Journal o f Youth and Adolescence, Vol. 2, No. 3, 1 973

Adolescents as Mothers: An I n t e r d i s c i p l i n a r y Approach to a Complex Problem H o w a r d J. O s o f s k y , 1 J o y D. O s o f s k y , 2 N o r m a n K e n d a l l , 3 and Renga R a j a n 4 Received February 19, 1973 Pregnancy among adolescents, and especially among low-income adolescents, represents a high-risk situation from multiple points o f view. When compared to data for the population at large, obstetrical outcome is worsened, subsequent educational attainment is poor, social prognosis is guarded, and repeat unwanted pregnancies are common. The surviving infants, similarly have relatively high incidences o f medical and developmental problems. In recent years, comprehensive interdisciplinary programs have been organized to offer more meaningful help to these individuals. The present report describes the authors' 5-year experience with one early intensive program. Considerable medical, educational, and social successes have been noted. The results are especially striking when contrasted with the authors' current experience with an improving but still more fragmented and less successful program. Findings concerning infant development and the mother-infant interaction are also noted. Finally, issues related to the achievement o f successes and the persistence o f problems after provision o f more adequate comprehensive services are discussed.

This study was supported in part by Grant No. 03-H-000-079-03-0, Maternal and Child Health Service, H.S.M.H.A., H.E.W. 1Professor of Obstetrics and Gynecology and Chief of Obstetrics at Temple University Health Sciences Center, Philadelphia, Pennsylvania. While on the faculty of the State University of New York, College of Medicine at Syracuse, was a founder and the first medical director of the YMED program. 2Associate Professor of Psychology at Temple University, Philadelphia, Pennsylvania. Specialty is Developmental Psychology, and research interests concern infant and early child development and the effects of children on parents. While on the faculty of Cornell University, served as a consultant to the YMED program. 3professor of Pediatrics and Chief of Neonatology at Temple University Health Sciences Center, Philadelphia, Pennsylvania. Project director of the high-risk program. 4Associate Professor of Obstetrics and Gynecology at Temple University Health Sciences Center, Philadelphia, Pennsylvania. While on the faculty of the State University of New York, College of Medicine at Syracuse, was obstetrical director of the YMED program. 233 9 1973PlenumPublishingCorporation,227 West I 7th Street,New York,N.Y. 10011.

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INTRODUCTION At present, a considerable body of data exists which tends to demonstrate that pregnant adolescents, and especially those who are economically poor and/or nonwhite, represent high-risk individuals from medical, educational, and social points of view. Similarly, the infants resulting from such pregnancies appear to have a considerably worsened prognosis when compared to infants from the population at large. Before describing a specific intervention program together with some of its results it would appear worthwhile to briefly review available data in these areas. With few exceptions, both national and international data have indicated that teenage pregnancy is accompanied by considerably more difficulty than pregnancies in general (Aznar and Bennett, 1961; Battaglia et al., 1963; Birch and Gussow, 1970; Glaman and Bell, 1964; Hassan and Falls, 1964; Menken, 1972; Mussion, 1962; Osofsky, 1968a; Osofsky and Kendall, 1972; Pakter et al., 1961a; Polliakoff, 1958; Semmens, 1965; Stine et al., 1964; Vincent, 1961; Zackler et al., 1969). For example, Pakter et al. (1961b) reported information from a large group of such pregnancies in New York City and found that complications were more frequent. They noted increased incidences of toxemia, syphilis, prematurity, maternal mortality, and infant mortality. Aznar and Bennett (1961), Claman and Bell (1964), Mussio (1962), and Polliakoff (1958) all found an increased incidence of toxemia among this group of patients. Hassan and Falls (1964) studied 159 young primiparas between the ages of 12 and 15 and compared them to two control groups. One control group consisted of 22-year-old primiparas and the other was comprised of all of the remaining patients delivered at two Chicago hospitals. The authors found that the study group had increased incidences of excessive weight gain, prolonged labor, toxemia, cesarean section, cervical laceration, premature labor, and neonatal and perinatal mortality. Stine et al. (1964) reviewed the records of Baltimore residents in 1961 and compared neonatal death rates and prematurity rates by age and race of the mother. Their figures revealed marked racial differences in all age groups, with the nonwhite population contributing a significantly higher rate of pregnancy loss. Further, age alone, regardless of race, seemed to play a significant role. Increased prematurity and higher neonatal death rates were found in the groups under 20 years of age; these complications were especially prevalent in females younger than age 17. Battaglia et a t (1963) studied all deliveries at the Johns Hopkins Hospital for the years 1939-1960 and compared mothers aged 14 or less with a group of 15- to 19-year-old nonwhite mothers and with another group consisting of the remainder of the clinic population. They found significantly increased incidences of prematurity, perinatal mortality, toxemia, and contracted pelvis in the group aged 14 or less. Chase (1970), in reviewing available data for the United States from 1950 to 1967, found consistent differentials in incidences of low birth weight infants

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related to maternal age. In 1967, for example, 15.1% of infants delivered of mothers under the age of 15 weighed less than 1500 gs. This was more than twice the overall national rate. The figure then gradually fell but did not reach the national rate until the mothers were age 20-24. In a recent study performed at Temple University Health Sciences Center, which primarily serves low-income patients and which has an improving, although not as yet totally comprehensive, adolescent pregnancy program, it was found that the percentage of smal infants was somewhat elevated and that the perinatal mortality rate for pregnancies to mothers aged 16 and younger was 50.8 per 1000 live births (Osofsky and Kendal, 1972). This rate was considerably higher than that noted for all other pregnant females with the exception of individuals aged 35 and older. In sum, therefore, most authors have found significant increases in the incidences of excessive weight gain, toxemia, fetal-pelvic disproportion, prolonged labor, prematurity, and perinatal loss, and, of ominous portent, have reported increases in maternal loss in very young mothers. Educational and social service data are also of great concern. Pregnant teenagers have had a considerably worsened educational prognosis than teenagers in general. In many areas of the United States, pregnancy has been the number one condition resulting in teenage girls leaving school prior to graduation. In data from Maryland in the early 1960s, pregnancy was found to be the cause of teenagers leaving school more than twice as often as all other medical and physical conditions put together (Stine et al., 1964). Frequently among pregnant teenagers there has been a long history of uninterest, repeated school absence, and even truancy. Especially among the relatively large proportion of lowincome, inner-city residents, educational attainment has commonly been below achieved grade level. Yet until relatively recently in most areas of the country, pregnancy has resulted in school exclusion (Burchinal, 1960; Keley, 1963; Welfare Law Bull., No. 11, 1968); in most areas, this situation overtly or covertly stil exists. For the low income individual who has been unable to conceal the pregnancy, exclusion for periods of up to I~A years has not been uncommon. In some areas, permanent exclusion has been mandatory. Given their prior history and the length of their exclusion, the subsequent poor success rates ar6-not unexpected. Social service data are equaly distressing. Kovar (1971) has estimated that during the years 1964 through 1966, in the United States, 42% of infants born in wedlock to mothers within the ages of 15 and 19 were delivered less than 8 months after marriage. Landis (1964) has found that approximately 50% of marriages between two high school students in California involved an already conceived pregnancy. When adolescent pregnancy has been accompanied by marriage, divorce has been common, occurring three to four times more frequently than among couples married at a later age (Rankin, 1964). When early marriage has not taken place, the pregnancy has been associated with an out-of-wedlock condition, with its accompanying social pressures and frequent

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societal condemnations. Yet counseling and meaningful services have remained relatively sparse (Adams and Gallagher, 1963; Bernstein, 1963; Herzog and Bernstein, 1964; Rashbaum et al., 1963; Teele etal., 1967). Fewer than 10% of females pregnant out of wedlock have been cared for in a maternity home; relatively few of the mothers receiving such care have been from the lower socioeconomic groups, and a still smaller percentage have been nonwhite. Where counseling has existed for the poor and/or nonwhite, it has usually consisted of planning for welfare assistance. Adoption has seldom been offered as an alternative. Meaningful birth control education and methods for future use have rarely been given. Some counselors have even suggested that low-income girls terminate their educational and meaningful work plans for the future. It would therefore appear worthy to note Krantz's (1965) data which indicated that the typical girl who became pregnant out of wedlock in her teens and required welfare assistance might be expected to deliver nine out-~f-wedlock pregnancies during her reproductive years; the cost to the social welfare department over the course of the girl's lifetime at that time averaged $100,000. This figure does not include additional cost for the children such as special education, which is frequently required, and does not take into account recent increases in expenses due to rises in the cost of living. Further corroboration is provided by a report from Sarrel (1966) which demonstrated that among 100 clinic girls in New Haven who were pregnant at age 15 and who were followed for 5 years the average number of deliveries was 3.4, almost all out of wedlock. Only 5% of the girls in the study had no repeat pregnancy, and medical complications and institutionalization appeared to play a preventive role in this small group. The surviving infants of adolescent pregnancies also appear to be in considerable jeopardy. As has been noted, there are much higher incidences of both premature and small-for-dates infants among pregnancies occurring within the teenage population. Knoblock and Pasamanick (1962, 1966), Pasamanick (1959), Pasamanick and Knobtoch (1966), in the United States, and Drillien (1959, 1964), in Scotland, have found in extensive studies considerably increased incidences of both mental subnormality and neurological deficit among surviving premature infants. When birth weight is 3 lb or less, as many as 20% of all infants may require subsequent special schooling or institutionalization. Although the figures are not as striking for small-for-dates infants, the incidences of developmental problems and retardation appear higher among this group than among the population at large. However, the prematurity and small-for-dates status do not by themselves account for all of the developmental problems, and some question the etiological relationship between low birth weight and subsequent developmental difficulty. Drillien (1964) for example, has demonstrated that by age 5 most premature infants in middle and upper socioeconomic classes have intellectually caught up with their peers. Where social conditions are not as favorable, the incidence of persistent problems tends

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to increase. Conditions which adversely affect the prognosis include deprived socioeconomic environment, other small offspring in the family, overcrowding of the home, and illegitimacy; obviously, many of these factors accompany low-income teenage pregnancies. Further, among those infants delivered at apparently normal maturity, there still appears to be an increased incidence of problems. Pakter e t al. (196 la) have found infant death rate due to respiratory infections and accidents to be more than twice as high among infants born out of wedlock than among infants delivered to married mothers. Menken, in reviewing data from a variety of studies as well as the National Natality Survey and the National Infant Mortality Study (NCHS, 1971), has demonstrated a considerable increase in mortality rates among infants delivered to young mothers; the discrepancy has been further increased when the infants have been delivered out of wedlock. Knobloch and Pasamanick (1966) and Pasamanick and Knobloch (1966), in their studies of childhood development problems, have singled out pregnancies in low socioeconomic groups-and especially in low socioeconomic teenage populations-as placing the infants in especially great jeopardy, even when prematurity is not a factor. DESCRIPTION OF A N I N T E R V E N T I O N PROGRAM

In order to gain a further understanding of the problems, and in order to offer some meaningful solutions to the difficulties which confront pregnant adolescents and their offspring, comprehensive interdisciplinary programs have been started in many communities throughout the country. Although such programs were relatively rare only a few years ago, by the end of 1971 over 175 were actively functioning. Because of individual community needs and resources, the programs have differed considerably in their scope and direction; there has been differential stress placed on various aspects of the problems contributing to the already defined increased risk. All of the programs, however, have been attempting to provide, within their capabilities, necessary and heretofore unavailable services. In spite of the encouragement which the establishment of such programs has provided to individuals concerned with the welfare of pregnant adolescents and their offspring, it should be emphasized that only one-fourth of eligible individuals have services available in the United States at the present time. The present report will focus on the results of one of the earliest functioning programs in the country, a program which was designed to provide, under one roof, intensive medical, educational, social, and psychological services for low-income pregnant adolescents and their offspring (Osofsky, 1968b; Osofsky et al., 1968a,b; H. Osofsky, 1970; and J. Osofsky, 1970). The report will deal with the years when one of the authors (H.J.O.) was associated with the program, first as a founder and subsequently as medical director.

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The YMED program (Young Mothrs Educational Development) was set up in Syracuse and Onondaga County in the fall of 1965. From the outset, the program was interdisciplinary. It was conceived and jointly sponsored by the State University of New York, the Upstate Medical Center at Syracuse, the Syracuse Board of Education, and the Onondaga County Department of Health. In more recent years, services were added by the Onondaga County Department of Social Services, Syracuse University, and Cornell University. YMED was designed to cut across professional lines and to offer individual services based on the multiple skills available. The program was concerned at all times with the individuals being served, and an effort was made to provide mothers and infants with maximum opportunities to lead useful, productive, and fulfilled lives within society. The YMED program was established and housed in a school building which had previously been closed to usual school function. The school was selected for three reasons. The first was that a traditional school would have been unacceptable to the parents of nonpregnant schoolgirls and to the community (in New York State, as elsewhere, schoolgirls whose pregnancy is apparent are, or at least were, usually excluded from classes). The second was its close proximity to the Medical Center. It was felt that since the girls were pregnant and going to school, and since medical care was to be an important part of the program, hospital and laboratory facilities should be available at all times. The third was related to the differences in meaning for teenagers between a hospital and a school. It was hoped that a school building would avoid the usual medical and social stigma associated with teenage pregnancy and might encourage the girls to seek out meaningful comprehensive care earlier in their pregnancy. Within the portion of the school devoted to YMED, rooms were utilized as classrooms, social service and psychological offices, a cooperative kitchen and cafeteria, a medical facility for examination and prenatal observation, and a nursery facility for infants (the nursery facility was provided so that mothers might continue attending school after the delivery of their offspring and, at the same time, learn meaningful techniques of child care). Although, at the time, combining such facilities under one rool was most nontraditional, it was felt that such a combination was absolutely necessary if a meaningful program were to be offered. From its inception, YMED was visualized as a highly intensive and personalized effort. A clinic-type situation was to be avoided; girls were to know and have individual relationships with their staff members who were providing the services. Girls were to have knowledge of their reproductive function and postpartally were to have all contraceptive options. Individualized planning was to be accorded each individual from the time she entered the program, and the duration of her stay was to be determined by her needs. In addition, follow-up and future planning were to receive high priority. During the first 589 years of the program's existence, 490 girls were

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enrolled (another 75 were partially enrolled during the early months of the program, before full services were available); 450 girls delivered within the program. The girls ranged in age from 10 to 20 years at the time of entry into the program; the mean age was approximately 16 years 3 months. Of the girls, 62.5% were nonwhite, 36.5% white, and 1% American Indian. The duration of residence within the community had a bimodal distribution. The bulk of the girls resided in the area either 1 or 2 years or for most of their lives. Almost all the girls were economically poor. Approximately 75% required full welfare assistance; an additional 10% required partial welfare support. RESULTS OF THE PROGRAM The general results of the program in all areas appear encouraging, and have been summarized in Table I. The majority of girls have been seen early in the course of pregnancy. Fifty percent have received medical care by the twentieth week of pregnancy. The average number of prenatal visits has been 11 per girl. Perhaps related to the intensive care, the incidence of major complications of pregnancy has been markedly reduced as compared to national figures for comparable populations. The prematurity rate, as determined by obstetrical and pediatric assessments, has averaged 4.6%, the combined prematurity and small-for-gestational-age rate has averaged 12.8%. This contrasts with the 23.4% incidence of tow birth weight among mothers younger than 15, the 18.3% figure for 15- through 19-year-old mothers in Baltimore between 1951 and 1960, the 17.2% national figure for mothers under the age of 15 in 1967,

Table

I. Summary of General Results of the YMED Program

Medical (for 450 deliveries) Average number of prenatal visits Percent with hemoglobin below 11.5 Percent with hemoglobin below 10.0 Percent of premature deliveries Percent of small-for-datesavailable Number of perinatal deaths Perinatal mortality 6.7

11 50 18 4.6 8.2 3 6.7

Educational (1968-1971) High school graduates Percent electing higher education

40

Social Percent requiring full or partial welfare assistance when entering program Percent of 1967-1969 students in neither school, employment, or marriage and requiring welfare assistance (follow-up)

91

85 13

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and the 15.9% figure for mothers under the age of 17 at Temple University Health Sciences Center in 1971. Of considerable significance, there have been only three perinatal mortalities among the entire 450 deliveries, for a rate of 6.7 per 1000 live births. This rate is lower than that which would be expected within a privileged middle-class adult population; it is less than one-seventh the rate for mothers under the age of 17 at Temple University Health Sciences Center in 1971 (Table II). Educationally the success rate has been high. Many underachieving students have responded with gains of 2 to 3 years of skill from 1 year of instruction. Between 1968 and 1971, 91 girls received high school diplomas related to attendence at YMED. Approximately 40% of all the girls graduating have elected some form of post high school education. The overwhelming majority of girls have been functioing well within either an educational or a work program. Social service data, as compiled in conjunction with other disciplines, have been equally encouraging. A follow-up of girls enrolled in the program during the school years 1967 through 1969 revealed that only 13% were at home with their infants-without meaningful education, work or marriage-and receiving welfare assistance. In a study of the first 325 consecutive girls delivering in the program, some of whom were followed up in 4 years after delivery, it was found that only 59 had become pregnant again; 18 of the 37 delivering more than 3 years ago, 27 of the 83 between 2 and 3 years, and 2 of the 127 between 1 and 12 months had become pregnant again. (Table III). Twenty-two of the group were married at the time of the subsequent pregnancy. Only one girl had apparently become pregnant more than once since her delivery within the program. These figures would indicate a projected diminution in repeat unwanted pregnancies of at least 75% when compared with the figures cited earlier. When one contemplates these figures, it is perhaps worth noting that, of the 267 individuals under the age of 17 who delivered during a 9-month period

Table II. Maternal Age v~ Pregnancy Outcome, Temple University Health Sciences Center, 9 Months, 1971 Maternal age 17 Live births Fetal deaths Neonatal deaths

Live births < 500 g Live birth s < 1000 g Live births(2500 g Fetal mortality rate Neonatal mortality rate Perinatal mortality rate Low birth weight percent

17-19 20-34

35+

232

356

818

53

4 8

5 9

12 21

3 2

3 9 129 14.4 25.6 39.7 15.7

0 1 I1 53.5 37.7 89.2 20.7

0 3 37 16.9 34.4 50.8 15.9

0 5 48 13.8 25.2 38.7 13.4

Totals 1459 24 40 3 18 225 16.1 27.4 43.1 15A

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Table lIl. Deliveries and Repeat Pregnancies at YMED-Based on First 325 Deliveries Time elapsed since delivery More than 1 More than but less than 12-24 months 24-36 months 36 months Totals 12 months No. deliveries No. repeat pregnancies Frequency in group

118 2 1.7%

87 12 13.8%

83 27 32.5%

36 18 50%

325 59 18.1%

in 1971 at Temple University Health Sciences Center, 43 were pregnant for the second time, four for the third time, and one for the fourth time (Table IV). It should be emphasized that although the results are most encouraging, there still exist many areas of concern. Some complications of pregnancy, including bacilluria, mild toxemia, and even gonorrhea occurred with greater frequency than would be expected among the population at large. Considering the youthfulness of the patients, and the supposed good health which should accompany the onset of pregnancy, the incidence of anemia has been disturbing. Fifty percent of the girls had a hemoglobin below 11.5 during pregnancy. Eighteen percent had a hemoglobin below 10. Although the combined incidences of prematurity and small-for-dates infants were reduced, they still did not approach optimal levels, and the mean birth weight of all infants in the program was 10 oz below the national average. GROWTH AND DEVELOPMENT OF THE INFANTS In light of the data demonstrating a somewhat increased incidence of premature and small-for-dates infants, and an average reduced birth weight for all infants in the program, it is of some interest to note data related to physical growth and development of infants in the program during the first year of life Table IV. Parity of Pregnant Females Under Age 17, Temple University Health Sciences Center, 9 Months, 1971

Maternal age

Maternal parity 1 2 3 4

Totals

12 13 14 15 16

2 l0 24 54 99

l 16 26

4

1

2 10 25 70 130

Totals

189

43

4

1

237

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(Table V). At 1 month of age, 74% of the infants studied ranked below the 50th percentile in weight and 76.9% in length. At 3 months, the figures improved considerably and by 6 months the infants resembled the population at large. Only 46.5% were below the 50th percentile in weight and 47.6% in length. After 6 months, the infants fell behind again. At 9 months, a greater number have ranked below the 50th percentile in each category, and by 1 year of age even more have been behind-61.9% in weight and 61.8% in length. RATINGS OF MOTHERS' AND INFANTS' BEHAVIOR In order to gain a greater understanding of the nature, strengths, and weaknesses of the mother-child relationship within this group, observations and videotapes were made of mother-child interaction before pediatric examinations, when mothers were alone with their infants, and during the examinations, in the presence of the doctor. Seventy-one consecutive mothers and their infants volunteered to participate in this portion of the study. The mothers appeared to reflect the larger group in the parameters of age, race, and economic background. Infants ranged in age from 3 to 62 weeks. Nurses and doctors cooperated with the study by leaving the mother alone with her infant for a sldecified time period prior to the examination and by having the mother actively participate with her own infant during the examination. The variables utilized to evaluate infant style and mother-infant interaction included both modifications of meausres previously developed and used to describe characteristics considered important for child development and other measures developed specifically for use in the present study. Infant behavior was rated on a 5-point scale for the amount of the following: 1. Activity-an index of the amount of movement of arms, legs, and body. 2. Responsivity-an index of change in behavior to a stimulus, measuring the magnitude of change not the direction. The measure includes verbal responses, limb movements, and postural change. 3. Affectivity-an index of the amount of facial expression the infant displays, including smiling, and the amount of vocalization the infant emits. Table V. Physical Growth and Development of Infants: Percent of Infants Below 50th Percentile for Weight and Length Age of infant

I 3 6 9 12

No. studied 135 134 101 68 52

Weight Percent below 50th percentile 74.0 56~ 46~ 55.9 61.6

Length No. Percent below studied 50th percentile 130 76.9 129 69.7 126 47.6 95 57.9 55 61.8

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Mothers' behavior was rated on a 5-point scale for the amount of the following: 1. Verbal interaction with the child-an index of the mother's talking to and communicating with the infant. Functional speech is differentiated from that designed to stimulate. 2. Physical interaction with the child-an index of the mother's touching and general contact with the child, again differentiating functional touching from that designed to stimulate. 3. Warmth-a subjective measure of the amount and intensity of mother's emotional affective reactions and of her responsiveness to child's general and specific needs. After an initial pilot study, the infants and mothers were evaluated. Interrater reliability for the measures utilized was 0.94. Mean ratings of mothers' and infants' behavior before and during the pediatric examination are shown in Table VI. These ratings were made on the defined dimensions, with a score of 1 indicating the lowest and a score of 5 the highest obtainable. Some interesting differences emerged from these ratings. As can be noted, the mothers appeared to exhibit a relatively high amount of warmth and physical interaction with their infants. At the same time, they exhibited relatively little verbal interaction with their infants, with the scores on this measure averaging 2.15. The infants similarly demonstrated variability in the behavioral measures studied. They scored relatively high on measures of activity. However, on the ratings of both affectivity and responsivity they scored considerably lower. Because of the modification of developmental situational tasks, it was felt that the measures could not be compared with those for middle-class norms. Further, differences between means on the dimensions were not tested because the scaling for variables may not be completely equivalent, since each measures different behaviors. Specific maternal and infant behaviors varied with the age of the child. Table Vl. Ratings of Mothers' and Infants' Behavior Before and During Pediatric Examination a Ratings

Mean

Mother Physical interaction Verbal interaction Warmth

3.23 2.15 3.52

Infant Activity Responsivity

3.31 2.83

Affeetivity

2.84

al = low; 5 = high.

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Older infants scored higher on measures of activity and responsivity than did younger infants. No such relationship was noted for affectivity. Mothers demonstrated more verbal and physical interaction toward the older infants than they did toward the younger infants. Maternal warmth did not appear to relate to infant age. Since the situations were quite different and might be expected to result in different behaviors, data were analyzed separately for the pre-examination and examination periods for mother-infant interactions. Contrary to some expectations, the data revealed no sex differences in either infant responses or mothers' behavior toward the infants. Correlational analyses showed that maternal and infant behaviors related to each other in both situations. The one exception was infant affectivity, which related to maternal warmth and verbal interaction but not to maternal physical interaction. DISCUSSION AND CONCLUSIONS The previous sections have presented a brief overview of available information concerning adolescent mothers and their infants. Some focus has been placed on data concerning the medical, educational, and social risk to the mother and the developmental risk to the infant. In addition, results of an intervention program for low-income pregnant adolescents have been presented, together with some specific data concerning infant outcome and the motherchild relationship. As has been noted, there has traditionally been a great deal of risk for both the adolescent mother and her infant. Medical prognoses for both have been relatively poor; maternal school achievement has been limited; roles in the community have been disappointing, with poor marital success, low productivity, and high community expense being frequently encountered. Among individuals pregnant out of wedlock, repeat unwanted pregnancy has been common, and infant developmental prognosis has been limited. The various professions involved have raised questions concerning the reasons for the risk and have frequently centered hypotheses on environmental background, psychological difficulties, motivational problems, and age-specific difficulties, to name but a few. Certainly some of the cited reasons may play a role in individual cases. What YMED and other programs like it demonstrate is that given a reasonable opportunity, individuals who are high risk and who are supposedly uninterested will respond. Most individuals will take advantage of the offered options. Medical complications, prematurity, and even perinatal mortality will be considerably reduced. In spite of a significant incidence of prior school problems, individuals will make considerable educational progress and will aim for further achievement. Where sex education and contraception are available, the incidence of unwanted repeat pregnancies will be strikingly reduced. Many

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low-income individuals will leave local welfare rolls. The developmental prognoses for the children of adolescent mothers may also be expected to improve as society offers them better provisions and more alternatives. The data from YMED, and their implications, are especially striking when one compares them to the figures which still exist for many areas of the United States. The improved prognosis which results from high-caliber, comprehensive programs should not lead one to the conclusion that residual problems will not remain. As can be seen from the data presented, many medical complications will continue to persist at a frequency which is relatively greater than that expected within a more medically favored population. Some may be related to the state of adolescence, with age-specific physiological and/or psychological complications. Others, especially in a low-income group, may be related to long-standing poverty and possibly to accompanying factors such as dietary inadequacy. Answers cannot be given at this time. However, there are at least clues which implicate poverty and resultant dietary inadequacy as playing a role. A nutritional study involving 125 girls at YMED has demonstrated considerable protein deficiencies among 50% of the girls and deficiencies of one or more essential vitamins among over 90%. These deficiencies were not infrequently the result of lack of finances for purchase of adequate foodstuffs. The physical growth and development curves for the infants also would appear to raise questions related to nutritional status. Infants who are below the 50th percentile at birth seem to catch up by the sixth month of age and then begin to fall behind again. Numerous explanations are possible, related to constitutional, nutritional and other environmental factors. It is at least interesting, however, to note that the catch-up occurs during the early months of life when the infants are primarily receiving formula and milk, both of which are readily available to the mothers. If poverty borderline malnutrition were to play a role, it might logically be expected to influence the infants both at the time of birth and then again when household solid foods are introduced during the second 6 months of life. Such hypothesis would be consistent with data indicating that over one-third of black children from low-income families have significant anemia at 6 months of age and that 84.8% of these children have hemoglobins below 10.5 at 12-17 months of age (Gutelius, 1969). To the extent that it exists, both scientific and humane considerations would appear to obligate us to correct the situation which results in economically poor individuals having inadequate foodstuffs for optimal maternal and infant health. A second area which appears worthy of special consideration relates to the availability, or lack of availability, of sex education, contraception, and abortion services. It is too often assumed that adolescents and especially low-income adolescents begin their pregnancies at young ages because of indifference within their cultural patterns. Far too little attention has been paid to the provision of adequate education and birth control services. Although the number of out-of-wedlock pregnancies has been increasing in the United States, recent years

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have witnessed a decline in illegitimacy rates among individuals age 20 and over. It is likely that some of this decrease is related to the better provision of family planning services to individuals within this age group. Early reports have demonstrated a considerable utilization of available contraceptive services by adolescents (Arnold and Cogswell, 1971; Gordon, 1971), and certainly the present data, as well as those reported by others, have shown a marked decline in the occurrence of repeat out-of-wedlock pregnancy among low-income teenagers provided with adequate educational and contraceptive services (Furstenberg, 1971; Sarrel, 1970; Wallace, 1971). Similarly, the present authors and others have found a ready utilization ot" abortion services by low-income patients, often related to their desire to gain financial stability and leave welfare rolls, obtain greater educational and job opportunities, and have the ability to better care for their offspring at home (Gordon, 1972; Osofsky et at, 1971; Osofsky and Osofsky, 1972; Swarm, 1971). Although the issues have been complex and have related to maternal age, background, and mobility, legislation allowing legal abortions in New York State resulted, during the first year of its implementation, in a decline of approximately 30% in new patients seen at YMED. This decline contrasted with annual increases in patients served during each of the preceding 4 years~ New York City data collected during the first 18 months under the liberalized legislation demonstrated a decline in out-of-wedlock deliveries, including for the first time a decline in adolescent out-of-wedlock deliveries. There are complexities in the national data related to liberalized abortion, however. For example, initial trends have suggested greater utilization by more socially mobile and, perhaps, lower-risk individuals. Those less likely to obtain an abortion my be most in need of comprehensive supportive services. At present, all that can be emphasized is that professionals serving pregnant adolescents should not forget that these individuals need to be provided with a full complement of available sensitive and comprehensive services including sex education, contraception, and abortion, as an option, where legally appropriate. Another area of importance, which has received relatively little attention, concerns the development of the infants and the parent-child relationship. As has been alluded to previously, many data have suggested a worsened prognosis for infants of young mothers for medical, psychological, and social reasons. Not only are the infants at higher risk medically, but the mothers have additional pressures which are not always present for other mothers due to age factors, socioeconomic status, and social considerations. Suggestions have arisen concerning the likelihood of maternal inadequacy. Yet very few data of a factuai nature are available concerning patterns of development and the relationship between young mothers and their children. Little recognition has been given to the possibility that there may be specific strengths, as well as weaknesses, related to the youthfulness and/or background of these mothers. The present data suggest that both may exist. The mothers rank high on measures of physical interaction

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and especailly high on measures of warmth; their verbal interaction with their infants, however, is relatively low. At the same time, the infants rank high on measures of activity but somewhat lower on measures of responsivity and affectivity. More information is needed, and services appear necessary which give cognizance to the strengths and assistance in the areas of difficulty. In conclusion, the present report has reviewed the data and has attempted to summarize some of the information concerning the increased medical, educational, and social risks which have accompanied adolescent pregnancies from the point of view of both the mothers and the infants. A description of, and results from, a comprehensive service program have been presented. Data have been offered concerning the growth and development of the infants and the behaviors and the relationships between the young mothers and their infants in an interaction situation. Obviously, definitive answers cannot be provided for many of the questions which can be raised at this time. It is possible, however, to state that a considerable proportion of the risk can be removed when appropriate professional services are made available. Both scientific and humane indications would suggest the relevance of increasing the availability of such programs and services. Further, it must be emphasized that the services alone will not solve all of the problems. Factors related to the state of adolescence, poverty, lack of opportunity, and lack of preventive services will still exist. These problems must be solved, further careful investigations must be performed in order to better understand many areas, and new and innovative services must be made available if a more major impact is to be made in solving the problems of the young mother and her infant. REFERENCES

Adams, H-, and Gallagher, V. (1963). Some facts and observations about illegitimacy. Children 10: 43-48. Arnold, C-, and Cogswell, B. (1971). A condom distribution for adolescents: The ffmdingsof a feasibility study.Am. s PubL Health 61: 739-750. Aznar, R., and Bennett, A. (1961). Pregnancy in the adolescent girl. Am. s Obstet. Gyneeop. 81: 934-940. Battagfia, F., Frazier, T., and Hellegers, A. (1963). Obstetric and pediatric complicationsof juvenile pregnancy.Pediatrics 32:902-910. Bernstein, R. (1963). Gaps in services to unmarried mothers. Children 10: 49-54. Bixeh, H., and Gussow, J. (1970). Disadvantaged Children: Health, Nutrition and School Failure, Harcourt, New York. Burchinal, L. (1960). School policies and school age marriages. Coordinator 8: 43-48. Chase, H. (1970). Trends in prematurity: United States, 1950-1967. Am. J. Publ Health 60: 1967-1978. Claman, A., and Bell, M. (1964). Pregnancy in the very young teen-ager. Am. s Obstet. Gyneeol. 90: 350-354. Drillien, C- (1959). A longitudinal study of the growth and development of prematurely and naturally born children. III. Mental development. Arch. Dis. Child. 34: 37-45. Drillien, C. (1964). The Growth and Development of thePrematurely Born Infant, Williams and Wilkins, Baltimore. Furstenberg, F. (1971). As cited in MCH Exchange 1(4): 5.

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Gordon, M. (1971). Personal communication. Gordon, S. (I 972). Personal communication. Gutelius, M. (1969). The problem of iron deficiency anemia in preschool Negro children. Am. J. Publ. Health 59: 290-295. Hassan, H., and Falls, F. (1964). The young primipara: A clinical study. Am. J. Obstet. Gynecop. 88: 256-269. Herzog, E., and Bernstein, R. (1964). Health Services for Unmarried Mothers, U.S. Children's Bureau, Washington, D.C. Kelley, J. (1963).The school and unmarried mothers. Children 10: 60-64. Knobloch, H., and Pasamanick, B. (1962). Medical progress "mental subnormality." New Engl. J. Med. 2663: 1092-1097. Knobloch, H., and Pasamanick, B. (1966). Prospective studies on the epidemiology of reproductive casualty: Methods, findings, and some implications. Merrill-Palmer Quart. Behav. Develop. 12: 17-43. Kovar, M. (1970). Interval from first marriage to first birth: United States 1964-66 births. Unpublished paper for Population Association of America. Krantz, K. (1965). Ross Round Table on Maternal and Child Nursing, Ross Laboratories, Columbus, Ohio. Landis, J. T. (1964). Statement for the Asilomar Conference on the Teenage Parent. Sponsored by the Governor's Advisory Committee on Children and Youth, April 1964. Menken, J. (1972). The health and social consequences of teenage childbearing. Perspectives 4: 45-53. Mus~o, T. J. (1962). Primigravidas under age 14. Am. J. Obstet. Gynecop. 84: 442-444. NCHS (1971). Infant Mortality Rates by legitimacy status: United States, 1964-1966. Monthly Vital Stat. Rep. 20: 5. Osofsky, H. (1968a). The Pregnant Teen-ager: A Medical. Educational and Social Analysis, Charles C Thomas, Springfield, IU. Osofsky, H. (1968b). On attempting to reach the "unreachable" individual: A progress report of a program for pregnant schoolgirls. Obstet. Gynecol. 32: 869-881. Osofsky, H., and Kendall, N. (1972). Poverty as a criterion of risk. Clin. Obstet. Gynecol. (in press). Osofsky, H., and Osofsky, J. (1970). Adolescents as mothers: Results of a program for low-income pregnant teen-agers with some emphasis upon infants' development. Am. J. Orthopsychiat. 40: 825-834. Osofsky, J., and Osofsky, H. (1972). The psychological reaction of patients to legalized abortion. Am. J. Orthospsychiat. 42: 48-60. Osofsky, H., Braen, B., DiFlorio, R., Hagen, J., and Wood, P. (1968b). A program for pregnant schoolgirls-A progress report. Adolescence 3: 89-108. Osofsky, H., Rizk, P., Fox, M., and Mondanaro, J. (1970). Nutritional status of low income pregnant teenagers. Z Reprod. Med. 5: 29-33. Osofsky, J., Osofsky, H., Rajan, R., and Fox, M. (1971). Psychologic effects of legal abortion. Clin. Obstet. Gynecol. 14(1): 215-234. Pakter, J., Rosner, H., Jacobziner, H., and Greenstein, F. (1961a). Out-of-wedlock births in New York City. I. Sociologic aspects. Am. J. Publ Health 51: 683-696. Pakter, J., Rosner, H., Jacobziner, H., and Greenstein, F. (1961b). Out-of-wedlock births in New York City. II. Medical aspects. Am. J. Publ. Health 51: 846-865. Pakter, J. (1972). Personal communication. Pasamanick, B. (1959). Research on the influence of sociocultural variables upon organic factors in mental retardation.Am. J. Ment. Defic. 64: 316-322. Pasamanick, B., and Knobloch, H. (1966). Retrospective studies on the epidemiology of reproductive casualty: Old and New. Merrill-Palmer Quart. Behav. Develop. 12: 7-26. Polliakoff, S. (1958). Pregnancy in the young primigravida. Am. J. Obstet. Gynecop. 76: 746-753. Rankin, R. R. (1964). Statement for the Asilomar Conference on the Teenage Parent. Sponsored by the Governor's Committee on Children and Youth, April 1964.

Adolescents as Mothers: An Interdisciplinary Approach to a Complex Problem

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Rashbaum, W., Rehr, H., Paneth, J., and Greenberg, M. (1963). Use of social services by unmarried mothers. Children 10:11-16. Sarrel, P. (1970). Personal communication. Sarrel, P., and Davis, C. (1966). The young unwed primipara: A study of 100 cases with 5 year follow-up.Am, J. Obstet. Gynecol. 95: 722-725. Semmens, J. (1965). Implications in teen-age pregnancy. Obstet. Gynecol. 26: 77-84. Stine, O., Rider, R., and Sweeney, E. (1964). School leaving due to pregnancy in an urban adolescent population.Am. Z PubL Health 54: 1-6. Swartz, D. (1971). Personal communication. Teele, J., Robinson, D., Schmidt, W., and Rice, E. (1967). Factors related to social work services for mothers of babies born out of wedlock. Am. J. PubL Health 57: 1300-1307. Vincent, C. (1961). Unmarried Mothers, Free Press, New York. Wallace, H. (1971). As cited in MCH Exchange 1(4): 4. Welfare Law Bull (1968). 1 I: 10-11. Zackler, J., Andelman, S., and Bauer, F. (1969). The young adolescent as an obstetric risk. Am. J. Obstet. Gynecol. 103: 305-312.