From the Mamta Health Institute of Mother and Child,
33A, Saidulajaib, M.B. Road, New Delhi 110 030, India.
Correspondence: Dr. Sunil Mehra, Executive Director,
Mamta Health Institute of Mother and Child, 33A, Saidulajaib, M.B.
Road, New Delhi 110 030, India.
E-mail: mamta@ndf.vsnl.net.in,
mamtahealth@ vsnl.net
Abstract:
Adolescents among the urban and rural poor have a
high incidence of chronic energy deficiency (CED) and anemia, more
so in girls than in boys. Adolescent pregnancies (15-19 years)
contribute to 19% of total fertility in India and record the highest
maternal mortality rates. Besides maternal age, lack of education,
low socio-economic status, maternal undernutrition and limited
access to maternal health services are important determinants of
poor pregnancy outcomes. Low birth weight is the major adverse
outcome for the infant and an important determinant of increased
child mortality. There is a lack of data for long term follow up of
infants of adolescent mothers versus mothers 20 years and above, and
more specifically, in the urban poor setting, an emerging concern.
Key words: Adolescent, Low birth weight, Pregnancy, Urban.
In India, the adolescent population constitutes
more than one fifth (23%) of the total population(1). Among the SAARC
countries also, adolescents comprise a sizeable proportion (one-fifth)
of the total population and the total population in the region, as a
whole will increase by 18% by 2020(2). The growth in numbers is likely
to affect poor urban communities, since young people are the sector
most likely to migrate to urban areas(3).
India has the fastest growing segment of urban poor
in the world. India’s urban population increased by 31.2% between 1991
and 2001-nearly double the increase of 17.9% in rural population over
the same period(4). Young adults are the most fertile section of the
population so that urban growth has now become self-perpetuating .In
future the growth of the population of young people in the developing
countries will primarily be in urban areas(5).
Urban services and infrastructure have not kept
pace with rapid urbanization. Insecurity relating to regular income,
food, shelter, access to health care services, along with poverty and
difficult physical and social environment has adverse impact on the
health of the urban poor. The adolescent boys and girls in the urban
slum areas face the problem of malnutrition, early marriage, unwanted
pregnancy, illegal and unsafe abortion, sexually transmitted diseases,
sexual exploi-tation and violence that compound the difficulties of
adolescent physical and psycho-social development(6). Early marriage
has been and continues to be the norm, particularly for girls. The
risks of early pregnancy are exacerbated by poverty and inadequate
access to maternal and child health services.
Research on urban slums encounters a critical
problem. Existing data are rarely disaggregated in intraurban location
or socio-economic criteria. Data sets as NFHS disaggregate by "urban"
and "rural", but go no further. Thus the slum population and the
poorest squatters are statistically identical to middle class and
wealthy urban dwellers. Worst yet, the poorest urban populations are
often not included at all in data gathering. Without exception,
disaggregated data will show dramatic differences in health indicators
between slum and non-slum populations or between lower and upper
economic quintiles. There is a great need to promote disaggregated
urban data collection(4).
In this review, we look at adolescent health and
its determinants, and its impact on pregnancy and its outcomes. The
paper is divided into sections on the nutritional, biological and
social determinants of adole-scent health, which contribute to poor
pregnancy outcomes both for the young mother, a child herself, and her
infant. An effort has been made to present data specific to urban
slums, from varied sources, wherever available.
Determinants of Adolescent Health
(a) Nutritional determinants
An adolescent girl is a child herself with
significant nutritional requirements during the adolescent growth
spurt. In an adolescent mother who is likely to be already
mal-nourished if she is an urban slum dweller, the competing
nutritional needs of pregnancy and growth, will affect the growth of
the fetus and hence the birth weight of the child(7).
Anemia: Anemia is one of the primary contributors
to maternal mortality (20-25%) and is significantly associated with a
compromised pubertal growth spurt and cognitive development among
girls aged 10-19 years(8). The NFHS-2 found that 56% of adolescent
girls in the age group 15-19 are anemic in India(1). Results from
various studies conducted particularly in the urban slums, on the
prevalence of anemia in underprivileged adolescent girls 10-15 years
of age and summarized in a review by Kanani(9) has shown the
prevalence of anemia ranging from 65-75% with age specific variations.
Chronic Energy Deficiency (CED): Young adolescent
mothers have a lower body mass index (BMI) since the BMI increases
markedly during adolescence as pubertal changes occur(10). A low BMI
status, indicative of chronic energy deficiency, is a particularly
important aspect of the nutritional risks of women, during
reproductive years. In a study conducted in an urban slum of Varanasi,
70% of girls aged 13-18 years had BMI <20, 51.4% were suffering from
CED, and 10% were stunted(11).
The birth weights of newborns appear to be linearly
correlated with both maternal body weight and height. Naidu et al(12)
demons-trated that mean birth weights of infants improved as the BMI
value moved from grade 3 CED (BMI <16.0) to normal BMI value (between
18.5-25). The proportion of low birth weight infants increased among
mothers with low BMI. There is also some evidence to indicate that
poor maternal nutritional status, as exemplified by a low BMI, is
associated with poor lactational performance and poorer growth in
infants(13).
(b) Biological determinants
Maternal mortality has been reported to be higher
in adolescent pregnancies with 380 to 645 / 100,000 live births for
girls between 15-19 years while it is 250-342 / 100,000 live births
for women aged 20-34 years(14). The question is whether teenagers are
inherently a high-risk group due to biological factors or whether
social factors including prenatal care or both are important
determinants of poor pregnancy outcome in this group(15).
Physical maturity: The development of the pelvic
birth canal is slower than that of the early teenage spurt of long
bones. The birth canal does not reach its mature size until several
years after growth in height has ceased by the age of 18 years(10). As
a result cephalopelvic disproportion (CPD) is the commonest problem
encountered during labor in teenage pregnancies, as the pelvic
architecture is not yet completely formed and mature enough for
delivery(16). Significant incidence of prolonged / obstructed labor
and hypotonic uterine contractions in adolescent pregnancies have been
reported by Pachauri and Jamshedji(15).
Age: The mother’s age seems to confound the risk of
infant death as the Infant Mortality Rate (IMR) for adolescent mothers
is 40% higher than for older mothers (107.3 and 75.8 per 1000 live
births respectively)(17). Joshi and Pai(18) in their study of
organized slums of Mumbai have demonstrated a direct association
between maternal age and low birth weight (LBW) , the incidence being
47% in the adolescent age group as compared to 34% in the 20-24 years
age group and 29% in the 25-29 years. In a study of a semi urban
population by Kushwaha et al.(19), the incidence of LBW in age groups
15-17 years and 17-19 years were 81% and 56% respectively. It is well
documented that primigravidas pose a high obstetric risk. The vast
majority of teenagers are primigravidas. NFHS-1 survey (1992-93) shows
infant mortality rates to be higher for the first birth order (93/1000
live births) as compared to second and third birth order (77 & 72
respectively)(20).
(c) Social determinants
Early marriage: In most countries of the SAARC
region, nearly 60% of all girls are married by the age of 18 years
with one fourth marrying by the age of 15 years. In India, every third
adolescent girl in the age group of 15-19 years is married. Mean age
at marriage among female adolescents is 14.7 years and mean age at
cohabitation slightly higher (15.5 years)(17). This has been shown to
increase with the educational status and the standard of living, both
of which are more likely to be compromised in the slum setting.
Moreover, women who marry at a young age are likely to find motherhood
to be the sole focus of their lives, at the expense of development in
other areas such as formal education, training for employment, work
experience and personal growth.
Early childbearing: According to NFHS-1 nearly 58%
of adolescents have commenced childbearing. Only 7% adolescent females
use contraception(17). Given the poor educational and socio-economic
status and limited access to family planning services the situation
would be even worse in the slum settings. Fertility in the age group
of 15-19 years accounts for 19% of total fertility in India. About 23%
of married adolescent girls age 15-19 years have second order of
birth(1).
The age specific fertility rate (15-19 years) in
India has been shown to be the highest at 145 (births/1000 woman age
15-19 years) in the poorest urban quintiles (most likely to be
residing in the slums) as against 41 in the richest urban quintile,
135 in poorest rural quintile and a population average of 116(21).
The data may not reflect the actual situation as a
substantial numbers of pregnancies in married and particularly
unmarried girls go unreported because of the high rate of deliveries
at home or in places other than institutional settings.
Literacy: NFHS-2 data clearly indicates that only
7% of married women in the age group of 15-19 years have attained a
higher secondary level of education. As many as 55% are illiterate in
this age group and only 17% have completed primary schooling(1). Low
levels of literacy adversely affect reproductive and sexual health
awareness and thus quality of life. In a study undertaken in the urban
slums of Greater Mumbai, to study the impact of maternal biosocial
determinants on birth weight, it was observed that 52% of illiterate
mothers gave birth to low birth weight babies suggesting that
education plays a considerable role in preventing LBW(18).
Socio-economic status: The lower socio-economic
status of the mother is also associated with low birth weight
babies(16). Domestic responsibilities, working for livelihood,
inadequate rest along with malnutrition especially when the energy
demands are increased, contribute to a large number of women
delivering low birth weight infants(12,18). The consequences are
reinforced by the fact that children of young and illiterate mothers
tend to face the same cycle of economic deprivation and under
nutrition as experienced by their mothers.
Gender inequity: Gender disparities in feeding
patterns are widespread in India and take their toll on the growth of
adolescent girls(12). There is a gender gap in education reflected by
the 20% gap in literacy between boys and girls overall. School dropout
rates are also significantly higher for girls and since disaggregated
data is not available for literacy rates in urban slum settings, it
can only be assumed that the situation would be far worse given the
fact that there is lack of awareness among parents, frequent
migration, lack of resources and the compulsion to earn liveli-hood
and assume household responsibilities in childhood.
(d) Access to Health services
According to NFHS-(1) data, among mothers less than
20 years, only 7% receive antenatal care from a health worker or
professional and 41.6% are assisted at delivery by a skilled birth
attendant(6). Over two-thirds of deliveries occur outside the health
care institutions. One in six births to adolescents is mistimed or
unwanted(17). A large proportion of these births can be avoided if
adequate information on contraception and access to health services
are available to adolescents.
The reproductive and child health services in our
country are often barred to adolescents or require them to reach a
certain age before they can utilize them.
Outcomes of Adolescent Pregnancy
Pregnancy-related deaths are the leading cause of
mortality for 15-19 years old girls (married and unmarried) worldwide.
The risk of maternal death is about three times higher in late
adolescent (15-19) girls; and those less than 15 years old are 5 times
as likely to die as women in their twenties. They also have a higher
propensity to experience adverse outcomes such as higher fetal wastage
(miscarriage and / or still births)(2). Prior spontaneous abortions
and higher stillbirth rates have been reported in different
studies(15,16).
The most frequently encountered compli-cations
during pregnancy and labor are toxemia of pregnancy, eclampsia,
preterm labor and cephalopelvic disproportion. The risk of toxemia of
pregnancy has been shown to be three times higher. Fetal distress
during labor, respiratory distress syndrome (RDS), icterus and trauma
(birth injuries) have been reported more frequently for offspring of
teenagers(13).
Comparison of NFHS-1 and 2 data reflects a decline
in neonatal, infant and under five mortality cases from the year 1991
to 1998. However these rates continue to be higher in mothers less
than 20 years compared to 20-29 years age group (Table I).
|
IMR
(per 1000) |
CMR
(per 1000) |
U5M
(per 1000) |
Mother’s educational level |
Illiterate
|
101
|
44
|
141
|
Literate, not completed middle school
|
63
|
23
|
84
|
Middle school completed
|
56
|
9
|
65
|
High School & above
|
37
|
6
|
43
|
Mother’s age at birth
|
<20 years
|
107
|
38
|
141
|
20-29 years
|
76
|
35
|
104
|
30-39 years
|
91
|
34
|
122
|
40-49 years
|
112
|
58
|
163
|
Birth order
|
1
|
93
|
26
|
117
|
2
|
77
|
32
|
106
|
3
|
72
|
37
|
107
|
6
|
98
|
40
|
134
|
7
|
120
|
54
|
168
|
Source: NFHS-1, 1992-93(22).
IMR= Infant mortality rate; CMR = Child Mortality rate; U5M rate = Under Five Mortality rate.
Program Experiences
The issues related to female adolescent health need
to be viewed not only from the point of view of the health of the
adolescent herself, but also from the perspective of intergenerational
health and development. However, there are very few examples of
effective interventions for adolescent health and development in
India.
As of now adolescent health issues are being
addressed in government program at national level mainly through the
Reproduc-tive and Child Health program (under the Ministry of Health
and Family Welfare) and Integrated Child Development Scheme (under the
Department of Woman and Child Development). Both seem to have a tunnel
focus, viewing them as a future parent or preparing them for adulthood
rather than addressing their immediate concerns as adolescents. Very
little of its impact is seen in the urban poor context because of lack
of infrastructure and urban health planning.
Two examples of small-scale efforts made by non
government organizations are CEDPA’s (Center for Development and
Population activities) Better Life Options program (BLP) being
implemented in the urban slums of Delhi, rural Madhya Pradesh and
Gujarat(8) and the ‘Integrated Adolescent Development Program for
Women’s Empowerment’ in the urban slum of Tigri in New Delhi by MAMTA,
an NGO that works with special focus on adolescents across the
country. These programs take a holistic approach towards adolescent
health and development of both sexes by integrating education,
entrepreneurship development and sexual reproductive health, while
involving the community and ensuring adolescent participation for the
success of the program. The impact of these interventions can be seen
in the higher number of adolescents completing education, later age at
marriage, greater mobility for girls, engagement in livelihood
activities, greater access to health services and increased self
esteem and confidence.
The March Ahead
The issues related to adolescent health, and
particularly to adolescent pregnancy and improved child health
outcomes, are prevention of early marriages and manage-ment of
adolescent pregnancies. Integrated strategies, which are gender
sensitive, are required to address this multifaceted problem both at
the policy level and at the service delivery, as has been demonstrated
by certain program experiences till now. International experiences
show that an adolescent health and development approach, with
reproductive and sexual health as the main strategy, influences
maternal and infant health. It is time to act now – adolescents are
our biggest investment for the future. This is also the surest way to
achieve our demographic and population goals.
Some steps for immediate action are
• Strengthen national capacity in collection,
compilation, updating and analysis of quantitative and qualitative
data on adolescents. Create a national adolescent database on
various health determinants with special focus on urban poor.
• Formulate a comprehensive national strategy and
program of action to address the multidimensional needs of
adolescents in urban slums and involve adolescents in all stages of
planning and implementation.
• Establish adolescent counselling and guidance
centers in urban slum areas in partnership with NGOs and Private /
Public institutions. HIV /AIDS pre-vention, care and support should
form an integral part of this.
• Integrate adolescent health issues especially
pregnancy, childcare, contra-ception, nutrition and personality
develop-ment in our existing health care system. Ensure access to
quality health services that are gender sensitive and adolescent
friendly. Reorient and enhance skills of health providers to address
this important area.
• Focus on young male involvement in sexual and
reproductive health programs, enhance their knowledge on partner’s
needs, use of contraceptives and improve their access to
comprehensive health care services.
• Enforce and evaluate the ‘Child Marriage
Restraint Act’ through community partici-pation and adolescent
involvement in both urban and rural areas.
• Enforce girl child school retention preferably
till 18 years and incorporate life skill education in all schools.
Link education to livelihood opportunities.
• Recognize and promote the rights of
adolescents, including their rights to education, to enter into
marriage with free and full consent, to have their views taken into
account in matters that concern them, and their right to decide when
to have / not to have children, and the number and spacing of these
children (Rights Bound Approach).