Health inequality and population variation in fertility-timing

Abstract

We estimate the impact of fertility-timing on the chances that children in poor urban African American communities will have surviving and able-bodied parents until maturity. To do so, we use census and vital statistics data to compute age- and sex-specific rates of mortality and functional limitation among prime-aged adult residents of impoverished African American areas in Harlem, Detroit, Chicago, and the Watts area of Los Angeles and for blacks and whites nationwide. Findings are consistent with the hypothesis that the early fertility-timing characteristic of poor urban African American populations mitigates some of the costs to families associated with excess mortality and early health deterioration in young through middle adulthood.

Introduction

African Americans suffer disproportionately high rates of many diseases and disorders, (US DHHS, 1991) and racial gaps in some health status indicators, most notably premature mortality, may be growing (Feldman et al., 1989, Pappas et al., 1993, Preston and Elo, 1995). Studies have consistently shown racial or socioeconomic differences in morbidity and mortality to be most pronounced in the young and middle-adult ages. In an analysis of national survey data, House et al. (1990) found that functional status differentials by socioeconomic group were large at all ages, but widened after age 25 and were most pronounced among those ages 35–64. Elo and Preston (1996) observed a large and unexplained racial disparity in mortality between the ages of 25 and 64 using the National Longitudinal Mortality Survey. Geronimus (1994) described widening racial differentials in women’s health status over the reproductive ages for diverse indicators including hypertension prevalence and circulating blood lead levels. These findings reflect state or national averages and may seriously understate the rate of health deterioration among African Americans in poverty. Studies suggest that young to middle-aged African Americans in persistently poor populations face extremely disadvantageous mortality schedules (McCord and Freeman, 1990, Geronimus et al., 1996). Chronic diseases are the primary causes of premature death in these populations suggesting the possibility of excessive rates of morbidity and disability among reproductive and working-age adults as well (Geronimus et al., 1996).

Pervasive and severe threats to the health of young through middle-aged adults may reverberate throughout entire communities. In the United States, adults of these ages are expected to be important contributors to family economies and caretaking systems. It is possible that uncertain health at these socially critical ages would exert pressure to adapt family organization to mitigate risks associated with the premature loss or disability of adults.

Dramatic declines in US mortality among adults aged 20–50 years old have received credit for contributing to significant changes in the American family landscape, including enhanced independence of the nuclear family and the disappearance of orphanages (Uhlenberg, 1980). Communities who have not enjoyed these declines in full measure might be expected to exhibit different family adjustments. Indeed, the hypothesis that populations faced with severe health uncertainty in young through middle-adulthood may adapt their social or family structures in response has been discussed in the context of the heterosexually-based African AIDS epidemic (Caldwell et al., 1989, Caldwell, 1997; Palloni and Lee, 1993; Van de Walle, 1990, Foster et al., 1997, Urassa et al., 1997). For example, in the African context, Palloni and Lee (1990) posited important implications of the epidemic for families, as it increases the probability of widow or orphanhood, prolonged disability within the family, damage to the family economy and care systems, and pressure for multigenerational residential arrangements. The ravages of AIDS provide a dramatic case of increasing significance in some poor US communities (Holmes et al., 1990, Geronimus et al., 1996) of the more general hypothesis that population variation in family structure or fertility behavior may, in part, reflect health inequality.

Differences in key aspects of fertility and family behavior between US blacks and whites are striking. On average, African American mothers begin childbearing at younger ages than whites, and 43% of black first births are to teen mothers compared to 22% of white first births (Ventura et al., 1997). The majority (75%) of black first births are nonmarital compared to 29% of white first births (NCHS, 1996). African American children are also more likely than white to live in extended or multigenerational family households or to live in households where neither biological parent is present (Hogan et al., 1990, Sandven and Resnick, 1990, Hunter and Ensminger, 1992). These different childbearing and family patterns are most prevalent among African Americans who are socioeconomically disadvantaged (Abrahamse et al., 1980, Hayes, 1987; Geronimus and Korenman, 1992, Geronimus and Korenman, 1993). These patterns have been documented throughout this century (Evans, 1986, DuBois, 1908, Morgan et al., 1993, McDaniel and Morgan, 1996).

A common interpretation is that such fertility and family patterns cause or intensify the many disadvantages poor African American children suffer. In this light, the persistence of these behaviors has been a puzzle as well as a source of social concern. Teenage childbearing among African American residents of central cities, in particular, has been problematized as a “ghetto related” behavior or a defining characteristic of “the urban underclass” (Jencks, 1992, Wilson, 1996). The concept of an “underclass” gained currency in the United States in the 1980s. While the population characterized in this way is somewhat ambiguous, the image conjured up by this term encompasses African American residents of urban areas of concentrated poverty who have not mastered the cultural skills most Americans value, and who fail to conform to American ideals about social behavior (Jencks, 1992). These failures are thought to perpetuate their impoverishment and social isolation from the mainstream, rather than to be emblematic of cultural diversity or the pursuit of reasonable goals in the face of structural barriers to their achievement. One of the most widely accepted and intensely held norms in late 20th Century America is that teenagers should not have children (Jencks, 1992). In the underclass perspective, then, high rates of teen childbearing among urban African Americans are seen as a conclusive violation. Moreover, this particular violation is perceived to be harmful to children and families and to be a primary contributor to the persistence of severe intergenerational disadvantage and antisocial behavior (Alter, 1994, Geronimus, 1997).

However, an alternative explanation for high rates of early childbearing in impoverished urban African American communities is that fertility-timing varies among populations because of the contingencies members of different populations face in their efforts to provide for the survival and well-being of families (Chisholm, 1993, Geronimus, 1987, Geronimus, 1994, Geronimus, 1996a, Burton, 1990, Wilson and Daly, 1997). Such variable contingencies include prospects for labor force participation, educational opportunities, and other structural or economic factors. An additional contingency poor African Americans may contend with is early adult health deterioration, or “weathering” (Geronimus, 1994). Pervasive health uncertainty, expectations of premature illness or mortality, and other disadvantages might exert pressure on inner city youth toward accelerated life-course timetables and early fertility.

Qualitative findings, including ethnographic studies in unique settings and small-scale interview studies, are suggestive that health uncertainty and early-fertility timing norms in poor African American populations may be linked (Burton, 1990, Stack and Burton, 1993, Geronimus, 1996a). These studies provide rich data on the possible intra-family mechanisms that may mediate associations between health uncertainty and fertility-timing. However, these investigations focus on a small sample of individuals or families in specific communities and are not easily reproduced. To complement these studies, it remains for investigators to systematically quantify at the population level whether, in the context of pervasive health uncertainty, early fertility may have measurable benefits using quantitative methods that are easily replicated in several populations. Here, we begin to quantify the costs of delayed childbearing to poor, urban African American populations in terms of the loss of able-bodied caretakers. We study urban African American populations that typify populations engendering concern about “underclass” behaviors. In these populations and for blacks and white nationwide, we measure the impact of delayed relative to early fertility on the probability that parents will survive, able-bodied until children are grown.