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Brief Reports Indian Pediatrics 2001; 38: 1405-1409 |
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A.K. Sharma K. Verma* S. Khatri A.T. Kannan
Globally researchers have gathered substantial evidence in favor of the fact that pregnancy among adolescents is associated with maternal complications, premature birth, low birth weight, perinatal mortality, increased infant mortality and maltreatment of children(1). It is also emphasised by Mapanga that the health related disadvantage of adolescents who have become parents heavily outweigh any advantages that there may be(1). In a meta-analysis and review of pregnancy complications, Scholl et al. observed that in the developing countries, teenage mothers were at increased risk of maternal anemia, pre-term birth and Caesarean delivery(2). In a developing country like Nepal, girls are married off at a young age. The median age for first marriage among girls is around 16 years, thereby increasing the chances of child bearing in adolescence(3). Further, abortion is legally not permitted, therefore most pregnancies are carried to full term. Therefore, this study was carried out to assess the maternal risks and fetal outcome of pregnancy among adolescents as compared to women aged 20 years and above. Methods This study was carried out at B.P. Koirala Institute of Health Science, a deemed medical university located in eastern Nepal. It is the largest tertiary care hospital in this region catering to a population of 4,446,749(3). The study period was from 01 November, 1998 to 31 August, 1999. One of the authors (SK), visited the labor room and post natal ward every day during the study period to interview any adolescent mother who had delivered in last 24 hours. In order to eliminate the influence of parity and multiple pregnancy on birth weight of newborn, only primigravida with singleton pregnancies were included in the study as index cases. In all, 70 primigravida adolescent women delivered at the institute during the study period. Controls were selected from primigravida women of 20-29 years age. To provide a 1:1 comparison, 70 primigravida women of 20-29 years age, who delivered during the study period, were chosen randomly. Randomiza-tion was attained by randomly selecting same number of controls as the number of index cases who delivered on that day. A pretested, structured, questionnaire was used to collect information about antenatal period. Data was verified and missing information was collected from the antenatal records, if any, available with the mothers. Data regarding fetal outcome (birth weight, congenital defects, etc.) was obtained from the records of delivery kept in the labor room and/or nursery. The same steps were followed in collecting information about the controls as well. The determinants of maternal risks were duration of gestation, prevalence of anemia (Hb level <11.0 g/dl), complications of pregnancy and delivery. Fetal outcome was measured in terms of live births, birth weight and APGAR score. The findings of adolescent pregnancies were compared with that of the control group. The adolescent women constituted the index group. Suitable tests of signficance were applied for comparing the results. Results The profile of index group and the control group is given in Table I. All index group and control group respondents were married. The mean age at marriage of adolescents was significantly less than that of the controls. The husbands of adolescent pregnant women were on an average 6 years elder to their wives but the age difference was less among the controls. The educational status of index group was signficantly lower than that of the control group. The income profile of the study group suggests that adolescent pregnant women were comparatively disadvantaged, as majority were from the lower income groups. Antenatal care was received by 66 (94%) and 68 (97%) women in index and control groups, respectively. Antenatal care is provided by government run health posts and sub health posts, private practitioners, and antenatal clinics run by Non Government Organisations like Nepal Red Cross Society and Family Planning Association of Nepal, etc. Mean duration of gestation at the time of registration was 16.09 (±7.72) weeks for the index group and 13.35 (±6.91) weeks for the control group. Only half of the adolescent pregnant women had registered in the first trimester compared to 69% control group women doing so (p <0.03). Frequency of antenatal check up was poor among the index cases as compared to controls. About sixty one per cent of index cases had four or more visits to the antenatal clinic. The corresponding proportion of control group was 81% (p <0.02). Immunization with tetanus toxoid was received by 93% of index cases and 97% of control group. Average duration of gestation in both the groups was similar. The distribution of index cases and controls according to type of delivery was also similar. Eighty five per cent women in both the groups had delivered vaginally. One fifth cases in the index group and 11% in the control group had one or more complications of delivery. The common complications in index group were fetal distress (6.3%) and birth asphyxia (2.1%). In control group, the most common complications were meconium stained liquor (0.7%) and birth asphyxia (0.7%).
About 25% of the index group were moderately anemic compared to only 9.0% of control group (p <0.02). Common complications of pregnancy were pregnancy induced hypertension (PIH) and eclampsia. However, risk of pregnancy complications was 2.5 times higher among the adolescent pregnant women compared to the controls (Table II). Three still births occurred among the cases and one among the controls. Mean birth weight was 2.81 (±0.41) kg in index group and 2.69 (±0.50) kg in control group. Congenital defects were present in two children born to adolescent mothers and no congenital defect was found in the control group. Apgar score was similar in both groups.
Discussion The average age at marriage for women has a significant effect on the teenage birth rate(4). In Nepal median age at first marriage among girls is 16.4 years and 43.3% of girls in 15 to 19 years age group are married according to Nepal Family Health Survey 1996(5). In our study, teenage pregnant women were married at a mean age of 16.71 years, which was significantly lower than that in the control group. Thus, marriage at a younger age increase the risk of teenage pregnancy. Husbands’ age was in the twenties in both groups, suggesting that age at marriage for males is appropriate and as per norms. Though overall antenatal supervision was similar in both groups, early registration and check up in first trimester was more common among the elder women. Similarly, the frequency of antenatal check up was less among the teenage pregnant women. All this indicates that younger girls were less careful about their pregnancy probably because of lack of maturity. Lack of antenatal supervision and care among adolescent pregnant women is also reported by other researchers(6,7). In terms of complications of pregnancy, in our study it was observed that complications were more common among adolescents. This has been the finding of majority of researchers in developing countries like India(6,8), Bangladesh(9) and Nigeria(10) and also in developed countries(2). Still births were more common in adolescent pregnancy in our study. Several researchers have also reported higher prevalence of still births among teenage pregnancies(6,8,10). It should be kept in mind that this study was conducted in a referral hospital therefore the complications of pregnancy, delivery and fetal outcome may not be true reflection of their prevlaence in the catchment area, as only 7% of all deliveries are conducted in institutions in Nepal(5). It may be concluded that teenage pregnancy is a high risk condition. However, definite conclusions cannot be drawn from our study as the sample size is small. It was associated with higher frequency of anemia and pregnancy complications. Though fetal out come was better, the other risks were far greater. So teenage pregnancy should be discouraged by increasing age at marriage for girls and providing better education facilities for them. Acknowledgements The authors are thankful to Ms. Tara Shah and Ms. Vipana Bhandari, staff nurses in the department of Gynecology and Obstetrics, at B.P. Koirala Institute of Health Sciences, Dharan for their help in data collection. Contributors: AKS and KV conceptualized the study. All authors contributed to designing of data collection tools. SK and KV participated in data collection. ATK helped in finalizing discussion. AKS finalized the manuscript and will act as the guarantor. Funding: None. Competing interests: None stated.
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