Adolescent pregnancy is associated with adverse outcomes including premature delivery, low birth weight, increased neonatal and maternal mortality, and long term problems for offspring. While socio-demographic factors like low socioeconomic status increase risks, recent studies show biological immaturity is also a causal factor. Younger teenage mothers have significantly higher risks of adverse outcomes even after controlling for confounding variables like marital status and prenatal care. Their developing bodies may not be fully equipped for pregnancy and childbirth.

1. Adolescent pregnancy adverse
effects,
Is it evidence supported?
Wafaa B. Basta
Specialist Gynaecology & Obstetrics Mataria Teaching Hospital,
MRCOG
ERC MEMBER
Al-Azhar University Annual Conference April 2013

2. Adolescence
(from Latin: adolescere meaning "to grow up“)
Is a transitional stage of physical and
psychological human development generally
occurring between puberty and legal
adulthood (age of majority).

3. Age of Majority
• In the legal systems of many countries, there is an age
of majority when childhood officially ends and a
person legally becomes an adult.
• The age of 18 is the most widely accepted age .
• This is the age at which an individual is considered to
be (chronologically and legally) mature enough to be
entrusted by society with certain responsibilities:
Driving licence
Serving in the armed forces
Voting
Marriage.
Entering into contracts.

4. Adolescence
• During this period, the individual undergoes
extensive physical, psychological, emotional,
and personality changes.
• Pregnancy in teenage girls is generally
classified to have a higher risk than those in
adults.

5. Prevalence
• Annually, 13 million children are born to
women under age 20 worldwide.
• More than 90% of these births occur to
women living in developing countries.
• Complications of pregnancy and childbirth are
the leading cause of mortality among women
between the ages of 15 and 19 in such areas,
as they are the leading cause of mortality
among older women.
WHO Save the Children Report

6. World Teenage birth rate per 1000 women
15–19years (2000-2009)
Live births by age of mother and sex of child, general and age-specific fertility rates: latest available year, 2000-2009 —
United Nations Statistics Division - Demographic and Social Statistics

7. Teen birth rates internationally, per 1,000 girls aged
15-19 years, 2008 and 2009
Teenage birth rate per 1000 women aged 15–19, 2000-2009. Source: Live births by age of mother and sex of child, general
and age-specific fertility rates: latest available year, 2000-2009 — United Nations Statistics Division - Demographic and
Social Statistics

8. • The incidence of adolescent pregnancy is
highest in Sub Saharan Africa (143 per 1,000
girls aged between 15-19 years).
Verloskunde en Gynaecologie, Universiteit van Amsterdam, Henriëtte Bosmansstraat 4,
1077 XH Amsterdam. p.e.treffers@hccnet.nl

9. Egypt
• At national level, the latest WHO survey
indicated that approximately 4% of women
aged 15-19 were reported to be currently
pregnant with their first child.
WHO Department of making pregnancy safer Egypt country profile
ORC Marco,2007

10. The impact of teenage pregnancy
 Premature delivery.
 Small-for-gestational age infants.
 Low & very low birth-weight .
Late foetal death.
Increased neonatal mortality.
Maternal mortality.
 Anaemia
 Pregnancy-induced hypertension.
Postnatal depression.
Difficulties with breast feeding.
Female educational under achievement.
Sexually transmitted infections.
Long term problems in off-springs.

11. Association of Young Maternal Age with
Adverse Reproductive Outcomes
The New England Journal of Medicine
Alison M. Fraser, M.S.P.H., John E. Brockert, M.P.H., and R.H. Ward,
Ph.D. April 27, 1995
BACKGROUND: Pregnancy in adolescence is associated with an excess risk of poor
outcomes, including low birth weight and prematurity. Whether this
association simply reflects the deleterious socio-demographic environment of
most pregnant teenagers or whether biologic immaturity is also causally
implicated is not known.
METHODS: To determine whether a young age confers an intrinsic risk of
adverse outcomes of pregnancy, we performed stratified analyses of
134,088 white girls and women, 13 to 24 years old, in Utah who delivered
singleton, first-born children between 1970 and 1990. Relative risk for
subgroups of this study population was examined to eliminate the
confounding influence of marital status, educational level, and the
adequacy of prenatal care. The adjusted relative risk for the entire study
group was calculated as the weighted average of the stratum-specific risks.

12. • RESULTS: Among white married mothers with educational
levels appropriate for their ages who received adequate
prenatal care, younger teenage mothers (13 to 17 years of
age) had a significantly higher risk (P<0.001) than mothers
who were 20 to 24 years of age of delivering an infant who
had low birth weight (relative risk, 1.7; 95 percent
confidence interval, 1.5 to 2.0), who was delivered
prematurely (relative risk, 1.9; 95 percent confidence
interval, 1.7 to 2.1), or who was small for gestational age
(relative risk, 1.3; 95 percent confidence interval, 1.2 to 1.4).
Older teenage mothers (18 or 19 years of age) also had a
significant increase in these risks.
• CONCLUSIONS: In a study of mothers 13 to 24 years old
who had the characteristics of most white, middle-class
Americans, a younger age conferred an increased risk of
adverse pregnancy outcomes that was independent of
important confounding socio-demographic factors.

13. Late Foetal Death and Infant Mortality
Teenage pregnancies and risk of late foetal death and infant mortality
Petra Otterblad Olausson, Sven Cnattingius,
Bengt Haglund
BJOG: Volume 106, Issue 2, pages 116–121, February 1999
• Objective To estimate the effect of low maternal age on late foetal death and
infant mortality and to estimate the extent of any increase in infant mortality
attributable to higher rates of preterm birth among teenagers.
• Design Population-based cohort study.
• Setting Births recorded in the nationwide Swedish Medical Birth Registry.
• Population All single births to nulli-parous women aged 13–24 years (n=
320,174) during 1973–1989.
• Methods Using information recorded in the medical birth registry, linked to a
national education register, the effect of low maternal age on adverse
outcomes was estimated using logistic regression analysis.

14. 13-15ys 16-17ys 18-19ys 20-24ys
Neonatal
mortality
O.R =2.7 O.R =1.2
Post-neonatal
mortality
O.R =2.6 O.R =2.0 O.R =1.4
Very pre-term
birth rate(less
than 32 wks)
5.9% 2.5% 1.7% 1%

15. • Results Compared with mothers aged 20-24 years, adjusted risks of
neonatal and post-neonatal mortality were significantly increased
among mothers aged 13–15 years (odds ratios = 2.7 and 2.6,
respectively) and among those aged 16–17 years (odds ratios = 1.4
and 2.0, respectively), while mothers aged 18–19 years had a
significant increase in risk of post-neonatal mortality only (odds
ratio = 1.4).
• Rates of very preterm birth (≤ 32 weeks), according to maternal
age, were: 13–15 years, 5.9%; 16–17 years, 2.5%; 18–19 years,
1.7%; and 20–24 years, 1.1%. The high rates of very preterm birth
among young teenagers almost entirely explained the increased
risk of neonatal mortality in this group.
• Conclusions The increased risks of neonatal and post-neonatal
mortality among young teenagers may be related to biological
immaturity. The increase in risk of neonatal mortality is largely
explained by increased rates of very preterm birth.

16. Very Low Birth Weight (less than 1500gm)
Adolescence and very low birth weight infants: A disproportionate association
Obstetrics & Gynaecology Volume 87, Issue 1, January 1996, Pages 83–88
MD Hugh S. Miller , MD Karen B. Lesser, MD Kathryn L. Reed
• From the Department of Obstetrics and Gynaecology, University of Arizona, Tuscan,
Arizona, USA
• Objective: To examine the incidence of very low birth weight (VLBW) neonates,
defined as those weighing less than 1500 g, delivered by adolescents compared
with the general obstetric population.
• Methods: A retrospective observational study of 16,857 women delivering live-
born infants from January 1,1989, to June 30, 1993, was conducted at the
University of Arizona Health Sciences Centre. Adolescents were defined as those
having a maternal age of 18 years or less at the time of delivery. The rate of VLBW
infants delivered to adolescent mothers was compared with the general obstetric
population (women at least 19 years old) using χ2 analysis, multiple analysis of
variance, and multiple linear regression.

17. No. Of VLBW VLBW Rate
Overall 204 1.2%
Adolescent 35 2%
Adult 169 1.1%

18. • Results: During the study period, 204 VLBW infants were
delivered, yielding an overall VLBW delivery rate of 1.2%.
Adolescents had a VLBW delivery rate that was considerably
higher than the general obstetrical population: 35 of 1758
(2.0%) versus 169 of 15,099 (1.1%) (P = .002).
• Whereas adolescents accounted for 10.6% of the total
deliveries during the study period, they delivered 17% of
the VLBW neonates. The relative risk of an adolescent
delivering a VLBW infant was 1.7 (95% confidence interval
1.2–2.2).
• Conclusion: Although the association between adolescence
and preterm birth has been reported previously, specific
attention has not been focused on the VLBW neonate. We
conclude that adolescents deliver a disproportionate
number of VLBW infants.

19. Maternal & Neonatal Mortality
• Adolescent girls who give birth have a much
higher risk of dying from maternal causes
compared to women in their 20s and 30s.
• These risks increase greatly as maternal age
decreases.
• Adolescents under 16 facing four times the risk of
maternal death as women over 20.
• Moreover, babies born to adolescents also face a
significantly higher risk of death compared to
babies born to older women.
WHO: Volume 1, No.1, October 2008
Mangiaterra V., Pendse R., McClure K. and Rosen J.
(Department of Making Pregnancy Safer, WHO/HQ).

20. Pre-eclampsia in Pregnant Teens
• The incidence of pregnancy-induced
hypertension (PIH), is increase by two fold in
pregnant adolescence in comparison to
women between ages 30-34.
Scholl et al. 1994 , U.S. National Hospital Discharge Survey

21. Anaemia & teenage pregnancy
Comparison of obstetric outcome among teenage and non-teenage
mothers from three tertiary care hospitals of Sindh, Pakistan
• Objective: To compare the obstetric outcome of teenage
pregnancies with that of non teenage pregnancies.
Methods: A prospective case-control study was conducted in three
tertiary care hospitals of Sindh, Pakistan from September 2008 to
November 2008.
• The data regarding obstetric outcome of all teenagers (13-19 years)
delivering in the three hospitals was compared with that of selected
non teenage women (20 to 35 years) taken as controls. Chi-square
and students' t-test were applied with 0.05 as level of significance.

22. • Results: Teenage mothers were more likely to suffer
from severe anaemia (8% versus 4.3%; p = 0.03) and
chorio-amnionitis (2.8% vs 0.8%, p = 0.01) compared
to non-teenage mothers.
• Conclusion: Teenage mothers are at a higher risk of
developing severe anaemia and chorio-amnionitis.

23. Long-term Problems in Off-springs
• In the long term, the offspring of adolescents
have:
– Poorer cognitive development
– Lower educational attainment
– More frequent criminal activity
– A higher risk of abuse, neglect and behavioural
problems during childhood.
Moffitt TE, E-Risk Study Team
Teen-aged mothers in contemporary Britain
J Child Psychol Psychiatry2002 43 727–42.

24. Poor Social and Intellectual Competence
Teenage parenting and child development: A literature review
Mark W. Roosa PhD, Hiram E. Fitzgerald PhD, Nancy A. Carlson PhD
Infant Mental Health Journal
Volume 3, Issue 1, pages 4–18, Spring 1982
• Research related to the impact of teenage parenting
upon a child's developmental status is reviewed.
• Though the empirical base is limited, several researchers
agree that ;children born to teenage mothers show poor
social and intellectual competence relative to children
born to older mothers.

25. Language development of pre-school
children born to teenage mothers
Louise J. Keown, Lianne J. Woodward,Jeff Field
Infant and Child Development
Volume 10, Issue 3, pages 129–145, September 2001
• This paper compares the language development of pre-school children
born to teenage (n=22) and comparison mothers (n=20) and examines the
extent to which differences in language development can be explained by
social background, child and parenting factors.
• Mothers and children were assessed at home using a range of measures.
• Results showed that children of teenage mothers perform significantly
poorer than children of comparison mothers on measures of expressive
language and language comprehension.

26. Postnatal depression
• There is evidence that teenage mothers are
more likely to suffer from postnatal depression
than older mothers.
Deal LW, Holt VLYoung maternal age and depressive symptoms: results from the 1988
National Maternal and Infant Health Survey Am J Public Health1998 88 266–70.

27. Difficulties with breastfeeding
• One study reported a 37–54% reduction in milk
production 6 months after childbirth in adolescents
compared with older mothers.
• There were some differences in breastfeeding
behaviour between the two groups that may have
contributed to the result but it appears that
teenagers need extra support with breastfeeding.
Motil KJ, Kertz B, Thotathuchery MLactational performance of adolescent
mothers shows preliminary differences from that of adult womenJ Adolesc
Health1997.

28. Female Educational Underachievement
Teenage Pregnancy and Female Educational Underachievement:
A Prospective Study of a New Zealand Birth Cohort
David M. Fergusson, Lianne J. Woodward
Journal of Marriage and Family
Volume 62, Issue 1, pages 147–161, February 2000

29. • 20 young women studied from birth to 21 years.
• Results showed that young women who became
pregnant by the age of 18 years were at
increased risk of :
– poor achievement in the national School Certificate
examinations.
– leaving school without qualifications.
– failing to complete their sixth-form year at high
school.
– In addition, pregnant teenagers had lower rates of
participation in tertiary education and training than
their non-pregnant peers.

30. The impact of teenage pregnancy
 Premature delivery.
 Small-for-gestational age infants.
 Low & very low birth-weight .
Late foetal death.
Increased neonatal mortality.
Maternal mortality.
 Anaemia
 Pregnancy-induced hypertension.
Postnatal depression.
Difficulties with breast feeding.
Female educational under achievement.
Sexually transmitted infections.
Long term problems in off-springs.

31. The impact of teenage pregnancy
Biological Immaturity
OR
Socio-demographic
Variables?????

32. Socio-demographic factors
• Low socio-economic status.
• Inadequate prenatal care.
• Poor nutrition &Inadequate weight gain during
pregnancy.
• Higher rates of sexually transmitted infections.
• Pregnancy outside marriage & single parenting.
• Alcohol or substance abuse, smoking .
• Illiteracy and low educational achievement .

33. Biological Immaturity or Socio-demographic
Variables
• Socio-demographic variables associated with
teenage pregnancy undoubtedly increase the
risk of adverse outcomes.
• However, recent studies have demonstrated
that the relative risk remains significantly
elevated for both younger and older teenage
mothers after adjustment for marital status,
level of education and adequacy of prenatal
care.

34. Biological Immaturity
• Many adolescent girls continue to grow when
pregnant while their babies have lower fetal
growth rates as a result of the competition for
nutrients between the maternal body and the
growing baby.
• Uterine under development.
• Underdeveloped pelvises : increased
likelihood of obstructed labour .

35. Uterine development
• After menarche, the uterus continues to grow, even after the
almost complete development of the secondary sexual
characteristics .
• Normal adult values are not attained even by the sixth gynecologic
year.
• The adrenal steroids dehydroepiandrosterone and
dehydroepiandrosterone sulfate, which are reliable indexes of
biologic maturation, continue to increase during adolescence and,
interestingly, they correlate with uterine development.
The Infant and Adolescent Uterus –
Imaging in Pediatric and Adolescent Gynecology -

36. Uterine development

37. Uterine volume in adolescents
Uterine volume in adolescents
Ultrasound Med Biol. 2004 Jan;30(1):7-10.
Gadelha Da Costa A, Filho FM, Ferreira AC, Spara P, Mauad FM.
Source: Department of Gynecology and Obstetrics, Faculty of Medicine of Ribeirão
Preto, University of São Paulo, São Paulo, Brazil.
Objective to determine the uterine volume of adolescents by ultrasonography, and to
correlate it with pregnancy during adolescence and with the immaturity of the
female genital tract for pregnancy and delivery.
Method :A transverse observational study was conducted on 828 patients who were
10 to 40 years old by trans-abdominal ultrasonography and were divided into two
groups: group 1 consisted of 477 (57.6%) adolescents and group 2 consisted of 351
(42.3%) women 20 to 40 years old.

38. Results: Uterine volume increased with the presence of menarche, age
and parity (p < 0.05). Nulliparous and primiparous adolescents younger
than 18 years old had a smaller uterine volume, 41.3 +/- 17.9 and 51.6
+/- 19.7 cm(3), respectively, than nulliparous and primiparous women
20 to 40 years old (p < 0.001). However, secundiparous adolescents
had a uterine volume of 62.6 +/- 20.6 cm(3), which was significantly
similar to the uterine volume of women 20 to 40 years old (p = 0.22).
Conclusion: The differences in uterine volume between adolescents
younger than 18 years old or with less than two deliveries and women
who were 20 to 40 years old may be due to immaturity of the female
genital tract for pregnancy and delivery among younger women, with a
consequent higher incidence of preterm deliveries in this group.

39. Teenage pregnancy and adverse birth outcomes
A large population based retrospective cohort study. November 2006
Xi-Kuan Chen,Shi Wu Wen,Nathalie Fleming, Kitaw Demissie,
George G Rhoads and Mark Walker.
Background
Whether the association between teenage pregnancy and adverse birth outcomes
could be explained by deleterious social environment, inadequate prenatal care,
or biological immaturity remains controversial.
Objective of this study was to determine whether teenage pregnancy is associated
with increased adverse birth outcomes independent of known confounding
factors.
Methods
We carried out a retrospective cohort study of 3 886 364 nulliparous pregnant
women <25 years of age with a live singleton birth during 1995 and 2000
in the United States.

40. Results
All teenage groups were associated with increased risks for pre-term delivery,
low birth weight and neonatal mortality. Infants born to teenage mothers
aged 17 or younger had a higher risk for low Apgar score at 5 min.
Further adjustment for weight gain during pregnancy did not change the
observed association.
Restricting the analysis to white married mothers with age appropriate
education level, adequate prenatal care, without smoking and alcohol use
during pregnancy yielded similar results.
Conclusions
Teenage pregnancy increases the risk of adverse birth outcomes that is
independent of important known confounders. This finding challenges the
accepted opinion that adverse birth outcome associated with teenage
pregnancy is attributable to low socioeconomic status, inadequate prenatal
care and inadequate weight gain during pregnancy.

41. Pregnancy outcomes of mothers aged 17 years or less.
Saudi Medical Journal 2011 Feb;32(2):166-70.
Shuaib AA, Frass KA, Al-Harazi AH, Ghanem NS.
Source Obstetrics and Gynecology Department, Faculty of Medicine, Sana'a University, Sana'a,
Yemen.
OBJECTIVE: To study the obstetric complications of women who become pregnant at aged 17
years old or less.
METHODS: A retrospective study was performed from January to December 2009 at Al-Thawra
General Hospital, Sana'a, Yemen. We included all women aged 17 years or less who delivered
in the hospital with singleton births after 24 weeks gestational age. The study group
comprised 239 patients, and a control group (n=240) was chosen from women aged between
20-24 years. Data were retrieved from the hospital records.
RESULTS: Pregnancy in women 17 years old or less was associated with higher frequency of low
birth weight than the control group (21.3% versus 12%, p=0.0091). Anemia was higher in the
study group (17.5% versus 7%, p=0.0008). Preterm labor was 11.6% in the study group, and
5.4% in the control group. In the study group, 7.9% had preeclampsia compared to 5% in the
control group. The cesarean section rate in the study group was higher than the control
group (6.3% versus 2%, p=0.0331).
CONCLUSION: Pregnant women 17 years old or less were more likely to have maternal and
neonatal morbidity, and were more likely to have abdominal deliveries.

43. Adolescent pregnancy in Upper Egypt.
Int J Gynaecol Obstet. 2011 Jan;Rasheed S, Abdelmonem A, Amin M.
Source Department of Obstetrics and Gynecology, Faculty of Medicine, Sohag
University, Sohag, Egypt.
OBJECTIVE: To determine the reasons for adolescent pregnancy in Upper
Egypt and to evaluate maternal, foetal, and neonatal outcomes.
METHODS: All primigravidae under 30 years of age who attended the
labor/delivery ward at Sohag University Hospital, Sohag, Egypt, between
December 31, 2005, and December 31, 2009, were invited to participate.
Participants were allocated to the study group (up to 19 years of age at
first pregnancy) or the control group (20-30 years of age at first
pregnancy). Maternal, obstetric, fetal, and neonatal complications were
compared between the groups, and adolescent participants completed a
questionnaire to identify the reasons for pregnancy.

44. RESULTS: In total, 58.2% had married seeking motherhood.
Rates of ectopic pregnancy, pre-eclampsia, eclampsia,
premature rupture of membranes, preterm labor, and
cesarean were significantly higher among adolescents
younger than 15 years of age; the risk then decreased
steadily with age and became comparable to the control
group after 16 years of age.
CONCLUSION:
Adolescent pregnancy increases the risk of ectopic pregnancy,
pre-eclampsia, eclampsia, premature rupture of
membranes, preterm labor, and cesarean among mothers
up to 16 years of age. After 16 years of age, pregnancy is
not associated with increased risk of obstetric or neonatal
complications.

45. The impact of teenage pregnancy
Biological Immaturity
OR
Socio-demographic
Variables?????
Clearly, there is a complex
interplay between
socioeconomic and
biological factors that
influences the outcome of
teenage pregnancy .

46. Antenatal care
• Encourage to attend for antenatal care early as
attendance is frequently poor.
• Gestational age should be confirmed with early
ultrasound .
• Regular foetal growth follow up by growth charts.
• Advice on nutrition and adverse habits such as smoking .
• Social support is important .
• Information regarding antenatal care and labour should
be provided in a way that is easily understood (literacy
difficulties).

47. Care during labour
• Where age is the only risk factor, management
is usually the same as for other labouring
women.
• However, in very young adolescents there is
an increased likelihood of obstructed labour
because of a small, immature pelvis.

48. Postnatal management
• The postnatal period provides an opportunity
for counseling and education .
• Infant feeding, growth and safety need to be
observed.
• Discussion regarding returning to school and
contraceptive advice.
• Special attention to postnatal depression.

49. Conclusion
• Teenagers are at risk of a range of adverse pregnancy outcomes,
particularly preterm birth.
• The reasons for this are complex and reflect a combination of
adverse socioeconomic pressures and gynaecological and biological
immaturity.
• The obstetrician providing care for women in this age group should
be aware of the potential challenges.
• Studies have shown that delaying adolescent births could
significantly lower population growth rates, potentially generating
broad economic and social benefits, in addition to improving the
health of adolescents.
• A national target should be set to decrease the incidence of
teenage pregnancy in our country .
• Obstetricians should have a major role in such health education.

50. “Educated and
empowered
women and girls
can make
informed
decisions about
their own health.”
Thank you