Adverse perinatal outcomes of pregnancies among adolescents vs women of advanced age in the Brazilian public health system

Larissa de Lima Pessoa Veiga Micaely Cristina dos Santos Tenório Raphaela Costa Ferreira Marilene Brandão Tenório Sandra Mary Lima Vasconcelos Nassib Bezerra Bueno Alane Cabral Menezes de Oliveira About the authors

Abstract

Objectives:

to compare the adverse perinatal outcomes in pregnancies of adolescents and elderly women of public health network.

Methods:

a cross-sectional study carried out with pregnant women at the extremes of reproductive age according to the classification of the Brazilian Ministry of Health (adolescents those aged ≤19 years and those who were older than 35 years) and their newborns. Socioeconomic data (income, schooling, occupation and marital status), as well as clinical (diseases), anthropometric (maternal BMI) and perinatal (gender, weight, length, Apgar and gestational age) data were collected, and Poisson regression in hierarchical model was performed, with the results in Ratio of Prevalence (PR) and its respective Confidence Interval at 95% (95% CI).

Results:

when comparing adolescent and elderly women, 38.7% vs 54.6% (PR=0.71, CI=0.54-0.94, p=0.002) were observed, respectively, cesarean deliveries; 37.8% vs 25.2% (PR=0.83, CI=0.58-1.19, p=0.332) preterm births; 16.6% vs 20.5% (RP=1.07, CI=0.78-1.46, p=0.666) births of small infants for gestational age (SGA); 18.0% vs 15.3% (RP=1.01, CI=0.69-1.47, p=0.948) births of large-for-gestational-age newborns (LGA); 32.2% vs 34.7% (RP=1.08, CI=0.82-1.42, p=0.578), low birth weight infants and 28.5% vs 42.9% (RP=1.18, CI=0.91-1.54, p=0.201) with high birth length.

Conclusions:

When compared with adolescent women, pregnant women of advanced age presented a higher frequency of cesarean deliveries.

Key words
Maternal age; Pregnancy complications; Pregnant women

Resumo

Objetivos:

comparar os resultados perinatais adversos em gestações de adolescentes e mulheres em idade avançada de rede pública de saúde.

Métodos:

estudo transversal realizado com gestantes nos extremos de idade reprodutiva segundo classificação do Ministério da Saúde do Brasil (adolescentes aquelas com idade ≤19 anos e em idade avançada aquelas com idade ≥35 anos) e seus recém-nascidos. Foram coletados dados socioeconômicos (renda, escolaridade, ocupação e situação conjugal), clínicos (presença de doenças), antropométricos (IMC materno) e perinatais (sexo, peso, comprimento, Apgar e idade gestacional), e realizada regressão de Poisson em modelo hie-rarquizado, com resultados em Razão de Prevalência (RP) e respectivo Intervalo de Confiança a 95% (IC95%).

Resultados:

quando comparadas gestantes adolescentes e aquelas em idade avançada, foram observados, respectivamente: 38,7% vs 54,6% (RP=0,71; IC=0,54-0,94; p=0,002) partos cesarianos; 37,8% vs 25,2% (RP=0,83; IC=0,58-1,19; p=0,332) nascimentos de pré-termos; 16,6% vs 20,5% (RP=1,07; IC=0,78-1,46; p=0,666) nascimentos de recém-nascidos pequenos para idade gestacional; 18,0% vs 15,3% (RP=1,01; IC=0,69-1,47; p=0,948) nascimentos de recém-nascidos grandes para a idade gestacional; 32,2% vs 34,7% (RP=1,08; IC=0,82-1,42; p=0,578)recém-nascidos com baixo peso ao nascer e28,5% vs 42,9% (RP=1,18; IC=0,91-1,54; p=0,201) com comprimento elevado ao nascer.

Conclusões:

as gestantes em idade avançada quando comparadas com as adolescentes apresentaram maior frequência de partos cesarianos.

Palavras-chave
Idade materna; Complicações na gravidez; Gestantes

Introduction

Pregnancy at reproductive age extremes increased considerably worldwide.11 Karatasli V, Kanmaz AG, Inan AH, Budak A, Beyan E. Maternal and neonatal outcomes of adolescente pregnancy. Journal of Gynecology Obstetrics and Human Reproduction. 2019; 48 (5): 347-50. In Brazil, according to data from the Live Birth Information System for the year 2013, 19.2% of the total number of births was from adolescent mothers and 11.0% of women aged 35 years or older.22 Brasil. Ministério da Saúde. Departamento de Informática do SUS - DATASUS. Informações de saúde. Nascidos vivos. 2015 [acesso em 30 jan 2018]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvrn.def
http://tabnet.datasus.gov.br/cgi/tabcgi....

Pregnancies at extremes of reproductive age may increase gestational risk due to a high correlation with adverse perinatal outcomes in this period, such as prematurity, low birth weight, anemia, acute fetal distress, hemorrhage-parturition, preeclampsia, gestational diabetes, premature rupture of membranes, among other problems.33 Leader J, Bajwa A, Lanes A, Hua X, Rennicks White R, Rybak N, Walker M. The Effect of Very Advanced Maternal Age on Maternal and Neonatal Outcomes: A Systematic Review. J Obstet Gynaecol Can. 2018; 40 (9): 1208-18.,44 Whitworth M, Cockerill R, Lamb H. Antenal management of teenage pregnancy. Obstetrics, Gynaecol Reprod Med. 2017; 27 (2): 50-6.

In addition, reducing maternal and neonatal mortality rate is one of the goals of the global sustainable development goals for 2030, in which Brazil needs to advance in these indicators, conti-nuing the achievements within the Millennium Development Goals by 2015 and reach those unfinished.55 ONU (Organização das Nações Unidas). Nações Unidas no Brasil, 2017. [acesso em 30 jan 2018]. Disponível em: https://nacoesunidas.org/pos2015/agenda2030/
https://nacoesunidas.org/pos2015/agenda2...

In this context, considering the repercussions that pregnancy at extremes of reproductive age provides, it is necessary to develop further studies on this subject in order to foment mechanisms that contribute to the planning of public health policies that guide this population in the perspective of reducing maternal and fetal risk.

In view of the above, the present study aims to compare adverse perinatal outcomes of public health network in pregnancies of adolescents and women with advanced age.

Methods

Cross - sectional study carried out in a maternity school located in the city of Maceió, state capital of Alagoas, Brazil, from August 2015 to July 2016 with pregnant women at the extremes of reproductive age classified according to the Brazilian Ministry of Health (adolescents, those with age ≤19 years and in advanced age those ≥35 years old)66 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Gestação de Alto Risco. Manual Técnico. 5ª edição. Brasília, DF; 2012. and their respective newborns (NB), those with a single fetus being eligible, and those with a severe general condition in labor and with neurological problems were excluded.

The selection of the study participants was made in a random way, from the identification in the records book of the nursing station located in the maternity hospital itself. Then the interviewers, previously trained undergraduate students in the area of nutrition, went to the beds and, following explanation and invitation to participate in the research, proceeded with the application of a questionnaire of their own, containing socioeconomic, prenatal, clinical, anthropometric and perinatal data.

Regarding the socioeconomic data, pregnant women were classified as family income (<1 minimum wage / month / ≥1 minimum wage / month, current value in the year in which data were collected),7 by level of education (≤4 years of study / >4 years of study, considering the stratification for functional illiterate); occupation (in the household / works outside the home) and according to the marital situation (living with the spouse / not living with the spouse).

As for the prenatal data, the time of onset (1st trimester, 2nd or 3rd trimester) and number of visits (<6 visits / ≥6 visits) according to the Brazilian Ministry of Health.66 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Gestação de Alto Risco. Manual Técnico. 5ª edição. Brasília, DF; 2012.

For the clinical data, pregnant women were questioned about the presence of diseases, such as hypertension, diabetes, kidney disease, among others. In addition, blood pressure measurement was performed at the time of application of the research questionnaire with the help of the Omron 705 CP device, São Paulo, Brazil, following the recommendations of the Brazilian Society of Hypertension.88 Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol. 2016; 107 (Supl.3): 1-83. The evaluation of the frequency of anemia was made from the collection of hemoglobin values in medical records and subsequent classification according to the World Health Organization (WHO),99 WHO (World Health Organization). Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. Edited by Benoist B, McLean E, Egli I, Cogswell M. Geneva; 2008. p.40. considering values below 11.0 g / dL.

For anthropometric evaluation, weight and height of pregnant women were collected using the Filizola® digital scale and its stadiometer, São Paulo, Brazil, respectively, following a methodology described by the Brazilian Ministry of Health and cut-off points established by Atalah Samur et al.1010 Atalah SE, Castillo C, Castro R, Aldea PA. Proposal of a new standard for the nutritional assessment of pregnant women. Rev Med Chil. 1997, 125 (12): 1429-36. for classification of Body Mass Index (BMI). Pre-gestational BMI was also calculated for the esta-blishment of the gestational weight goal according to the United States Institute of Medicine (IOM).1111 IOM (Institute Of Medicine), NRC (National Research Council). Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: The National Academics Press; 2009.

After birth, data on the NB were collected as follows: gender, delivery, gestational age (GI), weight and length at birth, and Apgar score at 1 and 5 minutes of life, being classified as: (1) by GI: GI <37 weeks: preterm NB and GI ≥42 weeks: post-term NB,1212 WHO (World Health Organization). Public health aspects of low birth weight: third report of the Expert Committee on Maternal and Child Health. Geneva 21 to 26 November; 1960. (Technical Report Series no.217). (2) by birth weight and length, which were assessed using the new INTERGROWTH-21st charts,1313 Villar J, Ismail LC, Victora CG, Ohuma EO, Bertino E, Altman DG, Lambert A, Papageorghiou AT, Carvalho M, Jaffer YA, Gravett MG, Purwar M, Frederick IO, Noble AJ, Pang R, Barros FC, Chumlea C, Bhutta ZA, Kennedy SH, International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). International standards for newborns weight, length, and head circumference by gestational age and sex: the Newborns Cross-Sectional Study of the INTERGROWTH-21st Project. The Lancet. 2014; 384 (9946): 857-68. considered cut-off points in percentiles according to international standards, in which those weighing below the 10th percentile were classified as small for gestational age (SGA), between the 10th and 90th percentiles classified as suitable for gestational age (SUGA) and those weighing more than the 90th percentile large for gestational age (LGA), as well as through the classification used by the WHO1414 Puffer RR, Serrano CV. Patterns of birthweights. Washington DC: Pan American Health Organization; 1987. that classifies infants with low birth weight: <2500g, adequate weight: 2500g to <4000g, and fetal macrosomia: ≥4000g, and (3) by the Apgar score in the 1º and 5º minutes of life, considering that ≤6 values for both minutes are characterized as risk for NB.1515 AAP (American Academy of Pediatrics), Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists and Committee on Obstetric Practice. The Apgar Score. Pediatrics. 2006; 117 (4): 1444-7.

All statistical analyzes were performed with Stata software version 13.0. Poisson regression was used with robust estimation of the variance in a hie-rarchical model, where for this purpose, univariate analyzes were performed where the independent variables that presented statistical association with p<0.20 were selected to compose the multivariate regression model. The variables of the first hierarchical level (distal level) were analyzed together, and variables with significance greater or equal to 20% were progressively excluded. Then, the varia-bles of the second hierarchical level (intermediate level) were added to the model and proceeded in the same way, with progressive exclusion of the varia-bles of that level with a value of p≥0.20. In this way, all hierarchical levels were analyzed. For control of possible confounding factors, variables with p<0.20 values were maintained in the models at each hierarchical level.

The magnitude of the associations between the variables studied and the independent variables were expressed in Prevalence Ratio (PR) and their respective 95% confidence intervals (CI95%), with p<0.05 being considered significant.

To calculate the statistical power (1-beta) reached with the sample used, we considered an alpha value equal to 5% and the prevalence ratio between groups of the preterm birth variable, considered the primary variable of the study. The GPower v3.1.9.4 (Universitat Dusseldorf, Germany) statistical software was used.

The present study was approved by the Ethics and Research Committee of the Federal University of Alagoas, nº 1.073.200.

Results

A total of 217 pregnant women and 99 pregnant women with a mean age of 16.49 ± 1.8 years and 38.20 ± 2.52 years, respectively, were studied.

Regarding socioeconomic, prenatal, clinical and nutritional status conditions (table 1), women with advanced age presented a higher frequency of low schooling (11.5% vs 25.8%, PR=1.51, p=0.010); (72.1% vs 98.0%, PR=0.05, p=0.002) and had a higher frequency of diseases such as gestational hypertension, diabetes mellitus and heart disease (10.1% vs 26.2%, RP=1.55, p=0.010). The adolescents who had the highest frequency of occupation of the home (95.0% vs 68.7%, PR=2.15, p<0.001); absence of stable union (24.9% vs 4.0%, PR=3.58, p=0.01) and low weight (37.3% vs 4.0%, PR=0.22, p=0.020).

Table 1
Prevalence of factors associated with adolescent vs advanced age gestation according to hierarchical model. Maceio, Alagoas, 2014.

Regarding the perinatal outcomes (table 2), when were compared adolescent and elderly women, respectively, 38.7% vs 54.6% (PR=0.71, p=0.002) were found to be cesarean deliveries; 37.8% vs 25.2% (PR=0.83, p=0.332) and 0.0% vs 1.0% (PR=3.64, p=0.014) preterm and post-term , respectively; 16.6% vs 20.5% (PR=1.07, p=0.666) births of SGA NB; 18.0% vs 15.3% (PR=1.01, p=0.948) births of LGA NB; 32.2% vs 34.7%(OR=1.08, p=0.578) with low birth weight and 28.5% vs 42.9% (PR=1.18, p=0.201) with length at birth.

Table 2
Perinatal outcomes of adolescent vs advanced age gestation. Maceió, Alagoas, 2014.

Considering the sample of 217 pregnant women and 99 pregnant women, the PR in this study of 0.83 for preterm births and an alpha of 5%, the statistical power (1 - beta) found was 55.6%.

Discussion

The analysis of adverse perinatal outcomes in adolescent and elderly gestations is of extreme importance for the determination of strategies to prevent and/or ameliorate these complications, aiming to improve maternal and child health, highli-ghting the progress of indicators of development goals related to this public.1616 Brasil. Secretaria de Governo da Presidência da República. Ministério do Planejamento, desenvolvimento e gestão. Relatório nacional voluntário sobre os objetivos de desenvolvimento sustentável. Brasília, DF; 2017. p.1-43. [acesso em 7 abril de 2019]. Disponível em: https://sustainabledevelopment.un.org/content/documents/15801Brazil_Portuguese.pdf
https://sustainabledevelopment.un.org/co...

Initially, it is important to observe the socioeconomic and prenatal profile of pregnant women, where part of the adolescents were "home-aged" and a significant proportion did not present a stable union when compared to those with advanced age. On the other hand, the latter had a higher frequency of low schooling than the adolescents.

In this context, in a study carried out with pregnant women at a municipal health service in the state of Bahia,1717 Rocha LFA, Oliveira ZM, Teixeira JRB, Moreira RM, Dias RB. Significados nas representações de mulheres que engravidaram após os 35 anos de idade. Rev Enferm UFPE online. 2014; 8 (1): 30-6. it was observed that more than half of them had household occupation and an education level of only the initial years of elementary school, and about one-third of them had completed elementary school. On the other hand, a study carried out in Curitiba with pregnant adolescents pointed out that most of them were single - a cause for concern - because they are often abandoned by their partners and face pregnancy alone,1818 Taborda JA, Silva FC, Ulbricht L, Neves EB. Consequences of teenage pregnancy for girls considering the socioeconomic differences between them. Cad Saúde Colet. 2014; 22 (1): 16-24. when the presence of the partner is of fundamental importance for the pregnant adolescent, since it is able to reduce physical and psychological risks, besides promoting greater well-being to the health of the binomial mother-child.

Regarding prenatal care, similar to the results of this study, in a study conducted in Paraná, only 69.4% of the pregnant women with advanced age performed six or more visits, and among the adolescents the frequency was even lower (49.4%).1919 Sass A, Gravena AAF, Pelloso SM, Marcon SS. Resultados perinatais nos extremos da vida reprodutiva e fatores associados ao baixo peso ao nascer. Rev Gaúcha Enferm. 2011; 32 (2): 352-8. The literature indicates the importance of prenatal care as a determinant of adequate gestational evolution, being crucial for the reduction of age-related risks and obstetric and neonatal complications. In addition, the minimum number of six consultations recommended by the Ministry of Health ensures the performance of specific interventions and the identification of risk situations, especially at the end of gestation.66 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Gestação de Alto Risco. Manual Técnico. 5ª edição. Brasília, DF; 2012.

With regard to the adverse perinatal outcomes in this study, a high frequency of cesarean delivery was observed in pregnant women with advanced age (54.6%), and it should be considered that the WHO establishes a maximum prevalence of 15.0% of deliveries by this way.2020 OMS (Organização Mundial de Saúde). Declaração da OMS sobre Taxas de Cesáreas. [acesso em 20 de jan de 2018]. Disponível em: http://apps.who.int/iris/bitstream/10665/161442/3/WHO_RHR_15.02_por.pdf
http://apps.who.int/iris/bitstream/10665...
It has also been shown that, similarly to the findings in this study, women of advanced age are more likely to have a cesarean birth when compared to younger women.2121 Madeiro A, Rufino AC, Santos AO. Partos cesáreos no Piauí: tendência e fatores associados no período 2000-2011. Epidemiol Serv Saúde. 2017; 26 (1): 81-90. This finding may be justified by the high incidence of risk factors verified here, (greater frequency of diseases in pregnant women in old age when compared with the adolescents), disorders in labor and obstetric and fetal complications with advancing age.2222 Almeida NKO, Almeida RM, Pedreira CE. Resultados perinatais adversos em mulheres com idade materna avançada: estudo transversal com nascimentos brasileiros. J Pediatr (Rio J). 2015; 91 (5): 493-8.

In addition, in the present study, a high frequency of preterm births was observed in both groups of pregnant women when compared with data from Brazil2424 Brasil. Ministério da saúde. DATASUS Tecnologia da Informação a Serviço do SUS; 2015. Brasília, DF. [acesso em 29 mar 2018]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def
http://tabnet.datasus.gov.br/cgi/tabcgi....
of premature live births in the year 2015 (10.78%). On the other hand, in a transnational study2323 Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, Yamdamsuren B, Temmerman M, Say L, Tunçalp Ö, Vogel JP, Souza JP, Mori R, WHO Multicountry Survey on Maternal Newborn Health Research Network. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014; 121 (Suppl 1): 40-8. performed in 29 countries, a higher occurrence of preterm birth was found in the adolescent group.

Regarding birth weight deviations in this study, high birth rates of SGA, LGA and low birth weight infants were observed in both groups, with no signi-ficant difference when compared.

In this context, similarly, in a study carried out in a public tertiary maternity hospital in São Paulo,2525 Teixeira C, Parca M, Queiroga R, Peloso T, Anjos Mesquita MD. Frequência e fatores de risco para o nascimento de recém-nascidos pequenos para idade gestacional em maternidade pública. Einstein. 2016; 14 (3): 317-23. there was no significant relationship between maternal age and birth of SGA infants. Some authors report that the birth of SGA in adolescent gestation would be justified by physical immaturity and, in old age, by sclerotic lesions in the myometrial arteries.2626 Filho ACN, Leite AJM, Bruno ZV, Filho JGB, Silva CF. Gravidez na adolescência e baixo peso ao nascer: existe associação?. Rev Paul Pediatr. 2011; 29 (4): 489-94.

On the other hand, the prevalence of LGA found in the present study, elevated in both groups, is higher than that detected by other authors (3.4% and 7.3%)2727 Magalhães MLC, Furtado FM, Nogueira MB, Carvalho FHC, Almeida FML, Mattar R, Camano L. Gestação na adolescência precoce e tardia: há diferença nos riscos obstétricos? Rev Bras Ginecol Obstet. 2006; 28 (8): 446-52. which may be justified by changes in dietary and nutritional patterns of the global population, resulting in an increase in the rates of overweight, obesity, non-communicable chronic diseases, and a change in the pattern of distribution of morbidity and mortality in the population.2828 Jaacks LM, Vandevijvere S, Pan A, McGowan CJ, Wallace C, Imamura F, Mozaffarian D, Swinburn B, Ezzati M. The obesity transitions: stages of global epidemic. The Lancet. 2019; 7 (3): 231-40. Additionally, in the long term, LGA newborns are more prone to deve-loping childhood obesity and, as adults, metabolic syndrome, where the intrauterine scenario reflected by birth weight may be a determinant of the child's future nutritional status.2929 Meller FDO, Araújo CLP, Madruga SW. Fatores associados ao excesso de peso em crianças brasileiras menores de cinco anos. Ciênc Saúde Colet. 2014; 19 (3): 943-55.

Finally, despite the adverse perinatal outcomes presented, most of the NB in this study had good vitality at birth according to the values of Apgar in the 1º and 5º minutes of life. Muniz et al.3030 Muniz EB, Vasconcelos BB, Pereira NA, Frota RG, Moraes CEB, Oliveira MAS. Análise do boletim de Apgar em dados do Sistema de Informação sobre Nascidos Vivos registrados em um hospital do interior do estado do Ceará, Brasil. Rev Med Saúde Brasília. 2016; 5 (2): 182-91., evalua-ting the vitality of the NB, through the Apgar index in a hospital in Ceará, through data from the information system on live births, found higher Apgar values (8-10) among women in the age range of 20-29 years, with term delivery, as well as in those who performed more prenatal visits.

Thus, the results of this study suggest the need to adopt measures that allow a better quality of care for pregnant women with the objective of minimizing the possible adverse factors resulting from gestations at the extremes of reproductive age.

As limitations of this research, we highlight the type of study, a transversal one, as well as the selection and the provenance of the sample, making it difficult to extrapolate the results to the entire capital of the state of Alagoas.

In this study, older women, when compared with adolescent pregnant women, presented a higher frequency of cesarean deliveries.

Thus, the early detection of unfavorable outcomes in pregnancy and the adequate performance of prenatal care should be encouraged and prioritized by public health agencies, aiming at the adoption of preventive measures against the adverse outcomes of these pregnancies, including programs with multiprofessional actions in the health units. It is also relevant a greater interaction of these with the community agents, favoring an integral assistance to these women, and with that, smoothing unfavorable outcomes of gestations in the extremes of reproductive age.

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Publication Dates

  • Publication in this collection
    16 Sept 2019
  • Date of issue
    Jul-Sep 2019

History

  • Received
    10 Oct 2018
  • Reviewed
    29 Apr 2019
  • Accepted
    20 June 2019
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