This first report of LPI (i.e., ever being or getting someone pregnant) among a multi-city sample of street youth in Ukraine found that four of ten female and two of ten male Ukrainian street youth aged 15–24 years had ever been pregnant or gotten someone pregnant, with a considerable prevalence of repeat pregnancy involvement among those with at least one LPI event (45.2%). Rates of LPI were particularly high for certain subgroups of youth, exceeding 70% among females and 40% among males. For both genders, the prevalence of LPI generally increased as age at first sex decreased. We found that independent risk factors for LPI were mostly similar for males and females and included demographic, social, and sexual risk factors. Drug use was not significantly associated with LPI after adjustment for confounders. Although the majority of most recent LPI events among street youth were reported to be unintended and nearly half ended in abortion, more than one in three pregnancies resulted in a live birth.
Although our overall rate of LPI was within the range documented by other studies,8,9,20–23
LPI rates for males and for females with certain risky sexual behaviors were higher than those previously reported. For example, the rates of LPI among females with histories of sex exchange (76%) and STI (61%) observed in our assessment are higher than rates from previous reports (2–43% and 6–45%, respectively).22,23
Furthermore, most of the earlier research exploring LPI among street and homeless youth has been conducted among females only.18,20,22,23,28
Although three studies have included males,8,9,21
the only one to report LPI separately by gender found 10% LPI in a small sample of 50 males.9
We found a higher prevalence of LPI in our sample of 706 male street youth (24%), which is likely an underestimate given that male knowledge of partner pregnancy may be incomplete, especially in the setting of multiple partners.
Although exposure to traumatic events during childhood, such as abuse, neglect, and being raised in a single-parent household, have previously been linked to increased rates of risky sexual behaviors and LPI among runaway and shelter-based youth,22,23,29
to our knowledge, ours is the first report to examine the impact of cumulative exposure to abuse and family dysfunction as measured by ACEs. We found increasing odds of LPI as ACEs increased, underscoring the need to prevent negative childhood experiences and for programs to mitigate the long-term consequences of childhood family dysfunction. Of note, although the distribution of total ACEs did not significantly differ between males and females, the magnitude of influence of total ACEs on LPI was greater for females, as more than one-half of females who reported five to six ACEs experienced LPI compared with one-fourth of males.
Younger age at sexual initiation has been found to be related to LPI among minority youth populations in the USA;30
however, the only previous study examining this relationship among street youth found no difference in the mean age of first voluntary intercourse among females with or without LPI.22
In our assessment, we found high rates of LPI among street youth having an early sexual debut, with nearly three-quarters (71.4%) of females who initiated sexual activity at ≤12 years reporting LPI; the odds of LPI for females and males also increased significantly and incrementally as the age at sexual debut decreased. Although we did not assess the intent of first sex, it has been suggested that distinguishing between voluntary and involuntary sex at debut may be important among homeless youth and that sex among the youngest age categories most likely reflects forced sex.9
Although pregnancy involvement among teen and older street youth introduces additional challenges to life and survival on the streets, there is evidence to suggest that some pregnancies among this vulnerable population are intended. For example, it has been suggested that pregnancy among troubled youth, including those on the streets, may be welcomed as a time for positive change.31,32
In our assessment, we found that four of ten females and three of ten males reported that their most recent LPI was intended. This finding might reflect inclusion of older age (20–24 years) street youth in our sample or the desire of youth to use pregnancy as a way to improve one’s life trajectory, as at least two qualitative studies have reported that pregnancy motivated homeless youth to secure housing.28,33
Limitations of our assessment included our inability to establish the temporal relationship between the many exposure variables we considered and LPI, given that our data were cross-sectional and timing of LPI was not assessed. In the event that LPI preceded some of the characteristics examined, we may have overestimated the odds associated with these characteristics. Furthermore, data were based on youth self-report and, therefore, subject to recall and social desirability bias. In the event that sensitive sexual and drug-use behaviors were under-ascertained by self-report, we may have underestimated the odds associated with these characteristics. In addition, misclassification bias in our outcome variable may have occurred, particularly for males, who may not have known that they impregnated a sexual partner. Last, because pregnancy involvement among older and married/partnered street youth may be acceptable, even though not ideal due to their poor health and social environments as well as engagement in risky sexual and substance-use behaviors, future studies addressing LPI among street youth populations may be strengthened by the inclusion of data regarding marital and/or steady partner status currently and at the time of pregnancy involvement. Despite these limitations, our assessment was conducted among a systematically drawn sample from multiple cities; these characteristics, coupled with high participation rates, enhance the validity and generalizability of findings.
Universal access to sexual and reproductive health services, including access to high-quality family planning services, has been recognized as a basic right of individuals;34
nevertheless, our findings highlight the need for community-based pregnancy prevention programs and services for street youth in Ukraine. As many youth in Ukraine are excluded from state-sponsored services including medical care without permission from a parent or guardian and without documentation of residency status, promoting legal access to medical services including contraceptives, independent of parental consent and documentation of residency, is especially critical for street youth who may be orphaned or have little-to-no parental contact and often lack registration documents. Furthermore, promoting use of longer-acting reversible contraceptives (e.g., intrauterine devices, contraceptive implants, and injectables) for female youth who are medically eligible35,36
may prevent unintended pregnancy among this vulnerable population, since these methods are less user-dependent and provide maximum efficacy.37,38
These methods, however, are costly and may not be readily available to street youth. Wider availability of condoms, as well as efforts to promote their use, remains important strategies to prevent both unintended pregnancy and STIs among street youth populations.
Programs for street youth in Ukraine should incorporate strategies to reduce high-risk sexual behaviors that may lead to LPI, lessen the psychological trauma from familial dysfunction including abuse during childhood, and enhance protective factors such as self-esteem and social involvement.39
Because street youth often display clustering of sexual risk behaviors and past STI diagnosis was found to be associated with LPI in our assessment as well as in previous literature,22,23
efforts to integrate family planning into existing STI/HIV programs are essential. For example, youth diagnosed with an STI or seeking STI/HIV testing should be screened and counseled for risk of unintended pregnancy and provided proper education, medical supplies, and skills to practice effective contraception, in addition condoms to prevent disease. Potential benefits of integrating these services have been previously described and include increasing uptake of health services and prevention of unintended pregnancies, STIs including HIV, as well as of mother-to-child transmission of HIV and infant abandonment among HIV-infected females.40,41
A recent review of programs linking family planning and HIV services found that integration was generally feasible and effective.40
For street youth in Ukraine, community-based programs utilizing skilled outreach workers are critical to successfully reach and serve this high-risk and transient youth population. Fortunately, there are several existing evidence-based HIV prevention programs for homeless youth42,43
that could be easily adapted to integrate pregnancy prevention, as most already aim to reduce HIV-related sexual behaviors (e.g., reduction of multiple sex partners or unprotected sex) that also reduce pregnancy risk. To reduce psychological harm from exposure to traumatic events, including childhood abuse or maltreatment, several intervention models have been implemented with children and adolescents and evaluated, with individual and group cognitive–behavioral therapy having the strongest evidence of success.44
These intervention approaches should be considered for adaptation and use with Ukrainian street youth. Last, because pregnancy, childbearing, and childrearing among Ukrainian street youth are somber realities, there is a need for increased access to antenatal and pediatric services for street-based youth, as well as for shelters, drop-in centers, and other programs serving these youth to be equipped to serve families including children. Although these strategies to reduce LPI and increase access to services for street youth are based on our findings from Ukraine, given the common experiences and barriers to services faced by street youth worldwide, these recommendations are likely applicable to other urban populations of street-based youth as well.