This project was done in 2017, thanks to a seed grant from the Overdeck Foundation and the Woodrow Wilson School (Princeton).
Teenage pregnancy is considered a persistent development challenge in several low-income countries despite the technological advances in modern contraceptive methods and their availability. Our project “Raising a baby or raising your future? The effects of teenage pregnancy on educational choices” aims to understand the dynamics of teenage pregnancy, and in particular its determinants and risk factors among young Dominicans. We conducted field work activities during July 2017.
The results of this fieldwork allowed us to: (i) assess the extent to which girls were informed about sexual relations, contraceptive use and the quality of information they receive. (ii) assess the extent to which the absence of life goals and aspirations can lead to teenagers to plan a pregnancy and (iii) identify barriers to access to contraceptive methods such as lack of knowledge, supply, shame, fear or cultural attitudes. We gathered this information through qualitative interviews with female students and former female students who dropout due to a pregnancy.
Teenage pregnancy is recognized as an important policy concern as previous evidence suggests a negative relationship between early childbearing and later educational attainment and labor market outcomes (Fletcher and Wolfe, 2009; Hotz, McElroy and Sanders, 2005; Stange, Kevin, 2011). Teen parents may lose the opportunity to invest in their own human capital. Indeed evidence shows they have a lower probability of completing high school and attending college mothers (Haveman, Wolfe, and Peterson, 1997). Also, studies in developed and developing countries have found that teen childbirth is associated with a reduction in labor market participation, lower parental earnings and higher rates of poverty both in the short and long-term (Maynard, 1997; Azevedo et al., 2012; Arceo-Gomez and Campos-Vazquez, 2014).
Moreover, the consequences of teenage parenthood have intergenerational effects. A large number of studies have demonstrated that children born to teenage mothers tend to display lower human capital accumulation, and poorer health and labor market outcomes (Rosenzweig and Wolpin, 1995; Angrist and Lavy, 1996; Hoffman, 2008; Moore, Morrison, and Greene, 1997). Therefore, teenage pregnancy is considered a pervasive social problem that can contribute to the intergenerational transmission of inequality. Conceptually, teenage pregnancy is a complex decision that combines elements from a rational framework with other elements including imperfect information, gender role attitudes, aspirations, family structure, peer effects and behavioral issues (discounting, self-control, and empowerment).
Previous studies in Latin America and the Caribbean have identified several factors underlying early childbearing. The most common factors relate to the quality and value of education (opportunity costs), incentives, poor information, access to contraceptive methods, self-esteem, social norms and aspirations. For example, according to a large-scale quantitative-qualitative study on adolescent fertility in Ecuador by the World Bank, most of the teenage pregnancies are unplanned reflecting the lack of control of youth over their life goals. The same study in Ecuador reported that interviewed adolescents claim that they received limited sexual education in classes with lack of information about birth control, sexual interactions, and risk behaviors (World Bank, 2012).
In other countries like Peru and Paraguay, studies argue that adolescents deliberately choose to have a child because their school performance was poor and they were looking for a reason to quit school (Näslund-Hadley and Binstock, 2010). The authors find that teenagers did not believe that education could change their future. This highlights the perception that the opportunity cost of getting pregnant is low, and how important is to consider the role of aspirations in these contexts (Edin and Kefalas, 2005; Ross and Mirowski, 2003).
Teenage Pregnancy in Dominican Republic
We set our project in the Dominican Republic, which has the highest teenage pregnancy rate in Latin America and the Caribbean -104 births per 1,000 people between the ages of 15 and 19- comparable to sub-Saharan Africa rates (Inter-American Development Bank, 2016). Using repeated cross-section data from the Demographic and Health Surveys, figure 1 shows fertility trends (births per 1000 women) for different age groups between 1986 and 2013. As can be seen, fertility rates have been declining for women aged between 20-29, but they have remained constant among adolescents (ages 15-19). In contrast, figure 2 shows that the current use of family planning methods among sexually active women has been growing among adolescents, increasing from 5% in 1986 to 22% in 2013, but still remains low.
Figure 1: Fertility trends
Figure 2: Current Family Planning use among sexually active adolescents (ages 15-19)
In addition, teen pregnancy in the Dominican Republic is higher in low-income and rural populations, with 61.4% of pregnant teenagers belonging to the lowest two socio-economic status quintiles. Similarly, there are significant differences in the timing at which women start childbearing across SES status. The median age at first birth among women ages 20-49 is more than four years lower for women in households in the lowest wealth quintile (19.2 years) than for women in households in the wealthiest quintile (23.4 years). These disparities in the incidence of teen pregnancy rates across SES status can contribute to perpetuate the intergenerational transmission of poverty and inequality.
Regarding geographical differences, Figure 3 and 4 display the percentage of women 15-19 pregnant or with a child by region in 2007 and 2013 respectively. There is significant variation in the incidence of teen pregnancy between urban and rural areas. In addition, the regions in the border with Haiti have experienced an increase of around 10 percentage points in the incidence of teen pregnancy (from 29% to 38.5%).
Figure 3: Distribution by Region, 2007
Figure 4: Distribution by Region, 2013
Teenage Motherhood and Newborn Health
Thanks to our visit to the Dominican Republic, we were able to talk to several members of the government, including the Ministry of Health. They provided us with birth certificates data from 2015 and 2016, which they use for their own records. We will be able to match these records with other administrative data sets, like school enrollment and conditional cash transfers, allowing us to have a wider set of outcomes.
Figure 5: Share of Teen Mothers across Municipal Level
For this report, we analyze some simple statistics in order to learn about the the characteristics of newborns. In Figure 5, we calculate the share of births whose mother is under 20 years old. This indicator comes from micro data at municipal level and it can help us to see where teen mothers are more frequent and it shall not be confused with Teenage Pregnancy Rates.
Using data from 2015 and 2016 birth certificates, we perform a simple analysis to test the correlations between young mothers under 20 (Teen Mothers) and older mothers. We found that younger mothers are more likely to have babies with lower weight and less height. It is important to know that we have not included the status of risky pregnancies or abortions in these analyses.
Understanding Teen Pregnancy Factors: Our 2017 Exploratory Field Work
A key component of our project was the execution of qualitative interviews to understand the decision making process faced by Dominican teenagers.The objectives of our field work activities were the following: (i) assess the extent to which girls and boys are informed about sexual relations, contraceptive use and the quality of information they receive. We also wanted to (ii) assess the extent to which the absence of life goals and aspirations can lead to teenagers to plan a pregnancy and finally (iii) identify barriers to access contraceptive methods such as lack of knowledge, supply, shame, fear or cultural attitudes.
Methodology: Sample Selection and Interview Process
The selection of the sample for qualitative interviews was conducted taking advantage of professor’s Christopher Neilson previous projects in the Dominican Republic in partnership with the Dominican Government. In particular, we used data from the AVE Project (“Learning the Value of Education”) implemented in the east half of the country between 2015 and 2016. This intervention aimed to reduce dropout rates among students between 7th to 9th grade by providing returns to education information through videos and other outlets.
Within the intervention a sample of students and their families were surveyed in order to learn about their educational and personal aspirations. A key feature of the survey was that it followed students even after they dropped-out of school. Importantly, approximately 50 percent of female students who dropped out school were pregnant or had a baby during that year. Using this data, we selected two groups for our in-depth interviews:
-First Group (A): We selected a random group of students who dropped out because of a pregnancy.
-Second Group (B): We also selected a random group of female students who did not dropped out but lived in the same neighborhood as the girls from the First Group (A)
The selection of students are shown in Figure 6 below. Our final sample relies on the AVE project sample selection that was originally designed for dropout rates.Nevertheless, this selection is also correlated with areas with high teenage pregnancy rates.
Figure 6: Fieldwork Sample Selection
In total, we selected 25 potential interviewees. Those subjects were contacted by staff members of the AVE Project Call Center and were asked if they were willing to participate in a face-to-face interview regarding teenage pregnancy. As a result, 20 subjects were scheduled for an interview. Out of the 20 subjects, only 11 confirmed the interview after a re-confirmation call from the interviewer.
Moreover, interviews were conducted face-to face by two female researchers, Fabiola Alba and Daniela Urbina, with the logistic support of two research interns. On average, interviews lasted 20 minutes and were audio recorded with the participants’ consent. The survey questions and protocols for groups A and B are in the Appendix.
No compensations were given and consents were taken, following the AVE Project Implementation Rules and our IRB Protocols.
Preliminary Findings In-Depth Interviews
In this section we summarize the main findings of our interviews in the Dominican Republic.
The role of life goals and aspirations
An increasing body of literature looks at the role of women’s aspirations and life plans to explain unintended pregnancies among adolescents (e.g. Edin and Kefalas, 2005; Ross and Mirowski, 2003). Indeed, among our respondents we found clear differences in terms of life goals between girls that got pregnant during school and those who did not. More specifically, when asked about their aspirations before getting pregnant the majority of respondents explain they did not have particular career plans after school.
Yet they all mention they wanted to finish school before having children. For example, Paula (-we are not using the respondents’ real names to protect their identity as specified by IRB protocols and regulations -) explains she liked to go to school and was a good student, but never thought about University seriously because she didn’t know what to study, or what areas she liked. Currently, all respondents that drop-out when they got pregnant want to go back to school and finish their secondary education, although only one of them has actually executed this intention. After motherhood, respondents plans include finding a job, but their narratives do not show the existence of concrete goals.
In contrast, the majority of girls that haven’t had a pregnancy reveal more precise plans for their future. Several of them mention they want to develop careers when they finish high school. For instance, Inés is working hard to study medicine just like her older sister, while Vale plans to study social communication and is learning English to be prepared for it. Indeed, what is remarkable is that these adolescents have specific plans for their future. In addition, most of them want to have kids once they have a career, a concept that is not present in the narratives of teenage mothers. Also, the ideal age they report to have their first baby varies between 25 to 32 years old.
Fieldwork In Progress
Information on contraception methods
Naturally, one of the main purposes of our interviews was to have a sense of the quality and extent of information on contraception adolescents have in the DR. It seems that the majority of respondents that got pregnant had information on contraception. In particular, before their pregnancies they knew about two methods -condoms and the pill- with the exception of one interviewee who said she did not have any knowledge of birth control.
Interestingly, two respondents were using contraception pills, bought by their boyfriends, but decided to stop taking them because of the daily commitment to be effective. The latter suggests that for these girls a pregnancy may be more related to a lack of motivation to use contraception than by insufficient information. Currently, all respondents in this group are using some form of contraception including birth control implants, shots, and the pill.
Furthermore, across respondents that haven’t had a pregnancy we found important knowledge variations by age. As expected, girls between 13 to 15 years old have less knowledge on contraception methods, which is circumscribed only to condoms and birth control. For this group, their main source of information is their school and sexual education class, while friends and parents seem to play a minor role.
In contrast, older girls know a more comprehensive spectrum of methods that include birth control shots and implants. Also, their main sources of information include friends and neighborhood acquaintances that either recommend a method or are living examples of a method that did not work. For example, Maria cites the example of a neighbor that was taking the pill and got pregnant to argue why she would prefer to use a birth control implant.
Caro is reticent of using birth control shots and mentions the case of someone at school that got pregnant using this method.
Finally, when asked about their preferred birth control method most interviews mentioned contraception shots, in the case of older respondents, or the pill, in the case of younger girls. None of them indicated condoms as a preferred method.
Barriers to birth control
In general, respondents had knowledge about where and how to access contraceptive methods. Most of them say they can buy condoms or the pill at their local shops (colmados) or pharmacy, and the older respondents had knowledge on public programs that provide birth control shots and implants at hospitals. However, we identified two barriers to access contraceptive methods.
First, for younger adolescents embarrassment is an issue that inhibits them to approach a pharmacy or local shop to buy contraception. In fact, several of our younger respondents say they had never done so and were embarrassed to talk about these issues with their parents.
Second, several respondents were worried to use birth control methods because of their presumably secondary effects on body weight. Indeed, in almost all interviews contraceptive the pill, shots or implants were discarded because they make women too skinny. The veracity of this information is unclear, but in practice these messages regarding secondary effects operate as a deterrence against the use of birth control methods.
Gender roles, romantic relationships and pregnancy
Finally, we also wanted to explore how cultural aspects in the Dominican context, specifically gender roles and expectations, could be related to its high rates of teenage pregnancy. According to our interviews and previous scholarship in the area, the Dominican Republic is characterized by sharply defined gender roles and high levels of distrust against men and their abilities to provide or take care of a family.
In particular, several respondents argue that nothing is expected from Dominican men, and provide starkly negative depictions of their behavior. For instance, Caro explains that in her town many men just spend their days “hanging out” and want to be economically supported by their partners. The idea that young Dominican men do not work and want to be provided by their girlfriends is seconded by Camila, Vale, Susana and Inés. Other interviewees depict men as “malos” (bad), sexists and only interested in providing for themselves. This is why many women, according to our respondents, not only are in charge of housework and child rearing, but also are the main breadwinners of their households. Regardless if these perceptions are empirically true or not, the fact that so many young women hold these expectations of men is worrisome and definitely could be affecting family formation patterns.
In this vein, we were also interested in the perception adolescents had of the reasons why their peers got pregnant during school. All non-mother respondents answered that girls usually don’t use birth control because they actually want to get pregnant to retain their boyfriends. Luz explains:
“You say to them “protect yourself, get the shot” (…), they say they will, but in practice they want to “trap” their boyfriends by getting pregnant, do you understand? Today, young women have one boyfriend, but the boyfriend might have many girls so then I get pregnant so that he has to stick with me”.
As mentioned, this vision is widely shared by all non-mother respondents. They also add that usually this strategy doesn’t work; some responsible men will take care of the child but won’t necessarily continue a monogamous romantic relationship with the mother. Again, the perception women need to “trap” men via a pregnancy reveals a lack of trust in the existence of healthy romantic relationships were both men and women decide to form a monogamous union.
Overall, our in-depth interviews with Dominican adolescents suggest three potential areas of intervention that could decrease teenage pregnancy.
First, having specific goals and aspirations to look ahead after school seem to be an important mechanism to increase the cost of a pregnancy. Indeed, the lack of motivation to use contraception reveal that the costs of having a baby for these girls are not very high.
Secondly, adolescents accounts suggest the existence of two barriers to contraceptive use, embarrassment to access birth control, in the case of young girls, and myths surrounding the secondary effects of particular methods. An intervention that directly tackles both barriers could be effective, especially in the case of young girls.
Finally, sexual orientation lessons at school seem to be a key source of information for adolescents, especially at an earlier age. In this sense, we think its important to first analyze the type of information and approach to birth control provided by schools, and second use this space for the implementation of new programs regarding teenage pregnancy.
Questionnaire A: For adolescents that had a child during schooling.
Module 1: Background and experiences before pregnancy
- First, tell us a little bit about yourself. a. How old are you? b. With whom do you live?
- Tell me about your schooling experience so far a. [If in school] In which grade are you? b. [If not in school] Until which grade did you attend school? c. What did you like about your school? d. What did you not like about going to school? e. In general, how important you think is education for your future? f. Were you also working when you got pregnant?
Module 2: Gender Norms and Beliefs
Thinking in general about Dominican society a. What do you think is the ideal role woman should play? What are the traditional expectations for young woman? [Note: education, work, etc.] b. What about men? In Dominican society, was is the ideal role men should play? What are the traditional expectations for young men?
About Plans and Beliefs a. Did anyone in your family experienced having a baby during their adolescence? b. Tell me about your life before becoming a mother: What were your main activities? What were your plans for the future? (e.g working, schooling, mothering?) What were you doing to attain those plans? c. What about now? How motherhood has changed your life, your activities and plans for the future? [Note: Let interviewee freely speak].
Module 3: About the father
- Tell me a bit more the father of your kid. a. Were you in a romantic relationship with him at the time you got pregnant? And now? b. Was he your (first) boyfriend? a. How old is he? b. Was he working at the time you got pregnant? Or was he in school? c. Where did you meet him? Could you tell us a bit more about your pregnancy?
We have a set of questions about the context in which you become pregnant, if any of these questions make you uncomfortable just let us know and we’ll skip to the next question.
Module 4: Regarding Contraception
- Were you or the father of your child using any type of contraception at the time of the pregnancy?
If interviewer says she/partner were using contraception:
a. What type of contraception were you using? b. How did you learn about this method? At school? Friends? Family?
c. How did you have access to this method? d. Did you had problems accessing the method? What problems? i. Did you have issues with partner about using it? ii. Who was paying for it? iii. Other issues?
If she was NOT using contraception:
a. Why did you not use contraception? [Note: Let interviewee speak. Ask for the following topics if they do not naturally come up in her response]: i. Did you have any knowledge on contraception methods? [If yes] What method specifically? [Note: try to asses the knowledge of the method here] Where did you learn about them? ii. Did you know how to get these methods? [If yes] How could you get access to them [For example, pharmacy, local hospital?] ? iii. Did you and your partner ever discussed contraception? Did he had any thoughts on using them? iv. Did you ever discussed contraception methods with anyone? Friends? Your mom? Or other relative? [if Yes] Do you remember what did you discussed about them? [if Not] Why not?
Module 5: Was the pregnancy wanted?
- Did you and the father of your child decided to get pregnant together?
- [If yes] What were the motivations for having a child at that moment?
- Who was looking for to get pregnant? Who made the decision?
- Did you feel like you had control on the situation?
Module 6: The aftermath of pregnancy
When you realized you were pregnant… a. Who did you tell first? b. What was the reaction of your partner? c. Did you receive support from your family during the pregnancy?
d. How was the reaction in your school? [Ask about teachers, principal, but also friends] Where you able to keep going to school until when?
Currently, are you in a romantic relationship? a. [If Yes] Are you using contraception? b. [If Yes] What type? c. [If Not] Why not?
Questionnaire B: For adolescents that did not have a child during schooling
Module 1: Background and Schooling
First, tell us a little bit about yourself. a. How old are you? b. With whom do you live?
Tell me about your schooling experience so far (regardless if she is not in school anymore) and your family
a. In which grade are you? b. What do you like about your school? (Specific subjects, friends?) c. What do you not like about going to school? d. What are your plans for the future? (e.g working, schooling, mothering?) [Note: Let interviewee freely speak]. e. What are you doing to attain those plans? f. Did anyone in your family experienced having a baby during their adolescence? g. [If Yes] Have this event influence the decisions you make in your life?
Module 2: Gender Norms and Beliefs
- Thinking in general about Dominican society a. What do you think is the ideal role woman should play? What are the traditional expectations for young woman? [Note: education, work, etc.] b. What about men? In Dominican society, was is the ideal role men should play? What are the traditional expectations for young men?
We have a set of questions about relationships and pregnancy issues, if any of these questions make you uncomfortable just let us know and we’ll skip to the next question.
Module 3: About Relationships and Contraception
- What do you think about contraception? Are they good or bad?
- Do you have any knowledge on contraception methods? [If yes] What method specifically? [Note: try to asses the knowledge of the method here] Where did you learn about them?
- Are you in a romantic relationship? a. [If yes] Tell me about your partner. Does he work? Is he in school? How old is he? b. [If yes] Where did you first meet him? And how did you become a couple? c. How long have you been together? d. [If not in a relationship] Have you ever had a romantic partner? If yes, move to question 4, if not move to question 6.
- In your last or current relationship: Are you having sexual relations?
- [If Yes] Are you or your partner using any type of contraception?
- If YES using contraception: a. What type? [Note: try to asses the knowledge of the method here] b. How did you learn about this method? At school? Friends? Family? c. How did you have access to this method? d. Who pays for them? e. Did you and your partner ever discussed contraception? Did he had any thoughts on using them? f. Did you ever discuss contraception methods with anyone? Friends? Your mom? Or other relative? [if Yes] Do you remember what did you discussed about them? a. Did you had problems accessing the method? What problems? i. Did you have issues with partner about using it? ii. Who was paying for it? iii. Other issues?
- If NOT using contraception: a. Why do you not use contraception? [Note: Let interviewee speak. Ask for the following topics if they do not naturally come up in her response: b. Do you have any knowledge on contraception methods? [If yes] What method specifically? [Note: try to asses the knowledge of the method here] Where did you learn about them? c. Do you know how to get these methods? [If yes] Describe how could you get access to them [For example, pharmacy, local hospital?] ? d. Did you or your partner ever got them? Why not? e. Do you and your partner ever discussed contraception? Does he had any thoughts on using them? f. Did you ever discuss contraception methods with anyone? Friends? Your mom? Or other relative? [if Yes] Do you remember what did you discussed about them?
- Not ever or in a current relationship a. Do you know how to get contraceptives? b. [If yes] Describe how could you get access to them [For example, pharmacy, local hospital?] ? c. [If yes] Did you ever got them? d. Did you ever discuss contraception methods with anyone? Friends? Your mom? Or other relative? [if Yes] Do you remember what did you discussed about them?
Module 4: About Pregnancy
- Do you think that getting pregnant would change your future plans? In what way?
- At what age do you think it’s adequate to have the first baby?
- Would you like to ever have a baby? [Is yes] At what age would you like to have your first baby?