1. Introduction

Teenage pregnancy remains a global public health challenge, with an estimated 21 million girls aged 15–19 years in developing countries becoming pregnant, 12 million of whom give birth every year [1].

Sub-Saharan Africa had the highest prevalence of teenage pregnancy in the world in 2013 [2] with births to teenage mothers accounting for more than half of all the births [3]. Uganda has one of the highest rates of teenage pregnancy in the world at 25% which is more than twice the global estimate of 11% of all births [4].

Pregnant teenagers are at a higher risk of adverse maternal conditions, including preterm labor, puerperal sepsis, postpartum hemorrhage, and maternal trauma, and a high rate of cesarean sections for cephalopelvic disproportion, fetal distress, and preterm births. This same population of teenage mothers is at high risk of adverse fetal outcomes such as stillbirths, birth asphyxia, respiratory distress syndrome, admission to NICU, and early neonatal death (ENND) [5–8].

Several studies in developed and developing countries have shown that most teenage pregnant mothers do not attend the required antenatal care (ANC) visits or present late in labor, which has been associated with poor obstetric and fetal outcomes. Most of these studies were based on retrospective data collection, making them prone to missing data. No study has examined teenage mothers in Uganda, and the prevalence and factors associated with adverse maternal and fetal outcomes remain largely unknown. Therefore, this study is aimed at determining the prevalence of, and factors associated with adverse maternal and fetal outcomes among teenagers who delivered at a National Referral Hospital in Uganda.

2. Materials and Methods

This was a cross-sectional study.

The study was carried out in the postnatal wards of Mulago National Referral Hospital, which also functions as a teaching hospital for Makerere University College of Health Sciences. At the time of the study, the Department of Obstetrics and Gynecology was located at Kawempe Hospital, which had 27,202 deliveries in 2017 (1 January–31 December, departmental records, unpublished data).

3. Results and Discussion

The median age of the participants was 18 years, and 76% of the participants were older than 18 years. About 5% had no formal education, 61% had studied to the primary school level, and 34% had attained secondary school status. Approximately 2% of the participants were underweight and 6% were obese (Table 1).

The majority of the teenagers did not have any adverse maternal or fetal outcomes. There were 17 stillbirths with seven fresh stillbirths (FSBs), seven macerated stillbirth (MSB), and three ENND (Table 2).

The only factor associated with adverse maternal outcome was gestational age where teenage mothers had 4 times likelihood of delivering before 37 weeks (Table 3).

There were no factors found to be statistically significant in association with adverse fetal outcome except gestational age (Table 4). Teenage mothers had an 81% chance of delivery before 37 weeks.

4. Discussion

The median age of the participants was 18 years (IQR = 5.0), with approximately 76% of the teenage mothers between 18 and 19 years. Approximately 75% of the teenagers were unemployed (Table 1). This agrees with results of the UDHS 2016 which indicated that the teenagers in the lower quintile of wealth tend to begin childbearing earlier than those in the highest quintile of wealth, 34% versus 15%, respectively [4]. Of all the study participants, 34% had achieved secondary school education and above, with 61% dropping out at primary school level and 5% not having received any formal education (Table 1). This is similar to findings of the USAID-YALI (Young African Leaders Initiative) report of 2018 which reported a remarkable drop in the number of adolescent girls who continue their education beyond primary school; while 87% of girls enroll in primary school, only 39% complete secondary school. It is also worth noting that one of the government’s strategies for preventing teenage pregnancies is to keep girls in school. Therefore, our findings reinforce the government’s initiative to keep girls in school to minimize the risk of teenage pregnancy.

The prevalence of obstructed labor among teenagers was 18%, whereas 5% had preterm labor. No maternal death occurred during the study period (Table 2). This contrasts with a hospital study conducted in India, which reported a higher prevalence of preterm labor (27.45%) among teenage pregnant mothers [13]. This could be attributed to the fact that these studies were carried out on different races in totally different environments. Most of the babies delivered were below 2.5 kg. This is similar to a study done in Oman where teenage mother had a higher prevalence of low birthweight babies [14]. The low birthweight babies in this particular group may be associated with low ANC attendance and poor maternal nutrition which may be prevalent among teenage mothers bearing in mind the fact that many teenage mothers may be of low socioeconomic status [15]. The prevalence of birth asphyxia was 18% (Table 2). This is similar to a study done in Mogadishu, Somalia, which reported a prevalence of 13.3%. This may be because teenage mothers may be more likely to have a contracted pelvis because of their young age which may predispose them to obstructed labor and caesarian section. The prevalence of stillbirths (FSB, MSB, and ENNDs combined) was 4.4% (Table 2). While this may appear low, it fits in with reports that indicate that teenage mothers are prone to stillbirths because of the increased incidence of contracted pelvis, preterm labor, and caesarian section [16].

The only factor associated with adverse maternal outcomes among teenage mothers was preterm labor (delivery before 37 weeks). Teenage mothers were 4 times more likely to deliver before 37 weeks than at 37 weeks and above (AOR = 3.78, 95% CI 1.67–8.55) (Table 3). This is similar to a study done in Sao Luis, Northern Brazil, which showed that teenage mothers were prone to preterm labor (OR = 1.70, 95% CI 1.02–3.08) [14]. Some studies have however reported no association even after controlling for confounders such as socioeconomic status [17].

In this study, preterm birth was the only adverse fetal factor associated with teenage pregnancy. Teenage mothers had an 81% chance of having a preterm birth (birth before 37 weeks) (Table 4). All the other factors studied such as maternal age, education level, marital status, religion, employment status, household income, maternal BMI, and partograph use during labor did not show any significant association. This is similar to a study conducted in Cameroon, which showed no association between adolescent pregnancy and stillbirths and intrauterine growth retardation but demonstrated an association between adolescent pregnancy and low birth weight, prematurity, and ENND [18]. Another study conducted in Pakistan also indicated no association between teenage pregnancy and adverse neonatal outcomes, especially in a setting of good ANC [19]. Studies investigating the association between fetal outcome and maternal age have yielded contrasting results. Adverse fetal outcomes in teenagers have been postulated to be due to both biological immaturity and socioeconomic factors. Teenagers are more prone to poor nutrition, emotional stress, illicit drug use, and inadequate ANC, and the authors have postulated that improved socioeconomic status of teenagers can lead to better pregnancy outcomes [17]. While poor socioeconomic status is associated with adverse pregnancy outcome, it has also been reported to be a driver for high teenage pregnancy rates among teenagers who get involved in early sexual encounters to make a living, which makes it a viscous cycle [20]. The difference between our findings and other studies may be because of differences in the socioeconomic background of the teenagers included in the study.

5. Conclusions

Teenage pregnancy was generally not associated with adverse maternal or fetal outcomes except for preterm birth. The reasons for adverse pregnancy may reflect a combination of gynecological and biological immaturity, as well as adverse socioeconomic pressures. The interpretation of these results may be limited in relation to the bigger picture of adverse maternal and fetal outcomes, and a study comparing adverse outcomes between teenage mothers and mothers above 19 years may provide better results.

Ethics Statement

This study was approved by the Makerere University School of Medicine Research and Ethics Committee (SOMREC) approval number #REC REF 2019-002.

Consent

The participants provided written informed consent and were informed that the results may be published in international journals to which they had no objection. All the datasets were stored as password-protected files on a password-protected laptop belonging to the principal investigator. All authors have consented to participate in this publication by taking full responsibility and accountability for the content of the article. All the work, figures, and tables in this publication were prepared by the authors, and where other work is used, it has been appropriately cited.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

M.N.K., O.A.O., and M.N. made a significant contribution to the work reported, from the conception stage, study design, execution, acquisition of data, analysis, and interpretation, and drafting, revising, and critically reviewing the article. They gave final approval for the version to be published, agreed on the journal to which the article was submitted, and agreed to be accountable for all aspects of the work. M.N.K. and O.A.O. contributed equally to this work and are both first authors.

Funding

The authors received no specific funding for this work.