Running head: INFANT MORTALITY

Maternal Age as it Relates to Infant Mortality Sarah Elser, Tracy Giraud, Brianna Hall, Karin Mogren-Kuzma, and Jackie Wirth Ferris State University

INFANT MORTALITY Maternal Age as it Relates to Infant Mortality The purpose of this paper is to determine whether maternal age is associated with

increased risks of infant mortality. In the United States, infant mortality rate is higher than those in most other developed countries (Chen, Wen, Fleming, Yang, & Walker, 2008). According to the Centers for Disease Control and Prevention (CDC), infant mortality is defined as death within the first year of life, and infant mortality rate is defined as number of deaths per 1,000 live births. In 2008, the infant mortality rate in the United States was 6.6 per 1,000 (CDC, 2012). Numerous of research studies have been conducted focusing on social determinants such as prenatal care and demographic factors related to infant mortality and morbidity. However, whether there is a correlation between infant mortality and variations in maternal age is not as clear. By critically analyze the most current literature, the authors of this literature review aim to answer the question: Are infants born to mothers less than 20 years of age, compared to mothers older than 20 years of age, at risk for higher infant mortality? The literature review was carried out by using a variety of scholarly search engines such as CINAHL, EBSCOhost and PubMed. After finding a total of ten articles relating to women of childbearing age, the chosen clinical population for the project, four was selected to serve as the basis for the literature review and evidence analysis. The four selected articles were chosen based on an evaluation matrix (Appendix A) including criteria of current, relevant, and level of expertise in the clinical community to find the most relevant and reliable information. A critical appraisal was then performed by the use of evidence based critique principles. The criteria for selection of articles were based on representative sample sizes, valid statistical tools, and research purpose. Furthermore, the level of evidence was assessed to determine the validity of the study.

INFANT MORTALITY Findings from the literature review reveal that infant mortality is adversely associated with young maternal age. It is true that young women are at a higher risk for preterm and cesarean delivery, as well as gestational hypertension, and these factors could increase complications, and consequently lead to infant mortality. However, age alone cannot singly be used as a predictor for infant outcomes. The literature urges that in order to determine infant mortality, additional maternal and infant characteristics must be considered. Socioeconomic status, educational level, substance use habits among mothers as well as gestational age and infant birth weight are variables that must be accounted for. Literature Review

After an evaluation of the research, ten articles were selected for further review due to the individual subject content. Each of the ten research articles was reviewed and critiqued. Six of the ten articles were ultimately eliminated before the final analysis. The first criterion for consideration was determined by the year of publication, all of the selected articles were published within the last five years. Second, each article was selected based on relevance to the research question. Third, only scholarly peer-reviewed journal articles were selected. The fourth and final criterion was based on level of expertise in research area of interest. An article critique matrix was used to evaluate each article. The articles were evaluated based on the problem statement, hypothesis, methodology, data collection methods, validity of statistical results, and conclusions. The first article discusses neonatal and postneonatal mortality associated with teenage pregnancy (Chen et al., 2008). The objective of this study is presented in a clear manner. Chen et al. (2008) discuss the importance and relevance of the research problem referring to high infant mortality statistics in the U.S. for women less than 20 years of age. Chen et al. (2008)

INFANT MORTALITY describes breaches in the current literature relating to inconsistencies in the conclusions of previous studies carried out in the area of interest. This explains the necessity to adjust for

variables including maternal race, education level, tobacco and alcohol use, marital status, mode of delivery, and prenatal care (Chen et al., 2008). Methods used to gather data were assured for quality by the National Center for Health Statistics in the United States. After assuring that all subjects met the inclusion criteria, the final sample size consisted of 4,037,009 subjects (Chen et al., 2008). Study limitations included researches ability to determine participants socioeconomic status and use of illicit drugs because they were self reported and are known factors to affect infant mortality and morbidity. The statistical data was analyzed using the Statistical Analysis System, Version 9.1 and represented in table format using four models (Chen et al., 2008). Generalizations of the research indicate that there is a correlation between teenage pregnancy and neonatal mortality. However, no suggestions for additional research were indicated. The second articles research objective was to explore the effects of maternal age on pregnancy outcomes (Rajaee, Amizadeh, Mirblook, & Soltani, 2010). The purpose of the study is clearly defined as identifying maternal age as a potential contributing risk factor for increased infant mortality. The sample size consisted of 2,940 pregnant women in varying age groups. Initial data was gathered by questionnaires and patient interviews. Follow-up interviews were performed one day after birth. The data collection method was purposely used to assess details of predefined subsets findings. Subjects were divided according to their age group, and subset categories consisted of abnormal perinatal screenings during different trimesters and after delivery. No ethical considerations were described in the study. Strategies used to analyze data include the statistical package for the social sciences software (SPSS) 18. In addition, a chi-

INFANT MORTALITY square test compared incidences and percentages of each maternal age group. The studys findings are relevant because it demonstrates the increased risks to the infant that may occur from young maternal age. However, the findings also reveal that maternal age was not solely linked to adverse pregnancy outcomes (Rajaee et al., 2010). There are no recommendations for further studies. The next article for critique written by Pittard, Laditka, and Laditka (2008), focuses on the association between maternal age and infant health outcomes. The purpose of the study clearly indicates the objective to compare adolescent mothers to older mothers in relation to infant mortality rates. The article signifies that previous studies describe poor outcomes of teenage pregnancy. The researchers hypothesized that if adolescent and older mothers have

similar access to healthcare services, then the infants would have similar health status, regardless of mothers age (Pittard et al., 2008). However, when variables were accounted for the hypotheses was rejected (Pittard et al., 2008). The methodology used consisted of collecting data between 2000-2002 on infants born to mothers in varying age groups. Data collection was done by documenting all health care encounters for infants that were healthy at birth by then comparing the outcomes based on the maternal age. Variables controlled for was mother and infant characteristics. Mothers characteristics include level of education, age, alcohol, drug, and tobacco use as well as delivery method. Infant characteristics used as control variables include birth weight and gestational age. The sample size consists of 41,696 subjects (Pittard et al., 2008). The study was approved by the Medical University of South Carolina review board. Statistical software and analysis is described in detail. Limitations of the study included self-reported data on substance use and

INFANT MORTALITY socioeconomic status. Pittard et al. (2008) suggest additional research to determine specific interventions in order to improve infants health outcomes when born to adolescent mothers. The fourth and final article reviewed, written by Uzen, Orhon, Baskan, and Ulukol, (2013), aims to compare adolescent to older mothers in terms of infant outcomes. The authors refer to existing research studies confirming a relationship between young maternal age and infant mortality, this article attempts to explain why these relationships exist. The study was carried out on 100 adolescent mothers under 20 years of age and 100 mothers over 20 years of age. Variables were controlled for socio-demographic attributes, educational background, and employment status. The method for gathering information consisted of conducting interviews with randomly selected participants after written consent was obtained. Furthermore, the study was approved by the ethical committee of the hospital were the study was conducted. The statistical analysis evaluation tool used was reported as the Statistical Package for Social Sciences 11(Uzen et al, 2013). Five additional software programs where used for evaluating data. Results indicate that there is a statistically significant difference between mothers socio-demographic and educational background in terms of infant outcomes.

Implications of findings indicate that proper follow-up care during prenatal and postnatal periods could eliminate the adverse relationship existing between maternal age and infant mortality (Uzen et al, 2013). Evidence Analysis The first study was a quantitative study exploring the percentage rates of infant mortality to women younger than 25 years of age. Data was compiled over the course of five years; from 1995-2000 using the United States nationally linked birth/infant data set from the National Center for Health Statistics (Chen, et al, 2008). Results of the study affirm that infant mortality

INFANT MORTALITY rates are higher in infants born to mothers 10-19 years old as compared to mothers 20-25 years old (Chen, et al, 2008). The evidence in the study supports these results by presenting the maternal age into specific age groups and expressing the infant mortality rates for each age group. After adjusting for variables, pregnancy in women younger than 20 years of age was associated with an increased risk of neonatal death as compared to pregnancy in women older than 20 years of age. According to Stetler, Brunell, Giuliano, Morsi, Prince, and Newell-Stokes (1998), in order for results to be considered accurate and reliable, multiple sources should be used to compile data. The data collected by Chen et al. (2008) could be considered confounding due to

the single source of data collection. For this reason, the study would be considered a fourth level of evidence. According to the hierarchy of evidence rating system, level four evidence consists of a well-rounded cohort case-control study. It is considered relevant and credible for practice recommendations but not as consistent as level one or level two evidence (Stetler, et.al, 1998). The study by Rajaee et al. (2010) is considered a level five qualitative descriptive systematic evaluation of the evidence. Results coincide with previous studies suggesting young maternal age to be a risk factor for infant mortality. However, age alone was not statistically significant for predicting infant mortality. Rather, the increased infant mortality rate is affected by various pregnancy complications young women often encounter. (Rajaee et al., 2010). Factors contributing to infant mortality as reported by Rajaee et al. (2010) include cesarean delivery, preterm delivery, and gestational hypertension. The study by Pittard et al. (2008) investigates the risk of mortality and morbidity of infants born to adolescent mothers as opposed to older mothers. Valid statistical analysis methods were used, making the results of the study reliable for interpreting infant mortality rates

INFANT MORTALITY in adolescent pregnancy. Adolescents compared to older mothers, age 18 and older, were less likely to seek out prenatal care, which suggests compromised neonatal outcomes. In contrast, older mothers were found to have sought out more prenatal care when compared to adolescents. Researchers attributed this to specific characteristics of the older mother such as level of

education and socioeconomic status (Pittard et al., 2008). Pittard et al. (2008) discusses the need for additional research on detailed interventions that may decrease the negative health effects of infants born to teen mothers. Such research should focus on economic and social benefits, or programs for improving education, nutrition, and health care access. Uzun et al. (2013) use comparative and descriptive statistics in their study. The results of the study conclude that certain factors influence the risk of negative infant health outcomes. Uzun et al. (2013) states that risk factors such as lack of education and low socioeconomic status can contribute to unfavorable outcomes. Mothers age was reported to have a negative effect on infant mortality as well as mothers social circumstances. Practice recommendations based on this research article include the need to further support adolescent mothers in order to avoid negative effects on infants. Evidence Application Maternal education, socio-demographic factors, and economic status are proven contributing factors in determining the health outcomes of infants born to young mothers. Rajaee et al. (2010) argues that maternal age alone does not predict adverse infant outcomes; instead multiple factors contribute to the increase in infant mortality to young mothers. Additionally, Uzun et al. (2013) states many adolescent mothers lack access to adequate prenatal health care. To improve health outcomes of infants Pittard et al. (2008) recommends social support and economic policy change to preserve programs for vulnerable populations,

INFANT MORTALITY predominantly the economically disadvantaged and adolescents. In practice, this would be implemented by education and making referrals as appropriate. Health care clinicians should

advise their patients about factors affecting birth outcomes such as smoking, poor nutrition, drug and alcohol abuse, and insufficient prenatal care. Community networks of health care providers and counselors can play an important role to encourage healthy behaviors by pregnant women. For example Women, Infant, Children (WIC) is a national food and nutritional service that may be used as an additional support service along with community programs offering support, advising, and counseling. Chen et al. (2008) describes preterm delivery and substance abuse in teenage mothers as a major contributing factor to infant mortality. Obstetric office nurses and free care clinics nursing staff have the responsibility of educating young mothers regarding adverse outcomes as it relates to preterm delivery. Specific education to prevent preterm delivery includes avoiding tobacco, illicit drugs, and alcohol as well as eating well, monitoring weight gain, and taking prenatal vitamins. Education can only be successful when the patient is equally involved in their plan of care and patient preferences are explored and implemented. Summary Returning to the original question of research: Are infants born to mothers less than 20 years of age, compared to mothers older than 20 years of age, at risk for higher infant mortality? Evidence of the research reveals there is no single definitive answer. Nonetheless, findings from the literature review reveal that infant mortality is adversely associated with young maternal age because young women are typically at a higher risk for pregnancy complications such as gestational hypertension, preterm and cesarean delivery, directly affecting the infant mortality rates. However, age alone cannot singly be used as a predictor for infant outcomes. Other

INFANT MORTALITY situational circumstances are the most significant determinates of infant mortality. The literatures urge that in order to determine causes of infant mortality, additional maternal and infant characteristics must be considered. Socioeconomic status, educational level, level of

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prenatal care and substance use habits among mothers as well as gestational age and infant birth weight are variable that must be accounted for. Recommendations to utilizing the evidence include increasing awareness in the community about factors that contribute to infant mortality.

INFANT MORTALITY References Centers for Disease Control and Prevention. (2012). Infant Mortality. Retrieved from http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

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Chen, X., Wen, S., Fleming, N., Yang, Q., & Walker, M. C. (2008). Increased risks of neonatal and postneonatal mortality associated with teenage pregnancy had different explanations. Journal of Clinical Epidemiology, 61, 688-694. doi: 10.1016/j.jclinepi.2007.08.009 Rajaee, M., Amirzadeh, S., Mirblook, F., & Soltan, M. M. (2010). The effect of maternal age on pregnancy outcome. Asian Journal of Medical Sciences, 2(3), 159-162. Retrieved from https://fsulearn.ferris.edu/courses/ Pittard III, W. B., Laditka, J. N., & Laditka, S. B. (2008). Associations between maternal age and infant health outcomes among Medicaid-insured infants in South Carolina: Mediating effects of socioeconomic factors. Pediatrics, 122, 100-107. doi: 10.1542/peds.2007-1314 Stetler, C., Brunell, M., Giuliano, K., Morsi, D., Prince, L., & Newell-Stokes, V. (1998). Evidence-based practice and the role of nursing leadership. Journal of Nursing Administration, 28(7/8), 45-53. Uzun, A., Orhon, F., Baskan, S., & Ulukol,. (2013). A comparison between adolescent mothers and adult mothers in terms of maternal and infant outcomes at follow-ups. The Journal of Maternal-Fetal and Neonatal Medicine, 23(5), 454-458. doi: 10.3109/14767058.2012.733748

INFANT MORTALITY Appendix A Evaluation Matrix

Quantitative Research Evaluation Article: Introduction Is the purpose of the study presented? Is the significance (importance) of the problem discussed? Does the investigator provide a sense of what he or she is doing and why? Qualitative Research Evaluation Article: Statement of the phenomenon of interest Is the phenomenon of interest clearly identified? Has the researcher identified why the phenomenon requires a qualitative format? Has the researcher described the philosophic underpinnings of the research? Problem Statement Is the problem statement clear? Does the investigator identify key research questions and variables to be examined? Does the study have the potential to help solve a problem that is currently faced in clinical practice? Purpose Has the researcher made explicit the purpose of conducting the research? Does the researcher describe the projected significance of the work to nursing?

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Literature Review Does the literature review follow a logical sequence leading to a critical review of supporting and conflicting prior work? Is the relationship of the study to previous research clear?

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Does the investigator describe gaps in the literature and support the necessity of the present study? Theoretical framework and hypothesis Is a rational stated for the theoretical/ conceptual framework? Does the investigator clearly state the theoretical basis for hypothesis formulation? Is the hypothesis stated precisely and in a form that permits it to be tested?

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Methodology Are the relevant variables and concepts clearly and operationally defined? Is the design appropriate for the research questions or hypotheses? Are methods of data collection sufficiently described? What are the identified and potential threats to internal and external validity that were present in the study? If there was more than one data collector, was inter-rater reliability adequate? Sample Are the subjects and sampling methods

Method Is the method used to collect data compatible with the purpose of the research? Is the method adequate to address the phenomenon of interest? If a particular approach is used to guide the inquiry, does the researcher complete the study according to the processes described?

Sampling Does the researcher describe the selection of

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described? Is the sample of sufficient size for the study, given the number of variables and design? Is there adequate assurance that the rights of human subjects were protected? Instruments Are appropriate instruments for data collection used? Are reliability and validity of the measurement instruments adequate? Data Collection Is data collection focused on human experience? Does the researcher describe data collection strategies (i.e. interview, observation, field notes)? Is protection of human participants addressed? Is saturation of the data described? Has the researcher made explicit the procedures for collecting data? Data Analysis Are the statistical tests used identified and the values reported? Are appropriate statistics used, according the level of measurement, sample size, sampling method, and hypotheses/ research questions? Data analysis Does the researcher describe the strategies used to analyze the data? Has the researcher remained true to the data? Does the reader understand the procedures used to analyze the data? Does the researcher address the credibility, auditability, and fittingness of the data? Credibility: Do the participants recognize the experience as their own? participants? Is purposive sampling used? Are the informants who were chosen appropriate to inform the research?

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Auditability: Can the reader follow the researchers thinking? Does the researcher document the research process? Fittingness: Can the findings be applicable outside the study situation? Are the results meaningful to individuals not involved in the research? Is the strategy used for analysis compatible with the purpose of the study? Results Are the results for each hypothesis clearly and objectively presented? Do the figures and tables illuminate the presentation of results? Are results described in light of the theoretical framework and supporting literature? Findings Are the findings presented within a context? Is the reader able to grasp the essence of the experience from the report of the findings? Are the researchers conceptualizations true to the data? Does the researcher place the report in the context of what already is known about the phenomenon? Conclusions/ discussion Are conclusions based on the results and related to the hypotheses? Are study limitations identified? Are generalizations made within the scope of the findings? Are implications of findings discussed (i.e. for Conclusion, implications, and recommendations Do the conclusions, implications, and recommendations give the reader a context in which to use the findings? Do the conclusions reflect the study findings? Does the researcher offer recommendations for

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practice, education, and research)? Are recommendations for further research stated? Research utilization implications Is the study of sufficient quality to meet the criterion of scientific merit? Does the study meet the criterion of replicability? Is the study of relevance to practice? Is the study feasible for nurses to implement? Do the benefits of the study outweigh the risks? Summary Statements re usability of article for Evidence Based Nursing Practice: Summary Statements re usability of article for Evidence Based Nursing Practice: future study? Has the researcher made explicit the significance of the study to nursing?

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