Article Text
PDF
Abstract
Overview and aim The precocity of sexual intercourse among adolescent girls is a prominent source of unwanted pregnancy. Here, we aim to survey the past issues relating to the pregnancy, childbirth, and materno-fetal prognosis of Ivorian adolescent women.
Methods We conducted a retrospsective study with adolescent group (n = 1040) versus young adult group aged 20 to 24 (n = 736) over three years from1st January 2016 to 31rd December 2018 at the Department of Obstetrics and Gynecology at the University of Abidjan-Yopougon Hospital. Maternal and fetal outcomes of the two groups were analyzed and compared by using Pearson's Chi2 tests and Fisher's exact tests, followed by multivariate analysis and logistic regression using Stata software version 20.
Results The average age of adolescent girls in our study was 17.45 years (SD = 1.39) and a minimum of 12 years. Adolescents consulted less (P < 0.0001) and later (P < 0.0001) versus young adults aged 20 to 24. The proportion of adolescent girls (47.6%) versus young adults (39.1%) who had underwent caesarean section was significantly higher (P = 0.0004). These adolescents were 3.5-fold more likely to develop hypertension and its complications in the postpartum period and 2.5-fold more likely to contract a postpartum infection. Maternal mortality was not significantly associated with adolescence (OR = 0.52 (95%CI: 0.22–1.19; P = 0.0891). The risk of prematurity, early neonatal death, and neonatal admission were 2.02 (95%CI: 1.56–2.63; P < 0.0001), 1.55 (95%CI: 1.14–2.13; P = 0.0040), and 1.73 (95%CI:1.12–2.71; P = 0.0097) in adolescence, respectively.
Conclusion Adolescent childbirth remains associated with a poor prognosis.
Highlights
The large sample (1040) concentrated on a single center.
A long study period (5 years) are elements.
The comparison with a control group.
An update of African data especially Ivorian.
- High-risk pregnancy
- Adolescent girl
- West Africa
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Statistics from Altmetric.com
1 Introduction
According to the World Health Organization, teenage or adolescent pregnancy is a pregnancy occurring in girls aged 10–19.1 The incidence of adolescent pregnancy is highest in Sub Saharan Africa (143 per 1000 girls aged between 15 and 19 years). In Europe, it is well over 20 per 1,000.2 These pregnancies are considered by most authors to be high-risk pregnancies. High death rates among adolescent mothers are usually due to eclampsia, postpartum haemorrhage, sepsis, HIV infection, malaria and obstructed labour.3 Childbearing during adolescence is not only a risk factor for adverse maternal health outcomes but also has negative impacts on child health indices and the future well-being of the infants. Previous studies have documented associations between adolescent births and increased incidence of negative perinatal and child health outcomes, such as preterm delivery, low birth weight and perinatal death.4
According to the general population census in 2014 for Côte d'Ivoire, adolescents represented 31% of the total national population (7,028,113 people), of which 57% lived in urban areas.5 This continuously-growing population presents peculiarities because of its vulnerability in reproductive health. Indeed, adolescence is a sensitive developmental stage marked by physiological, morphological, psychosocial, and anatomical modifications leading to the appearance of secondary sexual characteristics.6 This period is also marked by emotional immaturity associated with risky sexual behavior. Thus, in Côte d'Ivoire, one in four young girls (25.4%) aged 20–24 had given birth before the age of 18 in 2016 according to the fifth multiple indicator cluster survey (MICS 5 Côte d ' Ivory).7 In this study, we aim to present the peculiarities over the course of pregnancy, childbirth, and the maternal-fetal prognosis of Ivorian adolescents to improve their obstetrical outcomes.
2 Methods
2.1 Study design
We performed an retrospective observational study of a historical cohort conducted over the course of three years from 1st January 2016 to 31rd December 2018. The study took place at the Obstetrics and Gynecology Service of University of Abidjan-Yopougon Hospital. This is a reference maternity hospital receiving patients from the northern zone of the city and its neighboring towns. This maternity hospital carries out more than 6000 deliveries per year.
2.2 Study population
The childbirth register formed the basis of our sampling from which we retained the following criteria:
Exposed group (adolescent): All adolescent girls aged 10 to 19 who gave birth in the maternity hospital of Yopougon after 28 weeks of amenorrhea (WA) (Professional consensus) different from the threshold set by the WHO (22 WA).
Unexposed group (young adult): This group constituted women aged between 20 and 24 who gave birth after 28 WA in the maternity hospital of the Yopougon University Hospital. They were selected at random. This selection was performed because involves less risk and young adults are the age group closest to adolescent girls, thereby limiting confounding biases such as sexual behavior. Finally, it constitutes the reference age group in most studies.8 The inclusion of patients from the unexposed group was made according to the following criteria: The patient was between 20 and 24 years of age, gave birth on the same day as an adolescent patient without associated co-morbidity (hypertension, diabetes, HIV, sickle cell anemia, cancer, previous surgery), and gave birth with the same team of caregivers as the adolescent patient. Patients whose information was incomplete or unusable for various reasons were not retained in the study.
2.3 Variables studied
The comparative study considered the socio-demographic characteristics and previous surgical history of patients, as well as the gyneco-obstetric history for the following items: the method of admission, the reason for admission, the history of pregnancy, clinical examination upon admission to the delivery room, delivery (mode, type of delivery, bleeding), condition of the newborn (resuscitated or not) and maternal condition postpartum 2 h and24 h (exeat, transferred or hospitalized).
2.4 Data collection and analysis
We identified patients who met our selection criteria in the admission register of the hospital. Subsequently, the partographs of these patients were consulted. The data appearing in said files were collected on a pre-established standardized survey form. Data analysis was performed using Stata version 20 software. Pearson's Chi2 tests and Fisher's exact tests made it possible to compare the proportions of the different parameters studied in the two groups, then a multivariate analysis and a logistic regression with an alpha significance threshold set at 5% were performed.
3 Results
There were 19,882 deliveries during the study period, including 1157 (5.81%) of teenage mothers with 1040 complete records versus 736 records of the unexposed group of young adults (Fig. 1). Our study sample consisted of 1776 patients including 1040 adolescent girls (58.56%). Their average age was 17.45 years (SD = 1.39) and a minimum of 12 years. The risk of being transferred was 5.77 times higher in adolescent girls (P < 0.001). By comparing with young adult group, previous surgery (P < 0.001) and diabetes history (P = 0.039) and surgery was lower in adolescent girls. Previous pregnancies, parity, abortion, and caesarean section were lower in adolescent girls (P < 0.001) (Table 1).
Contingency table for adolescent girl group versus young adult group according to the mode of admission, previous surgical and obstetric history n(%).
Flow chart of patients.
Adolescent girls were consulted less (P < 0.001) and later (P < 0.001) compared to young adult women, and performed less prenatal workup (P < 0.001). The pelvis was considered clinically abnormal by our obstetricians (OR = 10.18; 4.69–22.10; P < 0.001) in adolescent girls (Table 2).
Contingency table for the adolescent girl group versus young adult group according to the history of pregnancy and clinical examination n(%).
Notably, adolescent pregnancy increased the incidence of adverse pregnancy outcomes (P < 0.001). More specifically, adolescent pregnancy was associated with a 3.5-fold higher risk of developing hypertension and its complications in the postpartum period and 2.5-fold higher risk of contracting a postpartum infection. Maternal mortality was not significantly associated with adolescence (OR = 0.52; 0.22–1.19; P = 0.089) (Table 3).
Contingency table of the adolescent girl group versus young adult group according to the mode of delivery, the consequences of childbirth, maternal deaths and the condition of the newborn n(%).
The risk of premature birth, early neonatal death, and neonatal admission were 2.02 (1.56–2.63; P < 0.0001), 1.55 (1.14–2.13; P = 0.0040), and 1.73 (1.12–2.71; P = 0.0097) in adolescence and significantly different from those of young adults, respectively (Table 3).
Besides, adolescent girl in comparison to young adults were independently associated with a higher risk of being transferred (P < 0.001) realizing the first prenatal consultation after the first quarter (P < 0.001), achieving less than four prenatal consultations (P < 0.001), not realizing prenatal assessment (P = 0.037).
Multivariate analysis showed that adolescent pregnancy was associated with limited or narrowed pelvic bone (P < 0.001) and fetal prematurity (P = 0.016) (Table 4).
Multivariate analysis of factors associated with adolescent pregnancy.
4 Discussion
4.1 Epidemiological and clinical features of adolescent subjects
The proportion of adolescent mothers in our study was 8.05%. These results seem to be underestimated at the national level because the data were collected at a referral center. Indeed, according to the MICS 5 Cote d'Ivoire survey, there were still six children per woman in rural versus three children per woman in urban areas. Also, one in four women aged 20–24 had given birth before the age of 187. Teenage pregnancy rates are highly variable from country to country. Our numbers seem to be below the global average of 103 adolescent deliveries per 1000 deliveries according to an international study conducted by the WHO in 29 countries in Africa, Asia, Latin America, and the Middle East. This study involved 359 health facilities in the capital and two provinces selected at random from each participating country. Among these selected African countries, Angola led with 233 adolescent deliveries per 1000 deliveries, followed by Niger (148 per 1000), and the Democratic Republic of Congo (DRC; 144 per 1000).8 Another study carried out in four African countries representing the different regions of sub-Saharan Africa (south, west, east, and central) between September 2009 and December 2013 showed high rates in Gabon (35.5%) and Mozambique (39.5%), but lower rates in Benin (10%) and Tanzania (13.5%).9 This regional difference was primarily attributed to the socio-cultural and religious characteristics of the societies. Among these, the risk factors identified during teenage pregnancy were: a low level of education, an age of fewer than 15 years at first intercourse, absence of a partner, maternal history of pregnancy at adolescence, and lack of knowledge of and access to contraceptive methods.9 These factors can negatively influence adolescent mother reproduction and should be taken into consideration by public health programs when developing strategies for preventing teen pregnancy.9
Regarding hypertension and its complications, this study observed a 3.5-fold higher risk in adolescents. The risk factors linked to the young age of the parturient have been widely demonstrated by numerous studies.10 Santos et al.11 observed a relationship between low birth weight and weight during pregnancy, body mass index during pregnancy, and weight gain during pregnancy. Unfortunately, these parameters were either missing or unusable in our database.
Our results from the univariate analysis showed that adolescent girls were more likely to have premature babies (OR: 2.02), and neonatal death (OR:1.55) In the multivariate analysis, the risk of prematurity is 1.86. The majority of authors unanimously agree that adolescent girls often give birth to premature and low birth weight infants.9,12
4.2 Maternal and infant mortality
According to Granja et al. approximately 22% of maternal deaths among teenage mothers were caused by pregnancy-induced hypertension, puerperal sepsis, and septic abortion, accounting for 75% of the total number of teenage mother deaths.13 We recorded 12/1040 adolescent maternal deaths versus 16/736 during our work. Regarding maternal mortality, our study found that 60 maternal deaths per 100,000 live births to adolescents occurred during the study period, while it was 614/100,000 live births in 2016 for all of Côte d'Ivoire.7 This contrast is likely due to selection bias. Maternal mortality was not significantly associated with adolescence on univariate analysis. In contrast, adolescence was significantly associated with maternal death during multivariate analysis with an OR of 1.55 (CI: 1.14–2.13; and P = 0.0040). The other independent factors associated with adolescence were prematurity (OR: 1.86) and high blood pressure (OR: 2.64). Also, there was no significant difference between adolescents and young adults (OR = 1.55) regarding the risk of neonatal death. Although this finding is similar in most studies, an association between young maternal age and perinatal mortality has not been proven.12,14 However, we found twice as high of a risk of perinatal death in newborns of adolescent mothers in the DRC, results that can be compared to those found in Cameroon.15
4.3 Limitations
Given the retrospective nature of this study, it is subject to selection bias; especially in the choice of the control group. Thus, we carried out systematic recruitment of an age group a priori with fewer maternal-fetal risks. It is also necessary to note a few points which mar the external validity and applicability of our study. In this case, we refer to the representativeness of adolescent girls. We limited ourselves to the Yopougon University Hospital. The integration of other maternity hospitals in the city of Abidjan would have made it possible to improve the representativeness of the samples included in our study. The second limitation of our study in terms of external validity concerns the lack of integration of certain factors such as the socio-economic level of the parents of the adolescent and that of the partner. However, the large sample (1040) concentrated on a single-center spread over a fairly long study period (5 years) are elements that support the representativeness of our sample. In the methodology, we don't have many specific data to measure bleeding volume for example. Many of criteria diagnosis were clinic like anemia, hypertension and postpartum infection. Our study population was in emergency and no access to free care.
5 Conclusion
Adolescent childbirth remains associated with complications during pregnancy and delivery. Sensitization for prenatal care and the establishment of a prevention policy through the use of contraceptive methods will help to alleviate risks associated with adolescent pregnancy and childbirth and thus should be incorporated into healthcare programs.
Details of ethics approval
Because of retrospective study, ethics approval was exempt by University of Abidjan-Yopougon Hospital.
Consent for publication
The authors consent and approve this manuscript for publication.
Authors' contributions
EKA and AK designed the study, LO and PK collected the data collect, EKA, LO and PK analyzed the data, EKA and ATE were Responsible for methodology, EKA and MF has written the contents of this manuscript, and AH and MK were the supervisors of the manuscript.
Conflict of interest
The authors declare that they have no links of interest.