Abstracts

Introduction

Adolescent pregnancy is considered a social and health-related problem of global proportions, associated with risks for mothers and their offspring. It entails substantial costs as a result of welfare expenses and educational lags, in addition to hindering access to well-paying jobs ¹1. United Nations Population Fund. Socioeconomic consequences of adolescent pregnancy in six Latin American countries. Implementation of the Milena methodology in Argentina, Colombia, Ecuador, Guatemala, Mexico and Paraguay. https://lac.unfpa.org/sites/default/files/pub-pdf/eng_-_informe_consecuencias_socioeconomicas_del_embarazo_en_la_adolescencia_en_seis_paises_de_america_latina_y_el_caribe._vf.pdf (accessed on 11/Nov/2021).
https://lac.unfpa.org/sites/default/file... . In Latin America, adolescent fertility rate declined between 2010-2015 and 2015-2020, from 65.6 to 60.7 live births per 1,000 women aged 15-19 years. Nonetheless, this figure represents the second highest adolescent fertility rate worldwide, with marked disparities among countries in Latin America ²2. Pan American Health Organization; United Nations Population Fund. Adolescent pregnancy in Latin America and the Caribbeean. https://iris.paho.org/bitstream/handle/10665.2/53133/PAHOFPLHL200019_eng.pdf?sequence=1&isAllowed=y (accessed on 20/Nov/2021).
https://iris.paho.org/bitstream/handle/1... .

At the global level, the 2030 Agenda for Sustainable Development highlights the importance of achieving the Sustainable Development Goals in different aspects, including adolescent sexual and reproductive health ³3. United Nations. The 2030 agenda and the sustainable development goals. An opportunity for Latin America and the Caribbean. https://repositorio.cepal.org/bitstream/handle/11362/40156/S1801140_en.pdf?sequence=25&isAllowed=y (accessed on 11/Dec/2021).
https://repositorio.cepal.org/bitstream/... . In Latin America, the Montevideo Consensus on Population and Development stresses the need to implement specific actions in this area ⁴4. Economic Commission for Latin America and the Caribbean. Montevideo consensus on population and development. https://repositorio.cepal.org/bitstream/handle/11362/21860/15/S20131039_en.pdf (accessed on 15/Dec/2021).
https://repositorio.cepal.org/bitstream/... . Both initiatives seek to ensure a healthy life and promote the wellbeing of the population via education and universal access to sexual and reproductive health services, particularly those related to family planning, as a way to reduce adolescent fertility. Moreover, these initiatives advocate not only for gender equality and the empowerment of women and girls, but also for the elimination of all forms of violence in the public and private spheres, as well as harmful practices, such as child, early, and forced marriages ³3. United Nations. The 2030 agenda and the sustainable development goals. An opportunity for Latin America and the Caribbean. https://repositorio.cepal.org/bitstream/handle/11362/40156/S1801140_en.pdf?sequence=25&isAllowed=y (accessed on 11/Dec/2021).
https://repositorio.cepal.org/bitstream/... ^,44. Economic Commission for Latin America and the Caribbean. Montevideo consensus on population and development. https://repositorio.cepal.org/bitstream/handle/11362/21860/15/S20131039_en.pdf (accessed on 15/Dec/2021).
https://repositorio.cepal.org/bitstream/... . Some Latin American countries signed these agreements and recently confirmed their commitment to implement sexual reproductive health strategies ⁵5. Secretaría de Gobernación. Avances y retos en la implementación de la Agenda 2030 para el Desarrollo Sostenible en México. https://www.gob.mx/agenda2030/prensa/avances-y-retos-en-la-implementacion-de-la-agenda-2030-para-el-desarrollo-sostenible-en-mexico?state=published (accessed on 17/Dec/2021).
https://www.gob.mx/agenda2030/prensa/ava... ^,66. Secretaría de Gobernación; Consejo Nacional de Población; Fondo de Población de la Naciones Unidas. Informe nacional de avance en la implementación del Consenso de Montevideo. https://www.gob.mx/conapo/documentos/informe-nacional-de-avance-en-la-implementacion-del-consenso-de-montevideo (accessed on 11/Oct/2021).
https://www.gob.mx/conapo/documentos/inf... ^,77. Economic Commission for Latin America and the Caribbean. Montevideo Strategy for implementation of the regional gender agenda within the sustainable development framework by 2030. Santiago: Economic Commission for Latin America and the Caribbean; 2019.. In the last decade, many countries in the region have implemented several adolescent pregnancy prevention measures.

Mexico has developed two main strategies: a National Strategy for the Prevention of Teen Pregnancy (Estrategia Nacional para la Prevención del Embarazo en Adolscentes - ENAPEA) ⁸8. Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes. Estrategia Nacional para la Prevención del Embarazo en Adolescentes (ENAPEA). Ciudad de México: Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes; 2015. and a Model of Comprehensive Care in Sexual and Reproductive Health for Adolescents (Modelo de Atención Integral a la Salud y Reproductiva para Adolescentes - MAISSRA) ⁹9. Centro Nacional de Equidad de Género y Salud Reproductiva. Modelo de Atención Integral en Salud Sexual y Reproductiva para Adolescentes (MAISSRA). http://www.cnegsr.salud.gob.mx/contenidos/descargas/SSRA/ModeloAISSRA/web_ModAtnIntSSRA.pdf (accessed on 25/Oct/2021).
http://www.cnegsr.salud.gob.mx/contenido... . These strategies established official standards and technical guidelines for pregnancy prevention and care of this population, focusing on the youth aged under 15 years ¹⁰10. Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes. Guía para la implementación de la "Ruta para la atención y protección integral de niñas y adolescentes madres y/o embarazadas menores de 15 años". Ciudad de México: Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes; 2020.^,1111. Secretaría de Salud. NOM-047-SSA2-2015, para la atención a la salud del Grupo Etario de 10 a 19 años de edad. http://www.dof.gob.mx/nota_detalle.php?codigo=5403545&fecha=12/08/2015 (accessed on 08/Sep/2021).
http://www.dof.gob.mx/nota_detalle.php?c... .

The Mexican adolescent fertility rate dropped slightly from 2014 to 2018, declining from 77.0 to 70.6 live births per 1,000 women aged 15-19 years ¹²12. Instituto Nacional de Estadística y Geografía. Principales resultados de la Encuesta Nacional de la Dinámica Demográfica (ENADID). Nota técnica. https://www.inegi.org.mx/contenidos/programas/enadid/2018/doc/nota_tec_enadid_18.pdf (accessed on 09/Sep/2021).
https://www.inegi.org.mx/contenidos/prog... . Care coverage has improved as well, with 75% of adolescents receiving at least five antenatal consultations and with most pregnancies being cared for by health professionals in healthcare institutions (98%) ¹³13. Instituto Nacional de Salud Pública; Fondo de las Naciones Unidas para la Infancia. Encuesta Nacional de Niños, Niñas y Mujeres 2015 - Encuesta de Indicadores Múltiples por Conglomerados 2015. Informe final. Ciudad de México: Instituto Nacional de Salud Pública; 2016..

However, recent reports show an increase in the adolescent fertility rate in youths aged under 15 years, from 2012 to 2018; rising from 1.9 to 2.2 births per 1,000 girls ¹⁴14. Consejo Nacional de Población. Fecundidad en niñas y adolescentes de 10 a 14 años. http://coespo.sonora.gob.mx/documentos/Infografiamenores15.pdf (accessed on 20/Sep/2021).
http://coespo.sonora.gob.mx/documentos/I... ^,1515. Ipas México. Violencia sexual y embarazo infantil en México: un problema de salud pública y derechos humanos. Ciudad de México: Ipas México; 2018.. These studies also show that 42% of adolescent mothers were not provided with highly effective contraceptive methods in the immediate postpartum period ¹⁶16. De la Vara-Salazar E, Hubert C, Saavedra-Avendaño B, Suárez-López L, Villalobos A, Ávila-Burgos L, et al. Provisión de métodos anticonceptivos en el posparto inmediato en México, 2018-19. Salud Pública Méx 2020; 62:637-4.. This is worrisome, since 20-25% of pregnancies in this group constitute subsequent adolescent pregnancies, a rate that has not fallen in the last 10 years ¹⁷17. Sánchez-Pájaro A, Braverman-Bronstein A, De Castro F, Vidaña-Pérez D, Villalobos-Hernández A, Barrientos-Gutiérrez T. Contribution of second and higher-order births to adolescent fertility in Mexico. Stud Fam Plann 2019; 50:63-70..

Note that, comparisons of first and subsequent pregnancies among adolescents have revealed an association between subsequent adolescent pregnancy and higher physical/emotional health risks, school dropout, and lower economic self-sufficiency ¹⁸18. Conroy K, Engelhart T, Arandia P, Forbes P, Cox J. Relationship between rapid repeat pregnancy and depression in low-income, minority teen mothers. J Adolesc Health 2013; 52 Suppl 1:S109.^,1919. Villalobos-Hernández A, Campero L, Suárez-López L, Atienzo EE, Estrada F, de la Vara-Salazar E. Embarazo adolescente y rezago educativo: análisis de una encuesta nacional en México. Salud Pública Méx 2015; 57:135-43.. Research has also indicated that children of subsequent adolescent pregnancies tend to experience developmental issues and suffer from lower school performance ²⁰20. Raneri LG, Wiemann CM. Social ecological predictors of repeat adolescent pregnancy. Perspect Sex Reprod Health 2007; 39:39-47.^,2121. Ruedinger E, Cox JE. Adolescent childbearing: consequences and interventions. Curr Opin Pediatr 2012; 24:446-52..

Although various efforts have been made to prevent subsequent adolescent pregnancies, these pregnancies still represent a continuing public health problem. An analysis of public policy would make it possible to ascertain the extent to which this problem has been addressed on government agendas and to identify whether any specific actions have been undertaken to mitigate its prevalence.

The literature indicates that the study of public policy has shifted from a focus on decision theory to the theory of limited rationality ²²22. Shepsle K, Boncheck M. Las formulas de la política. Ciudad de México: Taurus; 2005.. The latter has given rise to a process approach in which the main interest is centered on complexity and interaction among the actors who structure the policies ²³23. Klijn E. Las redes de política pública: una visión de conjunto. In: Cerrillo i Martínz A, editor. La gobernanza hoy: 10 textos de referencia. Madrid: Instituto Nacional de Administración Pública; 2005. p. 213-44.. Under this perspective, the definition of problems and the agenda itself result primarily from a process of competition between specific groups, as well as from considerations regarding decision points and solutions ²⁴24. Lindblom C. Still muddling not yet through. Public Admin Rev 1979; 39:517-26..

Therefore, the process of formulating a particular public policy begins with the identification of a problem affecting society, such as sexual and reproductive health issues, in this instance, pertaining to adolescents. When a problem attracts widespread interest, it is positioned on the public-policy agenda and moves to the level of government decision-making regarding strategies for confronting the situation ²⁵25. Cobb R, Elder C. Participation in American politics: the dynamics of agenda-building. Baltimore: Johns Hopkins University Press; 1983..

Once the public-policy agenda has been defined, public-policy instruments are formulated. These comprise a “set of objectives, decisions and actions that the government must carry out to address the problems considered priorities by the population and the government itself” ²⁶26. Delgado L. Las políticas públicas. El ciclo de las políticas públicas. Clases de políticas públicas. Eficacia, legalidad y control. Indicadores de gestión. http://pagina.jccm.es/ear/descarga/A2T3.pdf (accessed on 08/Sep/2021).
http://pagina.jccm.es/ear/descarga/A2T3.... . The scope of these instruments depends on the degree of specificity of their approach.

The task of defining an action to combat a problem should include a series of essential factors such as context, processes, actors, and available resources; however, special attention should also be given to the adopted discourse and the manner in which the problem is presented ²⁷27. Alzate Zuluaga M, Romo Morales G. La agenda pública en sus teorías y aproximaciones metodológicas. Una clasificación alternativa. Revista Enfoques 2017; 15:13-35..

The task of defining national-level actions is informed by international guidelines derived from all the agreements, pacts, treaties, protocols, and conventions entered into by two or more States or entities subject to international law, all of them creating legally binding obligations for its signatories ²⁸28. Sistema de Información Legislativa. Glosario. Instrumento internacional. http://sil.gobernacion.gob.mx/Glosario/definicionpop.php?ID=129 (accessed on 20/Feb/2022).
http://sil.gobernacion.gob.mx/Glosario/d... . In the area of reproductive health and relevant services for the adolescent population specifically, the international agenda has set a benchmark for national agendas as well as for specific actions relevant to Mexico and other countries with similar problems ²⁹29. Naciones Unidas. Informe de la Conferencia Internacional sobre la Población y el Desarrollo. https://documents-dds-ny.un.org/doc/UNDOC/GEN/N95/231/29/PDF/N9523129.pdf?OpenElement (accessed on 23/Oct/2021).
https://documents-dds-ny.un.org/doc/UNDO... ^,3030. Nations Unies. Déclaration et programme d'action de Beijing. https://www.un.org/womenwatch/daw/beijing/pdf/BDPfA%20F.pdf (accessed on 23/Oct/2021).
https://www.un.org/womenwatch/daw/beijin... .

Notably, every six years, when a new political administration takes office in Mexico, the incoming president establishes a new National Development Plan. Accordingly, a new public-policy agenda and new action plans are drawn up for health and other major issues. This often leads to a lack of continuity in actions that would otherwise potentially have a positive impact on society in the medium and long terms ³¹31. Kauffer E. Las políticas públicas: algunos apuntes generales. Ecofronteras 2002; (16):2-5..

Thus, this study aimed to conduct a search of public-policy instruments seeking explicit references to subsequent adolescent pregnancies, as well as to discern what kinds of actions have been proposed as part of the international and national agendas to facilitate its prevention and care.

Methodology

An integrative review was performed ³²32. Russell CL. An overview of the integrative research review. Prog Transplant 2005; 15:8-13.. This methodological approach to reviewing material allowed for including different types of documents to understand the problem of interest. This strategy served a wide range of purposes, such as defining concepts, reviewing theories and evidence, and analyzing methodological problems linked to specific topics. The broad sample and multiple proposals analyzed provided a consistent and comprehensive perspective on complex concepts, health theories, and problems relevant to public health. The research was divided following Russell’s phases: (1) problem formulation, (2) data collection, (3) data evaluation, (4) data analysis, and (5) results interpretation and presentation ³²32. Russell CL. An overview of the integrative research review. Prog Transplant 2005; 15:8-13..

Problem formulation

During this phase, the subsequent adolescent pregnancy was defined as any sentence referring to second or higher-order pregnancies before the age of 20. Also, terms such as “repeated adolescent pregnancy” and “adolescent mother” were considered. Instruments of public-policies at international and national agendas were sought to identify actions focused on the prevention and care for this types of pregnancies.

Data collection

Throughout June 2021, national and international public-policy instruments and other documents were reviewed, in two steps. Firstly, to avoid excluding documents that could provide information on the subject of interest, a thorough search regarding adolescent sexual and reproductive health was conducted. Then, among the documents identified, those containing general information on subsequent adolescent pregnancies were selected.

At the international level, the team searched for regional and global strategies, action plans, guidelines, handbooks, and recommendations in documents published from 2010 to this date. At the national level, documents corresponding to the present 6-year presidential term (2018-2024), including unaltered and still current documents created during previous administrations were selected; among these were rules, regulations, specific action programs (Programa de Acción Específico - PAEs), technical guidelines, care models, official health standards (Normas Oficiales Mexicanas - NOMs), and clinical practice guidelines (Guías de Práctica Clínica - GPCs). No documents relevant exclusively to specific locations in Mexico were selected (Box 1).

At the international level, the websites of the following organizations were explored: the United Nations (UN), the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Development Program (UNDP), the Pan American Health Organization (PAHO), the United Nations Population Fund (UNPFA), the Economic Commission for Latin America and the Caribbean (ECLAC), and civil society organizations (with known expertise in adolescent sexual and reproductive health) working in the Latin American and worldwide.

At the national level, the websites of the government agencies with SRH responsibilities, such as the Ministry of the Interior (SEGOB), the Ministry of Health (SSA), the National Center for Gender Equity and Reproductive Health (Centro Nacional de Equidad de Género y Salud Reproductiva - CNEGSR), the National Center for Child and Adolescent Health (Centro Nacional para la Salud de la Infancia y la Adolescencia - CeNSIA), the National Population Council (Consejo Nacional de Población - CONAPO), and the National Institute of Mexican Youth (Insituto Mexicano de la Juventud - IMJUVE) were consulted. Also, the Official Journal of the Federation (Diario Oficial de la Federación - DOF) were consulted and the GPCs from the catalog and repository of the National Center for Health Technology Assessment (Centro Nacional de Excelenca Tecnológica en Salud - CENETEC) were extracted.

Documents noting key terms (both core and secondary) within the text were identified and selected. Core terms included adolescent, adolescent pregnancy, and subsequent adolescent pregnancy, and its variations: second or higher-order pregnancy in adolescence, repeated adolescent pregnancy, and adolescent mother. Secondary terms included family planning, counseling, contraception, contraceptives, unmet need for contraception, intergenesic period, intergenesic intervals, postponement of pregnancy, unintended and unplanned pregnancies, and breastfeeding.

In total, 135 public-policy documents related to adolescent sexual and reproductive health were extracted. They included 33 international directives, of which 14 were regional and global strategies and action plans, 11 were handbooks and guidelines, and eight were recommendations (Figure 1). At the national level, the documents consisted of: 102 instruments, one national plan, three national programs, three PAEs, two rules and regulations, five technical guidelines and care models, seven NOMs, and 81 GPCs (Figure 2).

Data evaluation

The acquired documents were categorized according to whether they dealt with promotion, prevention, and care, or referred to specific conditions, procedures, or care processes. They were subsequently categorized by theme.

Out of the 135 documents extracted, 57 were excluded from analysis, since only secondary search terms appeared in the text. Among the international documents, seven were eliminated: those pertaining to a global or regional strategies to deal with violence, five manuals or clinical guides on contraception, family planning, and violence, and one recommendation on combatting intimate partner and sexual violence. At the national level, 50 GPCs were excluded: 19 concerning care for comorbidities or conditions typical during pregnancy, one related to abortion, eight on delivery care, six linked to the puerperium, eight pertaining to newborn care, three for breastfeeding, four for family planning, and one for STIs.

Public-policy instruments constituted a unit of analysis. The contents were developed by extracting specific texts from the instruments or by noting the absence of subsequent adolescent pregnancy terms including its variations (second or higher-order pregnancy in adolescence, repeated adolescent pregnancy, and adolescent mother). Of the 78 documents containing the key terms of interest, 26 pertained to the international and 52 to the national sphere; out of these, only ten referred to subsequent adolescent pregnancy or its variations. Matrices were constructed according to the level (international or national) and type of document reviewed (rules, regulations, specific action programs, technical guidelines, models of care, official health standards, and clinical practice guidelines).

Data analysis

A qualitative content analysis was carried out in order to interpret the information from these texts. The information was catalogued by the type of policy referenced, following the methods proposed by Hood ³³33. Hood CC. The tools of government: public policy and politics. London: Chatham House Publishers; 1983., Howlett ³⁴34. Howlett M. Managing the "hollow state": procedural policy instruments and modern governance. Can Public Admin 2000; 43:412-31., and researchers in the field of Public-policy Implementation ³⁵35. Laswell HD. The immediate future of research policy and method in political science. Am Polit Sci Rev 1951; 45:133-42.. Contents were classified as symbolic and material proposals. The former included intentions articulating policy objectives, in this case pertaining to subsequent adolescent pregnancy; they do not recommend any specific actions, but rather suggest a vision for the future. Material proposals consists of declarations including actions and procedures for addressing specific problems (e.g., type, quantity, distribution of goods and services). In turn, material proposals were classified as substantive or procedural. Substantive-material proposals refers to government actions, aimed at a particular problem ²⁶26. Delgado L. Las políticas públicas. El ciclo de las políticas públicas. Clases de políticas públicas. Eficacia, legalidad y control. Indicadores de gestión. http://pagina.jccm.es/ear/descarga/A2T3.pdf (accessed on 08/Sep/2021).
http://pagina.jccm.es/ear/descarga/A2T3.... ^,3333. Hood CC. The tools of government: public policy and politics. London: Chatham House Publishers; 1983.^,3434. Howlett M. Managing the "hollow state": procedural policy instruments and modern governance. Can Public Admin 2000; 43:412-31., that is concerned with the contents or need of interest ³⁶36. Adelantado J, Couceiro M, Iglesias M, Souto J. La dimensión simbólica, sustantiva y operativa en las políticas autonómicas de servicios sociales en España (1982-2008). Zerbitzuan 2013; (53):41-56.. Procedural proposals specifies the ways in which the actions are to be carried out, as well as the activities, processes, budgets, and individuals involved, particularly those in charge ²⁶26. Delgado L. Las políticas públicas. El ciclo de las políticas públicas. Clases de políticas públicas. Eficacia, legalidad y control. Indicadores de gestión. http://pagina.jccm.es/ear/descarga/A2T3.pdf (accessed on 08/Sep/2021).
http://pagina.jccm.es/ear/descarga/A2T3.... ^,3636. Adelantado J, Couceiro M, Iglesias M, Souto J. La dimensión simbólica, sustantiva y operativa en las políticas autonómicas de servicios sociales en España (1982-2008). Zerbitzuan 2013; (53):41-56.. A member of the research team selected, extracted, and classified the texts by type of public policy; the research team was then divided into triads and reached a consensus on the classification of each text. The subsequent adolescent pregnancy references in the ten previously mentioned documents are presented in boxes according to their national or international level.

The interpretation and presentation of results phase, described in the following section, presents the documents that explicitly mentions subsequent adolescent pregnancy or any of its variations.

Results

We found at the international level, six documents that referred to the term of interest: three were regional/global strategies and action plans (I1, I2, I3), two were recommendations (I4, I5), and one was a manual (I6). At the national level, we identified four documents: a national strategy (N1), a specific action program (N2), a health-care model (N3), and a GPC (N4).

Instruments at the international level

At this level, instruments referring to subsequent adolescent pregnancy discussed six ideas: two symbolic policies ³⁷37. Ipas México. Actualizaciones clínicas en salud reproductiva (aborto). Ciudad de México: Ipas México; 2020.^,3838. World Health Organization. Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries: what the evidence says. https://apps.who.int/iris/bitstream/handle/10665/70813/WHO_FWC_MCA_12_02_eng.pdf?sequence=1&isAllowed=y (accessed on 23/Oct/2021).
https://apps.who.int/iris/bitstream/hand... , and four substantive-material proposals ⁴4. Economic Commission for Latin America and the Caribbean. Montevideo consensus on population and development. https://repositorio.cepal.org/bitstream/handle/11362/21860/15/S20131039_en.pdf (accessed on 15/Dec/2021).
https://repositorio.cepal.org/bitstream/... ^,3939. World Health Organization. Programming strategies for pospartum family and planning, 2013. https://apps.who.int/iris/bitstream/handle/10665/93680/9789241506496_eng.pdf?sequence=1 (accessed on 23/Oct/2021).
https://apps.who.int/iris/bitstream/hand... ^,4040. World Health Organization. WHO recommendations on adolescent sexual and reproductive health and rights, 2018. http://apps.who.int/iris/bitstream/handle/10665/275374/9789241514606-eng.pdf?ua=1 (accessed on 23/Nov/2021).
http://apps.who.int/iris/bitstream/handl... ^,4141. Pan American Health Organization; United Nations Population Fund; United Nations Children's Fund. Accelerating progress toward the reduction of adolescent pregnancy in Latin America and the Caribbean. Report of a technical consultation. https://www.unicef.org/lac/media/1346/file/PDF%20Accelerating%20progress%20toward%20the%20reduction%20of%20adolescent%20pregnancy%20in%20Latin%20America%20and%20the%20Caribbean.pdf (accessed on 23/Aug/2021).
https://www.unicef.org/lac/media/1346/fi... (Box 2).

Specifically, the reference to subsequent adolescent pregnancy in the document Preventing Early Pregnancy and Poor Reproductive Outcomes among Adolescents in Developing Countries: What the Evidence Says³⁸38. World Health Organization. Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries: what the evidence says. https://apps.who.int/iris/bitstream/handle/10665/70813/WHO_FWC_MCA_12_02_eng.pdf?sequence=1&isAllowed=y (accessed on 23/Oct/2021).
https://apps.who.int/iris/bitstream/hand... concerns a symbolic policy demonstrating the effectiveness of interventions that include home visits providing social support, but contains no further description of the activities carried out (Box 2).

The substantive-material proposal outlined in the Montevideo Consensus on Population and Development enumerates the basic services to which any woman should have access to prevent subsequent adolescent pregnancy ⁴4. Economic Commission for Latin America and the Caribbean. Montevideo consensus on population and development. https://repositorio.cepal.org/bitstream/handle/11362/21860/15/S20131039_en.pdf (accessed on 15/Dec/2021).
https://repositorio.cepal.org/bitstream/... . However, it does not specify the sectors that should participate in the development of such strategies, nor the ways in which they would need to interact in designing specific interventions (Box 2).

The substantive-material proposal concerning subsequent adolescent pregnancy in the document Accelerating Progress Toward the Reduction of Adolescent Pregnancy in Latin America and the Caribbean⁴¹41. Pan American Health Organization; United Nations Population Fund; United Nations Children's Fund. Accelerating progress toward the reduction of adolescent pregnancy in Latin America and the Caribbean. Report of a technical consultation. https://www.unicef.org/lac/media/1346/file/PDF%20Accelerating%20progress%20toward%20the%20reduction%20of%20adolescent%20pregnancy%20in%20Latin%20America%20and%20the%20Caribbean.pdf (accessed on 23/Aug/2021).
https://www.unicef.org/lac/media/1346/fi... addresses the need to include an ecological framework in designing evidence-based interventions from a human rights perspective, considering key community actors. However, this text does not outline any of the mechanisms or strategies to be followed in creating specific interventions for the prevention and care of subsequent adolescent pregnancy (Box 2).

In the document of recommendations entitled Clinical Updates in Reproductive Health (Abortion)³⁷37. Ipas México. Actualizaciones clínicas en salud reproductiva (aborto). Ciudad de México: Ipas México; 2020., the symbolic mention of our term of interest provides evidence to help identify protective factors that can prevent subsequent adolescent pregnancies. The document, however, does not elucidate the interventions needed for different levels and sectors (Box 2).

The substantive-material text on subsequent adolescent pregnancy in the document WHO Recommendations on Adolescent Sexual and Reproductive Health and Rights⁴⁰40. World Health Organization. WHO recommendations on adolescent sexual and reproductive health and rights, 2018. http://apps.who.int/iris/bitstream/handle/10665/275374/9789241514606-eng.pdf?ua=1 (accessed on 23/Nov/2021).
http://apps.who.int/iris/bitstream/handl... proposes adolescent mothers should be convinced to adopt contraceptive methods in the postpartum or postabortion period as a strategy, but provides no clear guidelines or mechanisms to be followed (Box 2).

Finally, the document Programming Strategies for Postpartum Family Planning³⁹39. World Health Organization. Programming strategies for pospartum family and planning, 2013. https://apps.who.int/iris/bitstream/handle/10665/93680/9789241506496_eng.pdf?sequence=1 (accessed on 23/Oct/2021).
https://apps.who.int/iris/bitstream/hand... proposes a substantive-material policy, focusing on compensating for the opportunity lost by not having carried out interventions to lengthen the periods between subsequent adolescent pregnancies. However, it fails to detail the nature of the proposal, when it should be implemented, and who should be in charge of carrying it out (Box 2).

Instruments at the national level

At the national level, we identified ten references to our term of interest. The ENAPEA includes 19 lines of action, but only one pertains to subsequent adolescent pregnancy prevention. In this document we identified three references to substantive-material policies ⁸8. Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes. Estrategia Nacional para la Prevención del Embarazo en Adolescentes (ENAPEA). Ciudad de México: Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes; 2015.. Although these specify what needs to be done and the areas in which the actions must be carried out, it does not specify how the objective can be achieved (Box 3).

The 2020-2024 PAE for sexual reproductive health contained a substantive-material reference ⁴²42. Centro Nacional de Equidad de Género y Salud Reproductiva. Programa de acción específico. Salud sexual y reproductiva, 2020-2024. https://www.gob.mx/cms/uploads/attachment/file/644374/PAE_SSR_24_5_21.pdf (accessed on 19/Aug/2021).
https://www.gob.mx/cms/uploads/attachmen... to the prevention of disease and health care in the adolescent population, regarding specifically its number-one objective: adolescent sexual and reproductive rights. However, it does not detail the specific strategies that should be implemented, nor the actors that should be involved (Box 3).

We found two symbolic and one procedural-material references to subsequent adolescent pregnancy in the Maternal Health section of the Guide for Implementing a Comprehensive Protection and Care Pathway for Girls, Adolescent Mothers and Pregnant Women under 15 Years of Age¹⁰10. Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes. Guía para la implementación de la "Ruta para la atención y protección integral de niñas y adolescentes madres y/o embarazadas menores de 15 años". Ciudad de México: Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes; 2020.. Regarding the symbolic proposals, the effectiveness of contraceptive methods in postponing a pregnancy - either after childbirth or an abortion - is demonstrated. This document is the only one we encountered identifying specific procedures, specifying the actions to be carried out, their focus, and who should implement the interventions (Box 3).

Finally, the GPC included three substantive-material proposals on the subject ⁴³43. Centro Nacional de Excelencia Tecnológica en Salud. Intervenciones de enfermería para la promoción de la planificación familiar en hombres y mujeres en edad fértil de 12 a 49 años en los tres niveles de atención. http://www.cenetec-difusion.com/CMGPC/SS-756-15/ER.pdf (accessed on 18/Aug/2021).
http://www.cenetec-difusion.com/CMGPC/SS... . These pertained to nursing interventions at the three levels of care considered within the framework of family-planning promotion among men and women of childbearing age (12-49 years old). All three references were included in the GPC section on family-planning promotion. Two of these proposals identify the actions required, but do not specify how they should be carried out, nor who should be in charge of implementation. The third elucidate what must be done and how to do it but fails to define the actors involved (Box 3).

Joint analysis of international and national level instruments

Our results showed that subsequent adolescent pregnancy prevention and care, at both levels, involved mostly symbolic actions and substantive-material proposals, thus circumscribing the problem and related activities. Only one text in a national-level document stipulated specific ways to execute a proposed strategy in favor of subsequent adolescent pregnancy prevention and care.

In the reviewed documents, subsequent adolescent pregnancy occupied only a marginal place on both the national and global agendas, with symbolic public policies barely positioning the issue as a relevant social and health problem. These documents establish only a few general guidelines on family planning and contraception post obstetric event (CPOE). Substantive-material public-policy actions concerned three types of actors: high-level decision makers, health-facility managers, and operational personnel.

Actions involving decision makers were aimed at creating favorable environments that facilitated access to health services and emphasized respect for adolescent sexual and reproductive rights; implementing intersectoral strategies; and adapting the GPC to the need for ensuring appropriate contraceptive counseling for youth aged under 20 years. The texts concerning these actions specified that counseling should focus primarily on adolescents, promote long-acting methods, and extend the intergenesic period.

Actions involving managerial and operational staff at primary- and secondary-care facilities centered on the promotion of family-planning counseling and CPOE. References to these actions defined the major themes that needed to be addressed: sex education, personal goals, healthy relationships, subsequent adolescent pregnancy prevention, safe reproductive practices, and postponement of pregnancies. They also indicated the appropriate times for counseling: antenatal care, labor, delivery, postpartum, the puerperium, well-child check-ups, and home visits. These texts delineated the means for communicating CPOE information: motivational interviews and information technologies, and acknowledged the need to incorporate parents, teachers, and the community at large into the counseling process. Finally, recommendations to managerial and operational staff at primary- and secondary-care facilities included offering contraception - preferably long-acting - while also ensuring that the methods provided have been freely chosen by the adolescents themselves.

Finally, the only procedural-material public-policy reference to subsequent adolescent pregnancy was directed at operational personnel of health facilities. It discussed the attitude and behavior that health-care providers should adopt during counseling to facilitate acceptance of contraceptive guidance. This reference also cited a consultation document for determining which method is the most appropriate for each patient.

Discussion

Our review of national and international public-policy documents indicates that the prevention and care of subsequent adolescent pregnancy are addressed only secondarily on the public agendas, with efforts geared primarily to the prevention of first-time pregnancy. This finding is based on the limited number of strategies, plans, programs, official standards (NOMs), GPCs, and recommendations that explicitly address the issue of subsequent adolescent pregnancy; moreover, most of which consist of symbolic and substantive-material policies. In other words, only a minimal number of actions comprise distinct and standardized measures to combat subsequent adolescent pregnancy according to the type of actors involved.

Based on the perspective of policies as a process, subsequent adolescent pregnancy would have been expected to occupy a more prominent place on the agendas, in part due to the interest that actors in academia and civil society have demonstrated in studying the issue ¹⁸18. Conroy K, Engelhart T, Arandia P, Forbes P, Cox J. Relationship between rapid repeat pregnancy and depression in low-income, minority teen mothers. J Adolesc Health 2013; 52 Suppl 1:S109.^,1919. Villalobos-Hernández A, Campero L, Suárez-López L, Atienzo EE, Estrada F, de la Vara-Salazar E. Embarazo adolescente y rezago educativo: análisis de una encuesta nacional en México. Salud Pública Méx 2015; 57:135-43.^,2020. Raneri LG, Wiemann CM. Social ecological predictors of repeat adolescent pregnancy. Perspect Sex Reprod Health 2007; 39:39-47.^,2121. Ruedinger E, Cox JE. Adolescent childbearing: consequences and interventions. Curr Opin Pediatr 2012; 24:446-52.; however, this is not reflected in the results of our analysis. The relatively low priority this issue occupies on the agendas illustrates the challenges Cobb & Elder ²⁵25. Cobb R, Elder C. Participation in American politics: the dynamics of agenda-building. Baltimore: Johns Hopkins University Press; 1983. identified regarding the low level of participation and the definition of problems. Decisions regarding the agendas primarily result from competition between groups; in this case, the instruments analyzed did not encompass the interests of all stakeholders involved in subsequent adolescent pregnancy care.

Also, according to Kauffer ³¹31. Kauffer E. Las políticas públicas: algunos apuntes generales. Ecofronteras 2002; (16):2-5., a government’s decision to remain inert in the face of issues relevant to society constitutes, in itself, a public policy that hinders the resolution of such issues ⁴⁴44. Cejudo G. Discurso y políticas públicas. Enfoque constructivista. In: Merino M, Cejudo G , editors. Problemas, decisiones y soluciones. Enfoques de política pública. Ciudad de México: Fondo de Cultura Económica; 2010. p. 93-126..

Notably, several strategies for regional and international development identified women, girls, boys, and adolescents as vulnerable groups, and emphasized guaranteeing their access to health care. International instruments included the 2030 Agenda for Sustainable Development, the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-2030, and the Plan of Action for Women’s, Children’s and Adolescents’ Health 2018-2030. These documents attached special importance to championing gender equality. They cited universal rights in support of their call-for-action within the field of Sexual Health and Family Planning, viewing these as a gateway to ending discriminatory practices ³3. United Nations. The 2030 agenda and the sustainable development goals. An opportunity for Latin America and the Caribbean. https://repositorio.cepal.org/bitstream/handle/11362/40156/S1801140_en.pdf?sequence=25&isAllowed=y (accessed on 11/Dec/2021).
https://repositorio.cepal.org/bitstream/... ^,4545. Every Woman Every Child. The global strategy for women's, children's and adolescents' health (2016-2030). Survive, thrive, transform. https://globalstrategy.everywomaneverychild.org/pdf/EWEC_globalstrategyreport_200915_FINAL_WEB.pdf (accessed on 01/Feb/2022).
https://globalstrategy.everywomaneverych... ^,4646. Pan American Health Organization. 56th Directing Council. 70th Session of the Regional Committee of WHO for the Americas. Plan of action for women's, children's, and adolescents' health 2018-2030. Washington DC: Pan American Health Organization; 2018.. However, none of the documents referred specifically to the problem of subsequent adolescent pregnancy.

Other strategies concerning actions related to adolescent sexual and reproductive health ⁴⁷47. Starrs A, Ezeh A, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet 2018; 391:2642-92.^,4848. United Nations Population Fund. 165 million reasons: a call for investment in adolescents and youth in Latin America and the Caribbean. https://lac.unfpa.org/sites/default/files/pub-pdf/165%20M%20-%20ENGLISH.pdf (accessed on 23/Sep/2021).
https://lac.unfpa.org/sites/default/file... ^,4949. World Health Organization. Core competencies in adolescent health and development for primary care providers. Including a tool to assess the adolescent health and development component in pre-service education of health-care providers. https://apps.who.int/iris/bitstream/handle/10665/148354/9789241508315_eng.pdf?sequence=1&isAllowed=y (accessed on 23/Sep/2021).
https://apps.who.int/iris/bitstream/hand... specified that services were to be considered essential and fulfill the criteria pertaining to availability, accessibility, acceptability, and quality. Additionally, they proposed reducing unintended pregnancies with effective contraception; health-care services before, during, and after childbirth; as well as access to safe abortions. However, strategies for the prevention of pregnancy and the provision of care for adolescents during pregnancy made no distinction based on subsequent adolescent pregnancy.

On a national level, it is concerning that the guiding actions pertaining to youth in the National Development Plan of the current presidential term (2019-2024) ⁵⁰50. Secretaría de Gobernación. Plan Nacional de Desarrollo, 2019-2024. https://dof.gob.mx/nota_detalle.php?codigo=5565599&fecha=12/07/2019 (accessed on 03/Aug/2021).
https://dof.gob.mx/nota_detalle.php?codi... are essentially limited to enhancing access to education by scholarships and employment. They refer neither explicitly nor implicitly to adolescent pregnancy or subsequent adolescent pregnancy prevention. This omission is particularly troubling considering its impact on the government agenda, since the National Development Plan establishes which issues are to be prioritized by public-policy actions.

On the other hand, the Health Sector Program - the normative instrument that regulates all health institutions in Mexico - recognizes the importance of ensuring that adolescents have access to sexual reproductive health services as a right. This document also emphasizes the need to promote educational campaigns using interactive technologies and social networks. It highlights the relevance of providing counseling and access to contraceptive methods as a means of preventing adolescent pregnancy and sexually transmitted infections. Furthermore, it draws attention to the violence many adolescents experience. However, the Program fails to explicitly address subsequent adolescent pregnancy prevention or issues pertaining to care for youth aged under 20 years ⁵¹51. Secretaría de Salud. Programa sectorial de salud, 2019-2024. http://saludsinaloa.gob.mx/wp-content/uploads/2019/transparencia/PROGRAM_SECTORIAL_DE_SALUD_2019_2024.pdf (accessed on 03/Aug/2021).
http://saludsinaloa.gob.mx/wp-content/up... .

Although the ENAPEA represents the guiding axis for eradicating adolescent pregnancy on a national level, it fails to address subsequent adolescent pregnancy prevention and care sufficiently and in a comprehensive manner. Subsequent adolescent pregnancy is a reality in the life experience of adolescent women and requires specific actions commensurate with its social and health-related implications ⁸8. Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes. Estrategia Nacional para la Prevención del Embarazo en Adolescentes (ENAPEA). Ciudad de México: Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes; 2015..

Regarding adolescents aged under 15 years, who are more likely to experience subsequent adolescent pregnancy, a specific guide exists on the care pathway for first pregnancies and the prevention of subsequent ones; however, this handbook is being piloted in one state, and has yet to be normalized and implemented nationwide ¹⁰10. Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes. Guía para la implementación de la "Ruta para la atención y protección integral de niñas y adolescentes madres y/o embarazadas menores de 15 años". Ciudad de México: Grupo Interinstitucional para la Prevención del Embarazo en Adolescentes; 2020..

Our analysis of national and international documents reveals that CPOE is considered the key strategy for subsequent adolescent pregnancy prevention ⁵²52. Oizerovich S, Perrotta G. La importancia de la anticoncepción post evento obstétrico para garantizar derechos. Revista AMAdA 2020; 16(1). http://www.amada.org.ar/index.php/numeros-anteriores/volumen-16-n-1-2020/57-revista/revista-n1-2020/385.
http://www.amada.org.ar/index.php/numero... ^,5353. von Hoveling A, Larrea E, Norambuena C, Carrasco L. Prevención del embarazo reiterado en adolescentes: una experiencia clínica exitosa. Rev Chil Obstet Ginecol 2020; 85:631-40.. However, several indicators for the Mexican population suggest that it has been insufficient or only partially effective ¹⁷17. Sánchez-Pájaro A, Braverman-Bronstein A, De Castro F, Vidaña-Pérez D, Villalobos-Hernández A, Barrientos-Gutiérrez T. Contribution of second and higher-order births to adolescent fertility in Mexico. Stud Fam Plann 2019; 50:63-70.^,5454. Zamberlin N, Keller M, Rosner M, Gogna M. Adopción y adherencia al uso de métodos anticonceptivos posevento obstétrico en adolescentes de 14-20 años. Rev Argent Salud Pública 2017; 8:26-33..

According to our findings, the actions required to implement CPOE adequately need to be set forth in greater detail. Further efforts must be made not only to ensure the availability of a wide spectrum of methods, but also to strengthen family-planning counseling, such that the proper use and side effects of contraceptives are fully explained to users. These conditions are indispensable for helping adolescents make free and informed decisions on the type of contraception they wish to adopt, favoring their adherence to the methods they obtain.

It is important to highlight that counseling should not stop at contraception but cover all the dimensions of sexual reproductive health. Physical, emotional, relational, and social-development processes of female adolescents differ from those of adult women; thus, their counseling must include topics such as self-esteem, their life projects, and positive parenting from the perspective of young people ⁵⁵55. Nóblega M. La maternidad en la vida de las adolescentes: implicancias para la acción. Revista de Psicología 2009; XXVII:30-54.. Incorporating procedural texts into public-policy instruments would offer practical tools for health-care providers to implement measures that effectively help prevent unintended pregnancies and subsequent pregnancies beyond adolescence. Moreover, health personnel should be encouraged to consult this type of document as a useful guide for their practice ⁵⁶56. Maya C, Flores S, Vértiz J, Ruelas M, Poblano O, Saturno P. Barreras y facilitadores en la implementación de guías de práctica clínica en México: perspectiva del personal de salud. Salud Pública Méx 2021; 63:662-71..

It is crucial that public policies specify and promote the development of distinct actions for subsequent adolescent pregnancy prevention; this would facilitate interlinking the actions set forth in the various instruments. The absence of an explicit position on subsequent adolescent pregnancy affects the levels of morbidity and mortality in the mother-child binomial, hindering the integrated development of adolescents, with negative consequences for society.

One of the limitations of this work concerns the sources of the information used for our international search. We included regional and international organizations dealing with health and other issues affecting adolescents (i.e., the UN, WHO, UNICEF, PAHO, and ECLAC), but failed to search as exhaustively among international civil society organizations. Therefore, we may have missed some international documents with references to subsequent adolescent pregnancy. Furthermore, limiting our objective to subsequent adolescent pregnancy prevention and care actions mentioned only in public-policy documents may have constrained the identification of other initiatives that address this problem but have been only partially disseminated.

One final limitation of our analytical approach concerns the classification of references by type of policy. In some cases, this task generated controversy among team members, particularly regarding the distinction between substantive- vs. procedural-material policies. In these cases, we opted to discuss and determine the assignment of references in triads.

Notwithstanding its limitations, our analysis is useful in compiling and disseminating the set of national and international guidelines, recommendations, and formal actions that contribute to subsequent adolescent pregnancy prevention and care. Our work reveals gaps in national and international public-policy actions. This type of analysis can be useful in other Latin American countries studying their own public-policy instruments. It facilitates the identification of unmet needs and provides the basis for finding a more effective solution to the problem of subsequent pregnancies within the adolescent population.

Acknowlegments

We thank the Mexican National Institute of Public Health for their support.

References

Publication Dates

History