PCOGS Papers ajog.

org

Labor and delivery outcomes among

young adolescents
Ana J. Torvie, MD; Lisa S. Callegari, MD, MPH; Melissa A. Schiff, MD, MPH;
Katherine E. Debiec, MD

OBJECTIVE: We sought to determine whether young adolescents aged
11-14 years and teens aged 15-17 and 18-19 years have an
increased risk of cesarean or operative delivery, as well as maternal or
neonatal delivery-related morbidity, compared to young adults aged
20-24 years.
STUDY DESIGN: We conducted a retrospective population-based
cohort study using Washington State birth certificate data linked to
hospital records from 1987 through 2009 for 26,091 nulliparas with
singleton gestations between 24-43 weeks. We compared young ad-
olescents aged 11-14 years, young teens aged 15-17 years, and older
teens aged 18-19 years to young adults aged 20-24 years. The primary
outcome was method of delivery. Secondary outcomes included post-
partum hemorrhage, shoulder dystocia, third- and fourth-degree
perineal lacerations, chorioamnionitis, prolonged maternal length of
stay, gestational age at delivery, birthweight, respiratory distress syn-
drome, neonatal length of stay, and death. We used multivariate
regression to assess associations between age and delivery outcomes.
RESULTS: Young adolescents aged 11-14 years had a lower risk of
cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI],
0.65e0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78e0.97)
delivery compared to young adults aged 20-24 years. Compared
to young adults, young adolescents had an increased risk of pro-
longed length of stay for both vaginal and cesarean delivery (RR,
1.34; 95% CI, 1.20e1.49, and RR, 1.71; 95% CI, 1.38e2.12,
respectively), with no significant differences in indication for ce-
sarean delivery or other measures of maternal morbidity. Young
adolescents had an increased risk of preterm delivery (RR, 2.11;
95% CI, 1.79e2.48), low and very low birthweight (RR, 2.08; 95%
CI, 1.73e2.50, and RR, 3.25; 95% CI, 2.22e4.77, respectively),
and infant death (RR, 3.90; 95% CI, 2.36e6.44) compared to
young adults.
CONCLUSION: Young adolescents have a decreased risk of cesarean
and operative vaginal delivery compared to young adults; however,
their neonates face higher risks of preterm delivery, low and very low
birthweight, and death. This information can be used to inform clinical
care for this population.
Key words: adolescent pregnancy, cesarean, low birthweight, peri-
natal mortality, preterm birth

Cite this article as: Torvie AJ, Callegari LS, Schiff MA, et al. Labor and delivery outcomes among young adolescents. Am J Obstet Gynecol 2015;213:95.e1-8.

A lthough adolescent fertility rates

have declined worldwide over the
past 2 decades, rates in the United States
remain signicantly higher than other
similar high-income countries. In 2013
alone, US adolescents aged 10-14 years
experienced 3108 births (0.3 births/1000
women).1 Multiple studies demonstrate
that childbearing is associated with
greater health consequences for teens
than for adult women. The occurrence of
preterm delivery,2-5 low birthweight,2,4-6
hypertension,7 preeclampsia and
eclampsia,5,8 anemia,7,9 and neonatal
death10 are all higher among teens
compared to 20- to 29-year-olds, with
increased risk of low birthweight and
preterm delivery in the youngest ado-
lescent age groups.4,5,8 Although data
regarding pregnancy among adolescents
<15 years of age are limited, this popu-
lation has been shown to be less likely
to have adequate prenatal care and more
likely to have increased risks of intra-
uterine growth restriction, preterm de-
livery, stillbirth, and infant death.11
It has been hypothesized that adoles-
cents <15 years of age may have an
increased risk of cesarean and operative
vaginal delivery compared to adult

From the Departments of Obstetrics and Gynecology (all authors) and Epidemiology (Dr Schiff), University of Washington School of Medicine, and Health
Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System (Dr Callegari), Seattle, WA.
Received Dec. 24, 2014; revised March 26, 2015; accepted April 21, 2015.
The Lynn S. Mandel, PhD, Endowed Trainee Education and Research Award provided nancial support for this project.
The authors report no conict of interest.
The ndings and conclusions in this report are those of the authors and do not represent the views of the Department of Veterans Affairs or the US
Government.
Presented in abstract and poster format at the 29th Annual Clinical and Research Meeting of the North American Society for Pediatric and Adolescent
Gynecology, Orlando, FL, April 16-18, 2015, and the 83rd annual meeting of the Pacic Coast Obstetrical and Gynecological Society, Marana, AZ, Oct.
22-26, 2014.
Corresponding author: Ana J. Torvie, MD. atorvie@uw.edu
0002-9378/$36.00
2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2015.04.024

JULY 2015 American Journal of Obstetrics & Gynecology 95.e1

PCOGS Papers
women, possibly due to cephalopelvic
disproportion resulting from underde-
veloped bone structures.12,13 Multiple
large database studies have demon-
strated a decreased risk of cesarean de-
livery among teens5,11,14,15; however,
many of these studies have used samples
composed primarily of adolescents age
16 years, with fewer young adolescents
represented. One study among young
adolescents <15 years-old, specically,
found an increased risk of cesarean,
although the effect was limited to those
with normal-weight or macrosomic in-
fants.13 Two studies suggest an increased
risk of birth trauma in the youngest ad-
olescents, with higher risk of emergency
cesarean delivery, perineal trauma,16 and
forceps-assisted delivery7 compared to
older teens with infants at comparable
birthweight and gestational age. As few
population-based studies have reported
birth outcomes among young adoles-
cents, we used data from Washington
State to investigate method of delivery,
including cesarean and operative vaginal
delivery, and maternal and neonatal de-
livery complications among adolescents
aged 11-14 years, young teens aged 15-17
years, and older teens aged 18-19 years
compared to young adults aged 20-24
years.
M ATERIALS AND M ETHODS
We conducted a population-based re-
trospective cohort study using Wash-
ington State birth certicate data linked
to deidentied maternal and neonatal
hospital discharge records following de-
livery from the Comprehensive Hospital
Abstract Reporting System (CHARS).
Inclusion criteria for our subjects were
nulliparity, age <25 years, singleton
pregnancy, cephalic presentation, gesta-
tional age between 24-43 weeks, and
delivery from 1987 through 2009. We
categorized age into young adolescents
aged 11-14 years, young teens aged 15-17
years, older teens aged 18-19 years, and
young adults aged 20-24 years and used
young adults aged 20-24 years as the
reference group, in concordance with
categories used by the Centers for Dis-
ease Control and Prevention for Vital
Statistics reporting.1 A total of 2007 11-
to 14-year-olds delivering from 1987
95.e2 American Journal of Obstetrics & Gynecology JULY 2015
through 2009 met our inclusion criteria,
matched at a 1:4 ratio with the other 3
age groups by year of delivery to improve
power. The University of Washington
Institutional Review Board determined
that the study qualied for exempt
status and did not require full institu-
tional review board approval.
We obtained data using electronic
data sources including: (1) the birth
certicate database, which includes de-
mographic, pregnancy, and delivery-
related information; and (2) CHARS
records, which contain International
Classication of Diseases, Ninth Revision
(ICD-9) diagnosis and procedure codes.
A covariate was classied as present
if documented in at least 1 data source.
Our primary outcome was method of
delivery (cesarean vs vaginal). Among
vaginal deliveries, we compared sponta-
neous vs operative vaginal delivery me-
thods, including vacuum and forceps.
Both birth certicate and CHARS re-
cords were used to capture mode of de-
livery, with spontaneous vaginal (ICD-9
diagnosis code 650), operative vaginal
(ICD-9 procedure codes 72.0-72.4 and
72.7-72.9), and cesarean (ICD-9 diag-
nosis code 669.7 and procedure codes
74-74.2 and 74.4-74.9).
Our secondary outcomes were
maternal complications (corresponding
with ICD-9 codes) including postpartum
hemorrhage (666), third- and fourth-
degree perineal lacerations (664.2-
664.3), shoulder dystocia (660.4), and
chorioamnionitis (658.4), all obtained
from both birth certicate and CHARS
data. We obtained information about
length of stay from CHARS data, and
categorized this as >3 days for a vaginal
delivery (yes/no) and >5 days for a ce-
sarean delivery (yes/no), including
antepartum, intrapartum, and post-
partum time. We also assessed neonatal
complications using both birth certi-
cate and CHARS data, including preterm
delivery (645.10-645.13, and 645.20-
645.23); low and very low birthweight
(764.6-764.8, 765.6-765.8 and 764.1-
764.5, 765.1-765.5, respectively); small
for gestational age (SGA), or weight
<10th percentile for gestational age
(764); and respiratory distress syndrome
(RDS) (769). Neonatal length of stay
ajog.org
>5 or <5 days, and neonatal and infant
death were obtained from CHARS data
alone. Maternal complications were
stratied by vaginal vs cesarean delivery.
Perineal lacerations and shoulder dy-
stocia were evaluated only among vaginal
deliveries, while all other complications
were evaluated among both modes of
delivery.
We also evaluated demographic and
pregnancy characteristics. Race, place of
residence (urban, rural), insurance sta-
tus, and adequacy of prenatal care were
obtained using birth certicate data.
Adequacy of prenatal care was measured
using the Kotelchuck17 Index, which
combines the initiation of prenatal care
and number of visits compared with
the expected visits, adjusted for gesta-
tional age of initiation of care and de-
livery. Tobacco use (306.1 and 649.0);
prepregnancy weight (codes in adults
and children: 649.1, 278.0-278.02, 783.2,
and V85); and pregnancy comorbidities
such as diabetes (648, 250), chronic hy-
pertension (642.0-642.3, 642.9, 401),
preeclampsia (642.4-642.5, 642.7) and
eclampsia (642.6), and fetal anomalies
(740-760) were obtained using both
birth certicate and CHARS data.
We compared demographic and ob-
stetric characteristics of the 4 age groups
using c2 testing. To assess the risk of
adverse maternal and neonatal outcomes
among the youngest adolescents, we
performed multivariate regression ana-
lyses and estimated the risk ratios (RRs)
and 95% condence intervals (CIs).
We built separate models for each pri-
mary and secondary outcome, using lo-
gistic regression for most maternal and
neonatal outcomes and Poisson regres-
sion with a robust variance estimator for
common outcomes including cesarean
delivery, operative delivery, maternal
length of stay for vaginal and cesarean
deliveries, and SGA. We adjusted for
variables that we identied as potential
confounders based on our literature re-
view of factors associated with adolescent
pregnancy and birth outcomes and a
change in the RR estimate of >10%
comparing crude and adjusted RR.
We adjusted for infant birthweight in
delivery method models (cesarean,
operative). For maternal complications
ajog.org PCOGS Papers
of vaginal deliveries, we adjusted for
birthweight (lacerations, shoulder dys- TABLE 1
tocia), maternal race (postpartum hem- Demographics and pregnancy characteristics in parturients aged 11-24
orrhage, chorioamnionitis), and adequacy years
of prenatal care (shoulder dystocia). For Age 11-14 y Age 15-17 y Age 18-19 y Age 20-24 y
maternal complications of cesarean de- n [ 2007 n [ 8028 n [ 8028 n [ 8028
Demographic No. (%) No. (%) No. (%) No. (%)
liveries, we adjusted for maternal race
(postpartum hemorrhage). For neonatal Race/ethnicity
complications, we adjusted for gesta- Non-Hispanic White 807 (41.4) 4969 (63.1) 5721 (71.5) 6041 (76.8)
tional age (RDS, neonatal length of stay,
Hispanic 675 (34.7) 1564 (19.9) 1135 (14.4) 903 (11.5)
neonatal death, and infant death), ade-
quacy of prenatal care (RDS), and race Non-Hispanic Black 217 (11.1) 589 (7.5) 434 (5.5) 291 (3.7)
(neonatal and infant death). All analyses Asian 83 (4.3) 302 (3.8) 301 (3.8) 466 (5.9)
were conducted using Stata 13.0 (Stata Native American 163 (8.4) 452 (5.7) 293 (3.3) 162 (2.1)
Corp, College Station, TX).
Other 2 (0.1) 2 (0.0) 5 (0.1) 3 (0.0)
R ESULTS Place of residence
A total of 2007 young adolescents aged Urban 1381 (76.9) 5334 (73.8) 5537 (75.6) 5652 (76.7)
11-14 years met inclusion criteria for
Rural 416 (23.1) 1889 (26.2) 1789 (24.4) 1721 (23.3)
this study. The matched groups of
those aged 15-17, 18-19, and 20-24 years Insurance status
each contained 8028 subjects, for a total Medicare/Medicaid 1497 (74.6) 5588 (69.6) 5584 (69.6) 3911 (48.7)
sample of 26,091 subjects. Young ado- Private 449 (22.4) 2194 (27.3) 2256 (28.1) 3911 (48.7)
lescents 11-14 years of age were more
likely to be of minority race/ethnicity, Uninsured 61 (3.0) 245 (3.1) 187 (2.3) 205 (2.6)
less likely to have private insurance, and Prenatal care
less likely to be overweight compared to Adequate 710 (40.5) 3768 (52.5) 4151 (57.8) 4725 (65.8)
young adults aged 20-24 years (Table 1).
Inadequate 1044 (59.5) 3414 (47.5) 3034 (42.2) 2456 (34.2)
With regard to prenatal and intrapartum
characteristics, 11- to 14-year-olds were Tobacco use
less likely to have adequate prenatal care Yes 306 (16.7) 1831 (24.7) 1883 (25.3) 1336 (18.1)
or to have diabetes compared to older
No 1528 (83.3) 5595 (75.3) 5550 (74.7) 6032 (81.9)
teens and young adults. Hypertension,
preeclampsia and eclampsia, and fetal Prepregnancy weight, lb
malformations occurred similarly across <100 91 (7.1) 254 (4.8) 196 (3.7) 138 (2.6)
groups.
100-150 958 (74.7) 3853 (72.6) 3593 (67.0) 3172 (59.6)
Young adolescents aged 11-14 years
had a 27% lower risk of cesarean delivery 150-200 213 (16.6) 1041 (19.7) 1300 (24.2) 1513 (28.4)
compared to young adults aged 20-24 >200 20 (1.6) 156 (2.9) 276 (5.1) 499 (9.4)
years (RR, 0.73; 95% CI, 0.65e0.83)
Pregnancy comorbidities
(Table 2), as did young teens aged 15-17
years and older teens aged 18-19 years Diabetes (gestational, 15 (0.8) 102 (1.3) 145 (1.8) 238 (3.0)
pregestational)
(RR, 0.69; 95% CI, 0.64e0.74, and
RR, 0.81; 95% CI, 0.76e0.86, respec- Chronic hypertension 108 (5.4) 460 (5.7) 477 (5.9) 569 (7.1)
tively). Indications for cesarean delivery, Preeclampsia 207 (10.3) 686 (8.6) 664 (8.3) 718 (8.9)
including fetal distress, cephalopelvic Eclampsia 25 (1.3) 44 (0.6) 51 (0.6) 28 (0.4)
disproportion, malpresentation, active
Fetal anomalies 46 (2.3) 199 (2.5) 182 (2.3) 182 (2.3)
genital herpes, placenta previa, and
umbilical cord prolapse, did not differ Columns do not add to totals due to missing data.
among age groups (data not shown). Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.
Adolescents aged 11-14 years also had
a lower risk of operative assistance
with forceps or vacuum compared to 20- 0.71e0.82, and RR, 0.82; 95% CI, risk of third- and fourth-degree perineal
to 24-year-olds (RR, 0.87; 95% CI, 0.77e0.88, respectively). lacerations compared to young adults
0.78e0.97), as did teens aged 15-17 and Among vaginal deliveries, teens aged (RR, 0.80; 95% CI, 0.71e0.89, and RR,
18-19 years (RR, 0.76; 95% CI, 15-17 and 18-19 years had a decreased 0.74; 95% CI, 0.66e0.82, respectively).

JULY 2015 American Journal of Obstetrics & Gynecology 95.e3

PCOGS Papers ajog.org

TABLE 2
Delivery method in parturients aged 11-24 years
Variable Age 11-14 y, n (%) Age 15-17 y, n (%) Age 18-19 y, n (%) Age 20-24 y, n (%)
All deliveries n 2007 n 8028 n 8028 n 8028
Vaginal (spontaneous or operative) 1718 (85.6) 6928 (86.3) 6730 (83.8) 6419 (80.0)
Cesarean 289 (14.4) 1100 (13.7) 1297 (16.2) 1609 (20.0)
RR (95% CI) 0.73 (0.65e0.83) 0.69 (0.64e0.74) 0.81 (0.76e0.86) 1.00
Vaginal deliveries n 1732 n 7036 n 6833 n 6576
Spontaneous 1410 (82.1) 5802 (83.8) 5531 (82.2) 5018 (78.2)
Operative 308 (17.9) 1126 (16.2) 1199 (17.8) 1401 (21.8)
RR (95% CI) 0.87 (0.78e0.97) 0.76 (0.71e0.82) 0.82 (0.77e0.88) 1.00
Adjusted for birthweight, using Poisson modeling for common outcome.
CI, confidence interval; RR, risk ratio.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.

Young adolescents aged 11-14 years had
a similar risk of third- and fourth-degree
perineal lacerations compared to young
adults (Table 3). Young adolescents aged
11-14 years with vaginal deliveries were
34% more likely to have a length of stay
>3 days as compared to 20- to 24-year-
olds (RR, 1.34; 95% CI, 1.20e1.49).
Adolescents aged 11-14 years with ce-
sarean deliveries had a 71% increased
risk of hospital stay >5 days compared to
20- to 24-year-olds (RR, 1.71; 95% CI,
1.38e2.12) (Table 4). Teens aged 15-17
and 18-19 years also had an increased
risk of prolonged maternal length of stay
compared with 20- to 24-year-olds (RR,
1.23; 95% CI, 1.05e1.45, and RR, 1.21;
95% CI, 1.04e1.42, respectively),
although the risk was lower than that in
the youngest group.
With regard to neonatal complica-
tions, parturients aged 11-14, 15-17, and
18-19 years had an increased risk of
preterm delivery and low birthweight
compared to 20- to 24-year-olds
(Table 5). Young adolescents aged 11-14
years had a 2-fold increased risk of pre-
term delivery (RR, 2.11; 95% CI,
1.79e2.48) and low birthweight (RR,
2.08; 95% CI, 1.73e2.50), and a 3-fold
increased risk of very low birthweight
(RR, 3.25; 95% CI, 2.22e4.77)
compared to young adults. In addition to

TABLE 3
Maternal complications of vaginal deliveries in parturients aged 11-24 years
Age 11-14 y, n (%) Age 15-17 y, n (%) Age 18-19 y, n (%) Age 20-24 y, n (%)
Variable n [ 1733 n [ 7036 n [ 6834 n [ 6577
a
Postpartum hemorrhage 103 (6.0) 346 (5.0) 289 (4.3) 312 (4.8)
RR (95% CI) 1.07 (0.84e1.36) 0.96 (0.81e1.13) 0.85 (0.72e1.01) 1.00
b
Third- to fourth-degree perineal laceration 174 (8.7) 668 (8.3) 639 (8.0) 812 (10.1)
RR (95% CI) 0.93 (0.78e1.11) 0.80 (0.71e0.89) 0.74 (0.66e0.82) 1.00
c
Shoulder dystocia 32 (1.9) 144 (2.1) 184 (2.7) 153 (2.4)
RR (95% CI) 0.86 (0.57e1.29) 0.96 (0.75e1.23) 1.25 (0.99e1.58) 1.00
a
Chorioamnionitis 59 (3.4) 235 (3.4) 251 (3.7) 208 (3.2)
RR (95% CI) 0.95 (0.70e1.30) 1.01 (0.83e1.23) 1.13 (0.94e1.37) 1.00
Maternal length of stay
>3 dd 368 (21.4) 1134 (16.4) 1017 (15.1) 974 (15.2)
RR (95% CI) 1.34 (1.20e1.49) 1.05 (0.97e1.13) 0.98 (0.90e1.06) 1.00
CI, confidence interval; RR, risk ratio.
a
Adjusted for race; b Adjusted for birthweight; c Adjusted for birthweight and adequacy of prenatal care; d Adjusted for birthweight and using Poisson modeling for common outcome.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.

95.e4 American Journal of Obstetrics & Gynecology JULY 2015

ajog.org
TABLE 4
Maternal complications of cesarean deliveries in parturients aged 11-24 years
Variable
a
Postpartum hemorrhage
RR (95% CI)
Chorioamnionitis
RR (95% CI)
Maternal length of stay
>5 db
RR (95% CI)
CI, confidence interval; RR, risk ratio.
a
Adjusted for race; b Adjusted for birthweight and using Poisson modeling for common outcome.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.
the increased risk of preterm delivery
and its resultant inuence on birth-
weight in these women, young adoles-
cents aged 11-14 years and teens aged
15-17 years also demonstrated a 25%
increased risk of SGA infants, again with
adolescents aged 11-14 years at highest
risk (RR, 1.25; 95% CI, 1.11e1.40). In-
fants born to young adolescents aged 11-
14 years had a nearly 4-fold risk of infant
death, or death occurring from day 0-
364 of life (RR, 3.90; 95% CI,
2.36e6.44). Risk of infant death was also
increased for teens aged 15-17 and 18-19
years (RR, 2.18; 95% CI, 1.43e3.33,
and RR, 1.62; 95% CI, 1.05e2.57,
respectively).
C OMMENT
In this population-based study of
>26,000 women including 2007 young
adolescents age 11-14 years, we found
that young adolescents aged 11-14 years,
similar to teens aged 15-19 years, had a
decreased risk of cesarean and operative
vaginal delivery compared to young
adults aged 20-24 years. Neonates born
to the youngest adolescents, however,
faced an increased risk of preterm de-
livery, low and very low birthweight, and
death compared with neonates born to
young adults.
Our nding that adolescents aged 11-
14 years had a decreased risk of cesarean
delivery is largely supported by the
literature,11,14,15 although some studies
Age 11-14 y, n (%) Age 15-17 y, n (%)
n [ 275 n [ 992
6 (2.1) 17 (1.6)
0.68 (0.27e1.66) 0.56 (0.31e1.03)
21 (7.3) 92 (8.4)
0.79 (0.49e1.28) 0.92 (0.70e1.22)
83 (28.7) 221 (20.1)
1.71 (1.38e2.12) 1.23 (1.05e1.45)
report conicting data.13 A population-
based study of Swedish women demon-
strated a decreased risk of cesarean
delivery in women <16 years of age
compared with those aged 20-30 years.15
Similarly, a large database study of 37
million US women demonstrated lower
cesarean risk in adolescents age <15
years compared with all women age
>15 years.11 Another study published
using the same large dataset of US
women reported an elevated risk of ce-
sarean delivery in women aged 12-14
years compared with those aged 15-20
years, but this nding was limited to
women with normal-weight or macro-
somic neonates.13 Our analysis, in
contrast, adjusted for birthweight in
comparing vaginal to cesarean deliveries
and spontaneous vaginal to operative
vaginal deliveries. Authors reporting
an increased risk of cesarean delivery
in women age <15 years have cited
cephalopelvic disproportion as a poten-
tial etiology.5,12,13 Our ndings of an
overall lower risk of cesarean and oper-
ative vaginal delivery among young
adolescents, however, do not support
a substantially increased occurrence of
cephalopelvic disproportion or labor
dystocia in this age group. Although
our data do not clarify mechanisms for
a decreased risk of cesarean delivery
in young adolescents, possible factors
could include intrinsic biologic causes
such as uterine contractility and physical
JULY 2015 American Journal of Obstetrics & Gynecology
PCOGS Papers
Age 18-19 y, n (%) Age 20-24 y, n (%)
n [ 1195 n [ 1452
29 (2.2) 37 (2.3)
0.89 (0.53e1.47) 1.00
115 (8.9) 144 (8.9)
0.98 (0.76e1.27) 1.00
252 (19.4) 250 (15.5)
1.21 (1.04e1.42) 1.00
endurance and practice patterns such
as provider concern regarding the
impact of cesarean delivery on future
reproductive outcomes. Future studies
are needed elucidate these underlying
mechanisms.
Few studies addressing delivery out-
comes in adolescents have examined
the risk of operative vaginal delivery
or perineal lacerations. Contrary to our
nding that forceps or vacuum-assisted
delivery risk was decreased in parturi-
ents aged 11-19 years compared to 20- to
24-year-olds, Konje et al7 described that
teens age <16 years were 2-fold more
likely to have a forceps delivery than 20-
to 24-year-olds. However, this study was
limited by a small sample size and
restriction to 1 small geographic area in
England, United Kingdom, which may
introduce bias due to local practice pat-
terns. In addition, teens aged 15-19 years
in our study had a decreased risk of
third- and fourth-degree perineal lacer-
ations. A similar reduction was seen
among adolescents aged 11-14 years,
although the association was not statis-
tically signicant. In contrast, a small
prospective study found an increased
risk of similar lacerations in women 13-
15 years of age,11 although again the
overall low numbers of adverse events in
this study limit generalizability. Our
ndings may be explained by the fact
that operative vaginal delivery and
thus the associated risk of perineal
95.e5
PCOGS Papers ajog.org

TABLE 5
Fetal complications in parturients aged 11-24 years
Age 11-14 y, n (%) Age 15-17 y, n (%) Age 18-19 y, n (%) Age 20-24 y, n (%)
Indication n [ 2007 n [ 8028 n [ 8028 n [ 8028
Gestational age at delivery
Preterm (<37 wk) 235 (12.0) 677 (8.6) 560 (7.1) 481 (6.1)
RR (95% CI) 2.11 (1.79e2.48) 1.45 (1.28e1.63) 1.17 (1.04e1.33) 1.00
Birthweight at delivery
Very low
<1500 g 48 (2.4) 85 (1.1) 62 (0.8) 60 (0.8)
RR (95% CI) 3.25 (2.22e4.77) 1.42 (1.02e1.98) 1.03 (0.72e1.47) 1.00
Low
<2500 g 182 (9.1) 536 (6.7) 463 (5.8) 367 (4.6)
RR (95% CI) 2.08 (1.73e2.50) 1.49 (1.30e1.71) 1.27 (1.10e1.46) 1.00
a
Small for gestational age 304 (16.4) 1149 (15.4) 1063 (14.3) 963 (13.1)
RR (95% CI) 1.25 (1.11e1.40) 1.17 (1.08e1.26) 1.09 (1.00e1.18) 1.00
b
Respiratory distress syndrome 43 (2.1) 103 (1.3) 85 (1.1) 83 (1.0)
RR (95% CI) 1.35 (0.87e2.17) 1.05 (0.73e1.50) 1.04 (0.72e1.49) 1.00
c
Neonatal length of stay
>5 d 152 (8.2) 455 (6.1) 431 (5.7) 387 (5.1)
RR (95% CI) 1.20 (0.96e1.50) 1.01 (0.86e1.18) 1.05 (0.90e1.23) 1.00
d
Neonatal death 27 (1.4) 50 (0.6) 20 (0.3) 26 (0.3)
RR (95% CI) 2.03 (0.98e4.17) 1.69 (0.94e3.05) 0.79 (0.40e1.58) 1.00
d
Infant death 51 (2.5) 88 (1.1) 58 (0.7) 41 (0.5)
RR (95% CI) 3.90 (2.36e6.44) 2.18 (1.43e3.33) 1.62 (1.05e2.57) 1.00
CI, confidence interval; RR, risk ratio.
a
Using Poisson modeling for common outcome; b Adjusted for gestational age and adequacy of prenatal care; c Adjusted for gestational age; d Adjusted for gestational age and race.
Torvie. Adolescent delivery outcomes. Am J Obstet Gynecol 2015.

trauma18 were less common in our
young adolescent population.
Although young adolescents aged
11-14 years had a decreased risk of
cesarean and operative vaginal delivery
in our study and no signicant difference
in indicators of maternal morbidity
compared with 20- to 24-year-olds,
maternal length of stay >3 days for a
vaginal delivery and >5 days for cesarean
delivery was more common compared
with young adults. This nding has
not been reported in prior studies
examining this age group. The reasons
for prolonged admission were not clear
from the information in our dataset.
In the absence of increased peripartum
morbidity, possible explanations include
prolonged inpatient stay for social work
evaluation or for maternal or neonatal
observation given the increased psycho-
social vulnerability19,20 of these young
patients.
Our data regarding the increased
risk of preterm delivery, low and very
low birthweight, and SGA infants born
to 11- to 14-year-olds are consistent
with multiple other studies,2-6,8,9 and
contribute information regarding a large
sample of adolescents aged 11-14 years
to the existing literature. Inadequate
prenatal care has been hypothesized as a
risk factor for these ndings, supported
by data of Debiec et al21 that preterm
delivery is increased in teens with inad-
equate visits. However, Fraser et al2 and
Chen et al4 both noted persistent risks of
prematurity, low birthweight, and SGA
infants even among those with adequate
prenatal care. Chen et al4 also controlled
for weight gain in pregnancy, smoking
and alcohol use, and age-appropriate
education, suggesting that there are
intrinsic biologic factors associated with
age and distinct from environmental
risks inuencing neonatal outcomes in
this group. Our ndings support this
hypothesis, as adequacy of prenatal care
was not a confounder in our study.
Studies to date have not evaluated the
impact of depression; physical, sexual, or
emotional abuse; poor socioeconomic
status; untreated pelvic infections; or
lack of social support and supervision on

95.e6 American Journal of Obstetrics & Gynecology JULY 2015

ajog.org
the outcomes of neonates born to ado-
lescents. Any of these factors may
contribute to increased pregnancy risks
in this population,22-24 and further
investigation is warranted.
The risk of infant death in our popu-
lation was increased nearly 4-fold for
adolescents aged 11-14 years, with a 2-
fold increase in infants born to teens
aged 15-17 years. Phipps et al10 assessed
term infants of appropriate weight for
gestational age without congenital ano-
malies and similarly found a 4 times
higher risk of death in infants born to
adolescents <15 years of age compared
with 23- to 29-year-olds. These in-
vestigators hypothesized that the
increased risk of death was largely sec-
ondary to preventable causes such as
abuse and neglect. In our study, infant
death in each age group was too infre-
quent to identify clear trends involving
causes of death. Use of national data-
sets could further evaluate differences
in cause of death for infants born to
young adolescents compared with adult
women.
Strengths of our study include our
large, population-based sample size and
ability to control for many potential
confounding variables. In addition, al-
though cesarean rates in the general
population varied over the course of
the study period,25 our subjects were
matched by year of delivery, thus our
ndings are not confounded by this
factor. Important limitations also de-
serve mention. The Washington State
birth certicate data are retrospective
and depend on patient records, prenatal
care documentation, and patient recall,
all of which may introduce errors or
omissions that result in bias. In an effort
to improve data capture, we linked birth
certicate data to ICD-9 coding from
patient charts (CHARS), which has been
shown to markedly improve accuracy for
diagnoses, including delivery method
and associated complications.26 Addi-
tionally, we were unable to adjust for
certain factors not captured in the
birth certicate or CHARS records that
may be important, such as parental
support, supervision and care, nutri-
tional and socioeconomic differences
between groups, coexisting mental health
conditions, and child abuse, neglect, and
incest. While we were able to account for
some of these issues by looking at sur-
rogate psychosocial markers including
weight, insurance status, and high-risk
behavior such as smoking, some resid-
ual confounding may persist in our
ndings.
In conclusion, we found that adoles-
cents aged 11-14 years and teens aged
15-17 and 18-19 years had a decreased
risk of cesarean delivery or operative
vaginal delivery compared with women
20-24 years of age, with no increased risk
of peripartum morbidity. These data
may reassure providers that labor in 11-
to 19-year-olds may be treated similarly
to adult women, and that decisions
about operative intervention should not
be based on age alone. Our study also
conrms prior ndings that infants born
to young adolescents and teens are at
markedly higher risk of preterm deli-
very, low and very low birthweight and
SGA status, and infant death. These
patterns have signicant public health
implications and further study is war-
ranted to understand modiable risk
factors in both adolescent and teen
populations and develop evidence-based
interventions to reduce these adverse
outcomes.27 - proxy for pelvic size. J Pediatr Adolesc Gynecol
ACKNOWLEDGMENTS
We acknowledge the Washington State
Department of Health for providing the data for
this study, and William OBrien at the University
of Washington for building the database used
for our research.
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