Literature para Sa Thesis

Risk factors for preterm birth <37 weeks, either spontaneous or iatrogenic,
were evaluated for different age groups using multivariate logistic regression.
RESULTS: 165,282 births were included in the study. ... A maternal age of
30-34 years wasassociated with the lowest risk of prematurity
Early pregnancy predictors of preterm birth: the role of a prolonged

menstruation-conception interval.
Gardosi J, et al. BJOG. 2000.
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Abstract
OBJECTIVE: To study early pregnancy characteristics as possible risk factors
associated with preterm birth.
DESIGN: Retrospective analysis of prospectively collected maternity data.
POPULATION: 21,069 singleton deliveries with record of a specified last menstrual

period and a midtrimester dating scan.
SETTING: Catchment area of tertiary centre serving a general maternity population.
METHODS: Univariate and multivariate analysis. Variables included: maternal age;

height; weight at first visit; parity; ethnic group; cigarette smoking and alcohol
consumption recorded in early pregnancy; history of abortion; history of preterm birth;
and discrepancy between menstrual dates and ultrasound dates.
MAIN OUTCOME MEASURES: Adjusted odds ratios for factors associated with preterm
birth, stratified according to parity (nulliparae vs multiparae) and gestational age (early
preterm, 24-33 weeks; late preterm, 34-36 weeks; all preterm, < 37 weeks). Population
attributable risk (aetiologic fraction) of the significant variables for preterm birth.
RESULTS: The overall preterm (< 37 weeks) delivery rate according to scan dates was
7 x 0%. Preterm birth was associated with young (< 20 years), short (< or = 155 cm)
and underweight (< or = 52 kg) mothers, non-Europeans, cigarette smokers, previous
abortion or previous preterm delivery, and a prolonged menstruation-conception
interval. Preterm births which followed the spontaneous onset of labour (72%) had
results which were similar to the overall group, while there were too few iatrogenic
preterm deliveries for separate analysis. Logistic regression showed that associations
varied in different parity and gestational age groups. For nulliparae, smoking was not
associated with preterm birth, but it was strongly associated with multiparous women
(adjusted OR 1 x 8, 95% CI 1 x 6-2 x 1). A past history of premature delivery had the
highest risk for birth before 34 weeks in the index pregnancy (adjusted OR 5 x 1, 95%
CI 3 x 4-7 x 6). A discrepancy between menstrual and scan dates of greater than +7
days, suggestive of a prolonged interval between last menstruation and conception, was
present in 23 x 3% of all pregnancies, and was associated with an increased risk of
preterm delivery in all gestational age categories for nulliparae (adjusted OR 1 x 5, 95%
CI 1 x 3-1 x 8) and multiparae (adjusted OR 1 x 9, 95% CI 1 x 6-2 x 2). Because of its
high prevalence, this variable constituted a relatively high population-attributable risk for
premature birth for both nulliparae (10 x 7%) and multiparae (16 x 6%).
CONCLUSIONS: A discrepancy of more than +7 days between menstrual and scan

dates, indicating a prolonged interval between last menstruation and conception, is a
significant predictor of preterm birth. This effect is independent of other factors such as
maternal age, height, weight and smoking which are also associated with prematurity. In
a maternity population with ultrasound scan dates and recorded last menstrual period,
this variable can be easily calculated and used as a marker for increased surveillance.
ESEARCH ARTICLE
Effect of maternal age on the risk of preterm
birth: A large cohort study
Florent Fuchs, Barbara Monet, Thierry Ducruet, Nils Chaillet,Francois Audibert
 Abstract
Background
Maternal age at pregnancy is increasing worldwide as well as
preterm birth. However, the association between prematurity
and advanced maternal age remains controversial.
Objective
To evaluate the impact of maternal age on the occurrence of
preterm birth after controlling for multiple known confounders
in a large birth cohort.
Study design
Retrospective cohort study using data from the QUARISMA
study, a large Canadian randomized controlled trial, which
collected data from 184,000 births in 32 hospitals. Inclusion
criteria were maternal age over 20 years. Exclusion criteria were
multiple pregnancy, fetal malformation and intra-uterine fetal
death. Five maternal age categories were defined and compared
for maternal characteristics, gestational and obstetric
complications, and risk factors for prematurity. Risk factors for
preterm birth <37 weeks, either spontaneous or iatrogenic, were
evaluated for different age groups using multivariate logistic
regression.
Results
165,282 births were included in the study. Chronic hypertension,
assisted reproduction techniques, pre-gestational diabetes,
invasive procedure in pregnancy, gestational diabetes and
placenta praevia were linearly associated with increasing
maternal age whereas hypertensive disorders of pregnancy
followed a “U” shaped distribution according to maternal age.
Crude rates of preterm birth before 37 weeks followed a “U”
shaped curve with a nadir at 5.7% for the group of 30–34 years.
In multivariate analysis, the adjusted odds ratio (aOR) of
prematurity stratified by age group followed a “U” shaped
distribution with an aOR of 1.08 (95%CI; 1.01–1.15) for 20–24
years, and 1.20 (95% CI; 1.06–1.36) for 40 years and older.
Confounders found to have the greatest impact were placenta
praevia, hypertensive complications, and maternal medical
history.
Conclusion
Even after adjustment for confounders, advanced maternal age
(40 years and over) was associated with preterm birth. A
maternal age of 30–34 years was associated with the lowest risk
of prematurity.
Citation: Fuchs F, Monet B, Ducruet T, Chaillet N, Audibert F
(2018) Effect of maternal age on the risk of preterm birth: A
large cohort study. PLoS ONE 13(1): e0191002.
doi:10.1371/journal.pone.0191002
Editor: Julie Gutman, Centers for Disease Control and
Prevention, UNITED STATES
Received: May 25, 2017; Accepted: December 18,
2017; Published: January 31, 2018
Copyright: © 2018 Fuchs et al. This is an open access article
distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and
source are credited.
Data Availability: The data underlying this study are restricted
by the Research Ethics Board of CHU Sainte-Justine in order to
protect participant privacy. Data are available from the IRB of
CHU Sainte Justine ethique@recherche-ste-justine.qc.ca for
researchers who meet the criteria for access to confidential data.
Funding: The author(s) received no specific funding for this
work.
Competing interests: The authors have declared that no
competing interests exist.
Maternal age and adverse pregnancy outcome: a cohort study.
Khalil A, et al. Ultrasound Obstet Gynecol. 2013.
Show full citation
Abstract
OBJECTIVE: To examine the association between maternal age and a wide range of
adverse pregnancy outcomes after adjustment for confounding factors in obstetric
history and maternal characteristics.
METHODS: This was a retrospective study in women with singleton pregnancies

attending the first routine hospital visit at 11 + 0 to 13 + 6 weeks' gestation. Data on
maternal characteristics, and medical and obstetric history were collected and
pregnancy outcomes ascertained. Maternal age was studied, both as a continuous and
as a categorical variable. Regression analysis was performed to examine the
association between maternal age and adverse pregnancy outcome including pre-
eclampsia, gestational hypertension, gestational diabetes mellitus (GDM), preterm
delivery, small-for-gestational age (SGA) neonate, large-for-gestational age (LGA)
neonate, miscarriage, stillbirth and elective and emergency Cesarean section.
RESULTS: The study population included 76 158 singleton pregnancies with a live fetus
at 11 + 0 to 13 + 6 weeks. After adjusting for potential maternal and pregnancy
confounding variables, advanced maternal age (defined as ≥ 40 years) was associated
with increased risk of miscarriage (odds ratio (OR), 2.32 (95% CI, 1.83-2.93);
P < 0.001), pre-eclampsia (OR, 1.49 (95% CI, 1.22-1.82); P < 0.001), GDM (OR, 1.88
(95% CI, 1.55-2.29); P < 0.001), SGA (OR, 1.46 (95% CI, 1.27-1.69); P < 0.001) and
Cesarean section (OR, 1.95 (95% CI, 1.77-2.14); P < 0.001), but not with stillbirth,
gestational hypertension, spontaneous preterm delivery or LGA.
CONCLUSIONS: Maternal age should be combined with other maternal characteristics
and obstetric history when calculating an individualized adjusted risk for adverse
pregnancy complications. Advanced maternal age is a risk factor for miscarriage, pre-
eclampsia, SGA, GDM and Cesarean section, but not for stillbirth, gestational
hypertension, spontaneous preterm delivery or LGA.
Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
Maternal age and adverse pregnancy outcome: a cohort study

A. Khalil
A. Syngelaki
N. Maiz
Y. Zinevich
K. H. Nicolaides
First published: 30 April 2013

https://doi.org/10.1002/uog.12494
ABSTRACT
Objective
To examine the association between maternal age and a wide range of adverse pregnancy
outcomes after adjustment for confounding factors in obstetric history and maternal characteristics.
Methods
This was a retrospective study in women with singleton pregnancies attending the first routine
hospital visit at 11 + 0 to 13 + 6 weeks' gestation. Data on maternal characteristics, and medical and
obstetric history were collected and pregnancy outcomes ascertained. Maternal age was studied,
both as a continuous and as a categorical variable. Regression analysis was performed to examine
the association between maternal age and adverse pregnancy outcome including pre‐eclampsia,
gestational hypertension, gestational diabetes mellitus (GDM), preterm delivery, small‐for‐gestational
age (SGA) neonate, large‐for‐gestational age (LGA) neonate, miscarriage, stillbirth and elective and
emergency Cesarean section.
Results
The study population included 76 158 singleton pregnancies with a live fetus at 11 + 0 to
13 + 6 weeks. After adjusting for potential maternal and pregnancy confounding variables, advanced
maternal age (defined as ≥ 40 years) was associated with increased risk of miscarriage (odds ratio
(OR), 2.32 (95% CI, 1.83–2.93); P < 0.001), pre‐eclampsia (OR, 1.49 (95% CI, 1.22–1.82);
P < 0.001), GDM (OR, 1.88 (95% CI, 1.55–2.29); P < 0.001), SGA (OR, 1.46 (95% CI, 1.27–1.69);
P < 0.001) and Cesarean section (OR, 1.95 (95% CI, 1.77–2.14); P < 0.001), but not with stillbirth,
gestational hypertension, spontaneous preterm delivery or LGA.
Conclusions
Maternal age should be combined with other maternal characteristics and obstetric history when
calculating an individualized adjusted risk for adverse pregnancy complications. Advanced maternal
age is a risk factor for miscarriage, pre‐eclampsia, SGA, GDM and Cesarean section, but not for
stillbirth, gestational hypertension, spontaneous preterm delivery or LGA. Copyright © 2013 ISUOG.
Published by John Wiley & Sons Ltd.
INTRODUCTION
A rising trend in advanced maternal age has been observed over the last few decades,
particularly in high‐income countries1-7. A commonly accepted definition of advanced
maternal age is 35 years or more. Several studies have examined the association
between advanced maternal age and adverse pregnancy outcome, including
miscarriage, stillbirth, pre‐eclampsia, gestational hypertension, gestational diabetes
mellitus (GDM), preterm birth, delivery of a small‐ (SGA) or large‐ (LGA) for‐gestational‐
age neonate and elective or emergency Cesarean section; these studies have reported
contradictory findings8-15. Such discordance could be attributed to differences in the
populations studied and in the definition of outcomes, with some studies failing to
distinguish between pre‐eclampsia and gestational hypertension, iatrogenic and
spontaneous preterm birth or elective and emergency Cesarean section. Additionally,
many studies failed to adjust for potential confounders.
The aim of this study was to examine the association between maternal age and a wide
range of adverse pregnancy outcomes after adjustment for confounding factors in
maternal characteristics and obstetric history.
METHODS
This was a retrospective study in women attending for their first routine hospital
antenatal visit at three UK hospitals: King's College Hospital, London; University College
London Hospitals, London; and Medway Maritime Hospital, Kent. This visit, which was
held at 11 + 0 to 13 + 6 weeks' gestation, included recording maternal demographic
characteristics and obstetric and medical history, measurement of maternal weight and
height, ultrasound examination for the measurement of fetal crown–rump length and to
determine gestational age16, measurement of fetal nuchal translucency thickness17,
and examination of the fetal anatomy for the diagnosis of major fetal defects18. Data on
pregnancy outcome were collected from the hospital maternity records and the women's
general medical practitioners.
Participants completed a questionnaire on their age, racial origin (Caucasian, Afro‐

Caribbean, South Asian, East Asian or mixed), method of conception (spontaneous or
assisted), cigarette smoking during pregnancy, history of chronic hypertension, history
of Type 1 or Type 2 diabetes mellitus and obstetric history, including the outcome of
each previous pregnancy. The questionnaire was then reviewed by a doctor and the
woman together.
Outcome measures included miscarriage, stillbirth, pre‐eclampsia, gestational

hypertension, GDM, spontaneous and iatrogenic preterm delivery before 34 weeks'
gestation, delivery of an SGA or LGA neonate and delivery by elective or emergency
Cesarean section.
We excluded pregnancies with fetal aneuploidies or major defects diagnosed either

prenatally or in the neonatal period, and pregnancies ending in termination for
psychosocial reasons.
Miscarriage included spontaneous miscarriage and fetal death after screening at 11 + 0
to 13 + 6 weeks and before 24 weeks' gestation. Stillbirth was defined as fetal death at
or after 24 weeks. The diagnosis of pre‐eclampsia and gestational hypertension was
made according to the guidelines of the International Society for the Study of
Hypertension in Pregnancy19. Gestational hypertension was defined as systolic blood
pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg on at least two
occasions 4 h apart, developing after 20 weeks' gestation in a previously normotensive
woman in the absence of significant proteinuria. Pre‐eclampsia was defined as
gestational hypertension with proteinuria of ≥ 300 mg in 24 h, or two readings of at least
++ on dipstick analysis of midstream or catheter urine specimen, if no 24‐h collection
was available. We also subdivided pre‐eclampsia according to gestational age at
delivery into early pre‐eclampsia (< 34 weeks) and late pre‐eclampsia (≥ 34 weeks). In
the investigation of the relationship between maternal age and pre‐eclampsia or
gestational hypertension we excluded pregnancies ending in miscarriage or fetal death
before 24 weeks' gestation.
Screening for GDM was based on a two‐step approach. In all women, random plasma
glucose was measured at 24–28 weeks' gestation and, if the concentration
was > 6.7 mmol/L, an oral glucose tolerance test was carried out within 2 weeks. A
diagnosis of GDM was made if the fasting plasma glucose level was at least 6 mmol/L
or the plasma glucose level 2 h after oral administration of 75 g glucose was
≥ 7.8 mmol/L20. In women with a normal random blood glucose level, an oral glucose
tolerance test was performed if they had persistent glycosuria or developed
polyhydramnios or the fetus became macrosomic. In the investigation of the relationship
between maternal age and GDM we excluded pregnancies with prepregnancy diabetes
mellitus Type 1 or 2 and those ending in miscarriage or delivery before 30 weeks
because they might not have had screening and diagnosis of GDM.
Spontaneous preterm delivery included those with spontaneous onset of labor and
those with preterm prelabor rupture of membranes occurring before 34 completed
weeks (238 days) of pregnancy. In the investigation of the relationship between
maternal age and spontaneous preterm delivery, we excluded pregnancies ending in
miscarriage or stillbirth and those with iatrogenic delivery before 34 weeks. The
commonest causes of iatrogenic preterm delivery in our cohort were pre‐eclampsia and
fetal growth restriction. In the investigation of the relationship between maternal age and
iatrogenic preterm delivery, we excluded pregnancies ending in miscarriage or stillbirth
and those with spontaneous delivery before 34 weeks.
SGA and LGA neonates were defined as those with birth weight below the 5 th percentile
or above the 95th percentile for gestation, respectively21. In the investigation of the
relationship between maternal age and SGA or LGA, we excluded pregnancies ending
in miscarriage or fetal death before 24 weeks.
Emergency Cesarean section included all cases in which such delivery was undertaken
after the onset of labor, usually for failure to progress, fetal distress or intrapartum
hemorrhage. This group also included cases of antepartum hemorrhage requiring
Cesarean section. Elective Cesarean section was performed before the onset of labor
for obstetric or medical indications or at the request of the mother. In the investigation of
the relationship between maternal age and elective or emergency Cesarean section, we
excluded pregnancies ending in miscarriage or fetal death before 24 weeks.
Statistical analysis
We examined the association between maternal age, both as a continuous and as a
categorical variable, with each pregnancy complication. Women were categorized into
three age groups: < 35 years, 35–39.9 years and ≥ 40 years. First, univariable logistic
regression analysis was performed to examine the association between maternal age
and each of the adverse pregnancy outcomes by likelihood ratio test. Odds ratios with
their respective confidence intervals were calculated for the 35–39.9‐year and ≥ 40‐year
groups, using the group aged less than 35 years as a reference. The risk for each of the
pregnancy outcomes was then calculated from the formula: odds/(1 + odds), where
odds = eY, and Y was derived from the univariable logistic regression analysis. Second,
in those variables for which there was a significant association, in order to assess the
trend of this association, another logistic regression analysis was carried out with
orthogonal polynomial contrast, using the center of each interval for the metric (24.6,
37.5 and 47.7, respectively).
Multivariable logistic regression analysis was performed for the prediction of each
pregnancy outcome by maternal age, weight, height, racial origin, mode of conception,
smoking, history of chronic hypertension or diabetes, history of adverse outcome in a
previous pregnancy or family history of pre‐eclampsia. Before performing the
multivariable regression analysis, continuous variables were centered by subtracting the
mean from each measured value (69 for maternal weight in kg, 1.64 for maternal height
in meters and 30 for maternal age in years). The statistical software package SPSS
Statistics 20.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis.
RESULTS
During the study period, first‐trimester combined screening for aneuploidies was carried
out in 79 694 singleton pregnancies. We excluded from further analysis 3533 (4.4%)
women because there were no or incomplete data on pregnancy outcome (n = 2407),
because of the prenatal or postnatal diagnosis of aneuploidy or major defect or because
of pregnancy termination for psychosocial reasons (n = 1126).
In the remaining 76 161 singleton pregnancies, there were 75 104 live births, 764 (1.0%)
miscarriages and 293 (0.4%) stillbirths. In three of the stillbirths, fetal death was the
consequence of maternal death (car accident in two and eclampsia in one), and these
were excluded from further analysis.
In the 76 158 cases included in the study, the median maternal age was 31.3
(interquartile range (IQR), 26.8–35.2) years, median height was 164 (IQR, 160.0–
168.0) cm and median weight was 65.5 (IQR, 59.0–75.6) kg; 7651 (10.0%) women were
cigarette smokers, 870 (1.1%) had a history of chronic hypertension and 545 (0.7%)
had a history of Type 1 or Type 2 diabetes. The racial origin was Caucasian in 57 564
(75.6%), Afro‐Caribbean in 11 395 (15.0%), South Asian in 3645 (4.8%), East Asian in
1793 (2.4%) and mixed in 1761 (2.3%). Out of the 76 158 cases included in the study,
55 772 (73.2%) were under 35, 16 325 (21.4%) were between 35 and 39 and 4061
(5.3%) were 40 or more.
Pregnancy complications
The frequency of pregnancy outcomes according to the maternal age group is
described in Table 1. Univariable logistic regression analysis demonstrated that
maternal age at 11–13 weeks' gestation was significantly associated with miscarriage,
pre‐eclampsia, GDM, delivery of an SGA or LGA neonate and both elective and
emergency Cesarean section, but not stillbirth, gestational hypertension, or
spontaneous preterm delivery (Table 2, Figure 1). There was a significant quadratic
trend towards increased miscarriage, pre‐eclampsia, GDM requiring insulin, SGA and
elective Cesarean section, but not towards emergency Cesarean section (Table 3).
Table 1. Frequency of pregnancy complications according to maternal age group
More evidence links advanced maternal age to

preterm births
Lisa Rapaport


(Reuters Health) - The higher risk of preterm births for women over 40 may not
be completely explained by their greater use of reproductive technology or
medical interventions like induced labor or planned cesarean deliveries, a
Canadian study suggests.
The study confirmed that women over 40 do have the highest risk of preterm
births: 7.8 percent of pregnancies in this age group resulted in preterm births and
1 percent ended in extremely premature deliveries. Women age 30 to 34 had the
lowest risk: 5.7 percent of pregnancies involved preterm deliveries and 0.6
percent resulted in extremely early arrivals.
Compared with women age 30 to 34, the over-40 mothers were 14 percent more
likely to have a spontaneous preterm delivery and 31 percent more likely to have
early deliveries because of labor induction, cesarean births or other
interventions. This offers fresh evidence that age is an independent risk factor
for preterm births, researchers conclude in PLoS One.
“A common hypothesis is that the increased risk of preterm birth among aged mothers
is largely explained by early labor induction for medical conditions,” said Dr. Antonio
Simone Lagana of the Filippo Del Ponte Hospital and the University of Insubria in
Varese, Italy.
“However, this study found that advanced maternal age (40 years and over) was
associated with an increased risk of preterm birth even after adjustment for known
confounders, such as placenta previa, gestational diabetes, medical history, use of
assisted reproduction technologies and occurrence of invasive procedures that are all
more common in older mothers,” Lagana, who wasn’t involved in the study, said by
email.
The oldest mothers in the study had a higher risk of going into early labor on their
own and also of having a premature delivery induced for medical reasons. This
suggests that not all of the increased risk of premature deliveries can be explained by
decisions doctors make in the delivery room, said Dr. Alice Goisis of the London
School of Economics.
“The association cannot be entirely attributed to medical interventions alone,” Goisis,

who wasn’t involved in the study, said by email.
In the weeks immediately after birth, preemies often have difficulty breathing and
digesting food. They can also encounter longer-term challenges such as impaired
vision, hearing and cognitive skills, as well as social and behavioral problems.
Pregnancy normally lasts about 40 weeks, and babies born after 37 weeks are
considered full term. The study focused on preterm babies delivered during weeks 32
to 36 of pregnancy, as well as on extremely premature infants delivered before 32
weeks’ gestation.
The study by Dr. Florent Fuchs of CHU Sainte Justine in Montreal and colleagues
examined data on 184,000 births in 32 hospitals in Quebec, Canada. Fuchs didn’t
respond to emails seeking comment.
Women over 40 in the study were more likely to have many risk factors for
prematurity such as obesity, pregnancy-related diabetes or high blood pressure, and a
complication known as placenta previa, when the placenta nourishing the baby
separates from the uterine wall.
One limitation of the study is that data on weight was missing for 28 percent of
participants. Researchers also lacked data on several factors that can influence the
chances of a preterm birth including socioeconomic status.
Even so, the results add to the evidence that advanced maternal age can make a
preterm birth more likely, said Dr. Ali Khashan of the School of Public Health and
INFANT Center at University College Cork in Ireland.
But all women, including older women, can take steps to reduce their odds of a
preterm birth, Khashan, who wasn’t involved in the study, said by email.
“Women who are planning pregnancy, especially after age 40, should optimize their
health pre-pregnancy, maintain a healthy weight, and engage with health services
early in pregnancy,” Khashan advised.
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Risks of preterm delivery and association with maternal age, birth order,
and fetal gender
P. Astolfi L.A. Zonta
Human Reproduction, Volume 14, Issue 11, 1 November 1999, Pages 2891–
2894,https://doi.org/10.1093/humrep/14.11.2891
Published:
01 November 1999
Article history
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Abstract
The risk of preterm delivery in a recent sample (1990–1994) of Italian liveborns was
examined, taking into account child birth order, and maternal age and education in addition to
the fetal gender. Univariate analyses showed that a higher risk was associated with male than
female babies, with first- than second-born children, with older mothers, and with less
educated mothers. The relative weights of the factors examined were evaluated through
logistic regression analyses and the highest and the lowest risks were found to be associated
with advanced maternal age and male fetal gender respectively. Our findings therefore suggest
that biological factors associated more with advanced maternal age than with the male gender
of the fetus may influence premature onset of labour.
birth order, fetal gender, maternal age, preterm delivery
Topic:
 birth order
 child
 fetus
 infant
 premature obstetric labor
 male
 maternal age
 mothers
 gender
 teaching
 premature birth
 pregnancy with advanced maternal age
 univariate analysis
Issue Section:
PREGNANCY
Introduction
Gestational age is the second best prognostic factor, after baby weight, for the
outcome of pregnancy. Apart from pathological conditions, several factors
associated with a preterm delivery have been extensively investigated since the
1950s (Karn and Penrose, 1951; Wilcox and Skjoerven, 1992). On average, a
lower gestational age is observed among male compared with female babies. It
has been suggested that a preterm delivery may be induced by fetal gender
(Cooperstock and Campbell, 1996). These workers reported an excess of males
among preterm babies, in agreement with previous findings (Hall and Carr-Hill,
1982; McGregor et al., 1992), suggesting that male fetal gender, hormonally
involved in the control of labour onset, might be responsible for the shortened
duration of pregnancy. Possible determinants of the variation in the male to
female ratio with pregnancy duration have been extensively discussed. In
particular, a U-shaped variation has been suggested, which could be related to
time of fertilization in the cycle (James, 1994, 1997a; Bernstein, 1998a, 1998b).
In order to investigate the importance of fetal sex in comparison with other

factors, we examined the risk of preterm delivery in a recent sample of Italian
births. In addition to fetal gender we included in the analysis three other
characteristics well known to influence not only neonatal survival and health, but
also pregnancy duration: maternal age at delivery, maternal educational level,
and the baby birth order.
Maternal age, which has been widely reported to influence pregnancy outcome
(Fretts et al., 1995; Lansac, 1995; Breart, 1997; Zonta et al., 1997; Astolfi et al.,
1999) and which therefore might also affect pregnancy duration, is increasing in
importance since the frequency of mothers bearing children at advanced age has
been rising over the last 20 years. Maternal educational level, which is generally
accepted as a reliable indicator of the socio-economic status of the family, might
at least partially account for variation in gestational age, because of the
differences in availability of antenatal care.
Babies of different birth orders, who have been shown to run different stillbirth
risks (Astolfi et al., 2000), might also be differently exposed to the risk of a
shortened pregnancy. At present, however, because of the reduced size of Italian
families, a comparative analysis is suitable only between first- and second-borns.
The analysis of only the first two orders has therefore avoided the problem of
possible interactions between fetal gender and maternal age discussed by
several authors in relation to deliveries of very high order (Almagor et al.,
1998; James, 1998).
Materials and methods

Subject population and variables
Data were obtained on the authors' special request from the Italian National
Institute of Statistics (ISTAT, Rome, Italy) and consisted of 2 796 334 birth
records from 1990 to 1994. In order to deal with a homogeneous sample and to
eliminate the confounding effects of some factors, such as stillbirth, twinning and
unfavourable familial situations, from the original sample, we selected 2 300 127
children, who were legitimate liveborns of first (1 344 195) or second (955 932)
birth order. In fact, because of the reduced size of Italian families (total fertility
rate was as low as 1.2 children per woman in 1995) the first two birth orders
covered over 80% of total births.
For each newborn, information was available on gender (SX), birth order (BO),
gestational age (GA), maternal age (MA), and educational level (ED). Gestational
age, estimated from last menstrual date, ranged from 20 to 44 weeks, and
deliveries occurring before the 37th week were considered preterm, in
accordance with the World Health Organization (WHO) definition
(http://www.who.int/p11/ter/). The risk of preterm delivery was evaluated in
mothers older than 30 years, grouped into three age classes (30–34, 35–39,
⩾40), which covered the upper 50% in the maternal age distribution. As for
maternal education, the best available indicator of the family socio-economic
level, two levels (>8 and ⩽8 years of schooling) were considered.
Data analysis
Univariate analyses were carried out to evaluate the effects of single factors on
pregnancy duration and the risk of preterm delivery.
The relative risk of preterm delivery was estimated by logistic regression
analyses, with fetal gender and birth order, the maternal age and education, and
interactions of all factors included as explanatory variables.
Statistical analyses were performed by means of SPSS/PC 8.0 and SAS V6.10
procedures.
Results
Univariate analyses were first performed to evaluate the influence of some

characteristics of the baby (birth order and gender) and of the mother (age and
education) on the risk of a preterm delivery.
Birth order
In agreement with previous and current observations that second children are
generally less prone to the risk of stillbirth (Ulizzi et al., 1998; Astolfi et al.,
2000), a significantly lower percentage of preterm babies was found among
second- compared with first-borns (3.894% versus 4.426%; odds ratio (OR) =
0.875, 95% confidence interval (CI) 0.863–0.887).
Maternal educational level
Antenatal care, which may be differently available according to family socio-

economic and cultural levels, may have influenced not only the outcome but also
the duration of the pregnancy. We therefore evaluated the risk of preterm
delivery with respect to maternal education. As expected, among the less
educated mothers a significantly higher quota of preterm deliveries occurred
(4.4 versus 4.0%, OR 1.09 95% CI 1.076–1.105), and the risk was not
significantly different between first and second deliveries.
Maternal age
Mean pregnancy duration behaved as a second-degree function as maternal age

increased: it reached the maximum length (39.5 weeks) in 22-year-old mothers
and the absolute minimum (about 38.75 weeks) in mothers older than 41 years
(Figure 1). However, the difference between the extreme values, which
amounted to less than 1 week, seemed negligible from the biological point of
view.
In contrast, when the frequency of preterm deliveries was considered, maternal

age represented an important risk factor: preterm deliveries occurred in well
below 4% of births among mothers younger than 35 years, which was almost
half the frequency observed among the older mothers (⩾35 years). This
difference was particularly striking among the first children born to mothers
over 35 years (Figure 2). When the same graph was plotted but separating male
from female babies, no effect of maternal age over fetal gender was found (data
not shown). In other words, the effect of maternal age was consistent over fetal
gender.
Baby gender
Male babies are known to have a significantly higher risk of being preterm than
female babies (4.4 versus 4.0%, OR 1.109, 95% CI 1.095–1.124). In agreement
with previous reports (Hall and Carr-Hill, 1982; McGregor et al.,
1992; Cooperstock and Campbell, 1996), we also observed an excess of males
among preterm compared to term babies, the male proportion being 0.541 and
0.515 respectively. No significant difference was found between first and second
children. The week by week variation in the proportion of males among preterm
babies showed a pattern very similar to that recently reported (Cooperstock and
Campbell, 1996). Except for the low value observed among extremely premature
babies (20–25 weeks), the male proportion was consistently high up to the 37th
week, after which a sharp decrease occurred (Figure 3).
Since a significant though small relationship was revealed in the monofactorial

analyses between the four factors and the risk of preterm delivery, an estimate of
their relative weight by means of multifactorial analyses was obtained.
Multifactorial analyses
The risk of preterm birth was evaluated by logistic regression as a function of the
gender and birth order of the baby, the maternal age (from 30 years onwards),
the number of years of schooling, and their interactions. Since no order
interactions were found to be significant, the simplest model with only the main
factors was considered. According to this model, first-born children had a higher
risk than second-borns, and maternal age seemed to be the most important
factor contributing to an increased risk of premature babies (Table I). The
relative weights of low educational level and male gender were lower but still
significant. From the total sample equation, the predicted minimum and
maximum probabilities of a preterm birth, computed considering all favourable
and all unfavourable conditions respectively, turned out to be Pmin = 0.033 and
Pmax = 0.118. This was interpreted as meaning that a first-born male child
delivered to an uneducated mother older than 39 years had a risk of being born
preterm of more than 3.5 times higher than a second-born female child delivered
to a well-educated mother aged 30–34 years.
The significantly increased risk run by first-born children in comparison with

second-borns suggested that independent logistic regression analyses should be
carried out on the two sub-samples separately. The results of these analyses
confirmed that whatever the child birth order, maternal age accounted for the
highest weight while baby gender accounted for the lowest (Table I).
Discussion
Though all the characteristics of the mother and the baby included in the
analyses were significant risk factors for preterm delivery, maternal age
accounted for the highest weight, as shown by the results of logistic analyses
(Table I). The frequency of preterm deliveries was lowest in mothers aged
between 20 and 30 years, but this increased sharply as maternal age increased
(Figure 2). Contrasting the mothers <35 and ⩾35 years, which is generally
considered to be the threshold age for baby and maternal health risk, the
respective preterm percentages were 4.0 and 6.37 (OR 1.635, 95% CI 1.604–
1.666).
The high quota of preterm births in very young (<20 years) mothers (Figure 2)
may be indicative of unfavourable socio-economic situations: the current average
maternal age at delivery is approaching 30 years (Ulizzi et al., 1998) and only
3.2% of mothers face childbirth at a very young age. In addition, it cannot be
excluded that the weeks of gestation may be underestimated more frequently in
poorly educated and/or in very young mothers (James, 1997b).
Baby birth order, maternal education, and fetal gender were of descending
importance though always significant. Second-born children, previously reported
to be the least prone to stillbirth risk (Ulizzi et al., 1998), seem to be less
vulnerable even to preterm risk; and in spite of the improvement in health care,
less educated mothers still run a higher risk of preterm deliveries, probably due
to the relative lack of prenatal care in unfavourable living conditions. Finally, the
factor with the lowest weight in assessing a preterm delivery risk was found to
be fetal gender.
In conclusion, in our sample we found a clear indication that advanced age of the
mother, more than male gender of the baby, contributes an increased risk of
preterm delivery. Biological, most probably hormonal, factors related to
maternal ageing seem more important than the sex of the fetus in determining
the premature onset of labour.
On the other hand, the excess of males among preterm babies is in agreement
with the general finding of biological and even genetic weakness of male fetuses,
witnessed by the high sex ratio observed in unfavourable pregnancy outcome. In
fact a higher male proportion holds not only for stillborns, but also for
spontaneously aborted fetuses (Cann and Cavalli-Sforza, 1968; Hassold et al.,
1983; Jakobovits, 1991; Zonta et al., 1996). It should be noted, however, that
appropriate health care might increase the number of preterm babies born alive
even after a very short gestation, i.e. those babies who otherwise would have
been either aborted or stillborn.
https://academic.oup.com/humrep/article/14/11/2891/860109
BJOG: An International Journal of Obstetrics & Gynaecology

Volume 124, Issue 8
General obstetrics
Free Access
Advanced maternal age increases the risk of very preterm birth, irrespective of parity: a
population‐based register study
U Waldenström
S Cnattingius
L Vixner
M Norman
First published: 21 October 2016

https://doi.org/10.1111/1471-0528.14368
Cited by: 6
Linked article This article is commented on by KY Eichelberger, p. 1245 in this issue. To view this mini
commentary visit http://dx.doi.org/10.1111/1471-0528.14464.
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Abstract
Objective
To investigate whether advanced maternal age is associated with preterm birth, irrespective of parity.
Design
Population‐based registry study.
Setting
Swedish Medical Birth Register.
Population
First, second, and third live singleton births to women aged 20 years or older in Sweden, from 1990 to 2011
(n = 2 009 068).
Methods
Logistic regression analysis was used in each parity group to estimate risks of very and moderately preterm
births to women at 20–24, 25–29, 30–34, 35–39, and 40 years or older, using 25–29 years as the reference
group. Odds ratios (ORs) were adjusted for year of birth, education, country of birth, smoking, body mass
index, and history of preterm birth. Age‐related risks of spontaneous and medically indicated preterm births
were also investigated.
Main outcome measures

Very preterm (22–31 weeks of gestation) and moderately preterm (32–36 weeks) births.
Results
Risks of very preterm birth increased with maternal age, irrespective of parity: adjusted ORs in first, second,
and third births ranged from 1.18 to 1.28 at 30–34 years, from 1.59 to 1.70 at 35–39 years, and from 1.97 to
2.40 at ≥40 years. In moderately preterm births, age‐related associations were weaker, but were statistically
significant from 35–39 years in all parity groups. Advanced maternal age increased the risks of both
spontaneous and medically indicated preterm births.
Conclusions
Advanced maternal age is associated with an increased risk of preterm birth, irrespective of parity, especially
very preterm birth. Women aged 35 years and older, expecting their first, second, or third births, should be
regarded as a risk group for very preterm birth.
Tweetable abstract
Women aged 35 years and older should be regarded as a risk group for very preterm birth, irrespective of
parity.
Introduction
So far, it has not been possible to prevent preterm birth, mostly because the specific causes are
complex and difficult to establish in individual patients. Spontaneous preterm birth is regarded as
a syndrome initiated by multiple mechanisms, such as infection and inflammation, uteroplacental
ischaemia and haemorrhage, uterine overdistension, cervical insufficiency, hormonal disorders,
stress, or other immunologically mediated processes.1
Targeting maternal risk factors for preterm birth in epidemiological studies might provide clues to
the mechanisms leading to preterm birth, and help to identify women at risk.2 Low or advanced
maternal ages have been established as important risk factors for preterm birth, along with
socio‐economic factors, smoking, low or high body mass index (BMI), and an obstetric history of
previous adverse events.3-7 Whereas socio‐economic confounding may largely explain the
increased risk of preterm birth at young maternal age, this explanation seems less obvious in
relation to advanced maternal age.8 Parity is another factor associated with preterm birth, with
the highest rates reported in nulliparous women and the lowest rates reported in second
births.5, 6, 9 The combined effect of advanced maternal age and parity has been less explored,
as most studies have included nulliparous women alone,10-15 or have treated parity as a
covariate in the statistical analyses.16-23 A limited number of studies comparing nulliparous and
parous women,24, 25and studies comparing first and second births,26, 27 suggest that
advanced maternal age influences the risk of preterm birth risk, regardless of parity. A review of
studies from low‐ and middle‐income countries reported an increased risk of preterm birth in
older women (≥35 years) expecting their third birth or more, however.28
Considering maternal age and parity as two interrelated risk factors that may affect pregnancy in
different ways, it is important to study their combined effect on the risk of preterm birth. The
principal aim of the present study was to investigate associations between advanced maternal
age and risks of very preterm and moderately preterm birth in first, second, and third childbirths,
using a large population‐based cohort study. Subgroup analyses of spontaneous and medically
indicated preterm births were also conducted.
Methods
The study was based on data from the Swedish Medical Birth Register (MBR), which includes
more than 98% of all births in Sweden, and is validated annually against the National Population
Register, using the mother's and infant's unique personal identification numbers.29, 30 Starting
at the first antenatal visit, information is prospectively collected during pregnancy and delivery,
using standardised records. We included live singleton births to women aged 20 years or older,
recorded in the MBR from 1990 to 2011. Consequently, the majority of women contributed
information about all of their births, whereas some only provided information about their last birth
at the beginning of the observation period (1990), and others only provided information about
their first birth at the end of the observation period (2011).
From 1990 to 2011, the total number of births in Sweden was 2 267 989. We excluded births to
women younger than 20 years (2.0%), births to women of parity 4 or more (6.5%), multiple births
(2.9%), stillbirths (0.3%), and pregnancies with missing data on gestation (0.1%) and unique
maternal identification number (0.1%), leaving 2 009 068 pregnancies in the final sample.
Analyses stratified by spontaneous and medically indicated births were limited to the period
2000–2011, when information about onset of labour was most complete (99%), leaving 1 087
907 pregnancies in the stratified analyses.
The outcome variables were very preterm birth (22–31 weeks of gestation) and moderately
preterm birth (32–36 weeks of gestation), compared with pregnancies at ≥32 and ≥37 weeks of
gestation, respectively. Specifying a group of extremely preterm births (<28 weeks of gestation)
was not possible because of the insufficient power for analyses by both maternal age and parity.
The best available estimate of gestational age was determined by a hierarchical method based
on expected date of parturition according to ultrasound and last menstrual period.9 In Sweden,
all women are offered ultrasound pregnancy dating at 17 weeks or earlier, and more than 95% of
women accept this offer.31 Medically indicated births were defined as either starting with the
induction of labour or a caesarean section before the onset of labour.
The independent variable was maternal age when giving birth to the first, second, and third
infant. In each parity group, the maternal age range of 25–29 years was used as the reference
group, and compared with maternal ages of 20–24, 30–34, 35–39, and 40 years or older. The
rationale for the choice of reference group was the assumption that 25–29 years was an age
range when outcomes would be optimal,5, 32 considering the U‐shaped association between
maternal age and rates of preterm birth. The maternal age range of 25–29 years was also the
interval with the largest number of live singleton births during the 21‐year study period (Table 1).
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14368
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UNICEF: Philippines Has One of the Highest Premature
Birth Rates in the World
With the number of premature babies on the rise, the government joins forces with
institutions to improve essential newborn care guidelines.
Nov 23, 2012
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According to a statement from the UN Children's Fund (UNICEF), the Philippines ranks
the 8th highest among 184 countries when it comes to the prevalence of premature births. In
fact, according to the UN World Health Organization, premature birth is the biggest killer of
newborn babies, which accounts for more than a million deaths each year. Premature
babies, also referred to as "preemies", are born before they reach at least 37 weeks, and with
body parts that are not yet developed, are usually not fit to survive after childbirth.
According to past studies, premature babies are likely to suffer from long-term negative
effects such as poor academic and socialization skills, as well as a bigger risk of getting
afflicted with heart-related problems when they reach adulthood.
(Related story: Effects of Premature Birth can Last until Adulthood)

The good news is that through proper newborn care, the survival rate of premature babies
can be improved significantly. Said Elizabeth Mason, director of WHO's Department of
Maternal, Newborn, Child and Adolescent Health, "This means keeping them warm, clean,
and well-fed, and ensuring that babies who have difficulty breathing get immediate
attention."
Other methods which have been found to be effective in lowering the deaths of premature
babies is injecting women with steroids before childbirth to help boost the development of
the unborn child's lungs, using antibiotics to treat infections, as well as kangaroo care, which
involves skin-to-skin contact of the mother and infant to promote physiological and
psychological warmth and closeness between the two. This is because babies lose bodily
heat fast and makes them more prone to getting diseases or even dying.
The WHO also stressed the importance of preventing factors that influence premature birth,
such as diabetes, cigarette smoking, hypertension, among others.
In the Philippines, a protocol called the "Unang Yakap" ("The First Embrace") provides
"guidelines for quality and safe birthing services that are mother- and newborn-friendly".
The Philippine Obstetrical and Gynecological Safety (POGS), together with the Department of
Health (DOH) and the WHO, have also come up with guidelines on newborn care called the
DOH-WHO Guidelines on Intrapartum and Immediate Postpartum Care to ensure that moms
give birth safely.
Sources:
• November 17, 2012. "Premature birth leading cause of death among babies
in East Asia-Pacific region" www.unicef.org
• November 18, 2012. "UN stresses benefit of low-cost care in saving
newborns" www.philstar.com
• November 20, 2012. Rina Jimenez-David. "Born too
soon" opinion.inquirer.net
• "Time to focus on more than 350,000 preterm births in the Philippines
every year" www.unicef.org
New study links preterm birth
with microbes in mother's body
inShare
U.S. scientists might have found a new way to tell who's at risk of having a premature baby, by
checking the bacterial community that lives in the mother's reproductive tract.
Trillions of microbes share our bodies, living on the skin or in the gut, mouth or vagina, what
scientists call our microbiome. Many of these germs play critical roles in health, from good digestion
to robust immunity, but they can contribute to health problems if they get out of whack.
What about during pregnancy? Researchers at Stanford University tracked some of those microbial
neighborhoods week by week through 49 healthy women's pregnancies — and found those who
went into preterm labor harbored a different pattern of vaginal bacteria than the other moms-to-be.
It's not clear why, but there's one clue in Monday's study: At-risk mothers had low levels of
lactobacillus bacteria, a family of bugs long thought important for vaginal health.
"We may have a new hook, a new angle to pursue" against preterm birth, said Dr. David Relman, a
Stanford microbiology specialist who led the work. "It's possible that your microbiome could
contribute to this pretty common and devastating condition."
Larger studies are needed, in diverse populations of women, to confirm the link. Another question is
whether the problem is the lack of presumably protective bugs or whatever bacteria moved in in their
place, noted Dr. Catherine Spong, a maternal-fetal medicine specialist at the National Institute of
Child Health and Human Development.
Lifestyle Feature ( Article MRec ), pagematch: 1, sectionmatch:
But the finding "is very compelling," Spong said. It fits with some earlier evidence that "what our
normal host flora is might be important in whether or not you're at risk for certain conditions."
If the research pans out, it raises the possibility of one day trying probiotics or other methods to alter
microbial neighborhoods in women deemed at risk, said March of Dimes senior vice president Dr.
Joe Leigh Simpson.
The work, published in Proceedings of the National Academy of Sciences, was partly funded by the
March of Dimes Prematurity Research Center at Stanford.
About 450,000 U.S. babies are born premature, before completion of the 37th week of pregnancy.
That's 11.4 percent of the babies born in 2013, a rate that has been inching down from a peak of
12.8 percent in 2006. Doctors have made strides in saving increasingly early preemies, but those
babies are at greater risk of lasting vision and developmental problems.
Numerous factors play a role in preterm birth. Risks include pregnancy before age 17 or after 40,
having twins or more, and the mother's own health, such as being underweight or overweight, having
diabetes or high blood pressure, and whether she smokes. Part of the recent improvement in U.S.
preterm birth rates came from reducing elective deliveries ahead of mom's due date, leading to a
drop in "late preemies," or babies born a few weeks early.
But those factors don't explain all premature births, and scientists are trying to uncover other triggers
and how to prevent them.
Alterations in people's normal microbiomes already are thought to play a role in other health
conditions, from obesity to bowel disorders. And some previous research had reported that the
vaginal microbiome changes when a woman becomes pregnant.
At Stanford, Relman's team took a closer look at 49 pregnant women, 15 of whom delivered
prematurely. The researchers examined microbes from the vagina, stool, saliva and teeth and gums
weekly during pregnancy, and monthly for up to a year afterward.
The vaginal microbiome was the one researchers linked to premature birth. In addition to low levels
of lactobacilli, the women who had preemies also harbored some bacteria linked to a common
condition called bacterial vaginosis.
What happened next was a surprise: Everybody harbored a different and more diverse collection of
vaginal microbes after giving birth, whether they delivered early or not, vaginally or by C-section. The
change lasted up to a year for some women.
source: Philippine Star

http://www.philstar.com/health-and-family/2015/08/18/1489475/new-study-links-preterm-birth-
microbes-mothers-body
Journal of the ASEAN Federation

of Endocrine Societies
Home > Vol 28, No 1 (2013) > Natividad
Teenage Pregnancy in the Philippines: Trends, Correlates and Data

Sources
Josefina Natividad
Population Institute, College of Social Sciences and Philosophy, University of the Philippines,
Diliman, Quezon City
Corresponding Author
Josefina N. Natividad, Sc.D.
Director, U.P. Population Institute of the Phillippines
Diliman, 1101, Quezon City, Philippines
Tel. No. +632-9818500 loc. 2468 and 2457
Telefax: +632-9205402
E-mail: jnatividad55@yahoo.com
e-ISSN 2308-118x
Printed in the Philippines
Copyright © 2013 by the JAFES
Received April 18, 2013. Accepted April 23, 2013.
Abstract
Results from cumulative years of the National Demographic and Health Survey and the latest
result of the 2011 Family Health Survey, shows that teenage pregnancy in the Philippines,
measured as the proportion of women who have begun childbearing in their teen years, has
been steadily rising over a 35-year period. These teenage mothers are predominantly poor,
reside in rural areas and have low educational attainment. However, this paper observes a
trend of increasing proportions of teenagers who are not poor, who have better education
and are residents of urban areas, who have begun childbearing in their teens. Among the
factors that could help explain this trend are the younger age at menarche, premarital sexual
activity at a young age, the rise in cohabiting unions in this age group and the possible
decrease in the stigma of out-of-wedlock pregnancy.
Key words: teenage pregnancy, early childbearing, age at menarche
INTRODUCTION
Women’s age-specific fertility rates[*] follow a characteristic pattern. Soon after menarche,
the fertility rate starts at a low level, peaks at ages 20-29, then declines until it stops
completely following menopause. The optimal ages for successful pregnancy are in the peak
reproductive years. At either end of the reproductive spectrum, that is at the youngest
(below 20) and the oldest (40 and above) ages, there is a higher risk of adverse pregnancy
outcomes. Studies have shown that at age 35 and over, and especially at 45 and over, women
are more likely to experience gestational diabetes, placenta previa, breech presentation and
operative vaginal delivery than younger women aged 20-29. Other observed complications
that are more prevalent among older mothers compared to mothers in their twenties are
preeclampsia, gestational hypertension, cesarean delivery, abruptio placenta and preterm
delivery.1
Similarly, when the woman is at the younger extreme of the reproductive age spectrum,
below 20 years, pregnancy carries the same elevated risk of adverse outcomes. 2 Many
studies consistently show that teenage mothers are at increased risk of pre-term delivery
and low birth weight.3-6 From a large data base of births in the Latin American Center for
Perinatology and Human Development in Uruguay, it was found that after adjusting for
major confounding factors, women age 15 and younger were at increased risk for maternal
death, early neonatal death and anemia compared with women age 20-24. Furthermore,
women aged less than 20 had higher risk for postpartum hemorrhage, puerperal
endometritis, operative vaginal delivery, low birth weight, pre-term delivery and small for
gestational age infants.7 The same elevated risks for teenage pregnancies, independent of
known major confounders like low socioeconomic status, inadequate prenatal care and
inadequate weight gain during pregnancy were documented using data from the 1995-2000
nationally linked birth/infant death data set of the United States compiled by the National
Center for Health Statistics and the Centers for Disease Control and Prevention. 8 In
developing countries where no large data bases exist, evidence from smaller samples show
similar results indicating that the risks are not specifically linked to the level of development
of a country’s health care system and the availability of appropriate maternal care for very
young pregnant women,4 but are specific to the age group and its accompanying implication
of biological immaturity for childbearing. The risks follow an age gradient; they are generally
higher at the younger end of the teenage years and diminish toward the latter teen years.
Teenage pregnancy carries other significant non-health risks which are specific to this stage
in the life course.9
For example, when a teenager bears a child and consequently either marries formally or
enters into a consensual union, she puts herself at risk of not finishing her education 10-11
and of limiting her chances of realizing her full potential by being burdened with child care
when she herself is still, almost a child. If the teenager remains unmarried following a
pregnancy, she risks social stigma from having an out-of-wedlock pregnancy and of having
to bear its negative consequences. 12
At the aggregate level, a high teenage pregnancy rate contributes to high population growth
as teenage mothers will have considerably longer exposure to the risk of pregnancy than
those who enter into marital unions at a later age.
Teenage pregnancy has two aspects, and both could occur concurrently within the same
country, whether developed or developing. On the one hand, high teenage pregnancy rates
may result from the culturally sanctioned practice of early marriage and early marital
childbearing, and on the other, from premarital intercourse and unintended pregnancy.
Research evidence points to a shift in behaviors among young people in patterns of sexual
activity such that early childbearing is becoming more a consequence of early intercourse.
This is more often true in urban than in rural areas.13 Additionally, a downward trend in the
age at menarche in both developed and developing countries has been reported in a number
of studies.14-16 Zabin and Kiragu (1998) in their review report a connection between age of
onset of sexual activity or age at first birth and age at menarche resulting in earlier onset of
childbearing for the current generation of teenagers compared with earlier cohorts.17
Because of the increased risks to both mother and child of too early childbearing, there is a
need to understand the situation on teenage pregnancy in any country in order to design
appropriate interventions. But obtaining reliable and valid data for analysis is not always
easy, especially in a developing country.
This paper consists of two parts: the first discusses data sources for the study of teenage
pregnancy in general; the second part presents trends in teenage pregnancy in the
Philippines, some correlates and an analysis of the drivers for the observed trend using a
specific data source. We will use data from the National Demographic and Health Survey
(NDHS) conducted in the Philippines at 5-year intervals since 1968. The NDHS surveys are
part of the DHS program of surveys that are highly regarded for methodological soundness
and rigor in the design and conduct of data collection. With a common research design and
questionnaire adopted throughout all the surveys in the series, NDHS data lends itself well
to the analysis of long term trends in teenage pregnancy in the Philippines.
Sources of Data on Teenage Pregnancy
Hospital-based records
Data for the study of levels, trends, determinants and consequences of teenage pregnancy
are usually derived from varied sources and using a wide range of data collection methods.
Studies on the consequences of early childbearing, particularly the risk of adverse outcomes
normally use hospital-based records, using either prospective or retrospective designs. For
example, completed charts on births occurring in a hospital over a given period can be the
source of information for studying pregnancy outcomes, as these will normally contain basic
demographic information: the mother’s age, the pregnancy order as predictor variables and
factors like maternal complications, placental complications, medications administered in
hospital and neonatal outcomes as outcome indicators.2 The advantage of these data sets is
that they provide reliable and valid reports on the pregnancy outcomes under study using
medically accepted diagnostic criteria and are not based on the teenage mother’s self-report.
The main disadvantage is possible misclassification by age if there is reason for the mother
to conceal her true age. If such a bias exists, it is likely to be higher in the younger adolescent
than the older adolescent years as it may be less socially acceptable to have a birth at age 12
or 13 than at 18 or 19. Background variables on the mother that can serve as explanatory
factors may also be limited; some will record education but socioeconomic status is normally
not included in hospital records. As a data source for determining the total number of
teenage pregnancies, hospital-based records are not reliable as these cover only hospital-
based births. In most developing countries, majority of births occur in non-hospital settings.
Vital statistics
To determine the level of teenage pregnancy in a given country, one potential data source is
the Vital Registration System, which collects vital statistics such as births, death and
marriages in the population. Usually, the national government requires that these vital
events are officially reported through birth registration, death registration and marriage
registration. In the Philippines, recording these events is the main duty of Local Civil
Registrars. In some developed countries, there is a separate perinatal statistics collection
system based on data collected by midwives and other health practitioners for each live and
still birth which takes place in hospital and for home births.18 The vital registration system
is an ideal way to capture the level of teenage pregnancy year-on-year because it is a
continuing record of births as they occur. Unfortunately, most vital registration systems
especially in developing countries are hobbled by problems of underreporting and
incompleteness. For example, it is estimated that in 2000, the level of completeness of birth
registration in the Philippines was 78 percent, i.e., only 78 per cent of 5-year-olds at the time
of the survey have been registered in the birth registry (have a birth certificate, whether or
not it was physically with the household at the time of the survey) [†]. There is also a marked
disparity among regions in the Philippines in the completeness of birth registration, with the
Autonomous Region of Muslim Mindanao registering the lowest level of completeness of
birth registration.
Survey data
Even when vital registry data effectively capture all births in its reporting system, the type
of information contained in birth registration forms will still be unable to answer many
questions that will help understand fertility and its determinants better. Sample surveys fill
in this gap. The most commonly accepted alternative source of data for estimating teenage
pregnancy and investigating its correlates are nationally representative surveys of women
in the reproductive years (15-49), extracting the relevant data for women aged 15-19 in the
sample. Respondent to these surveys are the women themselves.
There have been a number of recent publications from the World Health Organization, USAID
and other international groups providing guidelines for the conduct of ethical research when
the subjects are children and adolescents. Among the recommendations are procedures for
securing informed consent from parents/guardians when the subject is a minor[‡]. The
recommended practice respects country-specific customs and traditions and may waive the
requirement for written parental consent and accept alternative procedures for
documenting consent that are appropriate to the local setting.22-23 In the field of survey
research on fertility at all ages including the teenage years, the Demographic and Health
Surveys (DHS) program funded by USAID and implemented by ORC- Macro has been the
gold standard.
DHS data are publicly available and easily downloadable hence are commonly used in many
cross-country comparisons. In the Philippines, the National Demographic and Health Survey
(NDHS) seriesis the major data source on long-term trends in teenage pregnancy and its
determinants. The surveys are undertaken in the Philippines by the National Statistics Office
in collaboration with the Department of Health and ORC Macro.24-25 The sample of women in
the reproductive years is representative at the national and regional levels. The NDHS
follows a standard protocol for obtaining informed consent from survey respondents.
In the succeeding analysis of teenage pregnancy in the Philippines, we use mainly the NDHS
survey results from various survey dates. For the long term trend in the age-specific fertility
rate at ages 15-19, we use NDHS data from 1973 to 2008. For the analysis of determinants
we refer to the survey results from 1993 to 2008 NDHS. Other data sources on correlates of
teenage pregnancy cited in this paper are the Young Adult Fertility and Sexuality surveys of
1994 (YAFS 2) and 2002 (YAFS 3) and the 2011 Family Health Survey (FHS). YAFS is a series
of surveys on young adults aged 15-24 gathering information on sexual and non-sexual risk
behaviors and its correlates while the 2011 FHS is the latest round of what used to be known
as the Family Planning Survey (FPS) series, also covering women age 15-49 as does the
NDHS, but mostly focused in scope on family planning. Since 2006, the FPS has incorporated
a complete birth history for measuring fertility and infant child mortality and a special
module to collect information for estimating maternal mortality.
Teenage pregnancy in the Philippines
Survey data from both the NDHS Series and the 2011 FHS supports findings of other studies
from other countries about the elevated risk of early neonatal deaths among teenage
mothers (Table 1).
Click here to download Table 1

Table 1. Neonatal and infant mortality rate for the 10-year period preceding the survey
Neonatal and infant mortality tend to be higher at both ends of the reproductive spectrum,
i.e., the youngest (less than 20) and the oldest (aged 45-49) age groups. Teenage mothers
also compare poorly with mothers from the older age groups in a number of reproductive
health indicators. For one, they tend to have the shortest birth intervals (Figure 1) of all age
groups. Taking into account the fact that their bodies are not yet ready for the physical
demands of childbearing, having closely spaced births exposes young mothers to further
health risks.
Still, having closely spaced births is not necessarily a matter of choice for these young
mothers as implied by the finding from the 2003 and 2008 NDHS and the 2011 FHS that
currently married women aged less than 20 have the highest unmet need for contraception
(Figure 2). For example, in the 2011 FHS, 37 percent of currently married 15-19 year olds
had an unmet need for contraception, mostly for spacing of births, compared to 19 percent
for all currently married women. This is an indication that adolescent mothers are an
underserved segment of reproductive health programs and services.
Click here to download Figure 1

Figure 1. Median number of months since preceding birth
Figure 2. Percent of women with unmet need for family planning
The WHO reports that about 16 million adolescent girls aged 15-19 give birth each year,
roughly 11% of all births worldwide. Almost 95% of these births occur in developing
countries. The adolescent fertility rate worldwide was estimated to be 55.3 per thousand for
the 2000-2005 period, meaning that on average about 5.5% of adolescents give birth each
year. In the Philippines, according to the latest Vital Statistics Report released by the National
Statistics Office, in 2008 a total 1,784,316 births were registered; of these 10.4%, (186,527
births) were born to mothers under 20 years of age. Total registered births in 2008 increased
by 2% from the previous year’s 1,749,878 births while births to teenage mothers increased
by 7.6 %, from 173,282 in 2007. Assuming the same level of underreporting for teenage
births as for total births, a comparison of the percent increase of total births and births to
teenage mothers suggests that fertility has a faster pace in the youngest reproductive ages.
To get further insight into how the fertility at the youngest reproductive age group compares
with that of later years, Figure 3 shows the long-term trend in fertility rates at three age
groups, the youngest (15-19), the peak reproductive years (25-29) and the oldest
reproductive group (45-49) over a 35-year period.

Figure 3. Age-specific fertility rates for women aged 15-19, 25-29 and 45-49, 1973 to 2008
NDHS
Over this period, there has been a dramatic decrease in the fertility rate at the largest and
the oldest reproductive age groups, accounting in large measure for the decline in the total
fertility rate[§][**] of the Philippines from 6.0 children in 1973 to 3.3 in 2008. In 1973, there
were 302 births per thousand women aged 25-29; by 2008 this has dropped considerably to
172. Similarly, in 1973, there were 28 births per thousand women aged 45-49 dropping
dramatically to only 6 births per thousand women in 2008. But, amidst these declining rates
in the reproductive ages above 20, the 35-year trend indicates that the fertility rate in the
15-19 age group has remained virtually unchanged, from 56 births per thousand women in
1973 to 54 in 2008.
Compared with the rest of the world, the Philippines’ adolescent fertility rate is within the
average range. Compared with its neighbors in Southeast Asia, it is also mid-range, at the
same level as Indonesia, but higher than Thailand and Vietnam (Figure 4). Despite anecdotal
reports to the contrary, the adolescent fertility rate has not changed significantly in four
decades.
The age-specific fertility rate (ASFR) for women 15-19 is a measure of the incidence of
fertility; it is the rate of births relative to the person years of exposure to the risk of
childbearing within the given age group. It is highly possible for one woman to contribute
more than one birth to the numerator as the reference period is usually about five years
before the survey date. Therefore, for purposes of gauging the level of early childbearing in
the population, the ASFR is not a good measure.
In place of the ASFR at 15-19, a more appropriate gauge of early childbearing is the
proportion of women in the age group who are pregnant/who have become
mothers.12,26,27 Unlike the ASFR, in this measure a woman can only be counted once. The
proportion of women who have already given birth at a certain age is a measure of the timing
of first birth and is an indicator of how early child bearing has begun in the population.
Source: World Health Organization
(http://apps.who.int/gho/data/view.main.310?lang=enaccessed 15 April 2013)

Figure 4. Adolescent Fertility Rate in Selected Southeast Asian Countries
Figure 5 presents the trend in the proportion who have begun childbearing at 15-19 over a
15-year period based on the 1993-2008 NDHS. The measure is further broken down into a
younger (15-17) and older group (18-19).
Figure 4 shows that the proportion of 15-19 year olds who have begun childbearing has been
steadily rising, from about 7 percent in 1998 to 10 percent in 2008. The increase is steeper
among the older teens (18-19) but there is a 100 percent increase among the younger teens,
from 2 per hundred in 1993 to 4 per hundred in 2008. Overall, the picture presented in this
figure is that the proportion of teenagers who have who have begun childbearing is higher
in 2008 than in 1993. Thus by this measure, we can conclude that indeed more women are
getting pregnant or have become mothers in their teens nowadays than in the past and that
the picture depicted by the age-specific fertility rate is a misleading one when describing the
trend in teenage pregnancy.

Figure 5. Percent who have begun childbearing, 1993-2008 NDHS
The question to ask now is, “Does early childbearing occur equally in all segments of the
young female population or does it occur more often in some subgroups than others?” Three
factors are usually cited as sources of variability in teenage pregnancy rates in any
population. Across countries, teenage pregnancy tends to be more prevalent in rural areas,
among women with low education and among the poor.
To investigate the situation in the Philippines, the next set of figures presents the same
longitudinal trend broken down by rural-urban residence, educational attainment and
socioeconomic status (as measured by the wealth index[††]). Those who had no formal
schooling are excluded in the analysis because they comprise a very small proportion of the
sample population
In terms of residence, Figure 6 shows that the percent who have begun childbearing at 15-
19 is generally higher in rural than in urban areas but the percent change from 1993 to 2008
is higher in the urban (62.5 percent) than in the rural (40.4 percent). In both areas the
proportions who have become mothers has been steadily increasing in the 15-year reference
period.

Figure 6. Percent who have begun childbearing by rural-urban residence, 1993 to 2008
NDHS
By educational attainment (Figure 7) there is a clear education gradient in early childbearing

but while teenagers with elementary level schooling have the highest proportions who have
become mothers, the trend shows no consistent pattern of increase through the years. The
rise in early childbearing is more pronounced among those with high school and college
education where the trend shows a persistent upward climb for each survey round. The
upsurge is especially pronounced among those with college education with the increase in
early childbearing from 1993 to 2008, a striking 290 percent change.
Figure 8 compares early childbearing across the wealth quintiles with the first quintile
representing the poorest 20% of the women (based on the status of their household) and the
fifth quintile the richest 20%. Only two data points are compared because only the 2003 and
2008 NDHS rounds had available information to compute the wealth index. The results
indicate a gradient of difference by socioeconomic status similar to that observed with
educational attainment, which is to be expected as these two variables are highly correlated,
i.e., those with the lowest education will tend to be among the poorest. Overall, early
childbearing is most prevalent among women in the poorest (first and second) quintiles.
Comparing the 2003 and 2008 data it appears that the prevalence of early childbearing did
not change much for women from a high prevalence level in the two lowest quintiles (in fact
it decreased among the poorest teenagers) but definitely increased for the higher quintiles
(3rd, 4th and 5th).

Figure 7. Percent who have begun childbearing by educational attainment, 1993-2008
NDHS

Figure 8. Percent who have begun childbearing by wealth quintile, 2003 and 2008 NDHS
The comparison of differences in early childbearing across residence, education and

socioeconomic status of the adolescent suggest a changing pattern in early childbearing. Not
only has the percentage who have become mothers in their teens been increasing, but the
composition of these teenage mothers has been changing. The transition has moved from
being mostly rural, poor and with the lowest educational attainment toward an increasing
proportion of urban residents, better educated and those from the middle to the richest
socioeconomic groups have likewise commenced childbearing in the teenage years.
What could be driving this trend of early childbearing among all groups in society? As stated
earlier, this could be a result of early marriage or of premarital sexual activity leading to
pregnancy or to both. To investigate which of these two factors could account for the change,
we compare the 1993 to 2008 marital status of teenagers categorized as never married,
married, living together and separated. Married refers to those who are formally in a marital
union, living together refers to those who are in a consensual union and have not formally
married.

Figure 9. Marital status of women aged 15-19, 1993 to 2008 NDHS
Figure 9 shows that from the 1993 NDHS, 92 percent of teenagers were never married. This
proportion has consistently declined through the years and in the 2008 NDHS, only 89
percent of teenagers were never married. If early marriage was driving the trend toward
higher prevalence of early childbearing, the proportion married should correspondingly
increase with the decline in the proportion never married. Figure 9 show that the proportion
who are married has been declining. What is steadily on the rise is the proportion in a
consensual union. This suggests that it is early premarital sexual activity that is the driver
for the trend toward the increasing prevalence of early childbearing in the Philippines.
Pregnancy resulting from premarital sexual activity often leads to the decision to begin
cohabitation but not necessarily to a formalized marital union. Corroborating evidence for
this shift toward non-marital fertility among teenage women is found in the vital statistics
report of the National Statistics Office which states that in 2008 “Majority (79.2 %) of babies
born to women under 20 (years) of age were illegitimate.”[‡‡] Illegitimate means that the
mother and father were not formally married at the time the birth was registered. The trend
toward non-marital fertility is by no means limited to the youngest women. The Vital
Statistics Report for 2008 further states that of the total births registered in 2008, 37.5
percent were born out of wedlock and 40 percent of illegitimate births were born to mothers
in the age group 20-24.
Evidence for early premarital sexual activity is further supported by findings from two
surveys on a national representative sample of young people aged 15-24 in the Philippines,
the Young Adult Fertility and Sexuality Study done in 1994 (YAFS 2) and in 2002 (YAFS 3).
In YAFS 2, 8 percent of 15-19 year olds reported ever having engaged in premarital sex; this
increased in 2002 to 12 percent. Only 24 percent used contraception during their first
premarital sexual activity.28 Since YAFS was conducted more than a decade ago, presumptive
changes in prevalent sexual behaviors and practices of young people may have undoubtedly
contributed to the increasing proportion of teenage girls becoming mothers at a very early
age.
Another contributory factor to the increasing prevalence of early childbearing is the
decreasing age at menarche, a development that is consistently reported in the literature as
occurring in countries that have experienced significant improvements in living conditions
and the nutritional status of female children. Table 2 presents the reported age at menarche
by women in the various reproductive age groups.
Click here to download Table2

Table 2. Percent distribution of age at menarche by age at time of the survey, 2008 NDHS
Table 2 indicates that the reported age at menarche has been declining across successive
cohorts of women. For example, among the 15-19 year olds, the reported age at menarche
peaks at age 12 (31%) while among the 45-49 year olds the peak is at 15 and above (30.7%).
This trend in consistent with that reported in the literature about the deceasing trends in the
age at menarche in other developed and developing countries.29
DISCUSSION
Overall, the findings in this paper from the analysis of the Philippines’ National Demographic
and Health Survey series over a number of years, together with findings from the Family
Health Survey, corroborates that more teenagers now are getting pregnant compared to
earlier cohorts. A confluence of factors have come together to make this happen: a trend
toward younger age at menarche, changing norms and practices with regard premarital
sexual activity among the youth and increasing acceptance of premarital sex coupled with
less societal pressure to legitimize out-of-wedlock pregnancies. Although there are
differences amongst groups, the increasing prevalence of early childbearing is observed in
all socioeconomic classes, all levels of education and in both urban and rural settings.
Teenage pregnancy exposes both mother and child to many health and other risks, both and
there is need to further study how to mitigate its effects or how to reverse the trend. Any
interventions should be cognizant of the following factors:
1. While early childbearing has increased among the non-poor, the better educated and
residents of urban areas, teenage pregnancy is still unacceptably higher among the poor,
those with lower education and rural residents. Interventions designed to help reverse the
trend should be tailored to the circumstances leading to early pregnancy that may be specific
to these subgroups.
2. The timing of school-based interventions such as sexuality education should be mindful of
the finding that teenage pregnancy is highest among those with the least education,
specifically those with elementary or lower educational attainment. Thus age-appropriate
sexuality education should begin in the pre-adolescent years before teenagers leave school.
The high unmet need for contraception among currently cohabiting or married teens,
requires specific services and family planning programs for this group. Teenage mothers
have the lowest birth intervals (median of less than 24 months) and expose themselves and
any more babies to greater risks if a subsequent pregnancy is not prevented. The fact that
there is high unmet need for contraception in this age group indicates that there is a desire
to space births longer but for some reason the expressed desire is not matched by the
corresponding action of using contraception for birth spacing (Figure 2). Further studies
should investigate barriers to the use of contraception among currently married teenagers
as no direct answers are available from either the NDHS or the FHS.
3. Hospital-based prospective and retrospective studies to study the adverse outcomes of
early pregnancy and childbirth on the mother and her baby compared to other age groups
are needed to better understand the specific health risks in the Philippine setting. Findings
of these studies will be an important input for intervention programs not only for the
teenagers themselves, but also for health providers who will be involved in the delivery of
services for this age group.
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NEONATAL BIRTWEIGHT
Mothers and Fathers in NICU: The Impact of Preterm Birth on

Parental Distress
Chiara Ionio, Caterina Colombo, [...], and Gianluca Lista
Additional article information
Abstract
Preterm birth is a stressful event for families. In particular, the unexpectedly early
delivery may cause negative feelings in mothers and fathers. The aim of this study
was to examine the relationship between preterm birth, parental stress and negative
feelings, and the environmental setting of NICU. 21 mothers (age = 36.00 ± 6.85)
and 19 fathers (age = 34.92 ± 4.58) of preterm infants (GA = 30.96 ± 2.97) and 20
mothers (age = 40.08 ± 4.76) and 20 fathers (age = 40.32 ± 6.77) of full-term
infants (GA = 39.19 ± 1.42) were involved. All parents filled out the Parental
Stressor Scale: Neonatal Intensive Care Unit, the Impact of Event Scale Revised,
Profile of Mood States, the Multidimensional Scale of Perceived Social Support
and the Post-Partum Bonding Questionnaire. Our data showed differences in
emotional reactions between preterm and full-term parents. Results also revealed
significant differences between mothers and fathers’ responses to preterm birth in
terms of stress, negative feelings, and perceptions of social support. A correlation
between negative conditions at birth (e.g., birth weight and Neonatal Intensive
Care Unit stay) and higher scores in some scales of Impact of Event Scale Revised,
Profile of Mood States and Post-Partum Bonding Questionnaire were found.
Neonatal Intensive Care Unit may be a stressful place both for mothers and fathers.
It might be useful to plan, as soon as possible, interventions to help parents through
the experience of the premature birth of their child and to begin an immediately
adaptive mode of care.
Keywords: prematurity, NICU, parental stress, parenting, caring
Introduction
Preterm birth is defined by the WHO as birth that occurs before 37 weeks of
gestation. Until the Nineties, prematurity was defined on the basis of birth weight,
however, in recent years gestational age has been considered as the main indicator
of physical and neurological maturation of preterm babies (Sansavini & Faldella,
2013). Preterm birth is a multi-problematic event that presents two main
consequences: first of all, the medical and neurophysiological conditions of the
new born baby put him or her in danger (particularly for infants with a weight
lower than 1.500 grams and with a gestational age less than 32 weeks), and
secondly, it could have a negative impact both on the mother and father’s
relationship and on parent–child interactions (Müller-Nix & Ansermet, 2009).
Although it has been widely demonstrated that preterm infants are at risk for
developing deficit and delays, the underlying causes of these poorer developmental
outcome, and the role of parents, are still less understood.
In particular, as far as we know still few studies investigate mothers’ and fathers’
initial experience and reactions immediately after the premature birth of their child
(Aagaard & Hall, 2008; Arnold et al., 2013; Jackson, Ternestedt, & Schollin,
2003; Maroney, 1994; Orapiriyakul, Jirapaet, & Rodcumdee, 2007). Furthermore
still few studies examined fathers’ experiences of preterm birth, although these
studies highlighted the importance of fathers’ experiences (Candelori, Trumello,
Babore, Keren, & Romanelli, 2015; Lundqvist & Jakobsson, 2003; Pohlman,
2005).
Preterm delivery potentially combines both biological and environmental risk
factors, therefore, simple cause-and-effect models that identify preterm birth itself
as the only cause for developmental disorder are lacking of predictive efficiency
(Sameroff & Chandler, 1975). Sameroff and Chandler (1975) proposed a
transactional model that described that children and parents influence each other.
This model predicts that preterm birth itself does not cause negative developmental
outcomes alone but that the stressful conditions following early delivery moderates
the risk for later developmental difficulties.
One month after preterm birth, parents are shocked by the physiological and
psychological conditions of their baby (Hoffenkamp et al., 2015; Singer et al.,
2003). The event could interfere with their transitions into parenthood: the adverse
medical condition of their baby prevents parents from taking care immediately of
their new born child (Axelin, Lehtonen, Pelander, & Salanterä, 2010; Feldman,
Weller, Leckman, Kuint, & Eidelman, 1999). When their baby stays in NICUi,
parents usually feel powerless and helpless; therefore, they may be more stressed
and vulnerable to emotional difficulties than parents of full-term babies (Clottey &
Dillard, 2013; Sansavini & Faldella, 2013). Furthermore, preterm birth could be a
traumatic event that affects parents’ everyday lives. In most cases premature birth
is the unexpected result of medical complications for the mother, which makes
necessary the immediate interruption of pregnancy, often in emergency situations,
in order to avoid serious threats to the baby’s and mother’s health (Coppola &
Cassibba, 2004). Referring also to the eight criteria for defining a potentially
traumatic event, identified by Green (1990), premature birth could be a traumatic
event since it is a threat to the physical integrity of the mother and a threat to the
integrity of a loved one, the baby.
This trauma could lead parents to develop post-traumatic stress disorder symptoms
of avoidance, hyperarousal, and intrusion (Lefkowitz, Baxt, & Evans, 2010),
preventing parents from having a normative transition to parenthood (Watson,
2011) and damaging the new relationship between them and their baby (Ionio & Di
Blasio, 2014).
Furthermore after birth the difficult medical conditions of premature babies and the
mechanical environment in the NICU usually prevent a skin-to-skin relationship
between children and their parents, and this could be dangerous for the future
development of the babies (Wigert, Berg, & Hellström, 2010). Several studies have
demonstrated the importance of parents’ extended presence and skin-to-skin
contact with their infants for the infants’ long-term outcomes. Positive effects of
skin-to-skin contact between children and their parents are related to effects on the
parents (de Macedo, Cruvinel, Lukasova, & D’Antino, 2007; Feldman, Eidelman,
Sirota, & Weller, 2002; Green & Phipps, 2015).
These findings are particularly important since a recent study pointed out that
although the majority of units in different European countries reported a NICU
policy that encourage both parents to take part in the care of their babies, parental
involvement as well as the role played by mothers and fathers are generally more
limited in Italy. Tasks involving more responsibility such as supporting the baby
during uncomfortable procedures were commonly allowed in Sweden, United
Kingdom and the Netherlands, but less in Italy. Furthermore in Italy many units
applied restrictions regarding the frequency and the time of parents' admission to
NICU and fathers are usually less involved than mothers as regards skin-to-skin
contact and Kangaroo Care (Pallás-Alonso et al., 2012).
Parents of premature babies also have to leave their regular routines and spend
many hours in the NICU, where they continue to experience the infants’ fragility
and mortality (Clottey & Dillard, 2013). They live in a state of psychological and
physical separation from their babies, aggravated by the artificial environment of
the neonatal intensive care unit (NICU), in which the medical staff takes care of
their infant’s neuropsychological and behavioral development and wellbeing,
which often causes parents further pain and distress (Montirosso, Provenzi,
Calciolari, Borgatti, & NEO-ACQUA Study Group, 2012; Sansavini & Faldella,
2013).
The sense of powerlessness and impairment could alter the parental role, and it
could also increase anxiety, depression, helplessness, frustration, guilt, and anger
(Müller-Nix & Ansermet, 2009).
In parents of preterm infants also external infant characteristics, associated with
immaturity and severity of medical status, could be stressors that could further
impair the very first relationship between parents and their baby (DeMier et al.,
2000; Müller-Nix & Ansermet, 2009). The appearance of preterm babies is
perceived as less physically attractive than the features of full-terms: they are
immature and show less infantile facial features (Goldberg & DiVitto,
2002; Hildebrandt & Fitzgerald, 1979; Hoffenkamp et al., 2012).
In general parents should try to establish a balance between adaptive or non-
adaptive behaviors in order to complete a functional transition to parenthood
(Cena, Imbasciati, & Baldoni, 2010).
In order to make this transition, fathers and mothers have to perform different roles
and develop specific competences. Different studies showed that after premature
birth fathers usually have a supportive role. They are expected to help their wives,
to contain their negative feelings such as sufferance, anxiety, and depression, and
to think about both their wives and their babies, giving them proper support
(Alkozei, McMahon, & Lahav, 2014; Lindberg, Axelsson, & Öhrling, 2007). Only
after the discharge of their babies do fathers seem to be safer and more confident
trying to establish a new active relationship with infants (Jackson et al., 2003). On
the other hand, mothers try to establish a positive relationship with their newborn
babies also by improving their abilities to take care of them and by learning new
techniques from the medical staff. Sometimes, this type of interaction allows
mothers to recover their self-esteem and their capacity to respond to their infants as
an “expert” caregiver (Sansavini & Faldella, 2013). Furthermore only few studies
on non-clinical sample have tried to identify the presence of significant differences
between mother-child and father-child interaction. In particular some studies have
shown that fathers are more prone to physical contact with their babies than
mothers during the interaction (Lamb & Lewis, 2010). Furthermore this physical
contact searched by fathers may affect the cognitive and socio-emotional child’s
development both directly and indirectly, encouraging mother-child exchanges and
supporting the triadic interactions within the family (Brown, McBride, Bost, &
Shin, 2011).
Other studies have pointed out that parental stress experienced during the infant’s
admission in NICU could influence the psychological and behavioral development
of the baby (Dudek-Shriber, 2004; Howe, Sheu, Wang, & Hsu, 2014). Thinking
about their babies as sick and in danger is very stressful for parents, and it may
bring them to an emotional crisis (Alkozei et al., 2014; Franck, Cox, Allen, &
Winter, 2005). For this reason, parents need to be informed about all the medical
procedures carried out on their sick baby. Moreover, having a good relationship
with medical staff and an active listener to their fears could reduce their anxiety
(Müller-Nix & Ansermet, 2009).
Teti, Hess, and O’Connell (2005) reported that parents of premature babies are
“preterm parents”: negative feelings, stress, anxiety, and the uncertain future of
their babies put them in a position of fragility that could damage their attachment
relationship with their babies (Coppola & Cassibba, 2004). Therefore, supporting
parents during the hospitalization of infants could protect the development of the
“preterm family” (Korja et al., 2010).
Since most of the studies examined focused on experiences over the longer period
of the infant being hospitalized, they may analyze situations which have already
become ‘normality’ for many parents. The main aim of the present study was to
explore mothers’ and fathers’ experiences immediately after the premature birth of
their babies and their first experience of NICU in order to increase our knowledge
about mothers’ and fathers’ initial experience and reactions. In particular this study
wanted to identify the most stressful factors for parents of premature babies and to
specify the role of mother and father inside the NICU. In particular we wanted to
investigate how mothers and fathers experience preterm birth immediately after the
delivery and how they deal with the difficulties of this event and to understand
how their feelings are linked to the NICU. Furthermore, we wanted to analyze the
relation between the parents’ feelings and their premature children’s characteristics
soon after their birth in order to better understand how this event influences the
maternal and paternal response.
Aim
Several studies (Matricardi, Agostino, Fedeli, & Montirosso, 2013; Miles,
Holditch-Davis, Schwartz, & Scher, 2007; Sansavini & Faldella, 2013) have
shown how premature birth (< 37 weeks) is often a traumatic event for parents that
could cause in mothers and fathers trauma-related symptoms, such as symptoms of
avoidance, intrusion and hyperarousal, negative states of mind and feelings, such
as anxiety, hostility, inertia, depression, and bewilderment, and stress related to the
NICU perception, the baby’s conditions and the perception of an altered parental
role (Ionio & Di Blasio, 2014; Lefkowitz et al., 2010; Müller-Nix & Ansermet,
2009).
One of the aims of this study was to investigate maternal and paternal responses
immediately after the premature birth of their child in terms of trauma-related
symptoms, negative states of mind and feelings and stress related to the NICU
perception, the baby conditions and the perception of an altered parental role by
comparing a clinical sample of parents of preterm children and a control sample of
parents of full-term children.
Furthermore, according to previous studies that showed that mothers experienced
higher level of stress than fathers after their baby’s premature birth and NICU stay
(Jackson et al., 2003), we wanted to better understand if mothers and fathers faced
in a different way the premature birth of their babies in terms not only of trauma-
related symptoms and negative states of mind and feelings but also of how they
perceive the NICU, their baby conditions and their parental role and external
support.
Finally, we wanted to understand how parental trauma-related symptoms, negative
states of mind and feelings and stress related to the NICU perception, the baby
conditions and the perception of an altered parental role in the preterm children
sample were linked to the neonatal characteristic of the babies and to the
hospitalization condition.
Based on previous studies (Ionio & Di Blasio, 2014; Lefkowitz et al.,
2010; Matricardi et al., 2013; Miles et al., 2007; Müller-Nix & Ansermet, 2009),
we expected:
1. the parents of preterm children would to show higher levels of trauma-related

symptoms, negative states of mind and feelings and stress related to the NICU
perception, the baby conditions and the perception of an altered parental role
than parent of full-term children;
2. mothers to show more trauma-related symptoms, to feel more stressed, anxious,
depressed and angry than the fathers and to respond more negatively to the
situation, in particular as regards the NICU perception, the baby conditions and
the perception of an altered parental role;
3. a correlation between higher levels of trauma-related symptoms, negative states
of mind and feelings and stress related to the NICU perception, the baby
conditions and the perception of an altered parental role in parents and the poor
biological condition at birth, such as low gestational age and birth weight.
Methods
Participants
Needs
Bonding
For any mother, her maternal instinct is to be continuously with her newborn infant, to
care and nurture. This is not possible for mothers of very low birth weight premature
infants, whose infants require hospitalisation. The need to bond with their infants was
expressed in statements like: “It would be better to be around my baby all the time.”
“We could be given a room to stay in order to check our babies day and night.”
Evans and Madsen (2005:190) report that some hospitals in their study had unlimited
visiting hours for parents, and others had areas in which parents could stay for prolonged
periods to be near their infants
What is bonding with your baby during pregnancy?

Bonding with a baby during pregnancy refers to a process through which a pregnant woman experiences
feelings and emotions for her foetus, interacts with her foetus and develops a maternal identity (i.e.
begins to identify herself as a mother) during pregnancy. The bond between a woman and her foetus is
often conceptualised by health professionals in terms of maternal-foetal attachment or prenatal
attachment.
Defining and measuring the extent of bonding during pregnancy
Scientists first began studying the maternal-foetal bond in the 1960s and 1970s, after observing women
grieving for infants who died during childbirth. They believed that the women’s grief would not have been
possible if they had not developed a bond with the infant during pregnancy.
Since then, numerous definitions of the maternal-foetal bonding have emerged. While there are many
differences in the definitions, they are generally split into two groups:
1. Definitions which describe attachment in terms of the woman’s emotions during pregnancy; and
2. Definitions which describe attachment in terms of the woman’s behaviours during pregnancy.
Questionnaires have also been developed to measure the extent to which a woman bonds with her foetus
during pregnancy. These questionnaires are used to assess levels of maternal-foetal bonding in pregnant
women, as well as describe the different characteristics (e.g. age) of women who bond with their foetus to
a greater or lesser extent.
Health benefits of bonding with the foetus during pregnancy

The extent to which a woman bonds with her foetus during
pregnancy is an important determinant of the extent to which
she bonds with her newborn baby after childbirth. Women who
bond more during pregnancy, also develop a greater bond with
their baby during infancy.
The bond between a mother and her newborn in turn
influences the baby’s future growth and development. A
strong bond between a mother and her baby is associated with
better development outcomes later in life.
Factors which influence a pregnant woman’s
bonding with her foetus
Research using questionnaires designed to assess maternal-foetal attachment has identified
many factors which influence the extent to which a woman bonds with, or feels attachment to her foetus
during pregnancy.
Socioeconomic and health status and health seeking behaviours

Like other poor maternal health outcomes (e.g. premature birth, delivering a low birth weight infant),
failure to bond with the foetus during pregnancy is thought to be more common amongst women from
poor social and economic conditions. Women from low socio-economic backgrounds tend to have
poorer health status and are also less likely to access health care facilities than women have higher
socio-economic status.
Scientists are still studying whether or not maternal-foetal bonding is associated with indicators of socio-
economic status like income and level of education.
There is some evidence that positive health seeking behaviours (which are more prevalent in women
from better socio-economic backgrounds) are associated with increased maternal-foetal bonding. These
include:
 Receiving prenatal care: women who receive prenatal care are more likely to bond with their foetuses
than those who do not;
 Maintaining a healthy diet: women on a healthy diet have greater levels of maternal-foetal bonding than
women on an unhealthy diet; and
 Obtaining regular exercise: exercising women developing greater bonds with their foetuses than non-
exercising women.
Race or ethnicity
Women from ethnic minorities are more likely than Caucasian
women to have low socioeconomic and health status and thus
it would be expected that they would also experience lower
levels of prenatal attachment. However scientists have not yet
produced strong evidence to determine whether or not race or
ethnicity is associated with greater or lesser maternal-foetal
bonding.
Age
Evidence suggests that age does not influence the extent to
which a woman bonds with her foetus during pregnancy.
Number of previous births

Evidence suggests that women who have less maternal experience (those that have experienced fewer
previous pregnancies) experience higher levels of prenatal attachment than women with more maternal
experience (those with greater numbers of children).
Social and relationship support during pregnancy

There is evidence that social support from a relationship with a significant other, such as the father-to-be
or the pregnant woman’s mother, influences maternal-foetal bonding. Studies have reported higher levels
of maternal attachment in women with:
 A positive and satisfying relationship with the father-to-be;
 Attachment to a significant other characterised by high levels of trust; and
 High levels of emotional closeness and intimacy in family relations.
Stage of pregnancy and awareness of the foetus

As a woman’s pregnancy progresses, she becomes more aware of her
foetus, and the foetus starts to grow and move. It would therefore be
expected that a woman would become more attached to her foetus as her
pregnancy progresses and her awareness of the foetus increased.
A number of studies have reported that women develop a greater bond
with their foetus as the pregnancy progresses. Some studies have also
found that women experience higher levels of maternal-foetal attachment
after they become aware of foetal movements.
Mood disorders
Mood disorders such as depression are highly prevalent during pregnancy
and evidence suggests that that these conditions may affect as many
women during pregnancy as they affect after childbirth (i.e. in the period
when women experience postnatal depression). Evidence from scientific
studies suggests that women who experience depression or other mood
disorders (e.g. anxiety) during pregnancy, do not bond with their foetus as
much as women who do not experience mood disorders.
High risk pregnancy

Some women have a higher risk for poor pregnancy outcomes than other women, for example women
who have previously had a miscarriage or those who are pregnant with twins or triplets.
Studies have examined whether or not there are differences in the extent to which a mother bonds with
her foetus in high vs low risk pregnancies. They have looked at bonding in:
 Pregnant women who have previously had a miscarriage;

 Pregnancies where the foetus has been diagnosed with a non-life threatening, congenital abnormality;
 Pregnancies which were conceived through in vitro fertilisation; and
 Multiple pregnancies – pregnancies in which the woman is carrying more than one foetus (e.g. twins or
triplets).
None of the studies have found differences in the extent of maternal-foetal bonding between women with
high risk pregnancies and those with normal pregnancies.
Substance abuse
Substance abuse during pregnancy is associated with poor maternal and infant outcomes (including an
increased risk of low birth weight and impaired childhood development). Women who abuse
substances during pregnancy may therefore find it more difficult to accomplish many of the tasks which
are vital to bonding with their infants. These tasks include things like feeling love or compassion for the
foetus or acting in the interests of the foetus and to ensure its safety.
No studies have directly compared maternal foetal bonding in substance abusing and non-substance
abusing women. There are studies which have examined maternal-foetal bonding in different groups of
substance users. These studies reported that substance users struggle to feel attachment with their
foetus and experience guilt, uncertainty and concern throughout their pregnancies.
Ultrasound
Ultrasoundtechnology enables women to view their foetus
growing in their womb. It has been argued that ultrasound is
likely to allow a woman to bond with the foetus earlier in the
pregnancy than she otherwise would (e.g. women may
otherwise only begin to feel attachment once they feel the
foetus moving).
One study which examined the difference between having an
ultrasound and not having an ultrasound reported greater
maternal-foetal attachment amongst women who had
ultrasound.
The type of ultrasound (eg two, three and four dimensional ultrasound) does not affect the extent to which
a woman bonds with her foetus.
Research has found that 76% of men bonded with the foetus before an ultrasound.
Maternal serum screening and amniocentesis

A number of studies have examined the use of a variety of tests for foetal abnormalities, and whether or
not the use of these tests is associated with greater or lesser bonding between a woman and her foetus.
One study examined differences in maternal-foetal bonding between women using maternal serum
screening (testing the pregnant woman’s blood for signs of birth defects in her foetus), women
using amniocentesis (testing the pregnant woman’s amniotic fluid for signs of birth defects in her foetus)
and a group of women who used neither of these tests. It reported that women who used maternal serum
screening were less attached to their foetuses than women who used amniocentesis or those who used
neither test.
Strategies for increasing maternal bonding
Bonding with a foetus during pregnancy enhances the bond between the
woman and baby after childbirth and has ongoing positive implications for
the child’s development. Thus increasing the extent to which
women bond with their foetuses would be expected to improve child
development outcomes.
Despite this, few interventions which aim to increase maternal-foetal
bonding have been evaluated.
There are a number of practices which are not scientifically proven but are
popularly believed to increase the bond between a woman and her baby,
such as talking to the foetus and massaging it in the womb.
Increasing foetal awareness

Interventions which have educated women about their foetus and
encouraged them to bond with it, as well as those which have encouraged
women to monitor the movement of the foetus, have been successful in
increasing the bond between pregnant women and their foetuses.
Maternal massage
Interacting with the foetus in the womb is an indicator of maternal attachment. Questionnaires about
maternal-foetal bonding ask women whether or not they do things like poke the baby or move it around in
their womb. One might thus expect that interventions which encouraged women to massage or in other
ways make physical contact with the foetus might increase maternal bonding. However, there have
however been no studies conducted to prove this.
Talking to the foetus
Similarly talking to the foetus is a behaviour often investigated in questionnaires about maternal-foetal
attachment, and talking to the foetus indicates a level of attachment or bonding to it. However, similar
to maternal massage, interventions encouraging women to talk to their foetuses have not been assessed.
More information
For more information on

pregnancy, including
useful animations and
videos see Pregnancy.
For more information on

various aspects of
parenting,
see Parenting.
References
1. Alhusen, J.L. A literature update on maternal-fetal attachment. J Obstet Gyneacol Neonate Nurs.
2008;37:315-28.
2. Cranley, M. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs
Res. 1981;30:281-4.
3. Muller, M.E. Development of the prenatal attachment scale. West J Nurs Res. 1993;15(2):199-215.
4. Yarcheski, A. Mahon, N. Yarcheski, T. et al. A meta-analytic study of predictors of maternal-fetal
attachment. Int J Nurs Studies. 2009;46:708-15.
5. Canella, B.L. Maternal-fetal attachment: an integrative review. J Adv Nurs. 2005;50(1):60-8.
6. Armstrong, D. Emotional distress and prenatal attachment in pregnancy after perinatal loss. J Nurs
Scholarship. 2004;34(4):339-45.
7. Tsartsara, E. Johnson, M.P. The impact of miscarriage on women’s pregnancy specific anxiety and feelings
of prenatal maternal-fetal attachment score during the course of a subsequent pregnancy: an exploratory
follow-up study. J psychosom Obstet Gynaecol. 2006;27(3):173-82.
8. Hedrick, J. The lived experience of pregnancy while carrying a child with a known, nonlethal congenital
abnormality. J Obstet Gynecol Neonatal Nurs. 2005;34(6):732-40.
9. Hjelmstedt, A. Widstrom, A. Collins, A. Psychological correlates of prenatal attachment in women who
conceived after in vitro fertilization and women who conceived naturally. Birth. 2006;33(4):303-10.
10. Damato, E.G. Predictors of prenatal attachment in mothers of twins. J Obstet Gynecol Neonatal Nurs.
2004;33(4):436-45.
11. Freeman, A. The influences of ultrasound stimulates paternal fetal bonding and gender identification. J
Doiagnost Med Sonog. 2000;16(6):237-41.
12. Lawson, K.L. Turriff-Janasson, S.I. Maternal serum screening and psychosocial attachment to pregnancy. J
Psychosomat Res. 2006;60:371-8.
13. Nelson, L.J. Fazio, A.F. Emotional content of talk to the fetus and coping behaviours during pregnancy. J
Infant Mental Health. 1995;16(3):179-91

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Risk factors for preterm birth <37 weeks, either spontaneous or iatrogenic,

Early pregnancy predictors of preterm birth: the role of a prolonged

DESIGN: Retrospective analysis of prospectively collected maternity data.

POPULATION: 21,069 singleton deliveries with record of a specified last menstrual

SETTING: Catchment area of tertiary centre serving a general maternity population.

METHODS: Univariate and multivariate analysis. Variables included: maternal age;

CONCLUSIONS: A discrepancy of more than +7 days between menstrual and scan

METHODS: This was a retrospective study in women with singleton pregnancies

Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Maternal age and adverse pregnancy outcome: a cohort study

First published: 30 April 2013

Participants completed a questionnaire on their age, racial origin (Caucasian, Afro‐

Outcome measures included miscarriage, stillbirth, pre‐eclampsia, gestational

We excluded pregnancies with fetal aneuploidies or major defects diagnosed either

Table 1. Frequency of pregnancy complications according to maternal age group

More evidence links advanced maternal age to

“The association cannot be entirely attributed to medical interventions alone,” Goisis,

SOURCE: bit.ly/2BQMA03 PLoS One, online January 31, 2018.

In order to investigate the importance of fetal sex in comparison with other

Materials and methods

Univariate analyses were first performed to evaluate the influence of some

Maternal educational level

Antenatal care, which may be differently available according to family socio-

Mean pregnancy duration behaved as a second-degree function as maternal age

In contrast, when the frequency of preterm deliveries was considered, maternal

Since a significant though small relationship was revealed in the monofactorial

The significantly increased risk run by first-born children in comparison with

BJOG: An International Journal of Obstetrics & Gynaecology

First published: 21 October 2016

Main outcome measures

(Related story: Effects of Premature Birth can Last until Adulthood)

source: Philippine Star

Journal of the ASEAN Federation

Teenage Pregnancy in the Philippines: Trends, Correlates and Data

Teenage pregnancy in the Philippines

Click here to download Table 1

Click here to download Figure 1

Click here to download Figure 3

Click here to download Figure 4

Click here to download Figure 5

Click here to download Figure 6

By educational attainment (Figure 7) there is a clear education gradient in early childbearing

Click here to download Figure 7

Click here to download Figure 8

The comparison of differences in early childbearing across residence, education and

Click here to download Figure 9

Click here to download Table2

Mothers and Fathers in NICU: The Impact of Preterm Birth on

1. the parents of preterm children would to show higher levels of trauma-related

periods to be near their infants

What is bonding with your baby during pregnancy?

Health benefits of bonding with the foetus during pregnancy

Socioeconomic and health status and health seeking behaviours

Number of previous births

Social and relationship support during pregnancy

Stage of pregnancy and awareness of the foetus

High risk pregnancy

 Pregnant women who have previously had a miscarriage;

Maternal serum screening and amniocentesis

Increasing foetal awareness

For more information on

For more information on

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