In this issue of Pediatrics, Woodall et al examine long-term trends of mortality for infants of teens by race/ethnicity, urbanicity, and maternal age from 1996–1997 to 2018–2019.1
The study also estimates the contribution of changes in the maternal age distribution and maternal age-specific infant mortality rates to differences in infant deaths.
The key finding in this study is that the decline in infant mortality rates among teen parents was significant across racial/ethnic and urbanization subgroups; however, mortality rates did not change significantly for infants of Black or Hispanic teens residing in rural counties. The authors conclude that additional research into the contextual factors in rural counties that are driving the lack of progress for infants of Black and Hispanic teens may help inform future efforts to advance health equity.
The consequences of unintended teen pregnancy range from contributing to infant mortality and associated racial disparities to the future economic potential of generations of families.2 As such, unintended teen pregnancy reduction remains an important public health priority. Opportunities exist to conduct additional research around the persistent racial disparity found in this study, as the authors indicate.
Because both research and improvement initiatives continue, thoughtful consideration should be given to incorporating the voice of those with lived experience in those efforts. The addition of qualitative analyses of the experiences of individuals most affected by the disparity, particularly in regard to maternal and child health, can provide better insight into community and social context; refine implementation strategy of best practices; and/or identify promising practices.3 Additionally, the incorporation of other partners outside of health care into this effort can drive the work from an individual-level focus to improvement at the community level.
Consequences of Teen Pregnancy
In addition to the effect of teen pregnancy on infant mortality and the associated racial disparities that were found in this study, consequences of unintended teen pregnancy include persistent racial disparities in high school graduation rates, economic achievement, and generational poverty.2
More than 30% of teenage girls who drop out of high school cite pregnancy, and only 50% of teen mothers report receiving a diploma by age 22 years.4 Furthermore, children of teenage mothers are more likely to have lower school achievement and to drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult.4
Incorporating the Voice of Lived Experience
We agree with the conclusion of Woodall et al in that subsequent study of this inequity must include contextual factors. To truly understand the challenges in seeking adequate care during and after pregnancy, the voices of Black and Hispanic birthing teens are paramount. Barnett et al demonstrated, through community listening sessions with Black birthing people in Columbus, Ohio, who had experienced pregnancy or birth complications, that there are many concerns when it comes to seeking prenatal care.5 In their study, which was funded through a state grant focused on addressing maternal disparities in care, they found that participants reported the importance of representation of their birthing provider, the importance of communication, and that they had experienced discrimination in their care. Although their study included adults, with the additional barriers and stigma associated with teen pregnancy, many of these themes would likely be amplified in a similar study among teens in rural communities.
Need for Community-Level Change
The socioecological model has long been used in public health; recognizing several levels for intervention: individual, interpersonal, organizational, and community.6
As the authors recognize, the 2 primary interventions that have been attributed to the decline in infants born to teenagers over the past 2 decades are education and access to contraception. There is an opportunity to push these 2 individual-/interpersonal-level interventions to drive community-level change through adoption of consistent practices across multisector partnerships. The Colorado Initiative to Reduce Unintended Pregnancy is commonly cited as an example of how to achieve community-level change through alignment of numerous stakeholders in a defined geographic area to collectively implement the same evidence-based strategies.7
These interventions are particularly important in the context of the growing problem of obstetric deserts in rural communities. Creative solutions will be necessary to ensure these birthing people have access to the services they need.
We applaud the work of Woodall et al in bringing to light this important inequity in infant mortality. We recognize much work will need to be done with cross-sector community collaboration, targeted expansion of services, and most important, incorporation of the lived experiences of the teens in rural communities in these interventions.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-060512.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.