Complications in adolescent pregnancy and childbirth

• Biologically, an adolescent’s body is still developing and not yet ready to take on an added strain. The pelvic bones are not fully mature, and cephalo- pelvic disproportion could occur. Her body has special nutritional needs and when pregnancy occurs, it is a strain on already depleted reserves, especially if she belongs to a low socio-economic background.
• The young girl may not be mentally prepared for motherhood with all its added responsibilities, etc. and this could give rise to mental health problems like depression.
• Socio-culturally, pregnancy outside of marriage bears a terrible stigma and the above situation worsens when the girl is not married, in which case she does not get the emotional support she needs as well as support in terms of nutrition, rest, antenatal check-ups, etc.

This situation is not unique to unmarried adolescents as the married ones may not be aware of the importance of antenatal care. For various reasons, the adolescent woman is more likely to deliver at home. The older women in the home feel that a traditional birth attendant is equipped to carry out the delivery, her services are cheaper and she is easily accessible. A trained birth attendant or a hospital is usually thought of when things get out of hand and complications have already set in.

The risks are high, starting from the antenatal period, through labour and the postpartum period. Adolescent mothers are most likely to give birth to low weight babies and both the mother and child face higher mortality and morbidity.

Pregnancy related complications that occur more commonly in adolescents than in adults

• Death
• Pregnancy-induced hypertension
• Anaemia during antenatal period
• STIs/HIV
• Higher severity of malaria
• Pre-term birth
• Obstructed labour
• Anaemia during postpartum period
• Pre-eclampsia
• Postpartum depression
• Too early repeat pregnancies
• Low birth weight
• Perinatal and neonatal mortality
• Inadequate child care and breastfeeding practices
• Problems in the antenatal period

Pregnancy-induced hypertension: Studies report an increased incidence of the condition in young adolescents, when compared with women aged 30-34 years.

Anaemia: There is an increased risk of anaemia in adolescents because of nutritional deficiencies, especially of iron and folic acid, and by malaria and intestinal parasites.

STIs/HIV: Sexually active adolescents are at an increased risk of contracting STIs, including HIV infection, owing to their biological and social vulnerability. There is also the increased risk of mother-to child transmission of HIV in adolescents, because the HIV infection is more likely to be recent, and therefore associated with higher viral loads. The presence of other STIs (syphilis, gonorrhea and chlamydia) with local inflammation may increase viral shedding, thereby increasing the risk of transmission during labour.

Higher severity of malaria is often seen in first time pregnant women (which includes many adolescents) and is a common cause of anaemia in this group. This puts them at risk and their unborn babies at risk of intra-uterine death.

Problems during labour and delivery

• Pre-term birth is common in women under twenty years of age because of immaturity of the reproductive organs, social factors such as poverty, at play.
• Obstructed labour in young girls (below 15 years of age) occurs due to the small size of the birth canal leading to cephalo-pelvic disproportion. Lack of access to medical and surgical care can result in complications like vesicovaginal and recto-vaginal fistulae.

Problems in the postpartum period

• Anaemia is commoner and further aggravated by blood loss during delivery thereby also increasing the risk of infection.
• Pre-eclampsia: Several studies report that pre-eclampsia occurs more often in young adolescents. The symptoms may worsen and sometimes recognized only during the first postpartum days.
• Postpartum depression and common mental health problems are common due to reasons described above.
• Too early repeat pregnancies, especially in unmarried adolescents can occur because of the difficulty in accessing reliable contraception.

Problems affecting the baby

Low birth weight: There is a higher incidence of low birth weight (weight <2500 grams) among infants of adolescent mothers.

Perinatal and neonatal mortality is increased in infants of adolescent mothers, compared with infants of older mothers.

Inadequate childcare and breastfeeding practices: Young mothers, especially those who are single and poor, may find it hard to provide their children with the adequate care. This is reflected in their poor child feeding, including breastfeeding, practices.

Care of adolescents during pregnancy, childbirth and postnatal period

Adolescent pregnancies and deliveries require much more care than adult pregnancies and all efforts must be made to reduce the occurrence of problems. This includes early diagnosis of pregnancy, effective antenatal care, effective care during labour and delivery, and during the postpartum period.

Pre-pregnancy Counselling

• Contraceptive counseling
• Building up hemoglobin
• Folic acid supplementation
• Detection and treatment of pre-existing medical diseases
• Thalassemia screening
• Rubella vaccination.

Early diagnosis of pregnancy

Health service providers and other adults like family members in more regular contact with the adolescent, have the shared responsibility of creating an environment in which she feels able to share information about her situation, especially if she is unmarried. She may not know that she is pregnant because she may not remember the dates of her last menstrual period, or because her periods are not regular. She may even want to hide her pregnancy or seek ways of terminating it. Being aware of these issues, and being on the lookout for telltale signs of early pregnancy such as nausea will help ensure an early diagnosis of pregnancy so that care is started early and complications are avoided.

Antenatal care

Many complications can be detected and many can be avoided if the adolescent is able to access good antenatal services. Pregnancy-induced hypertension (Pre-eclampsia) can easily be detected and referred to the PHC for management. In case of more serious complications (such as pre-eclampsia, eclampsia, and abruptio placentae), referral to a woman’s hospital is essential. Anaemia and malaria too can be detected and treated during routine antenatal care. Screening for STIs can lead to early referral and early treatment, if required. Iron and folic acid supplements will prevent anaemia to a large extent. Most importantly, antenatal visits could help identify those adolescents, who are at risk of preterm labour, though interventions to address this are limited.

Antenatal care also provides a valuable opportunity for the provision of information and counseling support that adolescents need. This is especially important in the case of adolescents, especially unmarried ones, because of their greater need for support.

Counseling during pregnancy

Information and counseling support is the right of every pregnant woman who reaches a health centre and pregnant adolescents have special needs and questions and concerns of their own. They must be given an opportunity to raise and discuss these issues.

Their needs must be matched with competent and sensitive counseling support in terms of the socio-cultural environment that has to be faced, the options available in terms of the pregnancy; the access to health services for routine antenatal care and in case of emergency; the danger signs that need to be aware of, etc.

Counseling should also include care of the newborn and prevention of an early repeat pregnancy.

Since adolescents are more at risk of STIs including HIV/AIDS, voluntary counseling and testing (VCT) services should be made available to them. As ANMs/LHVs, you should know where the nearest VCT centres is, to be able to refer your clients for screening.

Management of labour and delivery

If the pregnancy in an adolescent is normal and with no complications and anaemia is treated adequately, labour starts at term, and the infant is in cephalic presentation, labour is not at increased risk. Counsel the client for institutional delivery at PHC.

However, if the adolescent is severely anaemic, postpartum haemorrhage can be a dangerous possibilty. In very young adolescents, pre-term labour as well as obstructed labour are more likely to occur. Such adolescents are at high risk and it is advisable to encourage hospital delivery. The family should be advised to make arrangements for transportation to the hospital, when needed.

Besides observing and monitoring, supporting the woman is very important and studies have shown that continuous empathetic support during labour, provided by a technically qualified nurse or midwife results in many benefits both to the mother and the baby.

Postpartum care

This includes the prevention, early diagnosis and treatment of postnatal complications in the mother and her baby. It also includes information and counselling on breastfeeding, nutrition, contraception and care of the baby. The adolescent mother will require special support on how to care for herself and her baby.

Contraception: It is very important that too early repeat and unplanned pregnancies should not occur for lack of access to contraceptive services. The postpartum period presents a good opportunity for taking steps towards pregnancy prevention and for promoting dual protection by encouraging condom use.

Nutrition of the mother: The lactating adolescent needs adequate nutrition to meet her own as well as the extra needs required for breast-milk production.

Breastfeeding: Exclusive breast feeding is recommended for 6 months. A young adolescent, especially one who is single - would require extra support in achieving breastfeeding successfully.