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Pregnant again? Perspectives of adolescent and young mothers who and do not experience a repeat pregnancy in adolescence

ABSTRACT Introduction: Teen pregnancy remains a major social and public health issue in developing countries. Each additional child compromises the development of both the mother and children. Scarce studies have been performed in Latin America. Purpose: This study explores and analyzes individual and family factors associated with repeat pregnancies during adolescence to better elucidate the phenomenon. Methods: Qualitative-descriptive study. Thirty semi-structured interviews were conducted with mothers 20 years of age or younger from urban areas of Santiago, Chile. Participants were divided into Repeat Pregnancy (RP) and No Repeat Pregnancy (NRP) groups. Qualitative data analysis was based on elements of grounded theory. Results: The RP group generally related life stories reflecting greater psychosocial vulnerability. Most of the RP group dropped out of school after their first pregnancy to focus on parenting and had a passive attitude towards contraception. In contrast, members of the NRP group actively sought long-term contraceptive methods, motivated largely by the desire to continue their education to improve their living conditions and achieve greater personal fulfilment. They tended to have family support networks that facilitated school retention. Conclusion: Key differences between groups included use of contraception, focus on life projects, and motivation to finish school. Prevention strategies should promote long-term contraceptive methods, offer strategies to help young mothers continue their education, facilitate achievement of personal projects, and provide support for parenting.


Introduction
Chile has one of the lowest teenage fertility rates in Latin America, thanks to public policies that have improved access to adolescent sexual and reproductive health services (Department of Life Cycle, 2012; Department of Life Cycle, Ministry of Health of Chile) and educational policies aimed at school retention (Bylaw subsection three of article 2 of Law No. 18,962 that regulates the status of students in situations of pregnancy and motherhood, Supreme Decree of Education No. 79, 2004;General Education Law 20,370, art 11,15,16). However, the distribution of teenage pregnancies in Chile remains inequitable, with higher rates in disadvantaged social economical strata. Repeat pregnancy rates are also high and likewise concentrated in lower-income populations (Economic Commission for Latin America and the Caribbean, Reproduction in adolescence in Chile: inequality continues and active policies are urgently needed, 2017; Guerrero, 2020).
According to World Bank data, Chile enjoys a more advantageous socioeconomic position than many other Latin-American countries and is considered a highincome economy. However, 30% of the population is economically vulnerable. Furthermore, per capita household income is lower and less equitably distributed than in other member countries of the Organization of Economic Cooperation and Development (OECD), which Chile joined in 2010 (World Bank, 2020).
Chile's healthcare system is divided into public and private sectors. The public system covers 80% of the population, mainly in the middle-and lower-class strata, with free access to most services. Public services include sexual and reproductive counselling and guaranteed access to family planning, prenatal, and delivery care (Becerril-Montekio et al., 2011).
Female workers with social security also have the right to maternity leave for as long as 24 weeks, transferable to the father. In 60% of economically lessprivileged families, the female head of household is unemployed. These women may access a US$15/ month maternity subsidy from the fifth month of gestation to delivery. This benefit is also applicable to teenage mothers (Ministry of Social Development, 2017).
As in many Latin American countries, abortion in Chile is permitted only under exceptional circumstances. Abortion was made legal in 2017 in three specific cases: life-threatening situation for the expectant mother, non-viable foetus, and rape. Because abortion is otherwise banned, there is no data available on abortions for other reasons (Donoso & Vera, 2016;Huneeus et al., 2020).
In 2009, a sexual and reproductive counselling programme for adolescents was implemented to improve access to birth control. Almost a decade later, the reach of the program has quadrupled. Services are offered in community health centres, focusing on the areas that are the most vulnerable and have the highest pregnancy rates. A 2010 law made it mandatory for these centres to provide screening, counselling, and referrals to reproductive healthcare services for both adults and teenagers (Department of Life Cycle, Ministry of Health of Chile; Law No. 20418 "Sets Standards on Information, Guidance and Benefits in Fertility Regulation" Ministry of Health, 2010; Ministry of Health of Chile, 2018).
Educational policies have been implemented to improve school retention of pregnant students, including programmes to develop learning skills and promote well-child visit attendance (Exempt Resolution No. 0193of 2018, which approves Regulations on pregnant students, mothers and fathers that are students). Teen fathers have also been the target of such programmes. In pregnancies involving mothers under 14 years of age, 54% of the fathers were teenagers, while 33.5% of the fathers were teenagers in pregnancies involving mothers 15-19 years of age (National Statistics Institute, 2017). Despite these initiatives, unfortunately, paternal participation in pregnancy and well-child visits has remained low in this population. This low rate of involvement might be related to a cultural belief that child-rearing is a female role (National Institute of Youth (INJUV), 2020).
While teen fertility has decreased over the past three decades in Latin America and the Caribbean, regional rates remain the second-highest in the world, and there are great inequities between and within countries (Economic Commission for Latin America and the Caribbean, Reproduction in adolescence in Chile: inequality continues and active policies are urgently needed, 2017;World Health Organization, united Nations Population Fund, 2016). Moreover, successful strategies to reduce teen pregnancy rates have not had a similar impact on the incidence of repeat pregnancy, which has remained stable over the past decade (Ministry of Social Development, 2013; National Women's Service, 2015).
Although Chile has achieved a decrease in teen fertility, national statistics indicate that 10%-16.5% of teenage mothers had two or more children between 2007 and 2016, corresponding to about 3200 live births annually. Among mothers under 15 years of age, 1%-3.5% have already had a second child (National Statistics Institute, 2015;Vital Statistics Publication, 2019). Home visits have been employed as a strategy to prevent a second pregnancy in adolescent mothers. However, implementation has been insufficient according to national reports. This deficiency could explain, in part, the persistently high rates of recurrent teen pregnancy (Ministry of Social Development, 2013).
Repeat pregnancies during adolescence tend to occur in within 24 months of the first birth. A 2005 systematic review indicated that 20-37% of teenage mothers experienced a repeat birth within this period (Meadea & Ickovicsa, 2005). A longitudinal study published in 2017 suggested that 30% of teenage mothers become pregnant again within a year, and 25%-50% experience a repeat pregnancy within two years (Reese & Halpern, 2017). A short interpregnancy interval 1 is associated with adverse obstetric and perinatal outcomes such as preeclampsia, low birth weight, preterm birth, and infant mortality (Boardman et al., 2006;Nerlander et al., 2015).
In addition to the biological risks, having more children exacerbates the negative psychosocial impact of teen motherhood, provoking educational, economic, and social gaps. Teenage motherhood has a negative effect on education level and employment prospects, as reported in a national study that analysed the long-term impact of this experience (Berthelon & Kruger, 2017).
Although the absolute number of repeat pregnancies may not be great, the issue remains a matter of concern given its profound impact on the life course of a young mother and her children. As noted, recurrent pregnancies during adolescence carry biological risks, jeopardize educational opportunities, and reduce access to well-paid jobs, thus perpetuating the poverty cycle (Maravilla et al., 2019).
The risk factors associated with teenage pregnancy are widely known. However, the reasons for repeat pregnancies during adolescence are less obvious (Klerman, 2004). One systematic review identified several individual factors, such as dropping out of school, non-use or inconsistent use of contraception, history of depression, and prior abortions. Risk factors related to the couple were also identified, including cohabitation and age difference. The same study indicated that use of contraceptives, particularly long-acting reversible contraceptive methods (LARC), and higher education levels are the most important protective factors in postponing a new pregnancy. In addition, the review indicated that the lack of scientific evidence on repeat pregnancies and associated problems is concerning, given the high incidence of this situation in low-and middle-income countries such as Latin America (Maravilla et al., 2017).
This situation certainly applies to Chile. While there has been some research and policy-making aimed at reducing teen fertility, the focus has been on individual pregnancies and births. Data regarding recurrent teenage pregnancies, on the other hand, is scare.
Furthermore, few studies have explored these risk factors from the perspective of the teenage mothers themselves. This type of data could shed more light on the phenomenon and improve intervention strategies (Conroy et al., 2016;Wilson et al., 2011). Therefore, the present study explores and analyzes individual and family factors associated with repeat pregnancies during adolescence to better elucidate the phenomenon.

Study design
This qualitative exploratory-descriptive study sought to investigate recurrent teen pregnancy from the perspective of mothers who did and did not experience a repeat pregnancy during adolescence. A qualitative approach was adopted based on the understanding of a social construction of reality, where knowledge and actions develop out of the meaning attributed to them by the actors involved. The flexibility of this exploratory approach allows for a better comprehension of this type of complex phenomenon (Mendizábal, 2013).
The study population was teen and young mothers seen in the public health system in urban areas of the Metropolitan Region of Santiago, Chile. About 40% of the national population lives in the Metropolitan Region.
Theoretical sampling was used to enrol study subjects, in accordance with the chosen qualitative approach. The main inclusion criterion was mother aged 20 years or younger, in order to explore the perspectives of teen and young mothers who did and did not experience a repeat pregnancy during adolescence. We selected this age group, rather than older participants, in order to minimize memory bias.
We then divided the sample into two groups. The Repeat Pregnancy (RP) group had a new pregnancy within 36 months after the birth of the first child. The No Repeat Pregnancy (NRP) group did not experience a second pregnancy or had a second pregnancy more than 36 months after the birth of the first child. In total, 30 teenage and young mothers were interviewed; 16 in the RP group and 14 in the NRP group.

Recruitment
Potential participants were contacted in collaboration with institutions involved in caring for teen mothers, such as health centres in various municipalities of the Metropolitan Region of Santiago and nongovernmental organizations (NGOs).
Healthcare professionals at the centres provided the contact information for mothers 20 years of age or younger so that research team members could call individuals who met inclusion criteria and begin the informed consent process. We estimate that we interviewed only 10% of the contacts from the initial list, as many phone numbers were not current. All of the individuals contacted were interviewed, although some appointments were rescheduled due to absences.
NGO social workers invited young women who met the inclusion criteria to participate. Those willing to participate were contacted and interviewed by the research team. We do not know many of those invited by the social workers refused to participate.

Data collection
We collected data using semi-structured interviews. The flexible format allowed for in-depth exploration of the themes and addition of new topics as necessary, increasing the validity of the results. The interview outline was prepared according to the study objectives, based on a literature review and the expertise of the researchers. The relevance and comprehensibility of the questions to the target population was assessed using two pilot interviews with teenage mothers.
The topics included in the definitive outline were life and school history, reproductive decision-making, experiences and meanings surrounding motherhood, experience at health services, and life projects.
The interviews were conducted between May 2017 and April 2019 in a private location chosen by the participant, usually their home or healthcare centre. The interviews, which lasted 45-60 minutes, were conducted by one or two female members of the research team who were trained in qualitative data collection and experienced in treating and taking clinical interviews from adolescents. All interviews were audio-recorded and transcribed literally by a person independent from the research team, with experience and training in interview transcription. The quotes from respondents were translated literally from Spanish to English.

Analysis
Elements of grounded theory were applied, such as constant comparison and open and axial coding. This approach allowed us to identify and describe the main themes relevant to the study objectives as they emerged from the data (Soneira, 2013).
Open coding, as a starting point for the analysis process, produced an initial codebook with categories emerging from the 30 interviews. The analysis then proceeded to axial coding, where the categories were organized into four main themes that integrated and articulated the essential aspects of the results. MAXQDA Version 12 software was used for this analysis.
To ensure scientific rigour, triangulation among researchers was applied throughout the analysis process. Three researchers participated in the coding and agreed on the classification criteria used to produce the initial codebook. At least four researchers participated in each axial coding session. The researchers reached a consensus regarding the criteria for the category groups and relationships. Use of the constant comparison method; the large number of interviews, which allowed for saturation of the categories; and use of a workshop with experts in adolescent sexual and reproductive health to validate the results all contributed to the trustworthiness of the study (Morse et al., 2002).
The main themes that emerged from analysis of the available data were as follows. (1) Life history: significant personal history prior to the first pregnancy; (2) Reproductive decision-making: elements associated with the choice to seek or avoid pregnancy and use of contraceptives; (3) Motherhood: meanings attributed to motherhood and children; (4) Education: educational trajectory after the first pregnancy and factors associated school retention (Table I).

Ethical considerations
All participants signed an informed consent form. If the participant was under 18 years of age, her legal guardian also signed the informed consent form.
During the consent process, participants were informed of their right to withdraw from the study should at any time if they should feel uncomfortable during the interview, without negative consequences.
This study was approved by the Human Beings Ethics Committee of the Faculty of Medicine of the University of Chile.

Results
The sample was included thirty adolescent and young females from urban areas of the Metropolitan Region of Santiago, Chile. Of the total sample, 26 were Chilean, and 4 were Spanish-speaking foreigners. All participants were from middle or lower economic strata.
There were 16 participants in the RP and 14 in the NRP group. Median age was 19 years (range: 18-20) at the time of the interview. Median education level was 11.5 years, with a difference between the groups (RP = 8; NRP = 12).
Twenty-three of the respondents were in a relationship, and 16 lived with their current partner, who in most cases was the father of the child, at her or his parent's home. At the time of the interview, 17 of the respondents did not study or work outside their home, 10 were in school, and 3 were working. All of the interviewees had check-ups during their pregnancy at their local health centre, and their deliveries took place at a public hospital.
The first pregnancy occurred at a median of 16.1 years of age, and the recurrent pregnancy at 18.6 years. The median interpregnancy interval was 16.7 months (range: 1.5-33.8). None of the adolescents or young women with a repeat pregnancy had more than two living children at the time of the interview. Most recurrent pregnancies were with the same father (Table II). The two groups reported different patterns of life events. Mothers with a repeat pregnancy in Many interviewees in the RP group also reported low motivation to complete school, resulting in irregular attendance or gradual abandonment of school before the first pregnancy, whether permanently or temporarily. Their parents tended to accept this situation, assuming a passive attitude regarding school attendance. Some participants from the RP group reported that they began to cohabitate with the baby's father before the first pregnancy, often triggered by relationship problems with their own parents. Among participants who did not experience a repeat pregnancy, none lived with the baby's father before the pregnancy. Some interviewees in the NRP group did begin to live with the father and his family after the birth of the child. Although the interviewees in both groups were from households with a low socioeconomic status, serious rights violations during childhood and adolescence were more common in the RP group, according to the narratives. Family relationships characterized by conflict and parental neglect were risk factors for early cohabitation with a partner. This finding suggests that the interviewees may have been seeking a new family as a way to escape from their own family environment.

Before the first pregnancy
The majority of the interviewees reported that their first pregnancy was unintentional, although most had not been using any contraceptive method. Those who reported actively seeking a pregnancy did so as a way to satisfy emotional deprivation and overcome deep feelings of loneliness, sadness, and/or hopelessness.  It was rare in either group that the interviewee actively sought a pregnancy. Among those who stated an ambivalence about seeking a pregnancy, the main contributing factor seemed to be a lack of affection and bonding within their family. In general, failure to take measures to prevent pregnancy was the most frequent contributing factor in both groups. This finding suggests that effective sex education and access to birth control should be improved in the Chilean public healthcare system.

After the child's birth
After the birth of the first child, the vast majority of respondents in the NRP group used a long-acting reversible contraceptive method (LARC). These respondents stated that they actively sought a highlyeffective method to prevent a new pregnancy.
I decided on the IUD, because . . . I don't know, I think it's, like, easier, you don't have to take a pill or get a shot, you just have to come in every 6 months for a check-up . . . that's why I got the IUD when I had my daughter (NRP 2).
I started looking for a contraceptive method that would be more convenient for me and that was very safe. When I arrived at the doctor's office, they told me that could give me the implant, that it was free and all that, so I went for the implant (NRP 9).
The RP group, on the other hand, did not use contraception after the first pregnancy or used a lesseffective method than an LARC, such as the pill or injectable birth control. A few interviewees used a postpartum LARC but changed to injectable birth control due to discomforts associated with the LARC, such as spotting. This finding indicates that members of the RP group placed more emphasis on avoiding negative side effects than the effectiveness of the method.
Most of the RP group reported that they had not actively sought the new pregnancy. The interviewees who did become pregnant a second time intentionally cited reasons such as wanting a child of the opposite sex, increasing the stability of their relationship with their partner, or fulfiling the desire of the couple to have another child.
. . . I also wanted to have another baby . . . a little girl . . . my first one was a little boy, and now I wanted a girl (RP 10).
" [Interviewer] And why did you want to get pregnant again?
[Interviewee] I think that since I was with him, I saw it as family stability, mostly because of that, and because we agreed between the two of us (NRP 5) The majority of the interviewees who did not experience a repeat pregnancy in adolescence reported that they would like to have more children in the future. However, they chose to postpone additional pregnancies for economic reasons, stating that achieving income stability was a priority before having another child. Likewise, when expanding on these reasons, the interviewees reported that a personal reason to delay additional pregnancies was that having a new child would jeopardize their opportunity to achieve personal projects.
What did I think about getting pregnant again? It would be putting what I was doing on hold again, pausing it and then resuming it again later (NRP 8).
The two groups did not differ markedly in describing the experience and meanings surrounding motherhood. All of the mothers reported that raising the first child represented an important life change, especially during the first year. This change included the challenging process of adapting to their new duty as a mother, caring for the baby, and playing multiple roles, including as a parent, and for some as homemaker and/or student. Many of the respondents stopped attending school due to motherhood, and some also had to care for younger siblings. The mothers reported that it was difficult to assume these different functions abruptly in a way that was compatible with their daily lives. In addition to the challenge of taking on a multiplicity of roles, most of the teen and young mothers reported that motherhood meant limiting their social lives with their peer group and missing out on fun teenage activities.
Like, I miss all those things . . . Going to school, having friends, talking, laughing . . . I'm alone here. I don't go out; I'm with my partner, and that's it (RP 3).
Even though the experience was difficult and limiting, those interviewed also attributed positive meanings to motherhood, stating that the children had provided a motivation to improve themselves, develop goals, and achieve their objectives. For others, children represented a source of love, companionship, and/or joy: Because after having my daughter, I understood that I had to make plans and have a goal . . . so I said 'now, I have to study; I have to get it together (NRP 1).
You're all sad, and he come in with his mischief . . . it's like he makes the house happy, because if he weren't there, I would be alone with my parents, and nothing else (NRP 5).
Although family support in caring for the children was described as important by both groups, the father of the child was not seen as someone who contributes to child-rearing, but rather the person who should fulfill the role of income provider.
. . . I told my mom 'No, I got involved with him, he has to support me, not you.' And I went to live with him (RP 11).
Motherhood is a milestone marked by important challenges, including assumption of multiple adult roles during adolescence. Maternity was associated with restrictions rather than the life accomplishment of having a child. Fathers tended to be viewed as secondary co-parents who were expected to support their children financially. The majority of the interviewees in the NPR group stayed in school after the birth of their child or resumed their education after a temporary break. These young mothers stated that family support in caring for the baby while they attended school was essential for achieving this goal. In these cases, the family, especially the mothers of the adolescents, encouraged the young women to continue their education at least through high school, considered the minimum degree needed for a well-paid job. The reasons cited for continuing school were diverse. In material terms, finishing high school would allow for an improved economic situation and a better life for their child. Finishing school also provided a sense of personal achievement, the feeling that they were a source of pride for their parents, and the opportunity to be an example for their children. Finally, the young mothers valued attending school because it was a space that allowed them to socialize with peers. Avoiding a new pregnancy was seen as essential for achieving this goal.
My parents emphasized that I should finish high school, get good grades, graduate . . . the best thing they could leave me and him [son] with, would be that I would have a career or at least have graduated high school so I could look for a job, which would give me [economic] stability, so to speak (NRP 9). I, at least, felt that it was good, that I needed it [to go back to school], to have a connection with other people my age . . . to talk about things other than changing diapers or milk. The truth is that yes, I found that it was good for me to be in school again (NRP 2).
The majority of the mothers in the RP group also considered education as a means to accessing better job opportunities in order to support the child. However, these young mothers reported a lack of interest in education during adolescence as well as inadequate family support. These interviewees stated that their parents did not encourage them to attend school. In addition, they noted that the lack of family support in caring for the first child was a barrier to returning to school; therefore, they felt that the pregnancy meant putting off school indefinitely.
[Interviewer] Did you continue studying after having your [first] child?
[ Furthermore, many of the teenage and young mothers considered economic support to be the role of the father rather than their own. Therefore, so continuing school did not carry much urgency, nor did it bring a sense of personal fulfilment, as they associated the latter with motherhood.
I have heard a lot, a lot of Chileans talking, saying that it is better to finish their studies before giving birth to a child . . . I think that's wrong, because I say that children come before school (RP 4).
All of the interviewees valued continuing and finishing school. Family support with childcare during the day and having goals beyond motherhood were the main factors that facilitated school retention; conversely, lack of family support with childcare and absence of goals other than motherhood were the main obstacles to returning to school.

Discussion
The results show that participants in the NRP group tended to avoid a new motherhood experience, instead prioritizing their studies, training for an occupation, and/or entering the workforce. These actions may be interpreted as an attempt to reduce income dependency on the child's father and/or their families. These young mothers appeared to be striving for selfsufficiency in order to achieve personal and economic autonomy in decision-making and life projects. The adolescents and young women in the RP group, on the other hand, tended to concentrate on their role as a mother, reinforcing their view of motherhood as a personal setback. These interviewees often dedicate themselves exclusively to caregiving and domestic tasks, resulting in income dependency. Adherence to traditional gender roles was common among these young women, unlike those who did not experience a repeat pregnancy. The NRP group actively pursued life projects beyond parenting and motherhood, which required returning to school and postponing a second pregnancy.
From a gender perspective, a strong association between women and motherhood has historically justified the role of women as homemakers. Such gender roles tend to result in dependent relationships, decaying the autonomy of the women. The RP group tended to grant men the role of income provider and women the role of raising the children, as has been seen traditionally in Chilean and many other cultures. There has been plentiful discussion and questioning of traditional gender structure in Chile in recent years. Furthermore, the concept of gender equality has considerable support among young people. However, there is still a strong tendency to maintain conservative and unequal conceptions of motherhood and fatherhood, especially among lowincome and otherwise vulnerable young people, both in Chilean and other Latin-American societies (National Institute of Youth, 2015, 2019Weisbrot et al., 2019).
The family environment was the key in facilitating or impeding personal achievement. The bond with significant adults, especially maternal figures, was crucial. Tangible help with caregiving allowed the young mothers to finish high school and plan future projects. In both groups, the level of emotional and concrete support from adult reference figures was strongly related to the expectations of the family regarding the importance of their daughter's education, realization of personal projects, and opportunity to achieve a better economic status in the future. Participants in the NRP group tended to enjoy the benefit of family support. An effective family network helped the young mothers to reconcile the various roles they assumed, especially the role of student. In these families, the importance of education as a means of social mobility was emphasized. Therefore, the families tended to cooperate so that the adolescent could stay in school, earn a degree, and in some cases, continue on to higher education.
On the other hand, the RP interviewees reported that their families reinforced the idea that motherhood was a priority that should take precedence over school or personal aspirations. Thus, any plans made prior to pregnancy were postponed, temporarily restricting autonomy and social mobility. This finding represents a particularly complex problem, as teen pregnancies often occur in low-income strata. In sum, family support is a protective factor for remaining in school, consistent with prior investigations (Gbogbo, 2020;Maravilla et al., 2019); this issue is crucial, as a higher level of education allows for better opportunities in the future.
The use and choice of a contraceptive method after the first pregnancy was also important in differentiating the two groups, reflecting different levels of proactivity in preventing a second pregnancy. For the NRP group, using contraception, especially a highlyeffective method such as a LARC, was seen as crucial for successfully constructing a life project beyond motherhood. This motivation stimulated the young mothers to take an active stance in reproductive decision-making, with the understanding that using a reliable contraceptive method would open the door to greater opportunities. These young mothers believed that they could better achieve their future personal and career projects if they postponed a second pregnancy, improving their quality of life and that of their children.
In contrast, the adolescents who experienced an unintentional repeat pregnancy maintained a passive attitude and asserted less autonomy in reproductive decision-making, consistent with results from other studies (Bucknall & Bick, 2019;Nerlander et al., 2015). Because their role as a mother was their highest priority, other activities aimed at personal fulfilment outside the home, such as studying or working, were currently incompatible, resulting in the perpetuation of traditional gender roles as noted above.
The first two years after the birth of the first child were especially complex for the adolescent and young mothers, as they adapted to their motherhood role and performed the myriad tasks associated with parenting and caring for the child along with other roles such as homemaker and/or student. However, it is important to recognize that a teenage mother does not cease to be a developing adolescent. The interviewees reported that was a steep challenge to take on these new, highly-demanding roles in a way that was compatible with their daily lives as adolescents. The narrations of the teenage and young mothers indicated that support or lack thereof from their families and relevant institutions was crucial in mediating the outcome. Given the challenges that these adolescents face, it is important to consider the structure of the healthcare system in terms of the obstacles that it may place in the paths of these mothers. For instance, an adolescent mother seeking access to contraception (the pill or injectable birth control) may have trouble making an appointment at a time that does not conflict with her school or childcare schedule. Such barriers decrease the chances of adherence to the birth control method and increase the odds of a second unintended pregnancy, according to various studies (Meadea & Ickovicsa, 2005). Importantly, a LARC is the most-recommended method for preventing new teen pregnancies as it requires a relatively low frequency of follow-up visits, as described in the literature (National Institute of Youth (INJUV), 2020; Reese & Halpern, 2018, 2017.
This study has several limitations. These findings cannot be generalized to other populations of teen mothers. The participants live in urban areas and came from households with a low socioeconomic status. Therefore, the results do not reflect the realities and experiences of young mothers who, for example, reside in rural areas or have a different socioeconomic status.
Although the study employed a qualitative analysis based on elements of grounded theory, a major strength of this research is the findings assimilated the input of a great number of interviewees. Furthermore, this study is unique in exploring the perspectives of adolescents and young Chilean mothers who do and do not experience a second pregnancy during adolescence. In light of the results, it would be helpful to address this issue from a gender perspective in future research. It would also be beneficial to include the perspectives of other relevant informants, such as healthcare personnel and policy makers.

Conclusion
The first two years postpartum represent a critical and high-risk period for adolescent mothers. The healthcare system and policy makers should target interventions to support young mothers during this time. Teen mothers require individualized, focused attention to optimize adherence to contraceptive strategies. The various professionals who come into contact with the mother, for example, at their children's well-child visits, should all play a role in monitoring adherence. These visits can become opportunities for interventions to prevent or postpone a new pregnancy. Given that the population of teen mothers in Chile is relatively small and identifiable, these actions should be feasible.
Likewise, it is of the utmost importance that healthcare providers adopt counselling strategies appropriate for teenage mothers. Ideally, providers can help young mothers to select long-acting reversible contraceptive methods, given the evidence that such methods are the most effective in this population, always showing respect for the sexual and reproductive rights of the adolescent mother and the cultural standards of their environments (Bahamondes et al., 2018).
A major challenge is that some adolescent mothers may choose to seek a new pregnancy or are ambivalent regarding contraception. Further research into this group would be useful in developing specific strategies to help these adolescents either prevent a new pregnancy or plan an interpregnancy interval that minimizes risks for the mother and child.
Finally, our findings show that the level of concrete assistance available from family members, especially for childcare and parenting tasks, is a major factor in the life trajectory of adolescent mothers. This support or lack thereof is a key determinant in whether a young mother experiences a repeat pregnancy during adolescence and whether she finishes her secondary education. Additional research would be helpful in developing effective approaches to involving family members in preventing a repeat pregnancy.