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CHAPTER 8, THE CHILDREN OF TEEN CHILDBEARERS
Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, Volume II: Working Papers and Statistical Appendices
It is clear that being a child of a teenage mother often entails numerous risks: low birth weight, complications of the mother's pregnancy and delivery, and health problems associated with poor perinatal outcomes; greater risk of perinatal death; lower IQ and academic achievement later on, including a greater risk of repeating a grade; greater risk of socio-emotional problems; a greater risk of having a fatal accident before age one; and finally, a greater probability of starting one's own family at an early age. Although there are variations from study to study, most studies that survey a representative sample from a population that has had no special interventions and is of diverse socioeconomic makeup, and that do not control for SES or other factors, find that children of teen parents are at greater risk than children of older parents for a host of health, social and economic problems.
The critical objective, of course, is to explain why being a child of a teenager entails these risks. This is important because it affects the way we plan interventions to prevent undesired outcomes. The implications of an outcome due to physical immaturity (or, in the case of an older mother, the aging process) are different from those that are due to inadequate prenatal care or to inadequate nutrition, to poverty or to ignorance. Explanation is, therefore, the goal of this chapter, which is divided into several sections, each focusing on a specific outcome: health; cognitive development and school achievement; and socioemotional development. The fourth section focuses on intervening factors: e.g., family structure, socioeconomic status, and maternal education. It also looks at the part parenting behaviors play in distinguishing adolescent from older parents and the influence of such behaviors in mediating child outcomes. Finally, the last section focuses on methodological issues and substantive issues that need further research.
Two major data sets are used in this chapter, the Collaborative Perinatal Project (CPP) and the Health Examination Survey (HES). The CPP included all patients or a random sample of all patients qualifying for prenatal care in the 12 participating medical centers during 6 years of intake (1966–1973). The total sample size was 53,625. The children of respondents were followed at ages 6 to 8 and a subsample was again followed-up at about 12 years of age.
Cycle II of the Health Examination Survey (HES), conducted in 1963– 65, consists of a national random sample of 7110 children age 6–11. The children were given health and psychological exams. Information was also collected from the mother, the school, and from the birth certificate.
Cycle III of the HES, conducted in 1966–70, consists of a national random sample of 6768 youth 12–17. The information collected is the same as in Cycle II, with the addition of a questionnaire filled out by the Youth. A small subset of children interviewed in Cycle III had also been interviewed in Cycle II.
The first outcome of interest is perinatal mortality. A number of studies (see Strobino, this volume; also Makinson, 1985) report a higher incidence of perinatal mortality among teenage mothers. These studies show the relationship between mother's age and perinatal mortality as a J-shaped function. That is, it is high at very young ages, declining to a low point in the mid-twenties, and then climbing again among older mothers. The evidence is consistent that perinatal problems increase among mothers above age 30; however, recent evidence from the Danish Perinatal Study and from the Collaborative Perinatal Project in the U.S. show a linear relationship between maternal age and perinatal mortality with low rates among young women, and increasing rates with maternal age (Mednick and Baker, 1980)—or that there is no relationship (Broman, 1981), at least for ages 12–29.
There are two major types of explanations for the often found association between young age of mother and higher incidence of perinatal problems. First, it is hypothesized that the teenager is physiologically immature; thus her less desirable outcomes (see for example, NCHS, 1984:10). A second explanation is the differential social characteristics of teenage mothers-lower SES, lack of access to prenatal care, poor nutrition, poverty and ignorance (see, for example, Baizerman, 1977; Mednick and Baker, 1980). Whatever explanations are used (and different ones may hold for different age groups) should account for the higher levels of perinatal problems among both teen and older mothers.
In both the Danish and the U.S. Perinatal studies, relatively high risk groups were overrepresented.2 However, Mednick and Baker (1980: 38) argue convincingly that “In view of the unusually advantageous treatment conditions prevailing in the university hospital samples as a group, the teenage mothers in these samples probably received considerably more intensive and higher quality treatment than teenagers in the population at large.” Because a clear relationship does exist between quality of medical care and perinatal mortality rates (Mednick and Baker, 1980:39–40), the latter argue that
The relatively lower mortality rates observed among the teenage subjects, compared with the rates in older age groups in the American and Danish Perinatal samples, are due to the provision of adequate pre- and perinatal medical treatment…the previously reported higher mortality rate associated with teenage deliveries was not caused by physiological characteristics of the teenage organism but rather by social factors that have the ultimate effect of lowering the quality of medical treatment received by teenage mothers in the general population.
In contrast, constitutional changes do appear to determine the increased risk of perinatal mortality with increasing age of mother at birth. The results from studies of representative samples as well as from special hospital samples show a similar relationship for mothers over 30; increased age appears to be associated with increased rate of death (Mednick and Baker, 1980).
Vital statistics data (NCHS, 1984) show that children of teen mothers are more likely to be below 2500 grams at birth than children of mothers 20 to 39, and the younger the age of the mother the higher the proportion of infants of low birth weight. In 1982, twice as many infants of 10–14 year olds (13.8 percent) were low birth weight as infants of 20–24 year olds (6.9 percent). In that year 9.3 percent of the infants of 15–19 year olds were low birth weight. Low birth weight babies are subject to higher risks of death, mental retardation, and other health problems (Williams and Chen, 1982). Low birth weight has also been implicated in poor intelligence and achievement test scores in childhood (see, for example, Edwards and Grossman, 1979; Mednick and Baker, 1980).
A second measure of neonatal health is the Apgar score. The Apgar score is a summary measure used to evaluate the neonate's overall physical condition at birth. It is a composite evaluation of five factors—heart rate, respiratory effort, muscle tone, irritability, and color—each of which is assigned a value from 0 to 2. The overall score is the sum of the five values, with a score of 10 being optimal (NCHS, 1984:12). Infants of teen childbearers are more likely to score under 7 at either one or five minutes after birth than are infants of mothers 20 to 39. These results hold for both blacks and whites, though the proportion of low birth weight infants and the percent with low Apgar scores are consistently higher among blacks than among whites.
Although these relationships appear to hold in the population as a whole, there appears to be little difference between children of adolescent and non-adolescent mothers in special samples where prenatal and postnatal care are good. Sandler et al. (1981) evaluated the relationship between the age of mother and two measures of newborn behavior: 1) the Neonatal Behavioral Assessment Scale (Brazelton) and 2) a measure of infant temperament (Carey “My Baby” scale). No differences were found on the Brazelton Scale or Carey scale between children of adolescents and post adolescents (age not defined) within the first few days after birth.
Lester et al. (1982, 1983) used the Brazelton Scale on the second day after birth of a sample of Puerto Rican and American infants of teen mothers. In addition they obtained information on a number of health measures from medical records. In a regression analysis controlling for ponderal index, gestational age, marital status, drug score, 1 minute Apgar and the number of maternal parturitional and fetal nonoptimal conditions, none of the associations between maternal age and Brazelton scale cluster scores were significant. There did appear to be an interaction in the Puerto Rican sample between a complications index and age. Infants of young mothers with few complications had a wider range of states of arousal than infants of older mothers with few complications.
In both these studies (Sandler et al. and Lester et al.), mothers received excellent prenatal and postnatal medical care through a special program for low income families. A number of recent studies failed to find any difference by age of mother in health status of neonates at birth (Apgar score, birth weight, prematurity, birth trauma, etc.) once initial differences such as differences in SES between adolescents and non-adolescents were controlled (Zuckerman et al. 1983; Rothenberg et al., 1981). Net of SES, Broman (1981) found older women to have higher birthweights among blacks, but not whites. Also net of SES, Broman (1981) found the youngest adolescents (12–15) to have lower Apgar scores than older adolescents among whites and blacks. The differences were very small, however.
The medical risk to neonates of adolescent childbearers does not appear to be biological, but, rather, due to differential access to adequate medical care (Mednick and Baker, 1980). Less research has focused on the effect of age of mother on the health status of infants, that is from the first 28 days to one year of age.
Two studies have addressed maternal age differences and infant health status (Hardy, 1978; and Mednick and Baker, 1980). Hardy presents one figure which shows that the risk of infant death after the neonatal period is higher for the infants of black teen mothers than for the infants of black older mothers. However, no differences among whites by age of mother at birth were found. This study did not control for the SES of the mothers, however.
The Mednick and Baker (1980) study, using Danish data, looked at the physical health status of the infant at one year as an outcome measure (see Makinson, 1985, for results of other non-U.S. studies). They found that the relationship between mother's age and infant's first year physical health status was curvilinear. That is, infants of mothers under 20 and over 35 were the healthiest; those of mothers in their twenties had the most health problems. Comparing neonatal and one year outcomes, children of the youngest mothers were the best off at both points. In contrast children of older mothers were less well off at birth, but very well off at one year. This suggests different mechanisms influencing the different outcomes at two points in time: biological factors at birth, environmental factors at one year. Older mothers may have the most biological problems but the best environment. Age-related social variables may be enough to compensate for the negative biological effects seen at birth. Mednick and Baker show that the most important predictors of health status at one year were birthweight and being female. After controlling for these important factors, a number of environmental factors were associated with better child health, including an older mother, fewer previous pregnancies, and less exposure to institutional day care.
Why the infants of Danish mothers under 20 were healthiest at one year also needs explanation. Mednick and Baker hypothesized that teen mothers may have older adults to rely on for support. They found that infants living with their grandmothers had the best mean health score; infants living with both biological parents a mid-range score, while infants who lived with their unmarried mother or in an institution or foster home showed the worst scores at one year. In one analysis, after controlling for birthweight and pregnancy complications, number of nurturing adults was strongly related to a positive one year health status among children of teen mothers. Mothers in their twenties may lack the parental support of the young mothers as well as the maturity and experience that come with age.
In conclusion, it appears that once the birth occurs and survival is assured, health status varies strongly with social and environmental variables. In the case of the older mother, age implies a number of positive psycho-social and environmental aspects. In the case of the young mother, it may imply the availability of alternative caregivers to help out. The worst one-year outcomes occurred among children of 18–29 year olds. “Once infant survival is assured, environmental and social variables begin to emerge as important to the continued physical growth and development of the child” (Mednick and Baker, 1980:65).
The previous analysis of health status at one year did not control for a number of other factors that might affect health: health status at birth or complications of pregnancy and delivery. The question is whether there are residual effects of non-medical variables that may impact on one year infant status. A number of studies (e.g., Sameroff, 1979) have shown that environmental factors do not have major effects on cognitive and neurological measures within the first 12 months of life. Measures of infant physical health and motor development have been shown to be sensitive to variations in prenatal environment. Good perinatal care can insure good perinatal outcomes even when environmental conditions are less than adequate. During the first year of life, environmental influences may increase in importance as the positive effects of good prenatal care wear off. Intervention postnatally is less common than prenatal medical intervention. During the year after birth, the Danish cohort studied by Mednick was more similar in medical care to the general population. Thus effects of environmental factors could be expected to show at one year.
Mednick and Baker (1980) developed a path model to trace the causal connections between background, mother's age, and intervening medical and health factors on one year infant outcomes. Background factors (spacing, mother's age, previous health, data on previous pregnancy, wantedness, use of institutional day care, SES, mother's employment and family size) were assumed to predict one year infant outcome through the following health and medical variables: complications of pregnancy and delivery, multiple births, birth weight, and neonatal physical and neurological status. Two random samples were pulled from the full sample and models were tested separately on each sample. Unfortunately the results differed substantially between the two samples. Mother's age did not have a consistent direct or indirect effect on one year physical or neurological status or one year motor development. In sample 1, older mothers had children with poorer one year physical status. In sample 2, older mothers had children with better one year neurological status (direct effect) and better one year motor development through improved neonatal physical status (indirect effect).
However, given that the same findings don't hold up in both samples, there appears to be no consistent direct or indirect effect of mother's age on infant status at age one. Infant status at age one was influenced directly by birthweight and neonatal neurological status and indirectly by neonatal physical status. In addition, exposure to institutional day care significantly reduced rating of health status at one year. Thus mother's employment showed an indirect effect via daycare on one year health status. Higher birthweight was associated with improved one year motor development.
The analysis supports the conclusion that neonatal status is strongly influenced by factors subject to medical intervention. Maternal age, SES, and even previous pregnancy history effects on neo-natal health are weak in a sample which received excellent medical care. By age one, neonatal status exerts the strongest influence on physical and motor status. Although none of the expected background factors has an impact at age one, environmental influence on physical status can be seen through the direct (negative) impact of institutional day care, and the indirect (and also negative) influence of maternal employment.
This analysis assumed a linear relationship between maternal age and outcomes. In fact, other analyses by the same researchers have shown a non-linear relationship. The weakness of maternal age effects may be due to differential influences across the life cycle. Finally, this analysis did not and could not include the potential ameliorating influence of other adults in the home for the very young mother.
Thus although high quality medical care appears to have reduced the environmental influence on children's health over the first year, there is evidence that social conditions, which did not have an impact during that first year, at one year do have an impact.
Further evidence for the importance of environmental factors is found in a study using linked birth and death records from North Carolina and Washington State for 1968 through 1980. Wicklund et al. (1984) found a strong inverse relationship between maternal age and mortality rates from accidents for children under one, net of parity and educational level of mother (a proxy for SES). The actual mortality rate from accidents during the first year of life is actually quite low—in 1980 in North Carolina about 3 out of 10,000 live births died from accidents in the first year in Washington state the rate was 1.47 per 10,000 live births. There were substantial differences by race, maternal education and age of mother, however. Children of mothers under 20 who had 9 or more years of schooling were substantially more likely to die from accidents in the first year of life than children of mothers 20 and over with the same amount of schooling. Among children of mothers with very low levels of schooling, those with mothers 24 and younger were more likely to die than those with mothers 25 and older
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