This retrospective study examined the records of all pregnant adolescent patients consulted at the outpatient MMHC at Chris Hani Baragwanath Academic Hospital (CHBAH) for 6 months from January to June 2022. Data were collected from July to December 2022. All data were collected anonymously. Demographic profiles, schooling history, type of accommodation, substance use habits, contraceptive use and pregnancy-related factors were collected. The presence of a diagnosed psychiatric illness and assessment scores from the RFA (Risk Factor Assessment) and EDS (Edinburgh Depression Scale) were documented. These scales were used to screen for depression in all patients.

Chris Hani Baragwanath Academic Hospital is a tertiary academic hospital in Soweto, Johannesburg. It services a large catchment area in south Gauteng and includes acute inpatient adult, adolescent, child and outpatient psychiatric services. It receives referrals from district hospitals and specialised psychiatric clinics in its catchment area. The MMHCs at CHBAH and Rahima Moosa Mother and Child Hospital, are the only available specialised psychiatric services to assess pregnant adolescents, in the public sector for southern Gauteng. Referrals are received from the Departments of Obstetrics and Gynaecology and Psychiatry at CHBAH and local clinics in both disciplines. Referrals include pregnant women known to have mental illness, pregnant women who are screened as having an increased risk for mental illness, pregnant women presenting with acute mental illness and all pregnant adolescents under 18.

All adolescent pregnancies aged 10–18 years referred to the MMHC at CHBAH over 6 months from January to June 2022 were included in the study. Sample size was determined using an assessment of Z scores and expected frequencies, taking the prevalence of adolescent pregnancies in Gauteng Province in 2021 at 8.9%, to obtain a sample size of 124 patients that will detect statistical significance at the fifth percentage level at a low effect size. At a medium effect size, statistical significance can be expected with a sample of 100 patients.

Data were collected using a retrospective file review, documenting assessments done by psychiatric medical officers, registrars and consultants. The information was collected and documented from patient files using a data sheet. Identifying data were not included in the data sheet, thus maintaining anonymity. The files for patients are kept in a locked filing system within the psychiatry department at CHBAH.

The data for this study were collated in Microsoft Excel™. Statistical analyses were conducted in R software (version 4.00; www.R-project.org). Analyses were conducted on categorical variables only. Pearson’s chi-squared tests (goodness of fit) were used to assess whether the distribution of counts of socio-demographic, pregnancy conditions, substance use habits and diagnosis (psychiatric and comorbid) variables deviated from a null model. Binary post-hoc tests were used to assess pairwise comparisons of significant outcomes. The prevalence of psychiatric risk on the RFA and EDS scores was calculated as percentages of the total sample size with 95% CIs. Fisher’s exact tests were used to test the associations between selected socio-demographic/pregnancy variables and the RFA and EDS scores. Statistical tests were two-tailed, and the model significance was set at 0.05. Continuous variables are reported as mean and standard deviation, and categorical data are reported as percentages and presented in tables, text and charts.

This study is a retrospective record review. All identifying data were omitted from the data sheet to maintain anonymity. Ethics approval was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (Clearance Certificate M220401) and the CEO of CHBAH.

Participants had a mean age of 15.2 (standard deviation [s.d.] = 1.03), ranging from 13 to 18 years. Table 1 provides the socio-demographic characteristics of the participants. The majority of participants were in mainstream schooling, with three participants in remedial schooling (Table 1). Most participants were in Grade 9 or 10, and most did not repeat any grades. All but two participants planned to return to school. There was no difference in participants living in formal and informal dwellings, but this could be because of the low number of responses. The majority of participants lived with their families (Table 1). Three participants reported living with a partner, and one participant reported living alone.

Table 2 provides pregnancy-related characteristics of the participants. Most (97.9%) pregnancies were unplanned, and 89.4% of participants reported that the pregnancy was wanted. Significantly more participants were primigravida. No participants had a history of termination of pregnancy. Most participants were in the second and third trimesters of pregnancy when they visited the clinic (Table 2). Three participants mentioned using contraceptives, but the type of contraceptive used was not documented.

Table 3 provides the substance use information for patients in the study. Most (76.7%) participants reported no substance use. Of those using substances, more participants were not using substances during the study period (Table 3).

Most participants reported drinking alcohol (n = 19), three reported smoking cannabis and one smoked tobacco. None of the participants reported using methamphetamines, amphetamines, opioids, benzodiazepines, cocaine or nyaope. Five participants (33%) reported drinking alcohol weekly, and 10 (67%) did not provide any information. Three participants (50%) drank alcohol for less than a year, two (33%) for 1–5 years, and one (17%) for more than 5 years. No further details were available for participants using cannabis and tobacco. Eleven participants (100%) reported not having withdrawal symptoms at the time of assessment.

A prevalence of high patient risk (i.e. a score ≥ 3) was 44.4% (95% LCI (Lower Confidence Interval): 0.30; UCI (Upper Confidence Interval): 0.59; n = 45) from the risk factor assessment scores. Using the Edinburgh Depression Scale score, the prevalence of high patient risk (i.e. a score ≥ 13) was 47.7% (95% LCI: 0.36; UCI: 0.60; n = 34).

Thirty respondents answered questions for the Risk Factor Assessment and Edinburgh Depression Scales. Of these, 14 (47%) had a high risk (≥ 3 and ≥ 13) on both scoring systems.

Table 4 shows the psychiatric and comorbid diagnoses in the participants. Significantly more participants had major depressive disorder (52.6%), followed by adjustment disorder (21.1%). There were five other disorders and two comorbidities (Table 4).

The association of two variables with the Risk Factor Assessment and Edinburgh Depression Scale assessments is shown in Figure 1 and Figure 2. For the number of grades repeated, a significantly greater proportion (n = 5; 24%) of participants who repeated a grade also had a high-risk profile on the Edinburgh Depression Scale (Fisher’s exact test: p = 0.048) versus no participants who repeated a grade and had low risk on this scale (Figure 1). There was no significant association between grades repeated and Risk Factor Assessment (Fisher’s exact test: p = 0.583). For wanted and unwanted pregnancies, a significantly greater proportion (n = 5; 25%) of participants with an unwanted pregnancy had a high-risk profile on the Risk Factor Assessment scale (Fisher’s exact test: p = 0.016) versus participants who did not want to keep the pregnancy and had a low risk for this scale (Figure 2). There was no significant association between wanting to keep the pregnancy or not and Edinburgh Depression Scale (Fisher’s exact test: p = 0.091).

The mean age of patients presenting to the clinic was 15.2 years, ranging from 13 to 18 years. This is in keeping with the World Health Organization statistics that most adolescent pregnancies worldwide (about 16 million) are between 15 and 19 years. Fewer adolescent pregnancies (about 1 million) are younger than 15 years.³⁴ Reasons for this could include that, despite older adolescents being able to negotiate safer sexual practices with their partners and having more knowledge of contraceptives, they still face barriers in accessing and using contraceptives.³⁵ Adolescents are an at-risk group for developing psychiatric-related morbidity, as most mental illnesses start in adolescence and early adulthood.³⁶ Adolescents are also at higher risk of using substances.²⁷ The National Mental Health Policy Framework (NMHPF) and Strategic Plan for 2023–2030 highlight the importance of developing mental health promotion and prevention programmes for critical developmental life stages such as pregnancy and adolescence.³⁷ Adolescents are considered a special population by the NMHPF due to most mental health disorders originating in childhood and adolescence, with roughly 50% of mental disorders presenting by the age of 14.³⁷ The policy also emphasises that, in South Africa, childhood adversity, which includes all forms of abuse, has been associated with mood and substance use disorders, which increases the chances of children not completing school.³⁷ Despite being a vulnerable population, services for adolescent mental health are severely lacking and have been identified in the NMHPF as an area where intervention is needed³⁷. It has been proposed that all district health services routinely screen for mental illness during pregnancy and that adolescent mental health disorders are detected in primary health care clinics and referred where appropriate.³⁷

A common concern for pregnant adolescents is the ability to further their education.³⁸ The educational level prior to pregnancy has been linked with better health and well-being, which could possibly compensate for the mother’s age and the child’s IQ later in life.³⁸ We found that 72% of pregnant adolescents were still attending school, and 97.4% planned to return. This contrasts with the data reported by Statistics South Africa in 2016, which showed only 51.5% of adolescent mothers attended school.³⁹ This significant difference in statistics could be because, although pregnant adolescents are motivated to continue their schooling, it might not be possible practically. Previous studies done in South Africa showed that poverty and unmet childcare needs are major contributors preventing adolescents from returning to school postpartum.³⁸ A qualitative study conducted in Soweto, South Africa, showed that there are 2 pathways for pregnant adolescents while still enrolled in school: some managed to return to school, delaying their next pregnancy by 5–10 years and those who did not return to school and went on to have more children.^20,40 This in turn has a negative impact on future work opportunities and careers, contributing to unemployment among the youth.¹⁰ Supporting adolescents to return to school after childbirth is paramount, as prolonged absence increases the risk of not returning.³⁸ Further research is needed to compare the rates of pregnant adolescents planning to return to school, the rates of re-enrolment postpartum and other barriers preventing re-enrolment.

Data reporting on adolescent pregnancies occurring in mainstream schools versus remedial schools in South Africa is scarce. This study found that most adolescents attended a mainstream school (96.1%), and only 3.9% attended a remedial school. Most patients had never repeated a grade (87.5%). This may be a protective factor for these patients as an appropriate age for grade before pregnancy has been associated with greater odds of school return.³⁸ For the number of grades previously repeated, a more significant proportion (24%) of patients that repeated a grade also had a high-risk profile on the Edinburgh Depression Scale. This high percentage of pregnant adolescents never repeating a grade contrast with research done in KwaZulu-Natal, where non-pregnancy-related grade repetition was strongly associated with becoming pregnant while still enrolled at school and not returning following a pregnancy-related absence.⁴¹

This study found that most adolescent patients resided with their families (95.8%). This echoes previous research showing that most pregnant adolescents still depend on their families for their place of residence, financial and schooling needs and emotional support during this time.⁴² Pregnant adolescents often experience psychological distress in disclosing the pregnancy and the biological father’s identity to the family fearing sanctions,⁴³ a lack of support and stigmatisation.¹⁰ The parents actual or anticipated reaction to the pregnancy may be a major factor in whether the adolescent keeps the baby or decides on abortion.⁴³ After giving birth, these adolescents need family support in caring for the new-born baby, as a major contributing factor for an adolescent mother to continue with schooling is the support of her family, especially the support of her mother in assisting with childcare.¹⁰ Evidence on the burden of care experienced by these families indicates high levels of financial and emotional stress.⁴⁴ Further research is needed into the burden of care for the families of pregnant adolescents to inform practice on the support needed.

Too little data were captured on the type of accommodation to make statistical associations.

Most adolescent pregnancies were unplanned (97.9%) although most were wanted (89.4%). This contrasts with a study in sub-Saharan Africa, where 35% of adolescent pregnancies were unplanned and unwanted.⁴ A possible reason for this discrepancy could be that most unwanted pregnancies end up in early termination, and these adolescents were not seen at the study facility. In the United States, 91% of all pregnancies in 15- to 17-year-olds are unplanned,⁴⁵ which correlates with our findings. When comparing wanted and unwanted pregnancies, a significantly bigger proportion (25%) of patients who did not want the pregnancy had a high-risk profile on the Risk Factor Assessment scale. This was also shown in the UK, where unplanned pregnancy and negative feelings about the pregnancy resulted in significant psychological distress.⁴⁶

Most teenagers said this was their first pregnancy (97.9%). Two participants reported having a previous pregnancy. Among the two participants that reported a previous pregnancy, none reported a previous termination. This differs significantly from a study conducted in Soweto, South Africa, reporting that 23% of pregnancies in 13- to 16-year-olds and 14.9% in the 17- to 19-year age group resulted in abortion.^3,4 A possible reason for this significant difference in reported previous terminations could be that the patients in our study were reluctant to disclose previous pregnancies that ended with a termination due to the associated stigma or that those who terminate the pregnancy never reach the MMHC. Most patients presented to the MMHC in the second (41.24%) and third trimester of pregnancy (51.55%). Very few patients were seen during their first trimester (7.22%) when termination of pregnancy is legal in South Africa on patient request and without medical indication.⁴⁷ Further investigation is needed to ascertain why adolescents only present in the second and third trimesters, specifically examining the timeline from initial presentation to primary health care clinics to being seen at the MMHC. Earlier presentation to the MMHC can allow mental health problems to be addressed timeously, resulting in an improved outcome for both mother and baby.

Significantly more patients reported no substance use (76.7%). Of those using substances, most did not use them during the study period (94.7%). This differs significantly from the United States, where pregnant adolescents reported greater drug use than their same-age non-pregnant peers (13.8%).⁴⁵ In South Africa, 20% – 22% of Grade 8–11 adolescents reported using substances in the 2002 and 2008 youth risk behaviour survey.^27,48 In the same survey, the percentage of learners who reported ever having used dagga was 12.8%, inhalants 11.1%, Mandrax 6.0%, cocaine 6.4%, heroin 11.5%, club drugs 5.8% and over-the-counter or prescription drugs 15.5%.^27,48 The prevalence of alcohol use among adolescents ranges from 22 to 53.8%.⁴⁹ This discrepancy could be accounted for if there was under-reporting of substance use by the study population. Another explanation could be the difference in setting where the surveys were conducted, in a health care setting versus in the community, for example, at a school, where the adolescents may feel less stigmatised when reporting substance use. Early substance use intervention would benefit adolescents, and the NMHPF and strategic plan for 2023–2030 highlight the need for coordinated services between the Departments of Health and Social Development to provide prevention measures and treat substance use disorders.³⁷

A prevalence of high patient risk (i.e. a score ≥ 3) from the Risk Factor Assessment scores was 44.4%. Using the Edinburgh Depression Scale score, the prevalence of high patient risk (i.e. a score ≥ 13) was 47.7%. Thirty respondents answered questions for both the Risk Factor Assessment and Edinburgh Depression Scale; of these, 14 (47%) had a high risk (≥ 3 and ≥ 13) on both scoring systems. This agrees with several studies suggesting that adolescent mothers are at higher risk of developing depression.⁵⁰ This high risk can significantly impact the adolescent mother and the unborn child. Antenatal maternal depression has been associated with an increased risk of neurodevelopmental disorders and poor emotional adjustment in their offspring.²¹ Maternal depression can lead to adverse birth outcomes such as low infant birth weight, being small for gestational age and premature birth.⁵¹ Undiagnosed and untreated prenatal depression can continue as postpartum depression.⁵² Non-systematic reviews have identified that children born to mothers with untreated postpartum depression are at risk for poor cognitive function, behavioural inhibition, emotional maladjustment and externalising disorders.⁵³ A mother with untreated postpartum depression is likelier to use alcohol or illicit substances and have breastfeeding and relationship problems.⁵³

Significantly more patients had major depressive disorder (52.6%), followed by adjustment disorder (21.1%). There were five other disorders and two comorbidities. There is a slightly higher incidence of Major Depressive Disorder among pregnant adolescents at the MMHC at CHBAH compared to the findings reported by Stacy C. Hodgkinson et al. in the study ‘Depressive Symptoms and Birth Outcomes among Pregnant Teenagers’ (16% – 44%).⁵⁴ Further investigation would need to be done to ascertain the reasons for this difference.

Adolescent pregnancy prevention is an essential strategy for improving maternal and infant outcomes.⁵⁵ A lack of access or knowledge of contraceptive use leads to early unwanted pregnancies.⁵⁵ Unfortunately, no information on contraceptive use was recorded in patient files. This could speak to missed social interventions and understanding needs, given that 97.9% of pregnancies were unplanned. Prenatal contraceptive counselling is a topic that pregnant adolescents need to be educated about, as antenatal contraceptive counselling has been shown to increase postpartum contraceptive use by adolescents, thus preventing another unplanned pregnancy.⁵⁶

In this study, retrospective file review methodology was employed. Firstly, this meant that the researcher was limited by the information that was present and recorded in the study population’s files. For example, there was limited information provided with regard to the adolescent’s living conditions, extent of family support and contraceptive use. Further research that includes self-report questionnaires specifically asking about contraception use and knowledge will be informative to help develop strategies to prevent adolescent pregnancies. Secondly, the patient assessments were done by a combination of psychiatric medical officers and registrars with different levels of skill and expertise. The assessments of the patient’s mental health were therefore not done on a standard level of expertise. Thirdly, the study took place over a short period of only 6 months, and a more extended study with a larger study population would improve the reliability of the results. Fourthly, the study took place at a single centre, and included only patients referred to the MMHC (a tertiary institution); therefore, the results cannot be generalised to other adolescent populations. A study involving multiple centres, at all levels of care, would be of benefit to generalise the findings.