An embedded realist review of what works, for whom, how, and in what circumstances to reduce repeat pregnancies in adolescence: a systematic mixed-methods review

Abstract

BackgroundThe UK has one of the highest rates of pregnancies in adolescence in western Europe; a large number of them are repeat pregnancies. Previous research has demonstrated substantial emotional, psychological, and educational harm to young mothers after unintended conceptions. We aimed to synthesise evidence about how to reduce repeat pregnancies in adolescence. MethodsA multistreamed, mixed-methods systematic review was conducted. Between May 8 and May 27, 2013, we searched the major electronic databases for articles published from 1995 onwards, and updated the search between June 11 and June 16, 2014 (see appendix for list of databases and search terms used). No language restrictions were imposed during the searches; however, grey literature searches were restricted to English and a UK context, to enhance applicability of results to UK public health agencies. Data extraction was conducted independently by two reviewers, and disagreements resolved by a third reviewer if necessary. The principles of realist synthesis were applied to all included literature to uncover theories about what works, for whom, how, and in what context. Included literature was quality appraised with realist principles of relevance and rigor. Initial theory areas were developed through scoping the evidence, group discussion by the authors, and stakeholder engagement. Stakeholders included representatives from public health, primary care, sexual health, obstetrics, midwifery, and adolescent mothers. Theory areas were further refined and populated with evidence that either confirmed or contradicted the theory. A deliberative synthesis process resulted in the surfacing of an emerging story that included several key contexts and mechanisms, which resulted in a number of outcomes (context+mechanism=outcome configurations). FindingsThe searches identified 8664 documents initially, and 816 in repeat searches, filtering to 12 randomised controlled trials (RCTs), four quasi RCTs, ten qualitative studies, and 53 other quantitative studies published from 1995 to 2013. Four documents found in searches of the grey literature were also included in the realist synthesis. Contexts included experiences of young mothers, their knowledge and understanding, and their community or psychological perspective. Mechanisms included tailoring, motivations, and taking control. Potential outcomes resulting from the context+mechanism=outcome configurations included managing expectations, accessing services, and engagement with the issue of pregnancy in adolescence. InterpretationPregnancy in adolescence is a complex issue, with many factors to consider. The key contexts and mechanisms highlighted can help guide policy makers and professionals towards areas that need to be attended to concerning the issue of repeat pregnancy in adolescence. These findings provide a conceptual platform on which proposed interventions might be built to enhance their potential to work. FundingThis work was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) project number 11/141/05.