Teenage Childbearing as an Independent Risk Factor for Stress Urinary Incontinence in American Women Li Xie1, Zhuoyuan Yu2, Fei Gao3* Purpose: To evaluate the associations among teenage childbearing (Age at first birth<=19 years old) with later-life risk of stress and urgency urinary incontinence (SUI, UUI) in American women using nationally representative data from America. Materials and Methods: Data from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 were merged to include 2673 women. The question, “How old were you at the time of your first live birth?” was used to assess teenage childbearing. Urinary incontinence was ascertained by self-report. Multivariable logis- tic regression models were used to assess the association between teenage childbearing and urinary incontinence in American women, controlling for potential confounders. Results: Among the 2673 women with complete data, the prevalence of SUI was 27.3%, and the prevalence of UUI was 22.1%. Overall, 856 of female had given birth at or before the age of nineteen. Teenage childbearing was significantly associated with SUI (OR=1.9, 95%CI=1.5-2.3, p < 0.001), but teenage childbearing was not associat- ed with UUI (OR=1.2, 95%CI=1.0-1.5, p = 0.0658). Conclusion: After controlling for known risk factors, teenage childbearing seems to be signif-icantly related to female stress urinary incontinence. Keywords: teenage childbearing; stress incontinence; urgency incontinence; urinary inconti-nence; women. 1Department of Urology, The First Affiliated Hospital of Chongqing Medical Uni-versity, Chongqing, China. 2Department of Urology, The First Affiliated Hospital of Chongqing Medical Uni-versity, Chongqing, China. 3Department of Urology, The First Affiliated Hospital of Chongqing Medical Uni-versity, Chongqing, China. *Corresoindence: Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China. Tel: 15730285046. Fax: 023-68485000 . E-mail: 3329630790@qq.com. Received February 2022 & Accepted June 2022 INTRODUCTION According to ICS terminology, urinary incon-tinence(UI) is a complaint of any involuntary leakage of urine(1). Two main types are described: stressurinary incontinence(SUI), in which urine leaks in association with physical exertion, and urgency uri- nary incontinence(UUI),in which urine leaks in associa- tion with a sudden compelling desire to void(2). Urinary incontinence symptoms are highly prevalent among women(3), have a substantial effect on health-related quality of life and are associated with considerable per- sonal and societal expenditure. Age, obesity, gravidi- ty, hypertension and menopause are known to be risk factors for stress UI in women(4). Additionally, many studies have identified diabetes mellitus as a risk factor for in-continence in women(5). Obstetric risk factors are well defined in the literature, and parities are shown to increase UI risk by 67%(6). In addition, vaginal deliv- ery increased the risk of UI by 75% compared to c-sec- tions(7). Teenage childbearing is a major adolescent health con- cern worldwide. World Health Organi-zation (WHO) defines the age group 10–19 years as adolescents stage(8). The prevalence of teenage pregnancy remains high worldwide, despite recent prevention efforts, such as promo-tion of contraception use and sexual edu- cation(9). Teenage births result in health consequenc- es; children are more likely to be born pre-term, have lower birth weight, and higher neonatal mortality(10), while mothers experience greater rates of post-partum depression(11) and are less likely to initiate breastfeed- ing(12). Teenage mothers are less likely to complete high school, are more likely to live in poverty, and have chil- dren who frequently experience health and devel-op- mental problems(13). Although UI is associated with pregnancy and par- ity(14), few studies reveal the associations among teenage childbearing with SUI and UUI. The National Health and Nutrition Examina-tion Survey (NHANES) represents a population-based sample of American adults who com-pleted validated urinary symptom ques- tionnaires in select years and an assessment of self-re- ported ageat first live birth. Hence, we used the data of the NHANES program to in-vestigating the relationship between early childbearing and later risk of UI. The fo- cus of our paper is on longer term adult health outcomes of teen mothers. A better understanding of how UI is associated with teenage childbearing is important for clinical practice and public health interventions aimed Urology Journal/Vol 19 No. 5/ September-October 2022/ pp. 392-397. [DOI:110.22037/uj.v19i.7223] FEMALE UROLOGY at preventing teenage pregnancy. Methods NHANES Sample and Design The NHANES program consists of cross-sectional health surveys performed by the National Center for Health Statistics of the Centers for Disease Control and Prevention (http://www.cdc.gov/nchs/nhanes.htm). NHANES provides estimates of the health status of the United States population by selecting a nationally rep- resentative sample of the noninstitution-alized popula- tion using a complex, stratified, multistage, probability cluster design. NHANES oversampled individuals 60 years old or older and black, Mexican-American, and low-income white individuals to provide more relia- ble estimates of these groups. The National Centers for Health Statistics ethics review board approved the protocol, and all participants provided written informed consent. We obtained nationally representative data on demographic and health outcomes from NHANES 2015-2018. This study was a cross-sectional survey, which was carried out to investigate the relationship between teenage childbearing and UI among women. Study participants We used publicly available data from the 2015-2018 NHANES for this study. NHANES rep-resents a popu- lation-based sample of American adults who complet- ed validated urinary symptom questionnaires in select years. We restricted our analytic cohort to include female, aged 20 years or older when participating in NHANES, who responded to the “Kidney Con-ditions – Urology” survey questionnaire and “Reproductive Health” survey questionnaire (n=3949). We excluded 257 participants who reported a history of bladder can- cer (n=5), brain cancer (n=1), cervical or uterine can- cer (n=66), stroke (n=185) since bladder cancer, brain cancer, cervical or uterine cancer and stroke may affect urinary function. Participants with in-complete general survey data (n=1055) were also excluded. Ultimately, 2637 women were included in the present study. For this study, a sample size calculation based on error margin of 5%, 95% confidence level and expected ra- tio of SUI or UUI of 50% was run at the sample size calculator website: http://www.surveysystem.com/sam- ple-size-formula.htm , and the result was found to be 377. This study had a respectable sample size(2637). Study Variables Questions regarding UI were assessed by computer-as- sisted personal interviews methodolo-gy (CAPI). The primary outcome of interest was the presence of ei- ther SUI or UUI ("any in past year")as ascertained by self-report. Participants were asked if “During the past 12 months, have you leaked or lost control of even a small amount of urine with activity like coughing, lift- ing, or exercise?”(SUI) or “with an urge or pressure to urinate and could not get to the toilet fast enough?” (UUI). And, the question: “How frequently does this occur?” measures incon-tinence frequency. We per- formed a companion analysis defining SUI and UUI as a self-report of monthly or more, and weekly or more in- continence events. The use of this self-reported in-con- tinence questionnaire is considered to be a reliable and valid epidemiological tool for as-sessing the presence of incontinence(15). Women without the specific incon- tinence type of in-terest (SUI or UUI) were considered non-cases. According to the response to the question, “how old were you at the time of first live birth?”, we derive variables indicating whether the individual gave birth during teenager. Demographics Prevalence rates of Incontinence (self-reported) SUI%(95CI%) UUI%(95CI%) Overall prevalence 27.3(26.3-29.8) 22.1(20.5-23.7) Age 20-39 20.8(17.6-24.0) 13.1(10.4-15.7) 40-59 28.2(25.4-31.1) 19.1(16.6-21.6) 60-79 30.9(27.7-34.0) 28.7(25.7-31.8) 80+ 37.6(30.9-44.4) 36.1(29.5-42.8) Race Mexican american 32.4(28.2-36.6) 23.1(19.3-26.9) Other hispanic 27.1(22.3-31.9) 17.5(13.4-21.6) Non-hispanic white 33.6(30.5-36.7) 25.4(22.6-28.3) Non-hispanic black 18.4(15.7-21.9) 21.9(18.6-25.3) Other race-including multi-racial 24.6(19.9-29.3) 16.5(12.4-20.6) Education Less than High School 29.9(26.4-33.4) 24.6(21.3-27.9) High school/ged 30.8(27.2-34.5) 21.5(18.2-24.7) College 25.9(23.6-28.2) 21.2(19.0-23.4) Annual family income $0 to $19,999 29.9(26.5-33.3) 22.6(19.4-25.7) $20,000 to $34,999 28.3(24.8-31.7) 24.3(21.0-27.6) $35,000 to $74,999 27.1(23.8-30.4) 21.0(26.3-29.8) > $75,000 26.8(23.2-30.4) 20.4(17.2-23.7) Bmi Lean/normal (<25 kg/m2) 22.7(19.5-26.0) 22.4(19.2-25.6) Overweight (25-30 kg/m2) 28.7(25.5-31.9) 23.9(20.9-26.9) Obese (>30 kg/m2) 30.5(27.9-33.1) 20.8(18.5-23.1) Parity 1 28.2(24.1-32.2) 20.9(17.3-24.6) 2 31.3(28.2-34.4) 23.4(20.6-26.2) 3 25.6(22.2-29.0) 20.5(17.4-23.6) 4 26.7(22.1-31.3) 22.5(18.2-26.8) >=5 25.2(20.0-30.3) 23.4(18.4-28.4) Table 1. Weighted population prevalence rates of stress and urgency incontinence (n=2673) SUI in women: the role of teenage childbearing-Xie et al. Vol 19 No 4 July-August 2022 316Vol 19 No 5 September-October 2022 393 In addition, the following covariates were included: age; race; education; annual family income; BMI; hy- pertension; diabetes; parity; smoking history and his- tory of hysterectomy. Those co-variates included de- mographic and clinical characteristics that have been associated with UI in prior studies(16-19). Details of all study variables acquisition process are available at www.cdc.gov/nchs/nhanes/. Statistical analysis All estimates were calculated accounting for NHANES sample weights(full sample 4-year MEC examination weight of the 2015–2018). These weights consider un- equal probabilities of selec-tion and nonresponse. The subgroup analysis was carried out using stratified mul- tivariate re-gression analysis. Following adjustment for covariates, we used logistic regression to examine the independent association among teenage childbearing with stress and urgency urinary in-continence (SUI, UUI). Data were analyzed with the use of the statistical packages R (The R Foundation; http://www.r-project. org; version 3.4.3) and Empower (R) (www.empower- stats.com, X&Y solutions, inc. Boston, Massachusetts). The OR and 95% CI were obtained from the multivar- iable models with statistical significance considered at p <0.05. RESULTS prevalence rates of stress and urgency incontinence Overall, the study included 2673 women. The popula- tion prevalence of SUI was 27.3%(26.3%-29.8%) and UUI was 22.1%(20.5%-23.7%). Subgroups analyses To examine whether the associations among teenage childbearing (Age at first birth < =19 years old) with stress and urgency urinary incontinence (SUI, UUI) existed across subgroups, uni-variate logistic regres- sion was adopted for subgroup analyses (Table 2). No increased risks of SUI were found among participants whose age >=80 years old (P-value = 0.465), who be- long to Mexican American (p = 0.2635), whose pari- ty is three (p = 0.15). However, increased risks of SUI were observed in all the other subgroups (P < 0.05). Increased odds of UUI were only found among partic- ipants who belong to other race including multiracial (p = 0.0084), whose education level is college (p = 0.0032), who didn’t have diabetes (p = 0.0343). Teenage childbearing was associated with the odds of SUI in women Four regression models were constructed: Adjust 0 model adjust for: none. Adjust 1 model adjust for: age; race; education; annual family income. Adjust 2 model adjust for: BMI; hy-pertension; diabetes; parity; smok- ing history; history of hysterectomy; post-menopausal Pediatric Urology 317 Sub-group N SUI UUI OR (95CI) P value OR (95CI) P value Age 20-39 619 1.6 (1.0, 2.4) 0.0353 1.3 (0.8, 2.2) 0.2842 40-59 967 2.1 (1.5, 2.9) <0.0001 1.3 (0.9, 1.8) 0.1732 60-79 849 1.7 (1.2, 2.4) 0.0015 1.1 (0.8, 1.5) 0.5867 80+ 202 1.3 (0.7, 2.5) 0.465 0.9 (0.5, 1.8) 0.8478 Race 0n-hispanic black 481 3.1 (1.9, 4.8) < 0.0001 1.3 (0.8, 2.0) 0.3137 0n-hispanic white 332 2.1 (1.2, 3.6) 0.0091 1.3 (0.7, 2.5) 0.349 Mexican american 897 1.2 (0.9, 1.6) 0.2635 0.9 (0.7, 1.3) 0.756 Other hispanic 606 2.1 (1.3, 3.4) 0.0021 1.8 (1.2, 2.8) 0.0084 Other race including multiracial 321 2.3 (1.2, 4.5) 0.0114 1.4 (0.7, 2.8) 0.3669 Education level College 655 2.5 (1.7, 3.6) < 0.0001 1.8 (1.2, 2.7) 0.0032 High school/ged 620 1.7 (1.2, 2.5) 0.0067 1.2 (0.8, 1.8) 0.3612 Less than high school 1362 1.7 (1.3, 2.2) 0.0004 1 (0.8, 1.4) 0.7729 Annual family income > $75,000 696 2 (1.4, 2.9) 0.0004 1.3 (0.9, 1.9) 0.1827 $0 to $19,999 654 1.6 (1.1, 2.3) 0.0209 1.2 (0.8, 1.7) 0.4342 $20,000 to $34,999 705 1.8 (1.2, 2.6) 0.0022 1.4 (1.0, 2.1) 0.0807 $35,000 to $74,999 582 2 (1.3, 3.1) 0.0012 1.1 (0.7, 1.7) 0.7517 BMI >30 kg/m2 647 1.6 (1.0, 2.4) 0.0425 1.1 (0.7, 1.6) 0.7961 <25 kg/m2 770 1.7 (1.2, 2.5) 0.0022 1.4 (0.9, 2.0) 0.0917 25-30 kg/m2 1220 2.1 (1.6, 2.7) <0.0001 1.3 (0.9, 1.7) 0.1358 Hypertension Yes 1297 1.9 (1.4, 2.4) < 0.0001 1.3 (1.0, 1.7) 0.1006 No 1340 1.7 (1.3, 2.3) 0.0001 1.2 (0.9, 1.6) 0.3582 Parity 1 483 2 (1.1, 3.6) 0.0168 1.3 (0.7, 2.3) 0.4186 2 868 1.8 (1.2, 2.7) 0.0019 1.1 (0.7, 1.6) 0.7353 3 648 1.3 (0.9, 1.9) 0.15 1.3 (0.9, 2.0) 0.1675 4 360 2.3 (1.4, 3.7) 0.0007 1.5 (0.9, 2.5) 0.0955 >=5 278 2.3 (1.3, 3.9) 0.0036 1.3 (0.8, 2.4) 0.2964 Diabetes Yes 529 1.5 (1.0, 2.3) 0.0296 1.1 (0.8, 1.7) 0.5414 No 2108 2 (1.6, 2.5) < 0.0001 1.3 (1.0, 1.6) 0.0343 Smoking history Yes 892 1.8 (1.3, 2.4) 0.0002 1.4 (1.0, 1.9) 0.052 No 1745 1.9 (1.4, 2.4) < 0.0001 1.2 (0.9, 1.5) 0.227 Table 2. Results of subgroup analyses CI: confidence interval; OR: odds ratio; BMI: body mass index. SUI in women: the role of teenage childbearing-Xie et al. Female Urology 394 status. Adjust 3 model adjust for: age; race; education; annual family income; BMI; hypertension; diabetes; parity; smoking history; history of hysterectomy (Ta- ble 2). In the fully-adjusted model, we observed a pos- itive association between teenage childbearing and SUI (OR=1.9, 95% confidence interval [CI]: 1.5-2.3, P < 0.05), and SUI will come up early in the life of these women (Age: 20-39, OR=1.6, 95% confidence interval [CI]: 1.0-2.4, P < 0.05). However, teenage childbearing were not found to be associated with UUI (OR = 1.2, 95% confidence interval [CI]: 1.0-1.5, P = 0.0658). DISCUSSION The present study aimed to evaluate the associations among teenage childbearing (Age at first birth<=19 years old) with SUI and UUI in American women. In this study, we found that the risk of SUI was 1.9 times higher in women whose age at first live birth less than or equal to 19 years old than in women whose age at first live birth more than 19 years old in adulthood. However, after fully adjusting for multiple risk factors, we also found no relationship between teenage child- bearing and UUI. The risks and realities associated with teenage child- bearing are well documented(20); for exam-ple, Children are more likely to be born prematurely, have lower birth weight and have higher neonatal mortality(21), and teen- age mothers have higher rates of postpartum depression and are less likely to start breastfeeding(22). Hoffman et al. reported that Teenage mothers are less likely to finish high school, more likely to live in poverty, and children often experience health and developmental problems. Despite the historic decline in the U.S. teen birth rate during 1991–2015, from 61.8 to 22.3 births per 1,000 females aged 15–19 years, many teens con- tinue to have repeat births(23). These previous studies, along with ours, suggest that teenage childbearing may pose a significant public health hazard. To the best of our knowledge, this is the first study that explored the associations between teenage childbearing and urinary incon-tinence. UI can seriously affect one’s quality of life(24). SUI is an involuntary loss of urine due to in-creased intra-abdom- inal pressure, while UUI is caused by stimulation of bladder contractions or loss of nervous system control. In previous studies, parity(25), mode of delivery(26) and difficult birth history(27) were risk factors for UI. No statistically significant interactions were observed between teenage childbearing and UUI (P = 0.0068 > 0.05), but p values between 0.05 and 0.10 were report- ed as marginally significant in many studies. So more studies are needed to estimate the relationship of UUI and teenage childbearing. We found SUI increases in women whose age at first birth less than or equal to 19 years old. Based on our findings, we propose several possible hypotheses. The first is that anatomical differences in pelvis dimensions, uterine volume and hormone production between ado- lescents and adults(28,29) may increase the risk of pelvic floor dysfunctions after delivery, and the use of episiot- omy(29) may worsen this condition. The second hypoth- esis is that adolescent pregnancy is often unplanned,be- ing associated with fewer appointments, which usually start when the pregnancy is already advanced, and with lower follow-up rates compared with adult preg- nan-cies(30). Lack of knowledge of available prenatal care services, lack of decision-making au-tonomy, con- cealment of pregnancy, and financial difficulties may justify this association. Ad-olescents tend not to follow medical recommendations correctly, and are more ex- posed to poor nutrition, drug use, smoking and alcohol consumption, as well as emotional stress(31). None-the- less, our hypotheses require further investigation. Strengths of this study include the nationally represent- ative nature of the NHANES data and the large sample size, yet there are some limitations to our study. First, the cross-sectional nature of this study inhibits our abil- ity to assess causality. Second, other confounders such as histories of gynaecological disease and previous in- strumental vaginal delivery were not included in or con- trolled for in our analyses. Lastly, prevalence-incidence bias was also a problem we couldn't solve. This study does not provide further insight into the major mech- anisms of progression and exacerbation of SUI from teenage childbearing. Future longitudinal studies are needed to examine the association of SUI with teenage childbearing. CONCLUSIONS These results show that teenage childbearing was not related to UUI. However, an increased risk of SUI was demonstrated in participants whose age at first live birth Vol 19 No 4 July-August 2022 318 Table 3. Associations between teenage childbearing and urinary incontinence among women in NHANES 2015–2018 (n = 2673) Adjust 0 Adjust 1 Adjust 2 Adjust 3 OR P OR P OR P OR P (95%CI) (95%CI) (95%CI) (95%CI) SUI Age at first birth>19 Ref Ref Ref Ref Age at first birth<=19 1.8 (1.5, 2.2) < 0.001 1.8 < 0.001 1.9 < 0.001 1.9 < 0.001 (1.4, 2.2) (1.5, 2.3) (1.5, 2.3) UUI Age at first birth>19 Ref 0.0334 Ref 0.108 Ref 0.067 Ref 0.0658 Age at first birth<=19 1.2 1.2 1.2 1.2 (1.0, 1.5) (0.9, 1.4) (1.0, 1.5) (1.0, 1.5) Adjust 0 model adjust for: none. Adjust 1 model adjust for: age; race; education; annual family income. Adjust 2 model adjust for: BMI; hypertension; diabetes; parity; smoking history; history of hysterectomy; post-menopausal status. Adjust 3 model adjust for: age; race; education; annual family income; BMI; hypertension; diabetes; parity; smoking history; history of hysterectomy. SUI in women: the role of teenage childbearing-Xie et al. Vol 19 No 5 September-October 2022 395 less than or equal to 19 years old. Our findings empha- size the need for physicians and nurses to recommend proper treatment, medical help, or bring the disorder to light for teenage mothers. ACKNOWLEDGMENTS This work was supported by the National Natural Sci- ence Foundation of China to Fei Gao [NO. 81672893] and Mei Yang [NO. 81971230, 81671312]. Further- more, it is supported by Chongqing Science and health joint project [NO. 2020GDRC007], and supported by Senior Medical Talents Program of Chongqing for Yong and Middle-aged [NO. 204216qn] and Re-serve Talents Program for academic Leaders of the First Affiliated Hospital of Chongqing Medical University [NO. XKTS070] to Fei Gao. 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