Skip to main content
Download PDF

Adolescent pregnant women’s health practices and their impact on maternal, fetal and neonatal outcomes: a mixed method study protocol

Reproductive Health volume 16, Article number: 45 (2019) Cite this article

Abstract

Background

Considering that individuals’ health practices can affect the health of both mothers and babies, this study is designed to: (a) assess adolescent pregnant women’s health practices and their relationship with maternal, fetal, and neonatal outcomes; (b) explore the perception of adolescent pregnant women about their own health practices; and (c) recommend some strategies to improve adolescent pregnant women’s health practices during pregnancy.

Methods/design

This mixed-method study with the sequential explanatory design has two phases. The first phase (quantitative phase) is a prospective study to assess the adolescent pregnant women’s health practices and its relationship with maternal, fetal, and neonatal outcomes who live in Tehran, the capital city of Iran. A cluster sampling method will be used to select 316 adolescent pregnant women who visit health centers in Tehran. The second phase is a qualitative study designed to explore the adolescent pregnant women’s perception of important aspects and factors of health practices that can affect their health outcomes. In this phase, purposive sampling and in-depth individual interviews will be conducted for data collection. The conventional content analysis approach will be employed for data analysis. In addition to literature review and nominal group technique, the findings of the qualitative and quantitative phases, will be used to recommend some strategies to support adolescent pregnant women to improve their health practices during pregnancy.

Discussion

This is the first study looking into health practices in adolescent pregnant women which will be performed via a mixed-method approach, aiming to develop health practices improvement strategies. It is worth noting that there is no strategic guideline in Iran’s health system for improvement of health practices of adolescents. Therefore, it is hoped that the strategy proposed in the current study can enhance health practices of adolescents during pregnancy and ultimately improve their pregnancy and childbirth outcomes.

Ethical code

IR.TBZMED.REC.1397.670.

Plain English summary

Adolescent pregnancy is a public health concern that affects mothers, their children, and the broader community. Pregnancy and childbirth complications remain the leading cause of mortality and morbidity among female adolescents worldwide and can be influenced by lifestyle choices. The rate of adolescent pregnancy is increasing globally and due to recent changes in family planning policies in Iran, it is estimated that adolescent pregnancy will increase in the near future. The current study provides precise information about the health practices in Iranian adolescent pregnant women, and the factors related to them. This study is a mixed-method with the sequential explanatory design has two phases. The first phase (quantitative phase) is a prospective study to assess the adolescent pregnant women’s central and dispersion indices of health practices and its relationship with maternal, fetal, and neonatal outcomes who live in Tehran, the capital city of Iran. The second phase is a qualitative study designed to explore the adolescent pregnant women’s perception of important aspects and factors of health practices that can affect their health outcomes. The findings of the qualitative and quantitative study in addition to literature review and nominal group technique will be used to recommend some strategies to support adolescent pregnant women to improve their health practice during pregnancy. The strategy proposed by this study may be helpful in promoting health practices in adolescent pregnant women and improving pregnancy and childbirth outcomes in them.

Background

Adolescents account for approximately 1.2 billion people worldwide, which is one-sixth of the world population [1]. The World Health Organization (WHO) defines an adolescent as any person between ages 10 and 19 [2]. Findings of the 2016 population census in Iran showed that out of 79,926,270 Iranian population, 11,147,381 were adolescents including 5,450,270 females [3]. Each year, approximately 16 million girls aged 15 to 19 years and 2 million girls under 15 years give birth, with 95% in low- and middle-income countries [4]. Each year, 10% of babies are born to adolescent mothers, who account for 23% of maternal mortality and complications [5]. Despite the lower rate of adolescent pregnancy in Iran compared to the global rate (nearly 7%), it is expected that changes in human population planning policies will result in an increase in this rate in following years [6].

Adolescent pregnancy is a public health concern that affects both the adolescent mother, her child, and the broader community [7]. Pregnancy and childbirth complications are the leading causes of mortality among adolescents aged 15–19 years worldwide [2]; however, the majority of these complications are preventable [5, 8]. The adverse maternal and neonatal outcomes among adolescent pregnant women and their babies include abortion, preterm birth, anemia, postpartum depression, pregnancy hypertension, preeclampsia and eclampsia, puerperal endometritis, systemic infection, maternal mortality, low birth weight, stillbirth, and neonatal mortality [9,10,11,12,13,14,15,16].

The health practices of pregnant women can affect maternal and fetal health, and pregnancy outcomes [17, 18] and they include: avoiding tobacco, alcohol, and other illegal substances [19, 20], avoiding high-risk sexual behaviours [21], having a healthy diet for appropriate maternal weight gain during pregnancy [22], regular exercise, adequate rest and sleep [23, 24], oral hygiene [25], regular prenatal cares, and acquiring knowledge about pregnancy and childbirth [19, 26].

According to the literature review, no study into health practices of Iranian adolescent pregnant women, either quantitative or qualitative, and no relevant mixed-method study was found internationally. Only one cross-sectional study has been conducted in Iran on pregnant women at gestational ages between 33 and 41 weeks. The findings of this study showed that maternal-fetal attachment and health practices during pregnancy have a significant positive relationship with neonatal outcomes. Results from few studies into pregnancy and childbirth outcomes in adolescent pregnant women in Iran showed higher prevalence of adverse outcomes of pregnancy and childbirth among this age group. A systematic review study in Iran (2017) showed that adolescents are at a higher risk of pregnancy and childbirth complications, which may disrupt Iran’s national development objectives (lowering maternal mortality and morbidity). As a result, development of a health practice improvement strategy specific to adolescents may have a significant role in achieving national development goals. Given the high risk of adolescent pregnancy, maternal and neonatal complications, and positive effect of health practices on health status and reduction in adverse maternal and neonatal outcomes, pregnancy health practices should be promoted, specifically in adolescents. To this end, identification of the status of such practices is essential. It is worth noting that the Iranian Health System lacks a strategic guideline on the improvement of health practices of adolescents.

Study aim

This study aimed to determine the factors related to the health practices of adolescent pregnant women and their relationship with maternal, fetal, and neonatal outcomes. Moreover, health practices and their relevant factors will be explained from the perception of adolescent pregnant women. Then, an improvement approach to health practice in adolescent pregnant women will be developed.

The specific objectives are: 1) Determination of the health practices score of adolescent pregnant women visiting health centers in Tehran-Iran; 2) Determination of the relationship between health practices with some maternal outcomes (preeclampsia, type of delivery, anemia, pregnancy depression, and maternal weight gain) in adolescent pregnant women visiting health centers in Tehran-Iran; 3) Determination of the relationship between health practices and some neonatal outcomes (neonatal anthropometric indicators, low birth weight, preterm birth, and SGA) in adolescent pregnant women visiting health centers in Tehran-Iran; 4) Determination of the relationship between health practices and some fetal outcomes (abnormalities and stillbirth) in adolescent pregnant women visiting health centers in Tehran-Iran; 5) Determination of the relationship between socio-demographic characteristics and health practices in adolescent pregnant women visiting health centers in Tehran-Iran; 6) Determination of the relationship between health practices and maternal-fetal attachment in adolescent pregnant women visiting health centers in Tehran-Iran; 7) Exploration of the perception of adolescent pregnant women with high and low performance of health practices; 8) Exploration of the perception of adolescent pregnant women and the relationship between health practices and maternal, fetal, and neonatal outcomes; and 9) Provision of improvement strategies to health practice in adolescent pregnant women visiting health centers in Tehran-Iran.

Methods/design

Study design

This study uses a mixed method with an explanatory sequential approach for data collection and analysis. The mixed-method paradigm is based on the principles and logic of pragmatism. According to this paradigm, a mixed use of qualitative and quantitative approaches results in a better understanding of the problem [27, 28]. The quantitative data will be collected in the first phase of the study. The second phase will include the collection and analysis of qualitative data. Then, qualitative and quantitative findings will be mixed in the stage of data interpretation and development of improvement strategies to health practices in adolescent pregnant women (Fig. 1).

Fig. 1
figure 1

Study diagram

Full size image

Phase one: quantitative study

First, a prospective descriptive analytical study will be conducted to evaluate factors related to health practices in adolescent pregnant women and the relationship between health practices and maternal, fetal, and neonatal outcomes among a population of Iranian adolescent pregnant women. The target population are adolescent pregnant women visiting health centers in Tehran-Iran.

Sample size and sampling method

The sample size was calculated to be 158 based on the Madahi et al study [29], health practice variable, SD = 11.14, precision (d) of 0.02, α = 0.05, m = 123.57, and power of 90%. Regarding the use of cluster sampling, the final sample size was determined to be 316 by considering the design effect of 2.

This study will be conducted in health centers in south Tehran affiliated with the Tehran University of Medical Sciences, health centers in west and northwest Tehran affiliated with Iran University of Medical Sciences, and health centers in east and northeast Tehran affiliated with Shahid Beheshti University of Medical Sciences. In the cluster sampling, one-fourth of health centers will be randomly selected, using https://www.random.org. Then, a list of adolescent pregnant women at the gestational age between 18 and 22 weeks will be prepared using their medical profiles in each center. Then, the required samples from each health center will be determined using a proportional method and randomly selected. The researcher will explain the project to them via telephone (obtained from their medical records) and the eligible women will be invited to participate in the study.

Inclusion criteria

The eligible participants are 18 to 22 week pregnant Iranian women who are between 10 and 19 years old; without any medical conditions such as diabetes, hypertension, kidney, thyroid, and heart diseases; and live in Tehran.

Exclusion criteria

Women with multiple pregnancies, obstetric problems (such as placenta previa), history of bleeding in the current pregnancy, and plausible movement in the next four months will be excluded from the study. Moreover, exposure to stressful events during or one month before the pregnancy will lead to exclusion.

Scales and data collection

Quantitative data will be collected using the inclusion-exclusion checklist, socio-demographic and obstetrics characteristics questionnaire, Health Practice Questionnaire (HPQ), Edinburgh Postnatal Depression Scale, Maternal-Fetal Attachment Scale, and maternal, fetal, and neonatal outcome checklist. In addition, data will be collected through face-to-face interview or from medical records of the participants.

The socio-demographic and obstetrics characteristics questionnaire will include age, spouse age, educational attainment, socioeconomic status and etc.

The HPQ, designed by Lindgren in 2003, includes 34 items scored on a five-point scale anchored by “1 = never,” “2 = almost never,” “3 = sometimes,” “4 = almost always,” and “5 = always.” It measures the following six factors in pregnant women: balance between rest and activity, preventing disease and injury, diet, avoidance of harmful medicine and opiates, follow up health status and acquiring knowledge about pregnancy and childbirth. The maximum and minimum scores are 170 and 34, respectively. Higher scores reflect better practice. Items 5, 6, 7, 8, 12, 21, 22, 23, 24, 25 are inversely scored. The Farsi version of this instrument was applied on a group of pregnant women in Sirjan-Iran in 2014 and its reliability was measured using the intraclass correlation and internal consistency; where the intraclass correlation was 0.81 and Cronbach’s alpha was 0.83 [29].

The Edinburgh Postnatal Depression Scale was designed by Cox et al. (1987) to measure depression during and after pregnancy. This instrument includes 10 items with four response options, ordered from lowest-to-highest severity (Items 1, 2, and 4) and highest-to-lowest severity (Items 3, 5, 6, 7, 8, 9, 10). Items are scored between 0 and 3 based on the severity of the symptoms. The total score ranges from 0 to 30. Mothers with scores higher than the threshold of 12 have varying degrees of depression. In Iran, validity and reliability of this instrument were confirmed by Montazeri et al. and they obtained the Cronbach’s alpha of 86% [30].

The Cronley’s Maternal-Fetal Attachment Scale is a self-report instrument which evaluates the mother’s sense of attachment to her fetus. This 23-item scale is scored based on a five-point Likert scale anchored by “5 = Absolutely Yes,” “4 = Yes,” “3 = Not Sure,” “2 = No,” and “1 = Absolutely No.” Only Item 22 is scored inversely as “1 = Absolutely Yes,” “2 = Yes,” “3 = Not Sure,” “4 = No,” and “5 = Absolutely No.” The minimum and maximum scores are 23 and 115 respectively, and a higher score indicates greater attachment. Cronley reported the reliability of α = 0.85 for this instrument based on the internal consistency [31]. In Iran, validity and reliability of this instrument were confirmed by Abbasi et al. and they obtained the Cronbach’s alpha of 80% [32].

The maternal, fetal, and neonatal outcome checklist includes items on preeclampsia, type of delivery, anemia, pregnancy depression, maternal weight gain, maternal-fetal attachment, fetal abnormalities, stillbirth, neonatal anthropometric indices, low birth weight, preterm birth, and SGA.

The validity of the socio-demographic and obstetrics characteristics questionnaire and maternal, fetal, and neonatal outcome checklist will be determined using content and face validity. Reliability of the health practices, depression, and maternal-fetal attachment questionnaires will be determined through test-retest in 20 adolescent pregnant women and obtaining internal consistency (Cronbach’s alpha) and ICC (Intraclass Correlation Coefficient (. To determine the reliability of hemoglobin and hematocrit tests, the first 10 samples will be delivered to the laboratory with two different names. Then, the correlation of results will be calculated.

Data analysis

The quantitative data will be analyzed with SPSS-24. Sociodemographic and obstetrics characteristics and health practices will be described by frequency (percent), as well as mean (standard deviation) if the data are normally distributed or median (25 to 75 percentile) if they are not normally distributed. The relationship of health practices with maternal, fetal, and neonatal outcomes will be determined using the independent t and Pearson correlation tests in the bivariate analysis, and logistic linear regression adjusting the confounding variables in the multivariate analysis. The bivariate tests, including Pearson correlation, independent t-test, and one-way ANOVA, will be used to determine the relationship between socio-demographic and obstetrics characteristic with health practices. Then, the multivariate linear regression with backward strategy will be used to control confounding variables. The confounding variables will initially be controlled via inclusion and exclusion criteria. In the next stage, the multivariate tests (multivariate logistic regression and multivariate linear regression) will be applied.

Phase two: qualitative study

Phase two is an exploratory qualitative study with a conventional content analysis approach to explore health practices in adolescent pregnant women in more detail.

Sampling method

The extreme cases will be selected based on the overall mean score of the health practices obtained in the quantitative phase. Of that, women who obtain 10% of the lower and upper thresholds of the total health practices score will be selected as the extreme cases. The research participants will be selected through purposive sampling among extreme cases who have the tendency and ability to express their experience of health practices. Moreover, participants who differ from other participants in some variables, as well as those with unexpected findings will be interviewed.

Data collection

Qualitative data will be collected using in-depth and semi-structured interviews, containing open questions. Before conducting the qualitative phase, the desired items in the interview guideline will be designed based on the findings from the first phase and the relevant factors. The mechanisms of obtaining valid data and focusing on research items will be reviewed by the research team. The interview will begin with a key question, “what health practices do you adopt for yourself and your child?” Then, the interview will continue by presenting other questions, such as “what factors facilitate health practices?” or “what factors inhibit health practices?” based on the participants’ responses. The interview will continue with more in-depth items, such as “what do you mean? Why? Can you explain further? Can you give an example?” to explore the depth of their experience. During the interview, the researcher will record nonverbal data of the participants, such as tone, facial expression, and position, in a specific sheet, along with the time and place of the interview. The sampling will continue until data are saturated.

Data analysis

The qualitative data will be analyzed using qualitative content analysis with an inductive approach. In this approach, the data will be analyzed through frequent text reading to obtain a full understanding of it. Then, the texts will be read word by word to extract the codes. First, the objective words that contain the key concepts will be specified. The researcher continued digging the text by taking notes from the initial analysis until the major codes will be extracted. In this process, the code labels reflecting more than one key thought will be directly extracted and specified. Then, the codes will be categorized based on their difference and/or relationships. Ideally, 10–15 categories will be considered sufficient for categorization of a huge amount of data. This study uses an inductive content analysis based on the stages proposed by Graneheim and Lundman [33]. This method allows for extracting not only the explicit content of the texts, but also their implicit content with varying degrees of abstraction. Based on this method, the following five stages will be taken:

  1. 1.

    Transcribing the whole interview immediately after each session.

  2. 2.

    Multiple reading of the whole text to obtain a general knowledge of its content.

  3. 3.

    Dividing the text into semantic units, extracting a summary and coding them.

  4. 4.

    Categorizing the initial codes into classes and subclasses based on their differences and similarities.

  5. 5.

    Extracting the themes as the implicit concept and content of data.

Integration of quantitative and qualitative data

To develop improvement strategies for health practices in adolescent pregnant women, a comprehensive literature review will be carried out with a supportive approach to improve such practices. Following this, the improvement strategies to health practices in adolescent pregnant women, along with the results from qualitative and quantitative studies will be delivered to 10–12 experts. Then, their feedback and comments will be taken into account, using the nominal group technique.

Discussion

Adolescent pregnancy and childbirth are associated with adverse obstetrics, maternal, and neonatal outcomes [9,10,11,12]. Regarding the positive effects of health practices on health enhancement and reduction of maternal and neonatal complications [17, 29], they should be promoted during pregnancy, specifically among adolescents. To this end, the status of this practice should be identified. The current study provides precise information about the health practices in Iranian adolescent pregnant women, and the factors related to them. Data collection through qualitative and quantitative methods contribute to better understanding of health practices in adolescent pregnant women, and its relationship with maternal, fetal, and neonatal outcomes. The mixed-method approach focuses on Epistemological Pluralism. As a result, it supports the combination of opinions, approaches, and different, even contradictory, methods if they are helpful for understanding concepts [34].

The strategy proposed by this study may be helpful in promoting health practices in adolescent pregnant women and improving pregnancy and childbirth outcomes in them. Regarding the growing population of adolescents in the world, it is predicted that the global number of adolescent pregnancies will increase by 2030 [35]. It is also expected that recent changes in human population planning policies in Iran, aiming at promoting population growth policies and encouraging women to have 3 children before the age of 30, will increase this rate in future [6]. The development of health practice improvement strategies for promotion health practices in adolescent pregnant women will result in the improvement of pregnancy and childbirth outcomes.

Abbreviations

EPDS:

Edinburgh Postpartum Depression Scale

HPQ:

Health Practice Questionnaire

MFAS:

Maternal Fetal Attachment Scale

WHO:

World Health Organization

References

  1. World Health Organization. Adolescents:health risks andsolutions; 2017. Avaiavle from:www.who. int/mediacentre/factsheets/fs345/en/.

  2. World Health Organization. WHO Guidelines Approved by the Guidelines Review Committee. WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Health Outcomes Among Adolescents in Developing Countries. Geneva: World Health Organization Copyright (c) World Health Organization 2011. Avaiable from: https://www.ncbi.nlm.nih.gov/books/NBK304954/.

  3. Population and Housing Censuses Iran. National Census of Population and Housing of Iran; 2016.

  4. World Health Organization. Adolescent pregnancy. Geneva 2014. Available from: Declarations https://apps.who.int/iris/bitstream/handle/10665/112320/WHO_;jsessionid=8F7CB114DE4A06D16891A43BDE58C807?sequence=1.

  5. United Nations Population Fund UNP. UNFPA annual report 2007. Available at: https://www.unfpa.org/publications/unfpa-annual-report-2007. Accessed 30 May 2015.

  6. Karamouzian M, Sharifi H, Haghdoost AA. Iran's shift in family planning policies: concerns and challenges. Int J Health Policy Manag. 2014;3(5):231–3.

    Article  Google Scholar 

  7. Chandra-Mouli V, Camacho AV, Michaud PA. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. J Adolesc Health. 2013;52(5):517–22.

    Article  Google Scholar 

  8. Hawkins L, Spitzer RF, Christoffersen-Deb A, Leah J, Mabeya H. Characteristics and surgical success of patients presenting for repair of obstetric fistula in western Kenya. Int J Gynaecol Obstet. 2013;120(2):178–82.

    Article  Google Scholar 

  9. Kingston D, Heaman M, Fell D, Chalmers B. Comparison of adolescent, young adult, and adult women's maternity experiences and practices. Pediatrics. 2012;129(5):e1228–37.

    Article  Google Scholar 

  10. Quinlivan JA, Evans SF. Teenage antenatal clinics may reduce the rate of preterm birth: a prospective study. BJOG. 2004;111(6):571–8.

    Article  Google Scholar 

  11. Malabarey OT, Balayla J, Klam SL, Shrim A, Abenhaim HA. Pregnancies in young adolescent mothers: a population-based study on 37 million births. J Pediatr Adolesc Gynecol. 2012;25(2):98–102.

    Article  Google Scholar 

  12. Fleming NA, Tu X, Black AY. Improved obstetrical outcomes for adolescents in a community-based outreach program: a matched cohort study. J Obstet Gynaecol Can. 2012;34(12):1134–40.

    Article  Google Scholar 

  13. Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014;121 Suppl 1:40–8.

    Article  CAS  Google Scholar 

  14. Aliyu MH, Luke S, Kristensen S, Alio AP, Salihu HM. Joint effect of obesity and teenage pregnancy on the risk of preeclampsia: a population-based study. J Adolesc Health. 2010;46(1):77–82.

    Article  Google Scholar 

  15. Torvie AJ, Callegari LS, Schiff MA, Debiec KE. Labor and delivery outcomes among young adolescents. Am J Obstet Gynecol. 2015;213(1):95.

    Article  Google Scholar 

  16. Usta IM, Zoorob D, ABU-MUSA A, Naassan G, Nassar AH. Obstetric outcome of teenage pregnancies compared with adult pregnancies. Acta Obstet Gynecolo Scand. 2008;87(2):178–83.

    Article  Google Scholar 

  17. Lindgren K. Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy. Res Nurs Health. 2001;24(3):203–17.

    Article  CAS  Google Scholar 

  18. Widen E, Siega-Riz AM. Prenatal nutrition: a practical guide for assessment and counseling. J Midwifery Women’s health. 2010;55(6):540–9.

    Article  Google Scholar 

  19. Arslan Ozkan I, Mete S. Pregnancy planning and antenatal health behaviour: findings from one maternity unit in Turkey. Midwifery. 2010;26(3):338–47.

    Article  Google Scholar 

  20. Green-Raleigh K, Lawrence JM, Chen H, Devine O, Prue C. Pregnancy planning status and health behaviors among nonpregnant women in a California managed health care organization. Int Perspect Sexual Reprod Health. 2005;37(4):179–83.

    Article  Google Scholar 

  21. Lindgren K. Testing the health practices in pregnancy questionnaire-II. JOGNN. 2005;34(4):465–72.

    Article  Google Scholar 

  22. Weisman CS, Hillemeier MM, Downs DS, Feinberg ME, Chuang CH, Botti JJ, et al. Improving women's preconceptional health: long-term effects of the strong healthy women behavior change intervention in the Central Pennsylvania Women's health study. Womens Health Issues. 2011;21(4):265–71.

    Article  Google Scholar 

  23. Stutzman SS, Brown CA, Hains SM, Godwin M, Smith GN, Parlow JL, et al. The effects of exercise conditioning in normal and overweight pregnant women on blood pressure and heart rate variability. Biol Res Nurs. 2010;12(2):137–48.

    Article  Google Scholar 

  24. Zavorsky GS, Longo LD. Adding strength training, exercise intensity, and caloric expenditure to exercise guidelines in pregnancy. Obstet Gynecol. 2011;117(6):1399–402.

    Article  Google Scholar 

  25. Codato LA, Nakama L, Cordoni L Jr, Higasi MS. Dental treatment of pregnant women: the role of healthcare professionals. Cien Saude Colet. 2011;16(4):2297–301.

    Article  Google Scholar 

  26. Feinberg ME, Jones DE, Kan ML, Goslin MC. Effects of family foundations on parents and children: 3.5 years after baseline. J Fam Psychol. 2010;24(5):532–42.

    Article  Google Scholar 

  27. Johnson RB, Onwuegbuzie AJ. Mixed methods research: a research paradigm whose time has come. Educ Res. 2004;33(7):14–26.

    Article  Google Scholar 

  28. Creswell J, Clark V. Designing and conducting mixed methods research. 2nd ed. Los Angles: Sage Pubns; 2011.

    Google Scholar 

  29. Maddahi MS, Dolatian M, Khoramabadi M, Talebi A. Correlation of maternal-fetal attachment and health practices during pregnancy with neonatal outcomes. Electron Physician. 2016;8(7):2639–44.

    Article  Google Scholar 

  30. Montazeri A, Torkan B, Omidvari S. The Edinburgh postnatal depression scale (EPDS): translation and validation study of the Iranian version. BMC Psychiatry. 2007;7(1):11.

    Article  Google Scholar 

  31. Cranley MS. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res. 1981;30(5):281–4.

    Article  CAS  Google Scholar 

  32. Abasi A, Tafazoli M, Esmaeili H. The effect of foetal movement counting on primipara maternal foetal attachment. J Mazandaran Univ Med Sci. 2010;20(77):53–60.

    Google Scholar 

  33. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.

    Article  CAS  Google Scholar 

  34. Tashakkori A, Creswell JW. The new era of mixed methods. J Mixed Methods Res. 2007;1(1):3–7.

    Article  Google Scholar 

  35. World Health Organization. Adolescent pregnancy 2018 [updated 23 February; cited 29 2018 May]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy.

Download references

Acknowledgements

We should thank the Vice-chancellor for Research of Tabriz University of Medical Sciences for their financial support.

Funding

This Study is funded by Tabriz University of Medical Sciences.

Availability of data and materials

Not applicable.

Author information

Authors and Affiliations

  1. Students’ Research Committee, Tabriz University of Medical sciences, Tabriz, Iran

    Tahere Hadian

  2. Women Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

    Sanaz Mousavi

  3. Member of South Asia Infant Feeding Research Network (SAIFRN), School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia

    Shahla Meedya

  4. Social determinants of Health Research Center, Tabriz University of Medical sciences, Tabriz, Iran

    Sakineh Mohammad-Alizadeh-Charandabi & Mojgan Mirghafourvand

  5. Department of Nursing, School of Medicine, Tarbiat Modares University, Tehran, Iran

    Eesa Mohammadi

Authors
  1. Tahere Hadian
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sanaz Mousavi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shahla Meedya
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sakineh Mohammad-Alizadeh-Charandabi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Eesa Mohammadi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mojgan Mirghafourvand
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MM, SM, SM, SMAC, EM and TH contributed to the design of the protocol. MM and TH contributed to the implementation and analysis plan. MM and TH has written the first draft of this protocol article and all authors have critically read the text and contributed with inputs and revisions, and all authors read and approved the final manuscript.

Corresponding author

Correspondence to Mojgan Mirghafourvand.

Ethics declarations

Ethics approval and consent to participate

Written informed consent will be obtained from each participant. This protocol has been approved by the Ethics Committee of the Tabriz University of Medical Sciences, Tabriz, Iran (code number: IR.TBZMED.REC.1397.670).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hadian, T., Mousavi, S., Meedya, S. et al. Adolescent pregnant women’s health practices and their impact on maternal, fetal and neonatal outcomes: a mixed method study protocol. Reprod Health 16, 45 (2019). https://doi.org/10.1186/s12978-019-0719-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12978-019-0719-4

Keywords

Reproductive Health

ISSN: 1742-4755