Magdy H Balaha*, Mostafa A Amr **, Abdelhady A El-Gilany ***, Farid M Al Sheikh ****
* Prof. of Obstetrics & Gynecology, College of Medicine in Al- Ahsa
** Assistant Prof. of Psychiatry, College of Medicine in Al- Ahsa
*** Prof. of Public Health, College of Medicine in Mansoura University, Egypt
**** Consultant of Obstetrics & Gynecology, Al-Ahsa Maternity and Child Hospital

Correspondence:
Magdy Hassan Balaha
Prof. of Obstetrics & Gynecology, College of Medicine,
Tanta University, Egypt
Obstetrics & Gynecology Department,
College of Medicine in Al-Ahsa
King Faisal University, Al Ahsa, Saudi Arabia
P.O. Box 400 - Hofuf 31982
Saudi Arabia
e-mail: magdy_balaha@yahoo.co.uk, mbalaha@kfu.edu.sa
Mob: 00966 551 639 003

INTRODUCTION

Teenage pregnancy is defined as pregnancy in women under the age of 20, although in the United States, the term usually refers to girls younger than 18 years of age. Teenage pregnancy is a worldwide social problem and its incidence shows marked variation amongst developed countries. USA has the highest incidence in the developed world and the UK has the highest incidence in Europe.¹ Teenage pregnancy in Saudi Arabia comes as the 69th in the world ranking and the live birth rate at that age has an incidence of 38 per 1000.^2,3 In Saudi Arabia, antenatal care (ANC) coverage is comprehensive. The national figure of women not receiving ANC is 10%.⁴
Some studies from developed and developing countries have consistently reported that teenage pregnancy was at increased risk for pre-term delivery, low birth weight (LBW) and postnatal depression,^5,6 although other studies failed to find such an association.^7,8
In many developing countries, the focus of prenatal and delivery care is on women's medical and obstetrical problems and on the baby's wellbeing. The psychiatric profile of pregnant women as they experience biological, physical, and physiological changes need to be more addressed.
To the knowledge of the authors, this study is the first to assess both the obstetric and psychiatric morbidity in teenagers in Saudi Arabia and to examine some associated risk factors.

The aim of the present study was to assess the prevalence of adverse obstetric and psychiatric outcomes among primigravid teen-aged mothers compared with a matched group of older women in Al-Ahsa, Saudi Arabia.

This study was conducted in Al-Ahsa, Saudi Arabia in 2007-09. Data collection phase was completed over a six month period in 2007-08 and data processing and analysis extended to 2009. Al-Ahsa is the largest province in Saudi Arabia's Eastern region (population of 908,366).
Maternal services are provided by Al-Ahsa Maternity Hospital and a network of 47 primary health care centers (PHCCs) in addition to facilities in the private sector, ARAMCO Petroleum Company and National Guard. The antenatal care clinics provide regular care for pregnant women with the use of the classic schedule with 13 visits throughout pregnancy. 9 Women attending PHC centers represent low and middle social class residents of Al-Ahsa region. To cross validate these data, the authors compared the recorded data with data in maternity cards at PHC centers and also from the maternity hospital files.
This work utilized a case-control design. All primiparous with live births were counseled and invited to be enrolled in the study during their visit at the PHCCs for infant vaccination two months after delivery. The comparison group women were selected from the next four consecutive primigravid women in the age group of 20-29 years; as four cases for each one study case. Sample members were assured about data confidentiality and the data will be used for research purposes and for improving services. Verbal consent was obtained from all eligible cases of the sample and comparison groups.
Some women of both groups were not included from the start; as those with any pre pregnancy chronic medical disease (hypertension, diabetes, renal, cardiac and sickle cell disease), multiple pregnancies, cases with incomplete filing data and cases giving birth outside the Maternity hospital.

From a total of 7109 registered live births in the chosen PHCCs during the study period, there were 179 teenage mothers (25 per 1000). This figure is different from the published Saudi teenage pregnancy incidence (38 per 1000) 2,3 as this represents only a smaller selected sample taken from one region; Al Ahsa. Four second gravidae were excluded and 7 were excluded due to filing incompleteness or presence of pre pregnancy disease. The study eligible cases were 168 teenagers. Their age at delivery ranged from 16.6- 19.8 years with mean age 17.89 ± 0.65. Our sample has 27 cases less than 18 years (16.7% of adolescent cases). In the comparison group, a total of 632 primigravid women (mean age is 24.2 ± 3.3) were selected.

All eligible cases of the study and comparison groups were interviewed by trained medical staff to fill a structured questionnaire; including some demographic characteristics of the mother (education, occupation), husband education and time of first contact with the center, number of antenatal visits as well as past history of psychiatric illness. The information on antenatal outcomes (pregnancy induced hypertension, gestational diabetes, antepartum hemorrhage, anemia, urinary tract infection, premature rupture of membranes (PROM) and polyhydramnios)and. intranatal events were evaluated including route of delivery, gestational age at birth, birth weight, 1 minute Apgar score and the need for neonatal intensive care unit were obtained from the clinic files.

The psychiatric profile of each woman was assessed using Mini International Neuropsychiatric Interview (MINI) 5th edition as a valid and reliable diagnostic tool with closed-end questions. The interviewer read literally these close-ended questions as verbatim as possible to the interviewees. Psychiatric diagnosis was made according to the number of affirmative replies to the specific questions. 10

Statistical analysis
The chi-squared (x²) or Fisher's Exact test (FET) was used as a test of significance for comparison of categorical variables, as appropriate. Unpaired student's t test was used for comparison No of ANC visits. P = 0.05 was chosen as the level of statistical significance using the SPSS version 11 (Statistical Package for Social Sciences). To quantify the risk and denotes to the clinical significance of adverse antenatal or intranatal Obstetric outcomes and postnatal psychiatric outcomes in the study group, the odds ratio (OR) and 95% confidence intervals (CI) were computed.

Teenage mothers had comparable demographic findings to older mothers with non significant difference. Despite that, the number of ANC visits didn't show any significant difference, this study demonstrated that a significant higher proportion of teenagers (83.3%) had been booked for ANC in the first trimester. (Table 1)

Teenage mothers had a higher incidence of pregnancy induced hypertension, anemia, and urinary tract infections, but this increased incidence was not statistically significant. The other adverse antenatal outcomes including gestational diabetes mellitus, ante partum hemorrhage, and premature rupture of membranes were comparable. The OR analysis showed also values of no clinical significance as the CI was either wide or containing the value of 1. (Table 2)

Despite teenagers had a lower incidence of both assisted vaginal deliveries and cesarean sections if compared to older group, these differences were not statistically significant. The result demonstrated that the teenage mothers were neither at higher risk for delivering low birth weight nor macrosmic infants. There was no clinically significant difference as regard the gestational age at birth, 1 minute Apgar scoring and admission to neonatal intensive care unit (NICU). The OR analysis showed also values of no clinical significance. (Table 3)

The prevalence of psychiatric disorders in our sample was 14% of the teenage mothers and 15% of the older mothers, screened positive for at least one psychiatric disorder. On the other hand, the prevalence of combined disorders was higher as shown in table 4.When subgroups of psychiatric disorders were considered (mood disorders, anxiety disorders, eating disorders).The anxiety disorders were higher in the teenager group probably due to significant increased prevalence for the post traumatic stress disorder and generalized anxiety disorder ( P<0.05, significant OR). (Table 4)

* Significant

FET = Fisher's exact test

FET = Fisher's exact test
# = neonatal intensive care unit

* Significant
FET = Fisher's exact test

Teenage pregnancy is a worldwide social problem and its incidence shows marked variation amongst developed countries. USA has the highest incidence in the developed world and the UK has the highest incidence in Europe.1
In this research, the authors restricted inclusion of teenage mothers to only primiparas in order to have more similar/ homogenous group and to exclude factors that may contribute to adverse outcomes in multiparous women. The higher proportion of teenage primigravidae (83.3%) who were booked for ANC in the first trimester may reflect good awareness and may be due to over worried young women. This study demonstrated that there was no significant difference regarding both antenatal and intranatal Obstetric morbidities.
Some studies confirmed that teenage pregnancy was associated with increased preterm birth, low birth weight, stillbirths and neonatal and post neonatal death (Hidalgo L. et al¹¹ Haldre K et al¹² Phuong V and Suebnukarn k¹³ Maryam K and Ali S¹⁴). The attributable risks were the marital status, low socioeconomic status, inadequate prenatal care, the inclusion of too young women.
Some studies conducted in different areas in Saudi Arabia reported increased rates of preterm delivery, pre-eclampsia and low birth weight. (Shawky S. et al¹⁵, Mesleh RA et al¹⁶ and Abu-Heija, A et al¹⁷). They included teenagers <18 years which may be one of the highly contributing factors. Others have shown no difference in the obstetric outcomes among teenagers. (Oboro V.O et al (2003)¹⁸ Kaisa R et al (2005)¹⁹ Raatikainen K et al (2006)²⁰ Aruda M et al (2008)²¹). In the Southern area of Saudi Arabia (Abha), Mahfouz AA et. Al²² concluded that the prevalence of anemia, hypertension, rate of abnormal deliveries and average prenatal visits were not significantly different among both age groups and adolescence per se confers no increased obstetric risk if good prenatal care is provided.
In Cardiff Births Survey, there was lower incidence of multiple pregnancies, spontaneous rupture of membranes >24 h, pregnancy-induced hypertension, instrumental delivery and Caesarean section amongst teenage primigravidae but a higher incidence of anemia, and pyelonephritis.²³
In the current study, the overall prevalence of psychiatric disorders was not statistically different in both age groups. The prevalence of psychiatric disorders including the depressive category in our teenage pregnant women was (14%, 10.1 respectively).
The relationship between motherhood and psychiatric illness has been extensively studied in recent years. A large review of 20 studies of the prevalence of postpartum psychiatric illness showed large variations related to differences in methodology, sample size, assessment techniques (self-report vs. diagnostic interview), timing of assessment and period of risk²⁴.
In Dubai, Abu-Saleh and Ghubash (1997)²⁵ assessed 94 hospitalized pregnant adult women in the postpartum period using clinical and sociocultural instruments, namely the Self-Reporting Questionnaire (SRQ) on day 2 and the Edinburgh Postnatal Depression Scale (EPDS) on day 7 after delivery, found that the prevalence of psychiatric morbidity was 24% according to the SRQ and 18% according to the EPDS.
Interestingly, these rates were higher than obtained from a sample of Swedish women as psychiatric disorders were present in 14.1%, Depression in 10.2% and Anxiety disorders in 6.6% of patients.26 Recent studies on adolescent mothers revealed rates of depressive symptoms within the first postnatal 3 months of 53- 56% (Logdson et al., 2005).²⁷
Eating disorders are rare in our sample. Saudi culture discourages public display of the female body. Until a few decades ago, thinness was equated with poverty or ill health and people continue to consider mild obesity as a sign of wealth and health (Al-Sabaie, 1989).²⁸
Interestingly, the anxiety disorders in teenagers in our study are not surprising as it parallels the dramatic increase in literacy among females in Saudi Arabia in a very short period. (Gubash et al., 1992)²⁹ Also there is a change in the roles of women in the modern Saudi society. Women choose to pursue higher education and careers; also they are less accepting of having their roles restricted to motherhood. These factors may be the fuel of intergenerational conflict that may be culminating in anxiety and increased sensitivity.³⁰
There are several possible explanations for the reported differences concerning both the Obstetric and Psychiatric disorders of teenage pregnancies in our sample. Firstly, the age in teenagers varies between studies from under 13 to under 20 years of age. In the present study, only 27 cases (16.7%) of teenage mothers were less than 18 years old and the lowest age was 16.4 years. The effects of very young age could thus not be studied separately. However, one may speculate the effects of young age per se should be clearer in the youngest age groups.
Secondly, there are many differences in maternity care systems worldwide. In some countries maternity care systems are based on insurance and the availability of these services depends on the economic circumstances of the mother, which are likely to be worse in teenage mothers than in adults. In Saudi Arabia antenatal and maternity care is provided free of charge.
Finally, Saudi teenage pregnant cases were married; and received support from their families. Also fertility concept is highly valued, reproduction is encouraged by religious and social beliefs and the bride had higher self-esteem after having children.
In conclusion, Teenage pregnancy receiving adequate antenatal care and ending in live births is not associated with significant adverse obstetric outcomes or major psychopathology in Al Ahsa, Saudi Arabia.
We cannot exclude neither recall nor recruitment bias. Pregnancies ended in still births may present different characteristics. Our patients were therefore not representative of all teen-aged mothers, which potentially limits the generalization of the current findings. In addition, the study did not take into account the contribution of family competence on the psychological adjustment of young mothers.
Maternity care will also be supplemented with counseling for the acceptability and implementation of psychiatric screening at the maternity hospitals and primary health care centers to provide the optimal care for young mothers.
The study paves the way for a larger prospective community-based study.

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