Correspondence:
Dr. Audu I Aveka,
Department
of Psychiatry,
Ahmadu
Bello University Teaching Hospital, Zaria.
P.M.B
06, Zaria, Kaduna state, Nigeria.
E-mail
address: audu.veka@gmail.com
Phone
no. +234(0)8033492910
INTRODUCTION
Pregnancy
is a major physiological and psychological change in the life of a woman. In the predominantly Muslim society of
Northern Nigeria, early marriage and the resultant teenage motherhood abound.1
Very little attention has been paid to the emotional well-being of adolescents
in pregnancy, as most studies have concentrated on their physical health.2,3
Anxieties relating to the health of the unborn child as well as the welfare of
the newborn are considerable, and some women may
suffer psychological disorders at this time.4 Even though pregnancy
may occur at any time after menarche, there is a societal concern that
adolescents who are themselves children may not be psychologically mature to
handle the emotional challenges that often accompany pregnancy.5,6
Despite this concern, adolescent pregnancy is a common occurrence worldwide. In
the predominantly Muslim society of Northern Nigeria, early marriage and the
resultant teenage motherhood abound.1 According
to the Nigeria Demographic and Health Survey (NDHS) report 2023 – 2024,
approximately 15 % of young ladies aged 15 – 19 years have experienced
pregnancy.7 This figure is even higher among girls in the rural
Northwest and Northeast regions of the country, where early marriage is very
common. 1,6
Anxiety disorders
are a frequent occurrence in pregnancy, with over 50 % of pregnant women
experiencing worries and other anxiety symptoms.8 The expectant
mother, especially the adolescent, often expresses excessive worries and
concern over her ability to carry the pregnancy to term, fear of labour and
delivery, possibility of harm to herself and/or the baby, and reportedly
increases vulnerability to anxiety disorders during this period.9. Vulnerability to anxiety disorders is a
complex interplay between biological and psychosocial stressors.
Although sex hormones, which are abundant
in the pregnant state, are known to mediate some anxiolytic effects, anxiety
symptoms may still be precipitated in pregnancy as a result of failure to
down-regulate negative emotional responses to stress and fear.10
Several studies have reported an increasing incidence of pregnancy-related
anxiety disorders, especially during the late pregnancy period. 10,11
The review of
available literature has revealed a gap concerning anxiety disorders among
pregnant adolescents. Most of the studies assessing the emotional well-being,
including anxiety disorders in pregnancy, were mainly done in adult women aged
20 years and above.12,13 The few available studies relating to
adolescents in pregnancy have focused on the physical rather than emotional
well-being of the expectant mothers.2,3 Considering the negative
impact this may have on the overall physical and mental well-being of the
expectant mother and her developing foetus makes it imperative to conduct this
study to assess the prevalence and correlates of anxiety disorders among
adolescents in pregnancy.
MATERIALS AND METHODS
The study was conducted at the antenatal
clinics of Ahmadu Bello University Teaching Hospital, Zaria, over a period of
six weeks. It was a cross-sectional descriptive study involving 150 pregnant
adolescents at 32 weeks’ gestation or later. Assent was obtained from those under
18 years, while those aged 18 years and above provided consent. Those who had a
previous history of psychiatric illness were excluded. The ethical committee of
Ahmadu Bello University Teaching Hospital approved the study.
The calculated sample size of 150 was determined using
n = z^2pq/d^2, based on a previous study reporting a prevalence of
9.7%.11 Participants were selected using a systematic random
sampling technique. The attendance register of women
attending the antenatal clinic served as the sampling frame. The first subject
was randomly selected from the list using a table of random numbers, and
subsequent subjects were selected at the calculated sampling interval until all
participants were selected. Participants completed the sociodemographic and
clinical questionnaires, as well as the social support and GHQ-12
questionnaires, by self-report. The 41 participants who scored 3 or higher on
the GHQ-12, including about 10% of the 109 participants with scores below 3, were
interviewed using the SCID by the author. Data were collected over six weeks.
Data were analysed using the Statistical Package for the Social Sciences (SPSS)
version 20. Descriptive statistics were calculated for the variables.
Chi-square tests and p-values were calculated to assess associations. Odds
ratios and their 95% confidence intervals were calculated. All statistical
significance tests were carried out at the 5% level.
RESULTS
The
mean age of the participants was 17.04 years, with an SD of 0.04 years. The
majority were married. Most had no Western education, and they were mostly
full-time housewives (Table 1). The prevalence of anxiety disorders among the
participants was 11.3 %, and the GHQ-12 used for screening had a sensitivity
and specificity of 82.4% and 80.0%, respectively (Table 2). The variables found
to be associated with anxiety disorders among the participants were marriage
type, employment status, gravidity, history of stillbirth and poor social
support (Table 3). The independent determinants of anxiety disorders after
multiple regression of these associated variables were gravidity, previous
experience of stillbirth and level of social support (Table 4)
Table 1: Sociodemographic Characteristics of the
Participants (N=150)
|
Variable
|
Frequency
|
Percentage
|
Statistics
|
|
Age (Years)
14 – 15
16 - 17
18 – 19
Mean:17.04±0.04 years
|
9
70
71
|
6.0
46.7
47.3
|
ꭓ = 12.50
p= 0.11
|
|
Marital Status
Divorced
Married
Divorced
|
5
10
135
|
3.3
6.7
90.0
|
ꭓ = 2.86
p = 0.08
|
|
Educational Level
Tertiary
Secondary
Primary
None
|
10
32
38
70
|
6.7
21.3
25.3
46.7
|
ꭓ = 1.28
p = 0.12
|
|
Employment
Others
Civil
servant
Trading
Full-time
Housewives
|
4
11
37
98
|
2.7
7.3
24.7
65.3
|
ꭓ = 10.88
p < 0.001*
|
Table 2. Prevalence of Anxiety among the
Participants using GHQ-12 and SCID
|
|
SCID
|
|
GHQ-12
|
Anxiety
Disorders
|
No
Anxiety Disorders
|
Total
|
|
Positive
|
14
|
27
|
41
|
|
Negative
|
3
|
106
|
109
|
|
Total
|
17
|
133
|
150
|
*Sensitivity of GHQ-12 was 82.4 %; Specificity was
80.0 %
DISCUSSION
The
mean age of the respondents was 17.04 years, with an SD of 0.04 years. This is
lower than the 18.4 years reported by Oladeji et al.
among pregnant adolescents in Ibadan, Southwest Nigeria. 5 More than half of
the respondents were under 18 years of age, and about three-quarters had not completed
primary education. This finding concurs with that of Adeola et al., who found that
early marriage is detrimental to girl-child education 3, as further
affirmed by Erulkar et al.’s study, which found that two-thirds of young ladies in
rural Northwestern Nigeria were married by age 18
years.6 Educational attainment of the girl child
Table 3: Socio-demographic variables associated with
Anxiety Disorders among the Participants
|
Variable
|
Normal
N (%)
|
95% Cl
|
Anxiety disorder
N (%)
|
95% Cl
|
Statistics
|
|
Age (years)
14 – 17
17 – 19
|
67 (84.8)
64 (90.1)
|
74.4 – 90.6
82.6 – 97. 8
|
12 (15.2)
7 (9.9)
|
10.6 – 19.6
6.6 – 12.3
|
χ2 = 5.86
p = 0.09
|
|
Marital Status
Single/Divorced
Married
|
7 (87.5)
126 (88.7)
|
79.2 – 92.0
80.2 – 95.6
|
1 (12.5)
16 (11.3
|
9.4 – 15.2
7.4 – 15.8
|
χ2 = 2.86
p = 0.08
|
|
Marriage Type
Monogamy
Polygamy
|
54 (91.5)
79 (86.8)
|
82.1 – 97.5
70.7 – 91.5
|
5 (8.5)
12 (13.2)
|
2.5 – 17.9
12.5 – 29.3
|
ꭓ = 10.88
p < 0.001
|
|
Employment Status
Unemployed
Employed
|
113 (88.3)
20 (90.9)
|
70.2 – 95.8
87.9 – 102.3
|
15 (11.7)
2 (9.1)
|
10.2 – 19.8
6.3 – 10.1
|
ꭓ = 7.21
p < 0.001
|
|
Western Education
No
Yes
|
79 (88.8)
54 (88.5)
|
79.2 – 94.0
79.8 – 89.9
|
10 (11.2)
7 (11.5)
|
6.0 – 20.8
10.0 – 30.2
|
χ2 = 1.28
p = 0.12
|
|
Gravidity
Primigravida
Multigravida
|
90 (87.4)
43 (91.5)
|
80.3 – 98.1
67.8 – 95.6
|
13 (12.6)
4 (8.5)
|
5.9 – 21.7
4.4 – 12.2
|
ꭓ = 24.06
p < 0.001
|
|
Marital satisfaction
No
Yes
|
88 (92.6)
45 (81.8)
|
83.8 – 95.8
58.9 – 83.5
|
7 (7.4)
10 (18.2)
|
4.2 – 16.2
16.5 – 41.1
|
ꭓ = 8.30
p = 0.004*
|
|
History of Still Birth
No
Yes
|
119 (93.0)
14 (63.6)
|
87.1 – 96.7
55.7 – 68.1
|
9 (7.0)
8(36.4)
|
3.3 – 12.9
34.9 – 74.3
|
ꭓ = 32.85
p < 0.001
|
|
Social Support
No
Yes
|
112 (93.3)
21 (70.0)
|
84.5 – 95.3
50.7 – 75.5
|
8 (6.7)
9 (30.0)
|
4.7 – 15.5
24.5 – 59.3
|
ꭓ = 17.06
p < 0.001
|
*Significant
variables
has
a direct influence on the delay in age at first marriage. Lack of functional
education has a direct bearing on the employment and economic empowerment
of women. About 65% of the respondents were not income earners, as they were
full-time housewives. This may reflect the respondents' low educational attainment,
as most did not go beyond primary education. Studies have shown that young
women in marital relationships are more likely to be unemployed and
stay at home as full-time housewives. 1,6
The prevalence of anxiety disorders was 11.3 % in this
study. This is similar to the 11.4% reported by Bindt
et
al. among their respondents in Ghana 14, but is
far higher than the 4.2% reported by Magdy et al. among pregnant adolescents in
Saudi Arabia.[15] This difference may
be due to differences in the subjects’ ages and parities.
Table 4:
Logistic Regression Analysis: Independent determinants of anxiety disorders
|
Variable
|
Odds Ratio
|
95% CI OR
|
p-value
|
|
Marriage type
Polygamy
Monogamy
|
2.46
1
|
1.02 – 19.00
|
0.65
|
|
Employment
Yes
No
|
4.06
1
|
1.33 – 10.13
|
0.061
|
|
Gravidity
Primigravida
Multigravida (ref)
|
1.32
1
|
0.21 – 8.20
|
0.030*
|
|
Marital satisfaction
Yes
No
|
2.36
|
1.54 – 6.56
|
0.075
|
|
Still Birth
Yes
No (ref)
|
6.06
1
|
1.33 – 27.53
|
0.020*
|
|
Social support
Yes
No (ref)
|
3.15
1
|
0.12 – 8.15
|
0.001*
|
*Significant variables.
For
instance, adolescents in this study were younger, with a mean age of 17 years,
and three-quarters were primigravida, compared with participants in the study
by Magdy et al., who were slightly
more mature, with a mean age of 19 years, and most were multigravida.15 The
rate was also higher than the 10.7% reported by Audu
et al. among pregnant women attending a primary health care clinic.16 Unlike
in this study, the respondents in Audu et al.’s study
were adult women in pregnancy. The higher rate of anxiety disorders among the
respondents in this study may be because they were young and most of them were pregnant
for the first time, and were more likely to be preoccupied with excessive fear
about their capacity to cope with the demands of pregnancy and delivery.16
There is empirical evidence from studies that young people carry the
burden of negotiating the transition from childhood to adulthood, and carrying
the additional burden to cope with multiple stressors associated with pregnancy
may predispose the vulnerable ones to emotional disorders 17,18
The GHQ-12, used as a screening instrument for anxiety
disorders in this study, identified 14 out of 17 cases, representing a
sensitivity of 82.4%. It also showed specificity of 80.0%, making it a
reliable, simple tool that can be used in our busy clinic to identify those at
risk of anxiety disorders for early intervention. This study showed that
adolescents undergoing pregnancy for the first time in their lives are more
prone to developing anxiety disorders than those who have carried pregnancies
in the past. Primiparous adolescents are more at risk than their
multiparous counterparts for anxiety disorders, with an odds ratio of 1.32 (95%
CI 0.21 – 8.20). This finding supports the earlier report by Audu et al in a study on generalised anxiety disorder among
women in late pregnancy.16 This may not be unconnected with
excessive worries over the likely outcome of the pregnancy. In our routine
clinical services at antenatal care, the emotional needs of the women are
hardly inquired into to identify those at risk, and the fear and worries may
persist without any assurance given to boost the women's confidence; this
concern may become elevated to a point of causing emotional distress, including
anxiety disorders.
There is a significant association between a history
of stillbirth and anxiety disorder among the respondents in this study
(ꭓ=32.85, P<0.001). The odds of developing an anxiety disorder after
experiencing a stillbirth are six times higher than those without such a
history. This is similar to the finding of Akinsulore
et al, who reported a significant association between anxiety disorder and a
history of previous abortion. 7 The
fear of a possible repeat of the sad experience may be responsible for this association.
The perceived social support is associated with
anxiety disorders in this study. The level of social support from significant
others, such as the husband and in-laws, helps build confidence and soothe the
expectant mother's emotional needs. Where the environment is hostile without
social support being given to the adolescent by way of encouragement, and
overlooking the areas of deficiency, can precipitate a state of fear and
excessive worries. Studies have reported that the level of perceived social
support from family members has a significant association with the occurrence
of antenatal anxiety among pregnant adolescents. 19,20
CONCLUSION
This
study showed the need for a holistic evaluation of women in antenatal care,
especially the younger ones. Specific enquiries about the emotional health of
the antenatal attendees, with particular focus on primigravida, previous
history of adverse pregnancy outcomes and poor social support, should alert the
attending health personnel to request a thorough psychological evaluation of
such women. This may help in the prompt detection and treatment of those with
emotional disorders, including anxiety disorders.
Conflict
of Interest: None
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