Introduction

Adolescence is a period of psychological and somatic growth and development that spans between the ages of 10 and 19 [1,2]. Adolescent pregnancy and childbirth remain a public health problem [2,3], with medical and cognitive risks associated with biological immaturity, the social determinants of health and the quality of the healthcare system [3,4]. These risks include poor attendance at antenatal clinics [3,5], prematurity [5,6], obstructed labour [7], vaginal tears , puerperal psychosis [8], pre-eclampsia and eclampsia [9], low birth weight [9] and high neonatal mortality [10]. Rural areas are more vulnerable than urban areas [4]. Caesarean section is the surgical intervention that is constantly on the increase, especially in urban areas [11–13], with rates ranging from 5.0% to 42.8% [14], [15]. In Africa, the frequency of caesarean section varies from 5.0% to 37.5% and 6.6% among adolescents [11,14,16]. There are regional differences [15]. The main indications, in all age groups, are maternal and foetal. The impact on maternal and neonatal mortality is not negligible, especially in Africa [17,18]. Age under twenty favours caesarean section due to fetal-pelvic disproportion [2,11,19]. For Ymelle et al. [18] in Cameroon, caesarean sections in adolescents represent 6.9%. Eouni et al. [1] report 44% caesarean sections among teenage deliveries in the Republic of Congo. In the Democratic Republic of Congo, 11.7% of caesareans in the town of Mbuji-Mayi were adolescents [20], and the study conducted in the rural area of Moba reported 48 cases of caesarean section among 523 deliveries of adolescents, i.e. 9.2% [2].

The aim of this study is to determine the prevalence, indications, evolution and factors associated with the risk of caesarean section among adolescent in rural Lubao, in the central-eastern Democratic Republic of Congo. A comparison with adult women will enable factors associated with the risk of caesarean section to be determined.

Methods

Setting

This study was conducted at the Lubao general referral hospital, Lubao health zone and territory, Lomami province, central Democratic Republic of Congo. The territory of Lubao has three rural health zones (Kamana, Tshofa and Lubao), each of which has a general referral hospital, with no specialist gynaecology and obstetrics doctor.

Type and period of study

This was a cross-sectional, analytical study with data covering the period 2018 to 2022. The data were collected by KoboCollect from the maternity ward and operating theatre registers.

Inclusion criteria and sampling

For this study, we included all deliveries during the data collection period.

Data collection

Data relating to adolescents were obtained from partograms, delivery registers and surgical operations (caesarean sections). In some cases, operative protocols were reviewed to complete the data on vaginal deliveries. A KoboCollect data collection form prepared in advance was used to collect the variables sought on the adolescent girls and adult women targeted by this study.

Operational definitions

Adolescent: According to the WHO, this is a girl during the age period between 10 and 19, i.e. less than twenty years old.

Teenage pregnancy: This is pregnancy that occurs between the ages of 13 and 19.

Parameters studied

a) Independent variable: Age (years)

b) Dependent variable: Frequency of adolescent deliveries (by year of study), occupation, level of education, marital status, history of caesarean section, number of times scarred uterus, parity, gestational age, modes of delivery (vaginal and vaginal), type of pregnancy (singleton and multiple), indication for caesarean section, mode of admission (referred and non-referred), types of caesarean section (scheduled and urgent), fetal presentation (breech, cephalic, transverse), onset of labour (artificial, spontaneous), maternal outcome (good, bad, death), outcome of the newborn during the maternal early neonatal period (good, bad, death).

Data processing and statistical analysis

The data collected by KoboCollect during the study period were downloaded onto an Excel spreadsheet (Microsoft, USA, 2010) and imported for processing into Epi-Info 7.1 (Center for Disease Control and Prevention, Atlanta, USA, 2011) [21] and Jamovi 2.3.21 [22]. The results were presented in the form of tables and graphs (Figures) including numbers, proportions expressed as a percentage and indicators of location (central tendencies: mean, extremes, median) and dispersion (interquartile range and standard deviation). The relationship between the various parameters studied was established using the p-value and the odd ratio at the significance level p ≤ 0.05.

Ethics

The data for this study were collected in strict compliance with confidentiality and protocol. Authorisation had been obtained from the authorities managing the two health entities targeted by our study.

Results

From 2018 to 2022, 2,444 deliveries were recorded at the Lubao general referral hospital, including 375 caesarean sections, or 15.3%. Among adolescent girls, 64 caesarean sections were performed out of 82 deliveries (78.0%), while adult women recorded only 311 caesarean sections out of 2,362 deliveries (13.2%). The difference observed was highly statistically significant (OR 23.44 [CI95% 13.71-40.09]; p=0.0000) (Figure 1).

Figure 1: Delivery routes at Lubao General Referral Hospital (p=0.0000; OR 23.448; IC95% 13.71-40.09)

The typical profile of the adolescent and adult woman shows that the age varies from 15 to 19 years Vs 20 to 48 years, with a median of 18 ± 0.25 years Vs 30 ± 12.5 years; student (n=43 i.e. 67.2% Vs n=6 i.e. 1.9%) or farmer (n=19 i.e. 29.7% Vs n=160 i.e. 51.4%); secondary education (n=62 or 96.9% Vs n=266 or 85.5%); married (n=50 or 78.1% Vs n=309 or 99.4%); located less than six kilometers from the general referral hospital (n=36 or 56.2% Vs n=194 or 62.4%). The differences observed between the two groups were statistically significant for occupation (p=0.0000), level of education (p=0.0139) and marital status (p=0.0000) (Tables 1 and 3). There was no difference in the distance travelled from home to the general referral hospital (p=0.40803): the average was 9.95 ± 9.72 kilometers for adolescent girls and 8.3 ± 8.6 kilometers for adult women (Table 3).

Figure 2: Annual evolution of caesareans

Fetal macrosomia (n=36; 56.3%), acute fetal distress (n=15; 23.4%) and bony dystocia (n=7; 10.9%) were the main indications for caesarean section among adolescent women. Adult women in Lubao had fetal macrosomia (n=86; 27.7%), acute fetal distress (n=78; 25.1%) and placenta praevia (n=61; 19.6%) as the main indications for caesarean section.

Mechanical dystocia were predominantly encountered among adolescent women, compared with dynamic dystocia in the group of adult women. The difference observed was statistically significant (OR 2.08 [IC95% 1.11-3.87]; p=0.0190) (Tables 2 and 4).

The maternal outcome of caesareans was characterized by five deaths (1.3%) and 14 poor outcomes (3.7%), compared with 365 good outcomes (94.9%). Among adolescents and adult women: one death (1.6%) Vs. 4 deaths (1.3%), three poor outcomes (4.7%) Vs 11 (3.5%) and 60 good outcomes (93.7%) Vs. 296 (95.2%). The difference observed was not statistically significant (OR 1.31 (IC95% 0.42-4.10); p=0.6355). (Figure 3a)

In the early neonatal period, there were 49 deaths, 64 poor outcomes and 277 good outcomes among the 390 newborns (360 singleton pregnancies and 15 twin pregnancies). For adolescents and adult women respectively: 9 deaths (14%) vs. 40 (12.9%), 6 poor outcomes (9.4%) vs. 58 (18.6%) and 49 good outcomes (76.6%) vs. 228 (73.3). The difference observed was not statistically significant (OR 1.40 (IC95% 0.75-2.62); p=0.3589). (Figure 3b). Level of education did not influence maternal outcome [OR 0.276 (95% CI 0.09-0.81); p=0.0136].

Figure 3: Mothers (a) and new-born (b) evolutions

Discussion

Prevalence of caesarean sections among adolescents

The persistent high incidence of maternal deaths remains a challenge for Africa and the Democratic Republic of Congo. It is estimated that one woman in 42 is at risk of maternal death, and 70% of maternal deaths are attributable to Africa [15,23,24]. Preventable causes, including those related to childbirth, have been identified as the main causes of maternal death [23].

Adolescent childbirth spares no region of the World Health Organisation [13,25–27]. In this series of studies, we made a comparison with adult women in order to determine the proportion of caesarean sections in each group: the prevalence of caesarean sections is scientifically higher among adolescent girls than among adult women. These results confirm what has been reported in the medical literature in Guatemala, India, Kenya, Pakistan, Zambia and the Democratic Republic of Congo [26]. In Mbuji-Mayi, Claire et al. [20] reported 11.7% of caesarean sections and John et al. [28] 13.5% of caesarean sections among adolescents, which is close to our results: 3.4% of deliveries and 17.1% of caesarean sections. It should be noted, however, that in studies on caesarean section where the methodology does not include a control group of adult women, there is a risk of using the numbers of the majority of women giving birth as a basis for wrongly concluding that adult women present a higher risk of caesarean section than adolescent women. Precaution was used to avoid this risk of interpretation bias.

Adolescents present the risk associated with biological immaturity, as demonstrated by the high risk of fetal-pelvic disproportion and the numerous cases of consequences associated with obstetric inexperience [1,27].

Indications for caesarean section

The main indications for caesarean section vary from region to region [15]. In our study, caesarean sections were significantly indicated for mechanical and emergency dystocia. This may reflect the poor quality of antenatal consultations. Fetal macrosomia, acute fetal distress and bony dystocia (found only among adolescents) are the main indications for caesarean section among the adolescents studied. These results are similar to those reported by Adelaiye et al. [29] except that pre-eclampsia/eclampsia replaces macrosomia in first place. This predominance of foetal macrosomia in adolescent and adult women needs to be assessed. We are concerned about diagnostic errors and recommend prospective and KAP (knowledge, attitudes and practices) studies.

The majority of studies on caesarean sections do not take controls into account [7], [30], [31]. Comparative studies of caesarean sections between adolescent and adult women are still rare. We have not found a single study conducted in our area (province) or in the Democratic Republic of Congo.

Maternal and neonatal outcomes

Childbirth among adolescents must be carefully monitored because of the risks identified in the literature [7], [8], [32], [33]. These risks can lead to maternal and newborn deaths. In this study, overall maternal mortality was 13‰ (five women) and early neonatal mortality was 13.6% (49 newborns). It was found that there was no statistical difference between adolescent and adult women regarding maternal and neonatal outcomes. Health care staff must improve the quality of care for all categories of women undergoing caesarean section, as the proportions of maternal and newborn deaths remain high. Vasconcelos et al. [34]recommend low APGAR scores and the performance of resuscitation manoeuvres as unfavourable factors in the outcome of newborns born to adolescent mothers. In a meta-analysis, Amjad et al. [4] mention low level of education as a factor determining the unfavourable outcome of pregnancy among adolescents, which is contrary to our results. In our context, more in-depth studies (integrating factors such as neonatal resuscitation, maternal anaemia, birth weight, and neonatal infection) are absolutely necessary to evaluate the maternal outcome of caesarean section and neonatal outcome between adult and adolescent women.

Conclusion

Maternal and neonatal mortality and morbidity remain a concern for healthcare professionals. Childbirth remains a crucial period which, with quality care, could reduce the high frequency of maternal deaths in our environment. Pregnancy among minors is a serious public health problem for adolescent girls, despite the measures that have been put in place to combat it. Teenage girls have a very high risk of caesarean section compared with adult women. The main indications are avoidable. Raising parents' awareness of the risks of early marriage, educating girls about sex education in schools, churches and youth clubs, combating sexual exploitation and abuse, and even sexual violence, are all solutions that should be considered. Maternity wards also need to be equipped with neonatal resuscitation facilities to ensure that newborn babies are properly cared for. Priority should be given to incubators (of which there are none in the maternity unit) for temperature control.

This study opens up the possibility of multicentre studies to assess the impact of measures to combat the marriage of under-age girls.

Conflict of Interest

The authors do not declare any conflicts of interest in connection with this study. This study was funded by the authors' own contributions.

References

1. Eouani LEM, Mokoko JC, Itoua C, Iloki LH. Childbirth in the Adolescent Female at the General Hospital of Loandjili (Congo). Open Journal of Obstetrics and Gynecology. 2018;8(12):1140–6.
2. Kabemba BH, Alimasi YG, Ntambwe AM, Kalamba ME, Kitenge FF, Nyongonyi OE, et al. Adolescent Pregnancy and Delivery in the Rural Areas of DR. Congo: A Cross-Sectional Descriptive Study (2014 to 2016). Open Access Library Journal. 2018;5(8).
3. Amoadu M, Hagan D, Ansah EW. Adverse obstetric and neonatal outcomes of adolescent pregnancies in Africa: a scoping review. BMC Pregnancy Childbirth. 2022;27;22:598.
4. Amjad S, MacDonald I, Chambers T, Osornio-Vargas A, Chandra S, Voaklander D, et al. Social determinants of health and adverse maternal and birth outcomes in adolescent pregnancies: A systematic review and meta-analysis. Paediatr Perinat Epidemiol. 2019;33(1):88–99.
5. Uzunov AV, Secara DC, Constantin AE, Mehedintu C, Cirstoiu MM. Difference between Preterm Birth in Adolescent and Adult Patients. Maedica (Bucur), 2022;17(4):789–94.
6. Afulani PA, Altman M, Musana J, Sudhinaraset M. Conceptualizing pathways linking women’s empowerment and prematurity in developing countries. BMC Pregnancy Childbirth. 2017 Nov 8;17(Suppl 2):338.
7. Kabemba BH, Mongane TB, Kunda SK, Saturnin LBJJ, Ayumba DL, Tube JK, et al. Epidemiological Profile of Childbirth among Primiparous Women in Rural Areas of Tanganyika Province, Democratic Republic of Congo. Open Access Library Journal. 2021;8(3):1–13.
8. Poinso F, Samuellian JC, Delzenne V, Huiart L, Sparrow JS, Rufo M. Dépressions du post-partum: délimitation d’un groupe à haut risque dès la maternité, évaluation prospective et relation mère-bébé. La psychiatrie de l’enfant. 2001;44(2):379–413.
9. Ngowa JDK, Kasia JM, Pisoh WD, Ngassam A, Noa C. Obstetrical and Perinatal Outcomes of Adolescent Pregnancies in Cameroon: A Retrospective Cohort Study at the Yaoundé General Hospital. Open Journal of Obstetrics and Gynecology. 2015;5(2):88–93.
10. Ochieng AM, Agardh A, Larsson M, Asamoah BO. Survival patterns of neonates born to adolescent mothers and the effect of pregnancy intentions and marital status on newborn survival in Kenya, Uganda, and Tanzania, 2014–2016. Glob Health Action. 2022;15(1):1-17.
11. Essiben F, Belinga E, Ndoua CN, Moukouri G, Eman MM, Dohbit JS, et al. La Césarienne en Milieu à Ressources Limitées : Évolution de la Fréquence, des Indications et du Pronostic à Dix Ans d’Intervalle. Health Sci Dis. 2020;21(2). In https://www.hsd-fmsb.org/index.php/hsd/article/view/1771
12. Ganeriwal SA, Ryan GA, Purandare NC, Purandare CN. Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world. Taiwan J Obstet Gynecol. 2021;60(1):20–3.
13. Harrison MS, Garces AL, Goudar SS, Saleem S, Moore JL, Esamai F, et al. Cesarean birth in the Global Network for Women’s and Children’s Health Research: trends in utilization, risk factors, and subgroups with high cesarean birth rates. Reprod Health. 2020 Dec 17;17(Suppl 3):165.
14. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):e005671.
15. Osayande I, Ogunyemi O, Gwacham-Anisiobi U, Olaniran A, Yaya S, Banke-Thomas A. Prevalence, indications, and complications of caesarean section in health facilities across Nigeria: a systematic review and meta-analysis. Reprod Health. 2023;20(1):81.
16. Ochieng Arunda M, Agardh A, Asamoah BO. Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data. Glob Health Action. 2020;13(1):1748403.
17. Malonga FK, Mukuku O, Ngalula MT, Luhete PK, Kakoma JB. External anthropometric measurement and pelvimetry among nulliparous women in Lubumbashi: risk factors and predictive score of mechanical dystocia. Pan Afr Med J. 2018;31:69.
18. Ymele FF, Nenwa IFW, Fouedjio JH, Fouelifa LD, Enow RM. Pronostic Maternel et Périnatal de l’Accouchement chez les Primipares Adolescentes et Adultes à Yaoundé. Health Sci Dis. 2020;21(3). Available from: http://www.hsd-fmsb.org/index.php/hsd/article/view/1870
19. Nahaee J, Abbas-Alizadeh F, Mirghafourvand M, Mohammad-Alizadeh-Charandabi S. Pre- and during- labour predictors of dystocia in active phase of labour: a case-control study. BMC Pregnancy Childbirth. 2020;20(1):425.
20. Claire BKM, Fortunat MM, John KM, Cibangu K, Tshimanga K, Michel KN, et al. Determinants of the Quality of the Cesarean Section in Mbuji-Mayi City (Democratic Republic of Congo). Open Access Library Journal. 2021;8(2). Available from: http://www.oalib.com/paper/5432975
21. Dean AG, Arner TG, Sangam CG, Sunki GC, Friedman R, Lantinga M, et al. (2011) Epi InfoTM, a database and statistics program for public health professionals, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
22. The Jamovi project. Jamovi. (Version 2.3) [Computer Software]. Retrieved from https://www.jamovi.org. 2022.
23. Dumont A. Réduire la mortalité maternelle dans les pays en développement: quelles sont les interventions efficaces? Revue de Médecine Périnatale. 2017;9(1):7–14.
24. Kalombo PM. Problématique des accouchements dystociques au centre de santé maternel et infantile(CSMI) de Lubao, en République Démocratique du Congo [Problem of dystocic childbirth at the maternal and infantile health center (CSMI) of Lubao, Democratic Republic Of the Congo]. Tanganyika Journal of Sciences. 2022;2(1):17–24.
25. Dal’Maso E, Rodrigues PRM, Ferreira MG, Moreira NF, Muraro AP. Cesarean birth and risk of obesity from birth to adolescence: A cohort study. Birth. 2022;49(4):774–82.
26. Harrison MS, Pasha O, Saleem S, Ali S, Chomba E, Carlo WA, et al. A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low- and middle-income countries. Obstetricia et Gynecologica Scandinavica. 2017;96:410–420
27. Coelho SJDC, Simões VMF, Batista RFL, Ribeiro CCC, Lamy ZC, Lamy-Filho F, et al. Birth by cesarean section and mood disorders among adolescents of a birth cohort study in northern Brazil. Braz J Med Biol Res. 2021;54(1):e10285.
28. John KM, Claire BKM, Cibangu K, Ntumba M, Fleur MC, Tshimanga K, et al. Predictive Factors of Childbirth by High in the City of Mbujimayi (Democratic Republic of Congo). Open Access Library Journal. 2019;6(12). Available from: http://www.oalib.com/paper/5424214
29. Adelaiye SM, Olusanya A, Onwuhafua PI. Cesarean section in Ahmadu Bello University Teaching Hospital Zaria, Nigeria: A five-year appraisal. Trop J Obstet Gynaecol. 2017;34:34-8
30. Allagoa DO, Oriji PC, Tekenah ES, Obagah L, Ohaeri OS, Mbah KM, et al. Caesarean Section in a Tertiary Hospital in South-South, Nigeria: A 3-year Review. European Journal of Medical and Health Sciences. 2021;3(2):122–7.
31. Jombo S, Ossai C, Onwusulu D, Ilikannu S, Fagbemi A. Feto-maternal outcomes of caesarean delivery in Federal Medical Centre, Asaba: a two year review. Afr Health Sci. 2022;22(1):172–9.
32. Chill HH, Lipschuetz M, Atias E, Shimonovitz T, Shveiky D, Karavani G. Obstetric anal sphincter injury in adolescent mothers. BMC Pregnancy Childbirth. 2021;21(1):564.
33. Mboua BV, Essiben F, Nana LP et al. Devenir Maternel et Néonatal après Césarienne dans Trois Hôpitaux de la Ville de Maroua. Health Sci Dis. 2022 ;23(3). Available from: http://www.hsd-fmsb.org/index.php/hsd/article/view/3468
34. Vasconcelos A, Bandeira N, Sousa S, Machado MC, Pereira F. Adolescent pregnancy in Sao Tome and Principe: are there different obstetric and perinatal outcomes? BMC Pregnancy and Childbirth. 2022;22(1):453.