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Medical Anthropology: Cross-Cultural Studies in Health and Illness Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gmea20
Mother's age, birth order and health status in a British national sample a
Bernice A. Kaplan & C. G. N. Mascie‐Taylor
b c
a
Bernice A. Kaplan is a Professor in the Department of Anthropology , Wayne State University , Detroit, MI, 48202 b
Lecturer and the Head of the Department of Biological Anthropology , University of Cambridge , Cambridge, CB2 3D2, U.K. c
Fellow of Churchill College Published online: 12 May 2010.
To cite this article: Bernice A. Kaplan & C. G. N. Mascie‐Taylor (1992) Mother's age, birth order and health status in a British national sample, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 13:4, 353-367, DOI: 10.1080/01459740.1992.9966057 To link to this article: http://dx.doi.org/10.1080/01459740.1992.9966057
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
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Medical Anthropology, Vol. 13, pp. 353-367 Reprints available directly from the publisher Photocopying permitted by license only
©1992 Gordon and Breach Science Publishers S.A. Printed in the United States of America
Mother's Age, Birth Order and Health Status in a British National Sample
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Bernice A. Kaplan and C. G. N. Mascie-Taylor Using data from a longitudinal study of a national sample of British children, it is shown that mother's age and experience with child rearing are related to the attention paid to the child's health. Younger mothers, whose children are usually the first born, tend to be more concerned with health care facility use than are older mothers of children born subsequently. Younger mothers more often take their child to infant and toddler clinics, and are more likely to have their child immunized against the most threatening of childhood diseases. It is also the younger mothers who more often seek medical care for their children in addition to that provided in the infant and toddler clinics, more often have their child in hospital overnight, and more often report the child to be sickly (less healthy) than do older mothers with several children. Key words: mother's age, birth order, child health, British national sample
This paper examines, through the analysis of data collected in a longitudinal prospective study, the relation between the age of the mother at the time of the birth of her child and the health status of that child. Mother's age and the birth order of her child are clearly related; younger women tend to have had fewer children and older women are more likely to have had more. A previous study using the same data base (Kaplan and Mascie-Taylor 1991) shows that various childhood disease frequencies relate to birth order. In this study it was found that first born are more likely to receive the requisite number of immunizations, to be cared for in age-graded specialty clinics, to have fewer long absences from school, and to have a better socio-economic environment in which to develop than do children born later in the mother's reproductive life span, although first and second born children in more affluent families are more prone to early childhood asthma. Although the experience with childhood infectious diseases varies with birth order, it cannot be said that any particular position in the birth order confers an overall advantage, since children in each birth order experienced higher occurrences of some childhood diseases than others. First born children also live in less crowded conditions, are not competing with other siblings for food or other necessities of life, and experience better health in some respects. Yet older mothers, having had more experience with prior children, are more knowledgeable about the health hazards of childhood and could be assumed to be BERNICE A. KAPLAN is a Professor in the Department of Anthropology, Wayne State University, Detroit, MI 48202. Her research interests include medical anthropology, migration and health attitudes, and technological and social change. C. G. N. MASCIE-TAYLOR is a Lecturer and the Head of the Department of Biological Anthropology at the University of Cambridge, Cambridge CB2 3D2, U.K., and a Fellow of Churchill College. His research interests include human population structure, biosocial issues, epidemiology, and nutrition and disease. 353
354 B. A . Kaplan, C. G. N. Mascie-Taylor better able to cope. As a consequence these later born children may be expected to have fewer illnesses than those of younger mothers. Mother's Age as a Factor in Childhood Health
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We assume a relationship between a mother's age and social maturity, as well as her level of knowledge concerning child-rearing practices, and a different pattern of behavior between primaparae and multiparae mothers. There is a considerable literature to justify such assumptions (Blaxter 1981; Boyce et al. 1981; Hardy and Duggan 1988; Hare and Shaw 1965; Kolvin et al. 1983; Kramer 1987; Kruk and Wolkind 1983; Madge 1983; McCarthy and Meeker 1978; Oppel and Royston 1971). Socio-Economic Factors Affect Child-Rearing Practices
The oldest and youngest mothers have lower socio-economic status (as reflected in husband's occupation, housing facilities, educational level, and whether or not the mother was gainfully employed while her child was a pre-schooler), while mothers of middle years have higher socio-economic status (as reflected in the same variables). Younger women are more likely to be having their first child than those in their late 20s and 30s (Table I). Many scholarly accounts have, over the years, noted the increased health risks of infants born to teen-aged mothers (Baldwin and Cain TABLE I. Mother's age and child's birth order. Mother's Age Row % Col %
Child's Birth Order 1
2
3
4
Totals
593 87.3 11.9
82 12.1 1.9
3 .4 .1
1 .1 .0
679
20-24
2208 56.7 44.2
1237 31.8 28.4
339 8.7 15.6
110 2.8 4.9
3894
25-29
1477 32.4 29.6
1768 38.8 40.5
757 16.6 34.9
554 12.2 24.5
4556
30-34
524 18.3 10.5
910 31.8 20.9
654 22.8 30.2
777 17.1 34.3
2865
164 11.4 3.3
308 21.4 7.1
344 23.9 15.9
623 43.3 27.5
1439
28 7.9 .6
57 16.1 1.3
72 20.3 3.3
198 55.8 8.7
355
4994 36.2
4362 31.6
2169 15.2
2263 16.4
13788
teens
35-39
40+
Totals
X2 = 3917.18 15 d .f. P < 0.0001
4.9
28.2
33.0
20.8
10.4
2.6
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Mother's Age and Child Health 355 1980; Blaxter 1981; Boone 1985; Chamberlain 1975; Crellin et al. 1971; Douglas 1948; Lancaster and Hamberg 1986; Pearce and Foud 1977; Vinovskis 1981). Such accounts have indicated that young mothers (particularly teen-agers) are more likely to be unmarried, and to have less education than married women who begin their families at a later age. Where there is lack of adequate pre-natal care, such infants are often very light-weight at birth and infant mortality is higher in this group than in others. Some authors report a poorer health prognosis for these children than for others (Adelstein and Fedrick 1978; Baird 1972; Blaxter 1981; Reed and Stanley 1977; Wallace 1978). The information from the National Child Development Study, coming from a period before the dramatic increase in teen-aged pregnancies in the Western world does not support all of the later observations although, even in 1958, 5.2% of all infants in the sample were born to teen-aged mothers who tended to come from lower socio-economic groups (Butler and Alberman 1969; Butler and Bonham 1963; Davie et al. 1972; Pringle, Butler, and Davie 1966). We here hypothesize that other social factors (educational level, socio-economic status, type and ownership of housing accommodation, crowding in housing facilities, and spouse's occupation), which are associated with mother's age may also affect the health and well-being of children born at different stages of a woman's reproductive career. This paper examines these factors and considers the effect of their interaction with the age of the mother on the child's prospects for a healthy childhood.
MATERIALS
The data set consists of the National Child Development Study (NCDS), which constitutes a cohort of every child born in England, Wales and Scotland during the first week of March, 1958. In total, there are data on 18,559 individuals who have been followed since the first perinatal study at birth, subsequently in 1965,1969 and 1974 and, most recently, in 1981/2. The information available for each individual includes the birth order and mother's age at the time of the child's birth and, at each re-study, much familial and demographic information, illness experiences, medical reports, hospital experiences, a full school record, results of psychological tests, educational assessments and other matters not relevant to this study. At the time of each follow-up of the original birth cohort there were several sources of information on each individual. These included data gathered from the parents (usually the mother, though at age 16 the child was also interviewed), the school authorities, medical examiners (at the time of the interview), and medical records. Although there is information on every individual who was followed up, not all records are equally complete. "In terms of their parents' occupation and education . . . differences between those with and without data are small and the indices of physical development do not show any bias" (Fogelman: 1983:5). ! METHODS
The mother's age and the child's position in the birth order were recorded in 1958 at the time the index child was born. By maternal age is meant the chronological age
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356 B. A . Kaplan, C. G. N. Mascie-Taylor of the mother in the first week of March, 1958 when her child who is part of the NCDS cohort was born. Although follow-up contacts could not logistically be simultaneous, most subsequent interviews took place within a three month period. The NCDS data have been used in this paper to test the interrelationships between: mother's age; the index child's birth order; various health-related and medical experiences including attendance at infant and toddler welfare clinics; immunizations; childhood infectious diseases; in-patient and out-patient hospital experiences; and reasons for absences from school. These factors have been considered in terms of maternal socio-economic status (using a variety of housing measures and parental occupation(s)) and education, as they are related to health prognosis. The effect of mother's age (grouped into 5-year periods) and the various birth order, health and social factors were analyzed by a combination of Chi square and logistic regression analyses. All significant results reported have reference to X2 and logistic regression analysis values of P < 0.001.
RESULTS Birth Order
The most obvious difference occurs in the association between birth order and mother's age (Table I). First children are born in significantly large numbers to women up to the age of 25, second born children are more likely to have mothers aged 20-29, and fewer women over that age were starting their families in 1958. Few women over the age of 35 are delivering only their second child. The mothers of third-born children are more likely to be between 29 and 38, and fourth and subsequent children are most frequently born to women later in their reproductive cycle (aged 30-47).
Teen-Age Mothers and Birth Weight
Teen-age mothers have a significantly different distribution of birth weights in their newborn offspring than do older mothers (Table II), but in this group—mostly women in their upper rather than lower teens—the distinction is more in a dearth of heavy infants over nine pounds rather than high numbers of births under five and one-half pounds. In this regard they differ from the figures reported in the literature concerning risks of teen-aged mothers bearing very low weight infants.
Social Class Factors
Various measures of socio-economic status show significant relationships with mother's age and, by extension, with the life experiences and health status of their offspring. The youngest mothers, bearing children while still in their teens, were significantly more often unmarried. Of the youngest mothers who were married, significantly more had spouses engaged in manual occupations (Table III). Older
Mother's Age and Child Health 357 TABLE II. Birthweight and mother's age. Birthweight row % col % Light Thru 87 oz.
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Medium 88-144 oz.
Heavy 145-449 oz.
Totals
Mother's Age Young (teens)
Others
Totals
77
1,043
1,120
6.9 8.0
93.0 6.6
6.7
848
13,744
14,622
5.8 88.4
94.2 87.1
87.2
34
993
1,027
3.3 3.5
96.7 6.3
6.1
959 5.7
15,810 94.3
16,769 100.0
X* = 27.96 2 d.f. P < 0.0001
primaparae women (25 to 34 in 1958), were more likely to have husbands in a variety of non-manual occupations (Table IV) and very few of these women were unmarried. The husbands of women aged 20-29 most often held skilled manual jobs (Table IV). Significantly more women aged 25 to 34 in 1958 had non-manually employed husbands, while the oldest mothers (35-40+) resembled the teen-agers in that their husbands were more often semi-skilled or non-skilled manual laborers. This pattern, first recorded in 1965, remained very much the same in 1969 and 1973. There was little shift in familial socio-economic status (as based on husband's occupation) during the years 1965, 1969 and 1973. The oldest and the youngest mothers had significantly less education than those in their late 20s through mid-30s in 1958. The oldest mothers were born in the decade following World War I during a period when relatively few women were expected to continue with further education. The youngest mothers represent the early school leavers of World War II and the period just after World War II when the monetary contributions made by young working women were important to the well-being of their families. In this connection, mothers in their teens through mid-twenties were significantly more likely to work full-time when their child was of pre-school age than were the mothers aged 25-40+ (X* = 380.83, df = 10, P < 0.0001). The youngest mothers, however, usually had only one young child, and were able to have a parent or sibling care for the youngster while they were at work. Mothers over 30 in 1958 were well along in their reproductive career and significantly more likely already to have three or more children, and consequently less likely to be working following the birth of their youngest child in 1958.
358
B. A. Kaplan and C. G. N. Mascie-Taylor TABLE III. Mother's age (1958) and husband's occupation (1965). Mother's Age row % col % teens
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20-24
25-29
30-34
35-39
40+
Totals
Husband's Occupation Manual
Non-manual
Total
578 81.0 6.1
136 19.0 3.1
714
973 25.1 22.5
2908 74.9 31.2
3881
2866 63.5 30.7
1645 36.5 38.0
4511
1759 62.7 18.9
1048 37.3 24.2
2807
958 68.8 10.3
434 31.2 10.0
1392
255 74.1 2.7
89 25.9 2.1
344
9324
4324
13648
5.2
28.4
33.3
20.6
10.2
2.5
X2 = 226.16 5 d.f. p < 0.0001
Housing
Housing is related to birth order and hence, by extension, to mother's age. It is also related to the health status of the NCDS children. In 1965 the youngest mothers were more frequently living in efficiency apartments (single rooms with kitchen facilities or "bed-sits") and rented flats, and were under-represented among those living in whole homes. Those 24-29 in 1958 were more likely in 1965 to own or be buying their homes and significantly less likely to be found in rented accommodation either in council houses (public low-rent housing) or new-town homes (postwar purpose built low-rent housing in new [ex-urban] communities). The housing accommodations of the 34-39 year old group of mothers parallelled those of the teenagers, with more in rented council houses or new-town houses and fewer owning or buying their own homes. Similar findings, which we do not show in the tables, were recorded in 1969 (X2 = 205.6, df = 15, P < 0.001) and 1973 (X2 = 496.9, df = 15, P < 0.001). The youngest groups (teens to 24 in 1958) were, by 1973, still in the lower socio-economic classes and were more likely still to be renting accommodations than buying or owning their homes. Of those over 25 in 1958, more in 1973 owned or were buying their homes and fewer were renting.
Mother's Age and Child Health 359 TABLE IV. Mother's age and husband's social class, 1965. Mother's Age row % col % teens
20-24
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25-29
Husband's Social Class by Occupation Professional
Intermediate managerial
21 2.9 3.0
51 7.1 2.6
111
435
2.9 15.7
11.2 21.8
304 6.7
42.9 30-34
35-39
40+
Totals
196 7.0
766
17.0 38.4 487
Skilled
Semi-skilled
Unskilled
Total
432
135
75
714
60.5
18.9
5.7
5.5
46.7 10.5
5.2
2347 60.5 30.9
18.4 29.1
2467 54.7 32.5
16.2 29.7
1456 51.9 19.2
18.0 20.6
714
729
506
274 7.1
3881
30.7
28.4
245 5.4
4511
27.4
33.0
162 5.8
2807
18.1
20.6
27.7
17.3 24.4
60 4.3 8.5
217
717
297
51.5
21.3 12.1
101 7.3
1392
15.6 10.9
11.3
10.2 344
9.4
16 4.7 2.3
40
180
72
36
11.6
52.3
20.9
10.5
2.0
2.4
2.9
4.0
2.5
708 5.2
1996 14.6
7599 55.7
2453 18.0
893 6.5
13649 100.0
X2 = 275.90 20 d .f P < 0.0001
There is a direct relationship both between mother's age and the size of home occupied by the family and between her age and the number of children in the family. In 1965 the youngest mothers usually lived in the smallest number of rooms (3-4) while those over 30 were more likely to be in accommodations with 6 or more rooms. In 1969 the same general pattern could be discerned (X2 = 78.3, df = 15, P < 0.0001), although the differences were smaller. Even by 1973, when their study child had reached the age of 16, the youngest mothers continued to be in homes with fewer than 4 rooms. The number of people who sleep in the child's bedroom is a factor of the number of siblings in the family and is only indirectly related to the mother's age. However, more children of older mothers slept in a room alone than those from the families of the youngest mothers. This pattern, first seen in 1965, was even more pronounced in 1973 by which time the overall frequency of the index child sleeping alone had risen from 44.1% to 61.2%. The numbers sleeping two or more to a room decreased with the increasing age of the mother and fell overall from 16.6% in 1969 to 9.4% in 1973, as the oldest children in a family tended to move out when they finished school, reducing the pressure on space in the parental home.
360 B. A . Kaplan and C. G. N. Mastie-Taylor
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School Attendance At age 16 the children of the teen-aged mothers had significantly poorer school attendance records than those of older mothers, with more from this group being absent for up to 3 months and fewer with only brief absences up to 1 week. Supporting the findings in many other studies (Coffield 1983; Hunt et al. 1973; Jackson 1982; Kolvin et al. 1983; Kruk and Wolkind 1983; Madge 1983; Oppel and Royston 1971), children of teen-aged mothers—who themselves have had less schooling than those who postponed parenthood to an older age—are more likely to terminate their education at the minimum school leaving age, often having acquired no skill qualifications. The school attendance record of these youngsters supports a pattern of school truancy and disaffection characteristic of those who have lost interest in school. None of the reasons given for absence from school at either age 11 or 16 (primarily respiratory problems: colds, influenzas, bronchitis; but also headaches, bilious attacks, and infectious diseases) were significantly related to the age of the mother.
Mother's Age and Child's Health
Children with lower positions in the birth order were more likely to have been taken when young to the infant welfare clinic than were those who were third or later in the birth order. Younger mothers, with no other or only one prior child (Table I), and mothers aged 20-24 were more likely to attend the infant welfare clinic regularly. Non-attendance at these clinics by mothers 20-24 was lower than expected. The pattern was reversed for mothers 30 and older. Parallelling findings reported elsewhere in conjunction with social class differences (Boyce et al. 1991; Kolvin et al. 1983; Litman 1974), younger mothers reported more instances of the study child having been in hospital overnight than did older (30-39) mothers. More attention was given to childhood immunizations by the younger mothers than was the case with the older mulriparae mothers (Tables V, VI). The failure to immunize younger children may reflect experiences with previous children rather than the age of the mothers per se. Thus mothers under age 30 were significantly more likely to have their child immunized for diphtheria (Table V), significantly fewer refused the procedure, and the refusals were not because of objections but for "other reasons." However, when birth order effect, social class, and education were removed from consideration in the course of logistic regression analysis, mother's age is no longer a factor in the acceptance of diphtheria or polio immunizations, though it remains significant for immunization against small pox where younger mothers and teenagers were much more likely to have their children immunized. Responses for older mothers were the reverse. From this perspective one might expect that children of younger mothers would have better prognosis after exposure to these diseases than would children of older parents.
Mother's Age and Child Health 361 TABLE V. Mother's age and diphtheria immunization, 1965. Mother's Age row % col % teens
20-24
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25-29
30-34
35-39
40+
Totals
Immunization Yes
No, Objects
No, Other Reason
700 94.9 5.3
7 .9 2.5
31 4.2 6.1
738
3776 94.9 28.6
69 1.7 25.0
135 3.4 26.4
3980
4386 95.4 33.2
80 1.7 29.0
131 2.8 25.6
4597
2710 93.8 20.5
64 2.2 23.2
114 3.9 22.3
2888
1322 91.6 10.0
49 3.4 17.8
72 5.0 14.1
1443
324 90.3 2.5
7 1.9 2.5
28 7.8 5.5
359
13218 94.4
276 2.0
511 3.6
14005 100.0
Total
5.3
28.4
32.8
20.6
10.3
2.6
X2 = 58.79 10 d .f. P < 0.0001
Mother's Age and Childhood Diseases
Higher birth order children of older mothers (35-39 in 1958) reported significantly fewer childhood diseases (less measles, chicken pox and mumps) than expected at random, while 25-29 year old mothers reported more experience with childhood diseases (more rubella, chicken pox and mumps than expected). The children of teen-aged mothers reported less rubella and chicken pox, while those whose mothers were 20-24 had significantly more measles than the children of mothers of any other age. There is some suggestion in the literature that mother's recollection of childhood diseases of their children, and their consultation rates for these illnesses, vary by social class, being higher for professional and other non-manual classes than for those from unskilled, manual classes (Blaxter 1981; Fogelman 1983). We have no way of verifying the accuracy of the occurrences reported in the NCDS data. Pneumonia, whooping cough and scarlet fever were not significantly associated with maternal age (Table VII), as children of both younger and older mothers had these diseases less frequently than did those with mothers of about average age.
362 B. A . Kaplan, C. G. N. Mastie-Taylor TABLE VI. Mother's age and smallpox immunization, 1965. Mother's Age row% col% teens
20-24
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25-29
30-34
35-39
40+
total
Smallpox Immunization Yes
No, Objects
No, Other Reasons
547 75.6 5.2
47 6.5 4.4
130 18.0 5.8
724
3082 78.0 29.1
270 6.8 25.4
598 15.1 26.8
3950
3577 78.4 33.8
326 7.1 30.7
662 14.5 29.7
4568
2138 74.7 20.2
237 8.3 22.3
486 17.0 21.8
2861
1016 70.7 9.6
149 10.4 14.0
272 18.9 12.2
1437
235 66.6 2.2
34 9.6 3.2
84 23.8 3.8
353
10595 76.3
1063 7.7
2232 16.1
13890 100.0
Total
5.2
28.4
32.9
20.6
10.3
2.5
X2 = 71.7110 d.f. P < 0.0001
The contagious childhood diseases are cyclical in nature and, although all the children in this cohort were born at the same time, their likelihood of exposure to the several infectious agents depended on where they lived, and their siblings' experiences with these illnesses. These factors could account both for the observed differences and for the lack of any direction to the patterns of occurrence. In the logistic regression analysis mother's age was a significant predictor of frequency of child immunization after controlling for birth order, crowding, sex, education and social class. Thus, young mothers (teenagers and those aged 20-24 in 1958) were more likely to have had more of their children inoculated for diphtheria, polio and smallpox (Table VIII). Social class is associated with acceptance of immunization, with the reported gradient (Davie et al. 1972; Wedge and Prosser 1973) being parallel to our findings—that the highest acceptance is in the upper two social classes and the lowest in the semi-skilled and unskilled social classes.
Mother's Age and Child Health 363 TABLE VII. Mother's age and child's health. Contagious and other diseases Associations measured by X2
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Pneumonia Rubella Whooping Cough Chicken Pox Measles Mumps Scarlet Fever
n.s.
Medical Anthropology: Cross-Cultural Studies in Health and Illness Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gmea20
Mother's age, birth order and health status in a British national sample a
Bernice A. Kaplan & C. G. N. Mascie‐Taylor
b c
a
Bernice A. Kaplan is a Professor in the Department of Anthropology , Wayne State University , Detroit, MI, 48202 b
Lecturer and the Head of the Department of Biological Anthropology , University of Cambridge , Cambridge, CB2 3D2, U.K. c
Fellow of Churchill College Published online: 12 May 2010.
To cite this article: Bernice A. Kaplan & C. G. N. Mascie‐Taylor (1992) Mother's age, birth order and health status in a British national sample, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 13:4, 353-367, DOI: 10.1080/01459740.1992.9966057 To link to this article: http://dx.doi.org/10.1080/01459740.1992.9966057
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
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& Conditions of access and use can be found at http://www.tandfonline.com/page/ terms-and-conditions
Medical Anthropology, Vol. 13, pp. 353-367 Reprints available directly from the publisher Photocopying permitted by license only
©1992 Gordon and Breach Science Publishers S.A. Printed in the United States of America
Mother's Age, Birth Order and Health Status in a British National Sample
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Bernice A. Kaplan and C. G. N. Mascie-Taylor Using data from a longitudinal study of a national sample of British children, it is shown that mother's age and experience with child rearing are related to the attention paid to the child's health. Younger mothers, whose children are usually the first born, tend to be more concerned with health care facility use than are older mothers of children born subsequently. Younger mothers more often take their child to infant and toddler clinics, and are more likely to have their child immunized against the most threatening of childhood diseases. It is also the younger mothers who more often seek medical care for their children in addition to that provided in the infant and toddler clinics, more often have their child in hospital overnight, and more often report the child to be sickly (less healthy) than do older mothers with several children. Key words: mother's age, birth order, child health, British national sample
This paper examines, through the analysis of data collected in a longitudinal prospective study, the relation between the age of the mother at the time of the birth of her child and the health status of that child. Mother's age and the birth order of her child are clearly related; younger women tend to have had fewer children and older women are more likely to have had more. A previous study using the same data base (Kaplan and Mascie-Taylor 1991) shows that various childhood disease frequencies relate to birth order. In this study it was found that first born are more likely to receive the requisite number of immunizations, to be cared for in age-graded specialty clinics, to have fewer long absences from school, and to have a better socio-economic environment in which to develop than do children born later in the mother's reproductive life span, although first and second born children in more affluent families are more prone to early childhood asthma. Although the experience with childhood infectious diseases varies with birth order, it cannot be said that any particular position in the birth order confers an overall advantage, since children in each birth order experienced higher occurrences of some childhood diseases than others. First born children also live in less crowded conditions, are not competing with other siblings for food or other necessities of life, and experience better health in some respects. Yet older mothers, having had more experience with prior children, are more knowledgeable about the health hazards of childhood and could be assumed to be BERNICE A. KAPLAN is a Professor in the Department of Anthropology, Wayne State University, Detroit, MI 48202. Her research interests include medical anthropology, migration and health attitudes, and technological and social change. C. G. N. MASCIE-TAYLOR is a Lecturer and the Head of the Department of Biological Anthropology at the University of Cambridge, Cambridge CB2 3D2, U.K., and a Fellow of Churchill College. His research interests include human population structure, biosocial issues, epidemiology, and nutrition and disease. 353
354 B. A . Kaplan, C. G. N. Mascie-Taylor better able to cope. As a consequence these later born children may be expected to have fewer illnesses than those of younger mothers. Mother's Age as a Factor in Childhood Health
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We assume a relationship between a mother's age and social maturity, as well as her level of knowledge concerning child-rearing practices, and a different pattern of behavior between primaparae and multiparae mothers. There is a considerable literature to justify such assumptions (Blaxter 1981; Boyce et al. 1981; Hardy and Duggan 1988; Hare and Shaw 1965; Kolvin et al. 1983; Kramer 1987; Kruk and Wolkind 1983; Madge 1983; McCarthy and Meeker 1978; Oppel and Royston 1971). Socio-Economic Factors Affect Child-Rearing Practices
The oldest and youngest mothers have lower socio-economic status (as reflected in husband's occupation, housing facilities, educational level, and whether or not the mother was gainfully employed while her child was a pre-schooler), while mothers of middle years have higher socio-economic status (as reflected in the same variables). Younger women are more likely to be having their first child than those in their late 20s and 30s (Table I). Many scholarly accounts have, over the years, noted the increased health risks of infants born to teen-aged mothers (Baldwin and Cain TABLE I. Mother's age and child's birth order. Mother's Age Row % Col %
Child's Birth Order 1
2
3
4
Totals
593 87.3 11.9
82 12.1 1.9
3 .4 .1
1 .1 .0
679
20-24
2208 56.7 44.2
1237 31.8 28.4
339 8.7 15.6
110 2.8 4.9
3894
25-29
1477 32.4 29.6
1768 38.8 40.5
757 16.6 34.9
554 12.2 24.5
4556
30-34
524 18.3 10.5
910 31.8 20.9
654 22.8 30.2
777 17.1 34.3
2865
164 11.4 3.3
308 21.4 7.1
344 23.9 15.9
623 43.3 27.5
1439
28 7.9 .6
57 16.1 1.3
72 20.3 3.3
198 55.8 8.7
355
4994 36.2
4362 31.6
2169 15.2
2263 16.4
13788
teens
35-39
40+
Totals
X2 = 3917.18 15 d .f. P < 0.0001
4.9
28.2
33.0
20.8
10.4
2.6
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Mother's Age and Child Health 355 1980; Blaxter 1981; Boone 1985; Chamberlain 1975; Crellin et al. 1971; Douglas 1948; Lancaster and Hamberg 1986; Pearce and Foud 1977; Vinovskis 1981). Such accounts have indicated that young mothers (particularly teen-agers) are more likely to be unmarried, and to have less education than married women who begin their families at a later age. Where there is lack of adequate pre-natal care, such infants are often very light-weight at birth and infant mortality is higher in this group than in others. Some authors report a poorer health prognosis for these children than for others (Adelstein and Fedrick 1978; Baird 1972; Blaxter 1981; Reed and Stanley 1977; Wallace 1978). The information from the National Child Development Study, coming from a period before the dramatic increase in teen-aged pregnancies in the Western world does not support all of the later observations although, even in 1958, 5.2% of all infants in the sample were born to teen-aged mothers who tended to come from lower socio-economic groups (Butler and Alberman 1969; Butler and Bonham 1963; Davie et al. 1972; Pringle, Butler, and Davie 1966). We here hypothesize that other social factors (educational level, socio-economic status, type and ownership of housing accommodation, crowding in housing facilities, and spouse's occupation), which are associated with mother's age may also affect the health and well-being of children born at different stages of a woman's reproductive career. This paper examines these factors and considers the effect of their interaction with the age of the mother on the child's prospects for a healthy childhood.
MATERIALS
The data set consists of the National Child Development Study (NCDS), which constitutes a cohort of every child born in England, Wales and Scotland during the first week of March, 1958. In total, there are data on 18,559 individuals who have been followed since the first perinatal study at birth, subsequently in 1965,1969 and 1974 and, most recently, in 1981/2. The information available for each individual includes the birth order and mother's age at the time of the child's birth and, at each re-study, much familial and demographic information, illness experiences, medical reports, hospital experiences, a full school record, results of psychological tests, educational assessments and other matters not relevant to this study. At the time of each follow-up of the original birth cohort there were several sources of information on each individual. These included data gathered from the parents (usually the mother, though at age 16 the child was also interviewed), the school authorities, medical examiners (at the time of the interview), and medical records. Although there is information on every individual who was followed up, not all records are equally complete. "In terms of their parents' occupation and education . . . differences between those with and without data are small and the indices of physical development do not show any bias" (Fogelman: 1983:5). ! METHODS
The mother's age and the child's position in the birth order were recorded in 1958 at the time the index child was born. By maternal age is meant the chronological age
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356 B. A . Kaplan, C. G. N. Mascie-Taylor of the mother in the first week of March, 1958 when her child who is part of the NCDS cohort was born. Although follow-up contacts could not logistically be simultaneous, most subsequent interviews took place within a three month period. The NCDS data have been used in this paper to test the interrelationships between: mother's age; the index child's birth order; various health-related and medical experiences including attendance at infant and toddler welfare clinics; immunizations; childhood infectious diseases; in-patient and out-patient hospital experiences; and reasons for absences from school. These factors have been considered in terms of maternal socio-economic status (using a variety of housing measures and parental occupation(s)) and education, as they are related to health prognosis. The effect of mother's age (grouped into 5-year periods) and the various birth order, health and social factors were analyzed by a combination of Chi square and logistic regression analyses. All significant results reported have reference to X2 and logistic regression analysis values of P < 0.001.
RESULTS Birth Order
The most obvious difference occurs in the association between birth order and mother's age (Table I). First children are born in significantly large numbers to women up to the age of 25, second born children are more likely to have mothers aged 20-29, and fewer women over that age were starting their families in 1958. Few women over the age of 35 are delivering only their second child. The mothers of third-born children are more likely to be between 29 and 38, and fourth and subsequent children are most frequently born to women later in their reproductive cycle (aged 30-47).
Teen-Age Mothers and Birth Weight
Teen-age mothers have a significantly different distribution of birth weights in their newborn offspring than do older mothers (Table II), but in this group—mostly women in their upper rather than lower teens—the distinction is more in a dearth of heavy infants over nine pounds rather than high numbers of births under five and one-half pounds. In this regard they differ from the figures reported in the literature concerning risks of teen-aged mothers bearing very low weight infants.
Social Class Factors
Various measures of socio-economic status show significant relationships with mother's age and, by extension, with the life experiences and health status of their offspring. The youngest mothers, bearing children while still in their teens, were significantly more often unmarried. Of the youngest mothers who were married, significantly more had spouses engaged in manual occupations (Table III). Older
Mother's Age and Child Health 357 TABLE II. Birthweight and mother's age. Birthweight row % col % Light Thru 87 oz.
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Medium 88-144 oz.
Heavy 145-449 oz.
Totals
Mother's Age Young (teens)
Others
Totals
77
1,043
1,120
6.9 8.0
93.0 6.6
6.7
848
13,744
14,622
5.8 88.4
94.2 87.1
87.2
34
993
1,027
3.3 3.5
96.7 6.3
6.1
959 5.7
15,810 94.3
16,769 100.0
X* = 27.96 2 d.f. P < 0.0001
primaparae women (25 to 34 in 1958), were more likely to have husbands in a variety of non-manual occupations (Table IV) and very few of these women were unmarried. The husbands of women aged 20-29 most often held skilled manual jobs (Table IV). Significantly more women aged 25 to 34 in 1958 had non-manually employed husbands, while the oldest mothers (35-40+) resembled the teen-agers in that their husbands were more often semi-skilled or non-skilled manual laborers. This pattern, first recorded in 1965, remained very much the same in 1969 and 1973. There was little shift in familial socio-economic status (as based on husband's occupation) during the years 1965, 1969 and 1973. The oldest and the youngest mothers had significantly less education than those in their late 20s through mid-30s in 1958. The oldest mothers were born in the decade following World War I during a period when relatively few women were expected to continue with further education. The youngest mothers represent the early school leavers of World War II and the period just after World War II when the monetary contributions made by young working women were important to the well-being of their families. In this connection, mothers in their teens through mid-twenties were significantly more likely to work full-time when their child was of pre-school age than were the mothers aged 25-40+ (X* = 380.83, df = 10, P < 0.0001). The youngest mothers, however, usually had only one young child, and were able to have a parent or sibling care for the youngster while they were at work. Mothers over 30 in 1958 were well along in their reproductive career and significantly more likely already to have three or more children, and consequently less likely to be working following the birth of their youngest child in 1958.
358
B. A. Kaplan and C. G. N. Mascie-Taylor TABLE III. Mother's age (1958) and husband's occupation (1965). Mother's Age row % col % teens
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20-24
25-29
30-34
35-39
40+
Totals
Husband's Occupation Manual
Non-manual
Total
578 81.0 6.1
136 19.0 3.1
714
973 25.1 22.5
2908 74.9 31.2
3881
2866 63.5 30.7
1645 36.5 38.0
4511
1759 62.7 18.9
1048 37.3 24.2
2807
958 68.8 10.3
434 31.2 10.0
1392
255 74.1 2.7
89 25.9 2.1
344
9324
4324
13648
5.2
28.4
33.3
20.6
10.2
2.5
X2 = 226.16 5 d.f. p < 0.0001
Housing
Housing is related to birth order and hence, by extension, to mother's age. It is also related to the health status of the NCDS children. In 1965 the youngest mothers were more frequently living in efficiency apartments (single rooms with kitchen facilities or "bed-sits") and rented flats, and were under-represented among those living in whole homes. Those 24-29 in 1958 were more likely in 1965 to own or be buying their homes and significantly less likely to be found in rented accommodation either in council houses (public low-rent housing) or new-town homes (postwar purpose built low-rent housing in new [ex-urban] communities). The housing accommodations of the 34-39 year old group of mothers parallelled those of the teenagers, with more in rented council houses or new-town houses and fewer owning or buying their own homes. Similar findings, which we do not show in the tables, were recorded in 1969 (X2 = 205.6, df = 15, P < 0.001) and 1973 (X2 = 496.9, df = 15, P < 0.001). The youngest groups (teens to 24 in 1958) were, by 1973, still in the lower socio-economic classes and were more likely still to be renting accommodations than buying or owning their homes. Of those over 25 in 1958, more in 1973 owned or were buying their homes and fewer were renting.
Mother's Age and Child Health 359 TABLE IV. Mother's age and husband's social class, 1965. Mother's Age row % col % teens
20-24
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25-29
Husband's Social Class by Occupation Professional
Intermediate managerial
21 2.9 3.0
51 7.1 2.6
111
435
2.9 15.7
11.2 21.8
304 6.7
42.9 30-34
35-39
40+
Totals
196 7.0
766
17.0 38.4 487
Skilled
Semi-skilled
Unskilled
Total
432
135
75
714
60.5
18.9
5.7
5.5
46.7 10.5
5.2
2347 60.5 30.9
18.4 29.1
2467 54.7 32.5
16.2 29.7
1456 51.9 19.2
18.0 20.6
714
729
506
274 7.1
3881
30.7
28.4
245 5.4
4511
27.4
33.0
162 5.8
2807
18.1
20.6
27.7
17.3 24.4
60 4.3 8.5
217
717
297
51.5
21.3 12.1
101 7.3
1392
15.6 10.9
11.3
10.2 344
9.4
16 4.7 2.3
40
180
72
36
11.6
52.3
20.9
10.5
2.0
2.4
2.9
4.0
2.5
708 5.2
1996 14.6
7599 55.7
2453 18.0
893 6.5
13649 100.0
X2 = 275.90 20 d .f P < 0.0001
There is a direct relationship both between mother's age and the size of home occupied by the family and between her age and the number of children in the family. In 1965 the youngest mothers usually lived in the smallest number of rooms (3-4) while those over 30 were more likely to be in accommodations with 6 or more rooms. In 1969 the same general pattern could be discerned (X2 = 78.3, df = 15, P < 0.0001), although the differences were smaller. Even by 1973, when their study child had reached the age of 16, the youngest mothers continued to be in homes with fewer than 4 rooms. The number of people who sleep in the child's bedroom is a factor of the number of siblings in the family and is only indirectly related to the mother's age. However, more children of older mothers slept in a room alone than those from the families of the youngest mothers. This pattern, first seen in 1965, was even more pronounced in 1973 by which time the overall frequency of the index child sleeping alone had risen from 44.1% to 61.2%. The numbers sleeping two or more to a room decreased with the increasing age of the mother and fell overall from 16.6% in 1969 to 9.4% in 1973, as the oldest children in a family tended to move out when they finished school, reducing the pressure on space in the parental home.
360 B. A . Kaplan and C. G. N. Mastie-Taylor
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School Attendance At age 16 the children of the teen-aged mothers had significantly poorer school attendance records than those of older mothers, with more from this group being absent for up to 3 months and fewer with only brief absences up to 1 week. Supporting the findings in many other studies (Coffield 1983; Hunt et al. 1973; Jackson 1982; Kolvin et al. 1983; Kruk and Wolkind 1983; Madge 1983; Oppel and Royston 1971), children of teen-aged mothers—who themselves have had less schooling than those who postponed parenthood to an older age—are more likely to terminate their education at the minimum school leaving age, often having acquired no skill qualifications. The school attendance record of these youngsters supports a pattern of school truancy and disaffection characteristic of those who have lost interest in school. None of the reasons given for absence from school at either age 11 or 16 (primarily respiratory problems: colds, influenzas, bronchitis; but also headaches, bilious attacks, and infectious diseases) were significantly related to the age of the mother.
Mother's Age and Child's Health
Children with lower positions in the birth order were more likely to have been taken when young to the infant welfare clinic than were those who were third or later in the birth order. Younger mothers, with no other or only one prior child (Table I), and mothers aged 20-24 were more likely to attend the infant welfare clinic regularly. Non-attendance at these clinics by mothers 20-24 was lower than expected. The pattern was reversed for mothers 30 and older. Parallelling findings reported elsewhere in conjunction with social class differences (Boyce et al. 1991; Kolvin et al. 1983; Litman 1974), younger mothers reported more instances of the study child having been in hospital overnight than did older (30-39) mothers. More attention was given to childhood immunizations by the younger mothers than was the case with the older mulriparae mothers (Tables V, VI). The failure to immunize younger children may reflect experiences with previous children rather than the age of the mothers per se. Thus mothers under age 30 were significantly more likely to have their child immunized for diphtheria (Table V), significantly fewer refused the procedure, and the refusals were not because of objections but for "other reasons." However, when birth order effect, social class, and education were removed from consideration in the course of logistic regression analysis, mother's age is no longer a factor in the acceptance of diphtheria or polio immunizations, though it remains significant for immunization against small pox where younger mothers and teenagers were much more likely to have their children immunized. Responses for older mothers were the reverse. From this perspective one might expect that children of younger mothers would have better prognosis after exposure to these diseases than would children of older parents.
Mother's Age and Child Health 361 TABLE V. Mother's age and diphtheria immunization, 1965. Mother's Age row % col % teens
20-24
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25-29
30-34
35-39
40+
Totals
Immunization Yes
No, Objects
No, Other Reason
700 94.9 5.3
7 .9 2.5
31 4.2 6.1
738
3776 94.9 28.6
69 1.7 25.0
135 3.4 26.4
3980
4386 95.4 33.2
80 1.7 29.0
131 2.8 25.6
4597
2710 93.8 20.5
64 2.2 23.2
114 3.9 22.3
2888
1322 91.6 10.0
49 3.4 17.8
72 5.0 14.1
1443
324 90.3 2.5
7 1.9 2.5
28 7.8 5.5
359
13218 94.4
276 2.0
511 3.6
14005 100.0
Total
5.3
28.4
32.8
20.6
10.3
2.6
X2 = 58.79 10 d .f. P < 0.0001
Mother's Age and Childhood Diseases
Higher birth order children of older mothers (35-39 in 1958) reported significantly fewer childhood diseases (less measles, chicken pox and mumps) than expected at random, while 25-29 year old mothers reported more experience with childhood diseases (more rubella, chicken pox and mumps than expected). The children of teen-aged mothers reported less rubella and chicken pox, while those whose mothers were 20-24 had significantly more measles than the children of mothers of any other age. There is some suggestion in the literature that mother's recollection of childhood diseases of their children, and their consultation rates for these illnesses, vary by social class, being higher for professional and other non-manual classes than for those from unskilled, manual classes (Blaxter 1981; Fogelman 1983). We have no way of verifying the accuracy of the occurrences reported in the NCDS data. Pneumonia, whooping cough and scarlet fever were not significantly associated with maternal age (Table VII), as children of both younger and older mothers had these diseases less frequently than did those with mothers of about average age.
362 B. A . Kaplan, C. G. N. Mastie-Taylor TABLE VI. Mother's age and smallpox immunization, 1965. Mother's Age row% col% teens
20-24
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25-29
30-34
35-39
40+
total
Smallpox Immunization Yes
No, Objects
No, Other Reasons
547 75.6 5.2
47 6.5 4.4
130 18.0 5.8
724
3082 78.0 29.1
270 6.8 25.4
598 15.1 26.8
3950
3577 78.4 33.8
326 7.1 30.7
662 14.5 29.7
4568
2138 74.7 20.2
237 8.3 22.3
486 17.0 21.8
2861
1016 70.7 9.6
149 10.4 14.0
272 18.9 12.2
1437
235 66.6 2.2
34 9.6 3.2
84 23.8 3.8
353
10595 76.3
1063 7.7
2232 16.1
13890 100.0
Total
5.2
28.4
32.9
20.6
10.3
2.5
X2 = 71.7110 d.f. P < 0.0001
The contagious childhood diseases are cyclical in nature and, although all the children in this cohort were born at the same time, their likelihood of exposure to the several infectious agents depended on where they lived, and their siblings' experiences with these illnesses. These factors could account both for the observed differences and for the lack of any direction to the patterns of occurrence. In the logistic regression analysis mother's age was a significant predictor of frequency of child immunization after controlling for birth order, crowding, sex, education and social class. Thus, young mothers (teenagers and those aged 20-24 in 1958) were more likely to have had more of their children inoculated for diphtheria, polio and smallpox (Table VIII). Social class is associated with acceptance of immunization, with the reported gradient (Davie et al. 1972; Wedge and Prosser 1973) being parallel to our findings—that the highest acceptance is in the upper two social classes and the lowest in the semi-skilled and unskilled social classes.
Mother's Age and Child Health 363 TABLE VII. Mother's age and child's health. Contagious and other diseases Associations measured by X2
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Pneumonia Rubella Whooping Cough Chicken Pox Measles Mumps Scarlet Fever
n.s.
