Because of changing teenage sexual customs, a menarche occurring at an ever earlier age level and an early physical and sexual maturity in girls, an increasing number of extra-marital teenage pregnancies is to be expected. This thesis therefore deals with the question whether in con
nection with a greater chance of disturbances it is necessary to pay particular attention to certain aspects of pregnancy, labour and puerperium of unwed mothers.
From the literature we find the unanimous conclusion that unwed pregnant women have more complications during pregnancy, parturition and puerperium than married women. This is manifested in an increased toxemia frequency, more premature labour, more growth retarded fetuses and a higher fetal, neonatal and maternal mortality rate. On the question of anemia during pregnancy we find a division of opinion, as well on the duration of labour as on the frequency of artificial deliveries.
During the early post partum period more infections are observed as a rule in unmarried women than in married ones. All these complications can be related to poor social-hygienic conditions and inadequate prenatal care. In unmarried women we find a marked increase in mortality as a result of illegal abortion. The risks for the unmarried mother resulting from her pregnancy, parturition and puerperium however do not seem to be markedly higher.
Our own material included 5 86 unmarried primigravidae as well as a control-group of 5 5 9 married primigravidae of nearly the same age, registered for other than medical indications, who were delivered in the Groningen University Clinic during the years 1961-1969. Though the two groups could not be considered entirely equal as regards social background, we have the impression that if there was a difference at all, this was negligible. The groups were compared in relation to various aspects of pregnancy, delivery and postpartum period.
It appeared that unmarried pregnant women usually seek prenatal 114
care at a later stage of pregnancy than do married women. Because unwed mothers often give birth outside their residence, it is possible that they had already received some form of prenatal care in their own residence. We do not have an exact data on this point. The impression from our findings are in agreement with the literature that unwed mothers seek prenatal care at a later gestational age. In spite of this less frequent prenatal care of unmarried mothers this group did not show more toxemia than the control-group.
The duration of pregnancy was shorter for unmarried women than for married ones, which is entirely due to a higher frequency of premature delivery.
There was no significant difference between the two groups in the frequency of prolonged labour. The duration of parturition was significant
ly longer for married women than for unmarried ones, possibly caused by the fact that the married women generally bore heavier children.
Malposition and malpresentation occurred with the same frequency as well as artificial deliveries. The unmarried women, however, were delivered more often by caesarean section than married ones. The in
dication for caesarean section was mostly based on a combination of factors, such as contracted pelvis, prolonged labour and intra-uterine asphyxia. In both groups contracted pelvis and prolonged labour occurred with the same frequency, so that these factors do not entirely explain the difference. Possibly non-somatic factors are also related.
Perineum injuries, i.e. ruptures, occurred more often in the unmarried women than in the married ones. This was possibly due to the frequent occurrence of a swift expulsion.
In the post-natal period a hemorrhage of over 5 oo ml. was found more often in married women than in unmarried ones. This difference may be explained by the fact that the married women were in labour for a longer period and also bore heavier children than the unmarried women. These factors proved to be statistically related.
The course of puerperium was the same for both groups, aside from an increased frequency of endometritis in unmarried women and of anemia in married women (probably caused by a greater postpartum haemorrhage).
A comparison of the literature and our own investigation revealed that, contrary to the data presented in literature, a higher frequency of toxemia in unmarried women was not observed in our material. This remarkable discrepancy may be caused by inadequate attention in some studies to the comparability of the groups examined.
The higher frequency indicated in the literature of premature labour, intrauterine growth retardation and perinatal mortality, however, are in agreement with our conclusions. In the entire material investigated by us no maternal death occurred. The high maternal mortality described in the literature for unmarried gravidae as a result of abortion is also true for the Netherlands.
The higher percentage of disturbed labour indicated in the litera
ture as a result of infection was also found by us in the form of a higher frequency of endometritis in unmarried puerperae.
What was clearly shown from this investigation was that the child of a unmarried primigravida incurs more risks than that of a married primigravida and this for two reasons, viz. :
1 . unmarried women more often had a premature delivery;
2. unmarried women more often bore a growth retarded fetus, without this being caused by a higher incidence of toxemia or hypertension as compared to married women.
Both these factors entail great risks for the child, before, during and after birth, as is shown in an increase in perinatal mortality. We have not been able in this investigation to ascertain the cause of the high frequency of prematurity and dysmaturity. We have the impression, how
ever, that the menstruation history of unmarried women has not been taken sufficiently serious when the uterine growth indicated a discrepancy with the duration of pregnancy. As a result even extreme growth retardation was not always recognized as such and thus remained un
treated, with all the ensuing risks for an intra-uterine death of the fetus.
In order to restrict these risks to a minimum, we believe that special attention should be paid to the following points (particularly in a country like the Netherlands, were more than half of all deliveries are taking place at home) :
1 . The cause of premature delivery is unknown. Probable factors leading
to it in unmarried women are : poor social-hygienic conditions and mental stress. If these two conditions are indeed responsible, social guidance and a fully prenatal care might lower the frequency of threatened premature labour. Special attention to the premature con
tractility of the uterus and an early careful treatment might extend the average duration of gestation. For these reasons, as well as for adequate treatment of the premature newborn both clinical prenatal care and delivery are indicated for all unmarried women.
2. Many factors which may lead to intra-uterine growth retardation of the fetus are not (yet) within the sphere of influence of the obstetrician.
1 1 6
In connection with this matters might be improved by more attention to social-hygienic circumstances. Within the scope of the obstetrician are timely diagnosis and treatment of undernutrition. With the un
certain duration of pregnancy, such as often found in unmarried women and in the absence of other symptoms such as hypertension, this is definitely one of the most difficult parts of prenatal guidance.
Underdevelopment, moreover, has its consequences in that a careful attention has to be given during labour as well as in treating the neonatus. For these reasons also a clinical delivery for unmarried women is indicated.
Finally : the marked increase in maternal deaths of unmarried women resulting from criminal abortion can only be reduced by elimination of the criminal abortion and by preventing extra-marital pregnancies.
Extending the indications for therapeutic abortion may provide a con
siderable contribution. In this respect information and sex education of the teenager, as well as extending the possibilities for obtaining contra
ceptives are important.
I I7
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