The Journal of Maternal-Fetal and Neonatal Medicine, 2013; 26(5): 469472

2013 Informa UK, Ltd.

ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2012.738262

 dverse perinatal outcome in teenage pregnancies: is it all

A
due to lack of prenatal care and ethnicity?
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Daniela Liran1, Ilana Shoham Vardi2, Ruslan Sergienko2 & Eyal Sheiner3
1Faculty of Health Sciences, The Joyce and Irving Goldman Medical school, Soroka University Medical Center, Ben Gurion

University of the Negev, Beer-Sheva, Israel, 2Faculty of Health Sciences, Department of Epidemiology and Health Services
Evaluation, Be'er Sheva, Israel, and 3Faculty of Health Sciences, Soroka University Medical Center, Ben Gurion University
of the Negev, Department of Obstetrics and Gynecology, Be'er Sheva, Israel
Objective: To investigate teenage pregnancy outcomes controlling for lack of prenatal care (LOPC) and ethnicity. Methods:
A retrospective population-based cohort study comparing
singleton deliveries of nulliparous women classified into two
teenage groups: 1517, 1819, and a comparison group of
2024 years was performed. Multiple logistic regressions were
used to control for confounders. Results: The study population
consisted of 31,985 women, 1,482 1517 years old, 5,876 1819
years old and 24,627 2024 years old. A significant linear association was found between maternal age and perinatal mortality,
low birth weight (LBW) and preterm delivery (PTD). Using multivariable logistic regression models, controlling for LOPC and
ethnicity, the association between maternal age and perinatal
mortality was no longer statistically significant, but both LBW
and PTD were significantly associated with young maternal age
(>17 years). Conclusion: Teenage pregnancy is a risk factor for
LBW and PTD especially for parturient younger than 17.
Keywords: Ethnic minority, low birth weight, preterm delivery

Introduction
Teenage pregnancy, defined as a pregnancy which ends before the
mother reaches the age of 20 years old [1], poses a great challenge to health professionals and is recognized as an essential risk
to public health [1,2]. An estimated 16 million girls aged 1519
years give birth every year. This makes up 11% of all births worldwide [3]. Although the use of contraception has been increasing
globally, awareness among teenagers is still low and teenage pregnancy is common [1].
Recent data have shown a decrease in teenage birth over the
last 10 years [4,5].
The role of maternal age and its effect on adverse perinatal
outcomes has been a subject of ongoing controversy [3,4,68].
Several studies concluded that teenage pregnancy is a risk factor
for LBW (< 2500 grams [2,3,5,7,913]), PTD (< 37 weeks gestation [57,916]), eclampsia [7], fetal death [4,7,10], anemia
[4,6,8], congenital deformities, small for gestational age [9] and
chorioamnionitis [8]. In contrast, other studies disputed the
independent effect of maternal age on pregnancy outcomes by
showing that the associations of adverse perinatal outcomes in
teenagers had been confounded mainly by lack of or inadequate

prenatal care and other socio-cultural characteristics often associated with ethnicity [1,1719]. Therefore, it is not clear whether
adverse pregnancy outcomes are related to biological immaturity
or to social factors such as lack of prenatal care, poverty, smoking,
drug use, as well as single parenting [1,17].
The rate of teenage pregnancy in Israel is currently 32/1000.
This rate varies by religion and local culture. It has been shown
that in Israel teenage pregnancies rates in the Muslim population are three times higher than in the Jewish population [20].
The Bedouin population, a Muslim minority in southern Israel,
characterized by high fertility rates encourages marriages and
pregnancies at an early age [21]. On the contrary, in the majority
of the Jewish population pregnancy at an early age is less common
and is often associated with social marginality.
Prenatal care has been shown to be an important factor
affecting outcome of pregnancies [1,17,18]. In Israel prenatal
services are accessible to all residents [22]. During the study a low
payment covering all prenatal services as well as infant care and
immunizations was required.
The objective of the present study was to determine whether
young maternal age was an independent risk factor for adverse
perinatal outcomes in Jews and Bedouins, two distinct populations, while controlling for prenatal care.

Methods
A retrospective population-based cohort study comparing
singleton deliveries of nulliparous women between the years
1988 and 2010 was conducted at Soroka University Medical
Center (SUMC). Women were classified into two teenage groups:
1517, 1819, and a comparison group of 2024 years old,
enabling a comparison between two subgroups in order to assess
a linear association between maternal age and adverse perinatal
outcomes. Data were obtained from the perinatal database, which
consisted of information recorded immediately following delivery
by an obstetrician. SUMC is the only major hospital in the Negev
region, where practically all births in the region take place. Only
nulliparous women between the ages of 15 and 24 were included
in the study in an effort to eliminate any confounding factors
caused by parity.
The following maternal and pregnancy characteristics were
examined: ethnicity, lack of prenatal care, fertility treatment,
recurrent abortions, gestational diabetes mellitus, pre-gestational

Correspondence: Daniela Liran, Faculty of Health Sciences, The Joyce and Irving Goldman Medical School, Soroka University Medical Center, Ben Gurion
University of the Negev, P.O Box 151, Beer-Sheva, Israel. E-mail: danielaliran@walla.co.il

469

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470 D. Liran et al.

diabetes mellitus, polyhydramnios, oligohydramnios and
hypertensive disorders.
The following delivery characteristics were assessed: severe
preeclampsia, mild preeclampsia, premature rupture of
membranes (PROM), cephalo-pelvic disproportion, prolonged
first and second stage of labor, placental abruption, placenta
previa, malpresentation and cesarean section (CS).
The following perinatal outcomes were evaluated: gender, PTD,
LBW, very low birth weight (VLBW, <1500g), macrosomia, Apgar
score <7 at 1 and 5 minutes, perinatal mortality including antepartum death (APD), intrapartum death (IPD) and in-hospital
postpartum death (PPD).
Statistical analysis was performed using the SPSS package.
Statistical significance in the univariate analysis was calculated
using the chi-square test and Fishers exact test. Linearity was
assessed by the linear by linear (LBL) test. Continuous variables
were compared using analysis of variance (ANOVA). Multiple
logistic regression models were constructed in order to control
for confounders and assess the independent association between
maternal age and adverse perinatal outcomes. Odds ratios (OR)
and 95% confidence intervals (CI) were computed. A p < 0.05 was
considered statistically significant. The local institutional ethics
board approved this study.

Results
The study population consisted of 31,985 women, of which 4.6%
(n = 1482) were less than 17 years old, 18.4% (n = 5,876) were
1819 years old and 77% (n = 24,627) were 2024 years old
(comparison group). Maternal, pregnancy and delivery characteristics of the three groups are shown in Table I. The two younger
age groups were predominantly comprised of women of Bedouin

ethnicity, while in the comparison group the distribution between

Bedouin and Jewish ethnicities was nearly equal.
Lack of prenatal care and severe preeclampsia, were linearly
associated with younger maternal age. On the contrary, fertility
treatments, recurrent abortions, diabetes, oligohydramnios,
PROM, prolonged first stage and CS were associated with older
maternal age.
Pregnancy outcomes are presented in Table II. A significant
linear association was found between maternal age and the rates
of adverse perinatal outcomes including PTD, LBW, VLBW, perinatal mortality, and Apgar scores <7 at 1 and 5 minutes.
All three major adverse pregnancy outcomes were significantly associated with Bedouin ethnicity and with LOPC (data
not shown). As these two risk factors were also associated with
young maternal age, we conducted a multivariable logistic
regression analysis controlling for these potential confounders.
The association between maternal age and perinatal mortality
was no longer significant, but both LBW and PTD were significantly associated with young maternal age (1517 years) and
PTD was also significantly associated with maternal age (1819)
(Table III). LOPC and Bedouin ethnicity constituted risk factors
for all three adverse pregnancy outcomes PTD, LBW and perinatal mortality. In addition, we tested the association of maternal
age and complications while controlling for LOPC for each one of
the ethnic groups separately. In the group of the Bedouin women,
the association between maternal age and perinatal mortality
lost its statistical significance, but both LBW and PTD were
significantly associated with young maternal age (1517years)
(Table III). In the group of Jewish women, LBW, PTD and
perinatal mortality were all significantly associated with young
maternal age (1517 years). PTD was also significantly associated
with young maternal age (1819). In addition, LOPC was a greater

Table I. Maternal, pregnancy and delivery characteristics by age group.

Maternal and pregnancy characteristics
Ethnicity
Bedouin
Jewish
Fertility treatments
Recurrent abortions
Lack of prenatal care
Gestational diabetes mellitus
Pre-gestational diabetes mellitus
Polyhydramnios
Oligohydramnios
Hypertensive disorders
Delivery characteristics
Severe preeclampsia
Mild preeclampsia
PROM
Cephalopelvic disproportion
Prolonged first stage of labor
Prolonged second stage of labor
Placental abruption
Placenta previa
Malpresentation
Cesarian section

1517 (N = 1482)

Maternal age group

1819 (N = 5876)
2024 (N = 24,627)

p Value

LBLa

78.4%
21.6%
0.1%
0.5%
19.7%
0.7%
0%
2.2%
2.3%
0.3%

74.6%
25.4%
0.4%
1%
11.5%
1.1%
0.1%
2.4%
3%
0.5%

47.3%
52.7%
1.4%
1.7%
6.2%
2.4%
0.3%
2.2%
3.5%
0.8%

<0.000

<0.000

<0.000
<0.000
<0.000
<0.000
0.001
0.844
0.015
0.02

<0.000
<0.000
<0.000
<0.000
<0.000
0.733
0.004
0.005

2.8%
6.3%
6.3%
0.4%
1.1%
3%
0.7%
0.1%
5.7%
7.7%

2.1%
4.4%
9.3%
0.3%
1.4%
2.6%
0.5%
0.1%
5.4%
8.4%

1.7%
5%
11.1%
0.5%
2.2%
3.5%
0.6%
0.1%
6%
10.7%

0.003
0.007
<0.000
0.166
<0.000
0.001
0.496
0.715
0.223
<0.000

0.001
0.804
<0.000
0.114
<0.000
0.002
0.534
0.996
0.165
<0.000

aLBL,

linear by linear.
Data are presented as percentages and p value for statistical significance.

The Journal of Maternal-Fetal and Neonatal Medicine

Adverse perinatal outcome in teenage pregnancies: is it all due to lack of prenatal care and ethnicity?471

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Table II. Pregnancy outcomes by maternal age group.

Pregnancy outcomes
Gender
Male
Female
PTD
LBW
VLBW
Macrosomia (>4kg)
Apgar score <7 at 1 min
Apgar score <7 at 5 min
All perinatal mortality
Antepartum death (APD)
Intrapartum death (IPD)
Postpartum death (PPD)

1517 (N = 1482)

1819 (N = 5876)

52.1%
47.9%
15.5%
17.7%
2.9%
1.1%
8.6%
3.5%
2.5%
1.1%
0.2%
1.2%

52.5%
47.5%
11.2%
14.3%
2.3%
1.3%
7.6%
2.8%
2.0%
1%
0.2%
0.9%

Maternal age
2024 (N = 24,627)
51.3%
48.7%
9.1%
11.5%
1.7%
2.1%
6.7%
2%
1.5%
0.8%
0.1%
0.6%

p Value

LBLa

0.248

0.150

<0.000
<0.000
<0.000
<0.000
0.001
<0.000
<0.000
0.169
0.768
<0.000

<0.000
<0.000
<0.000
<0.000
<0.000
<0.000
<0.000
0.062
0.481
<0.000

LBL, linear by linear.

LBW, low birth weight; PTD, preterm delivery; VLBW, very low birth weight.
Data are presented as percentages and p value for statistical significance.

Table III. Multiple logistic regression models of risk factors for adverse perinatal outcomes in the total study population and in two ethnic groups.
Total population
Bedouins
Jews
Adverse perinatal outcomes
OR
95% CI
OR
95% CI
OR
95% CI
Perinatal mortality
Maternal age
1517
1.297
0.9151.837
1.100
0.7381.639
2.302
1.1414.644
1819
1.136
0.9171.408
1.047
0.8231.333
1.440
0.9182.260
2024
REF
REF
REF
Ethnicity (B/J)
1.689
1.3862.057
LOPC
2.048
1.6122.602
1.790
1.3812.326
4.981
2.8528.698
LBW
Maternal age
1517
1.304
1.1311.502
1.202
1.0261.408
1.841
1.3452.520
1819
1.081
0.9921.176
1.062
0.9651.169
1.121
0.9321.348
2024
REF
REF
REF
Ethnicity (B/J)
1.776
1.6501.912
LOPC
1.637
1.4731.820
1.538
1.4161.769
2.238
1.6333.067
PTD
Maternal age
1517
1.587
1.3661.844
1.438
1.2121.706
2.202
1.6192.995
1819
1.142
1.0401.255
1.100
0.9861.226
1.241
1.0301.494
2024
REF
REF
REF
Ethnicity (B/J)
1.355
1.251.466
LOPC
1.464
1.2981.652
1.381
1.2141.571
2.267
1.6443.126
Data are presented as OR and 95%.
B- Bedouin; J- Jewish.
LBW, low birth weight; LOPC, lack of prenatal care; PTD, preterm delivery.

risk factor for adverse perinatal outcomes in Jewish women than

in Bedouin women (Table III).

Discussion
The purpose of our study was to determine whether young
maternal age was an independent risk factor for adverse pregnancy outcomes in populations where the socio cultural context
of teenage pregnancy was different. The main finding of our population-based study was that in both ethnic groups young maternal
age, adjusted for prenatal care, was a significant risk factor for
both PTD and LBW, but not for perinatal mortality. PTD rates
were higher in both teenage groups (1517 and 1819 year olds)
when compared to controls (2024 year olds) and LBW rates were
higher only in the 1517 year old age group. Other studies have

2013 Informa UK, Ltd.

also shown maternal age to be a risk factor for adverse perinatal

outcome such as LBW [2,3,5,7,913] and PTD [57,916], but
many did not adjust for both LOPC and socio-cultural context of
teenage pregnancy. An advantage of our study was our ability to
adjust for LOPC and ethnicity in a large population composed of
two distinct ethnic groups.
After splitting the study population into two ethnic groups,
young maternal age was found as a greater risk factor for adverse
perinatal outcomes in Jewish women where teenage pregnancy is
relatively rare than in Bedouin women, where it is more common.
In addition, perinatal mortality was significantly associated with
young maternal age (1517 years) only in the Jewish group. The
finding that young maternal age is a greater risk factor in Jewish
women and not Bedouins might be explained by their significantly
different socio-cultural characteristics. Bedouin women tend to

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472 D. Liran et al.

marry and conceive at younger ages, and attribute great importance to family and fertility [21], all births are within wedlock and
many characteristics of teenage pregnancy in western countries
such as smoking, alcohol and drugs are culturally forbidden [23].
On the contrary, pregnancy at an early age is less common in the
Jewish population and might be related to high risk behaviors, such
as drugs abuse, alcohol and unplanned pregnancy out of marriage.
The different socio-cultural context of giving birth at a young age
might explain why young maternal age was found as a greater risk
factor for perinatal mortality only in the Jewish teenagers.
Lack of prenatal care is a known risk factor for adverse perinatal
outcomes in teenage pregnancies [2,4]. In our study we found
that this risk factor is actually more prominent in Jewish women
than in Bedouin women. This finding might also be explained by
socio cultural characteristic. While prenatal care is available to
all pregnant women in Israel, Bedouin women, who are of lower
socioeconomic status than Jewish women, for a variety of reasons
tend to use prenatal care services less that Jewish women [22].
LOPC is not common among Jewish women, and it may reflect
social marginality, associated with other behavioral risk factors
for adverse pregnancy outcomes.
The major limitation of this study is the lack of direct information
concerning socioeconomic indicators and behavioral risk factors.
However, we could make general inferences based on ethnic origin
as the Bedouin population is rather homogeneous concerning the
total ban of pregnancy outside of marriage, the use of alcohol and
drugs. Smoking is not forbidden by religion, but it is culturally
unacceptable for women at child bearing age [23]. The strengths
of this study emanate from its setting in SUMC which is the only
major hospital in the Negev region, and serves practically the entire
obstetric population in the region, thus there is no selection bias.
In conclusion, young maternal age was documented as a significant risk factor for PTD and LBW regardless of socio-cultural
factors and LOPC. Therefore, adolescents should be properly
educated about the risks inherent in teenage pregnancies. LOPC
presents as a risk factor for adverse perinatal outcomes in teenage
pregnancies. It emphasizes the importance of providing accessible and culturally adequate prenatal services to young pregnant
women in order to minimize adverse perinatal outcomes.

Acknowledgements
Performed in part of Daniela Liran MD requirements.
Declaration of Interest: The authors report no declarations of
interest.

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