CHAPTER ONE; INTRODUCTION

1.1 BACKGROUND

Adolescence is defined as all persons aged 10 to 19 years, and it is further subdivided into younger adolescents (10 to 14 years) and older adolescents (15 to 19 years) (1). In developed and developing nations alike, adolescent pregnancy is of growing public health importance with approximately 11% of global births occurring in girls aged 15 to 19 years, and about 95% of these births occur in low and middle countries (LMICs) (2). The regional burden in LMICs is more in sub-Saharan Africa (SSA), where it is estimated that about half of the women gave birth before the age of 20 years, with a resultant high pregnancy-related morbidity and mortality (3,4).

In Africa, a quarter of the estimated 6 million unsafe abortions and 22,000 abortion-related deaths annually occur among women aged 15–19 years (5), suggesting that adolescent pregnancy is often not the result of a deliberate choice. In these settings, adolescent pregnancy is a multifaceted problem and, among others, exposes these young girls to a variety of medical, socio-cultural and economic risks. Factors such as marital status, poverty, culture, inadequate knowledge on sexual education/contraceptive use, gender-based violence/inequalities and substance abuse have been implicated as some predictors of adolescent pregnancy (6,7,8). These young mothers face a higher risk of dropping out of school and social exclusion from family members, teachers and peers which may have a long-lasting negative impact on their physical and mental health (9,10,11,12). Also, increased risk of adverse pregnancy outcomes including stillbirth, preterm birth, low birthweight, perinatal death, obstructed labour, perineal tears, obstetric fistulae, postpartum haemorrhage and maternal deaths have been noted to occur among adolescent girls (13,14,15,16,17). Furthermore, it has been observed that babies born to adolescent mothers have a significantly increased risk of living in poverty, poor school performance and being unemployed later in life (18). All these have substantial costs to society and contribute to the vicious cycle of ill-health, neglect and poverty worldwide (2,15,19).

Thus, giving the considerable variability and somewhat controversial views on predisposing factors (predictors) and outcomes of adolescent pregnancy (16,17,20,21), there is a consequent need for a large and high-quality study, especially from LMICs where most of the adverse outcomes are documented to occur.

Maternal age at childbearing has dramatically shifted in the last decades due to a broad range of social and cultural determinants. In Italy the mean age at delivery rose from 25.2 years in 1981 to 31.7 in 2015 (22,23). This trend toward delayed childbearing is reported worldwide (e.g. USA or China) (24,25,26), and comes, in parallel, with a decline in pregnancies at a younger age, so that these are increasingly rare in developing countries. The teen birth rate in the USA has fallen 61% from 1991 (26).

Both extremes of the reproductive age are considered at risk for adverse pregnancy outcomes. Teenage mothers have a higher risk of preterm birth, low birth weight, low Apgar score and postnatal mortality (27). Whether this association is determined by a biological immaturity or rather by socio-economic disadvantages, behavioural factors or lack of access to high quality antenatal care is still a topic for much discussion. (28,29,30). On the other hand, delayed childbearing carries a higher risk of maternal and obstetric complications. The concern for the “elderly primigravida” was first published in 1950 (31); since then, many researchers investigated the effect of aging on birth outcome. The majority of studies report an association between advanced maternal age and preterm delivery, low birth weight, perinatal death, and cesarean section (32,33,34,35,36,37). There are some studies, however, that fail to demonstrate such unfavourable conclusions (25,38,39,40). And an emerging third category even demonstrates positive outcomes, with an example being a recent retrospective study from China which found a lower risk of adverse fetal outcome for older mothers (25). The impact of presumed social and economic advantages of older women outweighing biological vulnerability, advocated by some, still needs to be conclusively proven. It is however worth noting, that although infants born to mothers over 40 years of age are more frequently admitted to intensive neonatal care, these pregnancies tend to be associated with improved perinatal care outcomes over time (41,42). Contrary to developed countries where advanced maternal age women are more often primiparous, childbearing at advanced maternal age is more common among multiparous women in developing countries as a result of factors such as lack or ineffective family planning methods, favorable cultural disposition towards large family sizes and poverty (43). The aim of this study is to analyze prevalence and outcome of pregnancies conceived at extreme maternal ages (age equal or lower than 19 years old and equal or higher than 35 years old), and to verify the impact of maternal age on pregnancy outcome in our context.

1.2 PROBLEM STATEMENT

Despite the decreasing frequency of pregnancies occurring at extremes of maternal age in some developed countries (24,25,26), there is an increasing prevalence of both adolescent and advanced maternal age pregnancies and many adverse outcomes have been associated with it (4,25). This is however based on studies conducted out of Cameroon and the few studies done in Cameroon reported mainly obstetrical adverse outcomes associated with extremes of maternal age (43).

1.3 RATIONALE

Despite the increasing prevalence of pregnancies at extremes of maternal age, a study in

Cameroon have tried to evaluate the magnitude of the problem. One study has been published in Cameroon to the best of our knowledge that evaluated the adverse effects of pregnancy at extremes of maternal age (43). This study described some of the adverse effects mainly on the mother, with increased caesarean section rate being the main adverse outcome reported.

Therefore, this study titled; “Effect of extremes of maternal age on pregnancy outcomes in the Bamenda Regional Hospital “ will seek to identify whether these associations exist in our population, which will contribute to the knowledge in understanding these common impacts of extremes of maternal age on pregnancy outcomes and will help to inform public health interventions and clinical practice to improve both maternal and child health. 

1.4 RESEARCH QUESTION

• What is the frequency of pregnancy in both adolescent and advance maternal age groups at the Bamenda Regional Hospital?
• What are the neonatal outcomes of pregnancies at the extremes of maternal age at the Bamenda Regional Hospital?
• What are the maternal outcomes of pregnancies at the extremes of maternal age at the Bamenda Regional Hospital?
• What are the factors associated with adverse pregnancy outcomes at the extremes of maternal age at the Bamenda Regional Hospital?

1.5 RESEARCH HYPOTHESIS

Given that pregnancies at the extremes of maternal age is associated with adverse maternal and neonatal outcomes, pregnant woman below the age of 20 and above the age of 35 will have adverse perinatal outcomes.

1.6 RESEARCH OBJECTIVES

1.6.1 GENERAL OBJECTIVE

To evaluate the effects of extremes of maternal age on pregnancy outcomes at the Bamenda Regional Hospital.

1.6.2 SPECIFIC OBJECTIVES

• To determine the frequency of adolescent and advanced maternal age pregnancies at the Bamenda Regional Hospital.
• To identify the neonatal outcomes of pregnancies at the extremes of maternal age at the Bamenda Regional Hospital.
• To identify the maternal outcomes of pregnancies at the extremes of maternal age at the Bamenda Regional Hospital.
• To investigate the factors associated with adverse pregnancy outcomes at the extremes of maternal age at the Bamenda Regional Hospital.