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).  

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