FACTORS ASSOCIATED WITH LOW BIRTH

WEIGHT INFANTS OF TEENAGE PREGNANCY

IN TERENGGANU, 2018

DR. SITI FATIMAH BINTI SAMSURY

UNIVERSITI SAINS MALAYSIA

2020
 FACTORS ASSOCIATED WITH LOW BIRTH

WEIGHT INFANTS OF TEENAGE PREGNANCY

IN TERENGGANU, 2018

by

DR. SITI FATIMAH BINTI SAMSURY

Research project submitted in partial

fulfilment of the requirement for the degree of

Master of Public Health

JUNE 2020
 ACKNOWLEDGEMENTS

Alhamdulillah, raise be to Allah S.W.T, the greatest compassionate and most merciful,

whose blessing has helped me throughout the study until the submission of this

research. I would like to express my deepest gratitude to my supervisor who has

supported, assisted and share her expert to me in the preparation of this research, Dr

Tengku Alina binti Tengku Ismail.

My sincere thanks also go to Dr Kasemani binti Embong, Dr Azlina binti Ab. Manan

@ Kamaruddin and Matron Mimah binti Jantan from Terengganu State Health

Department for their support and help in obtaining the data of pregnant teenagers

attending government health clinics in Terengganu in 2018. I also like to send my

appreciation to all my lecturers, colleagues and department staff, as well as to all the

maternal and child health workers in all health districts who expressed their expertise,

encouragement and assistance.

Last, of all, I wish to express my gratitude to my family, especially to my beloved

husband and parents, for their ongoing support, courage, and to Allah for giving me

the strength and opportunity to carry out this task.

ii
 TABLE OF CONTENTS

Acknowledgements .................................................................................................. ii

Table of contents ..................................................................................................... iii

List of tables ........................................................................................................... vii

List of figures ........................................................................................................ viii

List of appendices ................................................................................................... ix

List of abbreviations and symbols............................................................................ x

Abstrak ................................................................................................................... xii

Abstract ................................................................................................................. xiv

CHAPTER ONE .......................................................................................................... 1

Introduction .............................................................................................................. 1

Teenage pregnancy......................................................................................... 1

Low birth weight ............................................................................................ 4

Management of teenage pregnancy ................................................................ 5

Statement of problem ..................................................................................... 8

Rationale of the study..................................................................................... 9

Research questions ....................................................................................... 10

iii
 Objectives ..................................................................................................... 11

Research hypothesis ..................................................................................... 11

CHAPTER TWO ....................................................................................................... 12

Literature review .................................................................................................... 12

Prevalence of low birth weight in Malaysia ................................................. 12

Low birth weight as the outcome of teenage pregnancy .............................. 12

Pathophysiology of low birth weight in teenage pregnancy ........................ 14

Other obstetric and perinatal outcomes of teenage pregnancy ..................... 15

Maternal outcomes .................................................................................... 15

Perinatal outcomes .................................................................................... 21

Factors associated with low birth weight infant among teenage pregnancy 24

Socio-demographic factors........................................................................ 24

Obstetric Characteristic ............................................................................. 29

Conceptual framework ................................................................................. 35

CHAPTER THREE.................................................................................................... 37

Methodology .......................................................................................................... 37

Study Design ................................................................................................ 37

Study Duration ............................................................................................. 37

iv
 Study Location ............................................................................................. 37

Study population .......................................................................................... 40

Reference population ................................................................................ 40

Source population...................................................................................... 40

Subject criteria .......................................................................................... 40

Sampling frame ............................................................................................ 40

Sample Size Determination .......................................................................... 41

Sampling method ......................................................................................... 44

Research tools .............................................................................................. 44

Operational definition .................................................................................. 49

Data collection ........................................................................................... 51

Statistical analysis ...................................................................................... 52

Ethical consideration .................................................................................. 53

Study flowchart .......................................................................................... 54

CHAPTER FOUR ...................................................................................................... 56

Results .................................................................................................................... 56

Socio-demographic characteristics of teenage pregnancy in Terengganu, 2018

............................................................................................................................ 56

v
 Obstetric characteristics and nutritional status of teenage pregnancy in

Terengganu, 2018 ............................................................................................... 57

Obstetric and perinatal outcomes of teenage pregnancy in Terengganu, 2018

............................................................................................................................ 59

Factors associated with low birth weight infants of teenage pregnancy in

Terengganu in 2018............................................................................................ 61

CHAPTER FIVE ........................................................................................................ 68

Discussion .............................................................................................................. 68

Characteristics of teenage pregnancy ........................................................... 68

The obstetric outcomes of teenage pregnancy ............................................. 70

The perinatal outcomes of teenage pregnancy ............................................. 72

Factors associated with low birth weight infant among teenage pregnancy 74

Factors not significant in this study ............................................................. 77

Strengths and limitations of the study .......................................................... 78

CHAPTER SIX ......................................................................................................... 81

Conclusion ............................................................................................................. 81

Conclusion ................................................................................................... 81

Recommendation.......................................................................................... 82

References .............................................................................................................. 84

vi
 LIST OF TABLES

Table 3.1: Summary of sample size calculation for factors associated with low birth

weight infants of teenage pregnancy .................................................................. 43

Table 4.1: Socio-demographic characteristics of teenage pregnancy in Terengganu,

2018 (n = 357) .................................................................................................... 57

Table 4.2: Obstetric characteristics and nutritional status of teenage pregnancy in

Terengganu, 2018 (n = 357) ............................................................................... 58

Table 4.3: Obstetric and perinatal outcomes of teenage pregnancy in Terengganu,

2018 (n=357) ...................................................................................................... 60

Table 4.4: Factors associated with low birth weight infants of teenage pregnancy in

Terengganu, 2018 using simple logistic regression analysis ............................. 62

Table 4.5: Factors associated with low birth weight infants of teenage pregnancy in

Terengganu, 2018 using multiple logistic regression analysis........................... 66

vii
 LIST OF FIGURES

Figure 2.1 Conceptual framework of factors associated with low birth weight among

teenage pregnancy .............................................................................................. 36

Figure 3.1: Map of the district in Terengganu ........................................................... 39

Figure 3.2: Flow chart of the study ............................................................................ 55

viii
 LIST OF APPENDICES

Appendix A: Maternal Health Record Book KIK 1/(b)/96

Appendix B: Pregnant Woman and Postnatal Book Registry

Appendix C: Proforma

Appendix D: Terengganu State Health Department Permission Letter for Data

Collection

Appendix E: Universiti Sains Malaysia Ethical Approval Letter

Appendix F: Ministry of Health (MOH) Ethical Approval Letter

ix
 LIST OF ABBREVIATIONS AND SYMBOLS

AOR: Adjusted odd ratio

BMI: Body mass index

CI: Confidence interval

GDM: Gestational diabetes mellitus

LMP: Last menstrual period

MCH: Mother and child health

OR: Odd Ratio

PIH: Pregnancy-induced hypertension

SES: Socioeconomic status

SGA: Small for gestational age

WHO: World Health Organization

>: More than

<: Less than

=: Equal to

≥: More than and equal to

x
≤: Less than and equal to

α: Alpha

β: Beta

%: Percentage

xi
 ABSTRAK

FAKTOR- FAKTOR YANG BERKAITAN DENGAN KELAHIRAN BAYI

KURANG BERAT BADAN DALAM KALANGAN REMAJA HAMIL DI

TERENGGANU, 2018

Latarbelakang: Kehamilan remaja sering dikaitkan dengan hasil yang negatif

termasuk bayi kurang berat badan, kelahiran pramatang dan anemia. Mengenalpasti

hasil dan faktor yang berkaitan dengan bayi kurang berat badan dalam kalangan

kehamilan remaja boleh membantu untuk meningkatkan pencegahan dan pengurusan

faktor ini, dan seterusnya memperbaiki hasil kehamilan.

Objektif: Kajian ini bertujuan untuk menentukan hasil obstetrik dan perinatal

daripada kehamilan remaja, dan faktor yang berkaitan dengan kelahiran bayi kurang

berat badan dalam kalangan remaja hamil di Terengganu pada tahun 2018.

Metodologi: Kajian keratan rentas dilakukan dari 1 Januari 2020 hingga 31 Mei 2020

dengan menggunakan data dari Buku Rekod Kesihatan Ibu dan Buku Daftar Program

Ibu Hamil dan Pos Natal. Sumber populasi adalah semua remaja hamil yang hadir di

klinik kesihatan kerajaan di Terengganu pada 2018. Analisa regresi logistik ringkas

dan berganda telah digunakan untuk menganalisis faktor-faktor yang berkaitan dengan

kelahiran bayi kurang berat badan dalam kalangan remaja hamil.

Keputusan: Kesemua 357 kes yang memenuhi kriteria kajian telah dimasukkan. Hasil

obstetrik yang paling biasa dalam kalangan kehamilan remaja adalah anemia (41.5%),

diikuti oleh pembedahan caesarean (10.9%), penyakit kencing manis gestasi (2.8%.),

dan darah tinggi sewaktu mengandung (1.4%). Bayi kurang berat badan adalah hasil

perinatal yang paling biasa dalam kalangan kehamilan remaja (19.3%). Ia diikuti oleh

xii
kelahiran pramatang (9.0%) dan markah Apgar yang rendah dan kematian bayi

sewaktu lahir, kedua-duanya adalah 1.4%. Faktor yang berkaitan dengan bayi kurang

berat badan dalam kalangan kehamilan remaja di Terengganu adalah suami remaja

(AOR 2.0; 95% CI: 1.01, 3.96; p = 0.047) dan tahap pendidikan ibu yang rendah (AOR

3.07; 95% CI: 1.20, 7.85; p = 0.019).

Kesimpulan: Suami berumur remaja dan tahap pendidikan ibu yang rendah adalah

faktor signifikan yang perlu ditangani untuk menambahbaik hasil kehamilan remaja.

Intervensi untuk memperbaiki faktor ini harus diberi dorongan secara berterusan.

KATA KUNCI: kehamilan remaja, hasil obstetrik, hasil perinatal, kurang berat badan.

xiii
 ABSTRACT

FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT INFANTS OF

TEENAGE PREGNANCY IN TERENGGANU, 2018

Background: Teenage pregnancy is known to be associated with negative outcomes

including low birth weight infant, preterm birth and anaemia. Identifying these

outcomes and factors associated with low birth weight infants of teenage pregnancy

may help to improve the prevention and management of these factors, and

subsequently improve the pregnancy outcomes.

Objective: This study aims to determine the obstetrics and perinatal outcomes of

teenage pregnancy, and factors associated with low birth weight infants of teenage

pregnancy in Terengganu in 2018.

Methodology: A cross-sectional study was done from 1st January 2020 until 31st May

2020 using data from the Maternal Health Record Book and Pregnant Woman and

Postnatal Book Registry. The source population were all teenage pregnancies

attending government health clinics in Terengganu in 2018. Simple logistic and

multiple logistic regression analysis was used to analyse the factors associated with

low birth weight infants of teenage pregnancy.

Result: All 357 cases that fulfilled the study criteria were included. The most common

obstetric outcomes among teenage pregnancy was anaemia (41.5%), subsequently

followed by caesarean section (10.9%), gestational diabetes mellitus (2.8%) and

pregnancy-induced hypertension (1.4%). Low birth weight infants were the most

common perinatal outcomes among teenage pregnancy (19.3%). It was followed by

preterm birth (9.0 %) and both low Apgar score and stillbirth, 1.4% respectively.

xiv
Factors associated with low birth weight infants of teenage pregnancy in Terengganu

were teenage husband (AOR 2.0; 95% CI: 1.01, 3.96; p =0.047) and mothers with low

education level (AOR 3.07; 95% CI: 1.20, 7.85; p =0.019).

Conclusion: Teenage husband and low levels of mothers’ education were the

significant associated factors that need to be addressed to improve teenage pregnancy

outcomes. Interventions to improve these factors should continue to be encouraged.

KEY WORDS: Teenage pregnancy, obstetric outcomes, perinatal outcomes, low birth

weight

xv
 CHAPTER ONE

INTRODUCTION

Teenage pregnancy

Teenage or adolescent is defined as an individual at the age of 10 to19 years old (WHO,

2004b). Teenage contributes to 16 per cent of the world’s population, with the total

number of 1.2 billion (UNICEF, 2019). In 2018, there are about 5.5 million teenagers

in Malaysia (NHMS, 2017). Teenage is one of the most critical phases of human

development. During this period, there are a transition from childhood to adulthood

through physical, neurodevelopment, psychological and social changes. The physical

changes that occur include the increases of height and weight, the development of

secondary sex characteristics, changes in the amount and distribution of muscle tissues

and fat, and also changes in respiratory and circulation system. The development of

secondary sex characters in female teenagers starts with the development of breasts

and continues with pubic and axillary hair growth and menarche (Özdemir et al.,

2016).

Teenagers neural development is characterized by an imbalance between under

develop prefrontal control system and the limbic systems, which developed earlier.

These imbalance in brain changes are relevant to teenage behaviour, for the typical

emotional reactive style of teenagers, and it may promote risky behaviour (Konrad et

al., 2013). Another change that occurs in female teenagers was psychosocial

development, which includes self-identification and personality characteristic

1
development. Related to the hormonal and neurodevelopmental changes that are taking

place, there are psychosocial and emotional changes and increasing cognitive and

intellectual capacities. In the psychosocial development, teenagers are prone to have

high-risk behaviour and experimentation. Besides that, the teenagers gradually become

more concern about their freedom and their right, as well as begin to take on larger

responsibility within the family. Teenagers also tend to explore their sexual behaviour

by establishing a new relationship (Özdemir et al., 2016). In National Health And

Morbidity Survey (NHMS), 2017: Key Findings from the Adolescent Health and

Nutrition Surveys also explained that teenage personality characteristics like attention-

seeking and impulsive behaviour explain their health risk behaviours and social

problems which include tobacco, alcohol and drug use, violence and unintentional

injury, unhealthy dietary behaviours, suicidal behaviour, and lastly unsafe sexual

behaviours which lead to teenage pregnancy (NHMS, 2017).

Teenage pregnancy refers to girls who are pregnant at the age of 10 to 19 years old

(WHO, 2004a). A few studies have reported some factors associated with teenage

pregnancy which include having teenage parents, inadequate parental supervision, low

educational level, peer influence, poverty, low socioeconomic status, not engaging in

extracurricular school activities, and involving in substance abuse (Horgan and Kenny,

2007; Mohd Azri et al., 2015; Omar et al., 2010). In addition, some reported factors

leading to teenage pregnancy were ethnic differences, social deprivation, child

marriage, low education, unplanned pregnancy, unprotected sex and reduced

prevalence of contraceptive (WHO, 2004b).

2
Worldwide, it was reported that 16 million teenage pregnancy gives birth each year

(UNFPA, 2015). The global population of teenagers continues to rise. Projections

indicate the number of teenage pregnancies will increase globally by 2030, with the

highest proportional increases in Eastern and Southern Africa and West and Central

Africa (Franjić, 2018). In Malaysia, the prevalence of teenage pregnancy was 10.0 %,

as stated by Kim et al. (2001) in 2001. Then the prevalence decreased to 5.0 % in 2010

and 1.1 % in 2013 (Maimunah et al., 2012; Sulaiman et al., 2013).However, the

Malaysian Registry Department reported that deliveries among teenagers increased

from 15,849 deliveries in 2004 to 17,600 deliveries in 2008 and up to 19,310 deliveries

in 2012 (MOH, 2015b). There was an average of 1,500 new cases of teenage

pregnancies registered per month in health clinics in Malaysia (MOH, 2015b). Even

more alarmingly, 24% of the total number of pregnant teenagers is unmarried (MOH,

2015b).

In 2012, about 1.3 million teenage pregnancy died globally from preventable death

(EWEC, 2015). The top causes of death in girls aged fifteen to nineteen years old were

complications during pregnancy and childbirth (EWEC, 2015). The Global Strategy

for Women's, Children's and Adolescents’ Health aimed an end to preventable

maternal, newborn, child and adolescent’s death and stillbirth by 2030, aligned with

the Sustainable Development Goals. Sexual and reproductive health education and

services are identified as one of the interventions (EWEC, 2015). Gynaecological

organ immaturity, socio-demographic characteristics like poverty and nutritional

status example, malnutrition may predispose the teenage mother to poor obstetric and

perinatal outcomes including the risks of eclampsia, puerperal endometritis, systemic

3
infections, low birth weight infant, preterm birth, severe neonatal conditions and

spontaneous miscarriage (Franjić, 2018; Horgan and Kenny, 2007).

Low birth weight

Low birth weight infant is defined as an infant who is born with birth weight less than

2500 grams (WHO, 2015). World Health Organization documented that the global

prevalence of low birth weight infant was 15% (WHO, 2004c). About twenty million

low birth weight infants born each year, mostly in developing countries (WHO,

2004c). The highest incidence of low birth weight was reported in South-Central Asia

countries like Afghanistan, Bangladesh and India (WHO, 2004c). Generally, the

prevalence of low birth weight in Malaysia was 10% in 2000, both 11.3 % in 2012

and 2015 (UNICEF-WHO, 2019).

The common causes of low birth weight were restricted intrauterine foetal growth or

intrauterine growth retardation (IUGR), small for gestational age (SGA), foetal

malnutrition and preterm birth (Alam, 2009; Belfort et al., 2018). Birthweight was one

of the predictors for foetal growth. It was a significant determinant of mortality and

morbidity in infancy and childhood. Low birthweight can predict short-term survival

and influence the long-term health of the new-born (Risnes et al., 2011). A systematic

analysis found evidence that lower birth weight was associated with increased adult

morbidity and mortality. The results also showed strong evidence that low birth weight

had a strong association with type 2 diabetes mellitus, hypertension, coronary heart

disease and cancer (Alam, 2009; Risnes et al., 2011). There were studies in Malaysia

and other countries that found that teenage pregnancy had higher risk to get low birth

4
weight infant (Franjić, 2018; Ganchimeg et al., 2014; Harville et al., 2012; Omar et

al., 2010; Saba et al., 2013; Sulaiman et al., 2013).

Management of teenage pregnancy

Prevention and management of teenage pregnancy play an significant role, as teenage

pregnancy can lead to mother and child morbidity and mortality. Ministry of Health

Malaysia had established several policies regarding teenager’s health. Primary

prevention of teenage pregnancy starts with sexual and reproductive health education.

A study on Reproductive Health and Sexuality 1994/1995 stated that the majority of

adolescent lack knowledge on reproductive health (MOH, 2007). Sex education

syllabus in school and Ministry of Health programs such as Adolescent Health

Services at health centres were a platform to increase knowledge and to promote sexual

and reproductive health among teenagers. Comprehensive sex education programs

emphasis on improving reproductive health outcomes such as preventing unwanted

pregnancy, premarital conception or increasing sexual transmitted disease knowledge.

Promote abstinence, safe sex and contraception for teenagers are also crucial in

preventing teenage pregnancy. Contraception use and provision are targeted for

teenagers that are already sexually active to prevent unwanted pregnancy and sexually

transmitted disease like HIV. However, there were same issues arise regarding sex

education syllabus in Malaysia. The implementation of sexual education in Malaysia

is time-consuming as long-term training of educators and policy negotiations are

needed. The Ministry of Health also has difficulties in establishing the subject in the

school curriculum due to the fact that educators have been adapting the existing

traditional style for too long (Fazli Khalaf et al., 2014).

5
Awareness about the importance of early booking, antenatal care and complication of

teenage pregnancy are essential to teenagers. Late booking and poor antenatal care

were the most prominent problem among teenage pregnancy. This awareness can be

given during pre-pregnancy counselling care. Pre-pregnancy care and counselling can

reduce maternal and child morbidity and mortality (MOH, 2013b). Ministry of Health

already establishes a pre-pregnancy clinic in the health clinic. However, the clinic also

covered thalassemia screening program, premarital counselling courses, HIV

screening, and screening for medical conditions (MOH, 2013b).

Once a teenager becomes pregnant, comprehensive antenatal care is essential to avoid

poor outcomes. Pregnant teenagers are encouraged to come to health care for early

booking and antenatal check-up. Every teenage pregnancy case will be registered in

Teenage pregnancy list and Pregnant Woman and Postnatal Book Registry. During the

first booking, detail history taking, physical examination and proper investigation will

be done. Patient confidentiality will always be maintained, and health professional

should be not judgemental. As for every patient, socio-demographic data will be

obtained, including marital status, age of husband, ethnicity, employment status and

education level. Proper physical examination, including baseline blood pressure and

nutritional status like body mass index (BMI), was taken. Teenage mother will be

screened for anaemia, gestational diabetes and infectious diseases like syphilis and

HIV. Early booking is encouraged for every teenage mother so that that early screening

can be done. There will be a regular health check-up for each trimester or referred as

antenatal visit. The aim is to monitor the conditions of the mother and the foetal, like

6
maternal blood pressure and weight gain, mother haemoglobin level, and foetal growth

(Borhan, 2019). Subsequently, the care continues with continuous education about

mother and foetal care, nutrition advice and providing adequate supplements to

mothers. All these interventions are crucial as anaemia, pregnancy-induced

hypertension (PIH) and nutritional status can lead to poor outcomes like low birth

weight infant.

Ministry of Health Malaysia had established a personalized health care system for

maternal and child health in all health clinics in Malaysia. The concept of personalized

health care involves specific nurses and medical officers that will be provided to care

and responsible for monitoring family health status in the care area and provide health

care plan holistically according to individual needs (Simmons et al., 2016). The

personalized care needs to continue in the antenatal care of the teenage mother. WHO

recommends that midwife or nurses need to support the teenage mother throughout the

antenatal, intrapartum, and postnatal period (Vogel et al., 2013). Every teenage

pregnancy needs to deliver at a tertiary hospital as complications during delivery and

postnatal is anticipated. After delivery, postpartum care will be continued by giving

support to this young mother in taking care of baby and breastfeeding. These include

mental health support and social support. Contraception counselling is also essential

to help the mother to recover and to continue their education later (Marino et al., 2016).

7
 Statement of problem

Teenage pregnancy is currently categorized as a high-risk pregnancy. In Perinatal Care

Manual 2013 (3rd edition), teenage pregnancy was tagged as yellow tagging.

Teenagers who are pregnant need to be referred to an obstetrics and gynaecology

specialist or family medicine specialist for optimum management (MOH, 2013b).

Teenage pregnancy was a significant risk factor for maternal and perinatal morbidity

and mortality (WHO, 2018). It was associated with poor outcomes including stillbirth,

low birth weight infant, preterm delivery, antenatal complications like PIH, and

maternal death (Omar et al., 2010; Sulaiman et al., 2013). In Malaysia, a study had

reported that low birth weight infant was among the commonest perinatal outcomes of

teenage pregnancy (Omar et al., 2010). However, there was limited information on the

factors associated with low birth weight as the outcomes of teenage pregnancy.

Low birth weight infant becomes the leading causes of neonatal death. It leads to

nearly 80% of all neonatal deaths (WHO, 2004c). Low birth weight infants were also

associated with many complications such as hypothermia, respiratory problems,

digesting problems like necrotizing enterocolitis, anaemia, impaired nutrition and poor

weight gain, neurological problem and sudden infant death syndrome (Abdullah et al.,

2014; Stanford Children's Health, 2019). Thus, the World Health Assembly Resolution

65.6 endorsed a policy that targets of reduction in low birth weight prevalence between

2012 and 2025, by 30% (WHO, 2014). Malaysia is still struggling to achieve this target

as our progress in reducing low birth weight has been stagnant since 2000; thus, more

understanding of the factors leading to low birth weight is needed.

8
In Malaysia, the percentage of low birth weight infant admitted to neonatal intensive

care units were increasing in trend from the year 2012 to 2016, 32.8% in 2012, 37.3%

in 2013, 37.5% in 2014 and 38.6% (MNNR, 2016; MNNR, 2017; MNNR, 2018;

MNNR, 2019). This will burden the hospital and the Ministry of Health to provide

optimum treatment with limited resources. Thus, it is very important to reduce the

incidence of low birth weight. Other studies elsewhere had reported the association

between teenage pregnancy and low birth weight. The similar association in our local

setting is yet to be determined. In addition, it is crucial to know the factors leading to

low birth weight among teenage pregnancy, to help in targeting suitable strategies for

its prevention.

Rationale of the study

Teenage pregnancy is a global problem that arises in high, middle, and low-income

countries (Franjić, 2018). Therefore, it is essential to know the outcomes of teenage

pregnancy and its burden. Studies have shown various poor obstetric and perinatal

outcomes of teenage pregnancy. However, the outcomes in our setting are yet to be

explored. Identifying these outcomes may help in prioritizing health services and

strategies.

In view of very limited studies on teenage pregnancy in Malaysia, and especially on

factors associated with low birth weight infants among teenage pregnancy, this study

may provide valuable information on the existing problems in our local setting.

Identifying factors associated with low birth weight infants of teenage pregnancy may

help to improve the prevention and management of these factors, and subsequently

9
improve the pregnancy outcomes. The preventable factors can be acted upon and may

subsequently lead to a reduction in low birth weight among teenage pregnancy.

Furthermore, by reducing low birth weight prevalence among teenage pregnancy, it

will help reduce the number of admissions to the neonatal intensive unit. Subsequently,

it will decrease the burden of workload and resources incurred by the Ministry of

Health in managing infants with low birth weight and its complications. Additionally,

this study may suggest some strategies to be conducted in order to reach the target of

30% reduction in low birth weight prevalence between 2012 and 2025. This can be

achieved by doing focus interventions to the factors associated with low birth weight

in teenage pregnancy. Finally, by reducing the prevalence of low birth weight, it may

help to reduce perinatal, neonatal and child mortality and morbidity in Malaysia.

Research questions

1. What are the obstetric and perinatal outcomes of teenage pregnancy in

Terengganu in 2018?

2. What are the factors associated with low birth weight infants of teenage

pregnancy in Terengganu in 2018?

10
 Objectives

General objective

To determine the outcomes of teenage pregnancy and factors associated with low birth

weight infants of teenage pregnancy in Terengganu in 2018

Specific objectives

1. To describe obstetric and perinatal outcomes of teenage pregnancy in

Terengganu in 2018

2. To determine factors associated with low birth weight infants of teenage

pregnancy in Terengganu in 2018

Research hypothesis

There are significant associations between socio-demographic characteristics,

obstetrics characteristic and nutritional status with low birth weight infants in teenage

pregnancy.

11
 CHAPTER TWO

LITERATURE REVIEW

Prevalence of low birth weight in Malaysia

There are a few studies on low birth weight done in Malaysia. In 1991, a study was

done among live births at the Maternity Hospital Kuala Lumpur. The prevalence of

low birth weight infant was 13.5% (Tahir et al., 1991). Another study was done at the

Lundu Hospital in Sarawak. The study reported the incidence of low birth weight to

be 11.8% among live births at the hospital (Yadav, 1994). A case-control study carried

out at Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan over a six-month

period found the prevalence of low birth weight was 10.9% (Fuad, 2015). Recently, a

cross-sectional study of low birth weight was done among women in the rural and

urban area in Selangor. The study reported that the prevalence of low birth weight

infants was 6.4%. Women who live in a rural area had more low birth weight infants

than urban women (9.8% vs 2.0%, p = 0.03) (Kaur et al., 2019).

Low birth weight as the outcome of teenage pregnancy

The most common perinatal outcome of teenage pregnancy was the low birth weight

infant. Teenage parents are more likely to give birth to low birth-weight babies,

unemployed and live in poverty (Franjić, 2018). There were a few studies in other

countries reported the prevalence of low birth weight in teenage pregnancy. One of the

studies was done using data from the National Longitudinal Study of Adolescent

12
Health, United States. Outcomes of pregnancies were reported by comparing data

between female cases who described a first singleton livebirth among teenagers and

those who were 20 years of age or older. Prevalence of low birth weight among female

participants less than 20 years old was 8.5% (Harville et al., 2012). Another study was

a descriptive study carried out in a district teaching hospital in Pakistan. Prevalence of

low birth weight in this study was 7% (Saba et al., 2013). A World Health Organization

multi-country study that involves twenty-nine countries in Asia, Latin America, Africa

and the Middle East was done in 2013. This study objective was to investigate the risk

of adverse pregnancy outcomes among teenagers in twenty-nine countries. The result

showed significant low birthweight as perinatal outcomes in teenage pregnancy (AOR

= 1.17; 95% CI, 1.01–1.37, p-value < 0.01) (Ganchimeg et al., 2014).

In Malaysia, a case-control study was conducted in 2008, at two main hospitals in

urban population that were Kuala Lumpur General Hospital and Universiti

Kebangsaan Malaysia Medical Centre. This study reported the highest prevalence of

low birth weight in teenage pregnancy that was 37.3% with a significant difference

compared to adult pregnancy (Omar et al., 2010). The teenage group had a higher rate

of low birth weight (24.1%) than the adult group (7.0%). Furthermore, another study

reported that 4.5% of teenage mothers delivered babies of very low birth weight that

was less than 1500 grams (Sulaiman et al., 2013).

13
 Pathophysiology of low birth weight in teenage pregnancy

Birthweight is greatly affected by the mother’s growth, foetal growth and her

nutritional intake from birth to pregnancy; thus, baseline body composition was very

important. Mothers with poor socio-economic conditions frequently have low birth

weight infants. The uses of energy by physically demanding work during antenatal

also contributes to poor foetal growth (WHO, 2004c).

The biological factor proposes that the blood supply to the cervix and uterus does not

develop completely during the physical development of a teenager. Inadequate blood

supply may predispose some teenage mothers to infections which sequentially may

precipitate preterm labour and preterm birth, which are the leading cause of low birth

weight in infants. Most of the teenagers need at least three years to develop a matured

ovulatory cycle; this will lead to low levels of gonadal hormones during teenage

pregnancy that may compromise proper attachment of the foetus to the uterine wall

and causing vaginal bleeding leading to premature contractions (Roth et al., 1998).

There was a hypothesis that teenagers are still growing physically and need adequate

nutrition for their own development. This mother’s physical development may

compete with the foetus for nutrients, which may result in impaired foetal growth and

causing low birth weight infants (Marvin-Dowle et al., 2018; Roth et al., 1998).

14
 Other obstetric and perinatal outcomes of teenage pregnancy

Currently, teenage pregnancy still represents a high-risk pregnancy. Giving birth

during teenager was not only a risk factor for poor obstetric outcomes but also poor

perinatal outcomes (Ganchimeg et al., 2014). Pregnancy in teenagers has been

associated with increased poor obstetric outcomes such as maternal mortality, anaemia

in pregnancy (PIH), pre-eclampsia or eclampsia, gestational diabetes mellitus (GDM),

caesarean section and postpartum haemorrhage (Althabe et al., 2015; Fayed et al.,

2017; Ganchimeg et al., 2014; Horgan and Kenny, 2007; Marino et al., 2016; MOH,

2016). Previous studies also had reported an increased incidence of poor perinatal

outcomes, such as low birth weight infant, preterm birth, low Apgar score and stillbirth

(Fayed et al., 2017; Franjić, 2018; Ganchimeg et al., 2014; Horgan and Kenny, 2007;

Marino et al., 2016; Sulaiman et al., 2013).

Maternal outcomes

a) Maternal mortality

Confidential Enquiries into Maternal Deaths (CEMD) Malaysia National Committee

reported a total of 264 pregnancy-related deaths in 2017. Teenage maternal mortality

was increasing in trend from 2014 to 2016. Teenage maternal mortality 2014 to 2016

were 11.8, 12.4 and 57.8 per 100000 live birth, respectively. In 2017, teenage maternal

death reduced to 15.0 per 100000 live birth (MOH, 2014; MOH, 2015a; MOH, 2016;

MOH, 2017a).

15
b) Maternal anaemia

A study done in Malaysia in 2010 showed that anaemia in teenage pregnancy was

46.9% and supported with another study in 2015, with a prevalence of 53.1% (95%

CI: 46.0, 60.0) (Jusoh et al., 2015; Omar et al., 2010). A latest cross-sectional study

done in Australia from 2004 to 2006 revealed that teenage pregnancy was more likely

to be associated with anaemia (14%) (Lewis et al., 2009). Studies in other countries

showed a higher prevalence of anaemia among teenage pregnancy. The prevalence of

anaemia in Kenya was 61% (Shipala et al., 2013). Another study in Pakistan, the

prevalence of anaemia among teenage pregnancy was 67% (Saba et al., 2013).

However, study of anaemia in general population showed that prevalence of anaemia

in pregnancy higher in advance maternal age more than 35 years old was 47% compare

to 25 to 34 years old mothers (23.1%) and 15 to 24 years old mothers (29.9%)

(Hasswane et al., 2015).

In a normal pregnancy, there is an increase in plasma volume and the subsequent

decrease in haemoglobin concentration and haematocrit, thus complicate the

assessment of anaemia. Generally, teenage pregnancy alone is not the cause of

anaemia. Anaemia in pregnancy is frequently caused by nutritional deficiencies,

especially of iron and folic acid or infestation by malaria and intestinal parasites like

hookworm. In developing countries, frequently children and female teenagers suffer

most from underprivileged environmental and social circumstances, including

inadequate diet, and this often leads to nutritional deficiencies causing anaemia

(Shipala et al., 2013; WHO, 2004b). Teenage pregnancy often receives inadequate

antenatal care and poor access to health services; consequently, they lack supplement

16
intake like hematinic that provided during antenatal care (Jusoh et al., 2015; Shipala

et al., 2013). A teenage mother is predominantly susceptible to anaemia because of

their rapid growth and associated high iron requirements.

c) Hypertensive disorder of pregnancy

In addition, pregnancy-induced hypertension, pre-eclampsia and eclampsia are the

commonest hypertensive disorders in pregnancy. Most of the studies included PIH as

the maternal outcomes of teenage pregnancy. Study of distribution of maternal risk

factors, pregnancy characteristics and outcomes in adult and teenage women in

Australia by Lewis et al. (2009) also showed that 10% of the teenage mothers had PIH.

Another study in India also had 10% of PIH among teenage mothers with OR 2.21,

95% CI (1.5–3.2) compared to adult mothers (Mahavarkar et al., 2008). PIH outcome

was lower in a study in Thailand by La-Orpipat and Suwanrath (2019) that was 4.5%.

These studies by La-Orpipat and Suwanrath (2019), Mahavarkar et al. (2008) and

Lewis et al. (2009) only included PIH which is hypertensive disease disorder as a

maternal outcome among teenage pregnancy their studies.

Studies by Pergialiotis et al. (2015) and Fayed et al. (2017) included both PIH and pre-

eclampsia in their study. They found the prevalence of PIH was 0.6% and 0.7%, and

pre-eclampsia was 0.4% and 2.4%, respectively. A study by Sulaiman et al. (2013)

listed only pre-eclampsia in the study. Prevalence of pre-eclampsia among teenage

pregnancy in Malaysia by Sulaiman et al. (2013) was 1.1%. Meanwhile, a study by

Ganchimeg et al. (2014) included pre-eclampsia and eclampsia outcomes, but they

17
divided the teenage mothers by age groups of ≤ 15 years, 16 to 17 years, 18 to 19

years and control group were 20– 24 years. The prevalence of pre-eclampsia in this

study was 3.8 % among the age of ≤ 15 years, 2.5% among the age of 16 to 17 years,

2.0% among the age of 18 to 19 years and 1.8% among the control group. Prevalence

of eclampsia were 1.0%, 0.9%, 0.7% and 0.3%, respectively. Therefore, this study

showed that the prevalence of pre-eclampsia and eclampsia were higher among those

in younger age groups.

Over the years, the physiopathology of hypertensive disorder in pregnancy has not

been totally explained. The pathophysiology of hypertensive disorder in teenage

pregnancy are not different from the rest of the affected population. Several factors

have been concerned in the pathophysiology of hypertensive disorder in pregnancy.

Potential mechanism started with abnormal cytotrophoblast invasion of spiral

arterioles subsequently lead to reduced uteroplacental blood flow. Placental ischemia

occurred result from reducing blood perfusion and then causing extensive dysfunction

of the maternal vascular endothelium. Dysfunction of the maternal vascular

endothelium will enhance the formation of endothelin and thromboxane, increased

vascular sensitivity to angiotensin II, and decreased formation of vasodilators such as

nitric oxide and prostacyclin. These endothelial abnormalities, sequentially, cause

chronic hypertension by impairing renal pressure natriuresis and increasing total

peripheral resistance. Besides the above postulation, there are also other factors

predisposing to hypertensive disorder in pregnancy, such as extreme ages which are

teenagers and elderly, nulliparity, obesity, smoking, quality of health care system,

18
accessibility to health care and history of pre-eclampsia in a previous pregnancy

(Granger et al., 2001; Rosales-Ortiz et al., 2019).

d) Gestational diabetes mellitus

Another maternal outcome of teenage pregnancy was gestational diabetes mellitus

(GDM). A study of demographic profile and pregnancy outcomes of adolescents and

older mothers was done in Saudi Arabia in 2017. In this study, the prevalence of GDM

in teenage mother was 17.7% compare to 20 to 29 years old mother (19.4%), 30 to 34

years old mother (26.4%), 35 to 39 years old mother (30.4%) and lastly, more than 40

years old mother (33.9%) (Fayed et al., 2017). The prevalence of GDM in teenage

pregnancy was high as compared to other previous studies, 0.85% in 2011, 5.4% and

1.18% in 1998 (Karcaaltincaba et al., 2011; Lao et al., 1998; Lemen et al., 1998).

However, a systematic review and meta-analysis reported that GDM risk increases

linearly with maternal age. Teenage had a significantly lower risk for GDM than older

mother (Li et al., 2020).

Throughout normal pregnancy, the mother’s body undergoes a series of adaptations or

physiological changes in order to provide the nutritional demands for the growing

foetus. One important physiological change is insulin sensitivity. Over the progression

of gestation, insulin sensitivity changes depending on the requirements of pregnancy.

19
During early pregnancy, the body needs to prepare for demands on the late gestation

of pregnancy; thus, insulin sensitivity increases, encouraging the uptake of glucose

into adipose stores, that later change to energy. However, as the pregnancy progresses,

there will be an increase of local and placental hormones, including estrogen,

progesterone, cortisol, leptin, placental lactogen, and placental growth hormone

together, causing a state of insulin resistance. Consequently, blood glucose is slightly

elevated, and this glucose is readily transported across the placenta to support the

growth of the foetus. This mild state of insulin resistance also encourages endogenous

glucose production and the breakdown of fat stores, thus will lead to an increase in

blood glucose and free fatty acid. Pregnant women will compensate for these changes

through increased glucose-stimulated insulin secretion, as well as hypertrophy and

hyperplasia of pancreatic β-cells. If the normal metabolic adaptations to pregnancy do

not sufficiently occur in the pregnancy, this will cause GDM.

e) Other maternal outcomes

One of the complications that may occur during delivery was a caesarean section.

Studies in Malaysia showed 9.8% of teenage mothers would end up with a caesarean

section compare to adult 12.7% (Omar et al., 2010; Saba et al., 2013). Study in among

teenage pregnancy in Pakistan reveal 6.6% of the teenage pregnancy had caesarean

section as outcome. The most common indication for caesarean section was foetal

distress, followed by cephalopelvic disproportion. Indication for caesarean section in

foetal distress and pre-eclampsia was more commonly found among the teenage

mothers than among the adult mothers. The possible reasons could be due to

underdevelopment of pelvis in younger mothers and occurrence of cephalopelvic

20
disproportion more frequently in teenage mothers; consequently, the number of

instrumental deliveries and caesarean sections was also higher (Mukhopadhyay et al.,

2010).

In addition, teenage pregnancy was also at risk to have postpartum haemorrhage. The

previous study in Pakistan by Saba et al. (2013) reported a higher percentage of

postpartum haemorrhage (18.6%) as compared to study done at South Asian Sites, in

which only 0.7% of postpartum haemorrhage in teenage mothers (Althabe et al., 2015;

Saba et al., 2013). However, another study found the prevalence of postpartum

haemorrhage among teenage mothers was lower (8.7%) compared to adult aged

between 21-25 years old (49.6%) and older mothers aged 26-30 years old (33.9%)

(Kodla, 2015). Nevertheless, the commonest risk factor for postpartum haemorrhage

was anaemia with 41.7%, in which anaemia was also the highest outcome in teenage

pregnancy with 53.1% (Jusoh et al., 2015). There was a study supported that anaemia

in pregnancy increased risk of postpartum haemorrhage; the patients with

haemoglobin of 7 g/dl or less were more likely to have postpartum haemorrhage due

to uterine atony, as compared to patients with Hb 7.1 to 10 g/dl (Frass, 2015).

Perinatal outcomes

In addition to low birth weight, preterm birth is also one of the perinatal outcomes in

teenage pregnancy. There were increased risks of premature delivery, restricted foetal

growth and abortion in teenage pregnancy (Franjić, 2018). A study by Sulaiman et al.

(2013) showed significant preterm birth complication in teenage pregnancy (24.3%).

21
This preterm birth of teenage pregnancy was also supported by another study in Saudi

Arabia, with adjusted OR 1.5, 95% CI = 1.1 to 2.1, a p-value less than 0.05 (Fayed et

al., 2017).

The association between teenage pregnancy and the adverse perinatal outcomes has

been attributed to gynaecological and growth immaturity and also the nutritional status

of teenage pregnancy. Preterm birth was also at higher risk to get a low Apgar score

and low birth weight infant (Ogawa et al., 2019). These are because low birth weight

infant in teenage pregnancy share the same pathophysiology that causing preterm birth

and lead to low birth weight infant.

Teenagers growth like height, weight and BMI continues until 18 to 19 years of age.

Shorter maternal height and underweight would reflect such physical immaturity in

teenagers. Shorter height and underweight are also known to increase risk of poor

perinatal outcomes such as small for gestational age (SGA), preterm delivery, and

pre-eclampsia among mature adults (Girsen et al., 2016; Ogawa et al., 2019).

The biological factor proposes that the blood supply to the cervix and uterus does not

develop completely during the physical development of a teenager and a hypothesis

that teenagers are still growing physically and need adequate nutrition for their

development precipitate low birth weight and preterm birth. Low levels of gonadal

hormones also may compromise proper attachment of the foetus to the uterine wall

22
and causing vaginal bleeding leading to premature contractions (Marvin-Dowle et al.,

2018; Roth et al., 1998).

Study in Malaysia also revealed that teenage pregnancy also had a significant risk for

low Apgar score,10.8% (Omar et al., 2010). Prevalence of low Apgar score among

teenage pregnancy in another study in Saudi Arabia was 1.9% (Fayed et al., 2017).

Preterm birth was reported to be a strong association for low Apgar score (Svenvik et

al., 2015). Thus, most of the risk factors that can cause preterm birth can lead to low

Apgar score infant.

There was a study that observed maternal height as a significant association between

adolescent pregnancy and preterm birth, low birth weight and low Apgar score. The

result in the study supports a hypothesis that shorter height of mother, which relates to

smaller pelvic size among teenagers was partly responsible for increased risk of

preterm birth. Preterm infants were also at a higher risk to get a low Apgar score and

low birth weight infant (Ogawa et al., 2019).

The rate of stillbirth among teenage mothers in Australia had increased from 9.5/1000

births to 15.0/1000 from 1991 to 2009 (Marino et al., 2016). The prevalence of

stillbirth among teenage pregnancy in Malaysia was 0.6%. Poor social environment

and low education have been proven strong indicators for stillbirth (Olausson et al.,

1999).

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 Factors associated with low birth weight infant among teenage pregnancy

Current review found five research done to determine the association between low

birth weight infant and teenage mothers, as well as their risk factors which were

studied by Roth et al. (1998), Harville et al. (2012), Guimaraes et al. (2013), Dennis

and Mollborn (2013) and Belfort et al. (2018). In view of the limited literature on

factors associated with low birth weight among teenage pregnancy, this section also

included those factors found from studies conducted among the general population.

Even though the populations were different, the factors might influence the occurrence

of low birth weight in both groups and provide important guidance for this study. The

factors can be divided into socio-demographic factor, obstetric factor and nutritional

status factor.

Socio-demographic factors

Socio-demographic factors include marital status, husband age, ethnicity, employment

status and education.

a) Marital status

Many studies showed that unmarried teenage mother or single mother was

significantly associated with low birth weight infants (Belfort et al., 2018; Shah et al.,

2011). The previous study in Brazil hospital also documented the same result. Teenage

mothers without her partner had a risk of low birth weight three-times higher than adult

mothers (Guimaraes et al., 2013).

24