The rate of pregnancy in Trinidad and Tobago : A comparison between pregnant teenagers and pregnant adults registered at three health centers

Departments of Paraclinical Sciences, Public Health and Primary Care Unit, Faculty of Medical Sciences, 1Mathematics and Statistics, University of the West Indies, St. Augustine, Trinidad and Tobago, 2Independent Health Policy Consultant, Christiana, Manchester, UK, 3Advanced Ob/Gyn Associates, 256 Columbia Turnpike #212N Florham Park, NJ, USA, 4Department of Pathology, University of the West Indies, Mona, Kingston, Jamaica


INTRODUCTION
This paper addresses the issue of pregnancy among teenagers 13-19 years old and women 20-41 years old (herein referred to as the older mother) living on the twin Island of Trinidad and Tobago.This country is situated at the Southern end of the Caribbean-Northeast of Venezuela; measures 5,128 square kilometers and comprises a population of 1,229,953, whereby teenagers represent approximately 22%. [1]The issue of teenage pregnancy worldwide is viewed as a major social and medical problem. [2]Studies have shown that teenage mothers are more likely to suffer many adverse medical outcomes, both during and after pregnancy. [3]These outcomes include hypertensive disorders, [4,5] anemia, [5] cephalopelvic disproportion, [6] increased rate of caesarian sections, [4] and postpartum depression. [7]The literature also noted that not only are pregnant teenage girls at risk for their own health, but that the unborn child is at increased risk of prematurity, [4] low birth weight, [8] congenital malformations, [9] increased risk of neonatal deaths, [10] and death during infancy. [11]nternational Journal of Medicine and Public Health | Jul-Sep 2013 | Vol 3 | Issue 3 those days, teenage pregnancy contributed 30% birth for countries such as St. Kitts and Nevis, Dominica and St. Lucia and 32% for Jamaica (Rawlins 1981). [13]Such concerns within the Caribbean deem teenage pregnancy a problem owing to its association with disrupted educational opportunities, high incidence of interrupted pregnancies, early sexual activity, and exposure to sexually transmitted infections (STIs) including human immunodefi ciency virus (HIV).The Caribbean Epidemiology Centre (CAREC) showed that the fastest growing rate for HIV/AIDS was within the 15-19 age group, which were said to be fi ve times more likely to be infected than their age mates. [14]It follows that teenagers, who become pregnant are exposing themselves to the risk of serious health consequences.
On the point of interrupted pregnancies, noted above, such statement is supported by Abdool et al., (2002), who claimed that the typical patient who abused misoprostol as an abortifacient, is usually young single women. [15]This sometimes result in hospitalization of the patient for approximately two days.The average cost for treatment and care of this nature within the health care facility is approximately TT $2,282 (US $380) in 2007.This paper addresses the social-economic status of the pregnant teenagers in Trinidad and Tobago, as well as their past obstetric history in relation to abortions and still births; their use of contraceptives and the matter of breastfeeding practice.Further, the paper compares the women who were teenagers at the time of fi rst pregnancy, as against those who reported their fi rst pregnancy during post-adolescence (ages of 20-41).

MATERIALS AND METHODS
This study utilizes mixed method approaches: Primary and secondary.The former represents collecting data directly from respondents who attended antenatal clinics at three different locations in Trinidad and Tobago, while the latter involves information obtained from desk review.Pregnant women in the third trimester of pregnancy were recruited by nurses in three Health Centers in Northern Trinidad.The sample size comprised 132 women (ages 13-41 years old), who were interviewed by medical students of the University of the West Indies, Mount Hope, St. Augustine Campus, in Trinidad and Tobago.These students were professionally trained to conduct such interviews.Consent forms were signed by the respondents prior to the interviews.The interviewees were given the option to opt-out should they become uncomfortable with any of the questions asked.
The instrument was a 60-item interview schedule.Data collected included demographic information, the respondents' fi nancial status, obstetric history, their preferred contraceptive method(s), and breast feeding practice.
Data were analyzed using Statistical Package for the Social Sciences (SPSS) 12.0.Two control groups were established: (1) Those who had their fi rst pregnancy while in their teenage years (13-19 years old) and (2) those who experienced their fi rst pregnancy during their post-adolescence/adulthood (20-41 years old).

First pregnancy per age category
The data obtained from three Health Centers in Northern Trinidad and Tobago represents cases by categories of women who had their fi rst pregnancy as teenagers (13-19 years old), as well as adults within the age group of 20-41 years.The sample comprised 132 women within the 13-41 years age category.A signifi cant percentage (53%) of this sample experienced their fi rst pregnancy before the age of 20 years.The youngest age reported for fi rst pregnancy was 13 years.Most of the older women had their fi rst pregnancy between the ages 20-24 years.

Ethnicity
Table 1 gives a breakdown of the age at fi rst pregnancy by ethnicity.It is revealed that the Afro-Trinidadians were the most likely to become teenage mothers (48.6%), followed by those who were Mixed (31.4%) and Indo-Trinidadians (20%).The respondents who were categorized as the older women (20-41) were not signifi cantly different in terms of those of their racial status: Bi-racial (31.4%),Indo-Trinidadians (21.3%), and Afro-Trinidadians (42.6%).

Marital status
The marital status of the respondents were assessed, and it was noted that of the 71 respondents who had their fi rst pregnancy as teenagers, 38.0% reported to be single; 43.0% engaged in common-law relationship, and 18.3% were married.In terms of the post-adolescent/older respondents, 37.7% reported being married, 36.1% single, while 26.2% engaged in common-law relationship [Table 1].

Employment and income status
Although, there is no signifi cant difference in the reported cases of marital status versus employment, the findings reveal that teenage mothers (35.2%) were more likely to be unemployed than the older mothers (23.0%).On the contrary, although the teenage mothers (22.5%) were less susceptible to being unskilled compared to the older mothers (34.4%), they were more likely to become homemakers/housewives (21.1%) than the older mothers (19.7%).
Where income was concerned, the teenager mothers reported lower income than the older mothers.The income for the teenagers ranged from TT$ 700 to 4500 per month (TT$ 6.00 is approximately US$ 1.00), whereby 36.4% earned $700-2000 and 45.5% reported earnings of TT$ 2001-TT$ 4500 per month.For the older mothers, 50% reported family income in excess of TT$ $4,500 per month, with 37% earning between TT$ 2,000-TT$ 4,500 per month.

Obstetric history
A particular concern of this study was the obstetric history of the mothers in relation to breast-feeding practice, live births, stillbirths, abortion, and contraceptive use.Breast-feeding is practiced more among the older woman (95.5%) than the teenage mother (90.7%), as indicated in Table 2. Of the 71 respondents who reported having had at least one previous live birth, 85.9% represents teenage mothers.The average number of children for the teenage and older mothers represents 1.4% and 1.4%, respectively.Fewer teenage mothers (3.3%) experienced stillbirths than the post-adolescent/older mother (8.2%) [Table 2].
Regarding the number of abortions experienced, this study postulates that the older mothers were more likely to have two or more abortions than the teenage mothers, who were more likely to have one abortion.While 50.0% of teenage mothers had never experienced an abortion, 38.0% of the older mothers fell within this category [Table 2].
Table 2 shows the outcome of the last pregnancy and notes that there was no statistical difference in relation to induced abortion between the teenagers and older mothers (² =0.83, P = 0.01).

Contraceptive prevalence
With regard to the issue of contraceptive use prior to fi rst pregnancy, Table 2 shows that 28.0% of the teenage mothers and 51.0% of the older mothers reported contraceptive use.Consonant with this fi nding, this Table also reveals that the older mothers were more likely to use the pill (62.5%) and other methods (12.5%) when compared to the teenage mothers (47.0% and 11.8%, respectively).However, the use of condom and dual methods ranked higher among teenage mothers (23.5% and 17.6%, respectively) than the older mothers (12.5% and 12.5%, respectively).

Intended family size
Table 2 reveals that there was no signifi cant difference between teenage mothers who wanted to have one or two children (61.0%) and the older mothers (69.0%) who desired same.There was also no signifi cant difference between the teenage mothers who were desirous of having three to fi ve children (38.0%) and the older mothers (32.0%) who shared a similar view point.

DISCUSSION
Age at fi rst sexual debut among Caribbean teens is not unusual before the age of 15 years.In countries such as Antigua and Barbuda, Haiti, Jamaica, Guyana, Trinidad and Tobago and the Dominican Republic, one in six females between the ages of 15 and 24 years become sexually active before the age of 15.A 2000 survey conducted by the Pan American Health Organization (PAHO) revealed that nearly half of all young girls reported that their fi rst sexual encounter was forced or coerced. [16] view of Trinidad and Tobago's unemployment rate of 5.2%, the paper reveals that teenage mothers (35.2%) were more likely to be unemployed than older women (23%).This evidence is supported by (Buvinic 1998), who intimated that adolescent motherhood was associated with poor earning opportunities for the teenager, necessitating the frequent occurrence of grandparents having to take over responsibility for child care. [17]Consonant with this perspective, Grogger and Bronars (1993) stated that the there are correlations between teenage pregnancy and lower family earning (including household income). [18]In supporting the views of the authors, the fi ndings of this paper also reveal that a large percentage of the teenage mothers were unemployed (35%) and for those who were employed (36.4%), earned less than TT$ 2,000 (less than US$ 350) per month.This stands to reason that the teenage mother is likely to be socially disadvantaged, with higher unemployment level, lower incomes, and a marital status which has limited or no security.Such insecurity, as well as low income and unemployment, often lead to teenagers forming intimate relationships with older men.This usually led to further pregnancies and income dependency.Daguerre and  Nativel (2006) hypothesized that minimal safety net is likely to incur higher rates and births to teenagers and that the use of contraception is dependent on low educational outcomes. [19]This is not unique to Trinidad and Tobago, as adolescent or teenage sexual activity and pregnancy in Jamaica, [20] Guatamala, [21] and Latin America [22] have been thought to be associated with poverty, poor education, among other social factors.In a number of cases, the insecurity of the relationships, as well as dependence on income, causes the teenage and older mothers to not be able to negotiate safe sexual practice via contraceptive method.Research has shown that unmarried young women, who face additional barriers to obtaining contraceptives, including social disapproval of contraceptive use, are less likely to use contraception than young married women. [23]In the case of Jamaica such barriers include (a) adolescent male gaining more favorable access to contraceptive service and treatment than their female counterpart; and (b) the female is categorized as bad and wanton when trying to access contraceptive methods, while masculinity of the male is being promoted. [24]The study also revealed that there was a relationship between male and female who encounter challenges in accessing contraceptive.
There was no correlation between the mother's age range and breastfeeding, as other relating factors would be considered.This lifestyle was practiced more among the older woman than the teenage mother.In comparing breastfeeding patterns in Africa (AFR) and the Latin American and Caribbean region (LATCAR) based on demographic and health, in surveys conducted in 23 countries between 1986 and 1990, the proportion of infants who are never breastfed is twice as high in LATCAR than in AFR.The average median breastfeeding duration is 1.64 times higher in AFR (193.0 months) than in LATCAR (11.8 months).The longer breastfeeding duration found in AFR was due to a better lactation performance in both rural and urban areas.In both LATCAR and AFR, 71% of the 0-4-month infants were not breastfed exclusively during the fi rst 4 months of life and breastfeeding duration was longer in rural than in urban areas.However, the degree of urbanization had a stronger negative effect on breastfeeding in LATCAR than in AFR.It is, therefore, concluded that (a) while LATCAR is in great need of breastfeeding promotion programs, breastfeeding in AFR should be protected as it becomes more urbanized; (b) the promotion of exclusive breastfeeding remains a priority in both regions; and (c) the magnitude of the inverse association between urbanization and breastfeeding is likely to vary among regions with different socio-economic and cultural backgrounds. [25]upled with the foregoing, the intense review of the literature notes that studies have shown that teenage pregnancy is considered a poor choice on both health and social grounds.Teenage parents tend to have poor antenatal health, lower birth weight babies, higher infant mortality rates, and an increased risk of congenital anomalies.While they are likely to seek antenatal care much later in pregnancy than older women, teenage mothers miss out on important and early pregnancy health measures, such as taking folic acid.Teenage mothers are also less likely to breastfeed their babies than older mothers and are more likely, if from a deprived background, to remain poor and to experience higher levels of unemployment.They are also disproportionately likely to suffer relationship breakdown.However, for some young women, having a baby is seen as a positive step, one that offers a sense of purpose in a life that might have few other options.It is towards this group of women that teenage pregnancy teams are directing their greatest efforts. [26]ile the literature points to many concerns about health risk for the outcomes of teenage pregnancy, it should be noted that the fi ndings of this study reveals that stillbirths among teenage mothers represents 3.3% and the older mother, 8.8%, and complements the overall concern of stillbirths in Trinidad and Tobago.Physicians in this island often postulate that this was as a result of failure of the pregnant woman to attend antenatal clinics. [12]other health issue that is being presented in this study is the matter of interrupted pregnancy or abortion.It is noted that teenage mothers who experience spontaneous abortions represented 64.3% and 60% of the induced abortions.This suggests that pregnant teenagers had a larger percentage of pregnancies which had been interrupted.

CONCLUSION
Teenage pregnancy is considered a risk factor and has socio-economic implications regarding the lives of the mother and child in terms health, income, employment, and marital status.Pregnancy of the teenager and older mother bears no association with ethnicity.Despite employment and marital status, the pregnant woman (both categories) become vulnerable owing to insecurity (single and unemployed), hence their inability to negotiate condom use.This paper assumes that owing to the respondents' exposure to antenatal treatment, this result in a small number of the subjects experiencing stillbirths.

Table 1 : Demographic characteristics
International Journal of Medicine and Public Health | Jul-Sep 2013 | Vol 3 | Issue 3

Table 2 : Sexual and reproductive health characteristics
International Journal of Medicine and Public Health | Jul-Sep 2013 | Vol 3 | Issue 3