Adolescent pregnancy – Overview Alternative Names Teenage pregnancy; Pregnancy – teenage Definition of Adolescent pregnancy: Adolescent pregnancy is pregnancy in girls age 19 or younger. Causes, incidence, and risk factors: The rate of adolescent pregnancy and the birth rate for adolescents have generally declined since reaching an all-time high in 1990, mostly due to the increased use of condoms. Adolescent pregnancy is a complex issue with many reasons for concern. Younger adolescents (12 – 14 years old) are more likely to have unplanned sexual intercourse and more likely to be coerced into sex.
Adolescents 18 – 19 years old are technically adults, and half of adolescent pregnancies occur in this age group. Risk factors for adolescent pregnancy include: * Younger age * Poor school performance * Economic disadvantage * Single or teen parents Adolescent pregnancy Teenage pregnancy; Pregnancy – teenage Last reviewed: September 12, 2011. Adolescent pregnancy is pregnancy in girls age 19 or younger. Causes, incidence, and risk factors Adolescent pregnancy and babies born to adolescents have dropped since reaching an all-time high in 1990. This is mostly due to the increased use of condoms.
Adolescent pregnancy is a complex issue with many reasons for concern. Kids age 12 – 14 years old are more likely than other adolescents to have unplanned sexual intercourse . They are more likely to be talked into having into sex. Up to two-thirds of adolescent pregnancies occur in teens age 18 – 19 years old. Risk factors for adolescent pregnancy include: * Younger age * Poor school performance * Economic disadvantage * Older male partner * Single or teen parents Symptoms Pregnancy symptoms include: * Abdominal distention * Breast enlargement and breast tenderness * Fatigue * Light-headedness or actual fainting Missed period * Nausea/vomiting * Frequent urination Signs and tests The adolescent may or may not admit to being involved sexually. If the teen is pregnant, there are usually weight changes (usually a gain, but there may be a loss if nausea and vomiting are significant). Examination may show increased abdominal girth, and the health care provider may be able to feel the fundus (the top of the enlarged uterus). Pelvic examination may reveal bluish or purple coloration of vaginal walls, bluish or purple coloration and softening of the cervix, and softening and enlargement of the uterus. A pregnancy test of urine and/or serum HCG are usually positive. * A pregnancy ultrasound may be done to confirm or check accurate dates for pregnancy. Treatment All options made available to the pregnant teen should be considered carefully, including abortion, adoption, and raising the child with community or family support. Discussion with the teen may require several visits with a health care provider to explain all options in a non-judgmental manner and involve the parents or the father of the baby as appropriate.
Early and adequate prenatal care, preferably through a program that specializes in teenage pregnancies, ensures a healthier baby. Pregnant teens need to be assessed for smoking, alcohol use, and drug use, and they should be offered support to help them quit. Adequate nutrition can be encouraged through education and community resources. Appropriate exercise and adequate sleep should also be emphasized. Contraceptive information and services are important after delivery to prevent teens from becoming pregnant again.
Pregnant teens and those who have recently given birth should be encouraged and helped to remain in school or reenter educational programs that give them the skills to be better parents, and provide for their child financially and emotionally. Accessible and affordable child care is an important factor in teen mothers continuing school or entering the work force. Expectations (prognosis) Having her first child
Women who have a baby during their teen years are more likely to live in poverty. Teen mothers with a history of substance abuse are more likely to start abusing by about 6 months after delivery. Teen mothers are more likely than older mothers to have a second child within 2 years of their first child. Infants born to teenage mothers are at greater risk for developmental problems. Girls born to teen mothers are more likely to become teen mothers themselves, and boys born to teen mothers have a higher than average rate of being arrested and jailed.
Complications Adolescent pregnancy is associated with higher rates of illness and death for both the mother and infant. Death from violence is the second leading cause of death durig pregnancy for teens, and is higher in teens than in any other group. Pregnant teens are at much higher risk of having serious medical complications such as: * Placenta previa * Pregnancy-induced hypertension * Premature delivery * Significant anemia * Toxemia Infants born to teens are 2 – 6 times more likely to have low birth weight than those born to mothers age 20 or older.
Prematurity plays the greatest role in low birth weight, but intrauterine growth retardation (inadequate growth of the fetus during pregnancy) is also a factor. Teen mothers are more likely to have unhealthy habits that place the infant at greater risk for inadequate growth, infection, or chemical dependence. The younger a mother is below age 20, the greater the risk of her infant dying during the first year of life. It is very important for pregnant teens to have early and adequate prenatal care. Calling your health care provider
Make an appointment with your health care provider if you have symptoms of pregnancy. Your health care provider can also provide counseling regarding birth control methods, sexually transmitted disease (STD) prevention, or pregnancy risk. Prevention There are many different kinds of teen pregnancy prevention programs. * Abstinence education programs encourage young people to wait to have sex until marriage, or until they are mature enough to handle sexual activity and a potential pregnancy in a responsible manner. * Knowledge-based programs focus on teaching kids about their bodies.
It also provides detailed information about birth control and how to prevent sexually transmitted infections (STIs). Research shows knowledge-based programs help decrease teen pregnancy rates. Abstinence-only education without information about birth control does not. * Clinic-focused programs give kids easier access to information, counseling by health care providers, and birth control services. Many of these programs are offered through school-based clinics. * Peer counseling programs typically involve older teens, who encourage other kids to resist peer and social pressures to have sex.
For teens who are already sexually active, peer counseling programs teach them relationship skills and give them information on how to get and successfully use birth control. Teenage pregnancy Teenage pregnancy refers to pregnancy in a female under the age of 20 (when the pregnancy ends). It generally refers to a female who is unmarried and usually refers to an unplanned pregnancy. A pregnancy can take place at any time after puberty, with menarche (first menstrual period) normally taking place around the ages 12 or 13, and being the stage at which a female becomes potentially fertile.
Teenage pregnancy depends on a number of societal and personal factors. Teenage pregnancy rates vary between countries because of differences in levels of sexual activity, general sex education provided and access to affordable contraceptive options. Worldwide, teenage pregnancy rates range from 143 per 1000 in some sub-Saharan African countries to 2. 9 per 1000 in South Korea. Pregnant teenagers face many of the same obstetrics issues as women in their 20s and 30s. There are however, additional medical concerns for mothers age 14 or younger.
For mothers between 15 and 19, risks are associated more with socioeconomic factors than with the biological effects of age. However research has shown that the risk of low birth weight is connected to the biological age itself, as it was observed in teen births even after controlling for other risk factors (such as utilisation of antenatal care etc. ). In developed countries, teenage pregnancies are associated with many social issues, including lower educational levels, higher rates of poverty, and other poorer “life outcomes” in children of teenage mothers.
Teenage pregnancy in developed countries is usually outside of marriage, and carries a social stigma in many communities and cultures. Many studies and campaigns have attempted to uncover the causes and limit the numbers of teenage pregnancies. In other countries and cultures, particularly in the developing world, teenage pregnancy is usually within marriage and does not involve a social stigma. Among OECD developed countries, the United States and United Kingdom have the highest level of teenage pregnancy, while Japan and South Korea have the lowest. Teenage pregnancy rates
In reporting teenage pregnancy rates, the number of pregnancies per 1000 females aged 15 to 19 when the pregnancy ends is generally used. The rates look at the age at which a pregnancy ends, and not the age when the woman conceives, so that if a woman aborts her pregnancy or misscarries while she is 19, she would be counted, while if she went full term and gave birth at age 20 she would not be counted. According to a 2001 UNICEF survey, in 10 out of 12 developed nations with available data, more than two thirds of young people have had sexual intercourse while still in their teens.
In Denmark, Finland, Germany, Iceland, Norway, the United Kingdom and the United States, the proportion is over 80%. In Australia, the United Kingdom and the United States, approximately 25% of 15 year olds and 50% of 17 year olds have had sex. In a 2005 Kaiser Family Foundation study of US teenagers, 29% of teens reported feeling pressure to have sex, 33% of sexually active teens reported “being in a relationship where they felt things were moving too fast sexually”, and 24% had “done something sexual they didn’t really want to do”. Several polls have indicated peer pressure as a factor in encouraging both girls and boys to have sex.
The increased sexual activity among adolescents is manifested in increased teenage pregnancies and an increase in sexually transmitted diseases. The rates of teenage pregnancy vary and range from 143 per 1000 girls in some sub-Saharan African countries to 2. 9 per 1000 in South Korea. The rate for the United States is 52. 1 per 1000, the highest in the developed world – and about four times the European Union average. Care must also be taken of the common actual marriage age in different countries, as in countries where teenage marriages are common can expect to also experience higher levels of teenage pregnancies.
In an attempt to reverse the increasing numbers of teenage pregnancies, governments in many Western countries have instituted sex education programs, the main objective of which is to reduce such pregnancies and STD’s. Save the Children found that, annually, 13 million children are born to women under age 20 worldwide, more than 90% in developing countries. Complications of pregnancy and childbirth are the leading cause of mortality among women between the ages of 15 and 19 in such areas. The highest rate of teenage pregnancy in the world is in sub-Saharan Africa, where women tend to marry at an early age.
In Niger, for example, 87% of women surveyed were married and 53% had given birth to a child before the age of 18. In the Indian subcontinent, early marriage sometimes means adolescent pregnancy, particularly in rural regions where the rate is much higher than it is in urbanized areas. The rate of early marriage and pregnancy has decreased sharply in Indonesia and Malaysia, although it remains relatively high in the former. In the industrialized Asian nations such as South Korea and Singapore, teenage birth rates are among the lowest in the world.
The overall trend in Europe since 1970 has been a decreasing total fertility rate, an increase in the age at which women experience their first birth, and a decrease in the number of births among teenagers. Most continental Western European countries have very low teenage birth rates. This is varyingly attributed to good sex education and high levels of contraceptive use (in the case of the Netherlands and Scandinavia), traditional values and social stigmatization (in the case of Spain and Italy) or both (in the case of Switzerland). The teenage birth rate in the United States is the highest in the developed world, and the teenage bortion rate is also high. The U. S. teenage pregnancy rate was at a high in the 1950s and has decreased since then, although there has been an increase in births out of wedlock. The teenage pregnancy rate decreased significantly in the 1990s; this decline manifested across all racial groups, although teenagers of African-American and Hispanic descent retain a higher rate, in comparison to that of European-Americans and Asian-Americans. The Guttmacher Institute attributed about 25% of the decline to abstinence and 75% to the effective use of contraceptives.
However, in 2006 the teenage birth rate rose for the first time in fourteen years. This could imply that teen pregnancy rates are also on the rise, however the rise could also be due to other sources: a possible decrease in the number of abortions or a decrease in the number of miscarriages, to name a few. The Canadian teenage birth has also trended towards a steady decline for both younger (15–17) and older (18–19) teens in the period between 1992 and 2002. The age of the mother is determined by the easily verified date when the pregnancy ends, not by the estimated date of conception.
Consequently, the statistics do not include women who became pregnant at least shortly before their 20th birthdays, but who gave birth, experienced a miscarriage, or had a voluntary abortion on or after their 20th birthdays. Similarly, statistics on the mother’s marital status are determined by whether she is married at the end of the pregnancy, not at the time of conception. Impact Maternal and prenatal health is of particular concern among teens who are pregnant or parenting. The worldwide incidence of premature birth and low birth weight is higher among adolescent mothers.
In a rural hospital in West Bengal, teenage mothers between 15–19 years old were more likely to have anemia, preterm delivery, and low birth weight than mothers between 20–24 years old. Research indicates that pregnant teens are less likely to receive prenatal care, often seeking it in the third trimester, if at all. The Guttmacher Institute reports that one-third of pregnant teens receive insufficient prenatal care and that their children are more likely to suffer from health issues in childhood or be hospitalized than those born to older women.
Young mothers who are given high-quality maternity care have significantly healthier babies than those that do not. Many of the health-issues associated with teenage mothers, many of whom do not have health insurance, appear to result from lack of access to high-quality medical care. Many pregnant teens are subject to nutritional deficiencies from poor eating habits common in adolescence, including attempts to lose weight through dieting, skipping meals, food faddism, snacking, and consumption of fast food.
Inadequate nutrition during pregnancy is an even more marked problem among teenagers in developing countries. Complications of pregnancy result in the deaths of an estimated 70,000 teen girls in developing countries each year. Young mothers and their babies are also at greater risk of contracting HIV. The World Health Organization estimates that the risk of death following pregnancy is twice as great for women between 15 and 19 years than for those between the ages of 20 and 24. The maternal mortality rate can be up to five times higher for girls aged between 10 and 14 than for women of about twenty years of age.
Illegal abortion also holds many risks for teenage girls in areas such as sub-Saharan Africa. Risks for medical complications are greater for girls 14 years of age and younger, as an underdeveloped pelvis can lead to difficulties in childbirth. Obstructed labour is normally dealt with by Caesarean section in industrialized nations; however, in developing regions where medical services might be unavailable, it can lead to eclampsia, obstetric fistula, infant mortality, or maternal death.
For mothers in their late teens, age in itself is not a risk factor, and poor outcomes are associated more with socioeconomic factors rather than with biology. Psychosocial Several studies have examined the socioeconomic, medical, and psychological impact of pregnancy and parenthood in teens. Life outcomes for teenage mothers and their children vary; other factors, such as poverty or social support, may be more important than the age of the mother at the birth. Many solutions to counteract the more negative findings have been proposed.
Teenage parents who can rely on family and community support, social services and child-care support are more likely to continue their education and get higher paying jobs as they progress with their education. In the mother Being a young mother in an industrialized country can affect one’s education. Teen mothers are more likely to drop out of high school. Recent studies, though, have found that many of these mothers had already dropped out of school prior to becoming pregnant, but those in school at the time of their pregnancy were as likely to graduate as their peers.
One study in 2001 found that women who gave birth during their teens completed secondary-level schooling 10–12% as often and pursued post-secondary education 14–29% as often as women who waited until age 30. Young motherhood in an industrialized country can affect employment and social class. Less than one third of teenage mothers receive any form of child support, vastly increasing the likelihood of turning to the government for assistance. The correlation between earlier childbearing and failure to complete high school reduces career opportunities for many young women.
One study found that, in 1988, 60% of teenage mothers were impoverished at the time of giving birth. Additional research found that nearly 50% of all adolescent mothers sought social assistance within the first five years of their child’s life. A study of 100 teenaged mothers in the United Kingdom found that only 11% received a salary, while the remaining 89% were unemployed. Most British teenage mothers live in poverty, with nearly half in the bottom fifth of the income distribution.
Teenage women who are pregnant or mothers are seven times more likely to commit suicide than other teenagers. Professor John Ermisch at the institute of social and economic research at Essex University and Dr Roger Ingham, director of the centre of sexual health at Southampton University – found that comparing teenage mothers with other girls with similarly deprived social-economic profiles, bad school experiences and low educational aspirations, the difference in their respective life chances was negligible.
Teenage Motherhood may actually make economic sense for young women with less money, some research suggests. For instance, long-term studies by Duke economist V. Joseph Hotz and colleagues, published in 2005, found that by age 35, former teen moms had earned more in income, paid more in taxes, were substantially less likely to live in poverty and collected less in public assistance than similarly poor women who waited until their 20s to have babies.
Women who became mothers in their teens — freed from child-raising duties by their late 20s and early 30s to pursue employment while poorer women who waited to become moms were still stuck at home watching their young children — wound up paying more in taxes than they had collected in welfare. Eight years earlier, the federally commissioned report “Kids Having Kids” also contained a similar finding, though it was buried: “Adolescent childbearers fare slightly better than later-childbearing counterparts in terms of their overall economic welfare.
One-fourth of adolescent mothers will have a second child within 24 months of the first. Factors that determine which mothers are more likely to have a closely spaced repeat birth include marriage and education: the likelihood decreases with the level of education of the young woman – or her parents – and increases if she gets married. In the child Early motherhood can affect the psychosocial development of the infant. Developmental disabilities and behavioral issues are increased in children born to teen mothers.
One study suggested that adolescent mothers are less likely to stimulate their infant through affectionate behaviors such as touch, smiling, and verbal communication, or to be sensitive and accepting toward his or her needs. Another found that those who had more social support were less likely to show anger toward their children or to rely upon punishment. Poor academic performance in the children of teenage mothers has also been noted, with many of them being more likely than average to fail to graduate from secondary school, be held back a grade level, or score lower on standardized tests.
Daughters born to adolescent parents are more likely to become teen mothers themselves. A son born to a young woman in her teens is three times more likely to serve time in prison. In other family members Teen pregnancy and motherhood can influence younger siblings. One study found that the younger sisters of teen mothers were less likely to emphasize the importance of education and employment and more likely to accept human sexual behavior, parenting, and marriage at younger ages; younger brothers, too, were found to be more tolerant of non-marital and early births, in addition to being more susceptible to high-risk behaviors.
If the younger sisters of teenage parents babysit the children, they have an increased risk of getting pregnant themselves. Causes In some societies, early marriage and traditional gender roles are important factors in the rate of teenage pregnancy. For example, in some sub-Saharan African countries, early pregnancy is often seen as a blessing because it is proof of the young woman’s fertility. In the Indian subcontinent, early marriage and pregnancy is more common in traditional rural communities compared to the rate in cities.
The lack of education on safe sex, whether it’s from parents, schools, or otherwise, is a cause of teenage pregnancy. Many teenagers are not taught about methods of birth control and how to deal with peers who pressure them into having sex before they are ready. Many pregnant teenagers do not have any cognition of the central facts of sexuality. Some teens have said to be pressured into having sex with their boyfriends at a young age, and yet no one had taught these teens how to deal with this pressure or to say “no”.
In societies where adolescent marriage is less common, such as many developed countries, young age at first intercourse and lack of use of contraceptive methods (or their inconsistent and/or incorrect use; the use of a method with a high failure rate is also a problem) may be factors in teen pregnancy. Most teenage pregnancies in the developed world appear to be unplanned. Sexuality In most countries, most men experience sexual intercourse for the first time before their 20th birthdays.
Men in Western developed countries have sex for the first time sooner than in undeveloped and culturally conservative countries such as Sub-Saharan Africa and much of Asia. Countries with low levels of teenagers giving birth accept sexual relationships among teenagers and provide comprehensive and balanced information about sexuality. However, in a Kaiser Family Foundation study of US teenagers, 29% of teens reported feeling pressure to have sex, 33% of sexually active teens reported “being in a relationship where they felt things were moving too fast sexually”, and 24% had “done something sexual they didn’t really want to do”.
Several polls have indicated peer pressure as a factor in encouraging both girls and boys to have sex. Role of drug and alcohol use Inhibition-reducing drugs and alcohol may possibly encourage unintended sexual activity. If so, it is unknown if the drugs themselves directly influence teenagers to engage in riskier behavior, or whether teenagers who engage in drug use are more likely to engage in sex. Correlation does not imply causation. The drugs with the strongest evidence linking to teenage pregnancy are alcohol, “ecstasy”, cannabis, and amphetamines.
The drugs with the least evidence to support a link to early pregnancy are opioids, such as heroin, morphine, and oxycodone, of which a well-known effect is the significant reduction of libido – it appears that teenage opioid users have significantly reduced rates of conception compared to their non-using, and alcohol, “ecstasy”, cannabis, and amphetamine using peers. Amphetamines are often prescribed to treat ADHD – internationally, the countries with the highest rates of recorded amphetamine prescription to teenagers also have the highest rates of teenage pregnancy. 2], Leonard Sax, M. D. , Ph. D. , 2005, Doubleday books, p. 128. Lack of contraception Adolescents may lack knowledge of, or access to, conventional methods of preventing pregnancy, as they may be too embarrassed or frightened to seek such information. Contraception for teenagers presents a huge challenge for the clinician. In 1998, the government of the United Kingdom set a target to halve the under-18 pregnancy rate by 2010. The Teenage Pregnancy Strategy (TPS) was established to achieve this.
The pregnancy rate in this group, although falling, rose slightly in 2007, to 41. 7 per 1000 women. Young women often think of contraception either as ‘the pill’ or condoms and have little knowledge about other methods. They are heavily influenced by negative, second-hand stories about methods of contraception from their friends and the media. Prejudices are extremely difficult to overcome. Over concern about side-effects, for example weight gain and acne, often affect choice. Missing up to three pills a month is common, and in this age group the figure is likely to be higher.
Restarting after the pill-free week, having to hide pills, drug interactions and difficulty getting repeat prescriptions can all lead to method failure. In the United States, according to the 2002 National Surveys of Family Growth, sexually active adolescent women wishing to avoid pregnancy were less likely than those of other ages to use contraceptives (18% of 15- to 19-year-olds used no contraceptives, versus 10. 7% average for women ages 15 to 44). More than 80% of teen pregnancies are unintended.
Over half of unintended pregnancies were to women not using contraceptives, most of the rest are due to inconsistent or incorrect use. 23% of sexually active young women in a 1996 Seventeen magazine poll admitted to having had unprotected sex with a partner who did not use a condom, while 70% of girls in a 1997 PARADE poll claimed it was embarrassing to buy birth control or request information from a doctor. In a study for The Guttmacher Institute, researchers found that from a comparative perspective, however, teenage pregnancy rates in the United States are less nuanced than one might initially assume. Since timing and levels of sexual activity are quite similar across [Sweden, France, Canada, Great Britain, and the U. S. ], the high U. S. rates arise primarily because of less, and possibly less-effective, contraceptive use by sexually active teenagers. ” Thus, the cause for the discrepancy between rich nations can be traced largely to contraceptive-based issues. Among teens in the UK seeking an abortion, a study found that the rate of contraceptive use was roughly the same for teens as for older women. In other cases, contraception is used, but proves to be inadequate.
Inexperienced adolescents may use condoms incorrectly, forget to take oral contraceptives, or fail to use the contraceptives they had previously chosen. Contraceptive failure rates are higher for teenagers, particularly poor ones, than for older users. Long-acting contraceptives such as intrauterine devices, subcutaneous contraceptive implants, and contraceptive injections (such as Depo-Provera and Combined injectable contraceptive), which prevent pregnancy for months or years at a time, are more effective in women who have trouble remembering to take pills or using barrier methods consistently.
Age discrepancy in relationships According to the conservative lobbying organization Family Research Council, studies in the US indicate that age discrepancy between the teenage girls and the men who impregnate them is an important contributing factor. Teenage girls in relationships with older boys, and in particular with adult men, are more likely to become pregnant than teenage girls in relationships with boys their own age. They are also more likely to carry the baby to term rather than have an abortion.
A review of California’s 1990 vital statistics found that men older than high school age fathered 77% of all births to high school-aged girls (ages 16–18), and 51% of births to junior high school-aged girls (15 and younger). Men over age 25 fathered twice as many children of teenage mothers than boys under age 18, and men over age 20 fathered five times as many children of junior high school-aged girls as did junior high school-aged boys.
A 1992 Washington state study of 535 adolescent mothers found that 62% of the mothers had a history of being raped or sexual molested by men whose ages averaged 27 years. This study found that, compared with nonabused mothers, abused adolescent mothers initiated sex earlier, had sex with much older partners, and engaged in riskier, more frequent, and promiscuous sex. Studies by the Population Reference Bureau and the National Center for Health Statistics found that about two-thirds of children born to teenage girls in the United States are fathered by adult men age 20 or older.
Sexual abuse Studies from South Africa have found that 11–20% of pregnancies in teenagers are a direct result of rape, while about 60% of teenage mothers had unwanted sexual experiences preceding their pregnancy. Before age 15, a majority of first-intercourse experiences among females are reported to be non-voluntary; the Guttmacher Institute found that 60% of girls who had sex before age 15 were coerced by males who on average were six years their senior. One in five teenage fathers admitted to forcing girls to have sex with them.
Multiple studies have indicated a strong link between early childhood sexual abuse and subsequent teenage pregnancy in industrialized countries. Up to 70% of women who gave birth in their teens were molested as young girls; by contrast, 25% for women who did not give birth as teens were molested. In some countries, sexual intercourse between a minor and an adult is not considered consensual under the law because a minor is believed to lack the maturity and competence to make an informed decision to engage in fully consensual sex with an adult. In those countries, sex with a minor is therefore considered statutory rape.
In most European countries, by contrast, once an adolescent has reached the age of consent, he or she can legally have sexual relations with adults because it is held that in general (although certain limitations may still apply), reaching the age of consent enables a juvenile to consent to sex with any partner who has also reached that age. Therefore, the definition of statutory rape is limited to sex with a person under the minimum age of consent. What constitutes statutory rape ultimately differs by jurisdiction. Dating violence Studies have indicated that adolescent girls are often in abusive relationships at the time of their conceiving.
They have also reported that knowledge of their pregnancy has often intensified violent and controlling behaviors on part of their boyfriends. Women under age 18 are twice as likely to be beaten by their child’s father than women over age 18. A UK study found that 70% of women who gave birth in their teens had experienced adolescent domestic violence. Similar results have been found in studies in the United States. A Washington State study found 70% of teenage mothers had been beaten by their boyfriends, 51% had experienced attempts of birth control sabotage within the last year, and 21% experienced school or work sabotage.
In a study of 379 pregnant or parenting teens and 95 teenage girls without children, 62% of the girls aged 11–15 years and 56% of girls aged 16–19 years reported experiencing domestic violence at the hands of their partners. Moreover, 51% of the girls reported experiencing at least one instance where their boyfriend attempted to sabotage their efforts to use birth control. Socioeconomic factors Teenage pregnancy has been defined predominantly within the research field and among social agencies as a social problem. Poverty is associated with increased rates of teenage pregnancy.
Economically poor countries such as Niger and Bangladesh have far more teenage mothers compared with economically rich countries such as Switzerland and Japan. In the UK, around half of all pregnancies to under 18s are concentrated among the 30% most deprived population, with only 14% occurring among the 30% least deprived. For example, in Italy, the teenage birth rate in the well-off central regions is only 3. 3 per 1,000, while in the poorer Mezzogiorno it is 10. 0 per 1,000. Similarly, in the United States, sociologist Mike A.
Males noted that teenage birth rates closely mapped poverty rates in California: County| Poverty rate| Birth rate*| Marin County| 5%| 5| Tulare County (Caucasians)| 18%| 50| Tulare County (Hispanics)| 40%| 100| * per 1000 women aged 15–19 Teen pregnancy cost the United States over $9. 1 billion in 2004. There is little evidence to support the common belief that teenage mothers become pregnant to get benefits, welfare, and council housing. Most knew little about housing or financial aid before they got pregnant and what they thought they knew often turned out to be wrong.
Childhood environment Women exposed to abuse, domestic violence, and family strife in childhood are more likely to become pregnant as teenagers, and the risk of becoming pregnant as a teenager increases with the number of adverse childhood experiences. According to a 2004 study, one-third of teenage pregnancies could be prevented by eliminating exposure to abuse, violence, and family strife. The researchers note that “family dysfunction has enduring and unfavorable health consequences for women during the adolescent years, the childbearing years, and beyond. When the family environment does not include adverse childhood experiences, becoming pregnant as an adolescent does not appear to raise the likelihood of long-term, negative psychosocial consequences. Studies have also found that boys raised in homes with a battered mother, or who experienced physical violence directly, were significantly more likely to impregnate a girl. Studies have also found that girls whose fathers left the family early in their lives had the highest rates of early sexual activity and adolescent pregnancy.
Girls whose fathers left them at a later age had a lower rate of early sexual activity, and the lowest rates are found in girls whose fathers were present throughout their childhood. Even when the researchers took into account other factors that could have contributed to early sexual activity and pregnancy, such as behavioral problems and life adversity, early father-absent girls were still about five times more likely in the United States and three times more likely in New Zealand to become pregnant as adolescents than were father-present girls.
Low educational expectations have been pinpointed as a risk factor. A girl is also more likely to become a teenage parent if her mother or older sister gave birth in her teens. A majority of respondents in a 1988 Joint Center for Political and Economic Studies survey attributed the occurrence of adolescent pregnancy to a breakdown of communication between parents and child and also to inadequate parental supervision. Foster care youth are more likely than their peers to become pregnant as teenagers. The National Casey Alumni Study, which surveyed foster care alumni from 23 ommunities across the United States, found the birth rate for girls in foster care was more than double the rate of their peers outside the foster care system. A University of Chicago study of youth transitioning out of foster care in Illinois, Iowa, and Wisconsin found that nearly half of the females had been pregnant by age 19. The Utah Department of Human Services found that girls who had left the foster care system between 1999 and 2004 had a birth rate nearly 3 times the rate for girls in the general population. Media influence
A study conducted in 2006 found that adolescents who were more exposed to sexuality in the media were also more likely to engage in sexual activity themselves. According to Time, “teens exposed to the most sexual content on TV are twice as likely as teens watching less of this material to become pregnant before they reach age 20”. Prevention Many health educators have argued that comprehensive sex education would effectively reduce the number of teenage pregnancies, although opponents argue that such education encourages more and earlier sexual activity. United Kingdom
In the UK, the teenage pregnancy strategy, which was run first by the Department of Health and is now based out of the Children, Young People and Families directorate in the Department for Children, Schools and Families, works on several levels to reduce teenage pregnancy and increase the social inclusion of teenage mothers and their families by: * joined up action, making sure branches of government and health and education services work together effectively; * prevention of teenage pregnancy through better sex education and improving contraceptive and advice services for young people, involving young people in service design, supporting the parents of teenagers to talk to them about sex and relationships, and targeting high-risk groups; * better support for teenage mothers, including help returning to education, advice and support, work with young fathers, better childcare and increasing the availability of supported housing. The teenage pregnancy strategy has had mixed success.
Although teenage pregnancies have fallen overall, they have not fallen consistently in every region, and in some areas they have increased. There are questions about whether the 2010 target of a 50% reduction on 1998 levels can be met. United States In the United States the topic of sex education is the subject of much contentious debate. Some schools provide “abstinence-only” education and virginity pledges are increasingly popular. A 2004 study by Yale and Columbia Universities found that 88% of those who pledge abstinence have premarital sex anyway. Most public schools offer “abstinence-plus” programs that support abstinence but also offer advice about contraception.
A team of researchers and educators in California have published a list of “best practices” in the prevention of teen pregnancy, which includes, in addition to the previously mentioned concepts, working to “instill a belief in a successful future”, male involvement in the prevention process, and designing interventions that are culturally relevant. On September 30, 2010, The U. S. Department of Health and Human Services approved $155 million dollars in new funding for comprehensive sex education programs designed to prevent teenage pregnancy. The money is being awarded “to states, non-profit organizations, school districts, universities and others.
These grants will support the replication of teen pregnancy prevention programs that have been shown to be effective through rigorous research as well as the testing of new, innovative approaches to combating teen pregnancy. ” For teens who choose to engage in sexual activity, the primary mode of preventing teen pregnancy becomes correct use of contraceptives. In the States, one policy initiative that has been used to increase rates of contraceptive use is Title X: Title X of the 1970 Public Health Service act provides family planning services for those who do not qualify for Medicaid by distributing “funding to a network of public, private, and nonprofit entities [in order to provide] services on a sliding scale based on income. Studies indicate that, internationally, success in reducing teen pregnancy rates is directly correlated with the kind of access that Title X provides: “What appears crucial to success is that adolescents know where they can go to obtain information and services, can get there easily and are assured of receiving confidential, nonjudgmental care, and that these services and contraceptive supplies are free or cost very little. In addressing high rates of unplanned teen pregnancies, scholars agree that the problem must be confronted from both the biological and cultural contexts. Netherlands The Dutch approach to preventing teenage pregnancy has often been seen as a model by other countries.
The curriculum focuses on values, attitudes, communication and negotiation skills, as well as biological aspects of reproduction. The media has encouraged open dialogue and the health-care system guarantees confidentiality and a non-judgmental approach. Developing world In the developing world, programs of reproductive health aimed at teenagers are often small scale and not centrally coordinated, although some countries such as Sri Lanka have a systematic policy framework for teaching about sex within schools. Non-governmental agencies such as the International Planned Parenthood Federation and Marie Stopes International provide contraceptive advice for young women worldwide. Laws against child marriage have reduced but not eliminated the practice.
Improved female literacy and educational prospects have led to an increase in the age at first birth in areas such as Iran, Indonesia, and the Indian state of Kerala. Teenage fatherhood In some cases, the father of the child is the husband of the teenage girl. The conception may occur within wedlock, or the pregnancy itself may precipitate the marriage (the so-called shotgun wedding). In countries such as India the majority of teenage births occur within marriage. In other countries, such as the United States and the Republic of Ireland, the majority of teenage mothers are not married to the fathers of their children. In the UK, half of all teenagers with children are lone parents, 40% are cohabitating as a couple and 10% are married.
Teenage parents are frequently in a romantic relationship at the time of birth, but many adolescent fathers do not stay with the mother and this often disrupts their relationship with the child. Research has shown that when teenage fathers are included in decision-making during pregnancy and birth, they are more likely to report increased involvement with their children in later years. In the U. S, eight out of ten teenage fathers do not marry their first child’s mother. However, “teenage father” may be a misnomer in many cases. Studies by the Population Reference Bureau and the National Center for Health Statistics found that about two-thirds of births to teenage girls in the United States are fathered by adult men age 20 or older.
The Guttmacher Institute reports that over 40% of mothers aged 15–17 had sexual partners three to five years older and almost one in five had partners six or more years older. A 1990 study of births to California teens reported that the younger the mother, the greater the age gap with her male partner. In the UK 72% of jointly registered births to women under the age of 20, the father is over the age of 20, with almost 1 in 4 being over 25. History Teenage pregnancy was normal in previous centuries. Perhaps the most famous teenage pregnancy in history was Mary, Mother of Jesus. She is generally believed to have been 13 years old when she gave birth to Jesus. Other sources place her age as high as 15 years.
Hildegard of Vinzgouw, the wife of Charlemagne was about 14 years old when she gave birth to her first son in 772 CE. The mother of Henry VII of England was 13 years old when she gave birth to him in 1457. Maria of Tver, the wife of Ivan the Great of Russia, gave birth to her first son when she was about 16 years old, in 1458. Empress Teimei of Japan was 16 years old when she gave birth to Hirohito in 1901. Lina Medina of Peru holds the world record for youngest live birth: She was five years, seven months old when she gave birth in 1939. Society and culture Teenage pregnancy has been used as a theme or plot device in fiction, including books, films, and television series.
The setting may be historical (The Blue Lagoon, Hope and Glory) or contemporary (One Tree Hill). While the subject is generally treated in a serious manner (Junk), it can sometimes play up to stereotypes in a comic manner (Vicky Pollard in Little Britain). The pregnancy itself may be the result of sexual abuse (Rose in The Cider House Rules), a one-night stand (Amy Barnes in Hollyoaks), a romantic relationship (Demi Miller in EastEnders); (Ronnie Mitchell in EastEnders); or a first time sexual encounter (Sarah-Louise Platt in Coronation Street) unusually, in Quinceanera, the central character becomes pregnant through non-penetrative sex. The drama often focuses around the discovery of the regnancy and the decision to opt for abortion (Fast Times at Ridgemont High), adoption (Mom at Sixteen, Juno, Glee), marriage (Sugar & Spice, Reba and Jeni, Juno) or life as a single mother (Saved! , Where the Heart Is, Someone Like You). In the German play Spring Awakening (and the Broadway musical based upon it), the central female character gets pregnant and dies from a botched abortion. Stephanie Daley deals with the aftermath of a teenage pregnancy that ends with a dead newborn baby. While the pregnant girl herself is normally the chief protagonist, Too Young to Be a Dad centers on a 15-year-old boy whose girlfriend becomes pregnant, while The Snapper focuses on the reactions of the family, particularly the soon-to-be grandfather.
Other fiction, particularly in a long-running television series, looks at the long-term effects of becoming a parent at a very young age (Degrassi Junior High). In Gilmore Girls, because Lorelai Gilmore is only 16 years older than her daughter Rory, the two are more like sisters than parent and child. Looking for Alibrandi also features the teenage daughter of a woman who was herself a teenage mother. In The George Lopez Show, Benny Lopez, gave birth to George at 16. In the ABC Family television show The Secret Life of the American Teenager centers on Amy Juergens, a 15-year-old who becomes a teenage mother after a one night stand. In the popular Comedy Central television show South Park the character Carol McCormick was said to have had her sons Kevin McCormick at 13, and Kenny McCormick at 16.
In the Japanese drama 14-sai no Haha: Aisuru tame ni Umaretekita, the protagonist Miki Ichinose becomes pregnant with her boyfriend’s child at age 14. The show examines the impact of her pregnancy on her, her family, her school life, the life of her boyfriend and his family, and the society in which she resides. Additionally, reality television shows have featured teenage pregnancy stories. MTV launched two reality shows about the topic, 16 and Pregnant and Teen Mom, in 2009. Each show depicts the gritty reality that pregnant teens face from friends and family while going through this life changing event, allowing teens to see what actually happens in this scenario through an outlet other than a scripted plot.
Autobiographies that look at the author’s own experience of teenage motherhood include I Know Why the Caged Bird Sings and Gather Together in My Name by Maya Angelou, Coal Miner’s Daughter by Loretta Lynn, and Riding in Cars with Boys by Beverly D’Onofrio. Songs about teenage pregnancy include downbeat tales of abuse (“Brenda’s Got a Baby”), poverty (“In The Ghetto”) and back-alley abortion (“Sally’s Pigeons”), as well as upbeat and defiant tunes such as “Papa Don’t Preach”. American pop singer Fantasia Barrino, who was 17 when she gave birth to her daughter, released a controversial song about single motherhood titled “Baby Mama”, describing the difficulty of raising a child alone with limited financial and family support. (Many U. S. adio stations would not play the song, ostensibly because it contains a profanity. ) “There Goes My Life”, a modern country song by Kenny Chesney, focuses on the reaction of the father, who rhetorically asks, “I’m just a kid myself; how am I going to raise one? ” As the daughter grows up, his attitude changes, and the song ends with his tearful farewell as she leaves for college. Due to its implied pro-life message, “There Goes My Life” was sung at the inauguration of George W. Bush in 2005 Teen pregnancies in the Philippines By Rebecca B. Singson Philippine Daily Inquirer First Posted 00:55:00 06/14/2008 Filed Under: Health, Lifestyle & Leisure, Gender Issues (First in a series)
MANILA, Philippines? The sexual revolution has ushered in a period in which the average adolescent experiences tremendous pressures to have sexual experiences of all kinds. Filipino teens get a higher exposure to sex from the Internet, magazines, TV shows, movies and other media than decades ago, yet without any corresponding increase in information on how to handle the input. So kids are pretty much left to other kids for opinions and value formation when it comes to sex. Sexual misinformation is therefore equally shared in the group. Parents at home and teachers in school feel equally inadequate or uneasy to discuss the topic of sex with youngsters.
The problem mounts because the barkada (gang) has a more profound influence than parents do and they exert pressure and expect the adolescent to conform to the rest of them. In fact, female adolescents whose friends engage in sexual behavior were found to be more likely to do the same compared to those who do not associate with such peers. If the teen perceives her peers to look negatively at premarital sex, she was more likely to start sex at a later age. Numbers Statistics in the United States show that each year, almost 1 million teenage women? 10 percent of all women aged 15-19 and 19 percent of those who have had sexual intercourse? become pregnant and one-fourth of teenage mothers have a second child within two years of their first.
In the Philippines, according to the 2002 Young Adult Fertility and Sexuality Study by the University of the Philippines Population Institute (Uppi) and the Demographic Research and Development Foundation, 26 percent of our Filipino youth nationwide from ages 15 to 25 admitted to having a premarital sex experience. What? s worse is that 38 percent of our youth are already in a live-in arrangement. The 1998 National Demographic and Health Survey (NDHS) reveals that 3. 6 million of our teenagers (that? s a whopping 5. 2 percent of our population! ) got pregnant. In 92 percent of these teens, the pregnancy was unplanned, and the majority, 78 percent, did not even use contraceptives the first time they had sex. Many of the youth are clueless that even on a single intercourse, they could wind up pregnant. Risks There are many reasons teen pregnancies should be avoided. Here? s a low down on the facts: ? Risk for malnutrition
Teenage mothers tend to have poor eating habits and are less likely to take recommended daily multivitamins to maintain adequate nutrition during pregnancy. They are also more likely to smoke, drink or take drugs during pregnancy, which can cause health problems for the baby. ? Risk for inadequate prenatal care Teenage mothers are less likely to seek regular prenatal care which is essential for monitoring the growth of the fetus; keeping the mother? s weight in check; and advising the mother on nutrition and how she should take care of herself to ensure a healthy pregnancy. According to the American Medical Association, babies born to women who do not have regular prenatal care are 4 times more likely to die before the age of 1 year. ? Risk for abortion
Unplanned pregnancies lead to a higher rate of abortions. In the United States, nearly 4 in 10 teen pregnancies (excluding those ending in miscarriages) are terminated by abortion. There were about 274,000 abortions among teens in 1996. In the Philippines, although abortion is illegal, it would shock you to know that we even have a higher abortion rate (25/1,000 women) compared to the United States where abortion is legal (23/1,000 women). For sure, there are more abortions that happen in our country that are not even reported. Backdoor abortions are resorted to with untrained ? hilots? with questionable sterility procedures, increasing the possibility for tetanus poisoning and other complications. Risk for fetal deaths Statistics of the Department of Health show that fetal deaths are more likely to happen to young mothers, and that babies born by them are likely to have low birth weight. ? Risk for acquiring cervical cancer The Human Papillomavirus (HPV) is a sexually-transmitted, wart-forming virus that has been implicated in causing cancer of the cervix. This is the most common cancer in women secondary to breast cancer. Women who are at increased risk for acquiring this are those who engage in sex before 18, have a pregnancy at or younger than 18, or have had at least 5 sexual partners, or have had a partner with at least 5 sexual partners.
If you start sex at an early age, you have a higher likelihood of going through several sexual partners before you settle down, thus increasing your exposure to acquiring the virus and acquiring cervical cancer. The men can get genital warts from this virus and can certainly pass it on to their partners, thus increasing her risk for cervical cancer. Is that something you would want to gift to your wife with on your honeymoon? There is a way to test women (HPV Digene test) but no test for the man so you can? t know if you have it. Using the condom does not confer protection against acquiring this virus since the condom cannot cover the testes where the warts can grow and proliferate. Adolescent Pregnancy: Current Trends and Issues Abstract
The prevention of unintended adolescent pregnancy is an important goal of the American Academy of Pediatrics and our society. Although adolescent pregnancy and birth rates have been steadily decreasing, many adolescents still become pregnant. Since the last statement on adolescent pregnancy was issued by the Academy in 1998, efforts to prevent adolescent pregnancy have increased, and new observations, technologies, and prevention effectiveness data have emerged. The purpose of this clinical report is to review current trends and issues related to adolescent pregnancy, update practitioners on this topic, and review legal and policy implications of concern to pediatricians. INTRODUCTION
Adolescent pregnancy in the United States is a complex issue affecting families, health care professionals, educators, government officials, and youths themselves. Since 1998, when the last statement on this topic was issued by the American Academy of Pediatrics (AAP), efforts to prevent adolescent pregnancy have increased,and new observations, technologies, and prevention effectiveness data have emerged. The purpose of this clinical report is to provide pediatricians with recent data on adolescent sexuality, contraceptive use, and childbearing as well as information about preventing adolescent pregnancy in their communities and in clinical practice. This report does not address diagnosis of pregnancy or management of the transition to prenatal care.
Information about counseling pregnant youth is provided in the AAP policy statement “Counseling the Adolescent About Pregnancy Options,” and from the Alan Guttmacher Institute, and information about early prenatal care is available from the American College of Obstetricians and Gynecologists SEXUAL ACTIVITY The proportion of American adolescents who are sexually active has decreased in recent years; however, rates are still high enough to warrant concern. Currently, more than 45% of high school females and 48% of high school males have had sexual intercourse. The average age of first intercourse is 17 years for girls and 16 years for boys. However, approximately one fourth of all youth report having had intercourse by 15 years of age.
Younger teenagers are especially vulnerable to coercive and nonconsensual sex. Involuntary sexual activity has been reported by 74% of sexually active girls younger than 14 years and 60% of those younger than 15 years. Sexually active youth, similar to older unmarried adults, usually have monogamous, short-lived relationships with successive partners. Current surveys indicate that 11% of high school females and 17% of high school males report having had 4 or more sexual partners. In addition to intercourse, many adolescents report having had oral sex or engaging in kissing, touching, or other mutual stimulation; however, data on these other behaviors are reported rarely.
There are several predictors of sexual intercourse during the early adolescent years, including early pubertal development, a history of sexual abuse, poverty, lack of attentive and nurturing parents, cultural and family patterns of early sexual experience, lack of school or career goals, substance abuse, and poor school performance or dropping out of school. Factors associated with a delay in the initiation of sexual intercourse include living with both parents in a stable family environment, regular attendance at places of worship, and higher family income. Recently, parental supervision, setting expectations, and parent/child “connectedness” have been recognized as clearly associated with decreasing risky sexual behavior and other risky behaviors among adolescents. CONTRACEPTIVE USE
Despite increasing use of contraception by adolescents at the time of first intercourse, 50% of adolescent pregnancies occur within the first 6 months of initial sexual intercourse. The human immunodeficiency virus (HIV) epidemic and public health education efforts have led more adolescents to use barrier contraceptives; nonetheless, in 2003, among high school students who reported that they had ever had sexual intercourse, only 63% reported having used a condom the last time they had intercourse. Despite HIV prevention guidelines, initiation of prescription contraceptives is often accompanied by decreased condom use, especially among adolescents who do not perceive themselves to be at risk of sexually transmitted diseases (STDs).
Many adolescents who currently report using prescription contraceptives delayed seeing a clinician for a contraceptive prescription until they had been sexually active for 1 year or more. Adolescent women, similar to adult women, have changed contraceptive methods in recent years, with decreases in pill use and increases in injectable contraceptive use. Factors associated with more consistent contraceptive use among sexually active youth include academic success in school, anticipation of a satisfying future, and being involved in a stable relationship with a sexual partner. The Centers for Disease Control and Prevention unambiguously recommends both abstinence and the use of barrier contraceptives for individuals who choose to be sexually active. However, some groups continue to question the effectiveness of condoms.
Youth who participated in programs that provided information about abstinence, condoms, and/or contraception; who were engaged in one-on-one discussions about their own behavior; who were given clear messages about sex and condom or contraceptive use; and who were provided condoms or contraceptives have been found to increase consistent condom and contraception use without increasing sexual activity. TRENDS IN ADOLESCENT CHILDBEARING Each year, approximately 900000 teenagers become pregnant in the United States, and despite decreasing rates, more than 4 in 10 adolescent girls have been pregnant at least once before 20 years of age. Most of these pregnancies are among older teenagers (ie, those 18 or 19 years of age). Approximately 51% of adolescent pregnancies end in live births, 35% end in induced abortion, and 14% result in miscarriage or stillbirth.
Historically, the highest adolescent birth rates in the United States were during the 1950s and 1960s, before the legalization of abortion and the development of many of the current forms of contraception. After the legalization of abortion in 1973, birth rates for US females 15 to 19 years of age decreased sharply until 1986. Rates increased steadily until 1991; since then, the birth rate among teenagers has decreased every year since 1991. Since 1991, the rate has decreased 35% for 15- to 17-year-olds and 20% for 18- to 19-year-olds. Rates for 10- to 14-year-olds were 1. 4 per 1000 in 1992 and have gradually decreased to 0. 7 per 1000 in 2002.
Although birth rates have been decreasing steadily for white and black teenagers in recent years, 1996 is the first year that birth rates decreased for Hispanic teenagers; Hispanic adolescents also have had the highest overall birth rates and smallest decreases in recent years. Once a teenager has had 1 infant, she is at increased risk of having another. Approximately 25% of adolescent births are not first births. ADOLESCENT PARENTS AND THEIR PARTNERS Adolescent childbearing is usually inconsistent with mainstream societal demands for attaining adulthood through education, work experience, and financial stability. Poverty is correlated significantly with adolescent pregnancy in the United States.
Although 38% of adolescents live in poor or low-income families, as many as 83% of adolescents who give birth and 61% who have abortions are from poor or low-income families. At least one third of parenting adolescents (both males and females) are themselves products of adolescent pregnancy. Although it is difficult to establish causal links between childhood maltreatment and subsequent adolescent pregnancy, in some studies as many as 50% to 60% of those who become pregnant in early or midadolescence have a history of childhood sexual or physical abuse. The problem of adolescent pregnancy is often assumed to be both an adolescent and an adult problem, because many partners of childbearing youth are adults.
The percentage of adolescent pregnancies in which the father is an adult is unclear; studies report a range from 7% to 67%. Adult men having sexual relationships with adolescents is problematic, because many of these relationships may be abusive or coercive. Adolescents who have sex with older men are also more likely to contract HIV infection or other STD. Although more than two thirds of adolescent girls’ sexual partners are the same age or within a few years older and the sexual activity is consensual in nature, some partners are more than 4 years older. Sexual relationships between adults and minors may be coercive or exploitative, with detrimental consequences for the health of both the teenager and her children.
Although some states and local jurisdictions have changed statutory rape laws and their enforcement, mandated reporting of all sexual activity as statutory rape or as child abuse has not been effective at changing behavior, does not allow for clinical judgment, and has the effect of deterring some of the adolescents most in need from seeking health care. Adolescent fathers are similar to adolescent mothers; they are more likely than their peers who are not fathers to have poor academic performance, higher school drop-out rates, limited financial resources, and decreased income potential. Some fathers disappear from the lives of their adolescent partners and children, but many others attempt to stay involved, and many young fathers struggle to be involved in their children’s lives.
Current programs in adolescent pregnancy and parenting are exploring ways to r