Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 3 - Jul/Sep - 2018

Original Article Imprimir 

Páginas 60 a 68


Pregnancy in adolescents: analysis of the macro region south/southwest of Minas Gerais, Brazil

Embarazo en adolescentes: análisis de la macro región sur/suroeste de Minas Gerais, Brasil

Gravidez em adolescentes: análise da macrorregião do sul/sudoeste de Minas Gerais, Brasil

Autores: Michelly Esteves Ribeiro1; Sandra Cristina Pillon2; Clícia Valim Côrtes Gradim3

1. Master in Nursing by the Post-Graduation Program in Nursing at the Federal University of Alfenas (UNIFAL/MG). Primary Health Care Nurse. Graduation in Nursing by UNIFAL/MG. Alfenas, MG, Brazil
2. Doctorate in Health Sciences in the Program of Psychiatry and Medical Psychology by the Federal University of São Paulo (UNIFESP). Full Professor of the School of Nursing of Ribeirão Preto - University of São Paulo (EERP/USP). Ribeirão Preto, SP, Brasil
3. Post-Doctorate by the Department of Psychiatric Nursing and Human Sciences, University of São Paulo, Brazil. Doctorate in Health Sciences by the School of Nursing of Ribeirão Preto - University of São Paulo (EERP/USP). Professor of Undergraduate and Post Graduation in the School of Nursing of the Federal University of Alfenas (UNIFAL/ MG). Alfenas, MG, Brazil

Michelly Esteves Ribeiro
Universidade Federal de Alfenas
Rua Afonso Arinos, 430
Alfenas/MG, Brasil. CEP: 37175-000
(michellyer@hotmail.com)

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Keywords: Adolescent, pregnancy in adolescence, pregnancy, parturition.
Palabra Clave: Adolescente, embarazo en la adolescencia, embarazo, parto.
Descritores: Adolescente, gravidez na adolescência, gravidez, parto.

Abstract:
OBJECTIVE: This study aimed to evaluate the characteristics related to gestation and type of delivery in adolescents.
METHODS: This is a cross-sectional study with a sample of 11617 adolescents from the southwest macroregion of Minas Gerais, comprising 154 municipalities evaluated between 2000 and 2013 through the DATASUS Live Births System. The following variables were evaluated: demographic data, obstetric data (duration of gestation, number of prenatal consultations, type of delivery and gestation) and neonatal (birth weight, Apgar at 1 and 5 minutes after birth and abnormalities).
RESULTS: Among the analyzed adolescents the prevalence age was between 17-19 years (62.9%) and 48.1% had low schooling. The adolescents performed seven or more prenatal consultations (62.2%); gestation was between 37 and 41 (88.4%), non-twin pregnancies (99.2%), with no anomalies (84.5) and predominance of vaginal delivery (51%). It was verified that had secondary education (OR = 1.7) and superior (OR = 1.9), did not perform prenatal consultations (OR = 2.0) and the presence of some type of malformation (OR = 2.1), influenced almost two timesthe odds ratio of having children by cesarean section.
CONCLUSION: The data point to the importance of increasing educational strategies during prenatal consultations by providing guidance to adolescents regarding the type of delivery and gestation, considering the high vulnerability of gestational and perinatal diseases; with humanized actions aimed at valuing vaginal delivery.

Resumen:
OBJETIVO: El estudio tuvo como objetivo evaluar las características relacionadas a la gestación y tipo de parto en adolescentes.
MÉTODOS: Se trata de un estudio del tipo transversal, con muestra de 11617 adolescentes de la macro región sur / suroeste de Minas Gerais que comprende 154 municipios evaluados entre 2000 a 2013 por medio del Sistema de Declaraciones de Nacidos Vivos del DATASUS. Se evaluaron las siguientes variables: datos sociodemográficos, obstétricos (duración de la gestación, número de consultas de prenatal, tipo de parto y gestación) y neonatales (peso al nacer, Apgar en el primer y quinto minuto después del nacimiento y anomalías).
RESULTADOS: Entre los adolescentes analizados se verificó predominancia de edad entre 17-19 años (62,9%) y 48,1% tenía baja escolaridad. Las adolescentes realizaron siete o más consultas de prenatal (62,2%); la gestación fue entre 37 y 41 (88,4%), el embarazo no gemelar (99,2%), sin anomalías (84,5) y predominio de parto vaginal (51%). Se verificó que tener Enseñanza Media (OR = 1,7) y, Superior (OR = 1,9), no realizar consultas de prenatal (OR = 2,0) y la presencia de algún tipo de malformación (OR = 2,0) OR = 2,1), influenció en casi dos veces la razón de probabilidad de tener hijos por cesárea.
CONCLUSIÓN: Los datos apuntan a la importancia de incrementar estrategias educativas durante las consultas de prenatal promoviendo orientaciones a las adolescentes en relación al tipo de parto y gestación, considerando la alta vulnerabilidad de los agravantes gestacionales y perinatales; con acciones humanizadas dirigidas a la valorización del parto vaginal.

Resumo:
OBJETIVO: O estudo teve como objetivo avaliar as características relacionadas à gestação e tipo de parto em adolescentes.
MÉTODOS: Trata-se de um estudo do tipo transversal, com amostra de 11617 adolescentes da macrorregião sul/sudoeste de Minas Gerais que compreende 154 municípios avaliados entre 2000 a 2013 por meio do Sistema de Declarações de Nascidos Vivos do DATASUS. Foram avaliadas as seguintes variáveis: dados sociodemográficos, obstétricos (duração da gestação, número de consultas de pré-natal, tipo de parto e gestação) e neonatais (peso ao nascer, Apgar no 1º e 5º minuto após o nascimento e anomalias).
RESULTADOS: Entre os adolescentes analisados verificou-se predominância de idade entre 17-19 anos (62,9%) e 48,1% tinha baixa escolaridade. As adolescentes realizaram sete ou mais consultas de pré-natal (62,2%); gestação foi entre 37 e 41(88,4%), gravidez não gemelar (99,2%), sem anomalias (84,5) e predominância de parto vaginal (51%). Verificou-se que ter Ensino Médio (OR = 1,7) e, Superior (OR = 1,9), não realizar consultas de pré-natal (OR = 2,0) e a presença de algum tipo de má-formação (OR = 2,1), influenciou em quase duas vezesna razão de chance de ter filhos por cesariana.
CONCLUSÃO: Os dados apontam para a importância de incrementar estratégias educativas durante as consultas de pré-natal promovendo orientações às adolescentes em relação ao tipo de parto e gestação, considerando a alta vulnerabilidade dos agravos gestacionais e perinatais; com ações humanizadas voltadas a valorização do parto vaginal.

INTRODUCTION

The World Health Organization (WHO)1 considers adolescence as a stage in the life cycle that covers the age group between 10 and 19 years, which, however, for the Statute of Children and Adolescents (ECA)2, includes 12 to 18 years old This period is characterized by a phase of transition between childhood and adulthood, marked by physical, psychosocial and in the form of social relationship of the individual3.

The occurrence of pregnancy in this period is a phenomenon of global repercussion, whose meaning differs in different cultures and contexts, representing a challenge for public policies, since pregnancy at the extremes of reproductive life can have psychosocial, economic and social implications that compromise maternal and newborn health4.

Since the 1970s, there has been a gradual reduction in the general and specific fertility rate in all ages of women in Brazil, from 5.8 to 1.8 children per woman in 2010. These rates may vary according to regional differences and level of schooling, there is still a relationship between lower level of schooling and higher fertility rate5.

The Southeast of Brazil, the most populated region of the country, concentrates the highest occurrence of pregnancy in adolescence, with about 40% of births, predominantly in the state of São Paulo6. In the State of Minas Gerais, 0.6% of live births in 2010 were children of mothers between 10 and 14 years old and 16.2% in the range of 15 to 19 years of age5. In 2013, the indices remained stable between the ages of 10 and 14, with a decrease in the age group between 15 and 19 years old, with 15.7% of births6. In this way, it is perceived that in the Southeast region, pregnancy rates in adolescence were equated to those of the rest of Brazil (17.7%)6.

In this context, it is essential that health managers know the indices of their region and use them to plan their birth control actions among adolescents, as well as actions for the distribution of income, labor market and development of the municipality. In the present study, this study aims to evaluate sociodemographic, obstetric and neonatal characteristics related to the type of delivery in adolescents of a microregion of southwest Minas Gerais.


MATERIALS AND METHODS

It is a descriptive, comparative, analytical and transversal study, based on secondary data. The sociodemographic, obstetric and neonatal information of the adolescents was obtained from official government documents, referring to a microregion composed of 154 municipalities of Southeast of Brazil, in the period from 2000 to 2013. The data were collected from the register of the Declarations of Live Births (DNV) of the Live Birth Information System (SINASC) of the Informatics Department of the Unified Health System (DATASUS).

For the eligibility criteria, the records of pregnant women between 10 to 19 years of age, primiparous and having their children by any type of childbirth in the years 2000 to 2013 were selected. Adolescents older than 19 years and who were not primiparous were excluded from the analysis.

In the records of the DNV there were 30545 (100%) cadastres of primiparous pregnant women in the period analyzed, involving all age ranges and types of delivery. From this total, 11617 (38%) cadastres of pregnant women who met the inclusion criteria were selected, which make up the present sample. In the present sample, the adolescents were classified according to the age group, being (a) pre-pubertal or adolescent precocious with ages between 10 to 16 years and (b) as a pubertal or late adolescent between 17 to 19 years7. The data were organized according to the information obtained in the DNV records, such as sociodemographic characteristics (age, marital status, and schooling), obstetrics (duration of pregnancy, number of prenatal visits, type of delivery and gestation) and neonatal birth weight, Apgar score in the first and fifth minute after birth and malformation).

For the analysis of the material, a database was developed in the Statistical Program of Social Science (SPSS) version 17 for Windows8. The exploratory analysis was carried out by means of averages, frequency and percentage of the data. The dependent variable (binary) was the type of delivery (vaginal or cesarean) and the predictive covariates were age, marital status, schooling, duration of pregnancy, number of prenatal visits, presence of malformation, as well as differences between the Weight and Apgar index means in the first and fifth minute after birth and type of delivery. The logistic regression analysis (Odds Ratio - OR) was also used, which allowed estimating the magnitude of the association of each characteristic independently. In this stage, variables with p <0.05 were considered significant values.

The research was approved by the Committee of Ethics in Research of the Federal University of Alfenas (UNIFAL-MG) on No. 1092303/15 and the Free and Informed Consent Term dispensed for being a database analysis.


RESULTS

Of the 11617 records of adolescents who had children between 2000 and 2013, 51.7% were by vaginal delivery and 44.2% by cesarean section (Table 1). The adolescents were characterized predominantly by being single, primiparous, with ages between 10 to 19 years old, possessing Middle School and self-declared of the white race. A predominance of cesarean delivery was observed in adolescents in the age group between 17 and 19 years (67.2%) and who had middle school (57.5%) and were single, while vaginal delivery occurred between adolescents between 10 to (37.1%), single (57.4%) and white (80.9%), with statistically significant differences (p <0.05).




Regarding the neonatal and obstetric information of the adolescents, the analysis showed that the gestational duration of the adolescents was between 37 to 41 weeks, that they performed seven or more consultations in the prenatal period, and they had a single gestation of newborns without anomalies (Table 2). In addition, differences were observed in the characteristics of adolescents with cesarean delivery, with a predominance of 37 to 41 weeks of gestation, who performed more than seven prenatal consultations and no anomalies in the newborn. While the adolescents who performed vaginal delivery, the difference stood out only in the non-twin newborn.




In the logistic regression analysis, it was verified that the significant predictive variables for the non-occurrence of vaginal delivery in adolescents were schooling (p = 0.000), race (p = 0.015), the presence of malformation (p = 0.001 the number of consultations in the prenatal period (p = 0.000), the type of pregnancy (p = 0.000) and the weeks of gestation (p = 0.000).

In this way, it was noted that having Medium Teaching (OR = 1.7) and Superior (OR = 1.9), not performing prenatal consultations (OR = 2.0), having some type of bad training (OR = 2). , 0) OR = 2.1), and having children by caesarean section increased almost twice in relation to vaginal delivery.

In adolescents of brown race (OR = 0.222 or 72.8%) who performed less than seven prenatal consultations (OR = 0.845 or 15.5%), without multiple pregnancy (OR = 0.157 or 84.3%), who were between 23 a27 (OR = 0.345 or 65.5%) and 37 to 41 (OR 0.417 or 52.9%) weeks of gestation, the chances of vaginal delivery declined in relation to having children by operative delivery.

When comparing the medians (Independent T-test) of the variables such as maternal age, Apgar of one and five minutes and weight of the newborn, it was verified that the average age of the adolescents who performed cesarean delivery was higher (Average M In the case of adolescents who had vaginal delivery (M = 17.6, Dp = 1.7), with statistically significant differences (95% CI [-0.286 - - = 17.1, Standard deviationDp = 1.7) 0,170], t = -7,737, p> 0.0001).

Regarding the mean of the APGAR index of one minute after birth, there was no difference between the means of those born by vaginal delivery (M = 8.27, Dp = 1.45) and by cesarean section (M = 8.29). , Dp = 1.285), without statistically significant differences (95% CI [-0.065 - -0.029] t =, 758, p = 0.449). However, the mean APGAR index of five minutes after birth by cesarean delivery (M = 9.48, Dp = 0.890), was higher in comparison with that of newborns (RN) who were born by vaginal delivery (M = 9). , 44, Dp = 1.064), with statistically significant differences (95% CI [-, 073- -0.005] t = -2.276, p = 0.023).

Regarding weight, the mean was higher among the NB who were born by caesarean section (M = 3.144, Dp = 505 g), when compared to those who were born by vaginal delivery (M = 3.004, Dp = 526 g), with statistically differences significant (95% CI [-147.6 - -112.5] t = 14.529, p = 0.000).


DISCUSSION

Considering the population of the sample in relation to the existing total, it is observed that 38% of deliveries were of adolescents with ages between 10 to 19 years. The sociodemographic conditions were observed, that in addition to age, there is a predominance of single women, levels of schooling compatible with age and satisfactory prenatal care, but this doesn´t prevent the vulnerability of adolescents, since the number of girls with less than 16 years that were already a mother was 35%.

It is interesting to note that 32.8% of adolescents between 10 and 16 years old and 67.2% with ages between 17 and 19 years of age performed cesarean delivery (Table 1). In Brazil there are estimates of the growing number of this type of birth, which has been a great challenge to be faced by the area of maternal and child health. The proportion of caesarean sections increased from 38% in 2000 to 52% in 201010,11. However, it must be considered that non-clinical factors also strongly influence the decision-making process on the type of delivery. In comparison, evidence points to a decreasing trend in adolescent pregnancy rates in developed countries4.

Literature is still scarce regarding adolescent pregnancy and mainly in relation to the types of childbirth and gestation. Studies conducted in the 1980s and 1990s showed results suggesting an increased risk of surgical delivery in this group, especially at younger ages, possibly attributed to aspects related to gynecological immaturity and anatomical problems related to mechanism of delivery,, would determine the greater occurrence of cephalopelvic disproportion4,9. However, in the present sample vaginal delivery was predominant (51.7%) (Table 1).

In the sample, 48.4% underwent cesarean section, which is an index well above those established by WHO1. The goal of this body proposes that between 10 and 15% of deliveries be operative, by means of medical indication and considering the morbidity of that age group1.

A study carried out in Campinas reports that vaginal delivery was higher (63.8%) than cesarean sections in adolescents under 20 years of age, where its frequency was higher than in adult women (45%) 2-4. In this way, it is evident that fewer cesarean deliveries are performed in the adolescent group, as has also been demonstrated in other studies12,13.

The incentive policy for the reduction of surgical deliveries of the Unified Health System seeks to minimize and optimize the recovery of mothers, in addition to lowering the birth rate of low-birth NB12,14. However, in the present study, the average weight of the NBs among the adolescents was 3,004 kg, with minimum rates of low weight.

There is evidence about the maternal and infant risks of morbidity derived from caesarean section compared with those of normal delivery. Even when the cesarean section is elective, this risk is substantially greater when compared with that of normal delivery10.

Adolescent pregnancy is a common phenomenon throughout the world and has been widely associated with low schooling, lack of peer support, late onset of prenatal care, low birth weight and prematurity15. However, in this study, low weight, prematurity and low schooling were not identified (Table 2).

Another study conducted in Minas Gerais showed a significant association between pregnancy in adolescence and low socioeconomic indicators in municipalities with a small population and a high percentage of families benefited by government social programs15. However, the region under study has a high Human Development Index (HDI), which may be a factor that explains the data found16.

In the present study it was verified that the shorter the study time, the greater the possibilities of performing the vaginal delivery and as school years accumulate, the prevailing delivery is cesarean. According to the statistical analysis, the adolescents with fundamental education had a higher number of vaginal births (48.1%) in relation to those with secondary and higher education (54.8% and 4.8%), respectively (Table one).

The literature shows a strong correlation between the low level of education and the tendency to maternity in adolescence, the recidivism of pregnancy and the association with social vulnerability, as well as being an exhibition factor for unplanned pregnancy17. However, it is observed that the schooling index of the studied population was of eight years or more, being that 50.9% had secondary education. As a consequence, the relationship between education and early pregnancy contributes to the maintenance of precarious living conditions and poverty, since pregnant adolescents tend to drop out of school. Motherhood in adolescence is often perceived as an alternative for personal and family success, generating the idea that there is no need for studies, which makes it difficult to return to school17,18.

In the present study, 76.5% of the adolescents who performed seven or more prenatal visits had surgical delivery (Table 2), number of consultations this corroborates that recommended by the Ministry of Health and the results of other studies19, twenty. However, the number of consultations performed by pregnant women is controversial, since, in other studies, four to six consultations were described13,14. It must be borne in mind that the reduced number of consultations may be related to the concealment of pregnancy, or because of disinterest and / or lack of information about its importance, both for the mother and for the fetus.

The findings of this study corroborate those of other studies regarding the association of caesarean section with better life conditions in adolescent primiparas, such as adequate level of education, health plan possession, lower obstetric risk, higher income and realization of more prenatal consultations10,13.

A study conducted in a municipality of São Paulo identified the profile of adolescents attended in public and private maternity hospitals. It was verified that the users of the public system carried out a smaller number of prenatal consultations, had less schooling, greater primiparity and normal delivery was more frequent. However, in the private sector, the number of prenatal care, schooling, primiparity and cesarean section was higher10. However, the SINASC doesn´t allow separating the type of service used by the users, since it might be important to have in the database.

Regarding the type of delivery, the benefits of prenatal care in this study lead us to question the quality of the care provided, since the largest number of consultations exposed the adolescent to the highest probability of having a cesarean section as a means of Birth. Perhaps the women who have more consultations with medical professionals have been advised about cesarean delivery, it is the best option, according to the vision of that professional, especially when the delivery is assisted by him7.

Regarding the duration of pregnancy, it is perceived that normal birth occurs the more prematurely the pregnancy and, as the gestation progresses, the greater the possibilities of cesarean occurrence. Based on the study data, 90.6% of full-term pregnancies in adolescents occurred by caesarean section, similar to other studies13. Regarding the type of pregnancy, the pregnancy of the only type in adolescents occurred by normal delivery in 99.6% of the cases analyzed, and when it was of the multiple type it occurred via cesarean section (1.9%).

In relation to congenital anomalies, both in the presence and in the absence of anomalies, they used the cesarean section for delivery, with 1.1% and 86.3%, respectively. A large number of subnotifications and ignored data of this variable were noted in the SINASC bank. The professionals responsible for filling out the DNV card must be trained to fill it, because through it you can see genetic and regional anomalies that can contribute to future studies.

The mean APGAR index of one minute after birth was stable when compared with the type of vaginal delivery (8.27) and caesarean (8.29), in the same way the rate of five minutes after the birth of the normal child-birth 9.44) and surgery (9.48), similar data compared with other studies20.

Regarding the mean weight of newborns at birth, in the study there were no significant differences between those who were born vaginal or cesarean birth, which were 3.004 Kg and 3.144 Kg, respectively. However, studies relate adolescent pregnancy with low birth weight newborns, mainly in the age group of 10 to 16 years, with precarious prenatal care, a fact not found in this study4,14,20.


CONCLUSION

We must consider that the SINASC is an instrument that offers data for health professionals and experts to evaluate modify, propose strategies to better serve the population and provide subsidies for the formulation of strategies for promotion, prevention, intervention and public policies to prepare adolescent programs in relation to sexual and reproductive health.

The study allowed us to know the data of the macroregion where it was verified that the adolescents who had their children in that region are predominantly single, they received prenatal assistance with seven or more consultations and self declared white; the weight of the newborns was adequate, as well as the APGAR of one and five minutes. It was also observed that vaginal delivery was predominant in girls up to 16 years of age with a lower level of schooling, and that the increase in age and race interfered in the type of delivery. The use of national data bases, such as SINASC, allows us to know the profile of this phenomenon, considering the multiplicity of factors that may interfere in the process of gestational evolution and delivery, as well as the health of the pregnant woman and the neonatal result, which they can provide subsidies for the formulation of prevention and intervention strategies and public policies in relation to sexual and reproductive health.

However, even with a normal delivery rate of 51.6%, the cesarean rate is still considered high, but the pregnancy rate in this macroregion has been decreasing over the years and has an emphasis on the late adolescent.


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