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Year : 2014 Month : October Volume : 3 Issue : 57 Page : 12910-12926

ADOLESCENT PREGNANCY: TRENDS AND DETERMINANTS

Mamatha S1

1. Assistant Professor, Department of Obstetrics and Gynaecology, M. S. Ramaiah Medical College, Bangalore.

CORRESPONDING AUTHOR

Dr. Mamatha S,
Email : mamtas6@gmail.com

ABSTRACT

CORRESPONDING AUTHOR:
Dr. Mamatha S,
No. 1019, Triveni Road,
Mathikere Post,
Bangalore-560054.
Email: mamtas6@gmail.com

ABSTRACT: OBJECTIVE: To Study the trends and determinants of adolescent pregnancy. METHODOLOGY: A prospective study was conducted at S.A.H. & R.C., B.G. Nagara, between August 2007 to January 2009. Pregnant women up to the age of 19 years admitted to antenatal ward were taken for the study and the pregnancy outcome assessed. RESULTS: Majority of the study population were of the age of 19 years, 1% were unmarried. Mean age at marriage was 14 years. Majority of the study population came from rural areas 98% and belonged to middle socio-economic status 76%. 94% of the cases were primigravida. Antenatal complications such as Anemia 43%, Preeclampsia / Eclampsia 7%, Mal presentations 5% were seen. Incidence of abortion and preterm labour were about 5% & 12.5% respectively. Incidence of cesarean section was about 23%, CPD being the commonest indication 52%. 23% of the babies were low birth weight and maternal mortality was 0%, PNMR was 4.17%. CONCLUSION: Pregnant teenagers are at greater risk, requiring additional efforts and resources to serve and protect their own health. The obstetric outcome in teenagers is influenced many socio economic and medical factors. They need more attention for prevention and treatment of Anemia, Pre-eclampsia, Eclampsia, Preterm labour, IUGR & Low birth weight babies.

KEYWORDS: Adolescence, Outcome, preterm labour, Complications.

 

INTRODUCTION: Pregnancy occurring in adolescent age group i.e., between 13-19 years is a subject of interest and concern, as they are incomplete in their growth and development both physically and psychologically.

India is the second most populous country in the world with total population of over 1081 million. Adolescents (10-19 years) form a large section of population of about 22%, that is, about 225 million. Teenage pregnancy varies from 10-15% of total pregnancies in India. In India the birth rate per 1000 females (15–19 years) is 107. In rural areas the adolescent birth rate is 121/1000 while in Delhi it is 36/1000 (NFSH-2, 1998-99).

Factors such as early onset of puberty, early marriage, socio cultural reasons, illiteracy, early onset of sexual activity, lack of awareness and access to contraception, ignorance and poverty etc., contribute to adolescent pregnancy. Pregnancy among unmarried is traumatic for the adolescent and it is also a social problem. These young girls face considerable health risks due to higher maternal and perinatal mortality. Such problems are more relevant in rural areas.

OBJECTIVES:

  • To study various trends and determinants of adolescent pregnancy.

 

MATERIALS AND METHODS: A prospective study on adolescent pregnancy, its various aspects including maternal and foetal outcome was carried out at Sri Adichunchangiri Hospital and Research Center, B. G. Nagara, Mandya, Karnataka from August 2007 to January 2009.

All Pregnant young women aged 13 to19 years admitted to ante natal wards, labour wards, SAH & RC were taken for the study. Pregnant women aged > 19 years were excluded from the study. Relevant data was collected using a proforma which included all variables affecting teenage pregnancy.

 

OBSERVATION AND RESULTS:

INCIDENCE: 120 cases were studied during the study period. Adolescent pregnancy rate is 10 %, i.e. about 100 per 1000 pregnancies.

Age

Years

Number

N=120

Percentage

13

-

-

14

-

-

15

-

-

16

-

-

17

-

-

18

26

22

19

94

78

TABLE 1: AGE DISTRIBUTION

 

Majority of study population were 19 years –78%.

 

Marital status

Number N=120

Percentage %

Married

119

99.17

Unmarried

1

0.83

TABLE 2: MARITAL STATUS

 

99% of study population was married.

 

Age

Years

 

Number

N=120

Percentage

13

0

0

14

0

0

15

1

0.83

16

12

10

17

32

26.67

18

43

35.83

19

31

25.83

TABLE 3: AGE AT MARRIAGE OF FEMALES

 

Mean age at marriage is 17.6 years. 71% of study population was married by 18 years of age. 45 adolescents (37 %) were of age less than 18 yrs, married but not conceived.

 

Age (yrs)

Number (119)

Percentage

<21

70

58.33

21 -23

46

38.33

>24

3

2.50

TABLE 4: HUSBAND'S AGE AT MARRIAGE

 

 

58% of husband population is married before the age of 21.

 

Age (yrs)

Number

N=120

Percentage

%

11

0

0

12

12

10

13

23

19.17

14

65

54.17

15

13

10.83

16

4

3.33

TABLE 5: AGE AT MENARCHE

 

Mean age at Menarche is -14- years.

 

Interval years

Number (120)

Percentage

≤1

3

2.50

2

8

6.67

3

22

18.33

4

40

33.33

≥ 5

40

33.33

TABLE 6: INTERVAL BETWEEN MENARCHE AND MARRIAGE

60% of teenagers were married ≤4 years of menarche. Low gynecological Age(<2years of menarche) was seen in 6% of the population.

 

Consanguinity

Number

N=120

Percentage

Consanguineous

First degree

Second degree

Third degree

29

3

6

20

24.17

10.34

20.69

68.97

Non-consanguineous

90

75

TABLE 7: CONSANGUINITY

 

Majority were Non -Consanguineous marriage among teenagers 75%, while Consanguineous marriages were about 24%.

 

Education

Number

N=120

Percentage

Illiterate

3

2.50

Primary school

25

20.83

High school

80

66.67

P U C

6

5.0

Degree

2

1.67

TABLE 8: EDUCATIONAL STATUS OF FEMALES

 

1/8 of the study population was illiterate, while 66% of the teenagers had high school education.

 

Education

Number

N=120

Percentage

Illiterate

2

1.67

Primary school

20

16.67

High school

70

58.33

P U C

27

22.50

Degree

1

0.83

TABLE 9: HUSBAND'S EDUCATIONAL STATUS

 

1 % of husband population was illiterate; about 58 % had high school education.

 

 

Area

Number

N=120

Percentage

Urban

2

1.67

Rural

118

98.33

TABLE 10: AREA OF STUDY

 

Majority of the study population came from rural areas.

Based on modified B. G. PRASAD Social classification, using per capita monthly income study group was classified as.

 

Socio-economic

status

Number

N=120

Percentage

Upper high

2

1.67

Higher

6

5.00

Upper middle

50

41.67

Lower middle

42

35.00

Poor

16

13.33

Very poor/BPL

4

3.33

TABLE 11: SOCIO-ECONOMIC STATUS

 

76% of the study population belongs to middle socioeconomic status (Upper and Lower).

 

Gravida

Number

N=120

Percentage

Primi

113

94.17

II

15

12.50

III

2

1.67

TABLE 12: GRAVIDITY

 

 

Ist booking

Number

N=120

Percentage

I trimester

70

58.33

II trimester

46

38.33

unbooked

4

3.33

TABLE 13: ANTENATAL CARE

 

94% of adolescents were primi gravida.

58% of the study population came in I trimester for ante natal check-up, 38 % in II Trimester and only 4 cases were unbooked.

 

No. of AN Visits

Number

N=120

Percentage

≤3

36

30

≥4

80

66.67

TABLE 14: NUMBER OF ANTENATAL VISITS

 

 

Nearly 66 % of the study population had adequate Antenatal visits, while 30 % had </= 3 ANC Visits.

 

Height (cm)

Number

N=120

Percentage

< 145

5

4.17

<155

55

45.83

>156

60

50

TABLE 15: HEIGHT (cm)

 

About 4% of the study population was of short stature

 

Weight (kg)

Number

N=120

Percentage

<40

0

0

41-50

30

25

51-60

60

50

>60

30

25

TABLE 16: WEIGHT (kg) NOTED AT TIME OF ADMISSION TO LABOUR ROOM

 

 

Only 25% of the stud population was under weight.

 

BODY MASS INDEX (kg/m2)

NUMBER N=120

PERCENTAGE

<18

5

4.17

18-25

90

75

>25-30

20

16.67

>30

5

4.17

TABLE 17: BODY MASS INDEX (kg/m2)

 

Only 4 % had compromised BMI, while majority (75%) of the study population had BMI between 18-25 and 4% were obese.

 

Total Weight gain

during pregnancy (kg)

Number

N=120

Percentage

<5

4

3.33

5-10

110

91.67

>10

6

5

Table 18

 

Majority of the study population had adequate weight gain.

 

Hemoglobin

(g/dl)

Number

N=120

Percentage

<6

2

1.67

6.1-8.0

9

7.50

8.1 – 10.0

41

34.17

10.1 -11.0

46

38.33

>11

24

20

TABLE 19: HEMOGLOBIN (g/dl)

 

43.3 % of the study population had Hb <10 g%, severe anaemia was seen in 8 % of the study population mainly of dimorphic and microcytic, hypochromic type of anaemia.

 

NUMBER OF

ANTENATAL SCANS

NUMBER

N=120

PERCENTAGE

NO

6

5

1

60

50

2

25

20.33

3

15

12.50

>3

5

4.17

TABLE 20: NUMBER OF ANTENATAL SCANS

 

50 % of the study population had at least one ante natal scan done.52 of the study population i, e. 43% had anomaly scan done.

 

Number of congenital anomaly that were detected by scan were-2:

1. Anencephaly-at 16 wks gestation.

2. Non- Immune Hydrops Fetalis with Cystic hygroma –at 20 wks.

 

 

Complications

Number

N=114

Percentage

Anaemia (<10g Hb) %)

52

45.61

Pre eclampsia/eclampsia

9

7.89

Mal presentations

6

5.26

Fetal growth restriction

12

10.53

Prolonged Pregnancy

8

7.02

Oligohydramnios

2

1.75

Twins (DADC)

 

2

 

1.75

 

A. P. H (abruption)

1

0.88

IUD

4

3.51

TABLE 21: ANTENATAL COMPLICATIONS

 

Anaemia was the most common complication 43 % followed by fetal growth restriction 10% while preeclampsia / eclampsia was only 7.5%. 3% had fetal demise.

 

 

Pre Eclampsia

 / Eclampsia

Number

N=120

Percentage

Mild PE

7

5.83

Severe PE

2

1.67

Eclampsia

0

0

TABLE 22: PRE ECLAMPSIA / ECLAMPSIA

 

7.5% of the study population was found to be having preeclampsia, no eclampsia case seen.

 

 

Mal – Presentations­

Number N=120

Percentage

Breech

6

5

Shoulder

0

0

Face

0

0

TABLE 23: MALPRESENTATIONS

 

5% of the study population had breech presentation.

 

 

Onset of

Labour

Number

N=120

Percentage

Abortion

EARLY

MID

6

2

4

5

33.33

66.66

A)     Preterm

15

12.50

Term

89

74.17

TABLE 24: ONSET OF LABOUR

 

74% of the study population had term delivery while pre-term delivery was noted in 12.5% and abortion was seen in 5 %.

 

Abortion

Number

N=6

Percentage

Spontaneous

2

33.33

MTP

3

50

Missed abortion

1

16.67

TABLE 25: TYPES OF ABORTION STUDIED AMONG TEENAGERS

 

 

3 cases (50%) of the study population under- went MTP.

 

Method

Number

Dilatation & Evacuation

4

Prostaglandin E1

2

TABLE 26: METHOD OF TERMINATION

 

Duration

hrs

Number

N=120

Percentage

< 6 hrs

80

66.67

7-9 hrs

20

16.67

10-12 hrs

10

8.30

> 12 hrs

6

5

TABLE 27: DURATION OF LABOUR

 

 

82 % of the study population delivered within 10 hrs of labour, 15 cases (12.5%) of them was multi gravid.

 

Mode of Delivery

Number of Cases

N=120

Percentage

Vaginal delivery

78

65

Assisted breech delivery

2

1.67

Out let Forceps

0

0

Vacuum

4

3.33

Cesarean

30

25

VBAC

0

0

TABLE 28: MODE OF DELIVERY

 

65% of the study population had normal vaginal delivery, while 25% needed caesarean delivery.

ONSET OF LABOUR

NUMBER

N=114

PERCENTAGE

SPONTANEOUS

60

52.63

INDUCED

1.PG E 2 (GEL)

2.PG E 1 (TABLET)

3.OXYTOCIN

20

4

8

8

17.54

20

40

40

TABLE 29: ONSET OF LABOUR

 

Majority (52%) had spontaneous onset of labour, 20 cases were induced of which 14 cases had vaginal delivery and 6 were taken for cesarean delivery.

 

 

Indications

Number 30

Percentage

CPD

13

52

Fetal distress

10

33.33

APH

1

3.33

Malpresentations

(Breech)

4

13.33

Previous LSCS

2

6.67

TABLE 30: INDICATIONS FOR CESAREAN SECTION

 

The main indication for cesarean section was cephalopelvic disproportion as noted in 52 % of cases, followed by fetal distress.

 

INTRAPARTUM PERIOD

Number of Cases

N=114

Percentage

PARTOGRAPH

114

100

PAIN RELIEF (Inj. Tramadol)

90

78.95

ACCELERATION(Inj. oxytocin)

100

87.72

CERVICAL DILATATION (Inj. Drotaverin)

60

52.63

III STAGE PROPHYLAXIS

114

100

BIRTH ATTENDED BY PEDIATRICIAN

114

100

TABLE 31: INTRAPARTUM PERIOD

 

Majority were provided with pain relief, 52% were given Inj drotaverin to promote cervical dilatation, Acceleration of labour was done using oxytocin in 87%, Management of labour was done using partogram in all the cases and III stage prophylaxis was given to all the cases. All deliveries were attended by Neonatologist.

 

Complications

Number

N=120

Percentage

Meconium stained liquor

10

8.33

PPH

Atonic

Traumatic

2

1

1

1.67

0.83

0.83

TABLE 32: COMPLICATIONS DURING LABOUR

 

Meconium stained liquor was seen in 10 cases (8%) and 2 cases of Post-Partum Hemorrhage were noticed in study population.

 

BLOOD TRANSFUSION

WHOLE BLOOD

NUMBER

N=120

PERCENTAGE

%

INTRAPARTUM

1

0.83

INCOMPLETE ABORTION

1

0.83

POSTPARTUM

4

3.33

TABLE 33: BLOOD TRANSFUSION /COMPONENT

 

5% of the cases required blood transfusion, 1 case was transfused intra partum, 1 case following incomplete abortion and 4 cases were transfused post-partum. Of the 6 cases, 5 were referred from outside in active labour. Whole blood was transfused due to lack of component availability at our institute.

 

APGAR

SCORE

Number

N=114

Percentage

1 MIN

<7

>7

21

93

18.42

81.58

5 MIN

<9

>9

21

93

18.42

81.58

TABLE 34: APGAR TABLE

 

21(18 %) Neonates had asphyxia i.e APGAR SCORE 1 MIN less than 7 and 5 MIN score less than 9.All of them were resuscitated and observed in NICU.

 

Birth Weight (kg)

Number N=114

Percentage

1.5-2

5

4.39

2.1-2.5

22

19.30

2.6-3

50

43.86

3.1-3.5

29

25.44

> 3.5

8

5.26

TABLE 35: BIRTH WEIGHT OF INFANTS (kg)

 

23% of the babies were of low birth weight.

 

Complications

Number

N=114

Percentage

Normal weight (>2.5 kg)

87

76.32

Low Birth weight (<2.5 kg)

27

23.68

Pre-term

15

13.16

FGR

12

10.53

IUD

3

2.63

Still birth

1

0.88

Perinatal morbidity

42

36.84

Congenital anomalies

1

0.88

Perinatal mortality

4

4.17

TABLE 36: FETAL / NEONATAL OUTCOME

 

About 23% of the neonates born to teenagers were low birth weight and majority of them were due to preterm birth, 1 stillborn and 3 case of IUDs were seen, PNMR being 4.17%.

 

NEONATAL MORBIDITY

NUMBER

N=114

PERCENTAGE

Birth asphyxia

21

18.42

Neonatal Resuscitation

21

18.42

NICU CARE

46

40.35

B)     Neonatal hyper bilirubinemia

6

5.60

Respiratory distress syndrome

10

8.77

Meconium Stained Amniotic Fluid

10

8.77

Meconium aspiration syndrome

2

1.75

Sepsis

2

1.75

Congenital anomaly

1

0.88

Neonatal death

0

0

Perinatal Mortality

4

4.17

TABLE 37: NEONATAL MORBIDITY AND MORTALITY

 

18 % of the neonates were asphyxiated requiring NNR, 40% required NICU care, of which 20 were observed for 1 day and given mothers side, 5% of the neonates had physiological hyperbilirubinemia.8% had RDS.8 % of the cases had MSAF of which 1% diagnosed with MAS, 2 babies required ventilator support and recovered, 1 case of B/L CTEV was observed. PNMR being 4.17 per 1000 live births.

 

BREAST FEEDING

NUMBER

N=114

PERCENTAGE

KNOWLEDGE PRESENT

40

35.09

PROMOTED

114

100

SUCCESSFUL

100

87.72

TABLE 38: BREAST FEEDING PRACTICE

 

Knowledge about breast feeding was present in 35 % of adolescents, all young mothers were encouraged to breast feed their neonates and 87 % were successful.

 

Knowledge

Number

N=120

Percentage

Present

80

66.67

Not Present

40

33.33

TABLE 39: KNOWLEDGE ABOUT CONTRACEPTION

 

66% of study population has awareness about contraception.

 

Method

Number

N=120

Percentage

Oral Contraception

20

16.67

Copper T

36

30

TABLE 40: CONTRACEPTION ADOPTED

 

Out of 80 patients who had knowledge about contraception only 50 had adopted contraception method.

 

POST NATAL FOLLOW UP

Number N=114

Percentage

MOTHER

 

 

Regular Follow up

80

70.18

Pelvic exam

75

65.79

Episiotomy wound gaping

10

8.77

Sepsis

4

3.5

Contraception adopted

56

46.67

NEONATE

 

 

Breast feeding

90

78.95

Immunization of baby

114

100

TABLE 41: POST NATAL FOLLOW UP

 

70 % of the study population came for regular follow up, 78 % of them practicing breast feeding, complications like episiotomy wound gaping was seen in 8%, sepsis was seen in 3%, immunization of the neonates was 100 %.contraception was adopted by 46% of the study population.

DISCUSSION: Total number of deliveries during the study period in our hospital was 1200 of which 120 deliveries belonged adolescent group. Adolescent pregnancy rate is 10 %, i.e. about 100 per 1000 pregnancies. The incidence is similar as seen in study by Mahavarkar et al (2008).

In this study no patient was 17 years or less and about 22% belonged to 18 years and a greater percentage of about 78% belong to 19 years of age. These results are showing a declining trend in the extremely young teenage group (< 15 years) to become pregnant. This is mainly due to improved education.

99% of our study population was married compared to A K Sharma et al (2003)2 The proportion of the unmarried pregnant girls is differing from population to population depending not only on the age but also in education, socioeconomic status, etc.

The mean age of marriage among girls in India is around 17.4 years A. K. Sharma (2003)2 and in Nepal about 16 years, in our study it is 17.6 years.

In our study, the mean age of menarche is around14 years. About 84% of the population attains menarche within 14 years.

The interval between menarche and marriage in our study is that 60% of the adolescent got married within 4 years of menarche.

In our study 24% of the teenagers had consanguineous marriage 68% of it was third degree consanguinity. Consanguineous marriage is one important contributor of early marriage, adding to complications by relatively increasing the risk of congenital malformation of the baby to be born.

In our study 58% of the men are married before the age of 21.

About 2.5% of the study populations were illiterate, but the female literacy 93% is less than the male literacy 96% in the present study

In the present study, majority of the population 76% belong to middle socioeconomic class (Upper and Lower) and 16 % belong to low socio economic status as compared to 10% patients in study conducted by Kavita N. Singh et al (2001)1. Majority of the young women were housewives.

In our study 98% of the population belonged to rural areas. A study by Kavita N Singh et al. (2001) 1 showed that 65.3% of population was from urban areas and 44.7% from rural areas.

Primi gravida constitutes 94% in the present study, 12% were gravida II and 1% were gravida III.

58% of the study population was booked in 1 st trimester. All the women in our study were immunized but 4 of them were unbooked. Results are comparable with study results by Ashok kumar et al.

Authors

Study Group

Kavita N. Singh et al., (2001)1

9%

Ashok kumar (2007)2

9.6%

Present Study

7%

 

Incidence of pre eclampsia was 7% in present study

 

Authors

Percentage

Ashok kumar (2007)2<11g

62.9 %

Present Study<11g

80%

Mild <10 g

43%

Moderate<8g

9.17%

Severe<6g

1%

 

The present study shows increased incidence of anemia compared to A. K. Sharma et al., (2003)3 and the reasons for this increased frequency is related to socio-economic status and greater requirements due to raised nutritional demand during pregnancy, pre-existing anaemia and or nutritional deficiencies.

 

Authors

Study Group

A. K. Sharma et al., (2003)3

0%

Ashok kumar (2007)2

26.1%

Present Study

12.5%

 

The incidence of preterm labour is 12.5% when compared to Kavita N. Singh (2001)1-7.14%.

1 Case was HBsAg Positive, had term spontaneous vaginal delivery, neonate was immunized. No HIV positive cases were noted.

Of 6 abortions, 2 were spontaneous abortions, 1 missed abortion and 3 were MTP s among them 1was 1st Trimester MTP in un married adolescent and other two were terminated in II Trimester for congenital anomaly.

82% of teenagers delivered within 10 hrs and 5% had prolonged labour greater than 12 hrs. Of the remaining 12 % cases, 8 % had vaginal delivery and 4 % were taken for cesarean delivery.

The incidence of caesarean section in present study was 25 %. The main indications being cephalopelvic disproportion 52%, fetal distress about 33%. Other common indications for caesarean sections were mal presentations, previous LSCS, antepartum haemorrhage. The results are comparable with that of study by Ashok kumar(2007).2

65% of study population had spontaneous vaginal delivery; about 2% had assisted breech delivery. Other assisted vaginal deliveries like vacuum 5% is high in our study compared to a study by Kavita N. Singh (2001).

Complications during labour were not significantly raised except for 1 case of atonic PPH another of traumatic PPH.

In the present study preterm birth rate was of 12% which is comparable to a study by Kavitha et al (2001)1.

The incidence of Low Birth Weight babies was 23 %, comparatively lower than A.K.Sharma et al., (2003) -57.1%

The incidence of birth asphyxia and respiratory distress syndrome was higher compared to the study by Ashok kumar et al.

Only 35 % of the study population had knowledge about breast feeding, all of them were encouraged and demonstrated to feed the baby, 87 % were successful in establishing breast feeding

The contraceptive awareness among our study population is present in 66 %. About 49% of them adopted contraceptive methods. Among the methods adopted, IUCD insertion was the commonest method being practiced 30%.

8% had episiotomy wound gaping, while 3% of the study population had puerperal sepsis, 10 % had partial failure of lactation, Gestational Hypertension was seen in 1% of the cases, Blood transfusion was required in 6 cases, no case of secondary hemorrhage or Post-operative infection was seen. There was no maternal mortality in our study.

CONCLUSION:

TRENDS OF ADOLESCENT PREGNANCY: Our study mainly involved adolescents Low and Middle socio economic status from rural areas with early age of marriage, early child bearing, societal influences, peer pressure, lack of knowledge on contraceptive measures and its accessibility, risk taking behavior –were some of the trends in adolescent pregnancy in our study.

DETERMINANTS OF ADOLESCENT PREGNANCY: Declining Age at Menarche, Low Gynecologic Age and Low Reproductive Age, Improved Basic education, Improved Socio cultural factors, Pregnancy within marriage, Improved access to Health care facilities, Heightened awareness among youth about prevalence of STD s and preventive measures, Improved pre-pregnancy weight with balanced diet and nutrition support, Timely approach to medical facilities during any complications in pregnancy.             Availability of investigations and trained personnel for supervision and conduct delivery, Presence of Neonatologist for timely interventions at time of complications, Encouragement and counseling during postpartum regarding breast feeding, immunization, bonding with baby –all these factors determined a satisfactory maternal and perinatal outcome among pregnant adolescents in our study.

BIBLIOGRAPHY:

1.    Singh K N. Outcome in adolescent pregnancy;; Journal of Obstetrics and Gynaecology of India 2001; 51(6): 34 - 36.
2.    Kumar A, Singh T, Basu S, Pandey S- outcome of teenage pregnancy Indian Journal Of Pediatrics- Oct 2007;74.
3.    Sharma A K, Chhabra P, Gupta P & Lyngdoh T. -pregnancy in adolescents, a community based study, Indian J. Prev. Soc. Med . 2003; 34 (1 & 22): p24-26.
4.    Sharma A.K, Varma K, Khatri S. and Kannan A. T. Pregnancy in adolescents. A study of risks and outcome in Eastern Nepal. Journal of Indian Paediatrics 2001; 38:1405 - 1409.

 

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