Adolescent pregnancy (social and age related challenges) prepregnancy and pregnancy care

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2021-1-HU01-KA220-HED-000027613 - COHRICE
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SYLLABUS

Adolescent pregnancy (social and age related challenges) prepregnancy and pregnancy care

(Advanced level)


Learning objective
To understand the relationship between maternal age and pregnancy and birth outcomes is important and could have major implications for adolescent reproductive care, policy and programming.

Introduction

The cohort of adolescents living today is the largest in history, encompassing 1.2 billion girls and boys aged 10 −19 years, the majority of whom live in a low-income or middle-income country (LMIC)- the principal source for modern migration. (1) Before their 20th birthday, 40% of girls in LMICs are married and almost 20% will have given birth. (2) Among the youngest adolescents (<16 years), a staggering 2.5 million births occur in LMICs annually. (1)

Adolescent fertility is traditionally high in LMICs, particularly in Sub- Saharan Africa and Latin America, due to pervasive underlying factors such as poverty, poor access to health services, lack of education and employment opportunities, low female autonomy, cultural practices related to sexual health and marriage, and gender norms and roles. (2)

Adolescence is a critical period marking phenomenal changes including rapid physical, psychosocial, sexual and cognitive maturation, and nutrient needs of adolescents are higher than at any other stage in the lifecycle. (3-5)

Pregnant adolescent girls are a particularly vulnerable group since the demands of regular growth and development are augmented by the heightened nutritional requirements of supporting a fetus. (6 -7-8)

An analysis of national surveys from 55 LMICs found that young mothers had a higher risk of poor health and mortality outcomes among their newborns than older mothers. (9)

A meta-analysis of 14 cohort studies conducted in LMICs found that nulliparous women aged <18 years had the highest risk of adverse birth and neonatal outcomes, including preterm birth, small-for-gestational age (SGA), neonatal and infant mortality, when compared to women 18−34 years with parity 1−2. (10)

Given the high number of births occurring during adolescence (estimated at 20% of all births in some countries), understanding the relationship between maternal age and pregnancy and birth outcomes is important and could have major implications for policy and programming.

Epidemiology

A recent extensive study published in 2022 by Lancet (8) was able to demonstrate that adolescence is a critical period of maturation when nutrient needs are high, especially among adolescents entering pregnancy. Using individual-level data from 140,000 participants, authors examined socioeconomic, nutrition, and pregnancy and birth outcomes for adolescent mothers (10−19 years) compared to older mothers in low and middle-income countries. This study was conducted between March 16, 2018 and May 25 and data were obtained from 20 randomized controlled trials of micronutrient supplementation in pregnancy.

Findings show that adolescent mothers, particularly the youngest mothers, are at a greater risk of experiencing adverse birth outcomes than older women.

Risk factors
Mother age: For girls aged 10−14 years, SGA prevalence reached 35.2% (33.3 - 37.3%), while for women 30−39 years it was 25.3% (24.2 - 26.4%) and for women 40+ it was 25.1% (21.3 - 29.3%).

Among 10 – 14year - old mothers, 6.3% (5.3 - 7.4%) of newborns died, compared to 3.8% (3.4 - 4.3%) among mothers aged 20−29 years, and 5.3% (3.7 - 7.5%) among mothers 40+ years.

Compared to mothers 20 −29 years, mothers who were 15−17 years and 18 −19 years had a 15% (RR (95% CIs); 1.08−1.22) and 6% (1.02−1.10) higher risk of maternal anemia, respectively.

Mothers aged 15−17 and 18 −19 years had a 11% (0.81−0.97) and 12% (0.80−0.97) lower risk of stillbirth, respectively, than mothers aged 20−29, while mothers aged 30−39 had a 43% (1.32 −1.56) increased risk and mothers 40+ years had a 103% higher risk of stillbirth (1.56−2.64).

Compared to the 20−29 group, mothers aged 10−14, 15−17, 18−19, and 30−39 years had 60% (1.35−1.91), 18% (1.06−1.31), 15% (1.04−1.28), and 25% (1.12−1.41) higher risk of perinatal mortality.

Parity: Increased with age: 3.6% (2.9 - 4.3%) of girls aged 10−14 were multiparous compared with 30.9% (30.3 - 31.6%) of girls aged 18−19. (8)
Overweight: Overweight prevalence reached nearly 10% (7.5 - 12.0%) among the youngest girls and was highest (15%) for women aged 30+ years. Low stature afflicted 24.2% (21.0 - 27.4%) of girls aged 10−14 years and around 40% of mothers among all other age groups.
Preterm birth: Preterm birth occurred most frequently in the youngest mothers (10−14 years) (23.1%; 95% CI: 21.6% - 24.7%),
25.9% (24.5 - 27.5%) of mothers aged 10−14 years had LBW babies compared to 20.3% (19.4 - 21.1%) of mothers aged 20−29 years.

Another previously meta-analysis found that nulliparous women <18 years had the highest odds of preterm birth, SGA, neonatal mortality, and infant mortality. (10) The authors conducted a sensitivity analysis that pointed to even higher odds for mothers <16 years, particularly for preterm births, though the results were not conclusive (which was likely due to small sample size). (8)

Neonatal mortality: For neonatal mortality, risks were also greatest for 10−14year-old mothers, reaching 63% (1.40−1.90) increased risk. Higher risks were also observed for mothers aged 15−17, 18−19, and 30 −39 years.

Compared to the 20−29 group, risks of both LBW and SGA were highest among mothers aged 10 −14, reaching 28% (1.22−1.35) and 22% (1.16−1.29) increased risk. Mothers aged 15−17 and 18−19 also had a greater risk of experiencing these adverse birth outcomes. (8)

Stillbirths: The exception to this was stillbirths, which were more common among older mothers (30+ years). Most outcomes examined followed a U-shaped pattern by age, whereby the youngest and oldest mothers experienced the worst outcomes, and mothers aged 20 −29 years had the lowest risk.

Within the cohort data, adverse outcomes were highly prevalent, reaching 35%, 26%, and 23% for SGA, LBW, and preterm births among the youngest adolescent mothers, respectively. Regional differences existed and most outcomes are worse in Asian versus African mothers. This could be due to the differing baseline characteristics between the populations, such as the higher rates of underweight and low stature among Asian women. (8)

A more recent meta-analysis of 18 studies examining complications associated with adolescent childbearing in Sub-Saharan Africa found that adolescent mothers (<17 years) had an increased risk of adverse neonatal and maternal outcomes including preeclampsia/eclampsia, LBW, preterm birth, perinatal death and maternal death. (12)

Social risk factors

Lack of empowerment of adolescent mothers, often due to early marriage, incomplete education, poor access to financial, healthcare and other resources, low decision-making ability, and other context-specific social and gender norms, contribute to suboptimal reproductive outcomes. In the USA, only 1.5% of women who give birth before the age of 18 will have a higher education by the age of 30.

Each of these domains of empowerment − alone or together − could lead to adverse pregnancy outcomes through a lack of knowledge of best practices (e.g. relating to nutrition), inadequate resources to exercise these practices, or poor access to quality maternal and other health services because of financial, social, and other barriers.

There is evidence to support the link between adolescent wellbeing, pregnancy, and undesirable pregnancy and birth outcomes.

A meta-analysis looking at factors influencing the utilization of health services by adolescent mothers in LMICs found that both maternal and paternal education were among the most important factors, along with wealth, media exposure, and urban/ rural residence. (14)

The association between advanced maternal age and increased risk of adverse birth and maternal outcomes has been found in many studies from high-income countries. (15-17)

Both social mechanisms and biological maturity play a role in birth outcomes. These conclusions are further supported by the lack of adverse outcomes found when considering young fathers. If being a young mother is simply a marker for poor social conditions, we might expect to find similar adverse child outcomes among children of young fathers. However, two studies that sought to examine differential effects of maternal and paternal conditions on child health, as a method of distinguishing between biological and social mechanisms, did not corroborate this, suggesting that factors beyond socioeconomic determinants could play a key role. In addition to nutrition partitioning, biological immaturity of young mothers, for example resulting in insufficiency in maturity of the uterine and cervical blood supply, may also be linked to adverse birth outcomes seen in this population.

Indeed, a plausible and well-referenced biological mechanism of action is incomplete physical and sexual maturation, coupled with higher nutritional demands during adolescence. In this situation, a young adolescent girl is at a much greater disadvantage than an older woman with adequate nutrient status who may not experience competing demands between mother and fetus. (6) Height and pelvic growth are not complete until close to two years following first menstruation, underscoring one of several vulnerable periods in an adolescent girl’s reproductive years. (8)

Undernutrition: Additional evidence has indicated that a mother’s undernutrition can lead to smaller placental mass, poor vascularization, and less nutrient transfer to the fetus, and some adolescent mothers weigh significantly less, with lower BMI, than adult mothers.

Maternal stunting and small pelvic size have been associated with poor fetal growth and adverse obstetric outcomes, including obstructed labor and asphyxia of the infant.

Anemia: Anemia in pregnancy has been associated with increased risks of LBW, preterm birth, perinatal mortality, and neonatal mortality, and examinations of adolescent-specific populations have confirmed these findings.

Much less is known about multiple micronutrient deficiencies in this population. Taken together, younger mothers, particularly those who have micronutrient deficiencies and other types of malnutrition prevalent in LMICs, are more likely to experience adverse outcomes relating directly to parturition and poor growth and development of the fetus.

While biology is likely to play a role, there may be socioeconomic and other social determinants that contribute to the observed risks for adolescents.

Future action and strategies
These data require immediate attention and action from global agenda setters and country governments; specifically, tailored interventions to support healthy antenatal care and delivery practices among young mothers are essential.

Adolescent mothers are at a clear disadvantage, both from a biological predisposition for high-risk pregnancies and because of status in a socioeconomic and cultural sense. Targeted strategies should be used to mitigate these risks, especially where contraceptive use is low and adolescent pregnancies are high.

Indirect approaches to delay pregnancy may include the initiation of female empowerment programmes, community sensitization to adolescent sexual and reproductive health and rights, and the inclusion of adolescent boys in educational initiatives.

Direct approaches may work to increase the provision of adolescent-friendly health services, including the promotion of contraceptive awareness and uptake through schools and other delivery platforms that can reach out- of-school adolescents. There is also a need to reach adolescents with quality antenatal care.

A group prenatal care model is one such platform that may benefit and support vulnerable groups of adolescent mothers and improve health outcomes, education, and adherence to pregnancy recommendations. (18) In addition, prenatal care that includes men has been shown to be effective at improving pregnancy outcomes. (8,18)

Impact of SARS-CoV-2 pandemic on adolescent reproductive health    
The current SARS-CoV-2 pandemic has likely increased these estimates because of restrictions in health services, lack of contraceptive access, increased school dropouts, and a complex inter- play of these factors with economic hardship and a deepening of gender-based disparities. (8, 18-27)

In the USA adolescent pregnancies are more common in the than in other wealthy nations, and about 80% are unintended. In addition to the growth in comorbid conditions, adolescent mothers are at an increased risk of living under the poverty line, and children born to teen moms may be at increased risk for adverse pediatric outcomes.

These pregnancies may be planned and desired but is unclear that there is an 'ideal' rate of pregnancy for this age group.

During the pandemic a shift has noticed in the number of teenagers coming to the teen obstetrics program: decade ago, about 30 adolescents gave birth in a given month; now, that figure is closer to 20.Observations mirror a national trend: The rate of teen births is falling in the United States, according to a study published in Obstetrics and Gynecology – a cross-sectional analysis of data from the 2000–2018 National Inpatient Sample of delivery hospitalization trends for patients aged 11–19 years.(28)

Of more than 73 million estimated delivery hospitalizations during that period, 88,363 occurred in patients aged 11–14 years, and 6,359,331 were among patients aged 15–19 years.

Deliveries among patients aged 11–14 years decreased from 2.1 per 1000 to 0.4 per 1000 during the time frame. Deliveries among patients aged 15–19 years decreased from 11.5% of all deliveries to 4.8% over the study period.

Among patients aged 11–19 years, rates of comorbidities significantly increased from 2000 to 2018, the researchers found. The prevalence of obesity increased from 0.2% to 7.2%, asthma increased from 1.6% to 7%, while mental health conditions increased from to 0.5% to 7.1%.

Severe maternal morbidity, defined as a patient having at least one of 20 conditions, including stroke, heart failure and sepsis increased from 0.5% to 0.7%. The rate of postpartum hemorrhage increased from 2.9% to 4.7%, the rate of cesarean section increased from 15.2% to 19.5%, and that of hypertensive disorders of pregnancy increased from 7.5% to 13.7%.

But, the adolescents who are giving birth are more likely to have obesity, mental health problems (bipolar disease, depression, anxiety), asthma and other conditions that can complicate their pregnancies, the research shows. Many also lack stable housing and adequate food. Rates of delivery complications also have increased in this age group. Compared to adult patients, teens tend to require longer medical visits. Most patients have limited knowledge of what prenatal care entails. Most of these patients have never even had a gynecologic exam before, they come in and they're not used to the equipment. They're not used to the terminology used in healthcare facilities. These factors make clinical practice more complex and in order to optimize adolescent pregnancy outcomes, prenatal care will likely need to provide increasingly complex clinical management in addition to addressing outreach challenges of this population. (28)

Conclusion
There is a tremendous need to focus on these vulnerable female population in LMICs to ensure that health pre-pregnancy, delivery and postnatal care is accessible for women and their children.
Clinical practice will probable be more and more complex because of more comorbidities associated to this group of patients.

References

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