Trends in repeated pregnancy among adolescents in the Philippines from 1993 to 2013

Despite high and stable levels of adolescent fertility in the Philippines, no specific research has been conducted to specifically measure the trend and magnitude of repeated adolescent pregnancy, which is defined as an adolescent who has had at least two pregnancies. Repeated pregnancy, therefore needs to be investigated as it reflects not only the reproductive health of adolescent mothers but also disparities in service delivery of health, education and welfare support to adolescents after their first pregnancy.

We used the Philippine Demographic and Health Surveys to sample 7091 women aged 15–24 who experienced at least one pregnancy. Annual RP and RB prevalence per age group in three and five categories were calculated and stratified by region, type of residence and wealth quintile. Trends were statistically analysed using Cochran–Armitage tests and multivariate logistic regression.

While a decline was observed in 19–21 and 22–24 year olds, we found a constant prevalence of one in every five in 15–18 years old from 1993 to 2013. This trend was evident across all regions, types of residence and socio-economic status. Our analysis also found that those from the poorest wealth quintile demonstrated a heightened risk of repeated pregnancy compared to other quintiles. The non-decreasing prevalence trend of repeated pregnancy among adolescents indicated the need for secondary prevention programs particularly for the poorest households. Epidemiological investigations are also necessary to explore the causes and impact of repeated pregnancy on maternal, child and neonatal health, not only in the Philippines, but also among other low- and middle-income countries.

The adolescent pregnancy epidemic in the Philippines has been acknowledged as one of the worst in the Western Pacific Region [1] with a recent prevalence of 13.6% among 15–19 year olds. The Philippines is the only country in this region with no significant decline in adolescent fertility in the past decades [2] from 56 per 1000 in 1973 to 57 per 1000 in 2013 [2, 3]. In order to address this entrenched public health issue, preventive policies and programs have been implemented [4, 5], and epidemiological studies have been developed to provide evidence of the current sexual health and behaviour of Filipino adolescents [6]. However, these measures have put little emphasis on the more serious problem of repeated adolescent pregnancies.

Repeated adolescent pregnancy, which is defined as a subsequent pregnancy among adolescents aged 10–19 years [7] is known to affect around 18% of adolescent mothers in the USA [7], Europe [8], and Australia [9]. Despite the evident chance of repeated adolescent pregnancy especially within 2 years postpartum [10], current research is unable to clearly establish its magnitude in developing countries such as the Philippines, nor how the trends have changed across time [11‐13]. Although a World Health Organization (WHO) multi-country report [14] discussed the relationship between age and parity among Filipino adolescents, this study did not assess the prevalence of multi parity as its primary measure.

As a marker for adolescent reproductive health, repeated pregnancy reflects health disparities particularly among the disadvantaged adolescent population. Repeated pregnancy also indicates poor distribution and unequal access to reproductive health services [15] and inadequate service capacity of individual localities. It relates to low educational attainment, limited employment opportunities and poverty among adolescent mothers [15, 16]. It has been shown that repeated adolescent pregnancy leads to an increase in national health and welfare expenditure as a consequence of the long-term dependency of adolescents and their families on government assistance [15, 17].

An increasing trend of adolescent sexual activity [3] ongoing poor compliance with modern contraceptives [2, 18] and inadequate use of family planning services all suggest that repeated adolescent pregnancy is highly prevalent in the Philippines [12]. Analysis of existing nationally representative data can be helpful in evaluating the extent of this public health problem. In this study, we aim to determine the prevalence of repeated pregnancies and births among adolescents and young adults from a series of national surveys conducted between 1993 and 2013. Moreover, we intend to analyze the trend of repeated pregnancies and births by age groupings and potential macro-level confounders across two decades, with resulting trends perhaps reflecting the effectiveness of existing policies and programs in addressing this under-recognized adolescent health problem.

Among women aged 15–24 years with at least one pregnancy (n = 7091), a large proportion (53.3%) were found among the 22–24 year olds. Despite the small proportion of adolescents captured by the surveys, the proportion of 15–18 year olds reported in the survey has increased over time from 7.64% (n = 107) in 1993 to 15.55% (n = 213) in 2013 (see Table 1).

Despite the declining trends of RP and RB in older age groups, the prevalence among adolescents younger than 18 years showed no decrease across 20 years of data, remaining stable across all regions, types of residence, and wealth quintiles. The prevalence was high with approximately one in every five adolescents aged 15–18 years with a history of pregnancy experiencing RP while one in every ten of those who had a livebirth experienced RB.

While the decreasing RP and RB trend among young adults can likely be attributed to their improved contraceptive use [20] and awareness of and participation in family planning (FP) strategies [3, 21]. The unchanged trend among adolescents may result from the unique socio-cultural characteristics and FP policies in the Philippines, wherein adolescents are prevented from accessing FP services, even after their first pregnancy. One of the possible explanations for this finding is that the strong influence of the Catholic church at the local level may have affected the health seeking behavior and the implementation of reproductive health programs among adolescents [22, 23].

Unclear and restricted health and health-related policies for adolescent mothers may also play a role. The initial adolescent health policy in the Philippines [24], which aimed to reduce unwanted pregnancies and provide adolescent-friendly health services, did not include strategies for dealing with the prevention of secondary pregnancies [25, 26]. This may have led to adolescents being discouraged to access essential health information and use birth control methods [23, 27].

Despite emphasizing the importance of health promotion and behavioral change, a recently introduced national law (Responsible Parenthood and Reproductive Health Act of 2012 or RH Law) and framework [4], did not embrace specific programmatic actions to address RP. The RH Law still prevents minors (i.e. below 18 years old) from accessing modern methods of contraception without parental consent and does not exempt adolescent mothers and adolescents who experienced miscarriage [28]. This policy restriction has already been found as a deterrent for adolescents to access contraceptives and counselling services in a review of evidence from 16 developing countries [29]. This study suggests that despite the availability of contraception, most of these developing countries retain barriers and restrictions towards the use of birth control methods, particularly among unmarried adolescents. In the context of this social and political environment, the RP/RB trends showed in this paper can be expected to continue for several years to come not only in the Philippines but also in other developing countries.

The role and reach of secondary prevention programs must be clarified due to the limited access to appropriate postnatal services (e.g. contraception, counselling, and educational support) for adolescent mothers. Health workers may also need to be trained to address the unique psychosocial characteristics and support the challenging developmental transition of very young mothers by enhancing adolescents’ readiness and decision-making abilities to delay another pregnancy and/or use modern family planning methods. Given the high rate of unmet need for modern contraception among married adolescents [21], policy initiatives/reforms such as providing exemption on contraception to adolescent mothers may be needed to achieve a reduction in the trend seen in this paper.

Our findings also suggest that prevention programs aimed at those from the poorest quintile may be warranted due to the high RP/RB prevalence among this group. In the Philippines and other low- and middle-income countries (LMICs), attempts to reach out to households from the poorest sector have been undertaken through the Conditional Cash Transfer (CCT) Program [30, 31]. For example, the CCT program in Mexico has been found to indirectly reduce adolescent pregnancy and increase contraceptive use among adolescents and young adults [31]. The potential of cash incentive schemes can also be used as an opportunity to monitor and provide prevention programs to adolescent mothers, particularly within 24 months after their first pregnancy [10].

Our study uniquely explores the status of repeated pregnancy and birth in LMICs in the Asia-pacific Region. Most published reports on this topic are primarily from the USA, Europe, and Australia [32]. Of the few reports identified from LMICs, many used birth order (i.e. 2nd order or higher) and a different denominator (i.e. total number of adolescents) in the computation of prevalence. Despite the availability of possible data sources among LMICs [33], few studies have attempted to look specifically at the distribution of adolescents and young adults with RP/RB. Most of the reports available may include vital statistics which is limited to those only with livebirths and does not necessarily account for previous unsuccessful pregnancies.

By placing RP as an issue of crucial importance to the public health especially of LMICs, our paper makes a significant contribution to the literature calling for improvement of sexual and reproductive health of adolescents. The Global Strategy for Adolescent Health for 2030 recognized childbirth and pregnancy complications as one of the two leading causes of death among 15–19 year old girls [34]—addressing RP would help to reduce this. The absence of a reduction in RP trend over 20 years that we identified, signals the need for secondary prevention programs in line with WHO recommendations [35].

This study finds strength in our use of nationally-representative individual datasets instead of aggregate estimates. This prevents the risk of producing results affected by the ecological fallacy, particularly in the analysis of year-age interaction. Furthermore, we were able to perform more thorough analyses such as the adjustment of trend estimates for confounders (i.e. wealth quintile, region, and type of residence).

There is a constant trend of one in every five adolescent mothers in the Philippines experiencing repeated pregnancy from 1993 to 2013 (across all regions, type of residence, and socio-economic status). These findings indicate the need for secondary prevention programs, particularly among the poorest households. Epidemiological investigations are also necessary to explore the causes and impacts of repeated pregnancy on maternal, child, and neonatal health in the Philippines and other low- and middle-income countries.