Course BASIC_Graduate level learning material about the challenges of human reproductive medicine in a changing Europe

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

SYLLABUS

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

(Basic level)

The aim of the lecture is to equip students with knowledge that will bring them closer to the concrete problems they will face later on.
    Becoming a mother is one of the most wonderful things a woman can experience. However, it is not an easy task - in fact, it is a very difficult one. However, becoming a mother as a child can be one of the most controversial feelings and experiences. A lot changes in a very short space of time, and it is difficult for an adolescent girl to cope with this, and in many cases still being judged by society in this situation. In the case of girl mothers, there is a huge internal struggle from conception to the birth of the child - and even afterwards, because they not only have to come to terms with themselves, but also live with the pressures of their environment.

What is typical of the adolescent age group?

Today's adolescents are the largest age group in history, comprising 1.2 billion girls and boys aged 10-19, most of whom live in low- and middle-income countries (LMIC) - a major source of modern-day migration. (1) Before their 20th birthday, 40% of girls in LMICs are married and nearly 20% will have given birth. (2) Among the youngest adolescents (<16 years old), a staggering 2.5 million births occur annually in LMICs. (1)
    Adolescent fertility has traditionally been 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 empowerment, cultural practices related to sexual health and marriage, and gender norms and roles. (2)
What is the social dimension of adolescent pregnancy?
Under-age pregnancy and childbearing is both a health and a social problem: health through contraception, abortion, premature birth, perinatal mortality, and social through the interruption of schooling and abuse after childbirth. Almost 20,000 underage girls become mothers in Romania every year, with a few hundred giving birth before the age of fifteen. According to data from the National Institute of Statistics, in 2021, 749 adolescent girls in Romania gave birth before the age of 15, and 18,938 became mothers between the ages of 15 and 19. The numbers have been similar in recent years and put Romania at the top of the European Union in terms of the number of mothers of girls.  The statistics show that the number of child mothers has continued to increase during the period of epidemiological restrictions. The sad statistic is led by Mures county, where 931 child mothers have been registered since EU accession. The child mother phenomenon, as the statistics show, has intensified since Romania joined the EU.
    Poverty, lack of information and the fact that sex education in schools is very rare or non-existent are major contributory factors. 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. The girl mothers are mainly young people from difficult circumstances, but there are also wealthy families where girls become mothers before they reach adulthood.  And, contrary to popular belief, it is not only Roma communities that are primarily affected. It is also the case of non-Roma communities that are poor and marginalized, and in many cases parents go abroad to work, leaving adolescent girls to the extended family. The problem is that we often don't take adolescents' problems seriously, we see them as childish things to be concerned about. But adolescence is one of the most difficult times in a person's life, a time of great change, hormonally, mentally and emotionally, with a lot of uncertainty. And if you have a child during this period, you go from the transition from childhood to adolescence to adulthood. This accelerated process leads to a high rate of depression and substance abuse. Most of the time, these children do not get involved in sexual relationships because they want to have children. In fact, in most cases they give in as a result of physical or psychological coercion. It is common for the partner to blackmail them or for the girls to need emotional support and not be able to say no. Another serious problem is that in most cases these girls conceal their pregnancy and only come to a professional when they feel they have lost their footing.

What is the age-specific features of adolescent pregnancy?

Adolescence is a critical period that marks phenomenal changes, including rapid physical, psychosocial, sexual and cognitive maturation, and adolescents' nutritional needs are higher than at any other stage of the life cycle. (3-5)
    Pregnant adolescent girls are a particularly vulnerable group, as the demands of regular growth and development are coupled with increased nutritional requirements for fetal support. However, it is unclear whether adolescent pregnancy limits maternal growth or whether girls with adequate nutrition continue to grow on a normal trajectory. (6) When there is competition for nutrients between mother and fetus (i.e., the mother has inadequate nutrient intake and stores), studies suggest that nutrient sharing favors the fetus. (7-8)
    It is not yet fully understood how age and nutritional status affect pregnancy and birth outcomes. (8)
    Obstructed childbirth (due to short stature and smaller pelvic size) has also been found among young adolescents (10-14 years), although limited and conflicting data are available on birth and reproductive outcomes. (8)
    An analysis of national surveys from 55 LMIC countries showed that young mothers are at higher risk of poor health and mortality of their newborns than older mothers. (9)
A meta-analysis of 14 cohort studies in low-income countries 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, compared with women aged 18-34 years with parity 1-2. (10,11)                            

What factors affect access to reproductive health services for adolescent pregnant?

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.

Some personality dimensions in the teenager pregnant woman are predictive of pregnancy adaptation, progress in labor, birth outcomes, and postpartum maternal psychosocial adaptation.  Pregnancy acceptance by the teenager

The normal course of childbearing is a test, a challenge for the pregnant woman. At young age it could be a crisis. The teenager woman has to accept the idea of pregnancy and assimilate it into her way of life. This isn’t easy. Reactions like euphoria, are common if the gravid woman has been looking forward to motherhood. It is not the same under 18 years, she may be assailed by doubts. It is hard to manage both her studies and caring for a child. She may also have finance problems. Anger, fear, and loneliness may occur during the transition to motherhood. The teenage gravida is less prepared for childbirth and motherhood. Acceptance of the pregnancy is low, and she is more likely to have fears concerning labor.

Not all adolescent woman with unintended or unplanned pregnancies are unhappy about them. Consciously planned pregnancy happens rarely in adolescents. This occur in some ethnic groups and is part of “tradition”.

Pregnancy symptoms like nausea, vomiting is associated with levels of anxiety.

Motherhood role, identification with it

Pregnancy is a period of transition from the woman-without-child to the woman-with-child state. The teenager has to assume the motherhood role. The extent to which the woman had prepared for this role varies. Every woman brings some doubts to pregnancy, and that they need not be considered abnormal. Most women, especially in a first pregnancy, wonder whether they will be able to nurture their baby properly. This is happening at an increased level in teenager primigravida. The development of maternal attachment to the infant is part of an overall process that begins well before birth. By the third trimester, accommodation to the reality of the anticipated birth generally occur even in teenager mothers.

Relationship with her mother (the grandmother)

The teenage isn’t a fully developed woman yet. These mother–daughter relationship is very important in pregnancy. This influences the gravida’s identification and adaptation to the motherhood role. The mother–daughter relationship during pregnancy and childbirth can be supportive and reassuring or can be hostile. Reconciliation is more difficult to achieve if the teenage gravida’s mother is unavailable, critical, or unsupportive. A poor relationship with the grandmother is associated with anxiety, poorer contractile activity in labor, prolong labor.

There are some key issues, important in the teenage gravida’s relationship with her mother:

• The availability of the grandmother to the gravida both in the past and during pregnancy (being available when needed).
• The grandmother’s reactions to the pregnancy are important. She must accept the teenage daughter as a mother and accept the grandchild.
• The grandmother must show a respect for her teenage daughter’s autonomy. It isn’t an easy task.  The gravida becomes mature adult rather than a child. The grandmother sometimes is enables to respect the independence of her adolescent daughter. This may be caused by a failure to “let go” her daughter as a child.
• It is helpful if the grandmother share experience with her daughter about her own childbearing. Such information enables the teenage gravida to anticipate labor and delivery and to prepare for the event. Good communication between mother and daughter increases the gravida’s confidence in herself.

Relationship with her partner

The teenage gravida may wonder whether her partner will indeed give her support when she needs it most. Majority of these pregnancies are unplanned. The father can be supportive, indifferent or hostile in this situation. She often feels an increased sense of vulnerability during her pregnancy. A poor relationship with her partner is associated with earlier admission to the labor unit, anxiety, prolonged duration of labor and lower birthweight (preterm birth, small for gestational age). It is also associated with depression during pregnancy and is predictive of maternal postpartum depression. It is important for the father to get into the fatherhood role. He must show empathy, availability and reliability.

What are the difficulties encountered during reproductive health care?- Pre-pregnancy counselling

Practical steps of the preparation for labor is to gather information about the labor process before delivery. (childbirth preparation classes, by sharing feelings, fears, and experiences with other women, and by using books, films). This is hard to achive, when the pregnant is an adolescent, sometimes in deep poverty. Doubts and fears appear more frequently in adolescent pregnant.

Childbirth education classes focus on learning a novel set of behaviors and skills, encourages a woman to develop techniques of control during labor and delivery in order to help her cope with pain. The pain of labor can be a trigger for the loss of control, especially if the pain became intolerable.

Most of the teenager gravidas has no husband, the partners support could be missing. Single gravidas reported more anxiety in acceptance of pregnancy and preparation for labor. The teenage pregnant can lose control over the body and/or over emotions more often because of lack of prenatal education. Crying, becoming hysterical, or being hostile to the medical staff may happen. A frightening experience in childhood during hospitalization, can have lasting effects on attitudes toward hospitals and doctors. It can be terrifying from a child’s point of view when doctors “do horrible things” with instruments. The fear of having contact with hospitals can reach phobic proportions.

Which maternal diseases are more often associated with pregnancy?

People living in poor social conditions, especially under-age pregnancies, are more likely to have problems with anemia, malnutrition, sexually transmitted diseases and smoking. This anemia leads to a reduction in the mother's immune system and increased susceptibility to infections. The fetal consequences of iron deficiency anemia may include premature birth or, in severe cases, stunted fetal growth, perinatal mortality, and neonatal mortality.
Preeclampsia and consequent intrauterine fetal retardation are more common in teenage pregnancies and among people living in poor social conditions. (12)

What are the particularities that occur during pregnancy and childbirth?

A young pregnant woman (under 18 year) at birth is a challenge for the medical stuff. Women with more education are better prepared for labor (have less anxiety). Unfortunately most of the teenager mothers have less education, and their knowledge regarding pregnancy, birth and puerperium is poor.

Both social mechanisms and biological maturity play a role in birth outcomes.
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.

Weaker partner relationships are associated with later initiation of prenatal care, higher anxiety about birth, antepartum complications, slower progress in labor and  lower birthweight (preterm birth, small for gestational age). Intimate support from a partner, or other family member is related to adequate prenatal care and feeling hopeful about the future.

More frequent during childbirth the low birthweight is more common (prematurity, intrauterin growth retardation). Contracted pelvis may be more frequent at teenager pregnant, but fetopelvic disproportion isn’t very high among these gravida because of low birthweight. One of the genetic problems found more frequent at birth is Monosomia X (Turner syndrome). The large majority of them are nuliparous,so preeclampsia could be more frequent.

References

UNICEF. Adolescents overview. October 2019. Retrieved https:// data.unicef.org/topic/adolescents/overview/. Accessed Jun 2, 2022.

Darroch JE, Woog V, Bankole A, Ashford LS. Adding It up: Costs and Benefits of Meeting Contraceptive Needs of Adolescents. Guttmacher Institute; 2016.
Das JK, Salam RA, Thornburg KL, et al. Nutrition in adolescents: physiology, metabolism, and nutritional needs. Ann N Y Acad Sci. 2017;1393(1):21–33. https://doi.org/10.1111/NYAS.13330.
Christian P, Smith ER, Christian Bill P, Gates M. Adolescent undernutrition: global burden, physiology, and nutritional risks. Rev Artic Ann Nutr Metab. 2018; 72:316–328. https://doi.org/ 10.1159/000488865.
Scholl TO, Hediger ML, Ances IG. Maternal growth during preg- nancy and decreased infant birth weight. Am J Clin Nutr. 1990;51 (5):790–793. https://academic.oup.com/ajcn/article/51/5/790/ 4695357. Accessed November 4, 2021.
Scholl TO, Hediger ML. A review of the epidemiology of nutrition and adolescent pregnancy: maternal growth during pregnancy and its effect on the fetus. J Am Coll Nutr. 1993;12(2):101–107. https:// doi.org/10.1080/07315724.1993.10718289.
Rah JH, Christian P, Shamim AA, Arju UT, Labrique AB, Rashid M. Pregnancy and lactation hinder growth and nutritional status of adolescent girls in rural Bangladesh. J Nutr. 2008;138(8):1505–1511. https://doi.org/10.1093/jn/138.8.1505.
Akseer N, Keats EC, Thurairajah P, Cousens S, et al. Characteristics and birth outcomes of pregnant adolescents compared to older women: An analysis of individual level data from 140,000 mothers from 20 RCTs. E Clinical Medicine 2022;45: 101309. https://doi.org/10.1016/j. eclinm.2022.101309
Finlay JE, Ozaltin E, Canning D. The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low-and middle-income countries. BMJ Open. 2011;12) e000226. https://doi.org/10.1136/ bmjopen-2011-000226.
Kozuki N, Lee ACC, Silveira MF, et al. The associations of parity and maternal age with small-for-gestational-age, preterm, and neo- natal and infant mortality: a meta-analysis. BMC Public Health 2013;13 Suppl 3.
Althabe F, Moore JL, Gibbons L, et al. Adverse maternal and perinatal outcomes in adolescent pregnancies: the global network's maternal newborn health registry study. Reprod Health 2015;12 Suppl 2 (Suppl 2): S8. doi:10.1186/1742-4755-12-S2-S8.
Silva LM, Coolman M, Steegers EA, et al. Low socioeconomic status is a risk factor for preeclampsia: the generation R study. J Hypertens 2008;26:1200–8.

Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the Foundation for the Development of the Education System. Neither the European Union nor entity providing the grant can be held responsible for them.