https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article The Consequence of Teenage Pregnancy on the Primigravida Health Outcome Delivers at Sulaymaniyah Maternity Teaching Hospital-Kurdistan Region-Iraq. ABSTRACT INTRODUCTION Teenage pregnancy is a terminology to define a teenage girl, usually within the ages of 13-19, becoming pregnant [1]. Globally, there are 16 million births a year to young married and unmarried women aged 15-19 years, representing 11% of all births worldwide [2]. Around 95% of these births arise in developing countries, as 49% of girls in these countries get married before the age of 18. First pregnancy at an early age is considered high risk for both the mother and infant [3]. Around the world, the rate of childbearing adoles- cent women shifts broadly, depending on cultural, religious, political, economic and other factors [4].Teenage pregnancy is present in all societies; however, the level of teenage pregnancy Background and Objectives: Teenage first pregnancy is a significant public health problem as it often occurs in the context of poor social support and maternal wellbeing. It is consid- ered high risk for both the mother and infant. This study aimed to find out the effect of teenage pregnancy on neonatal health outcomes. Methods: A descriptive, cross-sectional, prospective study was conducted in Sulaymaniyah in the Kurdistan Region of Iraq and involved all pregnant teenage mothers admitted to Sulaymaniyah Maternity Teaching Hospital from January 1, 2019, to June 30, 2019. Results: 332 of mothers aged ≤19 years and their newborns were studied. A higher pro- portion of teenage mothers were from rural areas than the urban areas (59.3% vs 40.7%). The percentage of teenage mothers who did not attend antenatal care was 11.14%, and irregular attendees represented 9.94 %. Compared with teenage mothers aged 14–16 years, teenage mothers aged 17–19 years had higher risks of anaemia, systemic infections, coincidental condition, low birth weight, preterm delivery and low Apgar score. The risk of aspiration of meconium and stillbirth among infants born to teenage mothers was statisti- cally not significant after adjustment for gestational age and birth weight, in addition to maternal characteristics and mode of delivery. Teenage pregnancy was associated with higher risks of adverse pregnancy outcomes. Conclusion: Prevention strategies and the improvement of healthcare are essential to re- duce the consequences of teenage pregnancy on maternal and neonatal health outcomes. Teenage women were less likely to receive antenatal care services. Use of community- and health facility-based education programs are necessary to prevent teenage pregnancy and thus reduce adverse maternal and neonatal outcomes. Keywords: Primigravida, Outcomes, Pregnancy, Teenage, Health, Consequences Kochar Ezat Abdulla; Department of Nursing, College of Nursing, University of Sulaimani, Sulaimani, Iraq. )Correspondence: kocheezat@gmail.com) Pary Muhammad Azize; Department of Nursing, Sulaimani Technical Institute Sulaimani Polytechnic University Sulaimani, Iraq. 143 Received: 18/03/2020 Accepted:27/07/2020 Published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article and childbearing varies from country to country [5]. In particular, unstable biologi- cal and social environments have an impact on the tendency, prevalence and the re- sults of teenage pregnancies. Additionally, the existing trends of teenage marriage in different parts of the globe also contribute to the problem persisting at various levels. Therefore, adverse pregnancy outcomes are significantly higher in teenagers than in adults. Babies of teen mothers are more likely to be premature and experience in- fant mortality [6]. The infants of teenage mothers often endure more risks to health and social wellbeing than do children of older mothers [7]. Among the young wom- en aged 15-19, the negative consequences of pregnancy and childbirth are the leading cause of death in developing countries. It is estimated that 90,000 adolescent mothers are not physically ready for parenthood [8]. Study of maternal and perinatal outcomes in teenagers by Dutta and Joshi (2013) in West Bengal, India, concluded that the rate of low birth weight (LBW) in teenage preg- nancy was relatively high in the teenage mothers (29.2%) compared to the adult mothers (16.6%) [9]. Also, birth asphyxia was found in 29.2% of the newborns of teenage mothers and 7.3% of the new- borns of the adult mothers [10]. These ad- verse outcomes may be the result of the high rate of preterm delivery in the teen- age group. Some researchers found that good quality prenatal and natal care re- duce adverse pregnancy outcomes in teen- agers [2].The fact established in many stud- ies about the negative consequences of teenage pregnancies is that it is still chal- lenging to know how much the biological factors related to age contribute to the physical outcomes such as birth weight, prematurity and other perinatal complica- tions [11]. Therefore, this study was con- ducted to describe the consequences of teenage pregnancy on maternal and the first newborn health outcomes at Sulaymaniyah Maternity Teaching Hospital in Sulaymaniyah, Kurdistan Region of Iraq. The descriptive, cross-sectional, prospec- tive study was conducted. The question- naire was given to each teenage mother after her verbal consent. The questionnaire was included in the postpartum patient file to be completed after the delivery. Teen- agers were asked to complete the 23 ques- tions and place the questionnaire in a sealed envelope provided by the research- er. The study was conducted in the Mater- nity Teaching Hospital in Sulaymaniyah in the Kurdistan Region of Iraq from January 1 to June 30, 2019.A purposive non- probability sample of 332 teenage mothers who delivered in the Sulaymaniyah Mater- nity Teaching Hospital and agreed to par- ticipate in the study was recruited to the study. During the study period, 6243 deliv- eries were registered and conducted at the Sulaymaniyah Maternity Teaching Hospi- tal. Among this group, 332 out of 6243 were teenagers. Among the 332-teenager mothers, 273 had a normal vaginal deliv- ery, and 59 had a caesarian section (Sulaymaniyah Maternity Hospital Statisti- cal Department, 2019).The study was con- ducted after obtaining agreement from the Sulimaniyah University and the Sulaymani- yah Maternity Hospital in Sulymaniyah. The questionnaire included 23 questions approved by the Human Subjects Com- mittee of the University of Sulaymaniyah. The study questionnaire consisted of three parts, as follows: Part one: maternal socio-demographic information (such as age, education level, occupation, residency, nationality, socio- economic status, Body Mass Index (BMI), Antenatal Care (ANC) visit, medical condi- tion and mode of delivery). 144 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article Data were collected through direct struc- tured interview of teenage pregnant women using questionnaire form, which was designed for the study purpose. The researchers clearly explained the purpose of the study to all pregnant women, and their verbal consent was obtained before filling the questionnaire. For mothers, the interview took approximately 15 minutes, but for some neonates, it took longer be- cause of checking neonatal outcomes or rechecking the condition. Pregnant moth- ers aged 19 years and less and pregnant for the first time were included in the study. Teenage mothers with the second or third pregnancies were excluded. The University approved the study for the Ad- vanced Nursing Research and Training by Sulaymaniyah Maternity Hospital. All infor- mation collected during the study will re- main strictly confidential. No identifying information (i.e. name, address and tele- phone number) was requested so that the participants would not be recognized. Par- ticipation was voluntary, and an informed consent document was included with the questionnaire. Informed consent was ob- tained from the study participants before the data collection. The collected infor- mation during the period of the research was stored with the utmost confidentiality. All statistical computation was enhanced using the Statistical Package for Social Sci- ences (SPSS 21). The data were coded, tab- ulated, and presented in a descriptive form. The statistical procedure that was applied to determine the results of the present study included: alpha-Cronbach for testing the reliability of the question- naire, descriptive statistical data analysis (maternal demography, neonate demogra- phy and neonate outcomes) and Chi-square, a simple regression model for inferential data analysis. Part two: neonatal demography and medi- cal history including seven items such as gender, gestational age (weeks), birth weight (grams), APGAR score, fetal dis- tress, aspiration meconium and shoulder dystocia). Part three: neonatal outcomes, consisting of six items such as small for ges- tational age (SGA), large for gestational age (LGA), medical condition, type of deformi- ty, neonate death and neonatal diagnosis. Also, it included information about BMI measurement, height and weight. BMI Grading as per WHO [12]: Underweight <18.5 Normal 18.5-24.99 Overweight 25-30 Obese >30 Newborn Birth Weight [13]: Extremely Low Birth Weight (ELBW) <1000 Very Low Birth Weight (VLBW) 1000-1500 Low Birth Weight (LBW) 1500-2500 Normal Weight 2500-4500 Over Weight >4500 APGAR score interpretation [14]: 0-3 Severely depressed 4-6 moderately depressed 7-10 Normal The Council of the College of Nursing ac- cepted the research protocol, and the ethi- cal committee approved the study of the College of Medicine University of Sulay- maniyah on February 7, 2019. Accordingly, an official letter from the College of Nurs- ing of the University of Sulaymaniyah was sent to the Sulaymaniyah Maternity Hospi- tal city to request facilitation and coopera- tion during data collection of this study. 145 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article score, 57.8% had a normal APGAR score, 25% were moderately depressed, and only 3.3% were severely depressed. Further- more, 22.6% of the newborns had fetal distress, and 14.8% were stillborn with me- conium aspiration. 1.5% of babies devel- oped shoulder dystocia. Table 4 demon- strates that 14.8% of newborns were still- born, 17.8% was small for gestational age (SGA), and 2.7% were large for gestational age (LGA), The majority of the newborns were healthy (75%), while 9% of the baby had intrauterine growth retardation (IUGR), and 1.2% of them had congenital anomalies. Most of the babies (56.9%) had no deformity, while 22% had a physiologi- cal type of the deformity and 0.6% had a neurological deformity. Among the study participants, 17.2% (57/332) of neonates died (stillbirth and intrauterine death IUD), out of which 85.96% (49/57) of the new- borns had a stillbirth, and 14.04 % (8/57) was IUD. In terms of the clinical diagnosis, 54.5% of the newborn were healthy, follow by neonatal respiratory distress (28.9%) and 3.3% of newborns suffered from res- piratory distress + asphyxia. The lowest percentage among all neonatal diagnoses types was death because of respiratory distress + sepsis (0.6%).Ho: There is not a relationship between teenage mothers’ age and newborns’ gestational timeH1: There is a relationship between teenage mothers’ age and newborns’ gestational time Ho: There is not the effect of the teenage mothers’ age on the newborns’ gestational timeH1: There is the effect of the teenage mothers’ age on the new- borns’ gestational time According to the model summary of regression analysis in Table 5, there is a significant positive sta- tistical correlation between teenage moth- ers’ age and gestational age, which is 0.709 and that the P-value = < 0.001. This indi- cates acceptance of the alternative hy- pothesis, a positive correlation between 146 Erbil Journal of Nursing & Midwifery Table 1 demonstrates that alpha-Cronbach was used to get the result of the reliability of the questionnaire. As a result, the value of alpha-Cronbach equaled to 0.895, and the validity was 0.801. The result of alpha- Cronbach and validity shows the high relia- bility of the questionnaire. Table 2 shows that out of 332 teenager mothers, 15.1 % were 14-16 years old, and 84.9% were 17-19 years old. The majority of mothers had a secondary level of edu- cation. Most of the participants(83.4%) were unemployed, and 59.3% were from rural areas. The majority of participants were Kurdish (65.1%), 61.7% were within the overweight BMI range, and 23.5% were obese. Most of the participants (78.92%) regularly visited ANC throughout pregnancy, while 9.94 visited the ANC ir- regularly, and only 11.14% of participants did not attend the ANC. Some of the par- ticipants (26.5%) were healthy, and 24.4% of participants had an infectious disease during pregnancy. 79.2% of participants had a normal vaginal delivery, while 18.1% had a cesarean section. Table 3 demon- strates that the majority of the newborns were male (53.6), more than half of the newborn were full-term in gestation age (59.9%), followed by extremely preterm (13.9%), and 11.1% were moderately and late preterm. However, only 6.6% of new- borns were very preterm. Most of the newborns (63.6%) had normal birth weight, while 12% of newborns had low birth weight and only 3% of them were overweight. Regarding APGAR RESULTS Table 1:Reliability and Validity Methods Result Alpha-Cronbach 0.895 Validity 0.801 https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 147 Erbil Journal of Nursing & Midwifery the extent of teenage mothers’ age and gestational age. On the other hand, R Square for this study is 0.5026. This indi- cates that 50.26% of the variance of gesta- tional age has been explored in teenage mothers ’age. In other words, this illustrates that only 50.26% of factors affect gestational age in teenage mothers’ age. Moreover, there was statistical sig- nificance by using the ANOVA table (F- test). This means that the method is possi- ble to be used to analyze this data. Variables Frequency (Percent) Age at first birth/years 14-16 50 (15.1) 17-19 282 (84.9) Education level Illiterate 14 (4.2) Primary school 77 (23.2) Secondary school 195 (58.7) Undergraduate 46 (13.9) Occupation Employed 3 (0.9) Unemployed 277 (83.4) Student 52 (15.7) Residency Rural 197 (59.3) Urban 135 (40.7) Nationality Kurd 216 (65.1) Arab 90 (27.1) Other 26 (7.8) Mother BMI Normal Weight 49 (14.8) Over Weight 205 (61.7) Obese 78 (23.5) Antenatal care visit (ANC) Not attendant 37 (11.14) Regular 262 (78.92) Irregular 33 (9.94) Medical condition Anaemia 42 (12.7) Infectious disease 81 (24.4) Coincidental condition 16 (4.8) Other condition 52 (15.7) Anaemia + Infectious disease 32 (9.6) Anemia + Infectious disease+ Coincidental condition 3 (0.9) Anemia+ Other condition 5 (1.5) Infectious disease + Other condition 13 (3.9) Normal 88 (26.5) Mode of delivery Vaginal delivery 263 (79.2) Instrument vaginal delivery 9 (2.7) Cesarean section 60 (18.1) Total 332 (100) Table 2: Teenage mothers’ socio-demographic and clinical data https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 148 Erbil Journal of Nursing & Midwifery Table 3: Newborns’ socio-demographic and clinical data Variables Frequency (Percent) Gender Male 178 (53.6) Female 154 (46.4) Gestational age /week Less than 28 Extremely premature 46 (13.9) 28 to 32 Very preterm 22 (6.6) 32 to 37 Moderate to late preterm 37 (11.1) 37 to 40 Full-term 199 (59.9) <42 weeks Post mature 28 (8.4) Birth weight (Grams) Extremely Low Birth Weight (ELBW) 56 (16.9) Very Low Birth Weight (VLBW) 15 (4.5) Low Birth Weight (LBW) 40 (12) Normal Weight 211 (63.6) Over Weight 10 (3) APGAR score Not recorded 46 (13.9) Severely depressed 11 (3.3) Moderately depressed 83 (25) Normal 192 (57.8) Fetal distress Yes 75 (22.6) No 208 (62.7) Stillbirth 49 (14.8) Aspiration of meconium Yes 27 (8.1) No 256 (77.1) Stillbirth 49 (14.8) Shoulder dystocia Yes 5 (1.5) No 278 (83.7) Stillbirth 49 (14.8) Total 332 (100) https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 149 Erbil Journal of Nursing & Midwifery Table 4: Neonatal outcomes Variables Frequency (Percent) SGA Yes 59 (17.8) No 224 (67.5) Stillbirth 49 (14.8) LGA Yes 9 (2.7) No 274 (82.5) Stillbirth 49 (14.8) Medical condition Normal 249 (75) IUGR 30 (9) Stillbirth 49 (14.8) Congenital anomalies 4 (1.2) Types of Deformity Physical 2 (0.6) Physiological 73 (22) Neurological deformity 2 (0.6) Physical+ Physiological 6 (1.8) Physiological+ Neurological deform- ity 14 (4.2) Physical + Neurological deformity 46 (13.9) Normal 189 (56.9) Neonate death Yes 57 (17.2) No 275 (82.8) Type of Neonate death (Yes ) Stillbirth 49 (85.96) IUD 8 (14.04) Neonatal Diagnoses Normal 181 (54.5) Respiratory distress 96 (28.9) Asphyxia 33 (10) Other 9 (2.7) Respiratory distress + Sepsis 2 (0.6) Respiratory distress + Asphyxia 11 (3.3) Total 332 (100) Table 5: Regression analysis of a dependent variable (gestational age) Effect of teenage mothers’ on the newborn’s gestational age Model Coefficients Model Summary ANOVA Table Unstandardized Coefficients t- value P- value R P-value R2 Adjust R2 F-value P-value B Std. Error Constant 50.76 4.745 10.697 < 0.001 0.709 < 0.001 0.5026 0.507 322.57 < 0.001 Teenage pregnancy 4.737 0.264 17.96 < 0.001 https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 150 Erbil Journal of Nursing & Midwifery Table 6 represents the association be- tween 14-16 years old and 17-19 years old related to birth weight characteristics. There was a highly statistically significant association between groups of 14-16 years old and 17-19 years old mothers and birth weight (p-value= < 0.001) because the re- sult of p-value was less than the common alpha 0.05. Most, (89.57%, 189/211) of the normal birth weight newborns was recorded in a 17-19 years old group, and only 10.43%, 22/211) of the newborns were from 14-16 years old teenage moth- ers group. Ho: There is not a relationship between teenage mothers’ age and new- born's birth weightH1: There is a relation- ship between teenage mothers’ age and newborn’s birth weight Ho: There is not the effect of the teenage mothers’ age on the newborn's birth weight H1: There is the effect of the teenage mothers’ age on the newborn’s birth weight According to the model summary Table 7 of regression analysis above, there is a significant posi- tive statistical correlation between teen- age mothers’ age and newborns’ birth weight, which is 0.732 and that the P- value is = < 0.001. This indicates ac- ceptance of the alternative hypothesis, a positive correlation between the extent of teenage mothers’ age and neonatal birth weight. On the other hand, R Square for this study is 0.534. This indicates that 53.4% of the variance of birth weight has been ex- plored in teenage mothers’ age. In other words, this illustrates that only 53.4% of factors affect birth weight and teenage mothers’ age. Moreover, there was statis- tical significance by using the ANOVA ta- ble (F-test). This means that the method is possible to be used to analyze this data. Table 8 shows the association between teenage mothers’ age (14-16 years old) and (17-19 years old) and the newborn‘s health outcomes. The result of the study shows that there were highly significant associations between both groups of the teenage mothers’ age and Apgar score at p= <0.001, fetal distress p= <0.001, aspira- tion of meconium p= <0.001, shoulder dystocia p= <0.001, SGA p= <0.001, LGA p= <0.001, medical condition p= <0.00, and a significant association of neonatal diagnoses at p=0.046 because the P-value was less than the common alpha 0.05. However, there was no statistically signifi- cant association between the maternal age and neonatal death (P = 0.56), which was more than the common alpha 0.05. Table 6: Association between teenage mothers’ age and newborns’ birth weight Variables Items 14-16 years old 17-19 years old Total Significance test N % N % Birth weight (ELBW) 18 32.14 38 67.86 56 χ2 =20.907 p= < 0.001 (VLBW) 0 0 15 100 15 (LBW) 7 17.5 33 82.5 40 Normal Weight 22 10.43 189 89.57 211 Over Weight 3 30 7 70 10 https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 151 Erbil Journal of Nursing & Midwifery Table 7: Regression analysis of a dependent variable (birth weight) Effect of teenage mothers’ age on the newborn’s birth weight Model Coefficients Model Summary ANOVA Table Unstandardized Coefficients t-value P-value R P-value R2 Adjust R2 F-value P-value B Std. Error Constant 9528.91 68159 13.98 < 0.001 0.732 < 0.001 0.534 00.513 338.66 < 0.001 Teenage pregnancy 702.346 38.165 18.403 < 0.001 Table 8: Association between teenage mothers’ age and newborns’ health outcomes Variables Items 14-16years old 17-19 years old Total Significance test N (%) N (%) Apgar score Not recorded 17 (37.0) 29 (63) 46 χ2 =21.928 p= < 0.001 Severely depressed 2 (18.2) 9 (81.8) 11 Moderately depressed 6 (7.2) 77 (92.8) 83 Normal 25 (13) 167 (87) 192 Fetal distress Yes 5 (6.7) 70 (93.3) 75 χ2 =22.829 p= < 0.001 No 27 (13) 181 (87) 208 Stillbirth 18 (36.7) 31 (63.3) 49 Aspiration of meconium Yes 1 (3.7) 26 (96.3) 27 χ2 =22.46 p= < 0.001 No 31 (12.1) 225 (87.9) 256 Stillbirth 18 (36.7) 31 (63.3) 49 Shoulder dystocia Yes 1 (20) 4 (80) 5 χ2 =21.411 p= < 0.001 No 31 (11.2) 247 (88.8) 278 Stillbirth 18 (36.7) 31 (63.3) 49 SGA Yes 6 (10.2) 53 (89.8) 59 χ2 =21.186 No 26 (11.6) 198 (88.4) 224 Stillbirth 18 (36.7) 31 (63.3) 49 LGA Yes 2 (22.2) 7 (77.8) 9 χ2 =21.976 No 30 (10.9) 244 (89.1) 274 Stillbirth 18 (36.7) 31 (63.3) 49 Medical condition Normal 27 (10.8) 222 (89.2) 249 χ2 =21.835 p= < 0.001 IUGR 4 (13.3) 26 (86.7) 30 Stillbirth 18 (36.7) 31 (63.3) 49 Congenital anomalies 1 (25) 3 (75) 4 Types of Deformity Physical 0 (0) 2 (100) 2 χ2 =26.159 p= < 0.001 Physiological 5 (6.8) 68 (93.2) 73 Neurological deformity 1 (50) 1 (50) 2 Physical+ Physiological 2 (33.3) 4 (66.7) 6 Physiological+ Neurologi- cal deformity 2 (14.3) 12 (85.7) 14 Physical + Neurological deformity 17 (37) 29 (63) 46 Normal 23 (12.2) 166 (87.8) 189 Neonatal death Yes (Stillbirth=49, IUD=7) 10 (17.5) 47 (82.5) 57 χ2 =0.33 p= No 40 (14.5) 235 (85.5) 275 Neonatal Diagnoses Normal 26 (14.4) 155 (85.6) 181 χ2 =11.28 p= 0.046 Respiratory distress 18 (18.8) 78 (81.3) 96 Asphyxia 0 (0) 33 (100) 33 Other 3 (33.3) 6 (66.7) 9 Respiratory distress + Sepsis 1 (50) 1 (50) 2 Respiratory distress + Asphyxia 2 (18.2) 9 (81.8) 11 https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 152 Erbil Journal of Nursing & Midwifery This study was conducted to provide infor- mation about the consequences of teen- age pregnancy on maternal and neonatal outcomes at Sulaymaniyah Maternity Teaching Hospital in Sulaymaniyah, Kurdi- stan Region of Iraq. Totally 332 teenager mothers participated in this study. Among them, around one-seventh were between 14-16 years old, and the majority were 17- 19 years old. The majority of participants had a secondary level of education, and the minority was illiterate. Among the study participants, more than half were from rural areas. In 2019, in a study about the predictors of teenage pregnancy among mothers aged 13–19 years in Uganda, the results showed that age of the respondents and place of residence of respondents were not significantly associ- ated with teenage pregnancy after ad- justing for all independent factors [15]. Teenage mothers, who reside in rural are- as were twice more likely to become preg- nant. These findings are inconsistent with the previous study in Nepal [16]. The use of ANC is essential and widely recom- mended for all pregnant women to reduce pregnancy-related morbidity and mortali- ty. This study found that more than three- quarters of pregnant mothers attended ANC; however, some attended irregularly, and more than one-tenth did not attend at all. Moreover, in this study, the minority were illiterate. Previous studies which were done in Slovenia [17] and Thailand [18], also showed significantly lower ante- natal care use among teenage mothers compared to others. This could be be- cause of the difference in educational sta- tus between teenage mothers and adult women. These findings indicate an urgent need to improve female health education. The high rate of neonatal complications can be reduced through health education and properly organized ante- natal checkup [11]. Therefore, improve- ment of healthcare is essential to reduce adverse pregnancy outcomes among teenage women in Iraq. Teenage wom- en who are less likely to receive ANC service, and follow-ups, have a lower mean age at first pregnancy and are less likely to receive food supplements dur- ing their first pregnancy [19]. As a conse- quence, the lack of knowledge, early pregnancy, and absent or insufficient antenatal checkup have contributed to the infant in in-utero growth, resulting in LBW [20].Regarding teenage mother’s BMI, nearly two-third were overweight and almost a quarter was obese. The majority had an infectious disease dur- ing pregnancy, while only a quarter was healthy. Out of the total number, three- quarter of teenage mothers had a nor- mal vaginal delivery, the minority had a cesarean section, and only 9 has instru- mental vaginal delivery. Some studies report that the risk of caesarean section is increased in teenage pregnancy [21]. This result agrees with other study done in Italy, which reported that two-third of teenage pregnant women had a normal vaginal delivery compared to less than half in the control group [17]. In compar- ison, some have the opposite finding stating that the chance of the infant’s lower birth weight can lead to a higher rate of success in normal vaginal deliv- ery [22]. In the current study, 332 new- borns were delivered. The majority of the newborns were male. More than half of the newborns had a gestational age between 37 and 40 weeks, which is the highest rate among all levels of ges- tational age, and 31.6% of all newborns were premature. This finding is in con- trast with the previous study done in Babylon, which reported a higher pro- portion of preterm deliveries in teenage DISCUSSION https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 153 Erbil Journal of Nursing & Midwifery mothers compared to only 6% in the adult mothers [23]. The mechanisms associated with preterm labour are not well known and evoke much discussion. It is suggested that it could be due to immaturity of the reproductive organ of young women, poor nutrition, inadequate ANC, urinary tract infection, anaemia and low level of education [24].According to the current study, about one-fifth of the newborns had SGA, almost one-seventh were still- born, while very few had LGA. More than a quarter of the newborns suffered from respiratory distress, one-tenth had as- phyxia as a medical diagnosis, and few had respiratory distress with asphyxia. A previ- ous study from the United States found that the first teenage birth was inde- pendently associated with an increased risk of intrauterine growth restriction and premature delivery [25].Regarding the as- sociation between both teenage mothers’ age groups and gestational age, there was a highly statistically significant association between 14-16 years old mothers and 17- 19 years old mothers and newborns, ges- tational age at p-value = 0.000. Some stud- ies agree with the present study results and found that low birth weight occurred significantly more often among infants of young mothers than among infants of old- er mothers (27,28). However, one of the studies from a high-income country did not show a significant association [26].There was a statistically significant association between both groups of the teenage mothers with the APGAR score, fetal distress, aspiration of meconium, shoulder dystocia, SGA, LGA, medical con- dition, types of deformity and neonatal diagnoses. However, there was no statisti- cally significant association between both groups and neonatal death. In another study that agrees with the present study regarding the association between early maternal age and newborn death, there was no statistically significant associa- tion between the teenage pregnancy groups and neonatal death (p=0.56). Katz et al. also found no association be- tween young maternal age and stillbirth in Nepal [27]. In comparison, de Vienne et al. found a significant relationship be- tween the two [28]. A study in the city of Sakarya in Turkey determined that post- natal infant death rate is 2.5% in adoles- cent pregnancies and 0.1% adult preg- nancies [29].Regarding neonatal out- comes, this study showed a significantly higher risk of SGA (p=0.000, χ2 =21.186) than LGA. However, LGA (p=0.000, χ2 =21.976) is less among newborn babies of teenage mothers. Socolov et al. (2017) in Romania who conducted a study among 3891 women aged < 19,9 and 9479 women aged 20-24, found the higher rate of SGA infants in the first group than in the second group (13.77% vs 10.40%, p < 0.001) [30]. The results correspond with previous results of oth- er authors ( 31,32) who found that the rate of SGA infants is higher in adoles- cents compared to adult women (3.5% vs.2.3%), while the rate of LGA infants is higher in adult mothers (3.2% vs 1.8%) [31]. Other study did not find a signifi- cant difference between both groups [32].A highly significant difference in the APGAR score of newborn babies at birth and at five minutes after birth was ob- served in the current study. Analysis of the association between teenage preg- nancy and adverse birth outcomes demonstrated that infants born to teen- age mothers aged 17 or younger had a higher risk for low APGAR score at five minutes [33].This could be attributed to the difference in the socio-demographic, obstetric, nutritional factors of the mother [34]. According to the model re- gression analysis, there is a significant positive statistical correlation between https://doi.org/10.15218/ejnm.2020.17 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 154 Erbil Journal of Nursing & Midwifery teenage mothers’ age and birth weight. R Square for this study is 0.534. This indi- cates that more than half of the variance of birth weight has been explored in teen- age mothers’ age. A local study was done in Basrah, which reported that one-fifth of the cases had LBW babies as compared to (6.8%) of the control group (19). Feto- maternal competition for nutrition is a common explanation for the higher risk of delivering low birth weight infant in ado- lescent mothers [35]. One-sixth of all births globally are LBW, with an increased risk of neonatal morbidity and mortality. As a result, the WHO during the sixty-fifth World Health Assembly in May 2012 planned to reduce LBW by 30% by the end of 2025 [36]. In this study, there was a sta- tistically significant association between both age groups and newborns’ gestation- al time. In other words, there was a highly statistically significant difference between 14-16 years old and 17-19 years old in the birth weight of their infants. The LBW is less likely in teenage mother aged 14-16 than in the teenage mothers who are 17- 19 years old. Therefore, strategies, which aim to reduce teenage pregnancy and ad- verse neonatal outcomes of adolescent pregnancy are necessary. Immediate and effective measures to reduce the teenage pregnancy need to be developed and im- plemented, to achieve such target. In this study, the number of teenage pregnancies was 332 out of 6243, which is high alert to this region as well as to other countries. The WHO recommends prevention of teenage pregnancy as the primary strategy to reduce neonatal mortality, especially in developing countries. Preventive measures such as prevention of early mar- riage and the use of contraceptive meth- ods are effective in reducing teenage preg- nancy and related complications. There- fore, the programs in the prevention of teenage pregnancy should be developed and delivered. The use of such steps can reduce unwanted pregnancy among ad- olescents; LBW and preterm birth com- plications, and can decrease overall child morbidity and mortality in the country [37]. Teenage pregnancy was associated with higher risks of adverse pregnancy out- comes. It has been demonstrated that pregnant teenagers have more signifi- cant health problems during pregnancy, labour and after labour. Teenage preg- nancy age significantly reduces the risk of gestational age as they were less like- ly to receive antenatal care service. The authors wish to thank the staff of Sulaymaniyah Maternity Teaching Hospi- tal and the hospital administration for their cooperation and say thank to all teenage mothers who accepted to par- ticipate in this study. The authors report no conflict of inter- ests [1] Ochen AM, Chi PC, Lawoko S. Predictors of teenage pregnancy among girls aged 13-19 years in Uganda: A community based case-control study. BMC Pregnancy Childbirth. 2019;19(1):1–14. [2] Ayele B, Tesfay G, Hailu Tesfay T, Assefa, Belete A. Determinants of teenage preg- nancy in Degua Tembien District, Tigray, Northern Ethiopia: A community-based case-control study. PLoS One. 2018;13 (7):1–15. [3] Kost K, Henshaw S. 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