Psychosocial interventions targeting mental health in pregnant adolescents and adolescent parents: a systematic review

While mental health during and after pregnancy has gained recognition as an important public health concern, adolescents who are pregnant or new mothers have been largely excluded from these conversations. Pregnant adolescents may experience stigma, higher rates of unplanned pregnancies, more physical health risks, and challenging social environments. Despite knowing the risks with adolescent pregnancy, there is limited understanding of how best to support this vulnerable group. This systematic review therefore aimed to identify if interventions using a psychological, behavioral, and/or social approach—psychosocial interventions—can effectively support the mental health of pregnant and parenting adolescents. To review the evidence, databases such as PubMed/Medline, PsycINFO, ERIC, EMBASE and ASSIA were searched. Seventeen eligible studies were included for the analysis. The results of this study showed that these types of interventions had a positive effect on positive mental health and school attendance outcomes. However, there was limited or no evidence for other outcomes such as parenting skills, substance use, self-harm and suicide or exposure to intimate partner violence. Only two studies included adolescent fathers, and no studies were based in low-income countries. The findings of this study show that there is a critical gap in knowledge about effective interventions for pregnant and parenting adolescents. There is an urgent need to adapt and/or design new interventions that can be tested and delivered to pregnant adolescents and adolescent mothers, fathers, and their extended networks, particularly in low-income settings, with a clear aim towards improving mental health outcomes.

The mental health of pregnant women and new mothers has long been a focus in the field of reproductive health [1‐3]. However, less attention has been paid to pregnant adolescents and adolescent parents, despite evidence showing that adolescent girls and young women are at greater risk for developing mental health problems during pregnancy and after they give birth [4‐7]. There is a growing imperative to focus on the needs of this vulnerable group. The global adolescent birth rate (ages 15–19) has fallen over the past two decades—from 56 births/1000 to 43.9/1000—but this decrease has been slower in low- and middle-income countries (LMICs) [8]. In an analysis of Demographic and Health Survey data from 30 LMICs, the percentage of all live births occurring to adolescents varied across countries from less than 10 to 33%, with a median of 18% for adolescents under 20 years of age [9]. To be able to support the health and wellbeing of pregnant adolescents and adolescent parents on a global level, it is critical to have a multifaceted understanding of their needs and challenges.

Pregnant adolescents and adolescent parents are vulnerable to poor mental health outcomes for three main reasons. Adolescence is a transitional stage characterized by psychological, biological, and social changes. Pregnancy and parenting during this critical period interferes with normative developmental processes [10], and the dual biological transitions of adolescence and pregnancy may increase individuals’ psychological and physical vulnerability [11]. The potential effect of these neurobiological changes can be observed in adolescent mothers experiencing higher rates of depression [6, 7], anxiety, and stress than older mothers. Pregnant adolescents and adolescent mothers also undergo social changes that may link to poor mental health outcomes. Adolescent mothers commonly overestimate the amount of support they will receive after childbirth, leading to increased stress and depression postpartum [4, 12]. Pregnancy, as a visible marker of early sexual activity, may lead to stigma, discrimination, and blame that can negatively affect adolescent mothers’ psychosocial wellbeing and isolate them at a time when they require more social support [13‐15].

Second, alongside the risks related to the transition to adulthood and parenthood, adolescent girls face physical changes and potential health complications associated with early pregnancy and childbirth. These complications may elevate stress levels in new mothers, or make them vulnerable to mood disorders. Risks specific to adolescent childbearing include a higher likelihood of obstetric fistula [16] and of delivering a preterm or low birth weight infant [6, 12, 17]. These challenges may trigger or compound existing vulnerability to mental ill-health; conversely, psychosocial distress may make it difficult for pregnant adolescents and young mothers to care for themselves and their infants, leading to poorer health outcomes for mother and child [18].

Finally, adolescent pregnancy often occurs within environments of risk, which expose young women to multiple drivers of psychosocial distress and barriers to accessing care and support [19]. As many as two-thirds of adolescent pregnancies may be unintended [12, 20, 21], introducing new responsibilities and demands for adolescents who may not be ready to become parents, or may undergo additional stressors when experiencing an unintended pregnancy [22]. Furthermore, many pregnant adolescents are involved in age-disparate relationships, which may or may not continue following the pregnancy [23]. Adolescents who become pregnant outside the context of marriage may also be heavily stigmatized and prevented from accessing a broader support network [24]. Research suggests a bidirectional relationship between risk factors and pregnancy: while poverty and vulnerability increase the risk for early pregnancy and parenthood, adolescent parenthood can also lead to increased vulnerability [4, 12, 25, 26]. The same risk factors that may drive adolescent pregnancy—such as school dropout, substance use, partner or household violence [27], early marriage [28], and economic deprivation—can be exacerbated following pregnancy and childbirth. Importantly, although there are specific social, biological, and environmental risk factors for pregnant and postpartum adolescent girls and young women, there are additional mental health risks for adolescent fathers, including increased stress, economic deprivation, and adoption of risk behaviors [29], about which little is documented.

Identifying the role of mental health within these contexts is critical to disentangling the risks that young parents face: poor mental health can complicate an adolescent’s ability to be resilient, re-enroll in school, plan future pregnancies, and earn an income. Adolescents who do not finish school may struggle to obtain employment and their families may be more susceptible to economic instability; they are also at risk for rapid repeat pregnancy [6, 12, 30, 31]. These factors may also have intergenerational effects: children of adolescent parents have been found to struggle with social and emotional behaviors and with academic performance and are more likely to become adolescent parents themselves [7, 25, 32, 33].

Given these risks, it is critical to identify how to prevent mental health challenges in this population. Despite the substantial literature of the risks associated with adolescent pregnancy and parenthood, there is limited evidence on the effectiveness of psychosocial interventions among pregnant adolescents and adolescent parents to guide best practice to support this vulnerable group [7]. Promoting skills for healthy functioning, and preventing the onset of mental health conditions, is a pressing need, especially given the fact that adolescents are more likely to face constraints in accessing appropriate medical and psychosocial care [4, 34]. While evidence-based interventions exist, there is a clear need to identify if psychosocial interventions can effectively support the mental wellbeing of pregnant adolescents and adolescent mothers and fathers—promoting positive mental health and preventing mental health disorders, risk behaviors, self-harm and suicide.

This review was part of a larger set of systematic reviews informing the new WHO Guidelines on Mental Health Promotive and Preventive Interventions for Adolescents [35]. These guidelines aim to provide global, evidence-informed recommendations on psychosocial interventions for adolescents, delivered across a range of platforms, to promote positive mental health and prevent the development of mental disorders and risk behaviors. We used a standardized systematic review methodology based on the process outlined in the WHO Handbook for Guidelines Development, Second Edition [36]. The review protocol was registered on PROSPERO (CRD42019123723).

Overall, 95,844 de-duplicated citations were identified through the database search. The high number of citations was due to the fact that we ran multiple searches concurrently. After screening of titles and abstracts, the full texts of 1699 articles were screened (Fig. 1). We excluded 1538 full-text articles based on reasons such as incorrect target group/age, intervention type, or incorrect study design. We allocated an additional 150 studies to other research questions included in this search strategy that belonged to other reviews under the WHO Guidelines on Mental Health Promotive and Preventive Interventions for Adolescents. This resulted in 17 included studies (n = 3245 participants) comparing psychosocial interventions for pregnant adolescents and adolescent parents with treatment as usual.

In this review, we synthesized and meta-analyzed randomized controlled trials of psychosocial interventions to prevent and promote mental health for pregnant adolescents and adolescent parents. Our findings showed overall significant improvements in positive mental health and school attendance outcomes for intervention beneficiaries compared to controls. Although we undertook sensitivity analyses to gauge differential intervention effects by gender and mental health screening, these analyses did not suggest any changes in the pattern of results. Similarly, excluding the two studies with the highest identified risk of bias did not alter our pattern of results. We did not find evidence of the potential impact of risk of bias on the results. Positive mental health, with a focus on building healthy relationships and social support networks, may be a particularly important focus area for this developmental stage and for these adolescent mothers, especially in the context of other life challenges.

We identified substantial heterogeneity in positive mental health outcomes, indicating a diversity of studies contributing to this outcome. This heterogeneity might be attributable to differences in modes of intervention delivery or content of the psychosocial interventions delivered; it might also be explained by differences in types of positive mental health outcomes measured across the nine studies that included this outcome. Studies employing similar types of positive mental health measures might provide more homogeneous results.

No significant heterogeneity was observed for school attendance outcomes. Although interventions resulted in significant positive school attendance outcomes compared to controls, there were only two studies (of n = 17) that measured this outcome [49, 57]. More evidence is needed, therefore, on outcomes related to school re-enrollment, attendance, and completion to gauge the impact of psychosocial interventions on this vitally important domain [26, 63].

There was limited evidence for the effectiveness of preventive psychosocial interventions among pregnant adolescents and adolescent parents on symptoms and diagnoses of depression and anxiety, substance use, risky sexual and reproductive health behaviors, adherence to antenatal and postnatal care, and parenting skills. This may be in part because few studies reported on most of these outcomes, but our meta-analysis did not show significant benefits. Surprisingly, only two studies reported on risky sexual and reproductive health (SRH) behaviors, despite the clear link between sexual risk exposure and pregnancy/childbearing. It is plausible that our review eligibility criteria (including a mental health outcome) may have excluded other relevant studies on interventions to reduce pregnancy risk by targeting adolescent SRH. Psychosocial interventions for adolescents who are pregnant or parenting should specifically target SRH, as they could be beneficial in bolstering adolescents’ negotiating skills, improving confidence, and reducing overall rates of repeat pregnancy and sexually transmitted infections [25, 26].

Furthermore, there were no available data on outcomes related to aggressive, disruptive, and oppositional behaviors or exposure to IPV. Each of these outcomes represents a critical evidence gap within interventions for pregnant and parenting adolescents. There is also a need to explore the effect of violence and aggression. Adolescent girls experiencing IPV have been found to be at a heightened risk for becoming pregnant [64, 65]. A recent study found that experiences of bilateral violence (where pregnant adolescents both experience and perpetrate violence) had the largest effect on adverse mental health outcomes [66]. There were also no studies tracking self-harm and suicide. Pregnant adolescents and adolescent parents may be at a greater risk for suicidal ideation and self-harm [67], yet no interventions in our sample actively measured these outcomes. Interventions and evaluations incorporating these core areas are urgently needed in order to build evidence to better support young mothers, their partners, and their children [15].

Although the focus of this review was mental health, we noted that many included studies also contained specific provisions for improving parenting-related skills, to equip adolescent parents to be better caregivers. While we recognize the importance of this approach, it is also critical to focus on the psychosocial needs of these adolescents to more explicitly target improvements in their mental health outcomes [2, 4, 5]. We propose adaptations to existing interventions and the design of new interventions that employ more mental health-specific intervention content in order to meet the specific needs of adolescent mothers and fathers.

We did not restrict our search to female adolescents, but we uncovered only two studies that included male participants (adolescent fathers). Of these two studies, only one was for fathers only, published in 2002 [48], and the other was focused on co-parenting skills for partners expecting a child [47]. Apart from a parenting focus, there is a need for building skills and identifying modes of support for adolescent fathers, many of whom are marginalized and vulnerable in different ways to adolescent mothers. There is also a need for more programming that includes adolescent couples and co-parents, to improve mental health as well as communication and problem-solving skills.

Finally, the most notable omission in the studies that were identified by our review was that no randomized studies of psychosocial interventions were conducted in LMICs. This is pertinent considering that adolescents in LMICs are much likelier to be vulnerable to early, unintended pregnancy [30]. Despite geographic limitations, our current analysis of pregnant adolescents and adolescent parents has relevance for broader contexts: many studies used lay health workers to deliver interventions, and the majority of intervention beneficiaries were characterized as vulnerable, often mobile, and living in socioeconomically deprived circumstances [46, 49, 62]. Nevertheless, critical populations and global regions were missing from the evidence available to this review, and as such, only limited conclusions about the relevance and applicability of these psychosocial interventions in LMIC settings can be drawn.

A growing adolescent population, aided by large reductions in neonatal and child mortality, means that more adolescents than ever will be transitioning to adulthood in the next 30 years, especially in low-income settings [68]. In societies facing challenges with education, employment, health care access, and conflict, adolescent girls and young women face a higher probability of unintended pregnancies [21]. For this group, psychosocial interventions may be valuable for promoting positive mental health and preventing mental health problems and risk behaviors. Positive mental health in particular—emphasizing how to identify social support and nurture interpersonal relationships—may be an especially important area of focus for fostering mental health in these populations. They also have central roles to play in interrupting intergenerational cycles of risk and continued adversity [25, 27]. The lack of evidence from LMICs also prevents more nuanced understanding of co-existing health and social vulnerabilities in this population and how to appropriately address them. For example, data on high HIV incidence amongst adolescent girls and young women living in sub-Saharan Africa are readily available, as are data on adolescent pregnancy in the region; yet these data rarely consider both concurrently to indicate the scale of this phenomenon [69]. Early marriage is also nearly invisible from the literature on adolescent pregnancy, although a significant proportion of adolescent mothers are married [28, 30]. There is an urgent need to adapt and/or design new psychosocial interventions that can be pilot tested and scaled-up with pregnant adolescents and adolescent mothers, fathers, and their extended social networks in LMIC settings, with an explicit aim of improving mental health outcomes. In many LMICs where additional stressors may exist, new data from implementation efforts could signal where more programming is needed and how to best tailor it to diverse circumstances.

We found that, in high-income countries, psychosocial interventions for pregnant adolescents and adolescent parents have resulted in small- to moderate-sized beneficial effects on adolescents’ positive mental health and school attendance. Though the conclusion related to positive mental health was based on very low quality evidence, the conclusion related to school attendance was based on high quality evidence. More high-quality evidence is urgently needed, especially from LMICs, to establish the effectiveness of psychosocial interventions on a range of additional interlinked mental health outcomes among pregnant and parenting adolescents.