Abstract
Background
-One of the major public health issues across the whole world these days is
teenage pregnancy which is defined as pregnancy having the age ranging from 13
– 19 years. 11% of all births which occurred worldwide accounted to girls aged
15 to 19 years old and from these about 95% teenage deliveries occur in low and
middle-income countries. World health 2014 statistics shows complications during pregnancy and
childbirth are the second cause of death for 15-19 year old girls globally.
Every year 3 million girls aged 15 to 19 undergo unsafe abortions. Objective –
To compare the magnitude of adverse obstetrical and perinatal outcome of
teenage and adult pregnancy among deliveries in Lemlem Karl General Hospital,
Tigray, Ethiopia, 2017/2018
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Methodology
–Institutional based comparative
cross sectional study was conducted among 618 systematically selected clients card
who deliver at Lemlem Karl General Hospital from 2014-2017GC. The data was collected
by reviewing the client’s card to assess the effects of teenage pregnancy on
obstetrical and perinatal outcomes using structured questions which prepared in
the form of checklist prepared by the principal investigator. The data entered
and cleaned by Epi info version 3.5.1 and analyzed using SPSS version 20 then
the data was presented in the form of texts, tables and figures. Bivariate and
multivariate logistic regressions used to test the association between
dependent and independent variables. After bivariate logistic regression
analysis variables with p-value less than 0.2 were included in multivariate
analysis. Statistical
significance will be declared at P-value <0.05.
Result:
Teenagers were significantly associated with
adverse obstetric and perinatal outcomes, cesarean delivery (AOR:
0.53; 95% CI, .333-.847) episiotomy (AOR: 1.9; 95% CI, 1.144-3.145), low birth
weight (AOR: 2.16; 95% CI, 1.091-4.257) and premature delivery were more likely
in teenagers than adults
Conclusion and
recommendation: This study shows that adverse obstetric
and perinatal outcomes were significantly associated with teenagers than adult
mothers so there is need for health care providers to put more emphasis on
focused ANC at Lemlem Karl hospital.
Key words:
teenage pregnancy, obstetric and perinatal outcome, Tigray
1. Introduction
1.1 Background
One
of the major public health issues across the whole world these days is teenage
pregnancy which is defined as pregnancy in girls' age ranging from 13 – 19
years old and very often the term adolescent pregnancy is also being used to
infer it. Furthermore it is categorized as early adolescents (10 -14 years) and
late adolescents (15 – 19 years) (1). According to
2017 UN world population prospect report, it is clearly depicted that from the
total world's population of 7.6 billion, nearly half of them (42%) are under 25
years old and yet 16% of world's population are comprised of youth age groups
(15 – 24 years). Apparently Africa, the second most populous continent next to
Asia, has the largest proportion of youth age groups (19%) followed by Latin America
& the Caribbean and Asia 17% and 16%, respectively (2). Globally it is
estimated that around 16 million babies (11% of all child births) are born to
adolescent girls. Ironically, 95% of these births occurred in countries with
low socioeconomic status (3). Furthermore
according to WHO, seven countries mainly constitute for half of all adolescent
births; namely, Bangladesh, Brazil,
the Democratic Republic of the Congo, Ethiopia, India, Nigeria and the United
States of America (1)(3) (4).
Levels
of adolescent childbearing which can have adverse health and social
consequences for both the young mothers and for the children they bear has
fallen in most countries. Nevertheless, high adolescent fertility remains a
concern in some parts of the world. Among regions, the adolescent birth rate
(births per 1,000 women aged 15-19) in 2010-2015 was highest in Africa, at 99
per 1,000 women, followed by Latin America and the Caribbean at 67 per 1,000.
The ratio of adolescent to total fertility was highest in Latin America and the
Caribbean, where the birth rate at ages 15-19 years contributed 16 percent of
total fertility. Births to adolescents as a
percentage of all births range from about 2% in China to 18% in Latin America
and the Caribbean. (2),(3),(4).
Determinants of teenage pregnancy in a study
employed in developing countries enumerated the following reasons as
attributing factors for teenage pregnancy; lack of knowledge on sexuality
education, ineffective utilization of modern contraceptives, cultural obedience
or permissiveness, poverty which lead to family disintegration, socioeconomic
dependence of females on males, peer influence and the like (5) . Due to the fact that adolescents are presumed
to be less mature both anatomically & physiologically than adult women. They
have the tendency to exhibit enormous adverse maternal and perinatal outcomes
when they get pregnant. Consequently teenage pregnancy have remained to be a
global public health problem, particularly in the third world countries (6). There are a lot of speculations for the
question why teenage pregnancy is associated with poor obstetric &
perinatal outcome. For instance, adolescents have lower socioeconomic status,
lower educational level, poor compliance to antenatal care, higher chance to
deliver low birth weight & premature babies (7). It is not surprising that teenage pregnancy is greatly
associated with adverse pregnancy outcomes like obstructed labour,
preeclampsia, anemia, operative deliveries, puerperal endometritis postpartum
hemorrhage, low birth weight, preterm delivery & perinatal death (8),(9),(10), (11). Nevertheless, the evidences have always been an
area of controversy; whether these adverse outcomes are owing to either
biological immaturity or socioeconomic deprivation & inadequate health care
service.
Pregnancy for the second time & more in
adolescents even carries higher risk of these adverse pregnancy & perinatal
outcomes. A study outlined the following predictors as significant indicators
of poor perinatal outcomes; age of first pregnancy less than 16 years old,
history of adverse pregnancy & perinatal outcomes in the previous pregnancy
and inter birth interval less than 18 months (12).
1.2.
Statement of the problem
According to 2017 UN report 16% of total
world's population are constituted by youth age groups, 15 – 24 years old (2).
Adolescent
pregnancies are becoming area of inquiries and emphasis as it is a public
health problem worldwide. According to WHO report, globally every year 16
million late adolescent girls and one million early adolescent girls get pregnant,
11% of total childbirth In which most of them (95%) reside in low and middle
income countries (3).
A
multi country assessment held in 29 countries of low and middle countries by
WHO ranked the following continents as the most prevalence areas for teenage
pregnancy; Latin America & the Caribbean, Africa and Asia with teenage
pregnancy rate of 35.5%, 35.1% and 11.5%, respectively (8). Moreover WHO
report also revealed that twenty three percent of overall morbidities owing to
pregnancy and childbirth are mainly attributed to adolescent pregnancies. Every
year it is estimated that around 3 million late adolescent girls undergo unsafe
abortion and on top of this complications that arise during pregnancy and
childbirth is the second commonest cause of death in late adolescent girls (3). There is also
an increased risk of NICU admission, preterm delivery, low birth weight,
stillbirths and neonatal death in babies born to adolescent mothers (13).
In
Ethiopia according to EDHS 2016, twenty two percent of total female populations
are late adolescents (15 to 19 years old). Of these 13% of them have begun
childbearing. Apparently teenage pregnancy is more predominant in rural residents
(15% Vs 5%) while Afar remained to be the most prevalent region for teenage
pregnancy (23%) followed by Ethiopian Somalia region (19%). Pertaining to the
educational level of adolescent mothers, teenage pregnancy predominantly
occurred in those with no education (28%) comparing to adolescent females
attained primary education (13%) and secondary education (4%) (14) .
Despite
the fact that there are studies which have concluded that teenage pregnancy is
associated with adverse maternal & perinatal outcomes, yet there are
other researches which contradict to
these speculations (15). This is due to
the fact that some of the studies conclude their associations with descriptive
statistics and some are attributed to heterogeneity of population and some are
owing to their study designs, study area setting and difference in sample
sizes.
1.3.
Significance of the study
As
it is mentioned earlier Ethiopia is one of the seven countries which comprise
half of adolescent pregnancy rate in the world. According to EDHS 2016 it is
estimated that teenage birth rate in Ethiopia is 80/1000 (14). Even though a
lot have been said about teenage pregnancy and its associated factors and some
deals about the outcomes across the globe, as far as the investigator knowledge
there are no published researches being employed pertaining to adverse
obstetric and perinatal outcomes of teenage pregnancy in Ethiopia. Furthermore those studies which were done by
different researchers in different parts of the world, their finding about
obstetric and perinatal outcome of teenage pregnancy contradict one another.
Therefore this study is intended to explore this rampant situation and its
aftermaths which could in turn provide preliminary information for other
researchers in Ethiopia
Identification
of the adverse outcomes in the area also has greater input for the program
managers and policy makers for designing proper implementation and evaluation
of programs to reduce the occurrence of these adverse outcomes.
For the midwifery professionals it will assist
to provide evidence based information about the adverse outcomes related to
maternal age and to promote the preventive and curative care of the mother and
the neonates to reduce the bad outcomes.
Furthermore
the findings of the study will create awareness in the community about the
problem and contribute towards formulating solutions at the grass root level.
2. Literature Review
2.1 Magnitude of
teenage pregnancy
Globally
it is estimated that 11% of total child births are born from adolescents (3). A study employed in 29 countries, low and middle
income countries, revealed that the magnitude of teenage pregnancy rate in
Africa, South America & the Caribbean and Asia was 35.1%, 35.5% and 11.5%,
respectively (8). A year later,
another facility based cross sectional study employed in 359 health facilities
of the world stated that 10.3% of deliveries were to adolescents aged 10 -19
years old (10). A comparative
retrospective study done in Turkey implied that teenage pregnancy rate was 8.1%
(16). A large scale
retrospective study enrolled in Korea showed the least adolescent pregnancy
rate 0.5% (17). Likewise
studies employed in Italy also revealed lesser teenage pregnancy rate than
other countries (9) . In contrast
to this a hospital based cross sectional study in Mexico showed higher
adolescent pregnancy rate, 34% (18). When we came
to Africa in Nigeria the prevalence was 1.67% (15). Studies held
in Yaoundé hospital, Cameroon and Egypt revealed that the prevalence of
adolescent pregnancy was 9.3% & 19.8%, respectively (6),(19). Cross
sectional study done in Assosa general hospital, Ethiopia showed that the
prevalence of teenage pregnancy was 20.4%
(20).
2.2. Adverse
perinatal outcomes
A
case control study done in North India outlined that babies of adolescent
mothers were 1.65 times more likely to be born prematurely and 1.6 times more
likely to be born with low birth weight. Nevertheless, this study also
concluded that there was no statistically significant association on the risks
of stillbirth (21). In another
study done in Turkey strikingly, adolescent mothers were 4.94 times more likely
to face IUFD and 2.7 times more probable to have premature babies than adult
mothers. However, preeclampsia was 50 % less likely to occur in adolescent
mothers. (22).
Retrospective
cohort study conducted in Taiwan showed
that teenagers were 1.58 times more likely to had preterm
delivery and 1.2 times more likely to had fetal
distress than that of the adults (23). Similarly retrospective
cohort study which was done in USA revealed that young teenagers and old
teenagers were 1.36 and 1.16 times more likely to had preterm
delivery than the adults respectively(24). And also study done in Korea shows
that teenagers were 2.47 times more likely to experience
preterm delivery (25). Furthermore
study in Sweden showed that there were
no significant difference between teenage and adult to had preterm delivery(AOR 1.03,95% CI;0.98-1.09) and still birth (AOR 0.97, 95%CI, 0.75-1.5) (26). Study in Nepal
depicted that (20% Vs 7 %, p=0.018) to had preterm delivery
than the adult. Low birth weight in
teenagers and adults were 24% Vs 9% (p=0.013) but this study showed fetal distress was not statistically significant in
two age groups(8% Vs 3%, p==0.178)(27). And also study
done in Ankara (Turkey) which was referral
hospital revealed that teenagers deliver 4.14 times more likely prematurely than adults (28)
Institutional
based cross sectional study done by World Health Organization on multi country
showed that adolescents 1.32 times more likely to give
still birth than the adult mothers. The risk of low birth weight was 1.17 times
higher among early adolescent mothers, compared with adults. The risk of
preterm deliveries was 1.60 times higher among
adolescent mothers as compared with adults. Adolescent mothers had 1.56 times
more likely to had neonatal severe conditions than
that of the adults(10).
Cross
sectional study done in Cameron revealed that teenagers were 2.8 times more
likely to deliver low birth weight neonates than that of the adults and preterm babies
(<37 weeks) (OR: 1.85; 95 % CI,(1.01-3.41). However this study showed that there were no
statistically significant difference in the risk of still birth (29).
Another Cohort study conducted in Cameron
revealed that teenage pregnancy experience 1.94 and 1.46 times more likely to
deliver very low birth weight and low birth weight neonate
than that of adults. And also teenage pregnancy faced 1.47 times more likely to had IUFD than the adults (30). Contrary to this another cross sectional study in Yaoundé
central hospital in Cameron also revealed that no significant difference in
delivery of low birth weight (p=0.42)(6).
Furthermore comparative cross sectional study done in Egypt revealed
that teenagers and adult had 18.7% Vs 14% (p=0.006) preterm delivery and low
birth weight 25.1%Vs 19.3 % (p=0.001)(19). In contrary to this study done in South Africa showed that there
were no statistically significant difference to deliver low birth
weight(p=0.174) and preterm delivery(p=0.702)(31).
2.3. Adverse
Obstetrical Outcome
A large scale
retrospective cohort study done in Sweden revealed that teenagers were 1.7
times more likely to give birth normal vaginally
and 45% less likely to undergo cesarean section than adult mothers. In addition
to this teenagers were 21%, 43% less likely to had post term delivery and
postpartum hemorrhage respectively (26). Furthermore study conducted in USA showed that younger adolescents had
decreased risks of cesarean delivery (AOR 0.49; 95% CI, 0.42-0.59) and older adolescents had decreased risks of cesarean delivery (AOR 0.75; 95%
CI,0.71-0.79) and teenagers were also 1.34 times more likely to develop pregnancy induced hypertension(24). In contrast to this, study done in Pakistan showed
that there was no difference in development of pregnancy induced hypertension
(p>0.05)(32). Similar to this, study done in Ankara, Turkey
revealed that pregnancy induced hypertension (p=0.31) and PPH (p=0.38) were not
statistically significant with maternal age (28).
Institutional
based, cross sectional study done by World Health Organization on multi country
showed that adolescents undergo 23% less likely of cesarean section than that
of adult mothers. Furthermore adolescent mothers had a lower risk of preeclampsia
which was 27% less likely than adult mothers. However the risk of eclampsia was
1.55 times more likely among adolescent mothers
compared with adult mothers(10).
A
large scale retrospective cohort study in Sweden concluded that teenagers were
30% less likely to develop PPH, 63% less probable to be complicated by APH
secondary to placenta previa & 57%
less likely experience grade 3 & 4 perineal tears. However this study
concluded that age was not significantly associated with risk of preeclampsia (33). In contrast to
this study done in India stated that there were no statistically significant
difference between teenage and adult mothers with the occurrence of APH and PPH(21). Retrospective register based study which was conducted in
Finland showed that teenagers are 1.2, 3.2 times more likely to develop
preeclampsia and eclampsia than the adults (34). A
retrospective cohort study in Romania showed that teenagers were 1.42 times
more likely to develop PPH and episiotomy (p<0.01) (35).
A
study in Turkey concluded that age did not appear to have statistically
significant association with mode of delivery, PPH, placenta previa.
Nevertheless, this study claimed that teenagers were 2.14 times more likely to
develop preeclampsia than adult mothers (11). Another study done in Turkey depicted that
teenage had higher rate episiotomy (p=0.0001) (22). comparative study in south
Africa showed that Significantly higher
rate of caesarean delivery was found among adult mothers compared to teenage
mothers (p=0.002) (31).
A
study conducted in Nigeria stated that there was statistically significant
difference between teenagers and older mothers with rate of unemployment,
marital status, ANC, preterm delivery(18.9% Vs 11.4%),episiotomy
(61.7% Vs 28.7% p=0.001) but there was no significant difference in the
development of eclampsia (36). Cohort study
conducted at Cameron shows that teenagers develop 3.46 times more likely of preeclampsia/eclamsia but
there were no significance difference in terms of placenta previa ,cesarean section ,instrumental delivery, perineal tear
and episiotomy(30).
Cross
sectional study in Cameron shows that teenagers were 2.15 times more likely to
had episiotomy than adults. In addition this study showed that post term
delivery was more common in teenage than adult(4.9 %versus 2.4) but it deals
there were no significant difference in cesarean
delivery, perineal tear and instrumental delivery (6). Furthermore
another cross sectional study done in Cameron revealed that teenagers were 1.6 times
more likely to face perianal tear than that of the adult. In addition to
maternal age Employment (p=0.003), marital status (p=0.017) and gravidity (p=0.001)
had also significant association with adverse maternal outcomes. However, this
study revealed that no significance difference between the two age groups in cesarean delivery (p=0.3) and episiotomy (p=0.2) (29).
