https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article Health Professional’s Knowledge and Attitude Regarding Adolescent Pregnancy Care in Primary Health Care Centers in Erbil City ABSTRACT INTRODUCTION Adolescence (meaning "to grow up") is a transitional phase of physical and psycho- logical human development that usually occurs for the duration of the time starting puberty to legal adulthood [1], a time of serious social, emotional, economic, and biological alteration [2].The World Health Organization (WHO) explained adolescence as the change from childhood to adulthood which may be referred to as ‘adolescence’ or ‘teenage’, which is a time between 10-19 years. This is the period when struc- tural, functional, and psychosocial devel- opments occur in an adolescent to organ- ize her for assuming the responsibility of motherhood [3]. Also, defines adolescent pregnancy as the pregnancy in which the mother is below the age of 20 at the time the pregnancy completes [4]. WHO stated that around 16 million adolescents aging between 15 and 19 years and approxi- mately one million adolescents younger Background and objectives: The World Health Organization defines adolescent pregnancy as pregnancy in which the mother is under the age of 20 at the time the pregnancy ends. About 16 million girls aging between 15 and 19 years give birth every year. The study aimed to assess the level of knowledge and attitude among nurses and physicians in Erbil Primary Health Care Centers regarding adolescent pregnancy care and comparing them. Methods: A quantitative; descriptive cross-sectional study was conducted in maternal and child health care units at twenty three Primary Health Care Centers in Erbil city, between November 15th , 2018 and November 15th , 2019. Non-probability, Convenience sam- pling technique was used for selecting sample which includes 95 from the total of 100 health professionals. Data was collected through interview (face to face) by using ques- tionnaire form which was designed by the investigator. Data were analyzed using the Chi square test, Fisher’s exact test. Results: Health professionals mean age + SD was 41.95 + 8.40 years, ranging from 27 to 62 years. The median was 42 years. Less than half (42.1%) of the sample were nurses, and the rest were physicians of different specialties. The highest percentage of the nurse’s knowledge and attitude were in medium level (42.5% and 47.5%, respectively). The high- est percentage of physician’s knowledge and attitude were in high level (58.3% and 65.5% respectively). There were significant difference between them regarding their knowledge (p = 0.32) and attitude (p = 0.006). Conclusions: Health professionals working in maternal and child health care units need improving their knowledge and attitude regarding adolescent pregnancy care. Nurses need more information and training sessions regarding that. Key words: Adolescent Pregnancy; Health Professional; Knowledge; Attitude. Srwa Abdulrahman Mustafa; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. )Correspondence: srwa.mustafa@hmu.edu.krd) Hamdia Ahmad Mirkhan; Department of Health Sciences, College of Health Sciences , Hawler Medical University,Erbil, Iraq. 91 Erbil Journal of Nursing & Midwifery Received: 20/11/2019 Accepted:22/12/2019 Published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article than 15 years present birth each year [5].The Central Bureau of Iraqi Statistics (2011) showed that 5% of Iraqi adolescents were married prior to the age of 15 years while about 22% of Iraqi adolescents were married before they turned 18. The prob- lem of adolescent childbearing in the Kur- distan region- Iraq is currently to be suffi- ciently researched and recognized in order to be successfully addressed through en- couragement and policy recommendations [6]. The majority were between 15 and 19 years. The Directorate of Health in Erbil/ Iraq registered approximately 770 per 25330 adolescent pregnancies in 2018 [7]. Adolescent pregnancy is allied with pro- gression of maternal and fetal complica- tions. Anemia, pre-eclampsia, eclampsia, preterm delivery, instrumental delivery, and increased Lower Segment Caesarian Section (LSCS) rate due to Cephalopelvic Disproportion (CPD) are strongly associated maternal complications in adolescent preg- nancy. Fetal complications being prema- turity, low birth weight, still birth, asphyxia, respiratory distress, birth trauma. Imma- ture pelvis in adolescents makes them prone to have CPD and end up in caesare- an delivery [8]. While the amount of ado- lescent pregnancies has already declined, there is still vast need for maintaining [9]. Physicians and nurses have responsibility for caring of a pregnant adolescent with distinctive characteristics of the adult preg- nant. They require to be aware of the phys- ical, emotional and social changes experi- enced by adolescents, the property that they have and what their ways of coping with these situations [10].The study aimed to assess the level of knowledge and atti- tude among physicians and nurses in Erbil primary health care centers regarding adolescent pregnancy care and comparing them. A quantitative, descriptive cross-sectional study was conducted between November 15, 2018 and November 15th, 2019. All eligible sample was involved which include 95 from total of 100 health professionals (55 physicians and 40 nurses) working in maternal and child health care units five of them drop out samples (one of them was take sick leave, two of them were take study leave and the rests were take mater- nity leave and they were excluded in the study) at twenty three primary health care centers in Erbil city. According to the study’s inclusion and exclusion criteria; all of those health professionals (nurses and physicians) that work in maternal and child health care departments at Primary Health Care Centers in Erbil city regardless of edu- cational level were included and those of health professionals that they were not available at the time of data collection were excluded. Data was collected through interview (face to face) by using question- naire format which was designed by the investigator through massive review of the literature and it was included three parts (first part an interviewing questionnaire which included socio-demographic charac- teristics of study sample. Second part was structured knowledge questionnaire con- sists of 33 questions related to knowledge regarding adolescent pregnancy care. There were three responses for items as following: I don’t know 0 score, no 1 score and yes 2 score. The maximum score on knowledge items was 66. The levels of knowledge were categorized as following: Low knowledge level ≤ 50%;Medium knowledge level = 51-75%;High knowledge level ≥ 75%. The third part was structured attitude questionnaire consists of 11 ques- tions related to attitude towards of health professionals regarding adolescent preg- nancy care. There were three responses for items as the following: disagree 92 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article for the following knowledge statements: Pregnant adolescents need advice by nutri- tionist, pregnant adolescents should have a nutritional assessment, pregnant adoles- cents should have vitamin and food, un- treated maternal depression in adolescent pregnant women is associated with ad- verse maternal, neonatal, and childhood outcomes, and taking information from pregnant adolescents about her location, family, financial, and her level education are very important. The other knowledge statements are presented in Table 2. score 1, neutral score 2 and agree score 3 from the item 1 to 9, for the items 10 and 11 responses were agree score 1, neutral score 2 and disagree score 3 . The different levels of attitude are categorized as: Low attitude level ≤ 50%;Medium attitude level = 51% - 75%;High attitude level ≥ 75%. [Sapkota, 2017] Ethical approval was ob- tained from ethical committee at the col- lege of nursing. Hawler Medical University (HMU) with serial number 73 at 23/6/2019. The informed oral consent was taken from the health professionals to participate in the study, after confirmation of confidenti- ality, anonymity and participants self- determination by the researcher. Formal permission was also obtained from Erbil Directorate of Health and Primary Health Care Centers (PHCC) in Erbil city. Data were analyzed by using the Statistical Package for Social Sciences (SPSS, version 22) through frequency, percentage, Chi square test of association was used to compare proportions, and Fisher’s exact test was used when the expected count of more than 20% of the cells of the table was less than five. A p value of ≤ 0.05 was consid- ered statistically significant. Ninety five health professionals (40 nurses and 55 physicians) had been included in the study. Their mean age + SD were 41.95 + 8.40 years, ranging from 27 to 62 years. The median was 42 years. Less than half (42.1%) of the sample were nurses, and the rest were physicians of different specialties like (obstetrician and gynecologist, family medicine, general practitioner, and nurses) those are working in (MCH). Regarding the educational level, more than one third (35.7%) of the sample were holding the Bachelor of Medicine, Bachelor of Surgery/ Chirurgery degree, and 28.4% were gradu- ates of the nursing institute. More than 90% of the studied samples answered ‘yes’ 93 Erbil Journal of Nursing & Midwifery RESULTS Table 1:Socio-demographic characteritics of the study sample Age No. (%) < 40 34 (35.8) 40-49 42 (44.2) ≥ 50 19 (20.0) Mean (+ SD) 41.96 (+ 8.40) Title Nurse 40 (42.1) Obstetrician/gynecologist 23 (24.2) General practitioner (GP) 13 (13.7) Family physician 11 (11.6) GP (gynecology) 8 (8.4) Years of experience in MCH 1- 4 25 (26.3) 5-9 24 (25.3) 10-14 22 (23.2) ≥ 15 24 (25.3) Educational level Bachelor of Medicine, Bache- lor of Surgery/Chirurgery degree 34 (35.7) Higher diploma 8 (8.4) Master 10 (10.5) Board 3 (3.2) Secondary nursing school 13 (13.7) Nursing institute 27 (28.4) Total 95 (100) https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 94 Erbil Journal of Nursing & Midwifery Table 2: Knowledge about adolescents’ pregnancy care I don’t know No Yes Questions related to knowledge No. (%) No. (%) No. (%) Adolescent pregnancy is a pregnancy in a women aged of 10-19 years. 11 (11.6) 12 (12.6) 72 (75.8) Adolescent mothers face higher risk of abortion 6 (6.3) 12 (12.6) 77 (81.1) Adolescent mothers face higher risk of still birth 13 (13.7) 23 (24.2) 59 (62.1) Adolescent mothers face higher risk of cesarean section 10 (10.5) 22 (23.2) 63 (66.3) Adolescent pregnancy has higher risk for gestational diabetes than adult pregnant women 11 (11.6) 57 (60.0)* 27 (28.4) Adolescent mothers face lower risks of eclampsia than women aged 20 to 24 years 10 (10.5) 37 (38.9)* 48 (50.5) Adolescent mothers face lower risks of puerperal endometritis than women aged 20 to 24 years 18 (18.9) 44 (46.3)* 33 (34.7) Adolescent mothers face lower risks of systemic infections than wom- en aged 20 to 24 years 12 (12.6) 52 (54.7)* 31 (32.6) Adolescent pregnancy has higher risk for placenta previa than adult pregnant women 21 (22.1) 38 (40.0)* 36 (37.9) Adolescent pregnancy has higher risk for abruption of placenta than adult pregnant women 21 (22.1) 30 (31.6)* 44 (46.3) Adolescent pregnancy has higher risk for oligohydraminos than adult pregnant women 19 (20.0) 34 (35.8) 42 (44.2) Adolescent pregnancy populations has higher risk of intrauterine growth restriction (IUGR) than adult pregnant populations 10 (10.5) 17 (17.9) 68 (71.6) In adolescent pregnancy Iodine deficiency can cause brain damage of the fetus 27 28.4) 18 (18.9) 50 (52.6) Adverse fetal outcomes of adolescent mothers is low birth weight 14 (14.7) 15 (15.8) 66 (69.5) Adverse fetal outcomes of adolescent mothers is preterm delivery 10 10.5) 18 (18.9) 67 (70.5) Adverse fetal outcomes of adolescent mothers is birth trauma and injury 21 (22.1) 20 (21.1) 54 (56.8) Complications during pregnancy and delivery are the leading causes of death for women aged 15 to 19 13 (26) 56 (13.7) 27.4 (58.9) Complications during pregnancy and delivery are the leading causes of death for adolescents than women in their 20s. 14 (14.7) 26 (27.4) 55 (57.9) Gentle prenatal exercise helps strengthen the body and increase stamina to prepare for labor and delivery 7 (7.4) 8 (8.4) 80 (84.2) Pregnant adolescents need advice by nutritionist on healthy eating during pregnancy 0 (0) 0 (0) 95 (100) Anemia (hemoglobin < 105 g/L) is a very common complication in pregnant adolescents 3 (3.2) 15 (15.8) 77 (81.1) Pregnant adolescents should have a nutritional assessment 0 (0) 3 (3.2) 92 (96.8) Pregnant adolescents should have vitamin and food 0 (0) 4 (4.2) 91 (95.8) Adolescent pregnancy visits to primary health care centers in the second or third trimester should be more frequently 2 (2.1) 12 (12.6) 81 (85.3) Psychological distress is associated with adolescent pregnancy 9 (9.5) 14 (14.7) 72 (75.8) Adolescent pregnancy are more likely to have mood disorders (depression) than adult pregnant women or non-pregnant adolescent 10 (10.5) 15 (15.8) 70 (73.7) Untreated maternal depression in adolescent pregnant women is associated with adverse maternal, neonatal, and childhood outcomes 4 (4.2) 5 (5.3) 86 (90.5) Untreated maternal depression in adolescent pregnant women is also associated with post partum depression 10 (10.5) 5 (5.3) 80 (84.2) The psychological needs of pregnant adolescent women can be great- er than of other women 3 (3.2) 9 (9.5) 83 (87.4) Adolescent pregnancies are more likely to experience violence within marriage 11 (11.6) 6 (6.3) 78 (82.1) The social needs of pregnant adolescent women can be greater than of other women 8 (8.4) 11 (11.6) 76 (80) Taking information from pregnant adolescents about her location, family, financial, and her level education are very important. 4 (4.2) 5 (5.3) 86 (90.5) Adolescent parents should be included as much as possible in adoles- cent pregnancy care prenatal/infant care 7 (7.4) 4 (4.2) 84 (88.4) *The correct response is ‘No’. For the other questions, the correct response is ‘Yes’. https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 95 Erbil Journal of Nursing & Midwifery It is evident in Table 3 that 91.6% of health care providers believe that the adolescent pregnant need special care, 83.2% believe that adolescent pregnancy is more pre- dominant (95%) in less educated popula- tions, 84.2% believe that adolescent preg- nancy is more predominant (95%) in socie- ties that accept and encourage childhood marriage. The other responses are presented in Ta- ble 3.Table 4: Shows that 58.2% of the physicians had high knowledge scores compared with 35.0% of the nurses (p = 0.032). Around two thirds (65.5%) of the physicians had high attitude scores which was significantly higher than the rate (32.5%) among nurses (p = 0.006). Table 3: Attitudes towards adolescents’ pregnancy Disagree Neutral Agree Attitudes No. (%) No. (%) No. (%) It is better that adolescent to postpone pregnancy. 6 (6.3) 16 (16.8) 73 (76.8) Adolescent pregnancy is more predominant (95%) in less educated populations. 5 (5.3) 11 (11.6) 79 (83.2) Adolescent pregnancy is more predominant (95%) with low to middle income populations. 7 (7.4) 21 (22.1) 67 (70.5) Adolescent pregnancy is more predominant (95%) in societies that accept and encourage childhood marriage 5 (5.3) 10 (10.5) 80 (84.2) Medical risks are associated with adolescent preg- nancy. 6 (6.3) 17 (17.9) 72 (75.8) Knowledge of adolescent pregnancy about sex increases with age. 8 (8.4) 14 (14.7) 73 (76.8) Parents should be responsible for teaching their children about sex. 14 (14.7) 12 (12.6) 69 (72.6) Adolescent pregnant need help for decision from her parents regarding the pregnancy. 21 (22.1) 16 (16.8) 58 (61.1) Adolescent pregnant need special care. 2 (2.1) 6 (6.3) 87 (91.6) Adolescent pregnancy is normal as in adult. 67 (70.5)* 16 (16.8)) 12 (12.6) Adolescents can adapt with pregnancy and con- tract with problems easily. 51 (53.7)* 23 (24.2) 21 (22.1) *Disagree is the correct response. For all the other statements, ‘agree’ is the correct response. Table 4: Knowledge and attitudes’ scores of physicians and nurses Nurses Physicians Total Knowledge score No. (%) No. (%) No. (%) P Low 9 (22.5) 4 (7.3) 13 (13.7) Medium 17 (42.5) 19 (34.5) 36 (37.9) High 14 (35) 32 (58.2) 46 (48.4) 0.032 Attitude score Low 8 (20) 5 (9.1) 13 (13.7) Medium 19 (47.5) 14 (25.5) 33 (34.7) High 13 (32.5) 36 (65.5) 49 (51.6) 0.006 Total 40 (100) 55 (100) 95 (100) *By Fisher’s exact test. https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 96 Erbil Journal of Nursing & Midwifery The present study explored knowledge and attitude of nurses and physicians re- garding adolescent pregnancy care. The study shows that the highest percentages of health professionals (physicians and nurses) have knowledge regarding adoles- cent pregnancy care. This result agree with a study reported by Tshitenge et al (2018) in Mahalapye, Botswana and mentioned that the majority (91.2%) of respondents have knowledge regarding adolescent pregnancy care [11].The overall attitude of health professionals (nurses and physi- cians) in current study revealed that 91.6% of them believed that the adolescent preg- nant need special care. It is similar to the findings of Agu et al., (2017) which re- vealed that general attitude of the mid- wives towards teenage pregnancy and motherhood were more positive (44.4%) [12].this study shows that 76.8% of health professionals believe it is better that ado- lescent to postpone their pregnancy. This is in consistent with study done by Carter et al, (2002) to find out birth control that 82.35 % of participants were agreed to the statement of both the men and women are responsible for using birth control [13]. It’s evident in the present study that 72.6% of health professionals believe that par- ents should be responsible for teaching their children about sex. This is in contrast to the results of the study by Carter et al, (2002) that 82.35 % of the respondents were strongly disagreed of these state- ments [13].Result of our study showed that 61.1 % of health professionals agreed with the statement of adolescent pregnant need help for decision from her parents regarding the pregnancy. It’s disagreed to finding of the study done by Carter et al, (2002) that 60 % of participants were strongly disagreed with this statement [13].The result of present study showed that most participants were agreed for statements of adolescent pregnancy is more predominant (95%) in less educat- ed populations, adolescent pregnancy is more predominant (95%) with low to middle income populations and adoles- cent pregnancy is more predominant (95%) in societies that accept and en- courage childhood marriage by (83.2 % , 70.5 %, and 84.2 %). This consistent to the results of study that done by Man- geli et al, (2017) on Iranian adolescent mothers to determine the challenges that facing them during the transition to motherhood; they reported in their study that one of the main challenges that adolescent mothers faced was in- effectiveness they were not able to take care from insufficient education of their family [14]. The other study was done by Papri 2016 reported that there were some factors that increase pregnancy among adolescents; teenage pregnancy is often occurs in a family with lower so- cioeconomic status, low educational attainment [15]. The result of our study revealed that 75.6 % of health profes- sionals were agreed to the statement on medical risks is associated with adoles- cent pregnancy. Is consistent with the results of the study that done by Azeve- do et al, (2015) they were studied sys- temic literature review to determine complications related to adolescent pregnancy in the finding of the study they were reported that the abortion, Hypertensive pregnancy disorders, lower urinary tract infections, premature rup- ture of membranes and placenta previa occurred more frequently in adolescent pregnancy [16]. According to profession- als’ attitudes toward the statement of adolescents can adapt with pregnancy and contract with problems easily; more than half 53.7 % of health professionals were disagreed with this statement. DISCUSSION https://doi.org/10.15218/ejnm.2020.11 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 97 Erbil Journal of Nursing & Midwifery This agreed to the finding of the study that done by Yahya, (2016); he pointed that most of the teenage mothers had less preparation to cope and adapt to the roles of parent. Their ability to cope with the stresses of teen parenthood and their lim- ited knowledge of appropriate child rear- ing skills affected their psychological well- being. This is because stress is assumed to place individuals at increased risk for de- pression, anxiety, and other emotional problems [17].The present study reveals that 58.2% of the physicians had high knowledge scores compared with 35.0% of the nurses (p = 0.032). This agreed to the finding of the study that done byMason- brink et al, (2019) reported that most re- spondents had insufficient knowledge re- garding adolescent’s reproductive health care (59%) [18]. This study is also con- sistent with the other study was done on adolescent mothers and health centers staff by Sychareun et al. (2018) they were reported that adolescent mothers report- ed in their study, low utilization of sexual and maternal health services was com- mon, and adolescent specific services were unavailable. This was also corrobo- rated by the healthcare workers, who re- ported low uptake off sexual and repro- ductive health services [19]. The present study also agreed with the other study that done by Hellerstedit et al. (2019) re- vealed that knowledge of nurses regarding adolescent pregnancy were 39 % [20].The current study shows that around two thirds (65.5%) of the physicians had high attitude scores which was significantly higher than the rate (32.5%) among nurses (p = 0.006). this agreed to the finding of study that done by Govender et al, (2018) exposed that nurses had poor attitude to- ward adolescent pregnancy care [21]. This also agreed with the study done by Sychareun et al., (2018) revealed that pro- viders themselves recognized that they were often uncertain of how to deal with pregnant adolescents and said they sometimes found them very frustrating to deal with [19]. The results of the study indicated that physician’s knowledge and attitude re- garding adolescent pregnancy care were more than nurse’s knowledge and atti- tude regarding adolescent pregnancy care. 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