CORRELATIONAL ANALYSIS BETWEEN TEENAGE PREGNANCY AND MATERNAL MORTALITY IN MALAWI Abiba Longwe-Ngwira and Nissily Mushani African Institute for Development Policy (AFIDEP) P.O. Box 31024, Lilongwe 3 Malawi July, 2015 1
Background About 16 million girls aged 15 to 19 and some 1 million girls under 15 give birth every year around the globe. However, most of these are from low and middle income countries. In Malawi, although adolescent fertility is decreasing, adolescent fertility rate is still among one of the highest in the region, with over 106,000 adolescent falling pregnant every year i. Slightly above one-quarter (26%) of Malawian adolescents have had a child or are pregnant by the age of 18. Early childbearing is a major health concern because of the increased risks of death and disability to both mother and child during pregnancy and childbirth including delivery complications, obstetric fistula, and low infant birth weight and child malnutrition ii. For some adolescents, pregnancy and childbirth are planned and wanted, but for many they are not. Research has shown that globally, adolescent pregnancies are more likely to occur in poor, uneducated and rural communities iii. Likewise in Malawi, there is a large urban-rural differential in the proportion of adolescent women who have started child bearing with rural percentage of 26.8% compared to 20.5% of their urban counterparts. This differential tendency also exist between the adolescent with no education and those who have completed some secondary education - 44.6% of uneducated adolescents, but only 15.5% of their educated counterparts. These proportions also decline with increasing wealth, from 31.1% in the poorest households to 15.6% in the wealthiest. The crude birthrate among adolescents echoes rural-urban differential pattern observed with teenage pregnancy above whereby it is higher in the rural areas than in urban areas and also there is a slight decrease from the recent 2010 Malawi Demographic Health Survey (DHS) period - 39.8% for rural and 36% for urban adolescents compared to the 2004 DHS, at 43.4% for rural and 37% for urban iv. Complications during pregnancy and childbirth are the second cause of death for 15-19 year old girls globally. Every year, some 3 million girls aged 15 to 19 undergo unsafe abortions worldwide. According to the 2010 DHS report, 34.7% and 4.8% of women are giving birth before the age of 18 and 15, respectively. Adolescent birth rate is 151.9 per 1000 women aged 15-19. Babies born to adolescent mothers face a substantially higher risk of dying than those born to women aged 20 to 24. 2
Teenage Marriage Early marriage and childbearing are associated with high parity and therefore higher risk of maternal death v. Child marriage (marriage below age 18) predisposes girls to early pregnancy, sexual and gender based violence (SGBV) as well as HIV, dropping out of school, maternal complications and death and reduced employment opportunities. Married girls are also exposed to a longer childbearing period giving them opportunities to have many children. In some countries, becoming pregnant outside marriage is not uncommon. However, in other countries, some girls may face social pressure to marry and, once married, to have children. More than 30% of girls in low and middle income countries marry before they are 18; about 14% marry before they are 15. In Malawi, at least half of young women are married before the age of 18. This rate is much higher than the global rate. Almost one-fifth (19.5%) of 15 19-year-old women are married and about 65.3% of 20-24 year old women are married. This is a decline from the 2004 DHS figures of 29.8% and 75.1% among 15-19 and 20-24 year olds, respectively. Early marriage among women persists, with little variation in more than a decade. Among young women ages 20 to 24, half were married by age 18. By delaying marriage, young women are more likely to have fewer children and continue their education. According to WHO 2014 factsheet on Maternal Mortality, approximately 800 women die from pregnancy or child birth related complications around the world every day, 99% of which occurs in developing countries. Improving maternal health is 1 of the 8 Millennium Development Goals (MDGs) adopted by the international community in 2000. Under MDG5, countries committed to reducing maternal mortality rate (MMR) by three quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 45%. A trend analysis of the MDGs health targets for the Health Sector Strategic Plan (MoH, 2012) in Malawi finds a reduction in MMR since 2000, but less than needed to meet the MDG target (Bowe, 2012). The maternal mortality rate decreased from 984 per 100,000 live births in 2004 to 675 per 100,000 in 2010, with a projected rate of 435 in 2015 against the MDG target of 155. 3
Teenage pregnancies contribute to 20-30 per cent of maternal deaths in Malawi. The risk of maternal mortality is highest for adolescent girls under 15 years old and complications in pregnancy and childbirth are the leading cause of death among adolescent girls in developing countries. Adolescent pregnancy therefore remains a major contributor to maternal and child mortality, and to the cycle of ill-health and poverty. While there has been many studies establishing the determinants of teenage pregnancy and maternal mortality, not much has been studied on the relationship of these issues, especially in Malawi. Does teenage pregnancy or early marriage have any effect on maternal mortality in Malawi? Understanding the correlation between teenage pregnancy and MMR is crucial in confronting the challenge of high maternal mortality rates. Problem Statement The problem of the study is high rates of maternal deaths and teenage pregnancies. The consequences are that the risk of maternal mortality is high in adolescent girls (aged 15-19) who face a lot of complications in pregnancy and childbirth. To investigate the cause of maternal deaths, this study was designed to determine whether teenage pregnancy is related to maternal mortality in Malawi. Research Question and Hypothesis This paper investigates the trends in relationship between teenage pregnancy and maternal deaths in Malawi over the past two decades (1995-2015). The main research question to be answered is whether there is any relationship between teenage pregnancy and maternal mortality. This paper will help in bringing out evidence on whether addressing teenage pregnancy can have a positive impact on reducing Maternal mortality and hence the achievement of the MDG5. Based on the research question, the paper will test the following hypothesis: There is no significant relationship between teenage pregnancy and maternal mortality. 4
Data The data used in this study are derived from the DHS. These are large representative household surveys held since the 1980s in many developing countries (see www.dhsprogram.com). The DHS programme is sponsored by USAID and executed in collaboration with national statistical agencies. DHS surveys consist of a household survey in which basic information on all household members is obtained and a women s survey in which all usual resident women aged 16-49 obtain an extensive oral interview. For the purpose of our study we select women who are 15-19 years old. We select this group of women because they are in the age group of the population we are interested in teenage pregnancy. We will use data from all the 1992, 2000, 2004 and 2010 DHS cross-sections. To compliment this, we have also WHO data for the maternal deaths. Methodology The study employed correlation analysis to analyze the data. Correlation methods of analysis aim to describe the correlation between two variables. Correlation analysis attests the relation between two or more variables, but does not measure the causal relation between them. Correlation analysis may also indicate the intensity of the relationship between variables. We will also do the following: -Look at distribution of teen pregnancies with relation to key social and economic characteristics: place of residence (region and urban/rural), educational attainment and household wealth (quintiles). -Summarize empirical evidence of the prevalence and recent trends in adolescent pregnancy, maternal deaths and MMR using data from the Demographic and Health Surveys (DHS) and the World Health Organization (WHO) data base. -The assessment is carried out in a descriptive and correlational manner to addresses associations that exists among teen pregnancy and maternal mortality over a period of 20 years. 5
Results This section presents descriptive on teen pregnancies with respect to some selected socioeconomic characteristics. The paper will also discuss existing relationship between teenage pregnancy and maternal mortality. Table 1 shows trends of teenage pregnancy rate by socio-economic characteristics over a period of 20 years or so. The results show that the total percentage of teen mothers has slightly decreased over time from 27.3 % in 1992 to 20% in 2010. The trend is similar for those pregnant with first child while they are teenagers. Disaggregating the data based on place of residence, the proportion of teenage pregnancy is higher in among rural girls than their urban counterparts for all years. Regarding wealth index, the teen pregnancies are shown according to quintiles. In general, results show that teen girls from lower wealth quintiles mostly pregnant than those from higher quintiles. However, we would like to note that in 1992 it was the three middle categories that registered highest pregnancy rates among teen girls compared to other years. Almost in all wealth categories, the highest proportion of girls starting child bearing early was in 2000 or 2004. Across the years, the data show that combining two lowest wealth quintiles account for about 50% of the teenage pregnancies. The proportion of teenage girls getting pregnant or giving birth by age 15 has decreased over time from 5.7% in 1992 to 1.6% in 2010 from those who are mothers and from 3.2% to 2% for those pregnant with first child (Table 1). The pregnancy rate is increasing with age such that over 50% of the young women interviewed are nursing mothers by age 19. In terms of highest educational level, the no education category has the highest proportion of young girls with a child compared to those with some education. For those without any education 6
and with primary level only, results show that the proportion of teenage girls having a child has been increasing from 1992 to 2004 only started to decline in 2010. But for those with at least some secondary, the trend has been declining since 1992 from 18.6% to 12.6%. Table 1: Teenage pregnancies by socio-economic characteristics Teenage pregnancy: Mothers* Teenage pregnancy: Pregnant with first child** Year 2010 2004 2000 1992 2010 2004 2000 1992 Total 20 25.3 25.4 27.3 6 8.7 7.6 7.4 Residence Wealth Index (quintiles) Age Highest Education al level Region Urban 16 18.2 20.1 23.4 4.5 6.6 7 5.2 Rural 21 27 26.4 27.8 6 9.2 7.8 7.7 Lowest 24.7 32.6 31.1 23.4 6.4 10.7 5.6 6.9 Second 24.9 36.1 22.9 33.1 6.2 10.7 7.5 6.7 Middle 23.2 25.4 19.7 31.5 7 10.4 9.5 10.4 Fourth 18.1 23.6 27.8 28.2 5.7 8.4 8 7.5 Highest 12.5 15.1 25.1 20.4 3.2 5.3 7.2 5.7 15 1.6 1.4 2 5.7 2 1.8 2.3 3.2 16 7.5 6 7.6 11.5 5.1 5.5 5.6 4.6 17 15 21.9 21.5 22.1 6.7 8.8 8 9.1 18 34.4 37.8 37 41.3 9 12.1 11.5 10 19 57.2 53.9 56.6 55.2 6.3 14 9.8 10 No education 32.9 49.8 46.6 36 11.6 13.7 9.4 6.8 Primary 22 27 25.2 24 6 9.2 8 8.1 Secondary or * Percentage of women 15-19 who are mothers ** Percentage of women 15-19 who are pregnant with their first child 12.6 13.2 14.8 18.6 2.9 5.7 4.9 1 higher Northern 20.7 24.9 23.8 18.9 7.5 7.7 9 8.6 Central 16.6 20.1 22.3 23.2 5.1 7.9 7.4 10.4 Southern 23 30.3 28.1 32.6 5 9.8 7.5 4.8 We also wanted to see whether pregnancy rate differs according to geographical position of the population. Table 1, indicates that throughout the entire period of study, southern region has registered higher rates of teen pregnancy compared to central and northern regions. For Northern region, the trend of teen mothers has been increasing over time, from 18.9 in 1992 to 20.7 in 2010 while we observe a declining trend for other regions. 7
According to table 2. The general picture of teenage pregnancies is that there has been a declining trend over time. Although the absolute numbers are increasing but the proportions have been decreasing. The maternal mortality rate as calculated by WHO show that there was an increase from 1992 to 2000 and then it started declining in later years. Looking at female deaths of those aged 15-49, the results show that the absolute figures first increased, declined and increased again. However the general trend is that the figures are increasing. Table 2. Descriptive of teenage pregnancies and maternal deaths Female Year Teen Pregnancy % Teen Pregnancy (Numbers) MMR*** deaths (aged 15-49)*** 1992 34.7 1,082 620 335 2000 33 2,867 1120 1599 2004 34.1 2,392 984 1376 2010 25.6 5,005 675 2134 ***source of information is the report by WHO et al, 2012. Correlation analysis Table x shows the relationship between teenage pregnancy and maternal deaths with the correlation coefficient of 0.94. The table further shows that the correlation coefficient is significant at 5% which indicates that the null hypothesis is rejected. This shows that teenage pregnancy has a positive significant relationship with maternal mortality. This implies that the higher the teenage pregnancy rate, the higher the number of women dying of pregnancy and child birth complications. Correlation analysis was also performed between, teenage pregnancy and MMR. The results were showing positive but insignificant relationship, hence we have not presented the results in this paper. 8
Table 3: relationship between teenage pregnancy and Female deaths Teen pregnancy (numbers) Female deaths (Numbers) Pearson Correlation 0.94 Sig. (2-tailed) 0.05 N 4 Discussion and Conclusion The results above have shown that teenage child bearing differs according to context and socioeconomic characteristics. Rural women were likely to have started child bearing while very young compared to their urban counterparts. The results also indicate that girls from wealthier households are less likely to get pregnant as teenagers. This implies that wealth has a positive influence in reducing teen pregnancy prevalence. Education, is another factor that plays a significant role in a teenage girl s life. Highest proportions of teenage girls were among those without education. It is therefore important to enhance girls education in order to reduce the prevalence of teenage pregnancies. While it is good to see the teenage pregnancies reducing over time in the country, it is worrying that the in the north the trend is increasing. Deliberate efforts need to be put in place to address this issue across the country but emphasis should also be put in the northern region to prevent this trend from soaring. The findings of this study further showed that, a positively significant relationship exists between teenage pregnancy and maternal mortality. This implies that teenage pregnancy positively relates to maternal mortality. Hence, this means that reduced teenage pregnancy rate is likely to lead to lower mortality rates. If family planning programmes can deliberately focus on addressing teenage pregnancy, this would have a positive impact on addressing maternal mortality hence contribute to the achievement of MDG 5. 9
References 1. Ghebrehiwot, M. 2004. "Measurement of Maternal Mortality in Eritrea." PhD diss., Johns Hopkins Bloomberg School of Public Health, Baltimore. 2. UNFPA, 2007 3. Malawi DHS 2010 report 4. Ministry of Health (2012) Malawi Health Sector Strategic Plan 2011-2016. Lilongwe, Malawi: Ministry of Health. p. Available:http://www.medcol.mw/commhealth/publications/3%20Malawi%20HSSP%20 Final%20Document%20%283%29.pdf. Accessed 29 September 2012. 5. Bowie C (2012). A selection of national research undertaken by the College of Medicine. Blantyre, Malawi: College of Medicine, University of Malawi. p. Available:http://www.medcol.mw/commhealth/publications/national%20research/nationa l_research.htm. i xxxxxxx ii cccxxxxxx iii WHO iv DHS 2010 v Ghebrehiwot 2004 10