RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE ANNEXURE-11 PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Ms. SHRUTHI.S UNITY ACADEMY OF EDUCATION UNITY COLLEGE OF NURSING 1 Name of the candidate and address SHEDIGURI, DAMBEL ROAD (in block letters) ASHOKNAGAR POST MANGALORE-575006 UNITY ACADEMY OF EDUCATION UNITY COLLEGE OF NURSING, 2 Name of the institution SHEDIGURI, DAMBEL ROAD ASHOKNAGAR POST MANGALORE-575006 M.Sc. NURSING 3 Course of study and subject OBSTETRICS AND GYNECOLOGICAL NURSING 4 Date of Admission to the course 07/07/2010 5 Title of the study “ A STUDY TO ASSESS THE LEVEL OF KNOWLEDGE AND ATTITUDE REGARDING EARLY MARRIAGE AND PREGNANCY AMONG ADOLESCENT GIRLS IN SELECTED RURAL SCHOOLS OF MANGALORE TALUK IN VIEW TO DEVELOP AN INFORMATIONAL BOOKLET”.

6 BRIEF RESUME OF THE INTENDED WORK 6.1 INTRODUCTION Adolescents are in the process of moving from childhood to adulthood. This prolonged maturational period is a phenomenon of modern developed countries. The age at which biologic maturation occurs has declined significantly during the last century. Adolescence is the period of adaptation and maturation. Risk behaviors and poverty make adolescents especially vulnerable to the challenges inherent in pregnancy and parenting. This event can prevent optimal development and threatening physiologic and psychological well being. The costs to adolescent, their offspring, their families, and their society can be enormous. The incidence of adolescent pregnancy has increased in recent years. Childbearing at any age is a momentous event. For the adolescent, however it is often accompanied by a different set of problems from those experienced by adult mothers. Adolescent pregnancy is commonly associated with an increased risk of maternal complications during pregnancy and delivery as well as increased risk to the fetus and neonate. The adolescent mothers my experience difficulty in accepting a changing self image and adjusting to new roles related to the responsibilities of infant care. They may feel different from the peers, be excluded from activities, and be forced to assume an adult social role. The combination of the conflict between their own desires and the demand of the infant and their low tolerance of frustration further intensive the normal psychosocial stress of childbirth.

6.2 NEED FOR THE STUDY

Adolescence is a period of transition from childhood to adulthood. According to World Health Organization( WHO )the period of adolescence extends from 13 to 19 years. 1 Adolescent girls are physically and psychologically immature for reproduction. In addition to these there are some extrinsic factors such as inadequate prenatal care, illiteracy and poor socio economic conditions which affect the outcome of pregnancy adversely in adolescent girls.2

Although adolescents aged 10-19 years account for 11% of all births worldwide, they account for 23% of the overall burden of disease (disability- adjusted life years) due to pregnancy and childbirth. Fourteen percent of all unsafe abortions in low- and middle-income countries are among women aged 15–19 years. About 2.5 million adolescents have unsafe abortions every year, and adolescents are more seriously affected by complications than are older women.Latin America, the risk of maternal death is four times higher among adolescents younger than 16 years than among women in their twenties.Many health problems are particularly associated with negative outcomes of pregnancy during adolescence. These include anaemia, malaria, HIV and other sexually transmitted infections, postpartum haemorrhage and mental disorders, such as depression.Up to 65% of women with obstetric fistula develop this as adolescents, with dire consequences for their lives, physically and socially. Stillbirths and death in the first week of life are 50% higher among babies born to mothers younger than 20 years than among babies born to mothers 20–29 years old.Deaths during the first month of life are 50–100% more frequent if the mother is an adolescent versus older, and the younger the mother, the higher the risk.The rates of preterm birth, low birth weight and asphyxia are higher among the children of adolescents, all of which increase the chance of death and of future health problems for the baby.Pregnant adolescents are more likely to smoke and use alcohol than are older women, which can cause many problems for the child and after birth.1

Incidence of adolescent pregnancy is highest in Africa and it accounts for 143 in 1000 girls aged 15-19 years. In Asia incidence is 119 in 1000 girls aged 15-19, in United Kingdom rate of adolescent pregnancy is 100.4 per 1000 girls aged 15-19. In India incidence of adolescent pregnancy is 8-14% of the total population.3 Almost one fourth of India’s population comprises of girls below 20 years of age and adolescent pregnancies. According to census of 2001, 200 million adolescents are present in India. 50% of girls are married by 18 yrs. An estimated of 20.2 million adolescent pregnancies was recorded in 2001 census.3 Indian culture promotes universal marriage. Of importance to Adolescent reproductive health (ARH) is the traditional young marriage age of girls- referred to as early marriage. The national average age at marriage for women in India is 16.4 years, although there are vast regional variations. Majority of the states in the western, central, and eastern parts of India reported an average age at marriage similar to the national survey. However National family health survey-2 (NFHS-2) reports that in states like Bihar, Rajasthan, Uttar Pradesh, Madhya Pradesh and Andhra Pradesh girls are married at the age of 15 years.3 According to NFHS-2 about one third of women were married by age 15 and two third (64.6%) by age 18. Marriage by age 18 yrs of age is most prevalent in Bihar, Rajasthan, Uttar Pradesh, Madhya Pradesh, Andhra Pradesh, where nearly 80% of girls are married by 18 years. In these states almost one half of the girls are married at the age of 15 years .3 Nationwide, the district based Rapid Household Surveys (RHS’s) found that in 145 of the 504 districts in India, one half of women were married before age of 18 years. In some districts, the proportion married by age 18 years was as high as 75 percent.15 A research found that there is an increased rate of complications seen during pregnancy and delivery among adolescent mothers. The result showed that there was presence of complications like pre-eclampsia, eclampsia,anaemia in pregnancy, premature labour, premature rupture of membranes, fetal distress, preterm labour and forceps delivery was more in adolescent mothers when comparing with others. Such high rates are due to the fact that adoscent girls are not psychologically mature enough for reproduction.4

A research found that depressive symptoms were more in adolescent mothers when compared to other mothers. 6.5% to 28% mothers reported to experience post partum depression. Adolescent mothers also had more chances of developing short lived postpartum mood disorder, or baby blues.5 An increased risk of preterm delivery and low birth weight babies were associated with young maternal age in both developed and developing countries.6

Census report of 2001 also showed the incidence of adolescent marriages more in rural areas than the urban areas. So the researcher felt the need for conducting a study to assess the knowledge as well as attitude among the adolescent girls so that the informational booklet can be given to them so that they will be aware about the complications that can occur due to early marriage and pregnancies

6.3 REVIEW OF LITERATURE

Review of literature is a systematic search of a published work to gain information about a research topic 11

The review of literature for the present study is organized under the following headings.

 Social issues of adolescent early marriage and pregnancy.

 Effects of adolescent early marriage and pregnancy on maternal health.

 Effects of adolescent pregnancy on neonatal outcomes.

I) Studies related to social issues of adolescent early marriage and pregnancy A conducted a study on association between early marriage and young women’s marital and reproductive health. Data from 8,314 married women aged 20-24 living in five Indian states, were used to compare marital, reproductive and other outcomes between young women who had married before age 18 and those who had married later. Results of the study was young women who had married at age 18 or older were more likely than those who had married before age 18 to have been involved in planning their marriage (odds ratio, 1.4), to reject wife beating (1.2), to have used contraceptives to delay their first pregnancy (1.4) and to have had their first birth in a health facility (1.4). They were less likely than women who had married early to have experienced physical violence (0.6) or sexual violence (0.7) in their marriage or to have had a miscarriage or stillbirth (0.6).7 A study was conducted on “early adolescent marriage and future poverty” .Both early teen marriage and dropping out of high school have historically been associated with a variety of negative outcomes, including higher poverty rates throughout life. The baseline IV estimate indicates that a woman who marries young is 31 percentage points more likely to live in poverty when she is older.13 Similarly, a woman who drops out of school is eleven percentage points more likely to be poor. Grouped ordinary least squares (OLS) estimates for the early teen marriage variable are also large, OLS estimates based on individual-level data are small, consistent with a large amount of measurement error.8 According to the study done on “early marriage problems” it suggests that the rapid increase in the number of early marriages over the past several years coupled with the extremely high rate of divorce within this same group makes this subject extremely important. While some financial problems are to be expected in almost any new marriage, it is important to take time to think sensibly, so that such problems will not destroy what could otherwise be a beautiful relationship, if not undertaken prematurely. It is also a good idea to realize that if parents or in-laws are depended upon too heavily for financial support that this can provide the basis for other later family conflicts as well. Regardless of the good intentions involved, it is almost always true that the person who controls the money ultimately rules the situation.9

II) Studies related to Effects of adolescent early marriage and pregnancy on maternal health. A study was conducted on ‘Health problems and social consequences in adolescent pregnancy in rural Kathmandu valley’. A rural health centre based cross sectionals study was under taken over six month period among teenage (10-19 years) in the rural Kathmandu Valley. The study sample comprises (15-19 years old) 180 subjects. Data includes demographical variables as anemia, preterm delivery, abortion and hemoglobin. Preterm delivery cases within 37 weeks of gestation. Below 10 gm. of Hb was considered as anemia. The prevalence of anemia was quite high (56.66%) in teenage pregnancy. However severe (<7.9 gm) anemia was observed in 55.67% cases.10 A study was conducted on “Early marriage and harmful effects on women” suggests that Statistics show that the majority of girls in Asia, Africa and Latin America are married by the age of 14. According to reports, in six of the 21 Sub-Saharan African countries surveyed, the average age of marriage was less than 18. In Bangladesh, Guinea, Mali, Niger and Yemen, more than half of all young women interviewed were married by age 16..Statistics show that in both Bangladesh and Bhutan, four percent of girls are married before the age of fourteen. In Maldives 12 percent, a staggering 40 percent in Nepal, four percent in Pakistan, and in Sri Lanka, 0.2 percent. Furthermore, additional reports indicate that nearly seven percent of girls were found to be married before reaching the age of 10. In summary, early marriage can have several harmful effects on the overall well being of a young girl.11

According to the study conducted on “Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries”. They suggest that Early age at first sexual intercourse (AFSI) has long been associated with an increased risk of invasive cervical carcinoma (ICC). Age at first pregnancy (AFP) and ICC have been investigated less, although AFSI and AFP are strongly interrelated in most developing countries. A pooled analysis of case-control studies on ICC from eight developing countries with 1864 cases and 1719 controls investigated the roles of AFSI, AFP, and ICC risk. Age at first sexual intercourse, AFP and age at first marriage (AFM) were highly interrelated and had similar ICC risk estimates. Compared with women with AFSI > or = 21 years, the odds ratio (OR) of ICC was 1.80 (95% CI: 1.50-2.39) among women with AFSI 17-20 years and 2.31 (95% CI: 1.85-2.87) for AFSI < or = 16 years (P-trend <0.001). No statistical interaction was detected between AFSI and any established risk factors for ICC.12

A community based study was conducted on “pregnancy in adolescents”. A nested case control study design was used in resettlement colony of east Delhi. Details of pregnancy and birth related events were recorded in pre tested questionnaire by trained social workers. There were 64 adolescent and 175 adult primigravida in a cohort of 843 antenatal women. Complications of pregnancy were more common among adolescents. Home delivery was 2 times more common in adolescents. Abnormal presentation and prolonged labour was also more among adolescents. Pregnancy wastage was 17.5% among adolescents.13

III) Studies related to effects of adolescent pregnancy on neonatal outcome

A study was conducted on “Second births to teenage mothers: risk factors for birth weight and preterm birth”. Teenagers are more likely than older women to have a low-birth-weight infant or a preterm birth, and the risks may be particularly high when they have a second birth. Identifying predictors of these outcomes in second teenage births is essential for developing preventive strategies.Method used for the study was, Birth certificate data for 1993-2002 were linked to identify second births to Milwaukee teenagers. Predictors of having a low-birth- weight second infant or a preterm second birth were identified using logistic regression.Results of the study was the same proportion of first and second infants were low-birth-weight (12%), but second births were more likely than first births to be preterm (15% vs. 12%). In analyses that adjusted for demographic, pregnancy and behavioral characteristics, the odds that a second infant was low-birth-weight or preterm were elevated if the mother smoked during pregnancy (odds ratios, 2.2 and 1.9, respectively), had inadequate prenatal weight gain (1.8 and 1.4), had an interpregnancy interval of less than 18 months (1.6-2.9 and 1.4-2.3) or was black (2.7 and 1.7). Women who had received an adequate level of prenatal care had reduced odds of both outcomes (0.6 and 0.4). Women younger than 16 also had increased odds of having a low- birth-weight second infant. Further adjustment for socioeconomic characteristics yielded largely the same results. In addition, women who were unmarried or did not identify a father were at increased risk of both outcomes (1.5 for each), and poor women were at risk of having a low-birth-weight infant (1.3).14 A study was conducted on “Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. Background of the study was, Whether the association between teenage pregnancy and adverse birth outcomes could be explained by deleterious social environment, inadequate prenatal care, or biological immaturity remains controversial. The objective of this study was to determine whether teenage pregnancy is associated with increased adverse birth outcomes independent of known confounding factors.Methods used for the study was researcher carried out a retrospective cohort study of 3,886,364 nulliparous pregnant women <25 years of age with a live singleton birth during 1995 and 2000 in the United States.Results of the study wasAll teenage groups were associated with increased risks for pre-term delivery, low birth weight and neonatal mortality. Infants born to teenage mothers aged 17 or younger had a higher risk for low Apgar score at 5 min. Further adjustment for weight gain during pregnancy did not change the observed association. Restricting the analysis to white married mothers with age-appropriate education level, adequate prenatal care, without smoking and alcohol use during pregnancy yielded similar results.Conclusions of the study was Teenage pregnancy increases the risk of adverse birth outcomes that is independent of important known confounders. This finding challenges the accepted opinion that adverse birth outcome associated with teenage pregnancy is attributable to low socioeconomic status, inadequate prenatal care and inadequate weight gain during pregnancy.15

6.4 PROBLEM STATEMENT

A STUDY TO ASSESS THE LEVEL OF KNOWLEDGE AND ATTITUDE REGARDING EARLY MARRIAGE AND PREGNANCY AMONG ADOLESCENT GIRLS IN SELECTED RURAL SCHOOLS OF MANGALORE TALUK ,IN VIEW TO DEVELOP AN INFORMATIONAL BOOKLET. 6.5 OBJECTIVES

The objectives of the study are to:-

 assess the level of knowledge among adolescent girls about early marriage and pregnancy, using a structured knowledge questionnaire.  assess the attitude among adolescent girls about early marriage and pregnancy, using an attitude scale.  find correlation between knowledge with attitude towards early marriage and pregnancy among adolescent girls.  find the association of selected demographic variables with the knowledge and attitude

of adolescent girl regarding early marriage and pregnancy..

6.6 OPERATIONAL DEFINITIONS

Knowledge In this study, knowledge refers to basic information’s possessed by the adolescent girls regarding early marriage and pregnancy which will be assessed using structured knowledge questionnaire, and measured as the knowledge scores obtained by them.

Attitude In this study, attitude refers to opinions and feelings that the adolescents have regarding early marriage and pregnancy which will be measured using an attitude scale.

Early marriage In this study, early marriage refers to marriage before completion of 18 years.

Adolescent girls In this study adolescent girl refers to girls in the age group 15-18 years of selected rural schools.

Rural schools In this study, rural school refers to schools situated in selected rural areas of Mangalore taluk .

Informational booklet In this study informational booklet refers to self contained sheet which contains information regarding well being of young girls and also harmful effects on women due to early marriage and pregnancy. 6.7ASSUMPTIONS

The study assumes that,

1. Early marriage and pregnancy may cause some adverse effects to the adolescent girls. 2. Adolescent girls will have certain opinions and feelings towards early marriage and pregnancy. 3. Knowledge about early marriage and pregnancy would help the adolescent girls to take right decision in their life. 4. Information booklet is an acceptable method of spreading awareness.

6.8 DELIMITATIONS

The study is delimited to,

1. Adolescent girls between age group of 15-18 yrs. 2. Adolescent girls who are unmarried. 3. Adolescent girls of selected rural schools. 4. Adolescent girls who can read and write Kannada or English

6.9 HYPOTHESES

All hypotheses will be tested at 0.05 level of significance

H1: There will be a significant correlation between knowledge and attitude of the adolescent girls regarding early marriage and pregnancy.

H2: There will be a significant association between knowledge and attitude regarding early marriage and pregnancy with selected demographic variables of adolescent girls

MATERIALS AND METHOD

7.1. SOURCE OF DATA

7 The data will be collected from those adolescent girls who are in the age group of 15- 18 years in selected rural schools of Mangalore taluk.

7.1.1. Research Design Descriptive survey design. 7.1.2 Setting

The study will be conducted in selected rural schools of Mangalore taluk.

7.1.3 Population

The populations of this study are the adolescent girls within the age group 15-18 years in selected rural schools of Mangalore taluk.

7.2 METHOD OF DATA COLLECTION

7.2.1 Sampling procedure

A stratified sampling method will be used for this study

7.2.2 Sample size

Sample size will be 100 adolescent girls, within the age group of 15-18 years in selected rural schools of Mangalore taluk .

7.2.3Inclusion criteria for sampling

Adolescent girls

 Between age group of 15-18 years.  Available during the period of study  Willing to participate in the study.  Who can read and write Kannada or English.

7.2.4 Exclusion Criteria for Sampling

Adolescent girls

 Who are interested in early marriage.  Married and/or pregnant.

7.2.5 Instruments Tool 1 a: Baseline Pro-forma. b : Structured knowledge questionnaires on effects of early marriage and pregnancy. Tool 2 : Attitude scale (Likert scale) for measuring attitude of adolescent girls towards early marriage and pregnancy,

7.2.6 Data collection method

Data will be collected from the adolescent girls using the structured knowledge questionnaires and attitude scale after obtaining consent from them.

7.2.7 Data analysis plan

Data will be analyzed using descriptive statistics and inferential statistics.

7.3 Does the study require any investigations or interventions to be conducted on patients, or other animals? If so please describe briefly.

No.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Ethical clearance will be obtained from the concerned authorities.

LIST OF REFERENCES 1. WHO Report. Adolescents. May 2006. Available from http://www.who.int/making_pregnancy_safer/topics/adolescent_pregnancy/en/index.html 8 2. UNICEF. Report on early marriage. May 2005. Available from http://www.unicef.org/publications/files/Early_Marriage_12.lo.pdf

3 .Gupta S D. Adolescent Reproductive Health in India policy project 2003

4.KM Kale, NR Aswar, GS Jogdand, JS Bhawalkar.Socio-medical co-relates of teenage pregnancy,J obstet gynaecol India.1996;4(2):180-4.Available from http://medind.nic.in/imvw/imvw12537.html

5. Secco, Loretta M, Profit Sheila, Kennedy Evelyn, Walsh Andrey, Letourneau Nicole,et al.Factors affecting post partum depressive symptoms of adolescent mothers, J Gynaecol nursing.2007;36(4): 47-4.Available from http://www.ncbi.nlm.nih.gov/pubmed/17238946

6. TO School, ML Hediger, DH Belsky. Prenatal care and maternal health during adolescent pregnancy, J adolescent health. 1994; Sep 15 (6):444-6. Available from http://www.ncbi.nlm.nih.gov/pubmed/7811676

7. K.G. Santhya, Usha Ram, Rajib Acharya, Shireen J. Jejeebhoy, Faujdar Ram. International perspectives on sexual and reproductive health. Sep 2010; 36 (3)

8. PP Kafle, KN Pakuryal, RR Regmi, Luintal S,NMCJ. 2010;march 12 (1):42-4. Available from http://www.nber.org/papers/w11328 9. Wither James. Early marriage problems, Innocenti digest .March 2001; no 7 10. Sharma AK, Verma K, Khatri S, Kannan A T;Pregnancy in adolescents: a study of risks and outcome in eastern Nepal.2001;38(1):1405-1409 11. Sarup Kamala. Early marriage and harmful effects on women; Aug 26:2007 12.Louie KS, DE Sanjose S, Diaz M, Castellsagué X, Herrero R, Meijer CJ. Early age at first sexual intercourse and early pregnancy; BJC . 2000 April;100 (7):1191-7. Available from http://www.ncbi.nlm.nih.gov/pubmed/19277042 13.Sharma A K, Chhabra P, Gupta Pushpa, Aggarwal Q P, Lyngdoh T. Pregnancy in adolescents:Indian J.Prev, soc Med Vol 34 no 1,2;Jan 2003 14.SN Partington, D L Steber, K A Blair, R A Cisler. Second births to teenage mothers:

risk factors for low birth weight and preterm birth. Perspect Sex Reprod Health;2009 jun:41(2):101-9. Available from http://www.ncbi.nlm.nih.gov/pubmed/17978452

15.X K Chen,S W Wen, N Fleming, K Demissie, G G Rhoads, M Walker. Teenage pregnancy and adverse birth outcomes: A large population based retrospective cohort study. Int J Epidemiol;2007 Apr : 36(2):368-73. Available from http://www.ncbi.nlm.nih.gov/pubmed/17213208

9 SIGNATURE OF CANDIDATE

10 REMARKS OF THE GUIDE

11 NAME & DESIGNATION OF ( IN BLOCK LETTERS)

11.1 GUIDE MS.LYGIA V. HALDER ASSOCIATE PROFESSOR AND HEAD OF THE DEPT.OF OBSTETRICAL & GYNAECOLOGICAL NURSING UNITY COLLEGE OF NURSING MANGALORE.

11.2 SIGNATURE

11.3 CO-GUIDE ( IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT MS.LYGIA V. HALDER ASSOCIATE PROFESSOR AND HEAD OF THE DEPT.OF OBSTETRICAL & GYNAECOLOGICAL NURSING UNITY COLLEGE OF NURSING MANGALORE.

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL

12.2 SIGNATURE