PCOGS Papers
ajog.org
Labor and delivery outcomes among young adolescents Ana J. Torvie, MD; Lisa S. Callegari, MD, MPH; Melissa A. Schiff, MD, MPH; Katherine E. Debiec, MD OBJECTIVE: We sought to determine whether young adolescents aged
11-14 years and teens aged 15-17 and 18-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20-24 years. STUDY DESIGN: We conducted a retrospective population-based
cohort study using Washington State birth certificate data linked to hospital records from 1987 through 2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents aged 11-14 years, young teens aged 15-17 years, and older teens aged 18-19 years to young adults aged 20-24 years. The primary outcome was method of delivery. Secondary outcomes included postpartum hemorrhage, shoulder dystocia, third- and fourth-degree perineal lacerations, chorioamnionitis, prolonged maternal length of stay, gestational age at delivery, birthweight, respiratory distress syndrome, neonatal length of stay, and death. We used multivariate regression to assess associations between age and delivery outcomes. RESULTS: Young adolescents aged 11-14 years had a lower risk of
cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI],
0.65e0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78e0.97) delivery compared to young adults aged 20-24 years. Compared to young adults, young adolescents had an increased risk of prolonged length of stay for both vaginal and cesarean delivery (RR, 1.34; 95% CI, 1.20e1.49, and RR, 1.71; 95% CI, 1.38e2.12, respectively), with no significant differences in indication for cesarean delivery or other measures of maternal morbidity. Young adolescents had an increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79e2.48), low and very low birthweight (RR, 2.08; 95% CI, 1.73e2.50, and RR, 3.25; 95% CI, 2.22e4.77, respectively), and infant death (RR, 3.90; 95% CI, 2.36e6.44) compared to young adults. CONCLUSION: Young adolescents have a decreased risk of cesarean
and operative vaginal delivery compared to young adults; however, their neonates face higher risks of preterm delivery, low and very low birthweight, and death. This information can be used to inform clinical care for this population. Key words: adolescent pregnancy, cesarean, low birthweight, perinatal mortality, preterm birth
Cite this article as: Torvie AJ, Callegari LS, Schiff MA, et al. Labor and delivery outcomes among young adolescents. Am J Obstet Gynecol 2015;213:95.e1-8.
A
lthough adolescent fertility rates have declined worldwide over the past 2 decades, rates in the United States remain significantly higher than other similar high-income countries. In 2013 alone, US adolescents aged 10-14 years experienced 3108 births (0.3 births/1000 women).1 Multiple studies demonstrate that childbearing is associated with greater health consequences for teens
than for adult women. The occurrence of preterm delivery,2-5 low birthweight,2,4-6 hypertension,7 preeclampsia and eclampsia,5,8 anemia,7,9 and neonatal death10 are all higher among teens compared to 20- to 29-year-olds, with increased risk of low birthweight and preterm delivery in the youngest adolescent age groups.4,5,8 Although data regarding pregnancy among adolescents
5 days compared to
20- to 24-year-olds (RR, 1.71; 95% CI, 1.38e2.12) (Table 4). Teens aged 15-17 and 18-19 years also had an increased risk of prolonged maternal length of stay compared with 20- to 24-year-olds (RR, 1.23; 95% CI, 1.05e1.45, and RR, 1.21; 95% CI, 1.04e1.42, respectively), although the risk was lower than that in the youngest group. With regard to neonatal complications, parturients aged 11-14, 15-17, and
18-19 years had an increased risk of preterm delivery and low birthweight compared to 20- to 24-year-olds (Table 5). Young adolescents aged 11-14 years had a 2-fold increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79e2.48) and low birthweight (RR, 2.08; 95% CI, 1.73e2.50), and a 3-fold increased risk of very low birthweight (RR, 3.25; 95% CI, 2.22e4.77) compared to young adults. In addition to
TABLE 3
Maternal complications of vaginal deliveries in parturients aged 11-24 years Variable Postpartum hemorrhage
a
Age 11-14 y, n (%)
Age 15-17 y, n (%)
Age 18-19 y, n (%)
Age 20-24 y, n (%)
n [ 1733
n [ 7036
n [ 6834
n [ 6577
103 (6.0)
346 (5.0)
289 (4.3)
312 (4.8)
RR (95% CI)
1.07 (0.84e1.36)
Third- to fourth-degree perineal laceration
b
174 (8.7)
RR (95% CI)
0.93 (0.78e1.11)
Shoulder dystocia
c
32 (1.9)
RR (95% CI) Chorioamnionitis
0.86 (0.57e1.29) a
59 (3.4)
RR (95% CI)
0.95 (0.70e1.30)
0.96 (0.81e1.13) 668 (8.3) 0.80 (0.71e0.89) 144 (2.1) 0.96 (0.75e1.23) 235 (3.4) 1.01 (0.83e1.23)
0.85 (0.72e1.01) 639 (8.0) 0.74 (0.66e0.82) 184 (2.7) 1.25 (0.99e1.58) 251 (3.7) 1.13 (0.94e1.37)
1.00 812 (10.1) 1.00 153 (2.4) 1.00 208 (3.2) 1.00
Maternal length of stay >3 dd
368 (21.4)
RR (95% CI)
1.34 (1.20e1.49)
1134 (16.4) 1.05 (0.97e1.13)
1017 (15.1) 0.98 (0.90e1.06)
974 (15.2) 1.00
CI, confidence interval; RR, risk ratio. a
Adjusted for race; b Adjusted for birthweight; c Adjusted for birthweight and adequacy of prenatal care; d Adjusted for birthweight and using Poisson modeling for common outcome.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.
95.e4 American Journal of Obstetrics & Gynecology JULY 2015
PCOGS Papers
ajog.org
TABLE 4
Maternal complications of cesarean deliveries in parturients aged 11-24 years Variable Postpartum hemorrhage
a
RR (95% CI) Chorioamnionitis RR (95% CI)
Age 11-14 y, n (%)
Age 15-17 y, n (%)
Age 18-19 y, n (%)
Age 20-24 y, n (%)
n [ 275
n [ 992
n [ 1195
n [ 1452
6 (2.1)
17 (1.6)
29 (2.2)
37 (2.3)
0.68 (0.27e1.66) 21 (7.3)
0.56 (0.31e1.03) 92 (8.4)
0.79 (0.49e1.28)
0.89 (0.53e1.47) 115 (8.9)
0.92 (0.70e1.22)
0.98 (0.76e1.27)
1.00 144 (8.9) 1.00
Maternal length of stay >5 db RR (95% CI)
83 (28.7)
221 (20.1)
1.71 (1.38e2.12)
252 (19.4)
1.23 (1.05e1.45)
1.21 (1.04e1.42)
250 (15.5) 1.00
CI, confidence interval; RR, risk ratio. a
Adjusted for race; b Adjusted for birthweight and using Poisson modeling for common outcome.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.
the increased risk of preterm delivery and its resultant influence on birthweight in these women, young adolescents aged 11-14 years and teens aged 15-17 years also demonstrated a 25% increased risk of SGA infants, again with adolescents aged 11-14 years at highest risk (RR, 1.25; 95% CI, 1.11e1.40). Infants born to young adolescents aged 1114 years had a nearly 4-fold risk of infant death, or death occurring from day 0364 of life (RR, 3.90; 95% CI, 2.36e6.44). Risk of infant death was also increased for teens aged 15-17 and 18-19 years (RR, 2.18; 95% CI, 1.43e3.33, and RR, 1.62; 95% CI, 1.05e2.57, respectively).
C OMMENT In this population-based study of >26,000 women including 2007 young adolescents age 11-14 years, we found that young adolescents aged 11-14 years, similar to teens aged 15-19 years, had a decreased risk of cesarean and operative vaginal delivery compared to young adults aged 20-24 years. Neonates born to the youngest adolescents, however, faced an increased risk of preterm delivery, low and very low birthweight, and death compared with neonates born to young adults. Our finding that adolescents aged 1114 years had a decreased risk of cesarean delivery is largely supported by the literature,11,14,15 although some studies
report conflicting data.13 A populationbased study of Swedish women demonstrated a decreased risk of cesarean delivery in women
ajog.org
Labor and delivery outcomes among young adolescents Ana J. Torvie, MD; Lisa S. Callegari, MD, MPH; Melissa A. Schiff, MD, MPH; Katherine E. Debiec, MD OBJECTIVE: We sought to determine whether young adolescents aged
11-14 years and teens aged 15-17 and 18-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20-24 years. STUDY DESIGN: We conducted a retrospective population-based
cohort study using Washington State birth certificate data linked to hospital records from 1987 through 2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents aged 11-14 years, young teens aged 15-17 years, and older teens aged 18-19 years to young adults aged 20-24 years. The primary outcome was method of delivery. Secondary outcomes included postpartum hemorrhage, shoulder dystocia, third- and fourth-degree perineal lacerations, chorioamnionitis, prolonged maternal length of stay, gestational age at delivery, birthweight, respiratory distress syndrome, neonatal length of stay, and death. We used multivariate regression to assess associations between age and delivery outcomes. RESULTS: Young adolescents aged 11-14 years had a lower risk of
cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI],
0.65e0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78e0.97) delivery compared to young adults aged 20-24 years. Compared to young adults, young adolescents had an increased risk of prolonged length of stay for both vaginal and cesarean delivery (RR, 1.34; 95% CI, 1.20e1.49, and RR, 1.71; 95% CI, 1.38e2.12, respectively), with no significant differences in indication for cesarean delivery or other measures of maternal morbidity. Young adolescents had an increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79e2.48), low and very low birthweight (RR, 2.08; 95% CI, 1.73e2.50, and RR, 3.25; 95% CI, 2.22e4.77, respectively), and infant death (RR, 3.90; 95% CI, 2.36e6.44) compared to young adults. CONCLUSION: Young adolescents have a decreased risk of cesarean
and operative vaginal delivery compared to young adults; however, their neonates face higher risks of preterm delivery, low and very low birthweight, and death. This information can be used to inform clinical care for this population. Key words: adolescent pregnancy, cesarean, low birthweight, perinatal mortality, preterm birth
Cite this article as: Torvie AJ, Callegari LS, Schiff MA, et al. Labor and delivery outcomes among young adolescents. Am J Obstet Gynecol 2015;213:95.e1-8.
A
lthough adolescent fertility rates have declined worldwide over the past 2 decades, rates in the United States remain significantly higher than other similar high-income countries. In 2013 alone, US adolescents aged 10-14 years experienced 3108 births (0.3 births/1000 women).1 Multiple studies demonstrate that childbearing is associated with greater health consequences for teens
than for adult women. The occurrence of preterm delivery,2-5 low birthweight,2,4-6 hypertension,7 preeclampsia and eclampsia,5,8 anemia,7,9 and neonatal death10 are all higher among teens compared to 20- to 29-year-olds, with increased risk of low birthweight and preterm delivery in the youngest adolescent age groups.4,5,8 Although data regarding pregnancy among adolescents
5 days compared to
20- to 24-year-olds (RR, 1.71; 95% CI, 1.38e2.12) (Table 4). Teens aged 15-17 and 18-19 years also had an increased risk of prolonged maternal length of stay compared with 20- to 24-year-olds (RR, 1.23; 95% CI, 1.05e1.45, and RR, 1.21; 95% CI, 1.04e1.42, respectively), although the risk was lower than that in the youngest group. With regard to neonatal complications, parturients aged 11-14, 15-17, and
18-19 years had an increased risk of preterm delivery and low birthweight compared to 20- to 24-year-olds (Table 5). Young adolescents aged 11-14 years had a 2-fold increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79e2.48) and low birthweight (RR, 2.08; 95% CI, 1.73e2.50), and a 3-fold increased risk of very low birthweight (RR, 3.25; 95% CI, 2.22e4.77) compared to young adults. In addition to
TABLE 3
Maternal complications of vaginal deliveries in parturients aged 11-24 years Variable Postpartum hemorrhage
a
Age 11-14 y, n (%)
Age 15-17 y, n (%)
Age 18-19 y, n (%)
Age 20-24 y, n (%)
n [ 1733
n [ 7036
n [ 6834
n [ 6577
103 (6.0)
346 (5.0)
289 (4.3)
312 (4.8)
RR (95% CI)
1.07 (0.84e1.36)
Third- to fourth-degree perineal laceration
b
174 (8.7)
RR (95% CI)
0.93 (0.78e1.11)
Shoulder dystocia
c
32 (1.9)
RR (95% CI) Chorioamnionitis
0.86 (0.57e1.29) a
59 (3.4)
RR (95% CI)
0.95 (0.70e1.30)
0.96 (0.81e1.13) 668 (8.3) 0.80 (0.71e0.89) 144 (2.1) 0.96 (0.75e1.23) 235 (3.4) 1.01 (0.83e1.23)
0.85 (0.72e1.01) 639 (8.0) 0.74 (0.66e0.82) 184 (2.7) 1.25 (0.99e1.58) 251 (3.7) 1.13 (0.94e1.37)
1.00 812 (10.1) 1.00 153 (2.4) 1.00 208 (3.2) 1.00
Maternal length of stay >3 dd
368 (21.4)
RR (95% CI)
1.34 (1.20e1.49)
1134 (16.4) 1.05 (0.97e1.13)
1017 (15.1) 0.98 (0.90e1.06)
974 (15.2) 1.00
CI, confidence interval; RR, risk ratio. a
Adjusted for race; b Adjusted for birthweight; c Adjusted for birthweight and adequacy of prenatal care; d Adjusted for birthweight and using Poisson modeling for common outcome.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.
95.e4 American Journal of Obstetrics & Gynecology JULY 2015
PCOGS Papers
ajog.org
TABLE 4
Maternal complications of cesarean deliveries in parturients aged 11-24 years Variable Postpartum hemorrhage
a
RR (95% CI) Chorioamnionitis RR (95% CI)
Age 11-14 y, n (%)
Age 15-17 y, n (%)
Age 18-19 y, n (%)
Age 20-24 y, n (%)
n [ 275
n [ 992
n [ 1195
n [ 1452
6 (2.1)
17 (1.6)
29 (2.2)
37 (2.3)
0.68 (0.27e1.66) 21 (7.3)
0.56 (0.31e1.03) 92 (8.4)
0.79 (0.49e1.28)
0.89 (0.53e1.47) 115 (8.9)
0.92 (0.70e1.22)
0.98 (0.76e1.27)
1.00 144 (8.9) 1.00
Maternal length of stay >5 db RR (95% CI)
83 (28.7)
221 (20.1)
1.71 (1.38e2.12)
252 (19.4)
1.23 (1.05e1.45)
1.21 (1.04e1.42)
250 (15.5) 1.00
CI, confidence interval; RR, risk ratio. a
Adjusted for race; b Adjusted for birthweight and using Poisson modeling for common outcome.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.
the increased risk of preterm delivery and its resultant influence on birthweight in these women, young adolescents aged 11-14 years and teens aged 15-17 years also demonstrated a 25% increased risk of SGA infants, again with adolescents aged 11-14 years at highest risk (RR, 1.25; 95% CI, 1.11e1.40). Infants born to young adolescents aged 1114 years had a nearly 4-fold risk of infant death, or death occurring from day 0364 of life (RR, 3.90; 95% CI, 2.36e6.44). Risk of infant death was also increased for teens aged 15-17 and 18-19 years (RR, 2.18; 95% CI, 1.43e3.33, and RR, 1.62; 95% CI, 1.05e2.57, respectively).
C OMMENT In this population-based study of >26,000 women including 2007 young adolescents age 11-14 years, we found that young adolescents aged 11-14 years, similar to teens aged 15-19 years, had a decreased risk of cesarean and operative vaginal delivery compared to young adults aged 20-24 years. Neonates born to the youngest adolescents, however, faced an increased risk of preterm delivery, low and very low birthweight, and death compared with neonates born to young adults. Our finding that adolescents aged 1114 years had a decreased risk of cesarean delivery is largely supported by the literature,11,14,15 although some studies
report conflicting data.13 A populationbased study of Swedish women demonstrated a decreased risk of cesarean delivery in women
