The Burden of Adolescent Pregnancy, Motherhood and Adverse Pregnancy Outcome in Uttar Pradesh and Bihar

doi:10.21203/rs.3.rs-1454585/v1

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Research Article

The Burden of Adolescent Pregnancy, Motherhood and Adverse Pregnancy Outcome in Uttar Pradesh and Bihar

https://doi.org/10.21203/rs.3.rs-1454585/v1

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Pregnancy during adolescence is a major risk factor for adverse pregnancy outcomes. Further, Motherhood at an adolescence period is identified as a major global health burden. Considering the wide known importance of negative impact of adolescent pregnancy, motherhood at an early age and adverse pregnancy outcome, this paper aim is to provides an insight into correlates of teen pregnancy, adolescent motherhood and adverse pregnancy outcome. This study utilizes the data from UDAYA survey conducted in Uttar Pradesh and Bihar. The eligible sample size for the study was 4,897 married adolescent girls between the ages of 15 and 19 years. Univariate analysis, bivariate analysis with chi square test of association and logistic regression analysis was performed to fulfil the aim of the study. Our study shows that a major proportion of married adolescent (61%) got pregnant before the age of 20years and around 42% of all adolescent married women gave birth to child before reaching the age of 20 years. Adolescents who married before the age 18 years were 1.79 times more likely to experience pregnancy (OR: 1.79; CI: 1.39–2.30) and 3.21 times more likely to experience motherhood (OR: 3.21; CI: 2.33–4.43). In the present study, women who experienced physical violence were at higher risk for having an adverse pregnancy outcome (OR: 1.41; CI: 1.08–1.84) than those who did not experience physical violence. The study highlights the need of addressing the others risk factors such as dietary habits, maternal care which impact the pregnancy outcomes.

Adolescent

Pregnancy

Motherhood

Adverse Pregnancy Outcome

Uttar Pradesh

Bihar

Adolescents aged 10–19 years represent over 16% of the world's population and play a central role in achieving the 2030 Sustainable Development Goals. India has the largest adolescent population in world and is home to 253 million adolescents aged 10–19 years. Despite a substantial decline of 11.6% in adolescent –specific fertility rate in past 2 decades globally, approximately 21 million girls in age-group 15–19 years become pregnant in developing countries (WHO, 2020). Additionally, it is estimated that out of them around 12 million adolescent mothers give birth. Motherhood at an adolescence period is regarded as a major global public health issue owing to the wide range of health effects and socio—economic consequences for mother as well as child. World Health Organization estimates that about 11% of total births occurred to women aged less than 20 years, and 95% of these births occurred in low-and middle- income countries (WHO, 2011), usually among the most disadvantageous adolescents (UNFP, 2015; UNFP, 2016). Further, with an adolescent population of 243 million, an unprecedented opportunity and challenge lies ahead for India. According to the fourth round of National Family Health Survey, an estimated 11.8 million teenager’s pregnancy occurred in India (National Family Health Survey, 2015-16). Further, Medhi and colleagues identify the major responsible factor for the higher rates of adolescent pregnancy to be deeply entrenched practice of child marriage, poor access to health care, poverty, and low literacy levels in India (Medhi et al., 2016).

A number of literatures supports the annotation that birth in teen age is a major risk factor for adverse pregnancy outcomes, it is also documented that teenage childbearing have a significant negative impact on the future well-being of infant as well as the mother (Olausson, 2001; WHO, 2007). The adverse maternal and perinatal outcomes of adolescent pregnancy have been well documented to be associated with low birth weight (Chen et al., 2010; De Vienne, Creveuil, & Dreyfus., 2009; Chen et al., 2007) preterm delivery (Chen et al., 2010; Chen et al., 2007, Conde-Agudelo, Belizan & Lammers., 2005), perinatal death (Mukhopadhyay, Chaudhuri & Paul., 2010) and maternal death (Granja et al., 2001; Conde -Agudelo, Belizan & Lammers., 2005). Further, in number of studies adolescent pregnancy is found to be associated with an increased risk of adverse birth outcomes especially preterm birth, low birth weight, neonatal asphyxia and perinatal death in low- and higher-income countries (Ganchimeg et al., 2014; Kawakita et al., 2016). Findings from a multi country-based study by Neal and colleagues highlight that maternal mortality and morbidity are mainly due to pregnancy and delivery related complications among 15–19 years old (Neal et al., 2012).

Adolescent pregnancy has been shown to be associated with low educational attainment of the mother, single parenthood and welfare dependency (Webb, Marshall & Abel., 2011). Evidence shows that other than the biological factors, socio-economic status is also associated with higher incidence of undesirable outcomes of adolescent pregnancies. There is a continued debate on the association between teenage childbearing and adverse pregnancy outcome i.e., if this is due to socio-demographic conditions of adolescent mothers or attributable to biological immaturity (Taffa & Obare., 2004). Findings from hospital-based studies accentuate that young maternal are alone is casually associated with poor obstetric outcomes such as antenatal delivery by skilled personnel and perinatal death (Wasunna & Mohammed., 2002; Anandalakshmy & Buckshee, 1993). Further, studies could not establish any association between high-quality maternity care provision provided to adolescent mothers and adverse pregnancy outcome among them (Raatikainen et al., 2006; Blomberg, Tyrberg & Kjølhede., 2014).

Pregnancies among adolescent women are documented to have major implications on the ill-health of women, educational opportunity and population growth (Kassa et al., 2018). Additionally, there are evidences that highlight that teenage pregnancy in India has a lifelong and intergenerational health costs, which substantially affect the lives of a major chunk of adolescent girl’s population (Nguyen et al., 2019). Several studies have shown that the rates of maternal and peri-natal morbidity and mortality can be reduced by lowering the high rate of adolescent pregnancy in developing countries (Westoff CF., 2003; Nove et al., 2014). While numerous researches exist on the determinants of adolescent child bearing in the context of developing as well as developed countries, there exists a necessity of in-depth examination into the factors determining the adolescent pregnancy and pregnancy outcomes. Further, in spite of the wide known importance of mortality and severe morbidity associated with the adverse pregnancy outcome, there is no sufficient epidemiological evidence in case of India specially when India has regionally highly variable rates of adolescent pregnancies with an existing multiple risk factors for adverse pregnancy outcomes. Further, insights into correlates of adolescent pregnancy would help in policy formulation and in providing programmatic response while addressing adolescent pregnancies and progress monitoring towards achieving the target 3.1 and 3.7 of Sustainable Development Goals (SDG), (United Nations, 2015). The aim of our study is therefore to investigate the contextual factors which determine and affect pregnancy outcomes among adolescents from Uttar Pradesh and Bihar states which hold a considerably high adolescent population from rest of the Indian states.

The study used data collected by the Population Council's “Understanding the Lives of Adolescents and Young Adults” (UDAYA) project survey, which was performed in two Indian states, Uttar Pradesh and Bihar, in 2016 under the supervision of the Ministry of Health and Family Welfare. To obtain estimates for the states as a whole, as well as the urban and rural areas of the states, the survey used a multi-stage systematic sampling design. The study's effective sample size was 4,897 married adolescent girls between the ages of 15 and 19. In Uttar Pradesh and Bihar, the sample sizes were 1,732 and 3,165 adolescents aged 15–19 years, respectively. Because they had not responded to the question about their pregnancy (have you ever been pregnant?), about 409 girls (7.8%) were removed from the overall sample (N = 5206). The Population Council's Institutional Review Board gave its approval to the project and its data collection. It also guaranteed that the participants' privacy was protected and that informed consent was obtained from respondents during the survey.

Variable Description

Outcome Variables

The variable name pregnancy hood was made by the variable ever been pregnant. If the respondent ever become pregnant the it was recoded as 1 means “yes” otherwise 0 means “no”. Second outcome variable was adolescent motherhood. The married adolescent who has given birth to any child before the date of survey were coded as 1 means “yes” otherwise 2 means “no”. Additionally, last explanatory variable was formed using the following question 1) Have you ever had a pregnancy, which ended in a stillbirth? (yes/no) 2) Have you ever had a pregnancy which ended in a miscarriage? (yes/no) 3) Have you ever aborted a pregnancy? (yes/no). The response of the above question was coded as 1 means “yes” and 2 means “no”. Now the variable names adverse pregnancy outcome was generated using above three questions. If the respondent has faced any of the problem mentioned above, then it was recoded as 1 “yes” otherwise 0 “no”.

Predictor Variables

Table 1

Characterization of variable used in this study
Variables	Questions	Response	Recode
Physical Violence	Do/did your husband ever do any of the following to you: slap you?	Yes	Yes
	Twist your arm or pull your hair?	No	No
	Push you, shake you, or throw something at you?
	Punch you with his fist or with something that could hurt you?
	Kick you, drag you or beat you up?
	Try to choke you or burn you on purpose?
	Threaten or attack you with a knife, gun or any other weapon?
Substance use (respondent)	Now I would like to talk about different habits like smoking, drinking, using drugs etc.	Yes	Yes
Substance use (respondent)		No	No
Dowry related abuse	Has anybody in your husband’s family ever said that the dowry/gift/cash you brought was too little	Yes
Dowry related abuse	Has anyone in your husband’s family ever asked you to bring more cash/gifts/dowry from your parent’s family?	No
Media Exposure	How often do you watch television? Would you say almost every day, at least once a week, at least once a month, rarely or not at all?	Almost every day	Rare
	How often do you read a newspaper/ magazine/story books/novels etc.? Would you say almost every day, at least once a week, at least once a month, rarely or not at all?	At least once
		a week
	How often do you listen to radio? Would you say almost every day, at least once a week, at least once a month, rarely or not at all?	At least once a month	Frequent
	How often do you watch films? Would you say almost every day, at least once a week, at least once a month, rarely or not at all?	Rarely

Married adolescent females (15–19 years) were chosen as the study sample in order to satisfy the objectives. The study was conducted in Bihar and Uttar Pradesh, and respondents' residences were classified as rural or urban, according to the survey. Caste was recoded as SC/ST (Schedule Caste/ schedule Tribe), OBC (Others Backward Classless) and Others. Religion was recoded as Hindu and Non-Hindu. The wealth index has been recoded into the following categories: poorest, poorer, middle, richer, and richest. The years of education of eligible respondents were classified as "0–7 years of schooling," "8–10 years of schooling," "11–12 years of schooling," and "12 + years of schooling. "The types of violence experienced by married adolescent women were classified as emotional, physical, and sexual. If the respondent was ever humiliated in front of others or threatened by her spouse to hurt or harm something close to her, the violence was classified as emotional. If the respondent was ever compelled to have sex by her husband, including her first-time sex with him, the violence was classified as sexual. Further, the age gap between the spouses was recoded as < 5 years, 5–10 years, and > 10 years. In addition, the ages of marriage and cohabitation were recoded as < 18 and 18–19 years, respectively. Other variables described in table-1.

Analytical Approach

Univariate analysis along with bivariate was carried out to access the sample characteristics of currently married adolescents and percentage distribution of pregnancy hood, motherhood and ever having adverse pregnancy outcome in adolescent reproductive age group 15-19years. Chi square test of significance were used to show the association between pregnancy hood, Motherhood, ever adverse pregnancy outcome and background characteristics. Further for analysing the significant predictors binary logistic model was used. Logistic regression analysis was used due to the fact that dependent variable was nominal with two categories namely no and yes (coded as 0 = No and 1 = Yes), and there were more than one independent variables. Based on individual attributes, a logistic regression will model the likelihood of a specific result. Further equation of the logistic regression model is expressed as

log (π/1 – π) = β₀ + β₁X₁ + β₂X₂ + ... β_mX_m

Where, π indicate the probability of happening of event (e.g., pregnancy, child birth, stillbirth, miscarriage, abortion), and βi indicate the regression coefficient associated with the reference group and the Xi indicates the explanatory variables (King, 2008; Sperandei, 2014). All of the Statistical analysis included in the study was done using Stata 16 software (StataCorp, 2019).

Figure 1 display the percentage distribution of adolescent pregnancy, motherhood and adverse pregnancy outcome. About three fifth of the sample population reported that they ever had become pregnant before age 20. Among all currently married adolescent 42% had given birth before age 20years. Around 19% of adolescents ever had gone through the adverse pregnancy outcome (miscarriage, stillbirth or abortion).

Sample characteristics of currently married adolescent in reproductive age group 15–19 years were presented in Table 2. A higher proportion of women (around 65%) belonging to the Bihar. Out of total adolescents 85% of adolescent lived in the rural areas. About three fifth (59.63%) of the currently married adolescent were from OBC followed by SC/ST (29.51) and Others (10.86%) respectively. Majority of adolescent belongs to Hindu (84.17) followed by other religion. Approximately half of sample population were having 8 or more years of schooling. Furthermore, lowest segment of women belonging to the richest wealth quantile (13.93%) followed by poorest (17.31%), poorer (21.38%), Richer (23.17%) and middle (24.22%) respectively. About 57% of the adolescent were having spouse within 5 years of age gap, while nearly 40% of adolescent spouse were more than 5 years to 10years older than their counterpart. Among all adolescent more than four fifth adolescents were married before the legal age of marriage (below 18 years) and nearly three fourth (74%) cohabited with spouse before the age of 18 years. While taking about violence among married we see that prevalence of emotional violence 28.57%, physical violence 26.01% and sexual violence 65.40% respectively. Just about one third of the total sample adolescent were exposed with the frequent media exposure. Furthermore, one fourth (25.87%) of the respondent faces the problem of more requirement of dowry by their husband family.

Figure 2 shows the mean age of some specific age events used in the study such as mean age of study population, mean age of marriage, mean age of first cohabitation with spouse, mean age of first otherhood and mean age spousal age gap. Mean age of married adolescent for discussed above events were found as follows 18 years for total married adolescents, 15.8 years for marriage, 16.4 years for first cohabitation, 16.7 years for first motherhood and 4.7 years for spousal age gap.

Association of socio-demographic and behavioural characteristics with adolescent pregnancy hood, Motherhood and Adverse pregnancy outcome hood were displayed in Table 3. Pregnancy hood and Motherhood shows the significant association with background characteristics such as state, wealth index, respondent level of education, spousal age gap, age at marriage, age at cohabitation with spouse, emotional, physical and sexual violence. Ever had adverse pregnancy outcome shows their significance with state, spousal age gap, respondent beaten by parents, substance use by respondent and physical violence. Prevalence of adolescent’s pregnancy hood is found to be highest in Bihar with 63.64% followed by UP 56.18%. At the same time adolescent motherhood is also found to highest 47.19% in Bihar followed by UP 33.47%. In addition to previous evidence the women belonging to the Uttar Pradesh display the highest prevalence (25.38%) for ever had termination of pregnancy in compare to Bihar (15.43%). Proportion of the cases does not vary much by place of residence and caste and religion. Nearly half of the adolescent in reproductive age group becomes motherhood in poorest wealth quantile and it decreases as the women wealth status increases. Whereas prevalence of pregnancy hood and motherhood varies a lot by educational status. As the respondent level of education is increasing motherhood (60.98% in 0-7years of schooling to 48.36% in 12 + years of schooling), pregnancy hood (44.46% in 0-7years of schooling to 31.38% in 12 + years of schooling) and adverse pregnancy outcome (19.38% in 0-7years of schooling to 12.69% in 12 + years of schooling) prevalence decreases. The women having husband with more than 10years of gap were more prevalent for pregnancy hood (75.06%) as well as for motherhood (63.4%) but less prevalent for adverse pregnancy outcome hood (11.65%). Additionally, all those adolescents who married and cohabited with spouse before the age of 18 years were more prevalent for pregnancy as well as mother with high significance level. Similarly, respondent belonging to the family whose members require more dowry were more prone to pregnancy hood and motherhood. Religion, substance use, and media exposure does not show the significant association with pregnancy and motherhood. More physical, sexual and emotional violence was associated with more prevalence of adolescent pregnancy, motherhood and adverse pregnancy outcome. Above events does not vary significantly with media exposure.

Table 4 declare the logistic regression estimates for adolescent pregnancy, motherhood and adverse pregnancy outcome in India. Result shows that as well as the women age increases by one-year odds of pregnancy increased by 2.42 times (OR: 2.42, CI: 2.24–2.62) and motherhood increased by 2.74 times (OR: 2.74, CI: 2.52–2.98) with highest significance level. The likelihood of pregnancy and motherhood was 1.32 times and 1.45 times more in Bihar in compare to UP respectively. Whereas Bihar shows the 46% less (OR: 0.54, CI: 0.43–0.67) likelihood of adverse pregnancy outcome in compare to UP. The women with 0–7 and 8–10 years of schooling were 69% and 85% more likely to have being pregnant respectively in compare to women with 12 and more years of schooling. The odds of pregnancy and motherhood increase significantly with increasing spousal age gap. Adolescents having spousal age gap 5 to 10 years were 52% more likely of being pregnant and with more 10years of spousal age gap shows 99% (OR: 1.99, CI: 1.35–2.95) of more likelihood of pregnancy. Similarly, reproductive aged adolescents with 5-10years of spousal age gap were 1.54 times more likelihood of motherhood and with more than 10 years of spousal age gap were 2.54 times more likelihood of motherhood. Whereas spousal age gap negatively associated with adverse pregnancy outcome such as adolescent with more than 10years of spousal age gap 48% less likelihood of adverse pregnancy outcome. Further when adolescent married before the age 18 years the odds of pregnancy and motherhood was increased by 1.79 times (OR: 1.79; CI: 1.39–2.30) and 3.21 times (OR: 3.21; CI: 2.33–4.43) respectively. Similarly, adolescent having cohabited with husband before age 18 were 3.40 times more likelihood of being pregnant and 5.75 times more likelihood of being mother. Emotional and physical violence were having significant effect on pregnancy and motherhood. For instance, the women who reported for emotional violence 1.43 times (OR: 1.43, CI: 1.16–1.76) more likelihood of being pregnant and 54% more (OR: 1.54, CI: 1.26–1.88) likelihood of being a mother, while in case of physical violence 1.26 times (OR: 1.26, CI: 1.02–1.54) more likelihood of being pregnant and 1.26 times (OR: 1.26, CI: 1.03–1.54) more likelihood of being a mother whereas 1.41 times (OR: 1.41, CI: 1.08–1.84) of being exposed to any adverse pregnancy outcome. Additionally, place of residence, caste, religion, wealth index, substance abuse, sexual violence, media exposure and dowry requirement does not show any significant relationship with any of the reproductive outcomes (Pregnancy hood, Motherhood, Adverse outcome hood).

Table 2

Sample Characteristics of Currently Married Adolescent.
Sample Variables	Sample	Percentage
State
Uttar Pradesh	1,732	35.38
Bihar	3,165	64.62
Place of Residence
Urban	722	14.75
Rural	4175	85.25
Caste
SC/ST	1,445	29.51
OBC	2,920	59.63
Others	532	10.86
Religion
Hindu	4,122	84.17
Non-Hindu	775	15.83
Wealth Index
Poorest	848	17.31
Poorer	1,047	21.38
Middle	1,186	24.22
Richer	1,134	23.17
Richest	682	13.93
Respondent level of education
0-7year of schooling	2,486	50.77
8-10year of schooling	1,684	34.38
11-12year of schooling	595	12.15
12 + year of schooling	132	2.71
Spousal Age Gap
< 5years	2,534	57.14
5-10years	1,753	39.53
> 10years	148	3.33
Age at Marriage
< 18years	4,109	83.90
18-19years	788	16.10
Age at Cohabitation with Spouse
< 18years	3,615	73.95
18-19years	1,274	26.05
Substance use (respondent)
No	4,744	96.87
Yes	153	3.13
Violence among married women
Emotional Violence
No	3,496	71.43
Yes	1,399	28.57
Physical Violence
No	3,623	73.99
Yes	1,274	26.01
Sexual violence
No	1,694	34.60
Yes	3,203	65.40
Media Exposure
Rare	3,246	66.28
Frequent	1,651	33.72
Dowry Requirement
No	3,630	74.13
Yes	1,267	25.87
Total	4897	100.0
*Total may not be equal to N due to missing cases

Table 3

Association of socio-demographic, personal and behavioural factors with Pregnancy, Motherhood and Adverse Pregnancy outcome among Adolescents
Variables	Pregnancy (%)		Motherhood (%)		Adverse Pregnancy Outcome (%)
State
Uttar Pradesh	56.18	0.000	33.47	0.000	25.38	0.000
Bihar	63.64	0.000	47.19	0.000	15.43	0.000
Place of Residence
Urban	62.39	0.003	40.64	0.269	18.41	0.437
Rural	60.76	0.003	42.63	0.269	18.6	0.437
Caste
SC/ST	62.61	0.202	44.85	0.029	18.73	0.175
OBC	60.87		41.97		18.14
Others	57.35		37.56		20.66
Religion
Hindu	61.11	0.881	42.83	0.259	17.9	0.261
Non-Hindu	60.42	0.881	39.72	0.259	22.18	0.261
Wealth Index
Poorest	63.69	0.017	48.25	0.000	18.84	0.866
Poorer	61.87		43.71		20.6
Middle	59.39		42.95		17.31
Richer	62.63		40.56		17.69
Richest	56.42		34.78		18.64
Respondent level of education
0-7year of schooling	60.98	0.000	44.46	0.000	19.38	0.155
8-10year of schooling	63.07		40.14		19.17
11-12year of schooling	58.07		42.11		14.15
12 + year of schooling	48.36		31.38		12.69
Spousal Age Gap
< 5years	57.81	0.000	38.45	0.000	19.8	0.022
5-10years	65.84		46.9		18.57
> 10years	75.06		63.4		11.65
Age at Marriage
< 18years	65.16	0.000	48.18	0.000	18.28	0.031
18-19years	39.33	0.000	11.87	0.000	22.08	0.031
Age at Cohabitation with Spouse
< 18years	66.78	0.000	51.46	0.000	18.51	0.469
18-19years	45.12	0.000	16.8	0.000	18.93	0.469
Substance Abuse
No	60.9	0.448	42.43	0.385	18.12	0.008
Yes	64.16	0.448	39.52	0.385	31.19	0.008
Violence among married women
Emotional Violence
No	57.4	0.000	37.32	0.000	18.28	0.569
Yes	70.09	0.000	54.94	0.000	19.11	0.569
Physical Violence
No	56.79	0.000	37.15	0.000	16.39	0.001
Yes	72.99	0.000	57.09	0.000	22.9	0.001
Sexual violence
No	60.09	0.000	40.05	0.000	17.7	0.339
Yes	62.74	0.000	46.66	0.000	20.06	0.339
Media Exposure
Rare	60.86	0.25	43.29	0.483	18.85	0.563
Frequent	61.3	0.25	40.47	0.483	18.02	0.563
Dowry related abuse
No	60.22	0.000	41.06	0.000	17.99	0.417
Yes	63.26	0.000	46.01	0.000	20.09	0.417

Table 4

Binary logistic regression analysis of socio-demographic, personal and behavioural factors with Pregnancy, Motherhood and Adverse Pregnancy outcome among Adolescents
Variables	Pregnancy	Motherhood	Adverse pregnancy outcome
Variables	Odds Ratio (95% CI)	Odds Ratio (95% CI)	Odds Ratio (95% CI)
Age
15 Years
16–19 Years	2.42*** [2.24,2.62]	2.74*** [2.52,2.98]	1.01 [0.90,1.14]
State
Uttar Pradesh
Bihar	1.32*** [1.14,1.54]	1.45*** [1.24,1.70]	0.54*** [0.43,0.67]
Place of Residence
Urban
Rural	0.91 [0.78,1.07]	1.01 [0.86,1.19]	0.96 [0.76,1.21]
Caste
Others
SC/ST	1.09 [0.85,1.42]	1.08 [0.82,1.41]	0.93 [0.64,1.37]
OBC	1.01 [0.80,1.27]	0.96 [0.75,1.22]	0.88 [0.62,1.24]
Religion
Hindu
Non-Hindu	1.06 [0.86,1.29]	1.04 [0.84,1.28]	1.05 [0.78,1.41]
Wealth Index
Richest
Poorest	1.29 [0.96,1.73]	1.24 [0.91,1.67]	0.91 [0.59,1.39]
Poorer	1.05 [0.80,1.38]	0.97 [0.73,1.29]	0.98 [0.65,1.48]
Middle	1.06 [0.83,1.34]	1.16 [0.90,1.49]	0.82 [0.56,1.19]
Richer	1.13 [0.90,1.41]	1.06 [0.84,1.34]	0.94 [0.67,1.33]
Respondent level of education
12 + year of schooling
0-7year of schooling	1.69* [1.13,2.51]	1.38 [0.86,2.20]	1.53 [0.69,3.37]
8-10year of schooling	1.85** [1.25,2.75]	1.33 [0.84,2.12]	1.54 [0.70,3.39]
11-12year of schooling	1.23 [0.81,1.86]	1.26 [0.77,2.04]	1.10 [0.48,2.54]
Spousal Age Gap
< 5years
5-10years	1.52*** [1.31,1.76]	1.54*** [1.33,1.78]	0.90 [0.73,1.11]
> 10years	1.99*** [1.35,2.95]	2.54*** [1.73,3.71]	0.52* [0.29,0.95]
Age at Marriage
18-19years
< 18years	1.79*** [1.39,2.30]	3.21*** [2.33,4.43]	0.55* [0.32,0.94]
Age at Cohabitation with Spouse
18-19years
< 18years	3.40*** [2.72,4.25]	5.75*** [4.51,7.32]	1.45 [0.94,2.24]
Substance use
No
Yes	0.97 [0.65,1.43]	0.71 [0.48,1.05]	1.14 [0.68,1.89]
Violence among married women
Emotional Violence
No
Yes	1.43*** [1.16,1.76]	1.54*** [1.26,1.88]	0.87 [0.65,1.15]
Physical Violence
No
Yes	1.26* [1.02,1.54]	1.26* [1.03,1.54]	1.41* [1.08,1.84]
Sexual violence
No
Yes	0.94 [0.80,1.10]	0.98 [0.83,1.16]	1.07 [0.85,1.36]
Media Exposure
Rare
Frequent	1.12 [0.94,1.32]	1.09 [0.91,1.29]	0.88 [0.68,1.13]
Dowry related abuse
No
Yes	1.08 [0.91,1.29]	1.07 [0.90,1.27]	1.12 [0.88,1.43]
* p < 0.05, p < 0.01, * p < 0.001

Adolescent pregnancy is a major global health burden which can lead to adverse pregnancy and perinatal outcomes. Analyzing the factors associated with pregnancy and adverse pregnancy outcomes among married adolescents is crucial to inform public policies to meet the objectives of SDGs. Adolescent pregnancy in Uttar Pradesh and Bihar is an important issue as these two states have the highest proportion of young age population in the country. Analysis indicates that despite a substantial decline in the overall fertility in the country (NFHS-5), adolescent pregnancy, motherhood and adverse pregnancy outcomes are still prevalent in the states of UP and Bihar. A major proportion of married adolescent (61%) got pregnant before the age of 20years and around 42% of all adolescent married women gave birth to child before reaching the age of 20 years. Additionally, around one-fifth (18.57%) of the eligible sample experienced an adverse pregnancy outcome (miscarriage, stillbirth or abortion) before the age 20 years. Research suggest an independent association between adolescent pregnancy and increased risks of adverse pregnancy outcomes (Conde-Agudelo, Belizan &Lammers., 2004). Early pregnancy has been documented to possess health risk and these risks are further exacerbated by poverty and inadequate access to maternal and child health care (Sing and Samara., 1996). The mean age of marriage and motherhood for the first time was found to be 15.8 years and 16.7 years respectively which is substantially lower than the minimum legal age at marriage (18 years) and safe motherhood (21 years) respectively. Adolescent motherhood has adverse health effects and socio-economic consequences for the child as well as the mother (Islam et al., 2017; Ganchimeg et al., 2014). Studies report a higher risk of death to be associated with adolescent pregnancy than for adults (Jutte et al., 2010).

Our study findings of logistics regression analysis show that state, respondents level of education, spousal age gap, age at marriage, age at cohabitation with spouse, violence (Emotional and physical) was found to be statistically significantly associated with experiencing pregnancy, motherhood and having an adverse pregnancy outcome. A large body of literature has reported an inverse association between women’s educational attainment and adolescent motherhood (Hubert et al., 2019; Gaudie et al., 2010). The possible explanation for this inverse association is inadequate knowledge of high risk fertility period, less awareness of family planning (Angeles, Guilkey & Mroz., 2005; Marchetta & Sahn., 2016). Findings from a study by Nahar and Min reveal that women’s higher educational attainment and higher age at marriage results in postponing the age of experiencing pregnancy in Bangladeshi Adolescent women (Nahar& Min., 2008). Another study done in Malaysia reveals that adolescent pregnancy is associated with low education, child raised by single parent, low socioeconomic status and substance abuse as well (Omar et al., 2010). Surprisingly, study result also indicates that women who got married before the of 18 years were 45% less likely to have an adverse pregnancy outcome in comparison to those who were married in age 18–19 years but level of significance is very less. Additionally, age at first cohabitation with spouse is negatively associated with pregnancy, motherhood and as well as adverse pregnancy outcome. A number of literatures have reported controversial findings regarding the association between marriage before 18 years and adverse maternal and child health outcomes such as pregnancy termination, unintended pregnancy, underutilization of maternal health services, female sterilization, stillbirth/miscarriage, infant mortality, child mortality, malnutrition (Garcia-Hombrados, 2018; Seth et al., 2018; Kamal & Hassan, 2015; Godha, Hotchkiss & Gage, 2013; Raj et al., 2010). Hospital based studies have reported that teenage pregnancy itself is ‘causally’ associated with poor obstetric outcome such as perinatal death (Anandalakshmy & Buckshee 1993). Further, no significant adverse pregnancy outcome is observed among adolescent mothers where high-quality maternity care is available (Blomberg et al., 2014; Raatikainen et al., 2006). Numbers of literature has highlighted the importance of quality maternity care in reducing the adverse pregnancy outcomes Blomberg et al., 2014; Raatikainen et al., 2006; Sulaiman et al., 2013). Results did not any significant association between wealth status and pregnancy hood, motherhood and adverse pregnancy outcome. However, it’s documented that lower educational status and wealth index results in low nutrients intake that can cause adverse pregnancy outcome (Kramer et al., 2000).

It is important to discuss if the pregnancy among adolescent women was planned or unintended. Since, among disadvantaged groups, knowledge awareness and access to contraceptives often leads to have unplanned pregnancies. Thus, it is important to aim at improving adolescent education on sexual and reproductive rights and access to preferred contraceptive methods (Hubert et al., 2019). Higher the spousal age gap, more was the likelihood of experiencing motherhood and pregnancy. Consistent with our findings, Islam and colleagues found that higher spousal age gap was associated with higher adolescent motherhood among adolescents as well as adult women. Unequal power relation and low inter-spousal communication between spouses with higher age gap renders into lower participation in decision making process of use of contraceptives (Acharya & Sureender., 1996; Das et al., 2011). In the present study, women who experienced physical violence were at higher risk for having an adverse pregnancy outcome than those who did not experience physical violence. The unequal position of women in a relationship and a patriarchal society and the material dependency of women, lack of alternative opportunities and the socially acceptable norm of female subordination to feudalistic values makes women vulnerable to IPV (Jewkes R., 2002). Published findings suggest that violence during pregnancy causes physical trauma and stress which adversely affects the pregnancy outcomes (Newberger et al., 1993)

To summarize, our study highlights the high prevalence of adolescence pregnancy and adverse pregnancy outcome. Further, violence was found to be significant factor affecting the motherhood and pregnancy outcome. Thus, in order to reduce the maternal and neonatal adverse outcomes, it is important to understand the risk factors that affects the adverse pregnancy outcomes and maternal deaths. Thus, a close and careful monitoring of pregnancy, counseling regarding weight, dietary habits, will be beneficial.

The cause or consequence of an adolescent pregnancy could not be established. For example, it was not possible to estimate the time spent in union before getting pregnant. Additionally, we did not include the access to health services in our analysis which might impact the pregnancy outcome; this highlights the need for further study including the access to health services. Since, time is an important determinant in examining adolescent motherhood, further research would be more beneficial by taking “time” effect into account.

Author’s contribution: NS, PP and RPJ contributed in conceptualizing the study. MS, DD, KB, PP, NS and RPJ were responsible for the analysis. All authors contributed to the interpretation of the data, and critically revised all versions of the manuscript and approved the final version.

Funding

There was no funding from any source for this study.

Availability of data and materials

The information was gathered as part of the Population Council's UDAYA project, which is publicly accessible on the Harvard Dataverse website on request at https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/RRXQNT and https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/ZJPKW5.

Ethics approval and consent to participate

Each interviewee gave informed consent, and consent from a parent or guardian was required for unmarried teenagers aged 10–17. Names were never entered into the computer forms used to collect data. Signing the consent form was optional to protect the respondent's or parent's privacy; nevertheless, the interviewer had to sign a declaration confirming she or he had communicated the consent form's content to the respondent or parent. The Population Council's Institutional Review Board gave its approval to the project and its data collection. All methods were performed in accordance with the declaration of Helsinki. It also guaranteed that the participants' privacy was protected and that informed consent was obtained from respondents during the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflict of interest, financial or otherwise.

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The Burden of Adolescent Pregnancy, Motherhood and Adverse Pregnancy Outcome in Uttar Pradesh and Bihar

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