Effect of maternal age on birth outcomes among young adolescents

Family Structure and Child Behavior Problems in Australia, the United Kingdom, and the United States

A large body of literature suggests that children living with two married, biological parents on average have fewer behavior problems than those who do not. What is less clear is why this occurs. Competing theories suggest that resource deficiencies and parental selectivity play a part. We suggest that examining different contexts can help adjudicate among different theoretical explanations as to how family structure relates to child behavior problems. In this paper, we use data from the Growing Up in Australia: Longitudinal Study of Australian Children (LSAC), the UK Millennium Cohort Study (MCS), and the US Early Childhood Longitudinal Study (ECLS-K) to examine the relationship between family structure and child behavior problems. Specifically, we look at how living in several configurations of biological and social parents may relate to child behavior problems. Findings suggest both similarities and differences across the three settings, with explanations in the UK results favoring selectivity theories, US patterns suggesting that there is a unique quality to family structure that can explain outcomes, and the Australian results favoring resource theories.

Adverse Maternal and Delivery Outcomes in Children and Very Young (Age ≤13 Years) US Adolescents Compared With Older Adolescents and Adults

This study uses a US claims database to compare morbidity and delivery outcomes among pregnant 10- to 13-year-olds vs 14- to 17-year-olds and 18- to 19-year-olds.

Elastography and Metalloproteinases in Patients at High Risk of Preterm Labor

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality. Its etiopathology is multifactorial; therefore, many of the tests contain the assessment of the biochemical factors and ultrasound evaluation of the cervix in patients at risk of preterm delivery. The study aimed at evaluating the socioeconomic data, ultrasound examinations with elastography, plasma concentrations of MMP-8 and MMP-9 metalloproteinases, and vaginal secretions in the control group as well as patients with threatened preterm delivery (high-risk patients). The study included 88 patients hospitalized in the Department of Obstetrics and Pregnancy Pathology, SPSK 1, in Lublin. Patients were qualified to the study group (50) with a transvaginal ultrasonography of cervical length (CL) ≤ 25 mm. The control group (38) were patients with a physiological course of pregnancy with CL > 25 mm. In the study group, the median length of the cervix was 17.49 mm. Elastographic parameters: strain and ratio were 0.20 and 0.83. In the control group, the median length of the cervix was 34.73 mm, while the strain and ratio were 0.20 and 1.23. In the study group, the concentration of MMP-8 in the serum and secretions of the cervix was on average 74.17 and 155.46 ng/mL, but in the control group, it was significantly lower, on average 58.49 and 94.19 ng/mL. The concentration of MMP-9 in both groups was on the same level. Evaluation of the cervical length and measurement of MMP-8 concentration are the methods of predicting preterm delivery in high-risk patients. The use of static elastography did not meet the criteria of a PTB marker.

Predictors of adverse birth outcomes among pregnant adolescents in Ashanti Region, Ghana

Adolescent pregnancy is associated with adverse birth outcomes. However, the determinants of these outcomes are understudied. The present study sought to identify the predictors of adverse birth outcomes among pregnant adolescents in Ghana. In this prospective health centre-based study, 416 pregnant adolescents, aged 13-19 years old, were followed, and 270 birth outcomes were evaluated. We collected data on socio-demographic variables, eating behaviour, household hunger scale (HHS), lived poverty index (LPI) and compliance to antenatal interventions. The prevalence of low birth weight (LBW) and preterm births (PTB) were 15⋅2 and 12⋅5 %, respectively. Pregnant adolescents with no formal education (AOR 9⋅0; P = 0⋅004; 95 % CI 2⋅1, 39⋅8), those who experienced illness (AOR 3⋅0; P = 0⋅011; 95 % CI 1⋅3, 7⋅0), those who experienced hunger (OR 2⋅9; P = 0⋅010; 95 % CI 1⋅3, 6⋅5) and those with high LPI (OR 2⋅5; P = 0⋅014; 95 % CI 1⋅2, 5⋅3) presented increased odds of delivering preterm babies compared with those who have had secondary education, did not experience any illness, were not hungry or having low LPI, respectively. Pregnant adolescents who used insecticide-treated net (ITN) (AOR 0⋅4; P = 0⋅013; 95 % CI 0⋅2, 0⋅9) presented reduced odds LBW children; while those who experienced illness (AOR 2⋅7; P = 0⋅020; 95 % CI 1⋅2, 6⋅0), poorer pregnant adolescents (OR 2⋅5; P = 0⋅014; 95 % CI 1⋅1, 4⋅8) and those who experienced hunger (AOR 3⋅0; P = 0⋅028; 95 % CI 1⋅1, 8⋅1) presented increased odds of LBW children compared with those who used ITN, were not ill, were not poor or did not experience hunger. Adverse birth outcomes were associated with ANC compliance and socioeconomic factors of the pregnant adolescents. Hence, strengthening antenatal uptake and compliance by pregnant adolescents, promoting their livelihood and socioeconomic status, and interventions to prevent teenage pregnancies are strongly recommended.

Trends of change in the individual contribution of risk factors for small for gestational age over more than 2 decades

PURPOSE

Over the past years, the prevalence of various risk factors for small for gestational age (SGA) neonates has changed. Little is known if there was also a change in the specific contribution of these risk factors to the prevalence of SGA. We aim to identify trends in the specific contribution of various risk factors for SGA by observing their odds ratios (ORs) throughout different time periods.

METHODS

A nested case-control study was conducted. The ORs for selected known risk factors for SGA occurring in three consecutive 8-year intervals between 1988 and 2014 (T1 - 1988-1996; T2 - 1997-2005; T3 - 2006-2014) were compared. Data were retrieved from the medical centre's computerized perinatal database. Multivariable logistic regression models were constructed and ORs were compared to identify the specific contribution of independent risk factors for SGA along the study period.

RESULTS

During the study period, 285,992 pregnancies met the study's inclusion criteria, of which 15,013 (5.25%) were SGA. Between 1988 and 2014, the incidence of SGA increased from 2.6% in 1988 to 2.9% in 2014. Using logistic regression models, nulliparity, maternal age, gestational age, hypertensive disorders of pregnancy, oligohydramnios and pre-gestational diabetes mellitus were found to be independently associated with SGA. While the adjusted ORs (aOR) of hypertensive disorders of pregnancy and pre-gestational diabetes mellitus had increased, aORs for nulliparity, maternal age and gestational age had remained stable over time. Oligohydramnios had demonstrated a mixed trend of change over the time.

CONCLUSION

In our study, the specific contribution of factors associated with SGA had changed over time. Having a better understating of the changes in the specific contribution of different risk factors for SGA may enable obstetricians to provide consultations.

Development and Validation of a Risk Score to Predict Low Birthweight Using Characteristics of the Mother: Analysis from BUNMAP Cohort in Ethiopia

At least one ultrasound is recommended to predict fetal growth restriction and low birthweight earlier in pregnancy. However, in low-income countries, imaging equipment and trained manpower are scarce. Hence, we developed and validated a model and risk score to predict low birthweight using maternal characteristics during pregnancy, for use in resource limited settings. We developed the model using a prospective cohort of 379 pregnant women in South Ethiopia. A stepwise multivariable analysis was done to develop the prediction model. To improve the clinical utility, we developed a simplified risk score to classify pregnant women at high- or low-risk of low birthweight. The accuracy of the model was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration plot. All accuracy measures were internally validated using the bootstrapping technique. We evaluated the clinical impact of the model using a decision curve analysis across various threshold probabilities. Age at pregnancy, underweight, anemia, height, gravidity, and presence of comorbidity remained in the final multivariable prediction model. The AUC of the model was 0.83 (95% confidence interval: 0.78 to 0.88). The decision curve analysis indicated the model provides a higher net benefit across ranges of threshold probabilities. In general, this study showed the possibility of predicting low birthweight using maternal characteristics during pregnancy. The model could help to identify pregnant women at higher risk of having a low birthweight baby. This feasible prediction model would offer an opportunity to reduce obstetric-related complications, thus improving the overall maternal and child healthcare in low- and middle-income countries.

Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study

BACKGROUND

Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes.

METHODS

A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief.

RESULTS

The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death.

CONCLUSION

In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.

Adolescent Health and Well-Being: Background and Methodology for Review of Potential Interventions

Owing to child survival initiatives around the world in the 1970s and 1980s, a dramatic rise in the population of adolescents has been seen, especially in the developing countries. A quarter of world's population in 2012 comprised adolescents and young adults; of these, 90% lived in low- and middle-income countries. More recently, there has been a consensus on investing in adolescent health and development for the success of post-2015 developmental agenda. In this series of articles, we aimed to assess various interventions identified in our conceptual framework to evaluate their effectiveness in improving adolescent health. We took a systematic approach to consolidate the existing evidence. This article is an introductory article detailing the background, conceptual framework, and methodology used for synthesizing evidence, followed by seven articles summarizing evidence on interventions for sexual/reproductive health, nutrition, immunization, mental health, substance abuse, and accidents/injury. The concluding article of the series summarizes the findings of the all the previous articles in the series and the relevance of the evidence for action in the post-2015 Millennium Development Goals era along with evidence gaps and future research priorities.

Interpregnancy intervals and the risk for infant mortality: a case control study of Arizona infants 2003-2007

There is well-documented evidence on how interpregnancy interval (IPI) is associated with adverse perinatal outcomes and how short and long IPIs are associated with increased risk for preterm birth, low birth weight, and intra-uterine growth restriction. However, the extremes of IPI on infant mortality are less well documented. The current study builds on the existing evidence on IPI to examine if extremes of IPI are associated with infant mortality, and also examines if IPI is associated with both neonatal and post-neonatal mortality after adjusting for several known confounders. Matched birth and death certificate data for Arizona resident infants was drawn for 2003-2007 cohorts. The analysis was restricted to singleton births among resident mothers with a previous live birth (n = 1,466) and a randomly selected cohort of surviving infants during the same time-frame was used as a comparison group (n = 2,000). Logistic regression models were utilized to assess the odds for infant mortality at monthly interpregnancy intervals (<6, 6-11, 12-17, 18-23, 24-59, ≥60), while adjusting for established predictors of infant mortality (i.e., preterm birth, low birth weight, and small for gestational age), and other potential confounders. Unadjusted analysis showed greater clustering at extreme IPIs of <6 months and ≥60 months for infants that died (32%) compared to infants that survived (24.7%). Shorter IPI (i.e., <6 months, 6-11 months, and 12-17 months) compared to 'ideal' IPI (i.e., 18-23 months), were associated with infant mortality even after adjusting for confounders. Short intervals were significantly associated with neonatal, but not post-neonatal deaths. IPI above 23 months were not associated with infant mortality in our analyses. Shorter IPIs (18 months or less) significantly increases the risk for neonatal infant mortality even after controlling for known confounders, and our study adds to the existing evidence on adverse perinatal outcomes. Counseling women of reproductive age on the benefits of spacing pregnancies to at least 18 months addresses one preventable risk for early infant mortality.

Obesity trends and perinatal outcomes in black and white teenagers

OBJECTIVE

Our objective was to explore the trends in prepregnancy body mass index (BMI) for black and white teenagers over time and the association between elevated BMI and outcomes based on race.

STUDY DESIGN

This was a retrospective cohort study of singleton infants (n = 38,158) born to black (34%) and white (66%) teenagers (<18 years of age). We determined the prevalence of elevated prepregnancy BMI between 1993 and 2006 and the association between elevated prepregnancy BMI (primary exposure) and maternal and perinatal outcomes based on race (2000-2006).

RESULTS

The percentage of white teenagers with elevated prepregnancy BMI increased significantly from 17-26%. White and black overweight and obese teenagers were more likely to have pregnancy-related hypertension than normal-weight teenagers; postpartum hemorrhage was increased only in obese black teenagers, and infant complications were increased only in overweight and obese white teenagers.

CONCLUSION

Because the percentage of elevated prepregnancy BMI has increased in white teenagers, specific risks for poor maternal and perinatal outcomes in the overweight and obese teenagers varies by race.

The impact of early age at first childbirth on maternal and infant health

The objective of this review was to assess whether early age at first childbirth is associated with increased risk of poor pregnancy outcomes. Early age at childbirth is variously defined in studies of its effect on maternal and infant health. In this systematic review, we limit analysis to studies of at least moderate quality that examine first births among young mothers, where young maternal age is defined as low gynaecological age (≤ 2 years since menarche) or as a chronological age ≤ 16 years at conception or delivery. We conduct meta-analyses for specific maternal or infant health outcomes when there are at least three moderate quality studies that define the exposure and outcome in a similar manner and provide odds ratios or risk ratios as their effect estimates. We conclude that the overall evidence of effect for very young maternal age (<15 years or <2 years post-menarche) on infant outcomes is moderate; that is, future studies are likely to refine the estimate of effect or precision but not to change the conclusion. Evidence points to an impact of young maternal age on low birthweight and preterm birth, which may mediate other infant outcomes such as neonatal mortality. The evidence that young maternal age increases risk for maternal anaemia is also fairly strong, although information on other nutritional outcomes and maternal morbidity/mortality is less clear. Many of the differences observed among older teenagers with respect to infant outcomes may be because of socio-economic or behavioural differences, although these may vary by country/setting. Future, high quality observational studies in low income settings are recommended in order to address the question of generalisability of evidence. In particular, studies in low income countries need to consider low gynaecological age, rather than simply chronological age, as an exposure. As well, country-specific studies should measure the minimum age at which childbearing for teens has similar associations with health as childbearing for adults. This 'tipping point' may vary by the underlying physical and nutritional health of girls and young women.

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

OBJECTIVE

To examine the association between maternal age at first birth and infant mortality, stunting, underweight, wasting, diarrhoea and anaemia in children in low- and middle-income countries.

DESIGN

Cross-sectional analysis of nationally representative household samples. A modified Poisson regression model is used to estimate unadjusted and adjusted RR ratios.

SETTING

Low- and middle-income countries.

POPULATION

First births to women aged 12-35 where this birth occurred 12-60 months prior to interview. The sample for analysing infant mortality is comprised of 176,583 children in 55 low- and middle-income countries across 118 Demographic and Health Surveys conducted between 1990 and 2008.

MAIN OUTCOME MEASURES

Infant mortality in children under 12 months and stunting, underweight, wasting, diarrhoea and anaemia in children under 5 years.

RESULTS

The investigation reveals two salient findings. First, in the sample of women who had their first birth between the ages of 12 and 35, the risk of poor child health outcome is lowest for women who have their first birth between the ages of 27 and 29. Second, the results indicate that both biological and social mechanisms play a role in explaining why children of young mothers have poorer outcomes.

CONCLUSIONS

The first-born children of adolescent mothers are the most vulnerable to infant mortality and poor child health outcomes. Additionally, first time mothers up to the age of 27 have a higher risk of having a child who has stunting, diarrhoea and moderate or severe anaemia. Maternal and child health programs should take account of this increased risk even for mothers in their early 20s. Increasing the age at first birth in developing countries may have large benefits in terms of child health.

Impact of change in maternal age composition on the incidence of Caesarean section and low birth weight: analysis of delivery records at a tertiary hospital in Tanzania, 1999-2005

BACKGROUND

Previous studies on change in maternal age composition in Tanzania do not indicate its impact on adverse pregnancy outcomes. We sought to establish temporal changes in maternal age composition and their impact on annual Caesarean section (CS) and low birth weight deliveries (LBWT) at Muhimbili National Hospital in Tanzania.

METHODS

We conducted data analysis of 91,699 singleton deliveries that took place in the hospital between 1999 and 2005. The data were extracted from the obstetric data base. Annual proportions of individual age groups were calculated and their trends over the years studied. Multiple logistic analyses were conducted to ascertain trends in the risks of CS and LBWT. The impact of age composition changes on CS and LBWT was estimated by calculating annual numbers of these outcomes with and without the major changes in age composition, all others remaining equal. In all statistics, a p value < 0.05 was considered significant.

RESULTS

The proportion of teenage mothers (12-19 years) progressively decreased over time while that of 30-34 years age group increased. From 1999, the risk of Caesarean delivery increased steadily to a maximum in 2005 [adjusted OR = 1.7; 95%CI (1.6-1.8)] whereas that of LBWT declined to a minimum in 2005 (adjusted OR = 0.76; 95% CI (0.71-0.82). The current major changes in age trend were responsible for shifts in the number of CS of up to206 cases per year. Likewise, the shift in LBWT was up to 158 cases per year, but the 30-34 years age group had no impact on this.

CONCLUSION

The population of mothers giving birth at MNH is progressively becoming older with substantial impact on the incidence of CS and LBWT. Further research is needed to estimate the health cost implications of this change.

Outcome of teenage pregnancy

OBJECTIVE

The objective of the study was to evaluate the obstetric, fetal and neonatal outcomes of teenage pregnancy in a tertiary care teaching hospital.

METHODS

A retrospective case control study was performed over a period of 5 years. Data were retrieved from hospital records. All teenage mothers (aged 13-19 completed years at delivery) delivering in the University Hospital were taken as cases. Next 3 consecutive deliveries in the age group of 20-30 year were selected as controls for each case. For statistical analysis the cases were further subdivided into 2 groups, 17 years (Group A) and 18 -19 years (Group B). Groups were compared for obstetric complications and neonatal outcome. Statistical analysis was done by software package SPSS 10.

RESULTS

The incidence of teenage deliveries in hospital over last 5 years was 4.1%. Majority of the teenagers were primigravida (83.2% vs. 41.4%, p< 0.01). Complications like pregnancy induced hypertension (PIH) (11.4% vs 2.2%, p< 0.01), pre-eclamptic toxemia (PET) (4.3% vs 0.6%, p< 0.01) eclampsia (4.9% vs 0.6%, p< 0.01) and premature onset of labor (26.1% vs 14.6%, p< 0.01) occurred more commonly in teenagers compared to controls. Teenage mothers also had increased incidence of low birth weight (LBW) (50.4% vs 32.3%, p< 0.01), premature delivery (51.8% vs 17.5%, p< 0.01) and neonatal morbidities like perinatal asphyxia (11.7% vs 1.9%, p< 0.01), jaundice (5.7% vs 1.2%, p< 0.01) and respiratory distress syndrome (1.9% vs 0.3%, p< 0.05). Teenage pregnancy was also associated with higher fetal (1.9% vs 0.3%, p< 0.05) and neonatal mortality (3.8% vs 0.5%, p< 0.05).

CONCLUSION

Teenage pregnancy was associated with a significantly higher risk of PIH, PET, eclampsia, premature onset of labor, fetal deaths and premature delivery. Increased neonatal morbidity and mortality were also seen in babies delivered to teenage mothers. Younger teenager group (17 years) was most vulnerable to adverse obstetric and neonatal outcomes.

Associations of maternal age- and parity-related factors with trends in low-birthweight rates: United States, 1980 through 2000

OBJECTIVES

We assessed the effects of changes in the maternal age-parity distribution and age-and parity-specific low-birthweight rates on low-birthweight trends in the United States.

METHODS

We used natality file data from 1980 through 2000 to assess very-low-birthweight and low-birthweight rates among singleton live-born infants.

RESULTS

Changes in age-and parity-specific low-birthweight rates were the main contributor to the overall trend in rates. However, changes in the age-parity distribution, primarily delayed childbearing, had a smaller but noticeable impact. The very-low-birthweight rate increased 27% among Black women, and changes in the age-parity distribution were associated with, on average, more than 20% of the increased rate during the 1990s. Among Hispanic and non-Hispanic White women, on average, more than 10% of the rate increase observed during the 1990s was associated with changes in the age-parity distribution.

CONCLUSIONS

Assuming minimal changes in age-specific rates, delayed childbearing may play an increasingly important role in low-birthweight trends in the United States.

Defining early adolescent childbearing

OBJECTIVES

This study determined the age group for the case definition of early adolescent childbearing based on rates of adverse clinical outcomes.

METHODS

We examined rates of infant mortality, very low birthweight (<1500 g), and very preterm delivery (<32 weeks) per 1000 live births for all US singleton first births (n = 768 029) to women aged 12 to 23 years in the 1995 US birth cohort.

RESULTS

Rates of infant mortality, very low birthweight, and very preterm delivery were graphed by maternal age. In all 3 cases, the inflection point below which the rate of poor birth outcome is lower and begins to stabilize is at 16 years; therefore, mothers 15 years and younger were grouped together to determine the case definition of early adolescent childbearing. The inflection points were similar when outcomes were stratified by the 3 largest US racial/ethnic groups (non-Hispanic White, non-Hispanic Black, and Mexican American).

CONCLUSIONS

From this population-based analysis of birth outcomes, we conclude that early adolescent childbearing is best defined as giving birth at 15 years or younger.

Perceptions of motivators and barriers to public prenatal care among first-time and follow-up adolescent patients and their providers

OBJECTIVES

To compare perceptions of the motivators and barriers to obtaining public prenatal care from the perspectives of pregnant adolescents coming for first-time and follow-up appointments, as well as among those of their prenatal care providers.

METHOD

The patient sample consisted of 250 consecutive, adolescent, public prenatal patients coming to one of the 5 prenatal clinics in one county in Arkansas. Patient responses were analyzed by appointment status (first-time vs. follow-up visitors). Sixteen providers at the same public prenatal clinics were also interviewed using the same survey instrument.

RESULTS

We observed striking differences between patients and providers with respect to their perceptions of both the motivators and barriers to prenatal care. Adolescents reported "concern over the health of their baby" as a primary motivation, while providers identified adolescents' "concern over their own health" as the most important reason. With regard to barriers, adolescents were more likely to identify system-related barriers (e.g., lack of finances and transportation, and waiting time for appointments), while providers were more likely to identify personal barriers (e.g., feeling depressed, fear of procedures, and needing time to deal with problems at home). Patients and providers agreed, however, that fear of procedures and not wanting to be pregnant were important barriers to care.

CONCLUSIONS

The differences in perceptions between adolescents and their prenatal care providers suggest that poor patient-provider communication may represent one of the single most important nonfinancial barriers to care. Possible explanations for inadequate patient-provider communication as well as solutions to improve their clinic interactions are discussed.