Hazards of adolescent pregnancy

By Dr MILTON LUM

The dangers of adolescent pregnancies are much greater than that of women in the second, third, or fourth decade of life.

PREGNANCY in adolescence, i.e. in a girl aged between 10 and 19 years, is increasingly becoming a problem in many developed and developing countries. This phenomenon has been influenced by the decreasing age of the first period (menarche) and schooling.

The former has been decreasing at a rate of about two to three months per decade in developed countries in the previous century, so much so that the overall decrease has been about three years in many countries. The latter has meant that many adolescents spend their time in school with more independence from parental supervision and influence. This has lead to increasing pre-marital relations and an increase in adolescent pregnancies.

As there is much difference between a 12- or 13-year-old and a 19-year-old, it is the practice to make a distinction between adolescents aged 10 to 14 years from adolescents aged 15 to 19 years.

The transition from childhood to adulthood takes place during adolescence. Although the rate of transition is variable in individuals, there are many factors that have to be in place before a person attains the physical and mental maturity necessary for motherhood.

A study by the National Population and Family Planning Board in 2004 reported that only 47% to 59.6% of adolescent respondents possessed knowledge about the different parts of the reproductive organs. – AFP

Many adolescents are getting pregnant

The World Health Organization (WHO) estimates that about 16 million adolescents aged 15 to 19 years old give birth annually. This comprises about 11% of all births worldwide.

The average adolescent birth rate in middle-income countries is more than twice that of high-income countries, with the rate in low-income countries five times higher than that of high-income countries. Adolescent pregnancies comprise 2% of all births in China, 18% in Latin America and more than 50% in sub-Saharan Africa.

Many adolescent Malaysians are getting pregnant. There were more than 70,000 adolescent girls admitted to public hospitals in 2005, with about 37% for pregnancy and related problems. Pregnancy in girls less than 15 years of age comprised 0.15% of the total births in 2006.

It has been reported that statistics from the Registration Department showed that there were 257,411 newborns without fathers, i.e. the birth certificates did not have their fathers’ names, between 2000 and 2008, i.e. an average of 78 babies are born out of wedlock daily.

The number of abandoned babies appears to be increasing as well. The Social Welfare Department recorded 407 abandoned babies in the past five years. Police statistics reveal an average of 100 cases annually. Recent media reports that some of the newborns being left to the elements and likely death were distressing, but is now part of the daily media fare.

Although no analysis has been reported, it would not be surprising to find that many of the newborns without the fathers’ names on the birth certificates and abandoned babies are the consequence of adolescent pregnancies.

Health hazards for mother and baby

Some of the complications of pregnancy are increased in adolescents compared to that of pregnancy in the third to fourth decade of life. This includes death from pregnancy or its complications.

The Malaysian Confidential Enquiry for Maternal Deaths Report in 2005 stated that adolescents aged between 15 to 19 years old comprised 4.8% of all maternal deaths, which is much higher than the percentage who were pregnant.

The risk of sexually active adolescents getting human immunodeficiency virus (HIV) and other sexually transmitted infection (STI) is increased. There is an association between the HIV viral load in mother and the risk of transmission from mother to child. The presence of other STIs, e.g. gonorrhoea and chlamydia, may increase the shedding of the HIV virus, thereby increasing the risk of transmission during labour.

The percentage of Malaysian females infected by HIV increased from 1.2% of the total number in 1990 to 19.1% in 2008. No female had AIDS in 1990 but 15.5% of AIDS victims in 2008 were female. Heterosexual transmission, i.e. male to female or vice versa increased from 4.8% in 1990 to 16.6% in 2008 for HIV infections and 29.6% for AIDS.

Vertical transmission, i.e. mother to newborn was first reported in 1991. By 2008, the number of vertical transmission cases totaled 742 (0.9%) for HIV and 186 (1.3%) for AIDS. There has also been an increase in the number of infected young people aged 13 to 19 years old, who now make up 1.4% of the total reported HIV/AIDS cases.

Pregnant adolescents are at increased risk of iodine deficiency. As iodine is essential for physical and mental development, its deficiency increases the risk of the developing foetus sustaining brain damage, which would lead to mental retardation and disorders of the nervous system.

The WHO estimates that about 2.5 million adolescents worldwide have unsafe abortions annually. Adolescents between 15 and 19 years account for about 14% of all unsafe abortions in low- and middle-income countries. The complications of unsafe abortions are increased and more severe in adolescents compared to older women.

There is evidence from some developing countries that the pelvic bones in girls below 16 years may still be in the process of growing, i.e. they are immature, especially in those who are poor. This predisposes the young girls to the complications of cephalopelvic disproportion and obstructed labour, which include the formation of connections (fistulae) between the vagina and bladder, and between the rectum and vagina. It has been estimated that about 65% of women with obstetric fistulae develop the condition from an adolescent pregnancy. The consequences of fistulae are dreadful as it has a disastrous impact on the physical and social life of the affected persons.

Anaemia is common in pregnant women. Some studies report that its prevalence is higher in pregnant adolescents than older pregnant women. However, other studies do not report such a difference.

The outcomes of adolescent pregnancies are worse than that of pregnancies in older women.

Unlike the pelvises of older women, the pelvic bones in girls below 16 years may still be in the process of growing. This predisposes the young girls to complications during labour, such as the formation of connections (fistulae) between the vagina and bladder, and between the rectum and vagina. – Reuters

There is much evidence from developed and developing countries that the risk for preterm delivery, i.e. before 37 weeks, is increased in adolescents, with the highest risk in the youngest age groups. This has been attributed to factors that include the short interval between menarche and pregnancy, and low educational attainment.

Adolescents are also increased risk of giving birth to a baby of low birth weight, i.e. less than 2.5 kg. This is due mainly to the increased incidence of preterm delivery.

There are studies which report an increased incidence of small for gestational age (SGA) babies in adolescent pregnancies. However, there are other studies which report that young maternal age is not an independent risk factor for SGA babies. As smoking is a determinant of SGA, adolescents who smoke are at increased risk of SGA babies.

It is therefore not surprising that many studies report that stillbirth and death rate of babies in the first week of life (perinatal) and/or first month of life (neonatal) was higher among the babies of adolescent mothers, with the risk highest among mothers in the youngest age groups. The perinatal mortality rate is 50% more in the babies of adolescents compared to those born to mothers in the third decade of life. The neonatal mortality rate is 50% to 100% higher in the babies of adolescents compared to older mothers. Babies who are born before 33 weeks gestational age or whose birth weight is less than 1.5 kg are increased risk of death or serious morbidity.

Pregnant adolescents are more likely to smoke and consume alcohol and they will expose their babies to additional problems consequent to their lifestyle behaviours.

The problems for adolescent mothers in the six weeks after the baby is born include raised blood pressure, anaemia, poor nutrition and some psychosocial problems.

The motivation of adolescent mothers, particularly those from lower socio-economic groups, to delay further childbearing is low. This, together with decreased access to contraception, for various reasons, results in unprotected sexual intercourse and repeat pregnancies, all of which have a deleterious effect on adolescent health.

There are many reports that pregnant adolescents are often subject to physical abuse and that the children of adolescent mothers are also at increased risk of physical abuse. The children of poor adolescent mothers in some developing countries have poorer development of language capabilities and increased behavioural problems.

Societal effects

Adolescent pregnancies impact on society. Many adolescents who get pregnant leave school for a variety of reasons. The curtailment of their education has adverse effects on them and their families.

There are many studies which report that a decrease in adolescent pregnancies considerably improve the general physical and mental health of adolescents, with socio-economic benefits for individuals and their families.

Limited knowledge

Francis Bacon’s statement that knowledge is power is true today as it was about five centuries ago. There is room for improvement in Malaysians’ knowledge of sexual and reproductive health and safe sexual practices.

The National Health & Morbidity Survey in 2006 reported that 35.8% of the respondents possessed knowledge about the symptoms of sexually transmitted infections (STI) and 49.6% about the sexual transmission of human immunodeficiency virus (HIV) infection. Of the sexually active respondents, 63% thought that condoms provide protection against HIV when used correctly every time during sexual intercourse.

A study on Sexual & Reproductive Health among Malaysian college and university students in 2005 by Mazlin Mohamad Mokhtar of the Faculty of Medicine of UiTM, which involved 727 respondents from two public and two private universities, reported that 50% of the students were sexually active, and of these, 80% did not practise contraception. 34% of the students thought that condoms were of no help in the prevention of the spread of HIV. 25% thought that HIV was transmitted through mosquitoes, bed bugs, or flea bites and 60% thought that a man could tell when a woman has STI.

Another study by the National Population and Family Planning Board in 2004 reported that between 47% to 59.6% of the respondents possessed knowledge about the different parts of the reproductive organs. Although 95.5% had heard about HIV, only 64.1% had heard about other STI. 77.4% of adolescents knew about oral contraceptive pills but only 54.9% knew about condoms. Knowledge about other contraceptive methods was less than 10%.

Prevention and support

The needs of adolescents worldwide are stated succinctly by the World Health Organization. They include:

·Information especially comprehensive sexuality education;

·Access to sexual and reproductive health services; and

·Safe and supportive environments devoid of exploitation and abuse.

Adolescents who get pregnant need the support of their families and society, not judgmental attitudes which will certainly aggravate a difficult situation. They require access to education and care, living skills and information on prevention of further pregnancies.

Some policymakers and regulators need to accept that comprehensive sexuality education is based on scientific evidence and promotes a positive approach to sexuality that has been proven to be effective in the making of safe and healthy sexual choices by young people in many countries. It integrates health, cultural, moral and social issues which contribute to the positive sexual development of children and young people.

Measures that encourage pregnancies in adolescents cannot be in their interests, whether it is viewed from a health, educational, or economic perspective. Such measures will negate the hard won success in the reduction of maternal mortality and morbidity, which has taken the country decades to achieve.

Our future

Children and adolescents are our future. Adults have a responsibility to meet their sexual and reproductive health needs as it is crucial to decreasing adolescent pregnancies, the hazards of which are much greater than that of women in the third or fourth decade of life.

Parents, family, politicians and community leaders need to discuss with young people about their needs, desires and concerns, and support them by providing education and youth friendly policies and services. This will empower them to make decisions that safeguard their sexual and reproductive health and ensure that they will form healthy families and communities in future.

■ Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.