Journal of Obstetrics and Gynaecology, April 2010; 30(3): 253256

OBSTETRICS

Obstetric outcome of teenage pregnancies from 2002 to 2008: The Shefeld experience

S. JIVRAJ, Z. NAZZAL, P. DAVIES & K. SELBY

Department of Obstetrics and Gynaecology, Jessop Wing, Shefeld, UK

Summary We compared the obstetric outcome of 1,922 teenage pregnant women with a control population of 10,550 women aged 20 39 years. The teenage women had a signicantly higher normal vaginal delivery rate (65% vs 45%; RR 1.44, 95% CI: 1.38 1.49; p 5 0.001) and a lower operative delivery rate compared with control women (elective caesarean section: 1.7% vs 4.9%, RR 0.347, 95% CI: 0.250.49, p 5 0.001; emergency caesarean section: 13.3% vs 22.9%, RR 0.58, 95% CI: 0.510.65, p 5 0.001; instrumental delivery: 19.3% vs 26.3%, RR 0.73, 95% CI: 0.660.81, p 5 0.001). There was no difference in the pre-term delivery rate or in the stillbirth rate between the two groups. When stratied further, there was no difference in the pre-term delivery rate and low birth weight rate between teenage mothers aged 1317 years and those aged 1719 years. Teenage pregnant women have better obstetric performance in terms of mode of delivery without an increased risk of stillbirth or prematurity compared with older women. Keywords Obstetric complications, teenage pregnancy

Introduction
The UK has the highest teenage pregnancy rate in Western Europe. In 2003, 42,000 girls under the age of 18 became pregnant in England and Wales, equivalent to a rate of 41.7 conceptions per 1,000 girls aged 1517 years (National Statistics 2006). Recently, alongside cardiovascular disease, cancer and mental health, teenage pregnancy has been considered a public health problem. Published data on the outcome of teenage pregnancies have variably shown an association with small for gestational age and pre-term labour (Yadav et al. 2008; Fraser et al. 1995; Lao and Ho 1997; Sharma et al. 2008; Smith and Pell 2001). A consistent feature however, is a low rate of caesarean section (Yadav et al. 2008; Lao and Ho 1997; Smith and Pell 2001). Previous studies have been carried out in areas of social and economic deprivation (Yadav et al. 2008; Sharma et al. 2008; Goonewardene and Deeyagaha Waduge 2005; Mahavarkar et al. 2008; Maryam and Ali 2008) or if in the UK, have been carried out before government initiatives of additional social and antenatal support for teenage pregnant women were introduced (Smith and Pell 2001; Osbourne et al. 1981). In the UK, specialised antenatal care and government initiatives facilitate an environment of social and economic support which differs from areas of social deprivation where much of published research on teenage pregnancy originates. Further many studies examining the perinatal outcome of teenage pregnancies have included both primigravidae and multiparous women. Studies have also shown a higher

stillbirth rate in this group of women (Yadav et al. 2008) and a recent UK Condential Enquiry into Maternal and Child Health (CEMACH) report suggested a high perinatal mortality rate in the 520 years age group (CEMACH 2008). We sought to examine the obstetric outcome of teenage women in Shefeld, UK, from 2002 to 2008 and compare this with a control group of women aged 2039 years. This was therefore a retrospective cohort study.

Methods Study population

All teenage pregnant women referred for antenatal care to the Jessop Wing, Shefeld are seen in a dedicated teenage pregnancy antenatal clinic for their booking visit. In addition to a dating ultrasound scan and routine antenatal screening, information is provided about support systems in place such as benets, parenting courses and future childcare provision for those women wishing to re-enter full/part-time education or employment. A further appointment is arranged after the mid-trimester fetal anomaly scan and future contraception is discussed. Thereafter, antenatal care is largely shared with the general practitioner and community midwife. All teenage women and women aged 2039 years, booked for antenatal care at the Jessop Wing between 2002 and 2008, were identied from a hospital database. Pregnancy outcome data were extracted from the hospital

Correspondence: S. Jivraj, Department of Obstetrics and Gynaecology, Jessop Wing, Tree Root Walk, Shefeld S10 2SF, UK. E-mail: sjivraj007@aol.com ISSN 0144-3615 print/ISSN 1364-6893 online 2010 Informa Healthcare USA, Inc. DOI: 10.3109/01443611003605294

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Signicantly more teenage women had low birth weight babies (10.5% vs 8.5%; RR 1.23, 95% CI: 1.061.42; p 0.005) compared with the control population of women aged 2039 years. Teenage women also had a signicantly higher normal vaginal delivery rate (65% vs 45%; RR 1.44, 95% CI: 1.381.49; p 5 0.001) and a lower operative delivery rate compared with control women (elective caesarean section: 1.7% vs 4.9%, RR 0.347, 95% CI: 0.250.49, p 5 0.001; emergency caesarean section: 13.3% vs 22.9%, RR 0.58, 95% CI: 0.510.65, p 5 0.001; instrumental delivery: 19.3% vs 26.3%, RR 0.73, 95% CI: 0.660.81, p 5 0.001). There was no difference in the pre-term delivery rate (8.5% vs 7.9%, RR 1.08, 95% CI: 0.921.27, p NS) or in the stillbirth rate (0.47% vs 0.38%, RR 1.23, 95% CI: 0.612.50, p NS) between teenage women and women aged 2039 years. More teenage women had vaginal breech deliveries. However, this difference was not statistically signicant (0.62% vs 0.48%, RR 1.29, 95% CI: 0.702.39, p NS) (Table I). When stratied further, teenage pregnant women showed no difference in pre-term delivery rate or in the incidence of low birth weight neonates between women aged 1316 years and those aged 1719 years (Table II).

maternity database: Protos Evolution. This was therefore a retrospective cohort study. Women with a history of recurrent miscarriage (3 rst trimester miscarriages) were excluded as they represent a group with a higher incidence of obstetric complications than the general population (Jivraj et al. 2001). Only women having their rst baby were included in the study. We however did include women who had previously had up to two rst trimester miscarriages or terminations of pregnancy. Women were divided into two age groups: those aged 520 years and those aged 2039 years. The latter age group was chosen to represent the control population. Maternal age was dened as the womans age at delivery. Low birth weight (LBW) is dened as birth weight 52,500 g irrespective of gestational age. Small for gestational age (SGA) is dened as birth weight less than the 10th percentile for any given gestational age. It is taken as a surrogate marker of intrauterine growth restriction. Pre-term delivery is dened as gestational age of 537 completed weeks at birth. Stillbirth is dened as birth of a baby with no signs of life after 24 completed weeks gestation. Maternal age, gestational age at delivery, birth weight and mode of delivery were recorded at delivery and a comparison was made between cases (520 years age group) and controls (2039 years age group).

Discussion
Previous studies reporting the perinatal outcome of teenage pregnancies have included both primigravidae and multiparous women (Yadav et al. 2008). It has been suggested that teenage women are more likely to have an adverse perinatal outcome in their second and subsequent pregnancies compared with their rst pregnancy. In one large Scottish study, stratied by teenage women in their rst and second pregnancies, Smith and Pell (2001) found that among rst births, compared with older women, teenage women were not at increased risk of having a small for gestational age baby dened as birth weight less than the 5th percentile for a given gestational age (4.2% vs 3.8%), or pre-term delivery (6.2% vs 5.4%), or stillbirth (0.5% vs 0.4%). However, among second births, teenage women were at signicantly increased risk of pre-term delivery (6.1% vs 3.5%, p 5 0.001) and stillbirth (0.7% vs 0.3%, p 0.002) compared with older women (Smith and Pell 2001). In our study, we only examined the outcome of teenage pregnancies among rst births. Both our study and the study by Smith and Pell (2001) demonstrated a lower emergency caesarean section rate among rst births and no

Statistical analysis
Statistical analysis was performed using SPSS version 12 (SPSS, Chicago IL, USA). Discrete variables were analysed using Fishers exact test or the w2 test and continuous variables were analysed using the Mann Whitney U test; p values 50.05 were taken as statistically signicant. Relative risk (RR) and 95% condence intervals (CI) were calculated where appropriate.

Results
A total of 1,922 teenage women 520 years of age (range 1319 years; median 18 years) were compared with a control population of 10,550 women aged 2039 years (median 28 years). The age group of 2039 years was selected as the control population, as this age group represents the largest group of childbearing women in Shefeld. This age groups also falls in between the two extremes of childbearing age groups those under 20 and those who are 40 years and over.

Table I. Outcome of teenage pregnancies vs pregnancies in women aged 2039 years. Cases, women 520 years (n 1922) Outcomes (%) Pre-term delivery rate Low birth weight rate Normal vaginal delivery Elective caesarean section Emergency caesarean section Instrumental delivery Vaginal breech delivery Stillbirth NS, not signicant. n 164 202 1251 33 255 371 12 9 (%) 8.5 10.5 65 1.7 13.3 19.3 0.62 0.47 Controls, women aged 2039 years (n 10550) n 831 899 4782 522 2416 2779 51 40 (%) 7.9 8.5 45 4.9 22.9 26.3 0.48 0.38 Relative risk 1.08 1.23 1.44 0.347 0.58 0.73 1.29 1.23 95% CI 0.921.27 1.061.42 1.381.49 0.250.49 0.510.65 0.660.81 0.702.39 0.612.50 p value NS 0.005 50.001 50.001 50.001 50.001 NS NS

Obstetric outcome of teenage pregnancies from 2002 to 2008

Table II. Outcome of pregnancies in 1316 years vs 1719 years age groups. 1316 years (n 285) Outcomes (%) Pre-term delivery rate Low birth weight rate n 23 (%) 8.1 1719 years (n 1637) n 141 (%) 8.6 Relative risk 0.94 95% CI 0.611.42 p value 0.85

255

32

11.2

172

10.5

1.07

0.751.51

0.79

teenage mothers, there was no difference in the obstetric outcome between mothers under 17 years and those aged 1719 years. Our study demonstrates that as a group, despite a higher rate of lower birth weight neonates, teenage pregnant women have better obstetric performance in terms of mode of delivery without an increased risk of stillbirth or prematurity compared with older women. Larger studies in the form of nationally coordinated data acquisition systems are needed to quantify the true obstetric complication rates among teenage pregnancies after accounting for sociodemographic variables.

Conclusion
Teenage pregnant women have better obstetric performance in terms of mode of delivery without an increased risk of stillbirth or prematurity compared with older women.

difference in the rate of pre-term delivery. We were thus able to conrm the ndings of Smith and Pell (2001). The ndings of our study however, differ from the ndings of a large study by Fraser et al. (1995), which was conducted among a predominantly Caucasian population in North America. In that study, the risks of low birth weight (12% vs 4%, p 5 0.001), pre-term delivery (18% vs 5%, p 5 0.001) and small for gestational age (26% vs 10%) were higher among teenage women compared with women aged 2024 years. Our study demonstrated a higher rate of low birth weight babies in the teenage population compared with the control population (10.5% vs 8.5%; RR 1.23, 95% CI: 1.061.42; p 0.005), but showed no signicant difference in the stillbirth rate between the two groups. An important limitation in our report is that our study has not controlled for all demographic variables such as smoking, nutrition, BMI, ethnic group, socioeconomic factors and parental support, which may play a role in contributing to obstetric outcome. Babies whose mothers smoke during pregnancy are more likely to have low birth weight than babies whose mothers do not smoke (Chan and Sullivan 2008). It has been suggested that gynaecological immaturity may explain in part the association of teenage pregnancy with adverse outcome. Growing pregnant adolescents are at increased risk of fetal growth restriction, possibly explained by an inadequately developed utero-placental blood supply and inadequate transfer of nutrients (Scholl et al. 1997). Nevertheless, reported studies have shown a variable inuence of sociodemographic factors with pregnancy outcome (Fraser et al. 1995; Chen et al. 2007). Another limitation to our data is the incidence of pre-eclampsia among teenage women. Our data acquisition system did not cater for this variable and we were thus unable to comment on the difference in the incidence of this complication of pregnancy between teenage women and older women. Studies comparing the outcome of older vs younger teenagers have shown variable results. In a large population study, Chen et al (2007) found that mothers ages 15 years and under had higher rates of pre-term delivery, low birth weight and low Apgar scores compared with older teenagers. In the present study, teenage pregnant women aged 1316 years showed no difference in pre-term delivery rate or in the incidence of low birth weight neonates compared with teenage pregnant women aged 1719 years. Our ndings are in keeping with the study by Lao and Ho (1998) in which they demonstrated that among 382

Acknowledgements
Our thanks go to Lyn Burgin and Angelina Gittens, teenage pregnancy midwives at the Jessop Wing, Shefeld Teaching Hospitals NHS Foundation Trust. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

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