Adolescent pregnancy adverse effects

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.
,

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. [email protected]

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 χ 2 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 t rans-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.

42. 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.

43. 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.

44. 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 .

45. 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).

46. 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.

47. 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.

48. 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.

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