Adolescent deliveries in rural Cameroon: comparison of delivery outcomes between primipara and multipara adolescents
Njim and Agbor BMC Res Notes
Adolescent deliveries in rural Cameroon: comparison of delivery outcomes between primipara and multipara adolescents
Tsi Njim 0 2
Valirie Ndip Agbor 1
0 Centre for Global Health and Tropical Medicine, Nuffield Department of Medicine, University of Oxford , Old Road Campus, Oxford, Oxfordshire OX3 7BN , UK
1 Ibal Sub-Divisional Hospital , Oku, North west Region , Cameroon
2 Health and Human Development Research Group (2HD) , Douala , Cameroon
Objective: Adolescent pregnancies are high risk and deliveries in this age group are usually associated with adverse outcomes. The perception that multiparous adolescents have better delivery outcomes than primiparous counterparts is not uncommon. We sought to determine if multiparous adolescents were precluded from having adverse delivery outcomes when compared to primiparous adolescents. The data used for the analysis is a side product from a published project aimed at mapping the epidemiology of adolescent deliveries in the Oku health district. Results: From an 8-year (2009-2016) retrospective register analysis of data from two primary healthcare facilities in the Oku health district-a rural area in Cameroon, the prevalence of multiparous adolescent deliveries was 21.5% (78/363). After multivariable analyses, and adjusting for age, sex of baby, gestational age, marital status and HIV status, primiparous adolescents were more likely to have low birth weight infants (LBW) (OR: 3.2; 95% CI 1.1, 9.7; p = 0.04) when compared with multiparous adolescents. Though primiparous adolescents were more likely to have LBW infants than multiparous adolescents, this group of mothers are generally ill-equipped to handle pregnancies and adolescent-friendly programs are necessary to decrease the associated burden.
Adolescent deliveries; Multipara adolescents; Delivery outcomes; Cameroon
Adolescent deliveries occur in girls aged 13–19 years
]. As they occur at the stage of biological,
psychological, and social transition in the adolescents’ lives [
are usually classified as high risk [
]. Compared with
adult deliveries, the risk of adverse maternal and
foetal outcomes in adolescent deliveries are higher. Indeed,
several authors have shown an increased association of
these deliveries with preeclampsia/eclampsia;
operative deliveries; maternal and foetal death; foetal distress;
low birth weight (LBW); neonatal asphyxia and stillbirth
]. Such deliveries are a huge public health problem
especially in the low-income countries where over 95% of
them occur . This poses major hindrance against the
attainment of Sustainable Development Goal 3 [
prevalence of adolescent deliveries in Cameroon is
relatively high—with a national prevalence of 14.2% [
prevalence is highest in rural areas of the country where
early marriages are promoted, and sexual education and
contraceptive use is low. The incidence of
complications in such areas cannot be underestimated as
optimal antenatal care and safe delivery procedures remain
]. The situation is worsened by concepts
that married adolescents or adolescents who have had
a previous pregnancy ultimately have better outcomes
than their single or primiparous counterparts. A recent
study in a suburban region in the country showed that
being married did not preclude an adolescent from
having adverse pregnancy outcomes when compared with
single adolescents [
]. This finding was also confirmed in
the Oku health district from published data that was used
in the analysis of the present study [
We sought to establish if being multiparous precluded
an adolescent from having adverse delivery outcomes
when compared with their primiparous counterparts in
a rural setting—the Oku health district in Cameroon.
Such findings could inform public policy for the
implementation of health promotion strategies that could help
reduce negative conceptions and reduce the burden
associated with adolescent deliveries.
1. To determine the prevalence of multiparous
adolescent pregnancies in a group of primiparous and
multiparous adolescents in the Oku health district.
2. To compare the delivery outcomes between these
primiparous and multiparous adolescents.
Study design, duration and setting
We carried out an 8-year retrospective-register
analysis of maternity records from 1st January 2009 to 31st
December 2016 in the Oku district hospital and Kevu
primary health centre. These two primary health care
facilities are the major health facilities in the Oku health
district (OHD) and carry out most of the deliveries in this
The data collection procedure, inclusion and
exclusion criteria have been described in a prior study [
All singleton deliveries recorded within the study period
were included. Records: without maternal age, babies
born before arrival, birthweights < 1000 g, multiple
deliveries and deliveries before 28 weeks gestation were
excluded from our study (Fig. 1).
From the 2343 deliveries that occurred during the
8-year study period, sociodemographic information (age,
marital status), clinical characteristics (gravidity, parity,
gestational age, human immunodeficiency virus [HIV]
status and sex of the neonates), maternal outcome (mode
of delivery, postpartum haemorrhage and second—
fourth degree perineal tear) and foetal outcome
(birthweight, fifth minute Apgar score and term gestational age
were collected from 1803 records giving a response rate
Data were entered using Epi info 220.127.116.11 software and
analysed using STATA version 12.1 after verification of
10% of the data. Means (standard deviations) were used
to summarize continuous variables and proportions for
categorical variables. Means for variables that are not
normally distributed were compared using the Kruskal–
Wallis test. Proportions were compared using the Fisher
exact test. Odds ratios and their corresponding 95%
confidence intervals (CI) were used to describe the
association between two categorical variables with
significance obtained at 5%. Time trends were established using
the Mann–Kendall test.
The 363 records eligible for subgroup analysis were
split into primiparous and multiparous adolescents.
Delivery outcomes were compared between the
primiparous adolescents and the multiparous adolescents. A
multivariable logistic regression analysis was performed
for significant adverse delivery outcomes between
primiparous and multiparous adolescents to adjust for
Ethics approval was obtained from the scientific and
ethical review board of the Northwest Regional delegation
for Public Health.
There were 363 adolescent deliveries with 21.5% (95%
CI 17.6, 26.0) of them being multiparous adolescents.
The prevalence of multiparous adolescent deliveries
from 2009 (25.9%) fell to 15.8% in 2010 and rose
steadily (20.6% in 2011, 22.7% in 2012 and 33.9% in 2013)
before falling (19.3% in 2014, 15.9% in 2015 and 9.4% in
2016). The trend was however not significant (p= 0.3)
(Additional file 1: Figure S1). The mean age of
primiparous adolescents was 17.8 ± 1.3 while that for their
multiparous counterparts was 18.3 ± 1.0 (p < 0.01). Fifty-nine
percent of multiparous adolescents were married
compared to 34.7% of primiparous adolescents (Table 1).
When compared with multiparous adolescents,
primiparous adolescents were three times more likely to have
a low birth weight (LBW) infant (OR: 3.3; 95% CI 1.1, 9.5;
p = 0.01) (Table 2). After multivariable logistic
regression analysis, being a primipa was the only independent
predictor of having a LBW infant in adolescents
(Additional file 2: Table S1).
There was no difference in the following outcomes
between primiparous and multiparous adolescent
deliveries: preterm and post-term deliveries, operative
deliveries, perineal tears, neonatal asphyxia, stillbirths and
high birth weight (HBW) (Table 2).
In this study, we assessed if delivery outcomes differed
between multiparous and primiparous adolescents. We
observed a downward insignificant trend in the
prevalence of multiparous adolescent deliveries from 2009 to
2016. The overall prevalence of multiparous adolescent
deliveries over the 8-year period was 21.5%.
Primiparous adolescents were more likely to have LBW neonates
when compared with multiparous adolescents. In the
prior study using this dataset, the prevalence of
adolescent deliveries was 20.4% and the outcomes of adolescent
deliveries compared with adult deliveries were: second—
fourth degree perineal tears, low birth weight (LBW) and
neonatal asphyxia at the fifth minute [
Throughout literature, only one study which tried to
assess pregnancy outcomes between these two groups of
adolescents was found. This was a study carried out in a
semi-urban region—Bamenda in Cameroon and showed
that adolescent primipas were just as likely to have LBW,
HBW, asphyxia and caesarean sections as adolescent
]. The sample size used in this study was
however small to get significant differences between the
two groups. It is a common perception in most rural
settings in Cameroon which encourage early marriages that
multiparous or married adolescents are precluded from
having complications when compared with primiparous
or single adolescents. A prior study in a semi-urban
population in the South west region of the country showed
that delivery outcomes were similar between married
and single adolescents [
]. From a prior study in this
same region which used the same dataset, these findings
were confirmed as outcomes were similar between
married and single adolescents [
]. We showed that though
primiparous adolescents were more likely to have LBW
babies, most of the pregnancy outcomes (preterm
deliveries, post-term deliveries, operative deliveries, neonatal
asphyxia and stillbirths) occurred in similar proportions
between these two groups. The sample size was
however small to show significant differences between some
of the outcomes. These hypotheses and findings should
therefore be confirmed using a larger sample size. Also,
the wide confidence intervals obtained for the association
between being a primiparous adolescent and having a
LBW neonate emphasises the need for more studies with
robust sample sizes. Caution is therefore required when
interpreting these results.
The fact that multiparous adolescents had a lower
proportion of LBW infants could probably be explained by
the hypothesis that these adolescents having had a
previous pregnancy during which they perceived the benefits
of antenatal care (ANC), thus, attended and received
optimal ANC during the current pregnancy. Danger
signs associated with LBW were therefore identified and
managed. This hypothesis however should be tested in
Though multiparous adolescent deliveries were
precluded from having a single adverse outcome in this
study—LBW, it should be noted that these group of
adolescents are still likely to have adverse delivery outcomes
when compared with adults as seen in the previous
Several authors have reported a high incidence of
adverse outcomes in adolescents such as perineal tears,
post-term deliveries and neonatal asphyxia. Perineal
tears are a common finding in adolescent deliveries as
reported by authors in Cameroon [
2, 11, 12
] while the
babies born from adolescent mothers are usually prone
to asphyxia [
]; probably because of the prolonged
labours that their mothers tend to have.
This analysis emphasises the fact that adolescents are
generally not prepared to handle the burden of pregnancy
]. Preventive strategies that could reduce the rate of
early marriages, adolescent pregnancies and its
associated complications are therefore warranted to reduce
this public health problem. These preventive strategies
could include more adolescent-friendly programmes that
encourage sexual health education and the use of
contraceptives among adolescents. This should be accompanied
by integration of contraceptive clinics in routine
healthcare practices in health centres and outreach activities to
schools targeting adolescents to promote sexual health.
Though primiparous adolescents were more likely to
have LBW neonates than their multiparous adolescents,
this group is generally ill-equipped to deal with the
burden of pregnancy. The hypothesis and findings generated
in this study needs to be confirmed by future studies with
Being a retrospective study, there is the potential
limitation that there were errors in the registers, some key
outcomes and exposures could not be measured and there is
the risk of selection bias. However, this study generates
an important hypothesis that needs to be supported by
more robust designs like cohort studies in future projects
guided by power and sample size calculations. The study
was carried out in two health facilities in the Oku health
district and does not necessarily reflect the entire
situation in all rural areas of Cameroon.
Additional file 1: Figure S1. The prevalence of multiparous adolescent
deliveries among adolescents in the Oku Health district over 8-year period
from 2009 to 2016.
Additional file 2: Table S1. Multivariable logistic regression analysis
showing the influence of parity on low birth weight after adjusting for
LBW: low birth weight; OHD: Oku health district; HIV: human
immunodeficiency virus; CI: confidence intervals; HBW: high birth weight; ANC: antenatal
Study conception: VNA and TN; Data collection: VNA; Data analysis: TN; Write
up of first manuscript: TN; Manuscript revision: VNA and TN. All authors read
and approved the final manuscript.
The authors will like to thank the staff of the Oku district hospital and Kevu
primary health centre for their cooperation during the study.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets generated and/or analysed during the current study are available
from the corresponding author on reasonable request.
Consent for publication
Ethics approval and consent to participate
Ethics approval was obtained from the scientific and ethical review board of
the Northwest Regional delegation for Public Health.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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