Articles
socioeconomic status, and 75.4% had either no education
or attended only primary school with 72% of their
husbands being unskilled workers.
Also, grandmultiparous women have the highest MMR
of 2688. This underscores the need to pay more attention
to education of women and take measures to improve
the socioeconomic condition of the populace in general.
More attention also needs to be focused on family
planning so that more women could be encouraged to
take up family planning in an attempt to reduce maternal
deaths.
It is possible that the high MMR obtained in this study
may overestimate the problem since it is a hospital-based
study from a referral centre where complicated cases are
managed with a high risk of death. However, the analysis
of hospital deaths can provide information about the
epidemiology and underlying causes of death, and the
adequacy of the existing health-care facilities.
To reduce maternal deaths, a strong political commit-
ment is required in addition to the suggestions made
above. There is a wrong perception that safe motherhood
programmes are expensive. However, recent reports15
showed that maternal deaths could be reduced in low-
resource settings, if there is strong political commitment.
Governments of developing nations must make emer-
gency obstetric care available in rural health centres and
district hospitals, increase the number of health personnel
allocated to remote areas and set up birthing centres in
remote areas.
More traditional birth attendants need to be trained
and retrained to recognize obstetric emergencies, and they
should be integrated into the health system to make them
acceptable to the orthodox physician. Workers must
address the sociocultural factors that inhibit utilization of
health-care facilities with communities to increase accep-
tance of and demand for hospital deliveries. Communica-
tion systems, roads and emergency transportations must
also be upgraded.
A strong political commitment is essential. As Jeremy15
put it, ‘ultimately the critical need may be one of
generating sufficient political and social will at interna-
tional and national level to overcome this avoidable
tragedy’.
References
1 Audu LR, Ekele BA. A ten-year review of maternal mortality
in Sokoto, Northern Nigeria. W Afr J Med 2002;21:74–6
2 Adegbola O Oye, Adeniran BA, Igwillo C. Maternal
mortality in Africa. Afr Health 2003;25:22–4
3 Elizabeth IR, Nancy VY. Making motherhood safer: over-
coming obstacles on the pathway for care. Populat Ref Bureau
2002;7
4 Aboyeji AP. Trends in maternal mortality in Ilorin, Nigeria.
Trop J Obstet Gynaecol 1998: 15–20
5 Adetoro OO. Maternal mortality – a twelve-year survey at the
University of Ilorin Teaching Hospital (U.I.T.H.) Ilorin,
Nigeria. Int J Gynaecol Obstet 1987;25:93–8
6 Adetoro OO, Okwerekwu FE, Ogunbode O. Maternal
mortality in Ilorin, Nigeria. Trop J Obstet Gynaecol
1988;1:18–21
7 UNFPA Population Reference Bureau Nigeria. Country
profiles for population and reproductive health: policy
developments and indicators New York: UNFPA, 2003:72
8 Verma K, Thomas A, Sharma A, Ohar A, Bhambri V.
Maternal mortality in rural India: a hospital based 10 year
retrospective analysis. J Obstet Gynaecol Res 2001;27:183–7
9 Orero S, Oyo OC, Ogattu M, Obunga C, Ombake C.
Mobilising resources to repair hospital beds and equipment
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to improve obstetric care in Western Kenya. Regional
Prevention of Maternal Mortality Network. Second Generation
Result Conference, Accra 2003: 4
10 Mazimba C. Emergency obstetric care services at Simwata-
chla Health Centre Kolomo Distric, Zambia: Needs assess-
ment finding. Regional Prevention of Maternal Mortality
Network. Second Generation Result Conference, Accra 2003;3
11 Ibison JM, Swerdlow AJ, Head JA, Marmot M. Maternal
mortality in England and Wales 1970–1985: an analysis by
country of birth. Br J Obstet Gynaecol 1996;103:973–80
12 United Nation System in Nigeria. Nigeria: Common Country
Assessment. New York: United Nations, 2001
13 Olatunji AO, Abudu OO. A review of maternal mortality in
Lagos University Teaching Hospital (1976–1985). Nig Med
Pract 1996;31:2–5
14 Egwatu VE. Reflections on maternal mortality in Nigeria –
the fifth Okoronkwo Kesandu Ogan Memorial ovation. Trop
J Obstet Gynaecol 2003;20:76–82
15 Shiffman J. Can poor countries surmount high maternal
mortality. Studies in family planning. 2000;31: 276–89
Teenage pregnancies and
their obstetric outcomes
S S Trivedi MS FICOG Shikha Pasrija MD
Lady Hardinge Medical College and Shrimati Sucheta Kriplani
Hospital, New Delhi 110001, India
Correspondence to: Dr Shikha Pasrija, C-A/16, Tagore Garden,
New Delhi 110001, India
Email: shikhapasrija@hotmail.com
TROPICAL DOCTOR 2007; 37: 85–88
SUMMARY This study was conducted to evaluate the
obstetric performance of teenage women in India. In total,
13,210 women were included in the study, of whom 840
were teenagers (o19 years) and 12,370 were X20 years.
Antepartum, intrapartum and postpartum events were
recorded and comparative analysis was done.We found
that teenage women were at a significantly higher risk for
development of severe anaemia (relative risk [RR] 1.61,
P valueo0.02), eclampsia (RR 1.95, P valueo0.05), preterm
labour (RR 1.25, P valueo0.001), intrauterine growth
retardation (RR 2.29, P value o0.001) and low birth weight
(RR 1.24, P valueo0.001). Assisted delivery (11.78% versus
2.23%, P valueo0.001) was significantly more common and
caesarean delivery (9.64% versus 17.18%, P valueo0.001)
was significantly less common in teenagers. Moderate
anaemia, mild pregnancy-induced hypertension, pree-
clampsia, premature rupture of membranes, antepartum
haemorrhage and post dates were all significantly higher
in X20 years group.To conclude, we found that teenage
women are a high-risk group, which is aggravated by social
and cultural factors. Special attention is required to
educate these women for more positive outcomes.
Introduction
Teenage pregnancies are found all over the world,
developed, developing or underdeveloped. The reasons,
however, vary in various societies. In India, the most
85
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common cause is early age at marriage. Various studies
have been conducted to find out the effects of age on
obstetric outcomes. Some have found that teenage
pregnancies are associated with higher rates of complica-
tions,1–7 while others have failed to find any such risk.8–12
The major risks found in studies include preeclampsia,
preterm delivery, intrauterine growth retardation, low
birth weight babies and increased caesarean section rates.
The current study was conducted to study the risks of
teenage pregnancies in Indian women.
Methodology
The study was conducted at Shrimati Sucheta Kriplani
Hospital in New Delhi, which is located in the central part
of the city and is a big referral centre. It caters to a large
population of all socioeconomic strata. A prospective
study was conducted to find out the effects of the teen
years on pregnancy outcome. The study was conducted
over a period of 1 year. Women ranging from 13 to 19
years of age were included in the study group irrespective
of gravidity or parity. All teenage pregnant women
attending antenatal clinic or admitted to the maternity
ward were studied and data collected on antepartum,
intrapartum and postpartum complications. The Control
group comprised of women X20 years. Pregnancy
outcomes were compared between the two groups. The
w2 test was used to determine the significance between
observations.
Results
The total number of deliveries that occurred over a period
of 1 year was 13,210. The number of teenage deliveries
among these was 840. In all, 12,370 women were X20
years old. Thus, the frequency of teenage pregnancies was
6.3%. Out of these 840 women, 468 (55.7%) were booked
and 372 (44.3%) were unbooked during the antenatal
period. Only five of these were unmarried. The number of
booked cases in the X20 years group was 7745 (62.6%),
while 4625 (37.4%) women were unbooked.
The majority of teenage women, 660, were aged 18–19
years (78.56%). Only 36 (4.3%) women were less than
17 years of age, three being 15 years and 33 being 16 years
of age.
Most of these women (84.0%) were primigravida, and
12.7% were pregnant for the second time. Third and
fourth pregnancies were seen in 2.6% and 0.6% of teenage
women, respectively.
The educational status of these women was generally
poor: 45.5% women were illiterate, while 27.3% women
had received only primary education. Secondary educa-
tion was completed by 5.71% and only six (0.7%) went to
high school or above.
Table 1 depicts the comparative analysis of complica-
tions among the teenaged and those X20 years of age.
For the purpose of this study, mild Pregnancy-induced
hypertension (PIH), preeclampsia and eclampsia were
defined as per the ACOG criteria.
Severe anaemia was taken as a haemoglobin level less
than 7 g% and moderate anaemia was taken as a
haemoglobin level less than 9 g%. Antepartum haemor-
rhage was defined as bleeding from or into the genital
tract after 28 weeks of pregnancy. Preterm labour was
labelled if three contractions were observed over a 10 min
period with a cervical dilation of more than 2 cm and
effacement of 80% or more after 28 and before 37 weeks
86
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of pregnancy. Pregnancy lasting for more than 40 weeks
was defined as prolonged. Rupture of membranes was
taken to be premature if established labour did not set in
within 6 h.
Low birth weight was less than 2500 g, and intrauterine
growth restriction was taken as weight o10th percentile
for that gestational age.
In the teenage group, eight women had twin pregnancy,
five had polyhydramnios, five had anencephaly and one
had hydrocephalous. Five fetuses had other congenital
malformations.
Table 2 shows the relative risks of various complica-
tions between booked and unbooked women, in both the
teenagers’ groups and the X20 years group.
Delivery was normal vaginal in 660 women (84.6%) in
the teenage group compared with 80.6% in the X20 years
group. The difference was statistically insignificant
(P valueo0.1). Assisted vaginal delivery (forceps and
vacuum) was required in 11.78% of the teenagers, while in
the X20 years group 2.23% women required assisted
vaginal delivery (P valueo0.001). Caesarean section was
the mode of delivery in 81 teenage women (9.6%), while in
the X20 years group 17.2% delivered by caesarean
section (P valueo0.001) (Table 3).
Teenage women had an incidence of 0.3% for
postpartum haemorrhage compared with 3% in the X20
years group. The incidence of maternal mortality was
0.48% (4) in the teenage women and 0.47% (58) in the
X20 years group.
Discussion
Early marriage is widely prevalent in our country, more so
in the lower socioeconomic strata. Poor antenatal and
intrapartum care may account for poor pregnancy
outcome in these women, but the question is whether
age also plays a role in the obstetric outcome of these
young women.
Verma and Das7 studied 200 teenage women and found
that Indian teenagers are a high-risk obstetric population
with higher incidence of anaemia, pregnancy-induced
hypertension, preterm labour, low birth weight babies and
perinatal mortality.
In another study done on Indian population by
Ambadekar et al.12 (n ¼ 1830 each teenage, and 420.29
years), only low birth weight was significantly higher in
teenage women. No other complication was significant in
this group when compared with adult controls.
van Enk et al.,13 in their study done over 3 years
(n ¼ 10,503 teenagers and n ¼ 54,501 in 20–24 years),
commented that obstetric outcomes were best in Hindus-
tani teenage women though the risk of preterm labour was
high.
In our study we found that the teenage women were at a
higher risk for severe anaemia, eclampsia, preterm labour
and low birth weight babies. We hypothesize that the
incidence of these complications could be higher because
of poor nutrition, inadequate antenatal care and failure to
use the medical facilities due to various reasons. Anaemia
was mainly iron deficiency anaemia, and in most cases
was due to lack of required substitution during the
antenatal period. Moderate anaemia, mild pregnancy-
induced hypertension, preeclampsia, premature rupture of
membranes, antepartum haemorrhage and post dates
were all significantly higher in X20 years group. Improper
antenatal care might be one of the major reasons behind
the poor obstetric outcomes as medical care by teenagers
Tropical Doctor April 2007, 37
 Articles

Table 1 Comparative analysis of pregnancy complications

Percentage (n) of Percentage (n) of

women in teenage women in X20 years
Complication group group Relative risk P value

Pregnancy-induced hypertension 1.43 (12) 2.3 (285) 0.62 o0.01

Preeclampsia 5.24 (44) 7.2 (891) 0.73 o0.02
Eclampsia 1.07 (09) 0.55 (68) 1.95 o0.05
Severe anaemia 2.74 (23) 1.7 (210) 1.61 o0.02
Moderate anaemia 10.48 (88) 64 (7917) 0.16 o0.001
Antepartum haemorrhage 1.79 (15) 1.7 (210) 1.05 o0.001
Premature rupture of membranes 0.83 (07) 2.6 (321) 0.32 o0.001
Preterm labour 12.62 (106) 10.1 (1241) 1.25 o0.01
Post dates 0.95 (08) 1.8 (222) 0.53 ---

Twins 0.95 (08) 1.33 (164) --- ---

Hydramnios 0.60 (05) 0.22 (27) --- ---
Low birth weight 48.3 (406) 27.8 (3439) 1.74 o0.001
Intrauterine growth restriction 22.5 (189) 9.8 (1212) 2.29 ---

Anencephaly 0.60 (05) 0.14 (18) --- ---

Hydrocephalous 0.12 (01) 0.07 (9) --- ---
Other congenital anomalies 0.60 (05) 0.4 (46) --- ---

Still births 3.45 (29) 2.6 (321) 1.33 ---

Neonatal deaths 4.40 (37) 0.01 (64) --- ---

Postpartum haemorrhage 0.36 (03) 3 (371) --- ---

wtest result

Table 2 Relative risks (RR) of pregnancy complications between booked and unbooked women

Percentage (n) of women in teenage group Percentage (n) of women in X20 years group
Complication
Unbooked Booked RR Unbooked Booked RR

Pregnancy-induced hypertension 0.83 (7) 0.59 (5) 1.41 0.74 (92) 1.56 (193) 0.47
Preeclampsia 3.57 (30) 1.67 (14) 2.14 3.73 (462) 3.47 (429) 1.07
Eclampsia 0.71 (6) 0.36 (3) 1.97 0.34 (42) 0.21 (26) 1.62
Severe anaemia 2.02 (17) 0.71 (6) 2.84 1.58 (195) 0.28 (35) 5.64
Moderate anaemia 5.71 (48) 4.76 (40) 1.20 38.15 (4719) 25.85 (3198) 1.47
Antepartum haemorrhage 0.95 (8) 0.83 (7) 1.14 0.57 (71) 1.12 (139) 0.51
Premature rupture of membranes 0.71 (6) 0.12 (1) 5.92 1.41 (174) 1.19 (147) 1.18
Preterm labour 8.57 (72) 4.05 (34) 2.11 6.10 (755) 3.93 (486) 1.55
Post dates 0.48 (4) 0.48 (4) 1 0.68 (84) 1.12 (138) 0.61
Low birth weight 23.21(195) 25.1 (211) 0.92 15.59 (1928) 12.21 (1511) 1.28
Intrauterine growth restriction 12.73 (107) 9.76 (82) 1.30 3.42 (423) 6.38 (789) 0.54
Maternal mortality 0.48 (4) 0 (0) --- 0.38 (47) 0.09 (11) 4.2

was sought only when the condition deteriorated. This Table 3 Mode of delivery
leads us to the interpretation that, if necessary care is
given to pregnant teenage women, their obstetric out- Percentage (n) Percentage (n) of
of women in women in X20
comes can be improved to a great extent. Mode of delivery teenage group years group P value
The incidence of assisted delivery was higher and that
of caesarean section was lower in teenagers versus non- Vaginal 84.57 (660) 80.6 (9970) o0.1
teenagers. This is in contrast with other studies,14 which Assisted delivery 11.78 (99) 2.23 (275) o0.001
LSCS 9.64 (81) 17.18 (2125) o0.001
have suggested an increase in operative delivery perhaps Breech 5.71 (48) 3 (374) ---
due to poor pelvic development early in life. Preterm Face 0.24 (02) 0.22 (27) ---
deliveries and low birth weight babies probably decreased w-test result
the caesarean section rates. In the teenage group, it was
often a lack of knowledge regarding the process of
parturition that resulted in apprehension, exhaustion and
the need for assisted delivery. Although the health-care facilities in general have
The study was done in a set-up where the population is improved, outcomes for teenage pregnancies are not
of varying ethnicity, socioeconomic and educational promising. Teenagers should be given more information
background. Our study has a few limitations. First, we about pregnancy, necessary antenatal care and the
did not study women under 15 years as a separate group. delivery process. Counselling and education ought to be
The number of these women was too small to allow for a enhanced so as to reduce the number of teenage
significant analysis. Another limiting factor was that pre- pregnancies and improve the obstetric outcome.
pregnancy weight and weight gain during pregnancy
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