Adolescent Pregnancy: Problems and Consequences

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Adolescent pregnancy continues to be a grave problem in India not only from the obstetrical point of view but from the social and economical perspectives also. Complications of pregnancy and childbirth are the leading cause of mortality among women between the ages of 15 and 19 in the developing world.

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Adolescent Pregnancy: Problems and Consequences

  1. 1. Adolescent Pregnancy: Problems and Consequences
  2. 2. Adolescent pregnancy: Problems and consequences Maitri Shaha,*, Saloni Prajapatib , V. Sheneeshkumarc ABSTRACT Background: Adolescent pregnancy continues to be a grave problem in India not only from the obstetrical point of view but from the social and economical perspectives also. Complications of pregnancy and childbirth are the leading cause of mortality among women between the ages of 15 and 19 in the developing world. Methods: The present study was carried out in a tertiary care hospital of Gujarat where various sociodemographic and cultural factors associated with adolescent pregnancies were documented and compared with controls. Devel- opment of any complication during antenatal period and perinatal outcome of each pregnancy was noted. Results: It was found that there are more chances of developing severe anemia, severe PIH and low birth weight babies in adolescent pregnancies. Poverty and illiteracy increase the risk for the same. Conclusion: Cultural practices, poor socioeconomic conditions and low literacy rate are the contributory factors to adolescent pregnancy associated poor obstetric outcome. Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved. Keywords: Adolescent pregnancy, Sociodemographic factors, Perinatal outcome INTRODUCTION Adolescent pregnancy continues to be a grave problem in India not only from the obstetrical point of view but from the social and economical perspectives also. Also known as teenage pregnancy, it is defined as a pregnancy occurring from the age of 13e19 years of age (or for the matter of fact from puberty to 19 years of age). It is not limited to any social, economic, racial and ethnic groups. According to UNFPA, State of world population data 2003, the incidence of teenage pregnancy is 45 per 1000 live birth. Worldwide rates of teenage pregnancy range from 143 per 1000 in some sub-Saharan African countries to 2.9 per 1000 in South Korea.1,2 Between 15 and 19 years, in addition to age there are other socioeconomic risk factors. Data supporting teenage pregnancy as a social issue in developed countries include lower educational levels, higher rates of poverty, and other poorer “life outcomes” in children of teenage mothers. Teenage pregnancy in developed countries is usually outside of marriage, and carries a social stigma in many communities and cultures. For these reasons, there have been many studies and campaigns which attempt to uncover the causes and limit the numbers of teenage pregnancies. In other countries and cultures, particularly in the developing world, teenage pregnancy is usually within marriage and does not involve a social stigma.3 Pregnant teenagers face many of the same obstetrics issues as women in their 20s and 30s. However, there are additional medical concerns for younger mothers, particu- larly those under 15 and those living in developing coun- tries. The worldwide incidence of premature birth and low birth weight is higher among adolescent mothers.4e6 Risks for medical complications are greater for girls 14 years of age and younger, as an underdeveloped pelvis can lead to difficulties in childbirth. Obstructed labor is nor- mally dealt with by Caesarean section in industrialized nations; however, in developing regions where medical a Associate Professor, b Assistant Professor, c Senior Resident, Dept. of Obs & Gynec, Medical College & S.S.G. Hospital, Baroda, India. * Corresponding author. 30, Gulabchand Park Soc., Karelibaug, Baroda 390018, India. Tel.: þ91 265 2485727, þ91 9426370499 (mobile), email: maitrishah.gynec@gmail.com Received: 9.4.2012; Accepted: 29.6.2012; Available online: 13.7.2012 Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2012.06.002 Apollo Medicine 2012 September Volume 9, Number 3; pp. 176e180 Original Article
  3. 3. services might be unavailable, it can lead to eclampsia, obstetric fistula, infant mortality, or maternal death.6 For mothers in their late teens, age in itself is not a risk factor, and poor outcomes are associated more with socioeconomic factors rather than with biology.7 The World Health Organization loping estimates that the risk of death following pregnancy is twice as great for women between 15 and 19 years than for those between the ages of 20 and 24. The maternal mortality rate can be up to five times higher for girls aged between 10 and 14 than for women of about 20 years of age. One-fourth of adolescent mothers will have a second child within 24 months of the first. Factors that determine which mothers are more likely to have a closely-spaced repeat birth include marriage and education: the likelihood decreases with the level of education of the young woman e or her parents e and increases if she gets married. This paper attempts to evaluate various sociodemographic and cultural factors responsible for adolescent pregnancies. It also shows various pregnancy related complications in this age group and compares them with the control group. MATERIALS AND METHOD This study was carried out in Medical college hospital of Vadodara, over a period of 1 year amongst antenatal mothers attending outpatient and emergency Departments. The case group includes mothers who are less than 19 years of age and are married primigravida with gestational age of less than 20 weeks. The next antenatal mother fulfilling the same criteria and between the age group of 20e29 years were taken as control for the same case. The mothers with any history of medical or surgical disorders, having Rh negativity, with multiple pregnancies or showing fetal congenital anomalies were excluded from the study. The aim of the study was to find out association between various socio-cultural and demographic factors with number of adolescent pregnancies. Various maternal complications and perinatal outcome of this age group were noted and compared with that of control group. It was a longitudinal follow-up study where data was compared amongst two groups. Semi-structured open ended questionnaire was provided to each case and control after obtaining their written informed consent. Both cases and controls were given antenatal care as per the existing stan- dards at the hospital. All the details of the cases and controls were documented systematically in the proforma. Details covered their sociodemographic aspects, antenatal care, baseline investigations, labor details and feto-maternal outcome. The data was then organized and subjected to statistical tests of significance. RESULTS AND DISCUSSION The present study highlights the magnitude of problem of adolescent pregnancies and discusses the consequences of perinatal outcomes. There were 4098 confinements in SSG Hospital Vadodara over a period of 1 year. Of these 115 were teenage pregnancies with prevalence, therefore, of 2.81%. The number of the adolescent mothers has increased by 50% during the last 27 years and is likely to increase further due to the population momentum.8 Teenage mothers included in this study ranged from 15 years of age to 19. Twenty percent of them were below the legal age of marriage. Thus in a significant number of cases marriage and conception occurred even before the legal age was attained (Table 1). Comparing educational achievements, 54.3% of the cases were illiterate compared to 12.9% controls. Husbands of 51.4% of the cases were illiterate whereas the same rate for controls was 14.3%. In all higher educational classes, cases lagged behind controls (Table 2). Important causes for early marriage were economic pres- sure, social pressure and family pressure. Same factors play a role in poor antenatal care. Education also plays a definite role in the causation of teenage pregnancy. Attainment of higher education leads to a late age of marriage and concep- tion due to professional pursuit and desire for economic independence. Other sociodemographic and cultural factors studied shows that 74.3% of the cases were from rural areas compared to 51.4% controls. 48.6% of the controls were from urban areas whereas the same rate for cases was 25.7%. This association was statistically significant (p ¼ 0.0056, Odds ratio ¼ 2.7). It also reflects that Husbands of 57.2% of cases were unskilled laborers whereas the same rate for controls was 24.3%. Respective rates of cases were lower compared to controls for all higher occupation levels. All the associations were statisti- cally significant. The results also show that 68.6% of cases were from low socioeconomic classes compared to 38.6% of the controls. 55.7% of the controls were from middle class and 5.7% from upper class. This was statistically significant (p ¼ 0.0007). Teenage pregnancy was Table 1 Age wise distribution of cases (n ¼ 70). Age No. of cases 15 1 (1.4%) 16 4 (5.7%) 17 9 (12.8%) 18 32 (45.7%) 19 24 (34.3%) Total 70 Adolescent pregnancy Original Article 177
  4. 4. statistically associated with larger families (p ¼ 0.003, Odds ratio ¼ 0.34) (Table 3). Thus teenage pregnancy is associated with low socioeco- nomic levels. This is an amalgamation of earlier tables all of which reflected parameters of socioeconomic stratifica- tion. Larger families means limited resources, lesser educa- tional opportunities and economic constraints. This leads to pressure to get the girl married off earlier so that she can play her traditional role of homemaker. Strategic planning must include socioeconomic upliftment and improving literacy rates so as to circumvent the problem of teenage pregnancy. There are increased chances of preeclampsia, anemia, preterm labor and prolonged labor in adolescent pregnan- cies. Due to increased rate of complications seen during pregnancy and at delivery, this group, comes under the preview of ‘high-risk pregnancy’ requiring constant and regular supervision.9 In our study, the incidence of severe anemia, severe PIH and short stature was more amongst the cases as compared to controls, which was statistically significant a p-value of 0.039, 0.029 and 0.029 respectively. However, the inci- dence of moderate anemia, mild PIH and eclampsia were comparable amongst the cases and controls, which was not significantly significant. The incidence of preterm labor was 17.1% in cases and 5.7% in the controls. This was however not statistically significant (p ¼ 0.063). The inci- dence of IUGR and oligohydramnios was 2.8% and 4.2% in the cases respectively. None of these were observed in the controls. One case of PROM was observed in the controls and none in the cases. The incidence of CPD and Abruptio Placentae was similar and not statically significant (Table 4). It was seen that adolescents aged 16 or younger in India were less likely to use any health care than were older women.10 The standard of antenatal care in teenage mothers was poor. 27.1% have never taken an ANC visit according to this study. The incidences of various complications like preeclampsia (23.7%), eclampsia (8.7%), anemia (11.2%), premature labor (30.0), prolonged labor (13.7%) are observed in study by Bhadauria et al9 (Table 5). Table 3 Socio-cultural factors. Case Control Residence Rural 52 (74.3%) 36 (51.4%) Urban 18 (25.7%) 34 (48.6%) Occupation Unskilled laborer 40 (57.2%) 17 (24.35) Skilled laborer 8 (11.4%) 18 (25.7%) Business 8 (11.4%) 6 (8.6%) Office 6 (8.6%) 21 (30%) Services 8 (11.45%) 8 (11.4%) Socioeconomic classa Low 48 (68.6%) 27 (38.6%) Middle 22 (31.45%) 39 (55.7%) Upper 0 4 (5.7%) Family size 3e4 20 (28.6%) 38 (54.3%) >4 50 (71.4%) 32 (45.7%) a Kuppuswamy’s classification. Table 4 Presence of complications in adolescent pregnancies. Complications Cases Controls p-value Anemia Mild 55 (85.8%) 64 (94.4%) e Moderate 2 (2.8%) 3 (4.2%) 1.0 Severe 8 (11.4%) 1 (1.4%) 0.039 PIH Mild 3 (4.2%) 2 (2.8%) 1.0 Severe 12 (17.1%) 3 (4.2%) 0.029 Preterm labor 12 (17.1%) 4 (5.7%) 0.063 Oligohydramnios 3 (4.2%) 0 e IUGR 2 (2.8%) 0 e Placenta praevia 0 0 e Abruptio Placentae 1 (1.4%) 2 (2.8%) 1.0 PROM 0 1 (1.4%) e CPD 4 (5.7%) 2 (2.8%) 0.678 Short stature 10 (14.3%) 1 (1.4%) 0.029 Eclampsia 2 (2.8%) 1 (1.4%) 1.0 Postdatism 1 (1.4%) 0 e Table 2 Educational levels of the study participants. Educational level Case Control Wife Husband Wife Husband Illiterate 38 (54.3%) 36 (51.4%) 9 (12.9%) 10 (14.3%) Primary 14 (20%) 2 (2.8%) 15 (21.4%) 5 (7.1%) Secondary 17 (24.3%) 17 (24.3%) 33 (47.1%) 18 (25.7%) Higher secondary 1 (1.4%) 7 (10%) 9 (12.9%) 7 (10%) College 0 8 (11.4%) 4 (5.7%) 20 (26.6%) 178 Apollo Medicine 2012 September; Vol. 9, No. 3 Shah et al.
  5. 5. According to our study, 17.1% of the babies born to teenage mothers were preterm compared to 5.7% in controls. This was statistically significant (p ¼ 0.039). Inci- dence of low birth weight babies was 77.2%. Of these 23% was less than 2 kg, 17.1% of the babies were preterm, 28.1% required NICU admissions. Important causes were prematurity and asphyxia (Table 6). After delivery, while asking preference for contracep- tion, 37.1% of the teenage mothers desired some form of contraception compared to 65.7% of controls. This was statistically significant (p ¼ 0.008%). This reflects signifi- cantly low desire for contraception amongst teenage mothers (Table 7). Adolescent motherhood adversely affects child survival and maternal life. Because of the high incidence of fetal wastage, women have to experience a comparatively greater number of pregnancies to give birth to a child that will survive. It has been observed that adolescent mothers suffer a higher child loss than mothers aged 20e24 or 25e29 years. Maternal mortality among mothers’ aged 15e19 is also very high as compared to that among mothers in the 20e24 age group. Due to frequent pregnancy, the health of the mother is badly affected she becomes anemic and gives birth to an underweight child who faces a higher risk of death at each age.18 Cultural and psychological barriers within communities may prevent young women-especially those who are very poor- from using clinic-based reproductive health services even when they do exist.19 Reynolds et al showed that young women are less likely than older women to know about pregnancy and reproductive health issues in general, and they have less experience in using health services.18 This paper aims to create awareness amongst health-care providers on the burning issue of adolescent pregnancies. A study on a larger scale is recommended to assess public health importance of the subject. However provision of information, counseling and life-skills education to adoles- cent through various “Adolescent friendly health centres” can be helpful to decrease the magnitude of the problem. In our literate society, where teenage pregnancies out of wedlock, are on rise, sex education and contraceptive knowledge should be made an integral part of health education.9 CONCLUSION This study shows that teenage pregnancies are still a common occurrence in rural India in spite of various legislations and government programs. Teenage pregnancy is a risk factor for poor obstetric outcome. Cultural prac- tices, poor socioeconomic conditions, low literacy rate and lack of awareness of the risks are some of the main contributory factors. Early booking, good care during preg- nancy and delivery and proper utilization of contraceptive services can prevent the incidence and complications in this high-risk group. CONFLICTS OF INTEREST All authors have none to declare. REFERENCES 1. Treffers PE. Teenage pregnancy, a worldwide problem. PMID. November 2003;47:2320e2325. 2. UNICEF. A League Table of Teenage Births in Rich Nations; 2001. 3. Mayor S. Pregnancy and childbirth are leading causes of death in teenage girls in developing countries. BMJ. May 2004;328(7449):1152. 4. Mehta Suman, Groenen Riet, Roque Francisco, United Nations Social and Economic Commission for Asia and the Pacific. Adolescents in Changing Times: Issues and Table 5 Incidence of certain complications in various studies.8,11e17 Studies PIH (%) Anemia Preterm labor Sharma et al 14.2 e e Sarkar et al 10.6 e e Mahaverkar e e e Bhalerao 10 25.5 20.1 Israel and Wouterz 7.8 e 14.7 Ghose & Ghosh 8 24 14.9 Ambedkar e e e Sen e 19.5 e Asha Negi 11.3 Present study 21.3 42.67 17.1 Table 6 Perinatal outcome. Case Control Maturity Preterm 12 (17.1%) 4 (5.7%) Term 58 (82.9%) 66 (94.3%) Birth weight <2 kg 16 (22.9%) 5 (7.1%) 2e2.5 kg 38 (54.3%) 16 (22.9%) >2.5 kg 16 (22.9%) 49 (70%) Table 7 Desire for contraception postpartum. Case Control Yes 26 (37.1%) 46 (65.7%) No 44 (62.9%) 24 (34.3%) Adolescent pregnancy Original Article 179
  6. 6. Perspectives for Adolescent Reproductive Health in The ESCAP Region; 1998. 5. Scholl TO, Hediger ML, Belsky DH. Prenatal care and maternal health during adolescent pregnancy: a review and meta-analysis. J Adolesc Health. September 1994;15(6): 444e456. 6. Makinson C. The health consequences of teenage fertility. Fam Plan Perspect. 1985;17(3):132e139. 7. Locoh Therese. Early Marriage And Motherhood In Sub- Saharan Africa. WIN News; 2000. 8. Mahavarkar SH, Madhu CK, Mule VD. A comparative study of teenage pregnancy. J Obstet Gynaecol August 2008;(6): 604e607. 9. BhadauriaS,SinghS,SarkarB.Teenagepregnancy: aretrospec- tive study. J Obstet Gynaecol. August 1991;41(4):454e456. 10. Reynolds WH, Wong EM, Tucker H. Adolescents’ use of maternal and child health services in developing countries. Int Fam Plan Perspect. 2006;32(1):6e16. 11. Bhalerao AR, Desai SV, Dastur NA, Daftary SN. Outcome of teenage pregnancy. J Postgrad Med. 1990;36(3):136e139. 12. Sharma AK, Chhabria P, Gupta P, Aggarwal QP, Lyngdoh T. Pregnancy in adolescents, a community based study. Indian J PSM. 2003;34(1,2):112e119. 13. Ambadekar NN, Khandait Devendra W, Zodpey Sanjay P, Kasturwar NB, Vasudeo ND. Teenage pregnancy outcome: a record based study. Indian J Med Sci. 1999;53(10):14e17. 14. Sen SP. Pregnancy in adolescence. J Obstet Gynecol India. 1974;4:93e96. 15. Israel SL, Woutersz TB. Teenage obstetrics, a co-operative study. Am J Obstet Gynaecol. 1963;85:659e668. 16. Ghose N, Ghosh B. Obstetric behaviour in teenagers (A study of 1138 consecutive cases). J Obstet Gynecol India. 1976;26: 722e726. 17. Pathak KB, Ram F. Fertility change in India: some facts and prospects. IJSW. 1987;XLVIII(2):147e161. 18. Pathak KB, Ram F. Adolescent motherhood: problems and consequences. J Fam Welfare. March 1993;39(1):17e23. 19. Manju R, Elizabeth L. Exploring the socioeconomic dimen- sion of adolescent reproductive health: a multicountry anal- ysis. Int Fam Plan Perspect. 2004. 180 Apollo Medicine 2012 September; Vol. 9, No. 3 Shah et al.
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