 12, 16]. Research has shown that women with higher educational levels are likely to have terminated a pregnancy at some point in time as opposed to them giving birth [17]. Bleek [18, 19] suggests that mass education contributed to the increase in induced abortions among the Akan in Ghana, where young women were terminating pregnancies in order to continue with their education [18‐20]. Among the reasons for inducing abortions, women often cite continuing with their education as one of them. The 2007 Ghana Maternal Health Survey (GMHS) [21] found that out of the 563 women who had terminated pregnancies between 2002 and 2007, about 10% cited the reason for it as wanting to continue schooling. Women who also want to continue schooling or have educational aspirations are more likely to delay the onset of sexual debut [14], or use contraception effectively to prevent unintended pregnancies [16], and if they happen to get pregnant are more likely to terminate it [22]. Not much research has focused on young girls’ experiences with spontaneous abortions. However, the literature does note that due to their physiological make up as well as a lack of sexual and reproductive health knowledge and access to services when pregnant, adolescent girls are more likely to experience miscarriages and stillbirths than older women [23, 24].

The relationships between these different pregnancy outcomes among adolescents and their educational attainment have rarely been studied together, but doing so provides a means to loosely compare women’s different birth outcomes and their subsequent socio-economic levels. Zabin, Hirsch and Emerson [25] were able to assess longitudinally the relationship between three groups of black adolescent girls who attended a facility to carry out a pregnancy test. One group opted for an abortion; the second opted to give birth while the last group had negative pregnancy test results. Two years later, the study found that young black girls who had opted to carry their pregnancies to term as well as those who were not pregnant suffered negative educational outcomes compared to those who opted for induced abortions [25]. Overall, young girls have different motivations driving them to their pregnancy outcome decisions and these may have repercussions on several aspects of their lives, including their educational attainment [22, 25].

As education continues to become important to women in Ghana, and opportunities for equal access to education, especially at the higher levels, exist, it may have a bearing on their pregnancy decisions and ultimately reproductive health. Ghana’s education policy strives to empower women by promoting gender equality in the classroom. The policies and programs intensified over the past few decades have included making basic education free and compulsory to ensure access to education for all [26, 27]. Affirmative action initiatives have also guaranteed that more women are enrolled in tertiary institutions [28, 29]. Despite these strides, there are still discrepancies between the highest educational attainment levels of men and women, with men exhibiting higher median years of schooling. In addition, literacy rates are higher among 15–24 year old men than their female counterparts (89.3% versus 80.9%) [4] while the tertiary school gender disparity index stands at 0.63² [30]. Female education has been deemed the solution to most problems in society, but unfortunately, there are challenges to some women’s attainment of higher educational levels. Pregnancy outcomes as barriers to adolescent female education are of particular interest to us in this paper.

To the best of our knowledge, not many studies have undertaken a quantitative assessment using nationally representative data from Ghana on the relationship between education and pregnancy outcomes, and whether it is similar across different age cohorts. Similar studies have used either hospital or community-based surveys or qualitative data [11, 25, 31‐33]. A nationwide examination of this phenomenon would aid in our understanding of Ghanaian women’s education and pregnancy actions as various policies and programs over 30 years have been implemented to benefit women’s educational attainment. Therefore, in this paper, we aim to examine the first pregnancy outcomes of women in Ghana during their teen years to gain insights into how the outcomes relate to their current educational attainment levels. We also assess this looking at three synthetic cohorts of women, 20–29 year olds, 30–39 year olds and 40–49 year olds, separately, to examine differences in attainment levels by pregnancy outcomes across the three time periods. This paper seeks to show the contribution of all the different outcomes of adolescent pregnancy to female education in Ghana.

The background characteristics of all women and across age groups in our sample are depicted in Table 1, while those of ever been pregnant women are shown in Table 2. Generally, among all women aged 20 to 49, just over one-half had not been pregnant as teenagers. The next highest proportion of women (39.8%) had live births as teenagers, while 2.9% and 6.5% had spontaneous and induced abortions, respectively. These results are significantly different across the three age cohorts, since as age groups increased the number of women with live births and induced abortions increased, while the proportions that had no teenage births reduced.

Close to half of the respondents were Akan, 13.5% were Ewe, about 10% were Mole-Dagbani. Other smaller ethnic groups came together to make up 20% of the sample. These proportions were consistent across the age groups. Women ascribed mostly to the Pentecostal/Charismatic Christian denominations. The proportion of Catholics and Protestants were 14% and 17.6% respectively. The ‘Other’ religion category consisted of Other Christians, Traditionalists/Spiritualists as well as Eastern and other religions.

The majority of respondents resided in rural settings across Ghana, and more 40–49 years olds lived in rural areas than did the 20–29 year olds. The general trend of the wealth quintile showed higher proportions of women in the poorer categories and lower proportions in the richer categories. However, the youngest cohort of women was an exception as they had the smallest proportion in the poorest category and higher proportions compared to the others in the rich and richest wealth categories. Women’s frequency of abortions was generally low. The majority had never had an abortion at the time of the survey. As the number of abortions increased, the proportion of women with repeat abortions reduced drastically. Also, as the age cohorts of women increased, the frequency of abortions increased. This is likely since older women would be exposed to more pregnancies and more opportunities to terminate them. The characteristics of the ever been pregnant only women were very similar to all women, as their proportions across the various categories of the background characteristics were generally comparable. However, removing women who had never been pregnant took out almost half of the younger age cohort residing in urban settings. These were also mostly women in the richer and richest wealth quintiles among the ever been pregnant group of women (see Table 2).

Table 3 displays the mean years of schooling, number of pregnancies, and ages at first pregnancies. As expected, years of schooling were inversely related to age, while number of pregnancies was directly related to age. Women who had ever been pregnant also exhibited less years of schooling and more pregnancies than all women. Finally, the mean age at first pregnancy was high at 19.9 years, and this was roughly the same across the three age cohorts.

Results from the bivariate regression analyses, as indicated in Table 4, show that among all women (20–49 years) and across the three age groups, those with induced abortions and no pregnancies had significantly more years of schooling than women who had live births as teenagers. The relationship was not significant for those who had spontaneous abortions. The same findings are noticed among only the women who had ever been pregnant, except that the beta coefficient value decreases, suggesting less years of schooling once women who have never been pregnant are excluded from the model. The same patterns are shown in Fig. 1, where the mean years of schooling are assessed by the pregnancy outcomes.

Similar levels are shown between adolescents with live birth and spontaneous abortion experiences. Those with induced abortions have the highest levels of education across the age groups. In addition, once women who had never been pregnant were excluded, the educational levels of women with no pregnancies as teenagers declined.

At the multivariate level of analysis, the same results seen in Table 4 still hold for all women ages 20 to 49 years, where those with induced abortions and no pregnancies have significantly more years of schooling than those with live births (see Table 5). However, upon examination of the age groups separately, we see that it is only among the 30–39 year olds that the relationship with induced abortion and educational attainment does not hold. Among this group who experienced induced abortion, they had similar years of schooling to those who had live births. Results for the covariates were consistent across the age groups. Akans had higher educational levels than the ‘Other’ ethnic groups; all other religious denominations except Protestants had less educational attainment levels compared to the Catholics. Urban residents were also more educated than the rural folks. As wealth quintile increased, the years of schooling of women also significantly increased. The number of pregnancies a woman had was inversely associated with her years of education attained, while the frequency of abortions a woman had was directly associated with her years of schooling. Finally, as women’s ages increased, they had significantly less years of schooling.

Once the age at first pregnancy was included in the model, which also simultaneously indicated that women with no pregnancies were removed from the analysis, the findings drastically changed (see Table 6). Women with no teenage pregnancy, suggesting their first pregnancy was after age 19, had educational attainment levels similar to those who had live births as teenagers. This indicates that it was the women who had never been pregnant that increased the years of schooling of the group; and thus, having experienced a pregnancy after teenage years gave women similar years of schooling as those who gave birth as adolescents. Once again, those with spontaneous abortions had educational levels similar to those with live births.

Across the three age groups, we see similar patterns in the relationship between education and pregnancy status, except for the 30 to 39 year olds, where after controlling for the age of mother at the time of her first pregnancy, women with no births as adolescents had significantly fewer years of schooling than those who gave birth. This means that the 30 to 39 year olds not experiencing adolescent pregnancy fared worse than those who had live births. Additionally, as with all women in Table 5, those aged 30 to 39 years with induced abortions as their first adolescent pregnancy outcomes had similar educational attainment levels to those who had given birth.

Age at first pregnancy was an overall significant predictor of educational attainment except among the 40 to 49 year old respondents. This implies that for them, the age of the mother at her first pregnancy did not significantly influence her years of schooling. However, generally, a one year increase in women’s age at first pregnancy resulted in an increase in the number of years of schooling by 0.119 years. The multivariate regression models had high adjusted R² values in the 40s which indicated good fitting models.

The aims of the study were to identify the effect of pregnancy outcome on educational attainment among women in Ghana, and also to assess the relationships between educational attainment and pregnancy outcomes across three age cohorts. At the various levels of analyses, the results show a significant relationship between first adolescent pregnancy outcome and educational attainment. As expected, the findings generally support the first hypothesis but partially support the second hypothesis; therefore, women with induced abortion experiences and no births, respectively, have higher educational attainment levels than those with live births. Without age at first pregnancy being controlled for in the model, women with no teenage pregnancies had significantly higher education; however, including their ages at that time resulted in similar educational attainment values with those who had live births. This implies that it may not be the pregnancy that results in the lower years of schooling but that eventually having a baby, especially at younger ages, may set women back in their education. Pregnancy and childbearing come with concomitant physiological, psychological, social and financial challenges, and without an adequate support system young girls, whether adolescents or young adults, may not be capable of returning back to school after these events take place [36]. Therefore, delaying childbearing well after adolescence should result in girls staying in school longer, especially if their motivations for discontinuing school were due to pregnancy.

The findings, however, fail to support the third hypothesis, since women whose pregnancies ended spontaneously had similar educational levels as those with live births. This could be because the young girls may have planned to keep the pregnancies and expected to give birth but then by chance did not go on to have live births. Thus, their dispositions toward the pregnancy may be similar to those who had live births. Perhaps, they even went on to have subsequent births soon after, as is the case for women who experience miscarriages, stillbirths and neonatal deaths [37‐40]. Additionally, the effects of the pregnancy loss, that is, the shame or disappointment, alongside the loss of desire to return back to the classroom, the ails of missing classes and possibly having to repeat a grade, among others, may have resulted in their truncated years of schooling [36].

In their longitudinal study among US female adolescents, Xie et al.’s [14] post hoc analysis showed that better academic performance and higher aspirations resulted in a lower likelihood of teenage pregnancy. This could infer that the brightest and more ambitious pupils, who have something to look forward to, may resort to abortion and continue schooling, while their less studious counterparts stop schooling and ultimately give birth [14]. With this particular dataset, it is difficult to determine whether this phenomenon occurred. In general, schooling can have a protective effect on young people [12] and does this through various means, that is, providing education, skills, monitoring, protection, and so on [41]. Dropping out exposes them to risks of pregnancy and childbearing since if they are no longer enrolled in school they are more likely to get pregnant and keep the pregnancy [14, 41]. On the other hand, schooling also provides networks that may expose young girls to sexual relationships and activity, which may include having sex for school fees and rides to school, as well as some of the luxuries that their friends may have [15, 42, 43]. Generally though, the benefits of formal education far outweigh the risks.

Even after controlling for subsequent pregnancies (if any, which could have resulted in childbirth and induced or spontaneous abortions) after that first pregnancy, the general patterns remain. Thus, we can see that young women in Ghana have accessed abortion services in order to continue with their schooling. This is made evident by the high educational levels of those whose first pregnancies as teenagers were terminated, and even seem to achieve more than those who never got pregnant. The women who gave birth or suffered spontaneous terminations as teenagers seem to be the most disadvantaged groups and this indicates a need to target any conditions that may be putting them at risk of pregnancy. Although not overtly indicated from the findings, the results subtly show that ambition and aspirations of women may be the underlying factor that leads to high educational attainment, confounding the relationship between induced abortion and educational attainment. Aspirations may act as a protective factor for women where ambitious girls are less likely to get pregnant but then if circumstances arise where they get pregnant they are also more likely to abort. Thus, the young girl’s personality or personal agency may drive her to continue her education, thereby resulting in a pregnancy termination or not. Reasons women in Ghana provide for terminating pregnancies vary [44]; and although personal decisions to stay in school or delay/space births are featured, external drivers such as family and partner influence are also very critical to determining how the pregnancy ends [44].

Traditionally, education is seen to contribute to the lowering of fertility through a variety of means, including effective contraceptive uptake [16] where educated women and their partners tend to adopt a modern method of contraception to prevent unintended pregnancies. However, in this study, induced abortion seems to be an alternative for sexually active young women to fall on, providing further evidence that young girls may be resorting to induced abortion as their means of birth control [20]. Additionally, the literature shows no relationship between women’s educational attainment and the safety of the induced abortion methods they employ [45]. Therefore, young girls may be putting themselves at risk as they resort to unsafe induced abortions to terminate their pregnancies in order to stay in school.

Findings across the age groups support hypothesis four, as all women and ever pregnant women, with age groups 30–39 and 40–49, had significantly less years of schooling than the youngest age group. In addition to this, the pregnancy outcome – education relationship was also assessed across three 10-year age cohorts. We see that there were generally similar patterns across the age groups. The only exception was with the 30 to 39 year olds. Among these women, those with induced abortions had similar years of schooling compared to those who had live births. It was rather those with no births that had significantly higher educational attainment level, and this reduced when age at first pregnancy was introduced into the model. In an attempt to understand the age group differences, especially the results among the 30–39 year olds, we briefly reviewed some literature that discussed the economic, social and political contexts that may have possibly influenced female education during the three decades. First, respondents aged 40–49, 30–39 and 20–29 years would have roughly enrolled in primary/basic school in the 60’s-70’s, 70’s-80’s and 80’s-90’s, respectively. During the 90’s, education became a priority, especially for girls, and these reforms may be influencing the high levels younger women are attaining [26, 27]. During the 70’s to the mid 80’s, Ghana went through economic turmoil, a series of coups and eventually a famine, which had a powerful negative effect on women’s lives including education [46, 47]. On the other hand, the 60’s represent more prosperous economic times in Ghana where, post-independence, education was deemed a necessity for development. The government invested in primary, secondary and tertiary education across the country for both boys and girls [47]. Despite this, our results imply that many young women still were not able to attend school during that period.

Our findings also show that educational attainment of women declined as age increased which may be indicative of the changing times and success of programs that have encouraged young girls to stay in school longer. However, in order to meet the Sustainable Development Goals (SDG) that call for access to equitable and quality education for all, a more inclusive system needs to be adopted countrywide to encourage pregnant teenagers to continue schooling, especially after they give birth. There is also the need to strengthen these young girls’ rights to education. In our study, both older and younger women who gave birth faced similar situations when it came to their educational attainment and showed that for decades, dropping out of school has left girls with roughly the same levels of educational attainment.

Current efforts to promote the sexual and reproductive health of young women include establishing adolescent health clubs in secondary schools and adolescent health corners in health facilities, providing access to information, education and communication on adolescent health issues through youth-centered television programs, to name a few [48, 49]. There has been no extensive evaluation of these interventions but generally contraceptive use among adolescents remains low, unmet need is high and adolescent pregnancies have slightly increased from 13.8% in 2008 to 14.2% in 2014 [4, 48‐50]. In a context where the median age at sexual debut is 18.4 years and the proportion of 15 to 19 year olds reporting sexual experience increased from 37.3% in 2008 to 42.7% in 2014 [4, 50], adolescent pregnancies are expected. It is these pregnancies, unless aborted, that pose as barriers to young girls’ educational attainment [18, 19, 33]. In-depth studies, especially concerning the sexual and pregnancy-prevention practices and life aspirations (whether educational, career, financial, marital, social, etc.) of adolescent girls, are essential to us understanding the issues holistically in order to provide interventions for their reproductive health needs.

Overall, among those pregnant at young ages, abortions may result in higher educational attainment, while live births are linked to low levels of education. As expected, women with induced abortion experiences had more education than those who chose to give birth. This finding cuts across for women of all age groups, suggesting that Bleek’s [18] statement may hold for women all over Ghana. Pregnancy at young ages may be setting women back, placing them at a disadvantage in life. Young women with spontaneous abortions had educational levels similar to those with live births and thus must be targeted together for any interventions; especially if those that miscarry eventually go on to have live births. Although women with no adolescent pregnancy had more education, factoring in their pregnancies after adolescence resulted in similar educational levels to those with live births. The issue of why births after adolescence also reduce the years of schooling of women needs to be fully understood through further research. The bi-directional nature of this topic, that is, whether pregnancies occur before girls drop out of school or vice versa, also needs additional investigation, as findings will ultimately generate interventions tailored to address the issues at stake. Finally, as interventions are carried out to help keep young girls in school, stakeholders must also focus on promoting their access to adolescent sexual and reproductive health services to prevent unwanted and mistimed pregnancies.