Teenage children of teenage mothers: Psychological, behavioural and health outcomes from an Australian prospective longitudinal study
Introduction
In many industrialised countries teenage pregnancy and teenage parenthood (regardless of marital status) have in recent years been identified as social and public health problems that need to be tackled, though the level of concern varies by context. A report by UNICEF (2001) asserts however that for most of history teenage parenthood has not been perceived as a problem, but as something normal and desirable; by contrast:
Today, parents, politicians and physicians warn against it…teenage parenthood has come to be regarded as a significant disadvantage in a world which increasingly demands an extended education, and in which delayed childbearing, smaller families, two-income households, and careers for women are increasingly becoming the norm. (UNICEF, 2001, pp. 5–6)
The UNICEF report categorises nations according to what degree fertility among women aged below 20 is considered a matter of concern and whether government is actively intervening to change that rate. This information is presented in Table 1, which additionally categorises countries according to whether their fertility rate for women under 20 is above or below 10/1000. Policy concern clearly varies by context: some countries with lower rates exhibit ‘major’ concern (France, Spain) whereas others with higher rates do not see this as a matter of concern (Czech Republic, Iceland, Ireland and Slovak Republic). Similarly, interventions are not the exclusive domain of countries with higher rates, although all countries which have identified this as a ‘major’ concern were actively intervening.
In Australia, where the rate is in the higher category (18.4/1000), teenage pregnancy is seen as of ‘minor’ concern with no active intervention in 1998 when the UNICEF data were collated. By contrast in England, a raft of policy documents (e.g. HDA, 2005; SEU, 1999) have addressed this issue since it first appeared on the policy agenda in the early 1990s (DoH, 1992). Such attention in policy rhetoric and activity in countries such as the US and UK, that are actively intervening to reduce teenage pregnancy rates, is often justified with reference to the implications for welfare dependency (in the US) and adverse health consequences for young mothers and their offspring (in the UK) (Bonell, 2004).
However, in terms of justifying why we would expect teenage mothers and their offspring to have poor health outcomes, this area is relatively under-theorised—such an effect is often assumed rather than explicitly justified. One form of argument is that teenagers, although mature enough to become pregnant, are physiologically too young to bear children successfully. Parallel to this is the position that teenagers are too emotionally immature to be good parents, not yet able to provide their children with the full range of support and stimulation they need. However, the most predominant form of justification for examining the health (and other) outcomes for teenage mothers and their children connects early childbearing intimately, and almost inextricably, with poverty and its transmission across generations. Indeed, having considered various outcomes for teenage mothers across Europe, Berthoud and Robson suggest that “…teenage motherhood may be seen as conceptually equivalent to poverty” (2001, p. 52, their emphasis). Studies which have sought to distinguish the effects of young age from the adverse effects of poor socioeconomic circumstances, however, tend to find that it is the latter which is the predominant causal factor (Cunnington, 2001; Geronimus, 2003; Lawlor & Shaw, 2002).
Teenage mothers are most likely to originate from poor families (Hobcraft & Kiernan, 2001) and younger mothers are more likely to have been brought up and currently live in deprived areas than their older counterparts (McLeod, 2001; Van der Klis, Westenburg, Chan, Dekker, & Keane, 2002). The relationship between deprived areas and higher rates of teenage pregnancy, however, is reported to be largely due to personal and household disadvantage rather than due to area effects (McCulloch, 2001).
Moreover, teenage parents also tend to remain poor and be relatively socially and economically disadvantaged. Comparing teenage to older mothers across Europe, Berthoud and Robson (2001) found that 40% of 18 year old mothers were living in poverty when their child was 10 years old, compared to only 11% of 28 year old mothers. However, it is unclear whether becoming a teenage mother results in worsening poverty or whether teenage mothers remain on the same socioeconomic trajectory that they were on before becoming pregnant. Studies have looked at a range of socioeconomic outcomes for young mothers in a variety of contexts. In Sweden, Olausson, Haglund, Weitoft, and Cnattingius (2001) have reported that compared to older mothers teenage mothers tended to be less likely to be employed, more likely to not be living with a partner and more likely to be reliant on welfare benefits. In the US, having a child before the age of 20 has been linked to lower rates of high school completion and post-secondary education (Hofferth, Reid, & Mott, 2001) and to significantly reduced educational attainment among white, blacks and Hispanics (Klepinger, Lundberg, & Plotnick, 1995). Similar findings are reported in the UK when younger mothers are compared with women who become mothers at older ages.
However, such comparisons cannot take into account “what the woman would have done if she did not have a child as a teenager” (Ermisch & Pevalin, 2003a, p. 1). Analysis of the British 1970 Cohort (Ermisch & Pevalin, 2003a) looking at various outcomes for women aged 30 who had a teenage birth compared with those who became pregnant as a teenager but who miscarried or had an abortion find little evidence of any differences between these two groups on the woman's qualifications, employment or pay at age 30 (although they did find that at age 30, her partner, if she did have one, was more likely to be unemployed). These findings suggest that the act of becoming a teenage mother does not itself result in worsening outcomes for the mother, rather women who become pregnant as a teenager remain on the same trajectory whether they continue with the pregnancy or not.
Teenage mothers and their offspring are reported to have a range of negative outcomes. There is evidence that teenage mothers are more likely to experience depression around the perinatal period (Quinlivan, Tan, Steel, & Black, 2004) and there may be slightly higher rates of perinatal death (ONS, 1997). Most research has looked at the health outcomes of young offspring. It is reported that the children of teenage mothers experience more health problems in the neonatal and early life period compared to the children of older mothers. Research from the British 1970 Cohort Study (Pevalin, 2003), for example, finds that babies born to younger mothers are more likely to be born pre-term and to be of low birthweight, which may have a range of consequences. An American study looking at the same outcomes found an increased risk of adverse outcomes for mothers aged less than 20 even when controlling for confounding socioeconomic factors (Fraser, Brockert, & Ward, 1995).
Some studies are able to consider longer-term outcomes. Hofferth and Reid (2002) used data from the US National Longitudinal Survey of the Labor Market Experience of Youth and the Panel Study of Income Dynamics to look at maternal age at first birth (age 19 or younger) and outcomes for children age 3–13. They found that in comparison with children of older women these children scored lower on achievement tests and had higher rates of behavioural problems, although when period effects were taken into account fewer achievement differences were found, thereby suggesting that comparisons across cohorts may exaggerate effects. Fergusson and Woodward (1999) looked at the relationship between maternal age at birth and outcomes at age 18 in a New Zealand cohort and found that maternal age (as a general gradient, not just comparing teenage mothers with older mothers) was associated with a wide range of educational and psychosocial outcomes—i.e. risks of educational under-achievement, juvenile crime, substance misuse, and mental health problems—such that younger mothers had worse outcomes. However Fergusson and Woodward caution:
It is also important to recognise that although maternal age was related to later outcomes, this relationship was by no means deterministic: the offspring of younger mothers were not invariably disadvantaged and neither were the offspring of older mothers invariable advantaged. Rather there were small, pervasive, and generally consistent trends for outcome risks to decline with increasing maternal age. (1999, p. 487)
The outcome that is most commonly reported for the older offspring of teenage mothers is that they are more likely themselves to become a teenage mother, thus contributing to a ‘cycle of poverty’. Data from the British Household Panel Survey and the British 1970 Cohort Survey show that those born to teenage mothers are twice as likely to become teenage mothers themselves (Ermisch & Pevalin, 2003b). In the US, Kahn and Anderson (1992) using data from the 1988 National Survey of Family Growth (Cycle IV) found that both black and white teen mothers were significantly more likely to be teen mothers than were daughters of older mothers. However, it is certainly not the case that being born to a teenage mother means that a young woman is herself necessarily destined to become a teenage mother—results from a study of black women in the US (who have high rates of teenage motherhood) find that the majority do not become adolescent parents, although they did have “bleaker educational and financial prospects than their mothers had” (Furstenburg, Levine, & Brooks-Gunn, 1990, p. 54).
Whether these adverse effects associated with early childbearing are due to young age per se or to poor socioeconomic circumstances, or to a combination of the two, the conditions of early life may have repercussions for health and other outcomes much later in life. Maternal depression in the perinatal period, for example, may in turn influence the child's early development and later cognitive ability and behaviours. Neonatal problems and poor socioeconomic circumstances in early life are both associated with adverse outcomes in later life, including cognitive performance and coronary heart disease (Jefferis, Power, & Hertzman, 2002; Lawlor, Davey Smith, & Ebrahim, 2004; Lawlor, Ronalds, Clark, Davey Smith, & Leon, 2005; Richards, Hardy, & Kuh, 2001). Further, there is an increasing body of evidence linking cognitive ability in childhood to increased risks of premature mortality, cardiovascular disease and mental health problems in later life (Batty & Deary, 2004).
This paper draws on data from an Australian context. As in many industrialised countries, overall fertility rates have been declining in Australia over the past 50 years. Moreover, women are increasingly delaying child-bearing: the median age at child-bearing rose from 26.7 years in 1981 to 28.5 years in 1991 and 30.0 years in 2001. Between 1981 and 2001 there was a fall in the proportion of births to teenage mothers, from 7.5% in 1981 to 4.8% in 2001 (ABS, 2004). The teenage fertility rate (births per year per 1000 females aged 15–19) has been declining since the 1970s. It peaked in 1971 at 55.5 births/1000 females, falling to 27.6/1000 in 1980 and reaching its lowest ever rate of 18.1 in 1999 (see Fig. 1). The decline is thought to be due to increased access to sex education, contraception and abortion (ABS, 2000). Despite similar rates to countries that see teenage births as a major problem and/or that are actively intervening to reduce teenage pregnancy (for example Canada, Germany, Portugal and Ireland) Australia does not see teenage pregnancy as a major problem and does not have a policy aimed at reducing it. Thus, Australia offers the opportunity to study the outcomes of teenage parenthood in a country where there may be less stigma than in countries that portray teenage parenthood as a major health and/or social problem.
Within Australia rates of teenage pregnancy are higher in rural areas (Evans, 2001), more economically disadvantaged areas (Coory, 2000), and in indigenous populations, with the birth rate for indigineous women aged 15–19 being 3.3 times that for the general population in Queensland (ABS, 2000). In 1999 the rate for Queensland was slightly higher than that for Australia as a whole, at 22.4/1000 (Coory, 2000).
The aim of this study is to examine, in an Australian cohort, the associations of maternal age (⩽18 years versus >18 years at their first antenatal visit) with outcomes among their 14 year-old offspring in terms of health and psychological and behavioural characteristics. Further, we aim to establish the role of socioeconomic factors and maternal characteristics, including maternal depression and health characteristics, in explaining any observed associations. In choosing to dichotomise maternal age we do not wish to imply that there is something unique about the age of 18, rather this choice reflects the approach used in those countries that have policy interventions to reduce teenage pregnancies with teenage pregnancy in these policy documents being defined by a cut-point of 18 or 19 years.
Section snippets
Participants
The Mater-University study of pregnancy (MUSP) and its outcomes is a prospective study of women, and their offspring, who received antenatal care at a major public hospital (Mater Misericordiae Hospital) in South Brisbane between 1981 and 1984 (see Keeping et al., 1989 for further demographic characteristics of the sample). Consecutive women attending their first obstetric visit for their current pregnancy (not necessarily their first) were invited to participate in the study (). Pre- and
Results
Of the 7223 original mother–offspring pair cohort members 5260 (73%) provided data when the children were 14 years of age. Table 2 shows the differences in maternal characteristics between those who were followed-up at age 14 and those who were lost to follow-up. The mothers of children who were followed-up at age 14, compared to those were not, were less likely to have been 18 years or younger at their first antenatal visit. They were also less likely to have been smokers throughout their
Discussion
We have found that the 14 year old offspring of mothers who were aged 18 years and younger compared to those who were offspring of older mothers were more likely to have disturbed psychological behaviour, had poorer school performance, poorer reading ability (assessed by WRAT3), were more likely to have been in contact with the criminal justice system and were more likely to smoke regularly and to consume alcohol. However, maternal age was not associated with health outcomes in the offspring at
Conclusion
This particular study is distinguished from previous work on this topic by the length of follow-up (few previous studies have been able to follow offspring to the age of 14), by the wide range of data collected, and by the consideration of a range of confounding factors. The results presented here are similar to those reported from other studies, most of which have focused on health outcomes in the perinatal period, in that a range of ‘adverse outcomes’ are found for the offspring (at age 14
Acknowledgements
The authors thank the Mater-University of Queensland Study of Pregnancy (MUSP) Team, MUSP participants, the Mater Misericordiae Hospital and the Schools of Social Science, Population Health, and Medicine, at The University of Queensland for their support. Funding The MUSP is funded by National Health and Medical Research Council (NHMRC), Queensland Health, the Centre for Accident Research and Road Safety—Queensland (CARRS-Q), and the Australian Institute of Criminology (AIC). DAL is funded by a
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