28 ADOLESCENT PREGNANCY: OCCURRENCE AND CONSEQUENCES Prof. Asoc. Dr. Makedonka RADULOVIC ¹* Prof. Asoc. Dr. Biljana TODOROVA ² Prof. Ass. Dr. Irena AVIROVIC BUNDALEVSKA ³ ¹ University ss. “Cyril and Methodius”, Faculty of Philosophy, radulovic@fzf.ukim.edu.mk *Corresponding Author ² University “Goce Delcev”, Faculty of Law, Biljana.todorova@ugd.edu.mk ³University ss. “Cyril and Methodius”, Faculty of Philosophy, avirovic@fzf.ukim.edu.mk Article history: Accepted 05 January 2020 Available online 31 April 2020 Keywords: Adolescents, Pregnancy, Adolescent Pregnancy, Teenagers, Family, Contraception.. A b s t r a c t Adolescent pregnancy is a problem that societies face, regardless of the level of development. Despite the availability of information and the availability of contraception, as well as the right to an abortion that is guaranteed in most of the modern societies, countries face many cases of adolescent pregnancies. Pregnancy in the period of adolescence irreversibly changes the lives of minors. It has influence on their health, their education, social life and their future as adults. Also, the families of the under-aged parents are directly affected by the consequences, disrupting the functionality of the family. In a wider sense, the health system and social functioning are burdened in their entirety. Therefore, it’s important to prevent adolescent pregnancies. Contraception is the primary protection against unwanted pregnancy and insufficient and inconsistent application of contraception, as well as the lack of information among young people about the available methods of contraception can be one of the main causes of adolescent pregnancies. Integrated sexuality education for adolescents can be great benefit to educate adolescents about risk factors of pregnancy in early life. The influence of parents is crucial in the prevention of adolescent pregnancy. This paper intention is to analyses current situation on this topic, through available indicators on birth rates, maternal and children mortality worldwide. Qualitative research conducted between the student (18-22), should give more information about use of contraception between young people, their opinion about importance of contraception… Important questions are: Are they well informed about contraception; are the contraception products available; Are they feel free enough to talk with their parents on those topics...etc. 1. Introduction The period of pregnancy, the birth and the care for infants is especially important period that influence woman health. Throughout history, many maternal and childhood lives have been lost as a result of ignorance, lack of adequate health protection and care. In the developed countries, the healthy nutrition and better living conditions, good care during pregnancy and childbirth, contribute to reduce maternal mortality. In the least developed countries, maternal mortality is still high, around 1800 per 100,000 newborns, while in industrialized countries it is about 15 per 100,000 (WHO, 2018). Maternity mortality is related to socioeconomic conditions, the general health of the woman, and education. Age of conception and the number of previous pregnancies can be a risk factor. Healthcare system care is very important as guarantee for good pregnancy outcome. mailto:radulovic@fzf.ukim.edu.mk mailto:avirovic@fzf.ukim.edu.mk https://orcid.org/0000-0002-3753-1521 https://orcid.org/0000-0002-5761-907X https://orcid.org/0000-0002-1609-000X 29 Bed socioeconomic conditions like law income and unemployment have negative influence on health in general. Proper nutrition, contagious disease control and education are basic guarantee that women will enter their reproductive age, physically and mentally fit for childbirth and upbringing. According to WHO, UNICEF and UN, women's literacy affects the survival rate of newborns. A literate mother can use appropriate literature and not just to rely on tradition. The degree of education is proportional to the chances of employment and family income (Tulchinsky and Varavikova 2014). Health issues, in the field of reproduction, refer to the planning and preparation of pregnancy, as well as professional care during pregnancy, delivery and the postpartum period. Health education and preventive measures are extremely important. Quitting smoking, alcohol, drugs and other risky behavior, at least during pregnancy, is an important step to protect mother and child mortality 2. Current conditions Reproduction is influenced by social, cultural, religious and other factors, as well as by existing contraceptive techniques. Due to the availability of contraception funds, better education, greater chances for women's employment, reproductive trends have changed in the industrialized countries where birth rates are declining, unlike to underdeveloped countries where they have the opposite problem, uncontrolled childbearing, resulting in children they cannot take care of (Radulovic, 2018). The global maternal mortality is continuously decreasing. Since 1990 it has decreased by 44%, from a total of 385 to 100,000 liveborn at 215 per 100,000. However, in 1997, worldwide, 585,000 women died from complications of pregnancy and childbirth, of which 99% were from underdeveloped countries. Between 1990 and 1997, maternal mortality ranged from 1,000 to 100,000 in the less developed countries, from 100 to 500 in the middle-income countries, less than 10 in industrialized countries, and somewhere below 5 to 100,000 (Israel, Sweden, Switzerland). In the Republic of North Macedonia, in 1990, maternal mortality was 14 per 100,000 lives births, while in 2015 it was 8 per 100,000 liveborn. According to the Millennium Development Goals 2008 National Report, "annual fluctuations and the relatively low maternal mortality rate can be due to insufficient or inadequate reporting" (UN, 2008). Adolescent pregnancy is an important issue for several reasons. For example, there are health risks for the baby. Children who are born of adolescent mothers are more likely to suffer from health, social and emotional problems than children born from older mothers. Also, women who become pregnant during their teenage years have increased risk of medical complications, such as premature death and social consequences. Adolescent pregnancy is a big problem, not only for the underdeveloped countries, but it is a global phenomenon. Adolescent pregnancies are a complex social, educational and labor problem that is not easily solvable. This is a growing problem in other industrialized countries. Globally about 40% of all pregnancies are unintended. Many of these pregnancies occur to be adolescents, as well. In developing countries, the marriage of teenagers and children causes serious health problems to the emotionally immature mothers who have caught up in the trap of life without the possibility of education or employment (Tulchinsky and Varavikova, 2014). One report on technical guidance on sexuality education from UNESCO shows that in Europe, France the number of adolescent pregnancies has dramatically increased between 2011 and 2013. According to the statistics in France, there were 100,000 students (18-22 age)’ pregnancies in 2013 compared to 81,000 in 2012 and 68,000 in 2011 (UNESCO, 2018) According to the World Health Organization (WHO), about 17 million adolescents gave birth annually. France has an extremely high adolescent pregnancy rate (330 per 1,000) compared to Europe (20,000). The United Nations says that if the rise of adolescent pregnancies in the world does not stop, the number of mothers under 15 years of the current two million a year, by 2030, would rise to three million (UNFPA, 2018). The use of contraception is crucial in the prevention of adolescent pregnancies. In the Republic of North Macedonia, the use of modern contraceptives is at a very low level with a prevalence rate of contraceptive use of 10%. Adolescents and younger adults use family planning services less than other population groups. In 2007, only 1.1% of women under 19 years of age used contraceptives. The number of abortions is continuously declining and in 2007 it was 26.8 per 100 births. However, given the low prevalence of contraceptives as a method for family planning, it may be a serious problem of inadequate reporting in relation to the actual number of abortions. According to the report of the United Nations Population Fund (UNFPA) about Republic of North Macedonia, abortion is a widely used method of contraception and is implemented, among other, in institutions that do not report on these cases (UN, 2017). 3. Adolescent pregnancy Adolescent or teenage pregnancy, also known as juvenile pregnancy, is a pregnancy of women under the age of 20 years. A woman may get pregnant from sexual intercourse after she began ovulating, which may be before her first menstrual cycle (menarche), but usually occurs after the beginning of her periods 30 (WHO, 2004) For well-nourished women, the menarche usually takes place at the age of 12 or 13 years. Pregnant juvenile teenagers face many challenges with pregnancy same as other women. However, there are additional concerns for those under the age of 15 because they are less likely to be enough physically developed to maintain a healthy pregnancy or to give birth (Mayor, 2004). For the girls aged 15-19 years, the risks are more related to socioeconomic factors than to the biological effects of age. In the article "The Health consequences of teenage fertility". Family planning Perspectives it is mentioned that the risks of low weight at birth, premature birth, anemia and pre- eclampsia are associated with the biological era, which is noticeable at adolescent birth even after controlling other risk factors (such as access to prenatal care, etc.) (Lotto and Ezeci ,2004). In the developed countries, underage pregnancies are associated with social problems, including lower educational levels, poverty, and other negative outcomes in adolescent children. Adolescent pregnancy in developed countries is usually out of wedlock, a situation that brings social stigma in many communities and cultures. Contrary to this, adolescent parents in developing countries are often married, and their pregnancy is greeted by the family and society. However, in these societies, early pregnancy can be combined with malnutrition and poor health care that will cause medical problem. According to the United Nations Population Fund (UNFPA), "Pregnancy among girls under the age of 18 has irreparable consequences. It violates the rights of girls with life-threatening consequences in terms of sexual and reproductive health and represents high development costs for communities, especially in encouraging the cycle of poverty.” The health consequences include not yet being physically prepared for pregnancy and childbirth, leading to complications and malnutrition, as most adolescents tend to come from low-income households. The risk of maternal death of girls under 15 years of age in low- and middle-income countries is greater than of women in their twenties years of age. Adolescent pregnancy also affects girls' education and income potential, as many are forced to give up school, which ultimately threatens the future possibilities and economic prospects (UNFPA, 2018). Several studies examined the socioeconomic, medical and psychological impact of pregnancy and adolescent parenting. Factors, such as poverty or social support, may be more important than the mother's age at birth. Many solutions have been proposed to remove negative consequents. Adolescent parents who can rely on family and community support, social services, and childcare support are more likely to continue their education and get higher paid jobs while progressing with their education (Stepp, 2009) A holistic approach is needed to address the adolescent pregnancy. This means that it does not focus on changing the behavior of girls, but rather addresses the root causes of adolescent pregnancy, such as poverty, gender inequality, social pressures and compulsion. This approach should include "providing comprehensive sexuality education for all young people, investing in girls' education, preventing marriages from children, sexual violence and compulsion, building gender equitable societies by empowering girls and involving men and boys and securing access to adolescents to information about sexual and reproductive health, as well as services that welcome and facilitate their choice." (WHO, 2004). Dysfunctional families (parents either have little or no time to talk to their children about sex and sexuality or discuss the use of contraceptives), poverty (girls give sex services for money, clothes and other items), lack of information about sex and contraception media (in 2014, 26% of television programs displayed explicit sex scenes) alcohol abuse, which often leads to risky behavior, are all involved as causes of unwanted pregnancy - especially among adolescents. 4. Inappropriate use of contraception as a cause of adolescent pregnancy Contraception is an important part of the overall sexual and reproductive health of young people. It is a very important part of family planning, and therefore it is extremely important to all young people, especially because it represents a way of controlling one’s own life, one’s own health, controlling one’s own future and achieving a family when the person is physically and mentally mature. Although contraception is characteristically a way to prevent unwanted and unplanned pregnancies, in all modern societies it is used as a protection against various diseases, as well. However, on daily basis we hear information about the increasing number of abortions, adolescent pregnancy, and an increased number of young people with sexually transmitted diseases. This topic is more present today than in the past twenty years, but statistics show that the current situation in the Republic of North Macedonia is not at an enviable level. According to the available data, regarding the use of contraceptives, it can be noticed that the Republic of North Macedonia is on the same level as the African countries (UNICEF 2008, HERA 2018). In the last few years, some progress has been made in this section: various state campaigns for informing young people about the benefits of contraception, greater presence of non-governmental 31 organizations dealing with this issue, etc. But that is not enough; the current situation in the Republic of North Macedonia can not be compared to the developed countries and their conditions. We continue to face a large number of abortions, illegal abortion, adolescent pregnancies, and sexually transmitted diseases among young people. One of the reasons for inconsistent use of contraception is the big barriers faced by young people. Nowadays, in the 21st century in the Republic of North Macedonia, at a time when the world is working to promote modern contraception, young people still encounter many obstacles every day. These obstacles become more relevant for the young people to use contraception and thus take care of their health. According HERA Organization, Institute of public health and UNICEF report on sexual health of young people in Republic of North Macedonia, the most common barriers that become a hurdle to the young people are: closed door, low level of information, high prices, difficult access, condemning views, lack of organizations and centers that would advise young people. (UNICEF, 2008, Institute for public health 2009; HERA, 2017) Every day, many young people are denied the right to choose precisely because of these reasons. Barriers, i.e. obstacles, prevent the access of young people to contraceptives (HERA, 2017). Such fact is confirmed by Jovanovski (2017) - Director of HERA: "About 60 percent of the population does not use any contraception in Macedonia, while only 14 percent use modern contraception; every fourth woman in Macedonia uses the traditional method of interrupted sexual intercourse." In addition to this conclusion are the results of a research conducted among the students at the Faculty of Philosophy at the Ss. Cyril and Methodius University in Skopje, in which around 200 students aged 18-22 years answered questions related to their habits for the use of contraception. The students were asked if they used contraceptives while having sexual relation. On this question from a total of 200 respondents, 30 of them answered that they used contraceptives, 150 of them did not use them, and also 20 respondents answered that they used contraceptives only at times. As may be noted, most of them responded negatively (150). Of those who responded to using contraception, it can be noted that this attitude most dominates among older girls, at the age of 22 years old. While the younger female population either does not use contraceptives or uses them in certain situations. This is most often due to their negligence and thoughtlessness or insufficient information. In terms of gender, according to the obtained results, we can see that the female population uses more contraceptives than the male population. Namely, only 30 male respondents reported using contraception. It is important to note that the majority of women respondents who reported using contraceptive methods were older, as a result of their experience and higher level of information. While those boys who declare that they do not use contraceptives, are usually at the age of 18 years old. Furthermore, the respondents were asked how well they were informed about the types of available contraceptives. From the results obtained, it can be noted that girls are informed about contraceptives, but only for specific types of them. Only a handful of them are informed about all existing types of contraceptives. Taking into consideration all of the above it can be noted that young girls are poorly informed about modern contraception, which in fact leads to their low usage. It is positive that the percentage of girls who do not know any of the existing types of contraceptive methods is low. When analyzing the answers, out of 200 respondents, 100 of them were informed with all types of contraceptives, 30 respondents did not know about the types of contraceptives and their purpose at all, while 70 of the respondents heard and were familiar with only some of them. This situation indicates a great risk to the possibility of adolescent pregnancy. Considering that contraception is the primary protection against unwanted pregnancy, it is logical that the insufficient and inconsistent application of contraception, as well as the lack of information among young people about the available methods of contraception, is one of the main causes of adolescent pregnancies. 5. Adolescents do not talk to their parents about their sexual health In the absence of integrated sexuality education for adolescents, the influence of parents is crucial in the prevention of adolescent pregnancy. But how many of the parents talk to their children and how many of the children feel free to entrust parents with such questions and problems? The research mentioned above, shows a negative picture of this relationship. The question asked of how many students were talking to their parents about sexual relations, possible pregnancy and protection from it, they answered negatively. Out of 200 respondents, only 30 answered that they openly and frankly talk to their parents about the topic of sexual relations, 100 respondents that they never talked to their parents about it, while 70 respondents stated that they talk only sometimes, but rarely they talk with their parents. 32 The majority of the respondents said that they never talk about it with their parents, or they do it very rarely. Only a small percentage of them said they were frankly discussing it with their parents. It is disastrous to conclude that young people (students that were part of this qualitative research) do not talk to their parents about sexual relations, protection and sexually transmitted diseases. The family has most important educational and socialization function. Though, parent is the first person from whom the children learn about all the challenges they will face, and the first one who can notice all the changes in their children. But our results from the conducted research show that there is lack of communication about sexual and reproductive issues in the families. Parents deliberately avoid this topic. Perhaps, that is so because they are not sufficiently informed about it and how they should properly advise their children. Or, simply do not know how to get close to their children and how to start the conversation. It is therefore important to undertake a series of measures through which the parent will become educated more about all aspects of sexual intercourse and complications in the same way, in order to help their children in an appropriate way and direct them to the right path, i.e. to indicate what is a sexual relationship, when there should be relationships, what are the consequences of those relationships, how to act on the prevention. Because, if the parent sincerely and openly talks with the children, and if he knows how to get to know the children with the consequences that can occur, there will be no side effects. However, this situation indicates that insufficient communication and trust between parents and children is one of the reasons that can lead to unwanted pregnancy. Improving this condition can act as a preventive measure in cases of pregnancy among adolescents. 6. Conclusion Unfortunately, today the problem of early motherhood is at the top of importance. One of the main reasons for teen pregnancy is that adolescents are not using contraception at all, or they are not using it constantly. The reason can be due to the lack of sexual education, at home or in schools. Parents don’t have enough time, or they don’t feel comfortable to talk with their children about sexual education and to explain all the dangers of sexual life in adolescence period. In addition, sexual education in schools doesn’t exist at all or its not implemented well. According to statistics only from adolescents, more than 40% of children were born out of wedlock. About 10 thousand cases of young pregnancy are ended with abortion each year. Pregnant teens represent 10-15% of the total number of pregnant women. And they are not just children from poor families. There are cases of early pregnancy in quite rich, well-off families. Psychologists attribute this to the fact that teens often experience a lack of attention from parents or want to separate themselves from the crowd, to prove something to others, influence of the hormones, changing of emotions, insecurity etc. Based on the previously conducted surveys and the wide range of the used existing literature on the use of contraceptives and methods in the Republic of North Macedonia, we can conclude that in our country these methods are used insufficiently. This can be due to low incomes (adolescents’ budget), price and availability of contraception, people's views, level of information, etc. Regarding the price, although it does not seem to be the main reason that affects the use of contraceptives, it is still a decisive factor, especially for the young population, which in a large percentage is dependent on the financial resources of the parents. It is therefore considered best to have the simplest contraceptives such as condoms and oral contraception at a more accessible price. Perhaps young people see the cost of contraception as one of the problems, but it is important to note that it is not an obstacle that cannot be solved. In addition, the fear of condemnation critically affects young people, and in that case, they choose not to protect themselves in sex, in return for not having to endure the condemning views of other people. The most important thing for young people is to get rid of taboos, and to become open and responsible for themselves and their health. The problem seems to be even more difficult and complex when it comes to the lack of contraceptives, or limited stock. It is therefore extremely difficult for young people to lead a healthy sex life. It is therefore considered important that they seek their sexual and reproductive rights. This would include access to contraceptives. These barriers are an obstacle on the way of the youth until they learn the process of application of contraceptives but still more research must be done according to more clear views. On the other hand, timely education and information that are adapted to the appropriate age is a key factor for young people to get to know how important it is to use contraceptives and contraceptives to become part of the everyday life of young people. Through the conducted research we can conclude that it is positive that the percentage of young people who do not know any of the existing types of contraceptive methods is lower, which means that work is being done in the field of informing the young population to get acquainted with them, to see their advantages and disadvantages, and start to apply the methods more often. 33 The best way to overcome these barriers is when a relevant person advises young people and helps them in their choice. Unfortunately, young people refuse to seek help on time, or simply do not feel comfortable during medical evaluation, so whenever there are some symptoms, they ignore them. However, on the other hand, through the obtained results, we can conclude that medical professionals do not pay enough attention to get close to young people with their advice and to direct them towards the right path when it comes to sexual intercourse and complications that can occur. These professionals are an extremely important segment of the sexual protection of young people, and that is the reason why it is necessary to work with them in several directions. This means that every expert should constantly improve in their area, to learn how to approach the young people, to give the young full counsel and encourage them to take care of their health constantly, etc., It is also important for parents to explain to their children what it means to have sexual relations, when to have sexual relations, what are the consequences, but the most important thing is to act on the prevention. However, it can notice that young people do not talk to their parents about sexual relations, protection, and sexually transmitted diseases. Although the parent is the first person from whom the child learns about all the challenges that one will face, and the first one who can notice all the changes in one’s child, however, when it comes to the topic of contraception, we can conclude that parents or deliberately avoid this topic because they are not sufficiently informed how to properly advise their children, or simply do not know how to get close and start talking to them on this topic. It is therefore important that a series of measures should be taken, through which parents will be educated more about all aspects of sexual intercourse. Because if the parent sincerely and openly talks with the children, and if the parent knows how to get to know them with the consequences that can occur, there will be no side effects. Regarding the obtained results, we also see the need of additional education for the young population. This education is needed for both parents and children and can be part of family education. Sexual and reproductive education can take part like separate curricula in the primary and high schools in order to increase the percentage of use of contraceptives. Special courses for parents can be conduct like a short-term workshops or trainings, teaching parent’s communication skills, better approach and how to deal with their kid’s problems. All these aspects represent an unbreakable link from the process of sexual health protection to adolescent pregnancy and its consequences. Raising awareness of the importance of sexual and reproductive health as well as improving these areas can help young people in our society be prepared for their era of healthy everyday life and to enter the world of parenting physically and mentally mature individuals. It affects this fact and is often an unfavorable family atmosphere. Deprived of domestic warmth, teenagers are often looking for attention, care and affection on the side. According to statistics, a large percentage of such situations occur in our country, because there is a great opportunity for obtaining financial benefits after delivery. Based on the above mentioned, we can conclude that adolescent pregnancy and its consequences are an urgent problem for our country. It is therefore very important to pay due attention to your children and parents not to hesitate, first to express the consequences and complications of conceiving the child as an adolescent. References 1. Radulovic, M. (2018). Zdravjeto kako parvo zdravjeto kako obvrska: Kultura 2. Tulchinsky, T., & Varavikova, E. (2014). The New Public Health: Academic Press 3. United Nations Educational, Scientific and Cultural Organization. (2018). International technical guidance on sexuality education. Retrieved from: https://www.unaids.org/sites/default/files/media_asset/ITG SE_en.pdf 4. World Health Organisation. (2004). Adolescent pregnancy-Issues in Adolescent Health and Development. Retrieved from: https://apps.who.int/iris/bitstream/handle/10665/42903/924 1591455_eng.pdf;jsessionid=2417CCC4A6920FE5485C3 9ECBDD30659?sequence=1 5. United Nations Population Fund. (2018). Adolescent pregnancy-overview. Retrieved from: https://www.unfpa.org/adolescent-pregnancy 6. Mayor, S. (2004). Pregnancy and childbirth are leading causes of death among teenage girls in developing countries. BMJ. 328 (7449): 1152. doi: 10.1136 / bmj.328.7449.1152-a. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC411126/ 7. Lotto, O., & Ezeci, OC. (2004). Poor obstetric performance of teenagers is it age- or quality of care-related. Journal of Obstetrics and Gynecology. 24 (4): p. 395-398 8. BBC. (2014). Young mothers face stigma and abuse say charities. Retrieved from: http://www.bbc.co.uk/newsbeat/article/26326035/young- mothers-face-stigma-and-abuse-say-charities 34 9. Stepp, G. (2009) Teen Pregnancy: vision.org. Retrieved from: https://www.vision.org/family- relationships-teen-pregnancy-causes-effects-challenges- 907 10. 11. UNICEF. (2001). A League table of teenage births in rich nation. Retrieved from: https://www.unicef- irc.org/publications/328-a-league-table-of-teenage-births- in-rich-nations.html 12. HERA. (2018). Seksualno obrazovanie vo Evropa I Centralna Azija: Republika Makedonija. Retrieved from: https://hera.org.mk/bzga-izveshtaj-za-sso-vo-evropa-c- azija/ 13. HERA. (2017). Mgunaroden den na kontracepcija 2017.Retrieved from: http://skopjeinfo.mk/mladite-baraat- besplatni-kondomi