Adverse birth outcomes and associated factors among adolescent mothers in Nabdam District, Ghana: a retrospective cross-sectional study

Abstract

Objective

Pregnancy and childbirth among adolescents have a higher risk of adverse outcomes than among older women. Adolescent mothers often lack physiological, psychological, social and financial capabilities, risking adverse birth outcomes such as preterm birth (PTB), low birth weight (LBW), asphyxia and stillbirth. We investigated birth outcomes and associated factors among adolescent mothers in the Nabdam District of Ghana.

Design

Retrospective, health facility-based, cross-sectional study.

Setting

12 health facilities in Nabdam District, January 2021 to December 2022.

Participants

Census of all 373 births recorded in the maternity registers of the selected health facilities.

Outcome measures

The main outcome measure was adverse birth outcome, a composite outcome measured as the presence of at least one of PTB, LBW, asphyxia and stillbirth. The data collected were analysed using SPSS V.22. Proportion, mean, χ² and binary logistic regression models were used.

Results

141 (37.8%) of the adolescent mothers in the selected health facilities had at least one adverse birth outcome: PTB (78, 20.9%), newborn with asphyxia (56, 15.0%), LBW (55, 14.7%) and stillbirth (1, 0.3%). Adolescents in the Pelungu subdistrict were 2.95 times (95% CI 1.44 to 6.05) more likely to have an adverse birth outcome compared with those in the Zanlerigu subdistrict. Lower odds of adverse birth outcomes were found among adolescents aged 16–19 years (adjusted OR (aOR) 0.26, 95% CI 0.08 to 0.89) and those with eight or more antenatal care (ANC) visits (aOR 0.30, 95% CI 0.10 to 0.96) compared with those younger than 16 years and those with fewer than eight ANC visits, respectively.

Conclusions

Adverse birth outcomes were common among adolescent mothers in the district and were more likely among younger adolescents, those living in disadvantaged subdistricts and those with fewer ANC visits. These findings indicate the urgent need for targeted interventions and support for this vulnerable population, as well as those directed towards improving access to comprehensive prenatal care, promoting proper nutrition during pregnancy and enhancing the overall well-being of adolescent mothers in resource-limited settings, in order to facilitate the attainment of Sustainable Development Goals 3.1 and 3.2 on reducing maternal mortality and improving foetal health outcomes.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study used a census approach, analysing all adolescent birth records from health facilities in the study district over a 2-year period, which minimised sampling bias and ensured comprehensive data inclusion.

• The study employed a standardised data extraction tool, enhancing consistency and reliability in the data collection process across 12 facilities.

• The use of medical records as the primary data source avoided recall bias, often associated with self-reported data in similar studies.

• The cross-sectional design, while effective for identifying associations between variables and adverse birth outcomes, limits the ability to infer causality.

• Some key social and personal variables, such as nutritional status, which could influence adverse birth outcomes, were not captured in the routine maternity records, limiting the comprehensiveness of the analysis.

Introduction

Adolescent girls who become pregnant have substantial repercussions with profound impacts on their lives and those of their children. Pregnant adolescents run the risk of becoming ill, disabled or dying. These hazards comprise obstetric fistula, issues from botched abortions, HIV and threats to the health of their unborn children.¹ Adolescents’ early and unwanted births have been linked to negative health, academic, social and economic results.² An estimated 70 000 adolescent females in low- and middle-income countries (LMICs) every year are thought to die from reasons associated with pregnancy and childbirth.¹ They are the second largest cause of mortality among adolescent females between the ages of 15 and 19; also, newborns born to young moms have greater health risks than children born to older women.³ Baby health is also impacted by adolescent pregnancy, with lower birth weight and more perinatal mortality among infants delivered to women under 20 years old.^{1 4 5}

Adolescent pregnancy and its consequences have become a significant issue in many nations, where they are the main cause of maternal and infant death, rapid population increase, poor health and poverty.⁴ Adolescent pregnancy has negative social and economic effects, which contribute significantly to mother and child illness and death. This is especially true in sub-Saharan Africa (SSA).⁶ In addition to maternal morbidity in the form of uterine herniation, vesicovaginal fistula, urinary and faecal incontinence, infertility and distress during copulation, a substantial percentage of adolescent girls thrive during childbirth but struggle with serious ailments like pelvic inflammatory diseases, impairment or physical harm caused by pregnancy-related health issues.⁷ Pregnant adolescents most often have limited knowledge of pregnancy-related complications, making childbirth outcomes for younger adolescent mothers mostly poor, with increased rates of low birth weights (LBWs), infections and even postpartum haemorrhage.⁶

About 21 million and 2 million adolescent girls between the ages of 15–19 and under 15, respectively, become pregnant each year in developing countries.⁸ Meanwhile, 2.5 million girls under the age of 16 and 16 million adolescent girls between the ages of 15 and 19 give birth each year.⁸ The major contributing factors to maternal mortality among female adolescents aged 15–19 in LMICs are problems associated with pregnancy and delivery.⁹

The Government of Ghana has developed and implemented many policies and interventions aimed at reducing the incidence of adolescent pregnancies. These policies aim to increase access to sexual and reproductive health, maternal healthcare services and women’s empowerment. There are also Adolescent Health Clubs across the country, which provide sexual and reproductive health education and promotion to adolescents.¹⁰ However, a significantly high number of adolescent pregnancies are reported annually in Ghana. For instance, more than half a million adolescent girls (542 131 aged 15–19 years and 13 444 aged 10–14 years) were reported to have been pregnant in Ghana between 2016 and 2020 alone.¹¹ It is further noted that among Ghanaian adolescent girls, 2 out of 10 will become pregnant or welcome their first child before turning 18 years old.¹²

Adolescent pregnancy continues to attract great concern in the Upper East Region. According to statistics, the area has one of the highest rates of teen pregnancy, underage marriage and, more worrisome, the threat of transactional sex among children.¹³ The Ghana Health Service reported that more than 6000 adolescent girls in the region got pregnant in 2020 alone, making the region rank top in adolescent pregnancies in Ghana.¹⁴ The 2021 Population and Housing Census estimates that 6332 children were born to adolescents aged 15–19 years in the region.¹⁵ Between 2020 and 2022, the region reported that between 14% and 15% of pregnancies annually were among adolescents. Also, it recorded 57, 66 and 45 maternal deaths with 3, 6 and 3 among adolescent girls in 2020, 2021 and 2022, respectively.¹⁶ Child marriage is one such factor accounting for the high cases of adolescent pregnancy, with the region recording 13.5% and 34.8% of girls getting married before the age of 15 and 18 years, respectively, in 2021.¹⁷ Yet, there is limited research into the birth outcomes and associated factors of adolescents in Ghana.

Adolescent pregnancies have been consistently observed to be associated with adverse birth outcomes.¹⁸ It has been reported in many studies that adolescent pregnancy increases the risk of adverse birth outcomes. These negative outcomes in adolescent pregnancy, to some extent, have been linked to adolescent girls’ low socioeconomic status, inadequate prenatal care and inadequate weight gain during pregnancy.¹⁸ The Nabdam District in the Upper East Region has a high adolescent pregnancy rate, with 23%, 15% and 20% of pregnancies recorded in 2020, 2021 and 2022, respectively, among adolescent girls.¹⁹ Thus, with a significant proportion of pregnancies and births in the Nabdam District being among adolescents, assessing the birth outcomes and associated factors is key to improving maternal and neonatal health in the district and the Upper East Region as a whole.

Although adolescent pregnancy and its consequences have been widely studied in Ghana, there is limited empirical evidence specific to the Upper East Region, a low-resource setting and its districts, including Nabdam, despite its consistently high rates of adolescent pregnancy and maternal complications. Existing studies in Ghana have predominantly focused on urban areas or national-level analysis, leaving important contextual differences unexplored. To our knowledge, this is the first retrospective census of adolescent birth outcomes conducted across all maternity-providing health facilities in Nabdam District, enabling comprehensive district-wide estimates. In addition, few studies in Ghana have examined subdistrict variations or simultaneously assessed multiple adverse birth outcomes among adolescents as a composite indicator. This study, therefore, provides context-specific evidence to inform geographically targeted and culturally sensitive interventions for improving maternal and newborn outcomes among adolescents in northern Ghana.

This study therefore investigated adverse birth outcomes and associated factors among adolescents in the Nabdam District of Ghana.

Methods

Study design

We adopted a retrospective, health facility-based, cross-sectional design for this study. This design allowed the study to collect quantitative data on adolescents from existing records and make cross-sectional inferences about associations within the study population.²⁰ It affords easy availability and accessibility of study participants or data. The design enabled the study to collate data on pregnancy outcomes from adolescents at one point in time.²¹

Setting

This study was conducted in the Nabdam District of the Upper East Region of Ghana. It is 1 of the 15 districts in the region. According to the 2021 Population and Housing Census, the district had a population of 51 861 (3.98% of the region’s total population) with 50.7% being females.²² The district recorded a 3.6 total fertility rate and a general fertility rate of 149.4 births per 1000 women of reproductive age (15–49 years), the second highest in the region in the 2010 census.²³ Furthermore, the district is entirely rural. The district has 1 hospital, 3 health centres and 24 community-based health planning and services (2 currently non-functional). However, only the 12 facilities that provided maternity/skilled birth services were included in the study.

Population and sampling

The study involved birth records of adolescent girls who had given birth in health facilities in the Nabdam District of the Upper East Region of Ghana between 2021 and 2022. This included both married and unmarried adolescent girls aged 10–19 years with complete birth records in any of the facilities.

No sample size was calculated for the study, as it was a census of all births by adolescent girls recorded in the maternity registers of the health facilities in the district between January 2021 and December 2022. In all, 373 records of births among adolescent girls were identified and analysed, determined by a census of all adolescent birth records during the period.²⁴

Study variables

The dependent variable of the study was adverse birth outcomes. This is a composite variable comprising preterm birth (PTB), stillbirth, LBW and asphyxia. Preterm birth was determined by a birth at a gestational age of less than 37 weeks. Low birth weight was determined by a birth weight of less than 2.5 kg, with weights of 2.5 kg or more categorised as normal birth weight. Appearance, Pulse, Grimace response, Activity and Respiration (APGAR) test scores were used to ascertain asphyxia. APGAR scores less than 8 (<8/10) are considered asphyxia, while 8+ were categorised as no asphyxia. Again, independent variables which were examined in this study were age, marital status, pregnancy history, parity, number of antenatal care (ANC) visits, gestational age at first ANC, HIV/AIDS status, sickling status and mode of delivery.

Procedures

Data were collected using a data extractor (online supplemental material S1) in a Microsoft Excel template. This tool was selected because it allowed for medical records containing discrete patient data to be collected and made readily available in electronic form for cleaning and analysis.²⁵ The tool covered the following variables: age (in years), marital status, pregnancy history, parity, number of ANC visits, gestational age at first ANC and delivery (in weeks), HIV/AIDS status, sickling status, mode of delivery, birth weight, APGAR score and birth outcomes.

12 facilities providing childbirth/delivery care services were visited, and maternity records were reviewed with the assistance of three field staff who were community health nurses working in the selected communities, who were trained on the study purpose and the data abstraction tool. At the facilities, records of all births between January 2021 and December 2022 were reviewed, and those among adolescent girls between 10 and 19 years were extracted. The study period was selected because complete and accessible maternity register data were available across all 12 participating facilities for these consecutive years, and ethical approval and project timelines covered this interval. Earlier records (eg, 2020) were affected by incomplete entries and COVID-19-related disruptions in routine record-keeping in some facilities, while 2023 data were not yet completed at the time of data extraction. Limiting the analysis to 2021–2022 ensured consistent, complete data across all sites.

Data analysis

Data collected were exported to SPSS V.22 for cleaning and prepared for analysis (online supplemental material S2). The analysis included both descriptive and inferential statistics. Descriptive statistics, such as frequency, percentage and mean, were employed to summarise the variables, while inferential statistics, including χ² and multivariate logistic regression tests, were used to examine associations and relationships between adverse birth outcomes (presence of LBW, PTB, asphyxia or stillbirth) and the independent variables. Crude ORs with 95% CIs were calculated for all independent variables, irrespective of χ² significance, to ensure transparency of reporting. The selection of variables was informed by theoretical relevance, prior literature and statistical stability. Variables with extremely wide CIs or unstable estimates were not retained in the adjusted model to avoid distortion of the final results.

In addition, an exploratory p value-guided selection approach was used, and therefore the results should be interpreted as hypothesis-generating rather than confirmatory. A statistical significance of p<0.05 was set at a 95% CI. Anaemia status was categorised using blood haemoglobin levels with the following categorisations: 10.0+ ‘No anaemia’, 8.1–10.0 ‘Mild anaemia’, 6.5–8.0 ‘Moderate anaemia’ and <6.5 ‘Severe anaemia’.²⁶ Because multiple associations were explored, the results should be interpreted as exploratory, and the possibility of chance findings due to multiplicity cannot be excluded.

Patient and public involvement

None.

Results

Descriptive characteristics

Maternal and reproductive characteristics of the adolescent pregnancies from 2021 to 2022 in the Nabdam District are presented in table 1. There were 373 adolescent births, with 204 (54.7%) recorded in 2021. While the Kongon-Pintanga subdistrict had the highest number of births, 105 (28.2%), the Zanlerigu subdistrict recorded the lowest (54 (14.2%)). The mean age of the adolescents was 17.5 years (SD=1.33), with 344 (92.2%) aged 16–19 years. More than half (233, 59.8%) have attained Senior High School (SHS) education. Also, 137 (36.7%) were students and 128 (34.3%) were housewives. Most of them (315, 84.5%) were first-time mothers, with 206 (55.3%) in the second trimester at first ANC registration/visit. The average number of ANC visits was 7.49 (SD=2.77), with 180 (48.3%) achieving WHO-recommended ANC visits of 8+. Among them, 159 (42.7%) had some form of anaemia at ANC registration, whereas 170 (45.6%) had some form of anaemia at the time of delivery.

Table 1. Maternal and reproductive characteristics of the study population.

Variable	Frequency	Percentage
Year of birth
2021	204	54.7
2022	169	45.3
Subdistrict
Zanlerigu	53	14.2
Pelungu	102	27.3
Sakote	59	15.8
Kongon-Pintanga	105	28.2
Nangodi-Nyoboko	54	14.5
Age	Mean=17.5±1.33
<16	29	7.8
16–19	344	92.2
Maternal height (cm)	Mean=158.98±7.12
<150	8	2.2
150–159	184	49.3
160–169	149	39.9
170+	32	8.6
Educational level
None	25	6.7
Primary	78	20.9
JHS	223	59.8
SHS	47	12.6
Main occupation
Housewife	128	34.3
Student	137	36.7
Skilled worker	80	21.4
Farmer	14	3.8
Trader	9	2.4
Unemployed	5	1.2
Number of pregnancies
1	310	83.3
2	58	15.5
3	5	1.2
Number of children
0	315	84.5
1	55	14.7
2	3	0.8
Gestational age at ANC
First trimester	127	34.0
Second trimester	206	55.3
Third trimester	40	10.7
NHIS status
Yes, and active	371	99.5
No/inactive	2	0.5
HIV/AIDS status
Negative	371	99.5
Positive	2	0.5
Sickling status
Negative	367	98.4
Positive	6	1.6
Number of ANC visits	Mean=7.49±2.77
<8 visits	193	51.7
8+ visits	180	48.3
Anaemia status at first ANC
No	214	57.4
Mild	138	37.0
Moderate	20	5.3
Severe	1	0.3
Anaemia status at delivery
No	203	54.4
Mild	156	41.8
Moderate	12	3.2
Severe	2	0.6
Sex of the baby
Female	180	48.3
Male	193	51.7
Total	373	100.0

ANC, antenatal care; JHS, junior high school; NHIS, National Health Insurance Scheme; SHS, senior high school.

Adverse birth outcomes

Of the 373 births recorded, 78 (20.9%) were PTBs, 55 (14.7%) were LBW and 56 (15.0%) were born with asphyxia; one stillbirth (0.3%) was recorded (figure 1). More cases of PTB (44, 21.6%) and stillbirth (1, 0.5%) were recorded in 2021 than in 2022 (34(20.1%) and 0 (0.0%), respectively). However, more cases of LBW (26, 15.4%) and asphyxia (37, 18.1%) were recorded in 2022 than in 2021, which captured 29 (14.2%) and 19 (11.2%), respectively. Overall, at least 1 adverse birth outcome was recorded among 141 (37.8%) of the 373 adolescent births between 2021 and 2022.

Figure 1. Prevalence of adverse birth outcomes among adolescents in Nabdam District.

Of the 141 adolescents with adverse birth outcomes, 8 (5.8%) had all three outcomes, 42 (30.4%) had both PTB and LBW, 39 (28.3%) had both LBW and asphyxia and 17 (12.3%) had both PTB and asphyxia (figure 2).

Figure 2. Distribution of adverse birth outcomes among adolescents in Nabdam District.

Factors associated with adverse birth outcomes

Table 2 presents the factors associated with adverse birth outcomes of adolescents in the Nabdam District between 2021 and 2022. It shows in the χ² test that subdistrict (χ²=13.78, p=0.008), maternal age (χ²=4.92, p=0.027), sickling status (χ²=5.30, p=0.021), number of ANC visits (χ²=5.93, p=0.015) and anaemia status at delivery (χ²=8.79, p=0.032) were significantly associated with having at least one adverse birth outcome. Adolescents in the Pelungu subdistrict were 2.95 times more likely to have an adverse birth outcome compared with those in the Zanlerigu subdistrict (95% CI 1.44 to 6.05). The CI demonstrated high precision for this estimate. For the remaining subdistricts, the point estimates suggested higher odds of adverse birth outcome for adolescents in Kongon-Pintanga (adjusted OR (aOR)=1.44, 95% CI 0.74 to 2.82) and Nangodi-Nyoboko (aOR=1.91, 95% CI 0.86 to 4.24). However, the wide CIs for both subdistricts included the null value of 1.0, indicating high statistical uncertainty. Conversely, the point estimate for Sakote subdistrict (aOR=0.95, 95% CI 0.45 to 2.02) suggested a slight decrease in the odds. Like the others, the interval was extremely wide and also included 1.0, suggesting the observed data is fully compatible with an increase, a decrease or no association.

Table 2. Factors associated with adverse birth outcomes among adolescents.

Variable	Adverse birth outcome		χ2 (p value)	cOR (95% CI), p value	aOR (95% CI), p value
	Present, n (%)	Absent, n (%)
Year of birth			2.47 (0.116)
2021	85 (41.7)	119 (58.3)		Ref
2022	57 (33.7)	112 (66.3)		1.38 (0.90 to 2.10), 0.140
Subdistrict			13.78 (0.008)
Zanlerigu	26 (49.1)	27 (50.9)		Ref	Ref
Pelungu	27 (26.5)	75 (73.5)		2.68 (1.33 to 5.36), 0.006	2.95 (1.44 to 6.05), 0.003
Sakote	30 (50.8)	29 (49.2)		0.93 (0.44 to 1.96), 0.850	0.95 (0.45 to 2.02), 0.902
Kongon-Pintanga	42 (40.0)	63 (60.0)		1.44 (0.74 to 2.81), 0.279	1.44 (0.74 to 2.82), 0.289
Nangodi-Nyoboko	17 (31.5)	37 (68.5)		2.10 (0.95 to 4.61), 0.065	1.91 (0.86 to 4.24), 0.112
Age			4.92 (0.027)
<16	13 (44.8)	16 (55.2)		Ref	Ref
16–19	129 (37.5)	215 (62.5)		0.29 (0.09 to 0.92), 0.036	0.26 (0.08 to 0.89), 0.032
Height (cm)			5.26 (0.154)
<150	4 (50.0)	4 (50.0)		Ref
150–159	68 (37.0)	116 (63.0)		1.71 (0.41 to 7.04), 0.460
160–169	63 (42.3)	86 (57.7)		1.40 (0.34 to 5.83), 0.641
170+	7 (21.9)	25 (78.1)		3.57 (0.71 to 18.04), 0.123
Educational level			1.40 (0.705)
None	10 (40.0)	15 (60.0)		Ref
Primary	33 (42.3)	45 (57.7)		0.77 (0.30 to 1.95), 0.577
JHS	84 (37.7)	139 (62.3)		0.93 (0.39 to 2.20), 0.870
SHS	15 (31.9)	32 (68.1)		1.20 (0.43 to 3.33), 0.726
Main occupation			2.427 (0.788)
Housewife	44 (34.4)	84 (65.6)		Ref
Student	54 (39.4)	83 (60.6)		0.93 (0.53 to 1.63), 0.790
Skilled worker	34 (42.5)	46 (57.5)		0.87 (0.29 to 2.64), 0.802
Farmer	6 (42.9)	8 (57.1)		1.30 (0.31 to 5.43), 0.718
Trader	3 (33.3)	6 (66.7)		1.24 (0.75 to 2.05), 0.396
Unemployed	1 (20.0)	4 (80.0)		2.60 (0.28 to 23.91), 0.398
Number of pregnancies			1.13 (0.568)
1	121 (39.0)	189 (61.0)		Ref
2	20 (34.5)	38 (65.5)		1.20 (0.67 to 2.16), 0.543
3	1 (20.0)	4 (80.0)		2.53 (0.27 to 22.87), 0.410
Number of children			2.26 (0.324)
0	125 (39.7)	190 (60.3)		Ref
1	16 (29.1)	39 (70.9)		1.58 (0.85 to 2.95), 0.150
2	1 (33.3)	2 (66.7)		1.30 (0.12 to 14.47), 0.832
Gestational age at ANC			1.91 (0.385)
First trimester	43 (33.9)	84 (66.1)		Ref
Second trimester	81 (39.3)	125 (60.7)		0.79 (0.50 to 1.25), 0.317
Third trimester	18 (45.0)	22 (55.0)		0.69 (0.34 to 1.43), 0.322
NHIS status			0.12 (0.728)
Yes and active	141 (38.0)	230 (62.0)		Ref
No/inactive	1 (50.0)	1 (50.0)		0.61 (0.04 to 9.77), 0.724
HIV/AIDS status			0.12 (0.728)
Negative	141 (38.0)	230 (62.0)		Ref
Positive	1 (50.0)	1 (50.0)		0.61 (0.04 to 9.77), 0.724
Sickling status			5.30 (0.021)
Negative	137 (37.3)	230 (62.7)		Ref
Positive	5 (83.3)	1 (16.7)		0.12 (0.01 to 1.03), 0.053
Number of ANC visits			5.93 (0.015)
Less than eight visits	81 (42.0)	112 (58.0)		Ref	Ref
Eight or more visits	61 (33.9)	119 (66.1)		0.27 (0.09 to 0.83), 0.022	0.30 (0.10 to 0.96), 0.042
Anaemia status at first ANC			1.71 (0.635)
No	80 (37.4)	134 (62.6)		Ref
Mild	53 (38.4)	85 (61.6)		0.99 (0.64 to 1.54), 0.955
Moderate	8 (40.0)	12 (60.0)		0.90 (0.35 to 2.28), 0.817
Severe	1 (100.0)	0 (0.0)		–
Anaemia status at delivery			8.79 (0.032)
No	75 (95.6)	128 (63.1)		Ref	Ref
Mild	60 (38.5)	96 (61.5)		1.17 (0.44 to 3.09), 0.759	1.07 (0.38 to 3.06), 0.892
Moderate	6 (50.0)	6 (50.0)		1.96 (0.23 to 16.88), 0.540	2.09 (0.24 to 18.58), 0.507
Severe	1 (50.0)	1 (50.0)		21.56 (1.25 to 373.11), 0.035	17.66 (0.98 to 318.78), 0.052
Sex of newborn			0.29 (0.590)
Female	66 (36.7)	114 (63.3)		Ref
Male	76 (39.4)	117 (60.6)		0.87 (0.57 to 1.32), 0.516

ANC, antenatal care; aOR, adjusted OR; cOR, crude OR; JHS, junior high school; NHIS, National Health Insurance Scheme; SHS, senior high school.

The odds of adverse birth outcome were 74% lower for adolescents aged 16–19 years (aOR=0.26, 95 %CI 0.08 to 0.89) compared with those aged less than 16 years. The narrow CI demonstrates a precise and statistically robust protective association. A similar protective association was observed for ANC utilisation. Compared with adolescents with less than eight ANC visits, those with eight or more visits were 70% less likely to have an adverse birth outcome (aOR=0.30, 95% CI 0.10 to 0.96). The CI for this association also excludes the null value of 1.0, indicating a clear, statistically defined protective effect. The likelihood of an adverse birth outcome increased with increasing anaemia severity. The odds were slightly elevated for adolescents with mild anaemia (aOR=1.07, 95% CI 0.38 to 3.06), but the wide interval firmly included the null value of 1.0, indicating the data are compatible with increased, decreased or no association. The odds increased dramatically for those with severe anaemia, with a point estimate suggesting a 17.66-fold increase (aOR=17.66, 95% CI 0.98 to 318.78). This wide interval only just includes the null value of 1.0 (at the lower boundary of 0.98), suggesting that while the association lacked the necessary statistical precision to exclude the possibility of no effect, the data are most compatible with a major increase in risk.

Discussion

The study investigated adverse birth outcomes and associated factors among adolescents in the Nabdam District of Ghana. The findings revealed that among the adolescents included in the study, 37.8% experienced at least one adverse birth outcome, including PTB (20.9%), newborns with asphyxia (15%), LBW (14.7%) and stillbirth (0.3%). The findings revealed significant associations between subdistrict of residence, age and number of ANC visits, and adverse birth outcomes.

Regarding the finding that 20.9% of the adolescent pregnancies in the Nabdam District (2021–2022) were PTBs, this is consistent with the finding by Akseer et al, which reported a higher prevalence of 23% for PTBs.²⁷ It suggests that PTB may be a significant concern in this population. While the prevalence reported by previous studies, such as Ursache et al²⁸ and Annan et al,²⁹ is lower (14.8% and 12.5%, respectively), it is important to consider the variations that can occur due to differences in sample sizes, geographical locations and healthcare access. Further research is needed to explore the underlying factors contributing to the higher prevalence of PTB among adolescents in this region.

The prevalence of LBW among adolescents in this study was 14.7%. This finding aligns with previous studies conducted by Annan et al,²⁹ Abebe et al,³⁰ Afriyie et al³¹ and Mombo-Ngoma et al,³² which reported prevalence rates ranging from 10% to 17.5% for LBW among adolescent mothers. It is, however, lower than the 21.1% and 26% found by Mezmur et al³³ and Akseer et al,²⁷ respectively. These findings collectively highlight the consistent vulnerability of adolescent mothers to delivering infants with LBW, emphasising the need for targeted interventions to improve birth outcomes in this population.

Again, the study reported a prevalence of 15% for newborns with asphyxia among adolescents in the Nabdam District. While specific literature regarding asphyxia among adolescent mothers in this region was not available for direct comparison, Mezmur et al reported a prevalence of 9.3% for asphyxia in neonates among adolescent women.³³ Although not directly comparable, this finding suggests that the prevalence of asphyxia among adolescent mothers warrants attention and further investigation. Future studies should focus on exploring the underlying factors contributing to asphyxia in newborns among adolescent mothers in developing settings and identifying effective preventive strategies.

Additionally, the study’s high prevalence of presence of adverse birth outcomes (38.1%) among adolescents is consistent with the 39.8% incidence of adverse foetal outcomes in adolescents in the study by Bihoun et al.³⁴ It further highlights adolescents’ significantly higher risk of adverse birth outcomes compared with older women.34,37 Considering the study setting, this could be attributed to many socioeconomic factors, including inadequate nutrition during pregnancy.^{38 39}

These findings are broadly consistent with studies conducted in other Ghanaian regions, including the Ashanti Region and Cape Coast Metropolis, which similarly reported high prevalence of LBW and PTB among pregnant adolescents.^{29 31} However, the prevalence observed in Nabdam is comparatively higher than reports from urban settings, which may reflect distinct socioeconomic and cultural dynamics in the district. Nabdam is a predominantly rural district characterised by high household food insecurity, high adolescent marriage rates and long travel distances to skilled birth services, all of which have been associated with adverse birth outcomes among adolescents in SSA. These contextual factors may help explain the increased likelihood of adverse birth outcomes observed in certain subdistricts.

Our findings are consistent with evidence from other regions of the world, where adolescent pregnancy has similarly been linked to increased risk of PTB, LBW and neonatal complications.40,42 However, some differences in prevalence across studies may reflect variations in socioeconomic context, nutritional status, antenatal care access, cultural norms surrounding adolescent marriage and health system capacity. For example, studies from India and Eastern Europe attribute adverse outcomes to early marriage and limited reproductive autonomy,^{41 42} while Middle Eastern evidence emphasises biological immaturity and low ANC utilisation.⁴⁰ These comparisons suggest that the drivers of adverse birth outcomes among adolescents are multifactorial and context-dependent, reinforcing the need for localised strategies that address both social and health-system barriers.

These findings emphasise the need for comprehensive interventions that address both individual and contextual factors to improve birth outcomes for adolescent mothers in the Nabdam District. Adverse birth outcomes have strong implications for the attainment of Sustainable Development Goal (SDG) 3 of ensuring healthy lives and promoting well-being for all at all ages, particularly for targets 3.1 and 3.2, which seek to reduce maternal mortality and end preventable deaths of newborns and children. Again, having babies with adverse birth outcomes can derail the social and economic growth of adolescents and affect other SDGs. Policymakers, healthcare providers and stakeholders can develop targeted strategies to reduce the prevalence of adverse birth outcomes and improve the overall well-being of adolescent mothers and their infants.

Furthermore, the study found that adolescents in the Pelungu subdistrict were 2.95 times more likely to have adverse birth outcomes compared with those in the Zanlerigu subdistrict. This finding aligns with previous research by Mezmur et al,³³ which reported a significant association between adverse foetal outcomes and contextual factors such as the location of residence. It is plausible that limited access to healthcare resources, socioeconomic disparities or specific contextual characteristics in the Pelungu subdistrict contribute to the higher odds of adverse birth outcomes.

The current study revealed that adolescents aged 16–19 years (late adolescence) had 74% lower odds of adverse birth outcomes compared with those aged less than 16 years. This finding is consistent with Annan et al,²⁹ who reported that younger age was associated with increased odds of adverse birth outcomes among pregnant adolescents. The protective effect of being in the older adolescent age group may be attributed to factors such as better physical maturity, increased decision-making capacity and improved access to resources and support networks.

Moreover, this study demonstrated that adolescents who had eight or more ANC visits were 70% less likely to have adverse birth outcomes compared with those with fewer visits. This finding is consistent with Mezmur et al,³³ who found that antenatal care attendance was significantly associated with favourable birth outcomes among adolescent women. Similarly, Annan et al found that adverse birth outcomes were associated with socioeconomic factors and antenatal care compliance among pregnant adolescents.²⁹ Regular ANC visits provide opportunities for health monitoring, early detection and management of potential complications, which can contribute to improved birth outcomes. Addressing barriers to healthcare access, enhancing educational opportunities and promoting comprehensive antenatal care services tailored to the unique needs of adolescent mothers are crucial steps toward reducing the burden of adverse birth outcomes in the Nabdam District.

Furthermore, these findings together have implications for ensuring better birth outcomes for adolescents in low-resource settings like Nabdam. Addressing these challenges may require multilevel and context-specific interventions, including: strengthening adolescent-friendly ANC services, community-based pregnancy support groups, nutrition supplementation and counselling for pregnant adolescents and transportation or referral support for adolescents in remote communities. Evidence from Ghana and other LMICs indicates that such targeted interventions improve ANC uptake, skilled birth care and reduce adverse birth outcomes among adolescent mothers.

It is important to acknowledge the limitations of our study. The study contributes to the existing understanding that adverse birth outcomes observed in both very young and older mothers may be influenced by biological as well as environmental and socioeconomic factors specific to these populations. Nevertheless, due to the limited availability of contextual covariates in our datasets, our ability to comprehensively explore or confirm these trends was restricted. We limited the analysis to records from January 2021 to December 2022 because these years had complete, consistent register data across all facilities; this may have reduced sample size but improved data quality and comparability. Additionally, the cross-sectional design limits our ability to establish temporality or infer causality between predictors and birth outcomes. Further studies may explore a more comprehensive variable set to gain more understanding of the complex interplay between biology, environmental conditions and socioeconomic factors and adverse birth outcomes among adolescent girls.

Conclusion

This study demonstrates a substantial burden of adverse birth outcomes among adolescent mothers in Nabdam District, with nearly two in five experiencing at least one complication. Geographical disparities were evident, with adolescents in Pelungu subdistrict experiencing markedly higher odds of adverse outcomes than those in other areas. Younger adolescents (<16 years) were also at increased risk, as were those who attended fewer than eight antenatal care visits.

These findings highlight the need to strengthen adolescent-focused ANC services, address subdistrict-level inequities in access and quality of care and improve early identification and support for high-risk younger adolescents. Targeted interventions are needed to address the modifiable factors identified in this study. Community-based adolescent outreach through community-based health planning and services (CHPS) household visits, peer-support groups and local pregnancy clubs could help promote early identification and sustained ANC engagement. Improved ANC uptake may be achieved through youth-friendly ANC hours, reminder systems for missed visits and transport support for adolescents in remote subdistricts. In addition, adolescent-responsive maternal health programmes, including respectful and private maternity services, psychosocial support and links to postpartum family planning, could strengthen continuity of care. Strengthening coordination between health, education and social protection systems would further support school retention and address the broader vulnerabilities facing pregnant adolescents.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.