Keywords

Teen mother; Maternal; Neonatal prognosis

Introduction

Adolescence is defined by the World Health Organization (WHO) by a chronological age between 10 and 19 years old [1]. In 2012 [2], WHO estimated that nearly 16 million girls aged 15 to 19 and 2 million girls under the age of 15 give birth each year around the world. Pregnancy and teenage childbirth are a very high risk of morbidity and mortality. This situation is linked to the physiological and sociological characteristics of adolescent girls. Adolescent pregnancies constitute increased risks for maternal health such as anemia, high blood pressure, eclampsia [3] also for low birth weight babies, prematurity and poor adaptation to extrauterine life [4]. Complications of pregnancy and childbirth are one of the leading causes of death for girls aged 15-19. Deaths at birth and neonatal deaths are 50% higher among children of teenage mothers than among women aged 20 to 29 [2,5].

This problem affects most developing countries and few recent data exist in Gabon. We aimed to assess the maternal and neonatal prognosis during teenage childbirth by conducting this study in the neonatal resuscitation and neonatology unit of the University Hospital Center of Libreville (CHUL).

Patients and Methods

We made a retrospective, comparative study covering a two years period, from 1 January 2010 to 31 December 2012. The CHUL is the largest health facility in the country. Its capacity and geographical location in the center of city allow it to receive the majority of parturients of the city and its periphery.

During this period, we recorded deliveries for which newborns were hospitalized in the ward. We divided mothers of newborns into two groups, according to their age: a group comprising women aged 18 or younger and a second group comprising women over 18 years of age. Maternal sociodemographic characteristics, maternal morbidity-related parameters, neonatal morbidity and mortality were collected from the delivery room register, the pregnancy tracking log and the department's medical record.

The maternal socio-demographic characteristics included: nationality (Gabonese, non-Gabonese); maternal age (less than or equal to 18 years and over 18 years); marital status (married, single/couple); profession (pupil) (female/male, female worker with gainful activity/employed, unemployed); socioeconomic level (low, medium, high); gynecologicalobstetrical history (number of pregnancies or gestations, number of deliveries or parity) and follow-up pregnancy (number of antenatal visits: CPN). A socio-economic level was qualified low when the monthly family income was less than 150,000 CFA francs, middle when income was between 150,000 and 300,000 CFA francs and high for an income of more than 300,000 CFA francs. For teenage mothers, the socio-economic level of the parents or the spouse was the reference. Pregnancy was considered poorly followed if the number of ANC was less than 3 and well followed if the number was 3 or more.

Parameters related to maternal morbidity included: cesarean section delivery, vicious sore or transverse presentation, maternal complications or pathologies that occurred during pregnancy and laboring maneuvers, such as episiotomy, the use of forceps and the type of pregnancy. We classified maternal pathologies into syndromes: hematological; infectious, vascular, obstetric, metabolic, painful, neuropsychic and bronchial.

Parameters related to neonatal morbidity and mortality included low birth weight in grams (g), prematurity; poor or poor uterine adaptation to APGAR score at first and fifth minute; performing resuscitation maneuvers; associated pathologies; hospital stay and neonatal death. The low birth weight corresponded to a value of less than 2500 g and the very low weight to a value of less than 1000 g. Prematurity was defined by lower gestational age (GA) of 37 weeks of amenorrhea. We classified as prematurity between 33 and 36 weeks old, very prematurely between 28 and 32 weeks and extremely premature for a GA below 28 weeks. Adaptation to ectopic life was considered poor for an APGAR score of less than 3 and mediocre for a score of 3 to 6.

Ethics

All the mothers signed the consent form before being included in the survey.

Statistics, we used the chi2 test or the Fisher exact test for categorical variables and the Student's test for continuous variables. The threshold of significance was set at p<0.05. Free and informed consent of all persons involved in this study was obtained verbally.

Results

Out of a total of 577 newborns consecutively recorded during the study period, we identified 78 newborns born to mothers aged 18 or younger, representing a frequency of 13.5%. Teenage mothers were Gabonese in 94.9% (n=74) of cases and foreigners for 5.1% (n=4). Adult parturients were Gabonese in 88.2% (n=440) of cases and foreigners 11.8% (n=59).

Mean age was 16.9 ± 1.1 years for adolescent mothers and 27.4 ± 3.5 years for adult mothers. In the group of teenage mothers, 96.2% were single, 79.5% were students and 19.2% were unemployed compared to 87.4%, 25.7% and 52.3% respectively in the group of adult deliveries. The socioeconomic level was low for 88.5% of teenage deliveries compared to 86.5% of adult deliveries. In the follow-up of pregnancy, the proportion of unattended pregnancies was 34.6% among teenage deliveries while it was 24.2% among adult deliveries. Adolescent mothers were more frequently primigest (82.1%) and primiparous (89.7%) than adult mothers with respectively 18.0% and 32.3%. Table 1 summarizes the socio-demographic characteristics, pregnancy monitoring and gynecological-obstetrical history of adolescent and adult mothers.

Table 1: Distribution of socio-demographic characteristics, pregnancy monitoring and gynecological-obstetrical history among teenage and adult mothers.

The intercurrent diseases observed during the pregnancy of teenage mothers consisted of infectious syndrome (5.1%), obstetric syndrome (5.1%), hematological syndrome (2.6%) and vascular syndrome (1, 3%). In adult mothers, the rates were 5.2%, 1.4%, 6.0% and 4.0%. The infectious syndrome included urinary tract infection, positive serology for Human Immunodeficiency Virus (HIV), malaria and vaginal candidiasis.

The obstetric syndrome consisted of cervical-isthmic openbite, placenta previa hemorrhagic, and the threat of premature labor. The hematological syndrome took into account anemia, sickle cell disease. The vascular-renal syndrome included arterial hypertension, toxemia of pregnancy, pre-eclampsia. The metabolic syndrome was represented by diabetes/obesity; bronchial syndrome by asthma.

Pregnancy was unique among 93.6% of teenage mothers, compared to 86.2% of adult mothers and 14.1% of teenage mothers and 14.4% of adult mothers reported having a seated presentation. Cesarean section was the mode of delivery for 11.5% of adolescent girls and 21.2% of adults. Maneuvers at delivery were observed in 1.3% of adolescent cases compared to 2.6% of adults. Table 2 shows the morbidity parameters reported for adolescent mothers and adult mothers.

Table 2: Distribution of morbidity parameters in adolescent mothers and adult mothers.

The proportion of newborns with very low birth weight accounted for 9.0% of teenage mothers, compared to 4.4% for adult mothers, while low birth weight was 39.7% vs. 43.7%, respectively. Adaptation to ectopic life in the first minute of life was poor in 1.3% of newborns of adolescent mothers compared to 2.8% in those of adult mothers; by the fifth minute of life, it remained poor for 17.6% of newborns of teenage mothers and 17.6% of those of adult mothers. Resuscitation maneuvers were performed in 25.6% of neonates of teenage mothers vs. 30.7% of those of adult mothers. The associated neonatal pathologies were respiratory distress in 37.2% of neonates of teenage mothers vs. 38.1% of those of adult mothers and hypoxic-ischemic encephalopathy for 16.7% and 18.0%, respectively.

The other pathologies were mainly convulsions, malaria, diarrhea and malformations. The duration of hospitalization was greater than 15 days for 38.5% of newborns of teenage mothers compared to 31.5% of those of adult mothers. The evolution was marked by the death of 34.6% of newborns of teenage mothers and 39.3% of newborns of adult mothers.

Parameters related to neonatal morbidity and mortality in neonates of adolescent mothers and adult mothers are summarized in Table 3.

Table 3: Distribution of morbidity and mortality outcomes in newborns of adolescent mothers and adult mothers.

Discussion

Our frequency is close to that found by Tambwe in the Democratic Republic of Congo with 13.9% [6] and Fouelifack et al. in Cameroon (9.3%) and Gandzien et al. in Congo-Brazzaville whose rates vary between 7. 0% and 13.0% [7,8]. It is higher than the rate reported by Ezegwui in Nigeria [9] which finds a frequency lower than 2.0%. This regional difference can be explained by the cultural or religious context that influences society's view of a young mother's situation. In some ethnic groups, becoming a mother is important because this state is a proof of fertility and in others, the teenage mother cannot declare her pregnancy on pain of attracting an unfavorable judgment on her family unless she is married. We note that women of non-Gabonese nationality become mothers after 18 years, although the difference with Gabonese nationality is not significant. The cultural habits of these communities seem to have a positive impact on their sexuality. The result observed among women of Gabonese nationality emphasizes the importance of reinforcing the program of sex education and family planning, which has insufficient coverage at the national level.

The average age of adolescent deliveries is similar to that found by other authors, such as Fouelifack et al. Cameroon with 17 ± 1.3 years; Hamada et al. in Morocco [10] with 17 years and four months. Socio-demographic parameters, pregnancy follow-up and gynecological, obstetrical history showed unfavorable criteria for teenage mothers compared to adult mothers, such as being single, being a student, not having their pregnancies have already experienced the first pregnancy or have given birth at least once. According to a British study, many teenagers become pregnant with intention and not by accident [11]. Several authors have noted the adverse socio-demographic aspects and the poor or lack of prenatal care of adolescent mothers [12]. Alouina et al. [13] in France found that 20.0% of adolescent girls were in school, the majorities were unemployed, lived in a couple and 23.5% had less than four NPCs. The rate of unattended pregnancies is similar to that of Tambwe [6] who finds 30.2%. These results raise the problem of early adolescent pregnancy, the absence of screening for high-risk pregnancies and the resulting complications. According to the WHO, in developing countries, young pregnant women come late or not at all for antenatal care. The causes found are the ignorance of the importance of ANC, the lack of family support, the lack of care by a specialized social agency, the reproving look of the caregiver on an adolescent girl who is pregnant and fear of HIV testing [14,15].

Our teenage girls have no more intercurrent pregnancy pathologies compared to adult mothers such as vascular syndrome such as arterial or hematologic hypertension such as anemia. We did not note a relationship between the young age of mothers, presentation in the siege, multiple pregnancy, cesarean section, or episiotomy. Kakudji et al. [16] in the Democratic Republic of Congo, found that fetal presentation, soft-tissue lesions, were not significantly related to young age, but compared to adult mothers, adolescent to give birth by cesarean section, to undergo an episiotomy and to have a pathological delivery. The frequency of cesarean section in children under 20 was found by Ayuba et al. [17]; Ebeigbe et al. [18], both in Nigeria whose studies report a significantly higher incidence of cesarean section in adolescents (respectively p=0.014 and 0.0002). Maryam et al. [19] in Iran found that the high rate of caesarean section was associated with an age of less than 17 years.

In adolescents, the pelvis grows more slowly and gradually until old age, explaining the need for frequent use of this practice. Conde-Agudelo et al. [20] in Colombia reports that adolescent girls were at higher risk of early neonatal death, anemia, operative vaginal delivery, episiotomy, low birth weight, childbirth premature but less likely to deliver by cesarean section. The significantly greater practice of vaginal delivery is similar to that found by Mahavarkar et al. [21] in India who find that adolescent mothers are more likely to deliver vaginally without a significant increase in the risk of vaginal delivery. Assisted or cesarean section like Leppälahti et al. [22] in Finland, report that teenage mothers were more likely to have a vaginal birth without complications. In Caesarean section practice, our results are similar to those of Kongnyuy et al. [23] in Cameroon, who found that cesarean delivery was not significantly associated with teenage pregnancy. In a meta-analysis, Scholl et al. [24] in New Jersey show that the risk of preterm birth was associated with early maternal age in both developed and developing countries. In developed countries, the risk of cesarean delivery was reduced for adolescent girls with a decrease in maternal anemia and pregnancy-induced hypertension compared to the risk in more mature women. In developing countries, adolescent girls were at increased risk of maternal anemia, premature labor and cesarean delivery. These differences confirm that comprehensive prenatal care programs reduce the risk of complications.

Tebeu et al. [25] in Cameroon shows that the occurrence of vascular syndrome depends on the biological and endocrine immaturity, the primigestity and the lack of prenatal follow-up in the young woman. We did not find the prevalence among teenage mothers, preterm newborns and low birth weight, unlike other authors. For Mahavarkar et al., adolescent mothers were nearly three times more likely to develop preterm birth (p<0.0001) and nearly twice as likely to give birth to low birth weight babies (p<0, 0001). Ganchimeg et al. [26] in Japan, in a WHO multi-country study reports that compared to mothers aged 20 to 24, teenage mothers aged 10 to 19 years were at increased risk of eclampsia, endometritis puerperal, systemic infections, low birth weight, premature labor and severe neonatal problems; and that the increased risk of early intra-hospital neonatal death in infants born to adolescent mothers has been reduced and is statistically insignificant after adjusting for gestational age and birth weight. Black et al. [27] in Canada concludes that teen pregnancy is at high risk for the newborn because of its relationship to prematurity, low birth weight, neonatal and infant mortality. In adolescents, the physical immaturity of the uterus associated with specific nutritional and dietary needs is responsible for the birth of a preterm or born child with low birth weight [28]. This risk of low weight is attributed to factors that may be associated with young age, such as anemia, maternal physical state, premature delivery, pregnancy-related conditions, inadequate maternal weight gain, maternal nutrition and quality of pregnancy monitoring. Ndiaye et al. [29] in a Senegalese study of adolescent girls under 20 years of age found that giving birth to a newborn with low birth weight was more common in women who had low weight gain during pregnancy (p=0.04) or a low number of antenatal visits (p=0.006).

The poor or poor adaptation to ectopic life at the first minute of similar life in both groups was reported by Usta [30] in Lebanon. We did not find an association between young maternal age and neonatal mortality. Our results are comparable to those of Ayuba et al. in Nigeria [17] who found no significant difference in perinatal mortality rate among teenage mothers compared to that of adult mothers. Like Raatikainen et al. [31] in Finland, there is no relationship between increased risk of preterm birth, fetal growth restriction, low birth weight or fetal or perinatal death and adolescent motherhood. This result is contrary to other studies that found an increased risk of perinatal mortality in neonates of teenage mothers [4,5]. Chen et al., [32] in the United States had demonstrated that when gestational age was adjusted at birth, there was no link between teenage pregnancy and neonatal mortality, while there was a significant association with postnatal mortality. The increased risk of neonatal death associated with teenage pregnancy is therefore largely attributable to a higher risk of premature births.

Conclusion

Adolescent pregnancy compared to adult women has often been associated with poor maternal and neonatal prognosis. This fragility is due to unfavorable socio-economic conditions and the inadequacy of antenatal surveillance. In this work, teenage pregnancy does not appear to be at hμd on sensitizing pregnant adolescents about pregnancy-related complications, correct care and psychological support during pregnancy, childbirth and postpartum by a multidisciplinary team.

Conflicts of Interest

The authors declare no conflict of interest.

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