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An evidence based approach to teenage pregnancy and early childhood development – The Quinlivan Triad of Care
Professor Julie A. Quinlivan
Executive Dean (Medicine)/Pro-Vice Chancellor (Medicine), University of Notre Dame Australia
This talk outlines the evidence behind the Quinlivan ‘Triad of Care’. This comprises:
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.
Many studies compare the outcomes of teenage versus nonteenage childbearing. Multiple adverse outcomes are reported in these trials. However, these are not 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 compared to those who do not. By example, the Sister’s study controlled for family background heterogeneity controlled by using ‘within family’ estimations. The study compared the differences in subsequent socio-economic status of sisters who experienced their first pregnancy at different ages, with one having their first birth as a teenager. They used 3 large data sets and found that “the long term socio-economic differences were minimal’. 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 socio-economic status of poor women and their children” The
National Longitudinal Survey Young Women’s Sample evaluated differences in maternal age and low birthweight, prenatal care, smoking and alcohol use in pregnancy, breastfeeding and well-child visits
They found that differences due to family background, NOT maternal age. They concluded that ‘Teenage birth may add little to already negative social circumstances’.
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
- Preterm birth and poor obstetric outcomes
- Lack of support in the form of housing, safety and practical skills to manage a household.
- Educational limitations limiting re-entry to the workforce
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 supporting evidence comes from our Australian study of over 700 teenage mothers. The aim of the study was: 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. Care was 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. Teenage antenatal clinics were associated with improved rates of infection and social support screening. Furthermore, when screening was performed, underlying rates of positive findings were similar. This suggests that problems are being missed in teenagers delivering in general clinics. Of greater importance, teenage antenatal clinics were associated with reductions in threatened preterm labour, preterm premature prelabour rupture of the membranes and actual preterm birth
Therefore, we can state that teenage specific antenatal clinics improve outcomes for teenage mothers and their infants. They are also cost effective where more than 70 teenage mothers deliver.
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.
Evidence based solution 2: Implement nurse home visitation commencing in pregnancy and continuing until 2 years of age
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. 2 large RCTs (rural New York/Memphis, Tenn) concluded that:
- 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.
Our Australian randomized trial also found nurse home visitation was associated with fewer adverse outcomes: Neonatal death, Nonaccidental injury and Nonvoluntary relinquishment. It was also associated with greater knowledge of: Contraception, Breast feeding and infant vaccination.
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.
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. 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.
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.
By example, when childcare is provided, programs tend to engage mothers and work. The New Hope Program developed by local, State and national organizations and was implemented in two neighborhoods in USA. The intervention group 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. At assessment 2 years later the findings were that the intervention group had increases in employment and earnings and positive effects on teacher-rated social competence, behaviour problems and school performance of their children.
In contrast when childcare is not provided, programs do not work. The US Dept of Health & Human Services program rolled out into 4 USA States to teenage mothers. The 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. At evaluation, 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.
The solution is to provide free childcare or peri-preschool for infants and educational programs for teenage parents that schedule within childcare or peri-preschool hours.
In summary, this talk outlines the Quinlivan ‘Triad of Care’. These interventions have well researched foundations and can achieve intergenerational shift in the cycle of disadvantage, especially when applied in serial combination. They are:
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.
Presentation handout © Julie A Quinlivan May 2010 Please reference presentation if used.
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