Open Journal of Obstetrics and Gynecology, 2011, 1, 47-52 OJOG
doi:10.4236/ojog.2011.12010 Published Online June 2011 (http://www.SciRP.org/journal/ojog/).
Published Online June 2011 in SciRes. http://www.scirp.org/journal/OJOG
Outcome of delivery in nulliparous teenagers aged less than 17
years: the cameroon university centre hospital experience
Pierre Marie Tebeu1,2, Inoussa Nsangou3, Philippe Nana Njotang1, Paul Théodore Tjek Biyaga1,
Anderson Sama Doh3, Joseph Nelson Fomulu1
1Department of Gynaecology & Obstetrics, University Hospitals, Yaounde, Cameroon;
2Ligue d’Initiative et de Recherche Active pour la Santé et l’Education de la Femme;
3Department of Paediatrics, University Hospitals, Yaounde, Cameroon.
Received 21 April 2011; revised 22 May 2011; accepted 29 May 2011.
ABSTRACT
In a previous study at the Yaoundé-Cameroon Uni-
versity Centre Hospital, we found that delivery at
extreme ages of reproductive health was associated
with several fetal and maternal risks. We conducted
this study aimed at testing the hypothesis that deliv-
eries by teenagers were associated with increased risk.
Data collection was retrospective from delivery room
registers at between 01/01/1996 and 31/12/2000. Data
were collected in singleton pregnancies. The identifi-
cation of each nulliparous woman aged less than 17
years was followed by that of 4 nulliparous women
aged 20 - 29 years following her in the order of deliv-
ery. Since it was possible to have consecutive nulli-
parous teenage pregnancies before four deliveries in
women in their twenties, we finally compared 65
cases of teenagers delivery with 218 cases of delivery
in women aged 20 - 29 years. The difference was con-
sidered significant if p value was less than 0.05. Odd
ratio with 95% confidence interval was used to mea-
sure the effect of age on the major outcomes. At uni-
variate analysis, the risk of delivery by caesarean
section for teenagers (21.5%) was significantly high
compared to women in their twenties (11.5%), (OR:
2.1; 95%CI: 1.0 - 4.1; p = 0.041). Similar observation
was found for stillbirth delivery with 12.3% by teen-
agers compared to 5.0% by women in their twenties
(OR: 2.7; 95%CI: 1.0 - 7.1; p = 0.044). The risk of
premature delivery by teenagers (30.8%) was also
significantly increased compared to women in their
twenties (12.4%) (OR: 3.6; 95%CI: 1.8 - 7.1; p =
0.0002). After adjustment for different factors associ-
ated with the occurrence of several risks, only pre
term delivery remained significantly increased at
teenage (OR: 3.7; 95%CI: 1.8 - 7.6; p = 0.003). These
findings underscore the importance of public health
programs in preventing the pregnancy in teenagers,
and in developing age-appropriate intervention.
Keywords: Adolescent; Delivery; Risk
1. INTRODUCTION
Teenage pregnancy is known to be associated with sev-
eral risks [1-5]. Nevertheless, teenagers contribute to
deliveries all over the world, and according to the litera-
ture their proportion varies from 7% to 25% of deliveries
[6-9]. Many studies have reported more complications of
deliveries and poor fetal outcome of pregnancy in ado-
lescents compared to women in their twenties [7,10].
Findings from different studies are conflicting. Most of
them found an increased risk of delivery by caesarean
section, but these findings were not confirmed by other
studies [4,10]. Conflicting results were also published
for the risk of premature delivery, fetal distress, intra
uterine fetal death, small for gestational age and post
term delivery [10,11]. In a previous study at the Univer-
sity Teaching Hospital, Yaoundé-Cameroon, we found
that delivery at extreme ages of reproductive health was
associated with many fetal and maternal risks [12].
However, we were not able to evaluate the impact of
teenage condition on exposure to different risks ob-
served. Thus, it appeared necessary to study the outcome
of pregnancy in teenagers in our setting where this topic
is little documented.
2. OBJECTIVE
The aim of this study was to test the hypothesis that
pregnancies in adolescents aged less than 17 years are
associated with high risks.
3. POPULATION AND METHODS
3.1. Population
This was a historical cohort study at the University

P. M. Tebeu et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 47-52 48
Teaching Hospital Yaoundé-Cameroon. Data collection
was retrospective from the delivery room registers be-
tween 1/01/1996 and 31/12/2000. Data were collected in
singleton pregnancies. The identification of each nul-
liparous woman aged less than 17 years was followed by
that of 4 nulliparous women aged 20 - 29 years follow-
ing her in the order of delivery. Since it was possible to
have consecutive nulliparous teenage pregnancies before
four deliveries in women in their twenties, we finally
compared 65 cases of teenagers delivery with 218 cases
of delivery in women aged 20 - 29 years.
3.2. Variables
The maternal risks considered in this study were: deliv-
ery by caesarean section and the occurrence of post par-
tum hemorrhage. The fetal outcomes were premature
delivery, intra uterine growth retardation, post term de-
livery, macrosomia, fetal distress and stillbirth. Women
were delivered in our hospital regardless of the place of
prenatal care.
3.3. Statistical Analyses
The software Epi Info 6 was used for analysis. The key
question guiding the sample size calculation of this his-
torical cohort study was “what level of exposure to de-
livery risks the teenagers should be compared to women
in their twenties.” The sample size calculation was based
on the occurrence of a caesarean section incidence of
20%, estimated as quadrupled compared to the low risk
parturient. With 1 exposed for 4 unexposed, 325 women
were needed to provide 90% power for a two sided, 5%
test to detect a proportion change that does not exist in
both groups. The univariate and multivariate analysis
were performed by logistic regression. Odd ratio with
95% confidence interval was used to measure the effect
of age on the major outcomes. The difference was con-
sidered significant if the p value was less than 0.05.
4. RESULTS
Delivery characteristics of women aged less than 17
years (n = 65), and those of women in their twenties (n =
218) are described in Table 1. Compared to women in
their twenties, teenagers were more likely to deliver
prematurely (30.8% vs. 12.4%), to develop post partum
hemorrhage (7.7% vs. 2.3%), and to be delivered by
caesarean section (21.5% vs. 11.5%).
Table 2 presents the result of univariate analysis of
delivery risks in teenagers. Delivery by caesarean sec-
tion for teenagers was significantly increased compared
to women in their twenties, (OR: 2.12; 95% CI: 1.03 -
4.4; p = 0.041). After, adjustment on the pregnancy age
and APGAR score, teenage status does not appear as an
in- dependent risk factor for caesarean delivery (P = 0.9)
(Table 3).
The risk of stillbirth delivery by teenagers was signi-
ficantly increased compared to women in their twenties
(OR: 2.7; 95%CI: 1.03 - 7.14; p = 0.044). After, adjust-
ment on the pregnancy age, teenage status does not ap-
pear as an independent risk factor for stillbirth (P = 0.1)
(Table 4).
The risk of premature delivery by teenagers was sig-
nificantly increased compared to women in their twen-
ties (OR: 3.6; 95%CI: 1.8 - 7.2; p = 0.002). After adjust-
ment for APGAR score, preterm delivery remained sig-
nificantly increased at teenage (OR: 3.7; 95%CI: 1.8 -
7.6; p = 0.003) (Table 5).
The risk to develop post partum hemorrhage by teen-
agers was somewhat equal to that of women aged 20 -
29 years, (OR: 3.5; 95%CI: 0.9 - 12.6; p = 0.051).
5. DISCUSSION
We conducted a historical cohort study. This study
showed that when the parturient age is less than 17 years
old, the risk of delivery by caesarean section is doubled.
Other studies published a higher rate of caesarean sec-
tion in teenagers compared to the women in their twen-
ties [13-15]. Unfer et al. found a higher incidence of
IUGR, acute intrapartum fetal distress and lower birth
weight, in the adolescent group [15]. They concluded
that the higher number of caesarean sections could be
attributed to these fetal conditions as means of prevent-
ing fetal death. In the current study, a similar rate of
IUGR in both study groups, did not confirm these condi-
tions as cause of caesarean delivery in teenagers. The
intrapartum fetal distress as a common indication of
caesarean section is subject of controversy because little
evidence of improved neonatal or long-term outcome is
reported [16]. However, in this study, the severe fetal
distress similar in both groups at one minute indicated
that there was not more intra partum fetal distress in
teenager than in the control group, and the increased risk
of caesarean section could not be attributed to the fetal
distress. However the high risk of overall stillbirth in
teenagers can indicate that some of caesarean section
procedure indicated for fetal distress failed in preventing
fetal death. Metello et al. found that incidence of Cae-
sarean section was lower in the teenage mothers [17].
They attributed the good results observed to the free and
readily available prenatal care and the quality of support
from the family or welfare agencies that were involved
with the care of teenage mothers. However, this study
included all teenagers until 19 years and is therefore a
heterogeneous population as shown by several studies
[15].

P. M. Tebeu et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 47-52 49
Table 1. Maternal, fetal and intrapartum characteristics according to the maternal age.
Maternal age classes (years)
12 - 16 20 - 29 Total
N = 65 N = 218 N = 283
Characteristics
N (%) N (%) N (%)
Mean age (SD) 15.51 (0.86) 24.08 (1.81) -
-
Gestational age (weeks)
37 - 42 35 (53.8) 171 (78.4) 206 (72.8)
<37 20 (30.8) 27 (12.4) 47 (16.6)
>=42 3 (4.6) 8 (3.7) 11 (3.9)
Unknown 7 (10.8) 12 (5.5) 19 (6.7)
Oxytocin
Yes 18 (27.7) 64 (29.4) 82 (29.0)
No 47 (72.3) 154 (70.6) 201 (71.0)
Misoprostol
Yes - 2 (0.9) 2 (0.7)
No 65 (100.0) 216 (99.1) 281 (99.3)
Fetal weight
2500 - 3999 (g) 45 (69.2) 180 (82.5) 225 (79.5)
<2500 14 (21.5) 27 (12.4) 41 (14.5)
>4000 2 (3.1) 8 (3.7) 10 (3.5)
Unknown 4 (6.2) 3 (1.4) 7 (2.5)
IUGR
Yes 13 (20.0) 24 (11.0) 37 (13.1)
No 52 (80.0) 194 (89.0) 246 (86.9)
APGAR Score at delivery
7 - 10 44 (67.7) 164 (75.2) 208 (73.5)
1 - 6 13 (20.0) 37 (17.0) 50 (17.7)
0 8 (12.3) 11 (5.0) 19 (6.7)
Unknown - 6 (2.8) 6 (2.1)
PPH
Yes 5 (7.7) 5 (2.3) 10 (3.5)
No 60 (92.3) 213 (97.7) 273 (96.5)
Caesarean delivery
Yes 14 (21.5) 25 (11.5) 39 (13.8)
No 51 (78.5) 193 (88.5) 244 (86.2)

P. M. Tebeu et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 47-52 50
Table 2. Distribution of teenage delivery according the obstetrical characteristics.
Maternal age classes (years)
12 - 16 20 - 29
N = 65 N = 218
Crude Odd
Ratioa (95% CI) P
Gestational age (weeks)
37 - 42 35 171 1 c
<37 20 27 3.6 (1.8 - 7.2) 0.002
>=42 3 8 1.8 (0.5 - 7.2) 0.388
Unknown 7 12 -
Oxytocin
Yes 18 64 1 c
No 47 154 0.9 (0.5 - 1.7) 0.795
Misoprostol
Yes - 2
No 65 216 - -
Fetal weight
2500 - 3999 45 180 1 c
<2500 14 27 2.1 (0.9 - 4.5) 0.071
>4000 2 8 1.0 (0.1 - 5.3) 0.629
Unknown 4 3 - -
IUGR
Yes 13 24 1 c
No 52 194 2.0 (0.9 - 4.2) 0.060
APGAR Score at delivery
7 - 10 44 164 1 c
1 - 6 13 37 1.3 (0.6 - 2.8) 0.459
0 8 11 2.7 (1.0 - 7.1) 0.044
Unknown - 6 -
PPH
Yes 5 5 1 c
No 60 213 3.5 (0.9 - 12.6) 0.091
Caesarean delivery
Yes 14 25 1 c
No 51 193 2.1 (1.0 - 4.4) 0.041
a Unadjusted; b = Confidence Interval; c reference category. IUGR = Intrauterine growth retardation; PPH= Post partum hemorrhage

P. M. Tebeu et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 47-52 51
Table 3. Incidence rate of caesarean delivery and Odd ratios according to the maternal age.
Maternal age
(years)
Total women
(N)
N of caesarean
delivery (N)
Incidence rate
(%)
Crude Odd
Ratioa (95% CI)
Adjusted Odd Ratiob
(95% CI)
20 - 29 218 25 11.5 1c 1 c
12 - 16 65 14 21.5 2.12.*(1.03 - 4.4) 1.82**(0.84 - 1.49)
a unadjusted, b adjusted for pregnancy age and APGAR score, c reference category. *P = 0.041; ** P = 0.960
Table 4. Incidence rate of stillbirth and Odd ratios according to the maternal age.
Maternal age
(years)
Total women
(N)
N of stillbirth
(N)
Incidence rate
(%)
Crude Odd
Ratioa (95% CI)
Adjusted Odd
Ratiob (95% CI)
20 - 29 218 11 5.0 1c 1 c
12 - 16 65 8 12.3 2.71*(1.03 - 7.14) 2.27**(0.84 - 6.08)
a unadjusted, b adjusted for pregnancy age, c reference category. *P = 0.044; ** P = 0.102
Table 5. Incidence rate of premature delivery and Odd ratios according to the maternal age.
Maternal age
(years)
Total women
(N)
N of premature delivery
(N)
Incidence rate
(%)
Crude Odd
Ratioa (95% CI)
Adjusted Odd
Ratiob (95% CI)
20 - 29 218 27 12.4 1c 1 c
12 - 16 65 20 30.8 3.61*(1.82 - 7.16) 3.70**(1.81 - 7.58)
a unadjusted, b adjusted for APGAR score, c reference category. *P = 0.002; ** P = 0.003
The behavior of obstetricians with anxiety about the
outcome of deliveries in teenagers could have contrib-
uted to the indication of operative procedure. This anxi-
ety can influence the premature decision of caesarean
delivery intending to reduce the delivery complications.
Regardless of the indication, caesarean section remains
an important problem in view of the high recurrence rate
[18-20].
We found that teenagers have a higher level of pre-
term delivery compared to women in their twenties. This
has been shown by other studies [21,22]. Olausson et al.
found that compared to women aged 20 - 24 years,
mothers who were 17 years or less at first delivery, were
at significant increased risk of preterm first delivery,
which fortunately shown a larger reduction at next de-
livery [21]. They concluded that there may be a biologi-
cal effect of very young maternal age on the risk of pre
term birth.
Inadequate antenatal clinic attendance by teenagers,
bacterial and parasitic infectious diseases and especially
malaria are common in developing countries and are
known as risk factors of pre term delivery [23]. The
consequence of pre term delivery is critical, as literature
report evokes that, according to the degree of pre matur-
ity, 20% - 30% of pre term babies died, and 10 to 30% of
those who survive will present neurological complica-
tions [24].
The stillbirth rate is also increased in teenagers, and is
three times that of the control group. This result is like
that of other studies, which found an increased stillbirth
rate in teenagers [25]. The poor socio-economic status,
the possibility of nutritional anemia, the inadequate pre-
natal care and emotion are common in developing coun-
tries and particularly during adolescence and can be
considered as risk factors for stillbirth [26-28]. In the
current study, the lost of significance of increasing still-
birth in teenagers after adjustment for pregnancy age
class suggests that the high risk of pre term delivery ob-
served in teenagers might contribute considerably in
fetal death.
We acknowledge that, some sources of bias are pre-
sent in this study. Some obstetrical conditions like small
pelvis, mal-presentation and premature rupture of mem-
branes which are common in teenagers and can put the
parturient as high risk of delivery by caesarean section
were not assessed.
6. CONCLUSIONS
Teenagers aged 16 or under are at high risk of delivery
by caesarean section. Other factors are also significantly
increased such as preterm and stillbirth delivery. Studies
are needed to determine the specific etiology of any risk

P. M. Tebeu et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 47-52 52
observed and the possibility of management. These re-
sults also underscore the importance of public health
programs in preventing pregnancies in teenagers, and in
developing age-appropriate interventions.
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