EVALUATION OF A SCHOOL FOR YOUNG MOTHERS

(1)

(Received December 18, 1969; revision accepted for publication April 18, 1970.)

ADDRESS: (O.C.S.) Community Pediatric Center, 412 \V. Redwood Street, Baltimore, Maryland 21201.

PEDIATRICS, Vol. 46, No. 4, October 1970

581

EVALUATION

OF A

SCHOOL

FOR

YOUNG

MOTHERS

The Frequency

of Prematurity

Among

Infants

Born to Mothers

Under

17 Years of Age,

According

to the Mother’s

Attendance

of a Special

School

During Pregnancy

Oscar C. Stine, M.D., Dr. P.H., and Elizabeth B. KeIley, Sc.M.

From the Community Pediatric Center, University of Maryland, Baltimore

ABSTRACT. Registration with a social agency’, re-quired attendance of prenatal care, a school lunch, supplemental milk, counseling, nutritional educa-tion, health education, group discussion, and

self-government are elements of a public school

pro-gram for teen-age mothers.

To study the health impact of this program, we located the birth certificates of children born to

mothers who were 16 years of age and under and

who attended the program. We matched these

cer-tificates with certificates of children of the same race and sex born to mothers of the same age liv-ing in similar socioeconomic census tracts who did not attend the school but who gave birth during the same period of time.

This gave us a study and control group totaling 448 births to mothers 14, 15, and 16 years old. We defined low birth weight as under 2,501 gm and

found 23.7% of the control group and 1 1.6 of the study group to be low birth weight infants. We defined gestation periods less than 37 weeks as

pre-mature and found 34.4% of the control group and

21.4% of the study group to be born prematurel’. Both of these differences were statistically’ signifi-cant at the level of p smaller than .01. The slightly diminished frequency of prenatal care in the control group was not significantly associated with the dif-ferences in birth weight or gestational age. One in-fant died in the study group and eight infants died in the control group.

The differences between the study group and the control group were most pronounced among the 14-year-old mothers.

Pediatrics, 46:581, 1970, ADOLESCENT

PREG-NANCY, PREVENTIVE HEALTH SERVICES,

PREMATUR-ITY, SPECIAL EDUCAtIONAL PROGRAMS.

P

REVIOUSLY an excess fruquency of

pre-mature births to mothers 16 years of

age and younger was reported. This was

ac-companied by an increased infant mortality

rate which was particularly high when the

mothers did not receive prenatal care.1

Sub-sequently, it was possible to evaluate the

effect of a program established in 1966 by

the Baltimore City Public Schools for

school aged mothers upon the health of

these mothers by studying their infants. The school for teen-age mothers required

each to register with a social agency and to either attend a clinic or engage a physician

for prenatal care. The school provided counseling sessions and student activities designed to permit ventilation of worries or fears and to promote awareness of

individ-ual responsibility. The home economics

courses demonstrated the selection and

preparation of foods to increase the health

of the pupils and their children. Milk was

distributed three times each day. Hot

lunches were served after the second year of operation. The school nurse gave nursing advice or referred the pupils to specific sources of care. Each of these activities was

expected to contribute to the health of the

mother and her infant.

The purpose of this paper is to describe th differences in morbidity and mortality in infants born to mothers attending the

special school with infants born to a control

group. Comparisons will be made l)etwcen

infants of the same sex born within the

same year of mothers who are the same age,

race, and economic level of neighborhood.

The dependent variables are limited to those reported on birth certificates and

(2)

TABLE I

LivE BIRThS ACCORDING TO BIRTH W’EIGIIT AND

MEMBERSHIP IN STUDY GROUP AND C0NTu0L GROUP

t=3.32 .OO1<p<.Ol 582

Birth Weight Study Control Grand

(gm) Group Group Total

1,000 or less 1,001-1 500

1 ,501-,000 2,O01- 500

,501-3 ,000 3,001-3,500 3,501-4,000 4,001-4,500

4,501 and over Total ,500 gni or less

(1 /0

,500 gin or less

- 3 3

-, t 4

.5 9 14

19 39 5s

8 64 146

90 81 171

25 t3 48

1 3 4

‘224 224 448

26 53 79

11.6 23.7 17.7

from the biological and pathological

pro-cesses, these variables are objective and

their importance has been established.

METHOD

We obtained maiden name, married

name, birth date, recent addresses, ex-pected date of confinement, and source of

medical care information from the records of the Edgar Allen Poe School

(

hereinafter called the school for mothers

)

for all girls

attending the school between September

1967 and December 1968. \Ve then searched the files of the Division of Vital

Rec-ords where births are listed by mother’s

name and the date of the birth. We used

mother’s birth date, address, and source of

care to confirm the correspondence be-tween the school registration of the mothers with birth registration of the child. This search revealed 259 birth certificates of children born to the mothers who attended this school.

We attempted to match these 259 infants

with 259 infants born during this same

pe-nod to mothers who did not attend the school for mothers. The variables selected for matching were race and age of mother,

sex and birth order of infant, hospital of birth, and census tract of mother’s resi-dence. These requirements had to be

re-laxed when hospital of birth and census tract

of mother’s residence were too restrictive. We did match 224 pairs requiring that the

census tracts of the mother’s residences

were economically similar and in the same

area of the city. We disregarded hospital of delivery. This left 35 births to school

moth-ens which were not matched. Of these,

there were four mothers who were 12 years old and seven who were 13 years old.

(

Six of these youngest mothers delivered before the thirty-seventh week of pregnancy. The

length of pregnancy was unknown for one

mother. Two of these 11 had low birth

weight infants

).

Since these could not be matched, they were all eliminated from the

study. Four mothers were eliminated when

the ages on the infants’ birth certificates ex-ceeded the age limits of the study. Two

oth-ers gave birth to twins and were eliminated. The remaining 18 unmatched births were to mothers 14 and 15 years of age for which

no match on sex of infant could be

ob-tamed; school mothers apparently had more

boys than were available in the remaining pool.

The matched 224 births represented 69 births to mothers 14 years of age, 129 to

mothers 15 years of age, and 26 to mothers

16 years old. The two groups were

com-pared with relation to birth weight, length of gestation, trimester of first prenatal care, and infant mortality.

Birth Weight

RESULTS

Table I shows the number of live births according to age of mother and birth weight for the study and control groups and the proportion

( %)

of infants weigh-ing less than 2,501 gm at birth for each

group. The difference in the number of

light weight (less than 2,501 gm

)

infants in the two groups is quite striking with 53 in

the control group compared to 26 in the

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TABLE IL

LIvE BIRTuS TO 14-YEAR-OLD AND 15-YEAR-OLD

MOTHERS ACCORDING TO BIRTh WEIGhT, AGE

OF MOTHER, AND STUDY GROUP MEMBERShIP

Study Group Control Group

__________ __________- Total Birth SS’eight in Grams .4geof .1!other

14 15 14

-- I 000 or less

--

-

3 3

ratios of 23.7% for the control group and

11.6% for the study group is statistically significant, p < .01. Not only is there a large difference in the proportion of light-weight

infants for the total of the two groups, but

within each single year age group, the

pro-portion in the study group is much lower than in the control group. The difference is

statistically significant for the 14-year-old group as shown in Table II.

Length of Gestation

Table III shows the number and percent distribution of the two groups according to birth weight and length of gestation. When the length of gestation was compared in

both groups, the study group again shows a more favorable outcome than that of the control group. In the school group, 21.4% were reported to have had gestation pen-ods of less than 37 weeks as compared to 34.4% in the control group. When the

mothers with unreported periods of

gesta-tion are removed from the denominator, the proportion with gestation periods of less than 37 weeks became 22.0% for the study group and 34.7% for the control group. This difference is statistically significant

p < .01.

Considering both birth weight and length of gestation together, the proportion with the most favorable pregnancy outcome, namely a birth weight 72,500 gm and a ges-tation of at least 37 weeks, was

approximate-ly 71% for the study group compared to 54%

for the control group.

Infants with low birth weights, but born after 37 weeks of gestation, were also of

special interest. Among this group may be infants whose growth has been retarded by inadequate nutrition or inadequate function of the placenta. The percent of the low birth weight for gestation infants was 5.4% for the study group and 10.7% for the con-rol group.

Prenatal Care

Table IV shows the number and percent

distribution of the two groups with regard

1,001-1,500 - I 1 4

I,5O1-,000 1 4 4 4 UI

.OOI-,5O0 6 ii 14 19 .50

.5O1-3,O00 3 4H 16 40 I9

8,001-3,50() 81 47 26 47 1.51 3,501-4,000 5 17 7 13 4

4,001-4.500 1 - I 4

4.501 aiol over -

--

-

-Total 69 I9 69 129 396

2,500 grams or less 7 17 19 27 70

#{182} 10.1 13.1 27.5 20.9 17.6

to the trimester of first prenatal care as re-ported on the birth certificates. More than 44% of the mothers who attended the school began prenatal care during the first trimester of pregnancy while less than 29%

of the control group began similar care. No prenatal care was reported for two of the

study group mothers and 12 of the control group mothers, and there were two mothers in each group for whom the extent of

pre-natal care was unkown.

Table V shows no remarkable differences in birth weights when infants are grouped

by trimester of first prenatal care. The more favorable outcome of infants born to moth-ens who attended the school for mothers is

seen regardless of the time of initiation of prenatal care. The differences between the groups in proportion of mothers receiving early prenatal cane, recorded in Table IV,

do not explain the differences in prematur-ity rates.

Infant Mortality

Although total infant mortality cannot be determined until all infants born in 1968 have reached 1 year of age, we counted those deaths that have already occurred. This count included all neonatal mortality.

There were no neonatal deaths among

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584

deaths in the control group. All six of these control group deaths occurred among

in-fants who weighed less than 2,501 gm at

birth and who had a gestation period of less

than 37 weeks. In all six instances the

mother was reported to have started prena-tal care during the first

(

two

)

or second

(

four

)

trimester of pregnancy.

There was one death reported at 3 months of age in the study group. The

cause of this death was coded as

pneumo-nia, unspecified. This infant weighed 3,000 to 3,500 gm at birth and had a reportcd

ges-tation of 41 weeks. In the control group

there were two additional deaths, each at 1 month of age. One of these infants had

weighed less than 1,001 gni at birth with a

gestation period of only 31 weeks. The

other infant had a birth weight of 2,501 to 3,000 gm and a 40-week gestation period,

hut he then .!icd from unspecified brain

disease.

Thus, at the time of matching, there had

l)een one infant death in the study group

collipared to eight infant deaths in the

con-trol group.

DISCUSSION

The Context of Our Inquiry

One of the biological problems of preg-nancy of a girl below 17 years of age is the problem of the growth of the fetus in a mother who is still growing; a condition of

competition for any nutrient essential for

growth which may not be adequately

sup-1)lie(l in the diet. We had the fol!owing im-that led us to carry out this study:

(

1

)

adolescent mothers with teen-age eat-ing habits, from low income families, and in

stressful urban neighborhoods will be less

able to support the growth of a fetus;

(

2

)

a special school program will partially correct some of the social stresses and the limited or distorted dietary patterns; and (3) the greatest effect will be demonstrated in the group of mothers with the largest

propor-tion of members who are still growing.

Lack of support for the growth of fetuses may be expressed by birth of infants before the thirty-seventh week of pregnancy, new-born infants that are small for the

gesta-tional dates, and that are more susceptible to injury, illness, and death.

Selection Factors

To interpret these findings, it is necessary to recognize multiple potential factors that

operated in selecting the school mothers as

well as yielding larger babies. The young mother who elects to attend the school may be more mature socially and physically. She may be more purposeful and less

fright-ened. She may be more capable of meeting

lien own needs and may he more

comfort-able than her age mate who could not

accept or complete a referral from her previ-ous school. Her family may be more accept-ing of the pregnancy and more supportive of the goals of the school. These develop-mental, attitudinal, emotional, and social

factors require further study.

To the extent that favorable selection

fac-tors are operating, we must use

absence-from-the school as an indicator of the

in-creased risks of the infant born to the

young mother who does not select herself

for the program. If the mother who is not

attending is less mature, more poorly

nour-ished, more frightened, more disorganized,

and more ostracized, she needs even more

help than those who do attend. This calls

for imaginative methods of assistance from

health services if the rate of 23.7% low birth weight infants found in the control group of this study is to be rcduccd in similar high risk groups.

School Factors

The school program constitutes another

series of potential causes of the observed differences. It provides improved nutrition through the school lunch, the extra milk in-take, and classroom instruction concerning diet. It reinforces use of medical and social

services. It gives much emotional support. It discourages cigarette smoking, at least during classroom time. It reduces tensions produced by conflicting social values by

em-ployment of discussion methods in many

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TABLE III

LIVE BhitTus ACCORDING TO BIRTH WEIGHT AND LENGTh OF GESTATION

STUDY AND CONTROL GROUPS

Study Group Control Group

Length of Birth Weight

(,‘estalion - ---.-.---

-

- -

---

-.----Under 2,501 gui Total Under 2,50 7 gin

,,501 gin and over 2 ,501 gin (111(1Oh’C

Nitii;ber

29

Total

145

48

121 6

224 53

0.4 11.6

2.2

88.4

21 .4

75.9 2.7

100.0 Under 37 wk

37 wk and over Unknown

Total

13 35 48

12 158 170

1 5

26 198

2 2

171 224

Percent Di.stribution*

Under 37 wk

37 wk and over Unknown

Total

5.8 15.6

5.4 70.5

12.9 21.4

10.7 54.0

-. 0.9

23.7 76.3

‘34.4 64.7

0.9 lOU .0

* Individual percentages may not add to row and column totals beCause of rounding.

sensible about responsibilities. It

encour-ages regular hours for activity, eating, and

sleeping through its own schedule and by supporting those attitudes. Many of these processes may interact with each other to

produce a more confident, goal-seeking mother in contrast to a frightened, dison-ganized adolescent whose pregnancy

ag-gravates all of her problems.

Adequate nutrition may be a crucial van-able in this experience. Ebbs2 documented a significant reduction in low birth weight infants for a group of mothers with low family incomes when the study group ceived milk and cheese supplements. Burke3

showed a direct correlation between birth weight of infant and protein intake of the mother in another low income population. Tompkins4 gave protein supplements to a group of mothers attending a prenatal clinic and demonstrated a significant neduc-tion in the frequency of low birth weight infants among the recipients in contrast to

the controls. This was especially true for underweight Negro mothers. These effects were all obtained in populations who were recognizable as having suboptimal

nutri-tion. Teen-agers from low income

popula-tions are likely to have deficient intake. By

offering hot lunches and milk supplements,

and by educating for improved food

selec-tion the school has made itself a means for the young mother’s attainment of more ade-quate nutrition.

Biological Age as a Factor

Although fewer in number, the 14-year-old mothers rather than the 15-year-old mothers demonstrated a statistically

signifi-cant difference between study groups and

control groups. This supports our interest in the biologic problem of a fetus competing for essential nutrients when the mother is still growing. This is also supported by an-other study in our department showing that, when birth occurs within 18 months of menanche, the frequency of low birth weight babies was double that of a group of mothers matched for the same chrono-logical age but who gave birth more than 18 months after menarche.6

Implications for Further Study

The continued presence in the

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* Inilividual percentages may

100.0 because of rounding.

not add to exactly

Study Group

Trimester 2.500 Ierrent

Total gm or 2,.00 pm IC,,., OT Less

p ,.500 Percent Total pm or 2,500 pm

Less or Less

None

tiiknown ‘I’otal

100 13

104 11

16 1

I 1

114 16

13.0 63 14 11.1

10.6 118 31 16.3

6.3 19 7 24.1

- 11 I 8.3

I

-11.6 214 53 23.7

TABLE IV

NUMBER AND PERCENT DISTRIBUTION OF LIVE BIRTHS

ACCORDING TO TRIMESTER OF FIII.ST PRENATAL CARE Stiuly Group Control (;rouji

7rimester ----

--

-

--- - --

-

---

-.

\‘umber Percent* Xuinber Pe,.eent*

1 100 44.6 63 28.1

2 104 46.4 118 52.7

3 16 7.1 29 12.9

None 2 0.9 12 5.4

LIlknOwIs 2 0.9 2 0.9

Total 224 100.0 224 100.0

TABLE V

NUMBER AND PERCENT OF LIVE BIRThS WITII BIRTII

\\EIGI1T OF 2,500 GM OR LESS ACCORDING TO

TRIMESTER OF FI1Isr PRENATAL CARE

bly be of even greater value if future stud-ies use post-menarchal age as well as chron-ological age to identify the mothers with greatest risk of low birth weight infant and in greatest need of services.

SUMMARY

Comparison of 224 births to mothers who

had attended a special school for teen-age mothers with 224 other Baltimore City births matched on age and race of mother and sex and birth order of infant showed a

statistically significant smaller proportion of infants weighing less than 2,501 gm at birth among the mothers of the special school. In

addition, a statistically significant smaller proportion had gestation periods of less

than 37 weeks. These differences could not be explained by an initiation of prenatal

care earlier in pregnancy among the

moth-ens attending the school, although a larger

Control Group proportion of these mothers had started

prenatal care during the first trimester of

pregnancy than of the other mothers. Infant

niortaHty was also much lower among the

infants of school age mothers, with one

death occurring in this group compared to eight in the control group. All but one of the eight deaths in the control group were

among infants weighing less than 2,501 gm

at birth.

school, suggests that intensive efforts to pro-vide optimal social assistance should be in-stituted at once. Can an intensive nutrition program or an intensive home counseling service show similar reductions in the fre-quency of low birth weight infants? If lim-ited resources can finance the correction of

only one problem, it becomes desirable to

rank variables according to their contribu-tion to the observed differences. An appro-priate research design may elucidate the in-teraction between variables inferred above.

We have suggested that any, or all, of the variables mentioned above may have an

ex-aggerated effect upon the mother who has

not yet completed her own adolescent spurt

of growth. The variables of age will

proba-REFERENCES

1. Stine, 0. C., Rider, R. V., and Sweeney, E.:

School leaving due to pregnancy in an ur-ban adolescent population. Amer. J. Public Health, 54:1, 1964.

2. Ebbs, J. H., Tisdall, E. F., and Scott, W. A.: The influence of prenatal diet on the mother and the child.J. Nutrn. 22:515, 1941.

3. Burke, B. S., Harding, V. V., and Stuart, H. C.: Nutrition studies during pregnancy. J. Pediat.,

23:506, 1943.

4. Tompkins, W. T., Mitchell, R. McN., and

Wiehl, D. : The Promotion of Maternal and

Newborn Health. New York: Milbank

Memo-rial Fund, 1955.

5. Wharton, M. A. : Nutritive intake of adolescents. Amer. Dietetic Ass. J. 42:306, 1963. 6. Erkan, K. A., and Rimer, B. A. : Prematurity

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ARTICLES 587

Acknowledgment

We gratefully acknowledge the help of and wish to thank Mrs. Vivian Washington, Principal of the Edgar Allen Poe School; Dr. Orlando F. Furno,

Assistant Commissioner of Education of Baltimore City Public Schools; and Mr. Sidney Norton, Di-rector of the Bureau of Vital Records, Baltimore City Health Department, who made this study pos-sible.

SIR WILLIAM WRITES ABOUT MASSIVE ABDOMINAL TUMORS IN CHILDREN

Osler delivered a number of lectures on how to diagnose abdominal tumors to a postgradu-ate class at the Johns Hopkins Hospital in 1893. The comments to this class about abdom-inal tumors in childhood, cited below, give an idea of Osler’s lecture style.

In children, massive tumors of the abdomen are not uncommon, and, as a rule, are either sarcomata of the kidney or of the retro-peritoneal glands. The

kidney tumors are the most frequent. Both

ulti-mately produce large, solid growths, which may occupy the greater portion of the abdominal cavity. In the differentiation of these two forms we rarely have any difficulty. Both develop painlessly, and the child may make no complaint whatever; the general health may not be seriously affected, even when the mass has attained a considerable size. Death, indeed, may occur, as in a remarkable case which I have reported of embolism of the heart (the transference of sarcomatous thrombi from the renal vein ) ,before there were any symptoms to at-tract attention. Progressive emaciation, with en-largement of the abdomen, usually painless . . . are

the prominent characters, which are common, how-ever, to both the renal and the retro-peritoneal growth. The two important points of differentiation are, first, the retro-peritoneal growth is more cen-tral in its origin, and, if seen early, it is found to occupy the umbilical region, not extending to the flanks; whereas, in the renal tumor, as in the case

before us, the growth is lateral, and fills the entire flank, extending deeply behind.

The kidney tumor is, as a rule, associated with changes in the condition of the urine. Blood is present, either as free haematuria, or the constant presence of a small number of red blood-corpus-des. There may be large clots, the passage of which causes great pain. In some cases molds in blood of the pelvis of the kidney and of the ureters are passed, though this is not so common in chil-dren as in adults. Other conditions which have to be differentiated are ovarian tumors, pyonephrosis, and cysts, but in cases of doubt the exploratory op-eration should be strongly urged.’

EDITORIAL NOTE: We now know that Wilms’ tumors (Osler’s sarcoma of the kidney) are

in-frequently associated with hematuria. Could

Osler have been in error? The contemporary reader will assume that the tumors of the retro-peritoneal glands, as mentioned by Osler, were ili fact neuroblastomas. (The word “neuroblas-toma” was first used in 1910.)

NOTED By T. E. C., JR., M.D.

REFERENCE

1. Osler, W. : Lectures on the Diagnosis of

Abdom-inal Tumors. New York: D. Appleton and

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1970;46;581

Pediatrics

Oscar C. Stine, P. H. and Elizabeth B. Kelley

Mother's Attendance of a Special School During Pregnancy

the

Prematurity Among Infants Born to Mothers Under 17 Years of Age, According to