National Women`s Hospital

An evidence based approach to teenage pregnancy and early childhood development – The Triad of Care Professor Julie Quinlivan

The Quinlivan ‘Triad of Care’: 1. Teenage specific antenatal clinics. 2. Home visitation by nurses starting in pregnancy and continuing until 2 years postpartum. 3. Free childcare or peri-preschool which is co-timed educational opportunities for teenage parents.

The argument: Is teenage pregnancy really associated with adverse outcomes? • Many studies comparing outcomes of teenage versus nonteenage childbearing • Multiple adverse outcomes reported • BUT • Were these fair comparisons?

Can you compare middle class, married women with solid financial and housing support ......

......to teenage mothers and attribute differences to maternal age alone?

Socio-economic differences account for differing outcomes – not race and not age.

More informative studies • Control for heterogeneity by comparing economic outcomes of sisters or of teenagers who miscarry to those who do not.

Sister’ study • Family background heterogeneity controlled by using ‘within family’ estimations.

• This study compared the differences between sisters who experienced their first pregnancy at different ages, with one having their first birth as a teenager » Geronimus et al, 1992

• 3 large data sets: – National Longitudinal Survey Young Women’s Sample – Panel Study of Income Dynamics – National Longitudinal Survey Youth Sample

• Found – “the long term socio-economic differences were minimal’ » Geronimus et al, 1992

• The authors concluded that – ‘within-family estimates suggest that the standard cross-sectional approaches to studying the effects of teen childbearing on future economic well-being overstate the costs of teen childbearing. These estimates also suggest that policy makers may be overly optimistic about the ability of programs that (solely) encourage delayed childbearing to improve the socioeconomic status of poor women and their children” » Geronimus et al, 1992

Another study • National Longitudinal Survey Young Women’s Sample • “Differences in maternal age and – – – – –

low birthweight, prenatal care, smoking and alcohol use in pregnancy, breastfeeding and well-child visits

• Were explained by differences in family background, NOT maternal age. • Teenage birth may add little to already negative social circumstances. » Geronimus et al, 1993

But aren’t Teenage mothers are expensive to society? • USA study comparing teen mothers to those who would have been teen mothers but miscarried • Results “ The total expenditures on public assistance would increase slightly’ “Moreover, the lifetime earnings of teen mothers would decrease slightly if they delayed childbearing, and hence, so would their contribution to the tax base.’ Hotz et al, 1996

The economic analysis concluded… • “the net (of taxes) annual outlays by government for cash-assistance and in-kind transfers to these women would actually increase by 35% or $4 billion. This increase in net expenditure associated with delayed childbearing would amount to over $1200 per teen mother.” – Hotz et al, 1996

Most of the adverse outcomes for teen motherhood relate to socioeconomic environment. These are poor unsupported women.

So how can we help teen mothers who have to overcome harsh socio-economic realities?

THREE areas need attention

The three major barriers prevent teenage mothers from breaking the poverty cycle: • 1. Preterm birth and poor obstetric outcomes • 2. Lack of support in the form of housing, safety and practical skills to manage a household and new baby. • 3. Educational limitations limiting re-entry to the workforce

1. Preterm birth and adverse obstetric barriers • Preterm birth is the leading cause of mortality and morbidity in modern obstetric practice. • Teenage pregnancy, particularly involving mothers less than 18 years of age, is an independent risk factor for preterm birth in developed and developing nations.

Evidence based solution 1: Implement teenage antenatal clinics where there are 70 or more teenagers delivering each year. The evidence for this…….

Large Australian cohort study • Study Aim: – To determine whether teenage-specific antenatal clinics that have comprehensive screening policies for infection and psychosocial pathology are able to reduce the incidence of preterm birth. – Quinlivan et al, BJOG, 2005

Teenage clinic care • Care provided by a multi-disciplinary team. • Staff had guidelines for the management of teenage pregnancy that included: – Screening for genital tract infection, anaemia and infections – Social work appraisals and housing assessments – Management plans for illegal drug use – An open hospital admission policy – Direct linkage to Centrelink.

Findings…. • Teenage antenatal clinics were associated with – Improved rates of infection and social support screening – When screening was performed, underlying rates of positive findings were similar – This suggests that problems are being missed in teenagers delivering in general clinics

More important findings…. • Teenage antenatal clinics were associated with – Reductions in threatened preterm labour, preterm premature prelabour rupture of the membranes and actual preterm birth

Cost of teenage clinic Unpublished data from cohort study

No teenage clinic (N=70)

Teenage clinic (N=70)

Cost of preterm birth

$122,000

$72,000

Cost of clinic

$0

$51,000

Total

$122,000

$123,000

Teenage specific antenatal clinics improve outcomes for teenage mothers and their infants. They are also cost effective where more than 70 teenage mothers deliver.

2. Lack of Support • Teenage mothers face a lack of support that they do not anticipate whilst pregnant. • The lack of support concerns practical parenting and life skills tasks as well and health issues. • This results in stress in pregnancy and as a new mother. • Teenage parents will accept advice and help from non judgemental and informed staff. » Quinlivan et al, J Ped Adol Gynecol 2004

Evidence based solution 2: Implement nurse home visitation commencing in pregnancy and continuing until 2 years of age The evidence for this is…

Home visitation • Meta-analyses and surveys of over 3,000 studies show that nurse home visitation consistently provide the most positive outcomes for vulnerable mothers children both in the short term and sustained over time. – Karoly LA, Greenwood PW et al. Investing in our children.: RAND Corporation, Santa Monica, CA, 1998

David Old’s nurse home visitor model • 2 large RCTs (rural New York/Memphis, Tenn). • Short term data: Children have fewer health encounters, injuries or ingestions, hospitalisations, injuries, incidences of child abuse or neglect. • 15 year follow-up data: Adolescents less likely to run away, be arrested, convicted, violate parole, fewer sex partners, less smoking, alcohol, less behavioural problems. • Kitzman H et al, JAMA 1997; Olds D et al, JAMA 1997; Olds D et al, JAMA 1998;Kitzman H et al, JAMA 2000

Australian RCT: Nurses • Reduce predefined adverse outcomes: • Neonatal death • Nonaccidental injury • Nonvoluntary relinquishment

• Improve knowledge of: • Contraception • Breast feeding • Infant vaccination » Quinlivan et al, Lancet, 2003

Anticipated Savings/100 Mothers and Infants - Birth to 6 Months Cost (A$)

$98,071

350000 300000 250000 200000 150000 100000 50000 0

Net saving Service cost Base cost

Control

Home visits

Nurse home visitation is an effective intervention to increase social support and prevent child abuse & neglect and improves many outcomes for children and mothers. It is cost effective.

3. Educational barriers • Disengagement with schooling frequently precedes teenage pregnancy • Poor self esteem and poor prior achievement levels mean teenage parents need encouragement to return to education or workforce. • If they can be motivated to return to education and training then access to childcare is the key barrier. » Quinlivan, Sexual Health, 2004; Kisker et al, 1998

3. Educational barriers • There has been little investment on providing time and opportunities where teenage mothers can re-engage in schooling • This revolves around childcare. • However programs exist that can provide teenage mothers with time to enable them to return to school and can simultaneously assist in the transition of her own child into primary school eg: peri-preschool.

Evidence based solution 3: Provide childcare for infants and educational programs for teenage parents that schedule within childcare hours. The evidence for this…….

Systematic review Parenting programs work when participation is adequate. • Findings of a systematic review, based upon 14 studies involving teenage mothers, found that parenting programs can be effective in improving a range of psychosocial and developmental outcomes for teenage mothers and their children. Coren E et al, J Adol 2003.

Why programs work: The New Hope Program Example • New Hope Program developed by local, State and national organisations • Implemented in two neighbourhoods in USA • Intervention: Received – supplemented income to above poverty level, – provided child care and peri-preschool subsidies and – mothers received assistance to receive employment training and subsequent employment. Zaslow et al. 1999

New Hope Program Example • Assessment 2 years later • Findings: – found increases in employment and earnings in intervention groups and – positive effects on teacher-rated social competence, behaviour problems and school performance of their children. Zaslow et al. 1999

Why programs don’t work: The Teenage Parent Demonstration Program • US Dept of Health & Human Services program rolled out into 4 USA States to teenage mothers. • 2 year randomised program offered job search training and education, workshops on life skills and parenting, case management, transportation and assistance to find a childcare spot but no funding support. • Follow up 3 to 4 years later found no benefits or harms from the program. Kisker et al, 1998

The Teenage Parent Demonstration Program • Only 30% to 50% of participants in TPD participated in any school, work or job training in any given month of follow-up. • A reported lack of childcare was cited by over half of the inactive participants as their primary barrier to involvement. Kisker et al, 1998

Solution: Provide free childcare or peri-preschool for infants and educational programs for teenage parents that schedule within childcare or peri-preschool hours.

Government scorecard for the Teenage ‘Triad of Care’. Item

Current status

Scorecard

Teenage-specific antenatal clinics at all sites where there are at least 70 births

Five teenage specific clinics in Australia founded on historical grounds. No systematic evaluation of sites that should have service provided.

D

Home visitation

Australian Nurse Family Partnership Program being rolled out. Needs high level of monitoring to ensure program integrity is maintained and that roll outs continue according to plan

B

Free childcare/peripreschool and co-timed education interventions for parents

No plans for this at present

E

Mean score

D+

How does the NZ Government score?