Pediatric Annals

The Infants of Adolescent Mothers

T Allen Merritt, MD; Ruth A Lawrence, MD; Richard L Naeye, MD

Abstract

The plethora of pregnancies among American adolescents reflects the changing psychosocial, societal, and biologic forces of the 20th century and provides the stimulus for perinatologists to examine infants of those gestations - the infants of adolescent mothers.

Unfortunately, the national "epidemic"1 of adolescent pregnancies has been accompanied by a paucity of systematically collected contemporary data on infants born to adolescent mothers. It remains to be determined whether biologic or social inadequacies best explain the apparent reproductive disadvantage of the American teenager and the well-being of her baby. A critical analysis of the short- and long-term consequences of these gestations will require thorough study.

The outcome for infants born to adolescent mothers, judging from the current literature, remains inadequately defined, yet speakers at recent congressional hearings2 suggest that "very young women . . . are biologically too immature for effective childbearing." The fact that the age of menarche has declined from an average of 14 years in 1900 to 12.5 years in 19703 would suggest earlier maturation of these young mothers, at least from the perspective of developmental pediatrics.

What is the incidence of adolescent pregnancy? Annually, one in 10 teenage girls in the United States becomes pregnant - 1,000,000 adolescents each year. From these pregnancies 600,000 infants are born each year - one-fifth of all births in the United States. Ninety-three percent of these adolescent mothers keep their infants.4

Thus, the social and medical consequences of adolescent parenting, although they have not received systematic analysis, are substantial. This article will address the questions of the perinatal, neonatal, and infant health and development of these children born to adolescent mothers as related to other biologic and social factors.

METHODS

Medical and legislative plans for adolescent mothers and their infants must be based on assessment of both mortality and morbidity of the infants born to adolescent mothers. In this arride we will focus on (1) neonatal data on 55,711 pregnancies collected by the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, which have been extensively analyzed by one of us;s (2) neonatal data from the University of Kansas Medical Center covering 4,000 pregnancies, 770 of which were gestations in teenage mothers recently studied and reported on by Miller and Merritt;6 and (3) obstetric, perinatal, and neonatal data concerning 6,087 pregnancies in 1976, 1977, and 1978 at the Regional Perinatal Center at the University of Rochester.7 BIRTH WEIGHT AND GESTATIONAL AGE

1. Lincoln, R. Is pregnancy good for teenagers? Testimony before lhe Select Commit lee on Population, 95th Congress, first session. Washington, D.C.: U.S. Government Printing Office, 1979, p. 318.

2. Lowe, C. U. Fertility and contraception in America: Adolescenl and Pre-adolescent Pregnancy Hearings before the Select Committee on Population, 95th Congress, second session. Washington, D. C.: U.S. Government Printing Office, 1979, p. 570.

3. Tanner, J. M. Growth at Adolescence. Oxford, England: Blackwell Scientific Publications, 1963, p. 1.

4. Richmond, ). Statement of the Surgeon General of the U.S. and Assistant Secretary for Health. Adolescent and Pre-adolescent Pregnancy Hearings before the Select Committee on Population, 95th Congress, second session. Washington, D. C.: U.S. Government Printing Office, 1979, pp. 148-158.

5. Naeye, R. L. Effects of maternal age on the outcome of pregnancy, (In Press.)

6. Miller, H. C., and Merrill, T. A. Fetal Growth in Humans. Chicago: Year Book Medical Publishers, 1979, pp. 1-174.

7. Merritt, T. A., and Lawrence, R. A. Unpublished data.

8. Hardy, J. B., and Mellits, E. D. Relationship of low birth weight to maternal characteristics of age, parity, education, and body size. In Reed, D. M., and Stanley, F. H. (eds.):…

The plethora of pregnancies among American adolescents reflects the changing psychosocial, societal, and biologic forces of the 20th century and provides the stimulus for perinatologists to examine infants of those gestations - the infants of adolescent mothers.

Unfortunately, the national "epidemic"1 of adolescent pregnancies has been accompanied by a paucity of systematically collected contemporary data on infants born to adolescent mothers. It remains to be determined whether biologic or social inadequacies best explain the apparent reproductive disadvantage of the American teenager and the well-being of her baby. A critical analysis of the short- and long-term consequences of these gestations will require thorough study.

The outcome for infants born to adolescent mothers, judging from the current literature, remains inadequately defined, yet speakers at recent congressional hearings2 suggest that "very young women . . . are biologically too immature for effective childbearing." The fact that the age of menarche has declined from an average of 14 years in 1900 to 12.5 years in 19703 would suggest earlier maturation of these young mothers, at least from the perspective of developmental pediatrics.

What is the incidence of adolescent pregnancy? Annually, one in 10 teenage girls in the United States becomes pregnant - 1,000,000 adolescents each year. From these pregnancies 600,000 infants are born each year - one-fifth of all births in the United States. Ninety-three percent of these adolescent mothers keep their infants.4

Thus, the social and medical consequences of adolescent parenting, although they have not received systematic analysis, are substantial. This article will address the questions of the perinatal, neonatal, and infant health and development of these children born to adolescent mothers as related to other biologic and social factors.

METHODS

Medical and legislative plans for adolescent mothers and their infants must be based on assessment of both mortality and morbidity of the infants born to adolescent mothers. In this arride we will focus on (1) neonatal data on 55,711 pregnancies collected by the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, which have been extensively analyzed by one of us;s (2) neonatal data from the University of Kansas Medical Center covering 4,000 pregnancies, 770 of which were gestations in teenage mothers recently studied and reported on by Miller and Merritt;6 and (3) obstetric, perinatal, and neonatal data concerning 6,087 pregnancies in 1976, 1977, and 1978 at the Regional Perinatal Center at the University of Rochester.7 BIRTH WEIGHT AND GESTATIONAL AGE

Figure 1. Distribution by birth weight of infants born to mothers in various age groups at Strong Memorial Hospital, Rochester, N.Y., 1976-78.

Figure 1. Distribution by birth weight of infants born to mothers in various age groups at Strong Memorial Hospital, Rochester, N.Y., 1976-78.

Ample evidence suggests a strong association between materaal age and birth weight. In particular, Hardy and Mellits8 found a higher frequency of low-birth-weight infants born to young black women. Interactions with other variables, including parity, clearly illustrate that firstborn infants are lighter than subsequent infants up to a maternal age of 35. Several authors have reported that infants of adolescent mothers are more likely to be born prematurely and have a low birth weight ( < 2,500 gm.). Unfortunately, few of these reports, which relate an increased incidence of unfavorable pregnancy outcome in young mothers, have considered other confounding growth-retarding factors in a rigorous way. For example, prenatal-care patterns, prepregnancy weight, weight gain during pregnancy, cigarette smoking, psychiatric disorders, and medical problems, all known to influence fetal growth, have not been systematically compared with those in appropriate populations of older mothers. Future studies of these relationships would also be benefited by a consideration of fetal growth as a function of gynecologic age rather than mere chronologic age.

Hoffman et al.9 have demonstrated that American women 18 years and under show a tendency to have infants of shorter gestational age than women 1 9 to 24 years of age, using bivariate distributions to explore shifts in birth weight and gestational age across maternal age categories. When women reach the age of 35, however, there is a simultaneous shift in the statistics; the infants born to them tend to have lower birth weights than those in the 24-34 age group, and there are more preterm babies.

This comprehensive evaluation by Hoffman and his associates demonstrates that the gestational period for adolescent primíparas 18 years of age or younger is shorter than in women over 1 8 but that birth weight of the infants born to them remains appropriate for gestational age - refuting the assumption that there is frequent growth failure among infants born to adolescent mothers.

When subdivided into age categories (^.14, 15-19, and 20-29), mothers giving birth at the University of Rochester Strong Memorial Hospital had a disproportionate number of low-birth-weight infants only when they were 14 years or younger. Mothers 14 or under were six times more likely to have an infant weighing < 2,500 gm. at birth than mothers 15 years and older. Distributions of infant birth weight from 500 gm. to 4,000 gm. or over for three maternal age categories are shown in Figure 1 . The trend toward an increased number of lowbirth-weight infants among mothers 19 years or under occurs across all weight categories. Of interest is the slight increase in the number of infants weighing at least 4,000 gm. born to women 14 or under. Gestational age patterns similarly confirm the adolescent disadvantage in having infants before term Figure 2). When considered by race, however, this increase in low- weight, preterm infants was found primarily among infants of black teenagers. White and Hispanic infants of adolescent mothers in our population had gestational ages and weights similar to those of infants of older mothers.

Figure 2. Average gestational age of infants bom to mothers in three age groups at Strong Memorial Hospital, Rochester, N.Y., 1976-78.

Figure 2. Average gestational age of infants bom to mothers in three age groups at Strong Memorial Hospital, Rochester, N.Y., 1976-78.

Table

TABLE 1MEDICAL COMPLICATIONS OF PREGNANCY

TABLE 1

MEDICAL COMPLICATIONS OF PREGNANCY

Cigarette smoking, alcohol and drug abuse, prolonged rupture of membranes (greater than 24 hours), seizure disorders, and gonorrhea were significantly more frequently diagnosed in teenage mothers. No substantial difference existed, however, between our study groups in the incidence of pregnancy-related hypertension, diabetes A, B, or C, cardiopulmonary disorders, urinary-tract infections, syphilis, or influenza during pregnancy. Approximately 3.6 percent of the adolescent mothers failed to gain weight or gained only 1 0 pounds or less during pregnancy, as against 3.8 percent of the mothers in the 20-29 age group.

Table

TABLE 2MATERNAL "BEHAVIORAL" CONDITIONS ASSOCIATED WITH PREGNANCY

TABLE 2

MATERNAL "BEHAVIORAL" CONDITIONS ASSOCIATED WITH PREGNANCY

Low-birth-weight infants. The studies showed that behavioral and medical complications in the mothers were more powerful determinants of infants born with weight of less than 2,500 gm. than maternal age alone. Miller and Merritt6 found that the weights of infants born to white teenagers in Kansas City were comparable to the weights of babies born to white mothers in all age groups. The incidence in their study of the medical complications of pregnancy listed in Table 1 was 15.0 percent for all white mothers and 15.4 percent in teenage mothers. While nearly half of the teenage mothers in this study (47.3 percent) had the associated behavioral conditions listed in Table 2 that have been linked with complicated gestations, their frequency was not much different from what it was in all white mothers 45 percent).

Teenagers with medical or behavioral complications of pregnancy were not more frequently observed in the Miller-Merritt study in the under- 17 group than in the 17-19-year-old group. Except in women less than 15 years of age, the incidence of known growth-retarding factors in the adolescent mothers was no different from what it was in mothers in the 20-34 age bracket.

Most low-birth-weight white infants born to adolescent mothers in the Kansas City study were born to girls with associated fetal-growth-retarding behavioral conditions (9.8 percent of the infants born to the 214 pregnant women); this compares favorably with the 10.5 percent of low-birth-weight infants born to women in the 20-34-year-old age bracket (Table 3). Similarly, the incidence of low-birth-weight infants born to adolescent mothers without known growth-retarding medical or behavioral conditions did not differ significantly from that of those born to control mothers (3 .6 percent vs. 2.3 percent, Table 3).

Thus, taken as a group, the adolescent women in these studies shared a disproportionate number of confounding fetal-growth-retarding factors. When these factors are rigorously excluded from the statistics, there are no demonstrated differences in prematurity or in low- birth-weight rates among infants born to adolescent mothers and those born to women in the 20-34-year-old age bracket.

In summary, when maternal- and fetal-growthretarding factors are taken into account among mothers of specific age categories, no biologic disadvantage appears unique to adolescent mothers.

RACE

Figure 3 presents the distribution by race of mothers in Rochester, N. Y. As has been pointed out in other studies,10'12 black teenagers constitute the vast majority of adolescent mothers. When examined by maternal age, white teenagers increase proportionately over the 15-19-year span, with Hispanic mostly Puerto Rican) mothers remaining a small constant percentage in both age groups. In the 20-29-year group in which the racial configuration conforms to the community, the disparity of teenage black mothers is even more striking.

Table

TABLE 3LOW-BIRTH-WEIGHT INFANTS BORN TO 770 TEENAGE MOTHERS AT THE UNIVERSITY OF KANSAS MEDICAL CENTER

TABLE 3

LOW-BIRTH-WEIGHT INFANTS BORN TO 770 TEENAGE MOTHERS AT THE UNIVERSITY OF KANSAS MEDICAL CENTER

PERINATAL MORTALITY

Basing his study on clinical and postmortem material, Naeye undertook a standardized examination of infants and their placentas. Primary and secondary diagnoses were assigned to each death. Primary diagnoses were used to determine case fatality rates and perinatal mortality so that these diagnostic categories were mutually exclusive. Criteria used to make the various diagnoses have been previously published.5 Findings from these analyses show that far more than an increased incidence of preedampsia13'14 and low birth weight15 are operative in the excess antenatal and neonatal mortality among offspring of adolescent mothers.

This study included mothers in age groups from 10 to 50 years, and of the 55,711 pregnancies, 12,908 were those of adolescent mothers. A summary of some of his findings are shown in Table 4. Note that the lowest perinatal mortality of all the women studied was achieved by girls in their íate adolescence (approximately 38 deaths per 10,000 live births). The mothers in the 10-15 age group had 36 percent more fetal and neonatal deaths than those in the 16-19 age bracket because of more amniotic infections, abruptio placentae, and placenta! -growth retardation in the very young mothers.

Figure 3. Distributions of births by race of mother in women 10 to 29 years of age. Figures cover live births at Strong Memorial Hospital, Rochester, N.Y., 1976-78.

Figure 3. Distributions of births by race of mother in women 10 to 29 years of age. Figures cover live births at Strong Memorial Hospital, Rochester, N.Y., 1976-78.

If one confined the analysis to a single race, however, the excess of amniotic fluid infections in the lO-to-15-year-old mothers disappeared, and if one restricted his analysis to nonpoor families, the excessive losses in this age group due to abruptio placentae and placental-growth retardation also disappeared. These findings suggest that diet or some other environmental factors are responsible for the excessive losses due to abruptio placentae and placental-growth retardation in very young mothers.

Overall, then, these findings fail to support the often expressed view that the mother's biologic immaturity is the main factor responsible for excessive fetal and neonatal deaths in infants born to very young mothers. Amniotic-fluid infections - much more common in blacks than in whites - are the likely explanation for the excessive preterm deliveries in the youngest adolescent mothers in Rochester.14 As previously noted, most of the very young mothers are black.

APGAR SCORES

Data from the Rochester study were used to compare the neonatal health of nearly 1,500 infants born to primigrávida adolescents with that of 4,668 firstborn infants of women in the 20-29-year age bracket. Infants born to adolescent mothers had significantly more Apgar scores of <_3 and 4-6 at one minute than the infants of the 20-to-29-year-old mothers. The difference was not present, however, at five minutes (Table 5). There were no differences between the groups with regard to cord-blood pH or first-arterial pH (Table 6).

NURSERY ADMISSION

Proportionately more infants born to adolescent mothers required admission to the intensive-care or special-care nurseries at the University of Rochester hospital than did infants born to mothers in their 20s (15.77 percent vs. 13.9 percent). This may not be significant, since birth to an adolescent mother in itself has been considered a high-risk factor and many such mothers might have been admitted to the special-care nurseries routinely.

Table

TABLE 4PLACENTAL, FETAL, AND NEONATAL DISORDERS BY MATERNAL AGE: CAUSES, FREQUENCY, AND PERINATAL MORTALITY

TABLE 4

PLACENTAL, FETAL, AND NEONATAL DISORDERS BY MATERNAL AGE: CAUSES, FREQUENCY, AND PERINATAL MORTALITY

Table

TABLE 5NEONATAL APGAR SCORES PER 1,000 BIRTHS

TABLE 5

NEONATAL APGAR SCORES PER 1,000 BIRTHS

NEONATAL COMPLICATIONS

Infants of mothers 19 years or younger had significantly more episodes of seizure activity, jitteriness, hypoglycemia, necrotizing enterocolitis, and transient tachypnea than infants of women aged 20 to 29 years when the Rochester data were analyzed (Table 7). There was an increased incidence of small-for-gestational-age infants among offspring of young mothers, which may account for selected neonatal complications, including hypoglycemia and seizure activity. No causal relationship was apparent for variations in other perinatal morbidities. In addition, infants of young mothers had significantly less hypotension, hyperbilirubinemia (regardless of cause), apnea, birth injury, or pulmonary air leaks than did infants of older mothers.

Screening for major and minor congenital malformations was done by routine physical examination. Affected infants were evaluated by a birth-defects team that enlisted the services of numerous subspecialists. Malformations were grouped according to the organ system most severely affected for ease of analysis, although many anomalies involved dysmorphic patterns of multiple systems. Cardiac, genitourinary, and renal malformations occurred significantly less frequently in infants of adolescent mothers. In addition, there were fewer documented chromosomal abnormalities among mothers 19 years and younger, although the difference was not statistically significant.

Table

TABLE 6ACIDOSIS* AT BIRTH PER 1,000 BIRTHS

TABLE 6

ACIDOSIS* AT BIRTH PER 1,000 BIRTHS

Time required to regain birth weight was slightly longer in infants of adolescent mothers, as was the total duration of hospitaliza tion. Although adolescent mothers visited and telephoned the nursery less frequently during their infants' hospitalization than did older mothers, increased financial and transportation problems among adolescent mothers make this fact difficult to interpret.

INFANT MORTALITY

The incidence of late fetal death in the Rochester study was nearly the same for infants of both adolescent mothers and older mothers. More infants of adolescent mothers died in the delivery room or within the first 24 hours of life. Neonatal mortality from the eighth to the 28th day of life was similar for both groups of infants. In-hospital deaths beyond the 28th day of life were significantly greater in infants of mothers 20 to 29 years old. Most of these later deaths were related either to complications or prematurity or to lethal congenital anomalies. Despite similar neonatal death rates in the two groups, an alarming increase in infant death among babies of young mothers occurred by their second birthday. These data compare favorably with those reported by Shapiro et al.15

In addition to being at risk for the causes of infant morbidity and mortality mentioned above, infants born to adolescent mothers are at greatest risk of dying of sudden infant death syndrome (SIDS). And the risk of SIDS was significantly increased when young mothers (i.e., less than 20 years old) were having their second or third infants. This finding was obtained by using multifactoria! analysis to control for other variables; no biologic cause can be implicated, and the reason for the greater prevalence of these deaths in infants born to this group of women remains unexplained.16"19

LONG-RANGE PROSPECTS FOR INFANTS BORN TO ADOLESCENT MOTHERS

Results of a number of studies indicate that infants bom to adolescent mothers are more likely to weigh less when they reach school age, more likely to have poorer grades, and more likely to be subject to child abuse and neglect than those born to mothers in other age groups.

Table

TABLE 7NEONATAL COMPLICATIONS IN RELATION TO MOTHER'S AGE

TABLE 7

NEONATAL COMPLICATIONS IN RELATION TO MOTHER'S AGE

Morbidity, abuse, and neglect. LaBarre20 has reported that the infant death rates due to respiratory infections and accidents are more than twice as high among infants bom out of wedlock as in infants born to married mothers. Hight et al.,21 in a study of inflicted burns in children, noted that 75 percent of the injured children had single parents who were in most cases young or adolescent at the time of birth. Spinetta and Rigler22 summarized their research on the personality characteristics of abusive parents by noting that they were more immature, less intelligent, and more aggressive, impulsive, selfcentered, tense, and self-critical than nonabusive parents. This portrayal indicates only that abusive parents who may also be young are members of muftiproblem families with a complete spectrum of personal and social pathology. Although reviews of adolescent pregnancy frequently include abuse and neglect as one of the significant features demonstrating poor outcome, there are no carefully controlled studies to substantiate this claim. Abused children clearly suffer from an extreme amount of deviant caretaking behavior. The temperament of the child is thought to contribute to the abusing tendency of the parent.

Growth. Infants born to adolescent mothers are more likely to be underweight and shorter in the first years of life than matched controls bom to adult mothers, Oppel and Royston23 have reported. But Hardy and his associates,24 in the Johns Hopkins Development Study, found no difference by the time the children reached the age of seven between physical growth of children bom to adolescent mothers and those of older mothers.

Intellectual ability. Lobi et al.2S compared the intellectual function of children over an eight-year period with the age of their mothers at the time the children were bom. Their study controlled for race, sex of infant, birth weight, and birth order. They found that intellectual function of both blacks and whites was higher the older the mother at the time of birth, regardless of the child's birth weight . This study also found the black-white difference to be less than that reported in most studies. This was attributed to the fact that the white families were of lower socioeconomic status and the blacks of slightly higher status thari their ethnic counterparts in other geographic areas.

Lobi et al. concluded that children of mothers 15 and younger and firstborn children of mothers 35 years and older are at a disadvantage in later intellectual functioning. Their findings compare favorably with those of Illsley" in a study of 11,280 seven-year-old children in Aberdeen, Scotland, where the Moray House Picture test was used as a measurement of I. Q. Higher I. Q. correlated with increasing maternal age when parity and social class were controlled.

In a 1 2-year longitudinal study of the offspring of mothers 17 and under and matched pairs 18 years and older as a part of the Baltimore study, Oppel and Royston23 reported a barely significant difference in mean LQ. (2.98 mean LQ. points) for the two groups on the Stanford-Binet test. The results on the Wechsler were not significant. When the Bender Gestalt test results were examined for differences in deprivation, ethnic group, and sex, it was found that deprived white children performed markedly better than deprived black children. This difference was found by some investigators to be exclusively in the males. When white advantaged children were compared with white disadvantaged children, there was no difference in their scores. Black advantaged children scored significantly better than black disadvantaged children on the Bender test.27 The rate of maturation on this test varied in different ethnic groups.

The long-range outcome of the children born to adolescent women was also examined by Hardy et al,24 as part of the Johns Hopkins study. When given the Stanford-Binet tests at the age of four, children who had been born to adolescent black mothers tended to cluster in the low-I.Q. group; few were in the above-average group. The scores of the four-year-olds increased as their mothers' ages at their birth increased.

The relationship of maternal age to other variables known to affect development has yet to be studied. In view of the data on the effect of race and socioeconomic status on I. Q. scores, any relationship of maternal age to the intelligence of offspring requires further controlled analysis.

Sameroff and Chandler28 have stressed that the data from various longitudinal studies of prenatal and perinatal complications have yet to produce a single predictive variable more potent than the familial and socioeconomic characteristic of the caretaking environment. The predictive accuracy of the socioeconomic status is especially sensitive at the low end of the intelligence scales. These authors also note that the organization of intelligence in the child changes with age. As the child ages, he moves from a sensorimotor mode of functioning to a conceptual mode, and early deficits tend to disappear. Parental attitudes and social status seem to influence this tendency. Of particular note among long-range studies is that done by Werner et al.,29 who followed 670 children born on the island of Ka vai in 1955. This study included the entire population and ample controls for race and socioeconomic status. The distribution of perinatal complications did relate to later physical and psychologic disabilities in lower-income families but did not influence outcome in stable upper-class families.

Academic achievement as a measure of outcome was used by Hardy et al.24 at both seven and 12 years of age. They found that children of adolescent mothers performed less well in school and repeated a grade more often than did the children of older women. Self-concept as determined by the Coopersmith and Piers-Harris tests showed no significant differences between the groups. Maternal educational achievement differed significantly. Only 35 percent of the younger mothers had completed high school, as against 77 percent of the older women , at the end of the study. In addition post-graduate education, skills, training, job levels, and income were significantly lower in the adolescent mothers.

In their match-control study of adolescent mothers, Oppel and Royston23 found that the children of young mothers were on the average 0.38 year below the reading level of children of older mothers. When reading levels were compared, 29 percent of the children of young mothers had achieved third-grade reading level as opposed to 55 percent of the children of older mothers. Their analysis of behavioral traits of the two groups of children at ages eight and 10 showed the offspring of young mothers to be more dependent and distractable. There were no differences in other personality traits studied.

MATERNAL BEHAVIOR

Parenting by the young mother has not been studied in depth, although several studies have been conducted to determine the effect of an intensive support system on the outcome of the mother and infant. The Young Mothers Educational Development (YMED) program described by Osofsky and Osofsky30 in Syracuse is such a program. The results of ratings of mothers' and infants1 behavior before and during the pediatrie examination showed that YMED mothers showed warmth and physical interaction. There were no control dyads. In the study of young mothers and their matched-pair controls reported by Oppel and Royston,23 mothers under 18 were less likely to remain with their children, were less likely to rear their children in healthy families, and exhibited less nurturing behavior than the adult controls. Williams31 studied the child-rearing practices of young mothers in a group-home program. The younger the mothers were, the less they talked to their children and picked them up, compared with the caregiver. A clear effect of age or singleness was not demonstrated in this setting.

The child-health supervision given unmarried black primiparous schoolgirls from socioeconomically deprived environments after their babies were born was studied by Gutelius et al.32 over a threeyear period and compared with the child-health supervision given matched controls. The study mothers had intervention from the seventh month of their pregnancy that included health care, counseling, individual cognitive stimulation for their babies, and group sessions.

Comparison of the behavior of the mothers who had received such care with the behavior of black mothers from similar surroundings who had not was revealing. Those who had received intervention had improved diet, better eating habits, more success at toilet-training their infants, and more abstract qualities, such as self-confidence, than those wKo had not been given child-health care. There was no attempt in this study, however, to evaluate the behavior of the adolescent mother as a function of her age.

Pregnancy for the adolescent has been recognized as a series of emotional crises, including the crisis of adapting to the maternal role and the reality of round-the-clock infant care. LaBarre20 studied school-age girls during pregnancy and early motherhood and concluded that adolescent mothers need but do not have preparation for parenthood in our present system of educational preparation. Als,33 in an ethnologic study of the human newborn and his mother, asked the question whether teenage women are less capable as first mothers than women in their 20s. Tabulation of certain typical interaction behaviors during the first three postpartum days showed little overall difference between adult and younger mothers. The study included 30 black HoIlingshead V primiparous mothers who delivered normal full-term babies vaginally and were bottlefeeding. Women's ages ranged from 16 to 25 years, with a mean of 20 years.

A pilot study of 1 5 primiparous women 1 8 years and younger reported by McAnamey, Lawrence, and Aten34 suggests that there is a relationship between the degree of immaturity of the mother and her ability to interact with her infant. They found that the younger the adolescent mother, the less she utilized typical maternal behaviors of touching, high-pitched voice, synchronous movements, and closeness to the infant. Similarly, Hales and Bergen35 reported findings in a pilot study of 10 Guatemalan mothers 14to I7yearsof age; the adolescent mothers were less able to establish close contact immediately after delivery than adult mothers. A pilot study of attitudes of inner-city adolescent mothers reported by Zuckerman et al.36 indicated that the adolescent mothers were more likely to seek medical advice from their mothers than from health professionals and that they were more insecure than older mothers in their maternal self-image if caretaking was shared. The authors suggested that further investigation is necessary to establish differences in maternal self-image, child-rearing practices, and available support systems.

CONCLUSION

Adolescent pregnancy has been said to lead to increased medical risk for both mother and baby. In reviewing our collective data and taking into consideration the race and socioeconomic status, it appears that age is not the critical factor unless the mother is 14 years of age or less. The ideal time to give birth, from a medical viewpoint, would appear from these data to be between the ages of 1 6 and 1 9 , provided the mother is given adequate prenatal care.

The data on the psychosocial outcome of premature parenting are sparse and inconclusive. While the intellectual development and educational expectations of children of adolescents appear to have been lower than those of older mothers, these children were disproportionately poor, black, and living in extended, often disrupted families with several care givers. In addition, the major studies to date have been of adolescents who bore infants between 1950 and 1960. Thus, our data suggest that the mothering skills and child-rearing practices of adolescent chtldbearing women have yet to be evaluated adequately.

REFERENCES

1. Lincoln, R. Is pregnancy good for teenagers? Testimony before lhe Select Commit lee on Population, 95th Congress, first session. Washington, D.C.: U.S. Government Printing Office, 1979, p. 318.

2. Lowe, C. U. Fertility and contraception in America: Adolescenl and Pre-adolescent Pregnancy Hearings before the Select Committee on Population, 95th Congress, second session. Washington, D. C.: U.S. Government Printing Office, 1979, p. 570.

3. Tanner, J. M. Growth at Adolescence. Oxford, England: Blackwell Scientific Publications, 1963, p. 1.

4. Richmond, ). Statement of the Surgeon General of the U.S. and Assistant Secretary for Health. Adolescent and Pre-adolescent Pregnancy Hearings before the Select Committee on Population, 95th Congress, second session. Washington, D. C.: U.S. Government Printing Office, 1979, pp. 148-158.

5. Naeye, R. L. Effects of maternal age on the outcome of pregnancy, (In Press.)

6. Miller, H. C., and Merrill, T. A. Fetal Growth in Humans. Chicago: Year Book Medical Publishers, 1979, pp. 1-174.

7. Merritt, T. A., and Lawrence, R. A. Unpublished data.

8. Hardy, J. B., and Mellits, E. D. Relationship of low birth weight to maternal characteristics of age, parity, education, and body size. In Reed, D. M., and Stanley, F. H. (eds.): The Epidemiology of Prematurity. Baltimore: Urban and Schwarenberg, Publishers, 1977, pp. 105-117.

9. Hoffman, H. J., Lundin, F. E., Bakketdg, L. S., and Hariey, E. E. Classification oí births by weight and gestaf ional age for future studies of prematurity. In Reed and Stanley, supra, pp. 297-325.

10. Spellacy, W. N., Mahan, C. 5., and Cruz, A. The adolescent's first pregnancy: a controlled study. South. Med. ]. 71 (1978), 768-771.

11. Dott, A. B., and Fort, A. T. Medical and social factors affecting eaiîy teenage pregnancy. Am. f. Obstet. Gynecof. 125 (19761, 532-535.

12. Niswander, N. R., and Gordon, M. The Women and Their Pregnancies. Philadelphia: W. B. Saunders Company, 1972, pp. 1-540.

13. Dwyer, J. F. Teenage pregnancy. Am, /. Obstet. Gynecol. US (1974), 373-376.

14. Edwards, L. E., Barrada, M. I., Marnanti, A. A., and Hakanson, E. Y. Gonorrhea in pregnancy. Am. J. Obstet. Gynecol 132 (1978), 637-640.

15. Shapiro, S., et al. Relevance of correlates of infant mortality for significant morbidity at one year of age. Am. ]. Obstet. Gynecol. (In Press).

16. Bergman, A. B.,etal. Studies of the sudden infant death syndrome in King County, Washington. Hl: Epidemiology. Pediatrics 49 (1972), 660-870.

17. Froggatt, P., Lynas, M. A., and Marshall, T. K. Sudden unexpected death in infants (cat death): report of a collaborative study in Northern Ireland. Ulster Med. i. 40 (1971), 116-135.

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TABLE 1

MEDICAL COMPLICATIONS OF PREGNANCY

TABLE 2

MATERNAL "BEHAVIORAL" CONDITIONS ASSOCIATED WITH PREGNANCY

TABLE 3

LOW-BIRTH-WEIGHT INFANTS BORN TO 770 TEENAGE MOTHERS AT THE UNIVERSITY OF KANSAS MEDICAL CENTER

TABLE 4

PLACENTAL, FETAL, AND NEONATAL DISORDERS BY MATERNAL AGE: CAUSES, FREQUENCY, AND PERINATAL MORTALITY

TABLE 5

NEONATAL APGAR SCORES PER 1,000 BIRTHS

TABLE 6

ACIDOSIS* AT BIRTH PER 1,000 BIRTHS

TABLE 7

NEONATAL COMPLICATIONS IN RELATION TO MOTHER'S AGE

10.3928/0090-4481-19800301-07

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