Delivering A Very Low Birth Weight Infant and The Subsequent Risk of Divorce or Separation

Article (PDF Available)inMaternal and Child Health Journal 10(6):473-9 · November 2006with 86 Reads
DOI: 10.1007/s10995-006-0146-3 · Source: PubMed
Cite this publication
Abstract
The simultaneous rise over the last two decades in the U.S. in the proportion of VLBW (<1500 grams) deliveries and the improvement in their chance of survival has increased the number of families caring for VLBW infants and children. The families of VLBW infants with adverse outcomes can face psychological and monetary stresses, which in turn may influence marital instability and increase the risk of divorce or separation. The purpose of this paper is to identify the relationship of having a VLBW birth with the probability of divorce or separation in the first two years following delivery. We use data from the 1988 National Maternal and Infant Health Survey (NMIHS). This national stratified, systematic "follow-back" survey augments information from birth records in 1988 by obtaining information on social, demographic, and economic variables from women that delivered a baby in 1988. We estimate a proportional discrete time hazard model of transitions to divorce/separation. Parents of a VLBW infant have 2-fold higher odds of divorce/separation compared with parents of a child with a birth weight greater than 1500 grams. Two years after delivery of a non-VLBW baby 95 percent of the marriages remain stable, while about 90 percent of the marriages remain stable following the birth of a VLBW baby. If the pregnancy was not desired, then only 85 percent of the marriages remain stable 2 years following the delivery of a VLBW infant. There is an evident need to counsel and support families with VLBW infants on mechanisms to cope with the initial stressors that can be anticipated to arise.
Matern Child Health J
DOI 10.1007/s10995-006-0146-3
ORIGINAL PAPER
Delivering A Very Low Birth Weight Infant and The
Subsequent Risk of Divorce or Separation
Shailender Swaminathan · Greg R. Alexander ·
Sheree Boulet
C
Springer Science+Business Media, LLC 2006
Abstract Background: The simultaneous rise over the
last two decades in the U.S. in the proportion of VLBW
(<1500 grams) deliveries and the improvement in their
chance of survival has increased the number of families car-
ing for VLBW infants and children. The families of VLBW
infants with adverse outcomes can face psychological and
monetary stresses, which in turn may influence marital in-
stability and increase the risk of divorce or separation. The
purpose of this paper is to identify the relationship of having
a VLBW birth with the probability of divorce or separation
in the first two years following delivery.
Methods: We use data from the 1988 National Maternal
and Infant Health Survey (NMIHS). This national strati-
fied, systematic “follow-back” survey augments information
from birth records in 1988 by obtaining information on so-
cial, demographic, and economic variables from women that
delivered a baby in 1988. We estimate a proportional discrete
time hazard model of transitions to divorce/separation.
Results: Parents of a VLBW infant have 2-fold higher
odds of divorce/separation compared with parents of a child
with a birth weight greater than 1500 grams. Two years after
delivery of a non-VLBW baby 95 percent of the marriages
remain stable, while about 90 percent of the marriages re-
main stable following the birth of a VLBW baby. If the preg-
S. Swaminathan (
) · S. Boulet
Department of Maternal and Child Health, School of Public
Health, University of Alabama at Birmingham, 320-A Ryals
Building, 1665 University Boulevard,
Birmingham, Alabama 35294-0022, USA
e-mail: SSwaminathan@ms.soph.uab.edu
G. R. Alexander
Department of Pediatrics, College of Medicine,
University of South Florida,
Florida, USA
nancy was not desired, then only 85 percent of the marriages
remain stable 2 years following the delivery of a VLBW
infant.
Conclusions: There is an evident need to counsel and
support families with VLBW infants on mechanisms to cope
with the initial stressors that can be anticipated to arise.
Keywords Very low birth weight
.
Marital status
.
Divorce
.
Family disintegration
.
Race
.
Multiple birth
.
Pregnancy wantedness
.
Total words
Introduction
Over the last two decades, there has been an ongoing rise
in the rate of low birth weight (<2500 grams) deliveries in
the United States [12]. Of particular concern, the annual
percentage of U.S. births that were very low birth weight
(VLBW: <1500 grams) rose from 1.15 to 1.45 between
1980 and 2002, an increase that is partly explained by the
rise in multiple births during that interval [2]. Compared to
normal or moderately low birth weight infants, these very
small newborns have a greatly increased risk of early mor-
tality, although the annual infant mortality rates of VLBW
infants has continued to decrease [3]. Surviving VLBW in-
fants are more likely to suffer significant debilitating con-
sequences, including cerebral palsy, neurological and sen-
sory impairment, mental retardation, learning disabilities and
other school-related problems [411]. Further, the costs as-
sociated with these births are over 10 times greater than
those of normal weight infants and include expenditures for
hospitalization, medical care, comprehensive follow-up, and
special education [7, 12].
In addition to the immediate and long-term adverse con-
sequences for the VLBW newborn, the families of these
Springer
Matern Child Health J
infants also face myriad pressures, including psychological
and monetary stresses that can persist well beyond the initial
hospital stay at the time of delivery [13, 14]. As the number
of U.S. families caring for VLBW infants continues to grow,
the impact of this trend is potentially far-reaching. The con-
sequences could be even greater than supposed if the related
stress on these families also influence marital separation and
divorce.
While having an infant with severe health problems may
increase the chance of divorce for some parents, having a
VLBW or disabled child might pull some spouses closer to-
gether. The shared act of witnessing their VLBW newborn
survive may leave parents with a collective sense of accom-
plishment, once the initial traumatic days after delivery have
passed [1516]. The economics literature suggests other rea-
sons why parents may feel there is more to gain from staying
married in response to the changing circumstances stemming
from the birth of a high-risk infant [17]. Since a VLBW child
makes a higher demand on time than a normal birth weight
baby, the mother might stop working to care for the infant,
while the father continues to work [18]. These choices may
eventually limit the future employment options for a woman
and thereby reduce the probability of her seeking a divorce
or separation [19].
While on one hand, the birth of a high-risk or unhealthy
child may act as a strong deterrent to divorce or separation,
the birth of an infant with serious health care needs may
nevertheless place unanticipated financial, psychological
and time demands on families that may eventually lead to
changes in employment and place of residence, in order to
meet the daily care needs of the child. Research has exam-
ined the role of poor health on marital instability. Evidence
from some of the earliest studies produced inconclusive
results [2023]. However, this absence of accord may not be
surprising, given study limitations that include inadequate
statistical power, lack of appropriate comparison groups,
and diverse approaches used to measure child disability [20].
A few recent studies to explore such effects have mostly
used earlier rounds of the National Health Interview Survey’s
(NHIS) Child Health Supplement or the Fragile Families
and Child Wellbeing Study. The results from these studies
suggest that married couples are more likely to divorce if
their child has a severe health problem [2426].
This limited set of papers has yielded valuable insights,
but is handicapped by a few methodological limitations. In
particular, all these papers use child health information that
is self-reported by the mother, a problem that we are able to
overcome in the present study, as discussed further below.
Moreover, the data from the NHIS and the Fragile Fami-
lies surveys do not contain a sufficient number of VLBW
babies for analysis. This sub-group of children is particu-
larly relevant for our purposes because several studies have
documented the negative health, educational, and earnings
potential of these VLBW babies. We are also able to sur-
mount this limitation in our study.
Despite the ongoing rise in the VLBW rate and its broad
economic ramifications, very few studies have assessed the
magnitude of this event on family disintegration. One recent
study examines the link between ELBW (BW <1000 grams)
and marital stress and divorce and finds negligible asso-
ciations between ELBW and divorce However, that study
used limited multivariate techniques [27]. Numerous health
care providers are often involved with the care of VLBW
cases, including obstetricians, neonatologists, pediatricians,
and specialty-care nurses. These providers have the opportu-
nity to counsel parents regarding the potential marital stres-
sors of caring for a high-risk infant and make referrals for
support services as indicated. In order to establish the need
for such services, the purpose of this paper is to determine if
there is a significant relationship between having a VLBW
birth and subsequent divorce/separation.
Methods
Study population
We used data from the 1988 National Maternal and Infant
Health Survey (NMIHS) and its follow-back survey, which
employed a stratified, systematic sampling scheme [28, 29].
The universe of the NMIHS sample included women be-
tween the ages of 15 and 49 who had a pregnancy outcome
in 1988. Women that deliveredVLBW babies were over sam-
pled. Starting in January of 1989, women were mailed ques-
tionnaires by the National Center for Health Statistics and
nearly 70 percent of the women mailed back the completed
questionnaires. For live births, there were six sampling strata
by race (black, non-black) and birth weight (<1500 grams,
1500–2499 grams, 2500 + grams). Responses to the ques-
tionnaire were received anywhere between 1 and 30 months
from delivery of the child.
We first selected the 9850 women that delivered a live
birth baby that survived beyond one year. Further, be-
cause we are analyzing the transitions from marriage to di-
vorce/separation, we selected only those women that were
married at the time of delivery thereby reducing our sample
size to 6031 live births.We did not exclude multiple births
in order to explore if having more than one infant influ-
enced marital instability. Finally, because we focus on those
women that responded in the first two years following deliv-
ery, our final sample included 6016 live births. Because we
have birth certificate data for all women, we tested for differ-
ences in a few observed characteristics between responders
and non-responders. We found that women that responded to
follow-up are significantly more likely to have VLBW chil-
dren than women that did not respond. Further, the women
Springer
Matern Child Health J
that responded were likely to be slightly less educated and to
have children with lower 1-minute Apgar scores than women
that did not respond. These disparate characteristics of the
responding and non-responding groups suggests that the re-
sponders may be at slightly greaterriskof divorce/separation,
which could result in our estimates of the role of having a
VLBW infant on divorce/separation being conservative.
Main outcome measure
We selected VLBW as a precursor measure of infant and
child health in recognition of the well-established elevated
risk of VLBW infants for infant mortality and developmental
delay [4]. Non-VLBW infants were used in our analysis for
comparison to VLBW infants. Since we wanted to analyze
the effect of a VLBW baby on the risk of divorce, we chose
to analyze marital transitions from delivery of the baby in
1988 to interview date up to 2 years after delivery.
If a woman did not experience a divorce or separation at
the time of the follow-up interview, she was considered a
censored observation. The event history for a woman was
recorded using a sequence of dummy variables Y
ij
where
iindexes woman and j indexes time period.
Y
ij
=
0 if woman is not divorced or separated in month
j after delivery of baby in 1988
1 if woman is divorced or separated in month
j after delivery of baby in 1988
The Y’s will be zero in every time period including the last,
indicating that the woman was never divorced or separated
during the time period through which we follow her. If the
woman was not censored, there will be a sequence of zeroes
terminating in the value one, indicating a divorce in that time
period. Once the value one occurs, no more data is used for
this woman.
It is important to note that the longitudinal framework
for the data is essentially derived using data collected at
one point in time (when the woman responds to the sur-
vey), i.e., using information on the month and year of the
divorce/separation in the case of the uncensored (for whom
divorce/separation has occurred) women and information (in
months) on the time between the delivery of the child and
the date of the interview in the case of the censored women.
In Table 1, we present a list of variables in our analysis.
The following variables were derived from tbe birth records:
VLBW, maternal race, congenital health limitations, multi-
ples or singletons, and the Apgar score. Other variables, such
as whether the woman had any health insurance at the time
of delivery and whether she wanted the pregnancy (mistimed
and unwanted were combined in one category), are derived
from the reports of the woman in the “follow-back” survey.
Missing data was imputed by the National Center for Health
Table 1 Descriptive characteristics of study population NMIHS
sample of married women who delivered a live birth baby in 1998
Variable %/Mean
Very low birth weight (VLBW) 13%
Multiples 6%
VLBW and multiples interaction 2.7%
Mother’s education <12 years 10%
Mother’s education 12–15 years 46%
Father’s education <12 years 8%
Father’s education 12–15 years 42%
Teen Mother (<=19 yrs) 6.5%
Income <100% of poverty 20%
Income 101–200% of poverty 17%
Income 201–300% of poverty 14%
Income 301–400% of poverty 28%
Black race of mother 30%
Non-white and non-black race 4.6%
Health insurance at delivery 75.5%
Years married 4.45
Wanted pregnancy 62.5%
First pregnancy 31.7%
Congenital problem 1.3%
One minute apgar score 7.0
Statistics using the hot-deck approach. Father’s education
was imputed in about 6 percent of observations while house-
hold income is imputed for 13 percent of the observations.
Statistical analysis
The stratified, systematic sampling scheme implies that the
standard errors of estimates derived by assuming a simple
random sampling scheme are incorrect [27]. We used the
software package STATA 8 SE to estimate our models and
correct the standard errors [30].
We use a discrete time hazard model [31]. Since the haz-
ards are conditional probabilities in the discrete time hazard
model, they can be reparameterized so that they have a logis-
tic dependence on the predictors and the time periods [32].
Our model is
log it(Y
ij
) = α
1
D
1
+···α
24
D
24
+β
1
VLBW
+β
2
Multiples +β
3
VLBW
Multiples
+β
4
X +u
ij
(1)
D
1
...D
24
is a series of dummy variables for each month
after delivery of the infant and X is a vector of other covari-
ates such as maternal education, race, household poverty, and
pregnancy wantedness, (i) denotes woman and (j =1...24)
denotes the month of observation following delivery. We ex-
plore the confounding effects of multiple births and include
an interaction with VLBW to see if the effects of VLBW
differ across multiples and singletons. In the model speci-
fied in equation (1), β
1
represents the effect of VLBW on
Springer
Matern Child Health J
divorce/separation for singletons, while β
2
is the effect for
multiples. Despite controlling for these variables in the vec-
tor X, there remains the concern that unknown confounding
factors (say risky behavior of the mother) could be correlated
with both the risk of delivering a VLBW infant and the risk
of divorce/separation. We explore the sensitivity of our esti-
mates to including a broader set of variables that proxy for
mother’s risky behavior such as maternal smoking and drink-
ing behavior during pregnancy. The hazard models provide
us with some key advantages relative to the more commonly
used logistic regression techniques. This is because, as noted
earlier, the interval between delivery and response to ques-
tionnaire ranged from 1–24 months. A logistic regression
model will treat similarly a woman that responded that she
had not divorced/separated at 1 month post-delivery, and a
woman that responded that she had not divorced/separated
at 24 months post-delivery. A discrete time hazard model al-
lows us to model the timing of the divorce/separation rather
than modeling whether or not the event happened.
Results
Based on live birth survivors, Table 1 presents descriptive
characteristics of the study population. Roughly 13 percent of
women in our sample had VLBW babies. Overall, 6 percent
of all births were multiples, while 2.7 percent of mothers
had both VLBW and multiple births. Further, 10 percent of
mothers and 8 percent of fathers had education less than
12 years, while 20 percent of households lived with income
<100 percent of the poverty line where the 1988 poverty
line was determined using data from the Social Security
Administration’s Annual Statistical Supplement. About 62
percent of women reported that they wanted the pregnancy.
For live birth survivors, Table 2 shows that a VLBW
infant increases the odds of divorce/separation (OR: 2.05;
CI: 1.44–2.92) relative to a non-VLBW baby. Multiple births
(relative to singletons) have a protective effect on the risk
of divorce/separation (OR: 0.37; CI: 0.14–0.96). While the
birth of multiples reduces the risk of divorce, having multiple
births that are VLBW results in a nearly 2-fold increase in
the risk of divorce, although the confidence interval on this
estimate (0.57–6.56) is too wide for definite conclusions to
be drawn. Nevertheless, a test of the equality of VLBW
effects for singletons and multiples (β
1
= β
3
in equation 1)
failed to reject the hypothesis of equality. Lower levels of
fathers’ education increased the risk of divorce (OR: 3.35;
CI: 1.88–5.97), but mother’s education did not significantly
alter the risk of divorce. A consistent pattern between family
income and divorcerisk was not apparent, although increased
divorce risk was observed for some income groups, e.g., the
201–300% of poverty group. A significantly different risk
of divorce/separation was not observed among race groups,
Table 2 Adjusted odds rations and 95% Cls for the risk of di-
vorce/separation NMIHS sample of married women who delivered
in 1998
Variable Odds ratio (CI)
VLBW 2.05 (1.44–2.92)
∗∗∗
Multiples 0.37 (0.14–0.96)
VLBW and multiples interaction 1.97 (0.57–6.56)
Mother’s education <12 years 0.71 (0.37–1.36)
Mother’s education 12–15 years 0.90 (0.6–1.36)
Father’s education <12 years 3.35 (1.88–5.97)
∗∗∗
Father’s education 12–15 years 1.12 (0.75–1.68)
Teen mother 1.04 (0.57–1.90)
Income <100% of poverty 1.94 (0.92–4.09)
Income 101–200% of poverty 1.17 (0.55–2.49)
Income 201–300% of poverty 2.02 (1.01–4.05)
∗∗
Income 301–400% of poverty 1.13 (0.56–2.27)
Black race of mother 1.71 (0.82–3.58)
Other race 0.25 (0.06–1.1)
Health insurance at delivery 0.81 (0.51–1.29)
Years married 0.91 (0.86–0.96)
∗∗∗
Wanted pregnancy 0.53 (0.37–0.76)
∗∗∗
First pregnancy 1.06 (0.72–1.58)
Significant p-values <0.10.
∗∗
Significant p-values <.05.
∗∗∗
Significant p-values <0.01.
Reference group: parents of non-VLBW, singleton infants, whites,
education levels 16+ years, income >400 percent of poverty line,
unwanted pregnancy, and at least 1 previous pregnancy. Model does
not constrain the baseline hazard and includes dummy variables for
each possible month between delivery and interview, i.e., months 1
through 24. Those estimates are not presented here, but each of the
dummy variables are significant at the 1 percent level.
which we considered as another proxy indicator for socio-
economic and cultural factors. Similarly, health insurance
coverage at delivery was also not associated with the risk of
divorce. Mothers that report that they wanted the pregnancy
are at lower risk of being separated or divorced. The risk of
divorce declined with increasing number of years married.
Figure 1 displays marriage survival probabilities for each
month following delivery up to two years. The marriage sur-
vival probabilities of families with VLBW and non-VLBW
infants are displayed for two groups: 1) surviving singleton
live births, which comprise the majority of the study sam-
ple, and 2) a subset of births for which the pregnancy was
reported to be unwanted (one of our identified significant
risk factors for divorce). For the singletons, two years after
the birth of a VLBW infant, approximately 90 percent of the
marriages were still intact, while 95 percent of the marriages
remained stable for families with a non-VLBW infant. For
the subset of families with unwanted pregnancies, there is an
even greater disparity in the marriage survival probabilities
and less than 84 percent of these families had intact mar-
riages at two years post-delivery. Survival probabilities for
Springer
Matern Child Health J
Fig. 1 Marriage survival
probabilities
of parents during
the months following their
infant’s delivery by infant’s birth
weight group
multiples are not graphed separately because as noted earlier
no significant differences in the effects of VLBW were found
between multiples and singletons.
Comment
As an appreciable proportion of VLBW infants will have de-
velopmental delays and experience serious disabilities, the
simultaneous rise in the proportion of VLBW deliveries in
the U.S. and the improvement in their chance of survival has
important implications for the allocation of critical long-term
health care and social support services, as well as for related
insurance costs. Our findings reveal that married mothers
of VLBW infants are more that twice as likely to become
divorced/separated than married mothers of non-VLBW in-
fants in the first two years following delivery. The risk of
divorce is even greater for population subsets with specific
characteristics associated with the risk of divorce, e.g. preg-
nancy wantedness. However, we recognize that the effect of
pregnancy wantedness on divorce/separation might be biased
if divorced mothers are more likely to report that they did
not want the pregnancy.
There are important limitations to this study that must
be considered. Data on the interval between delivery and
interview are only available in sufficient detail for two years
after delivery. Thus, our results do not reveal if the risk of
a divorce for a family with a VLBW child will increase
again after the child is older (say 2–6 years). Second, part of
the observed associative link between VLBW and the risk
of divorce or separation could be a result of serving as a
proxy for other early life health conditions such as lower
apgar scores. We re-ran our models including an indicator
of congenital abnormalities and 1-minute Apgar scores. We
find that the estimates of VLBW remain very robust to the
inclusion of these additional variables and the additional
health status indicators do not lead to an increase in the odds
of divorce/separation, over and above the increased odds
associated with a VLBW infant. In addition, to the extent
that VLBW is an error-prone measure of child disability, our
estimates may be regarded as conservative estimates of the
effect of child disability on divorce or separation.
Springer
Matern Child Health J
Another factor that could potentially confound the effects
of VLBW is maternal risky behavior during pregnancy. In
particular, consider a situation where a marriage was unsta-
ble even prior to the birth of the baby in 1988 but no formal
divorce or separation occurred prior to the birth in 1988.
The unstable marriage might have resulted in the mother in-
dulging in risky behaviors such as drinking or smoking dur-
ing pregnancy. The above scenario could potentially result
in both a VLBW baby and a marriage that ends in either a di-
vorce or separation. Thus, what we are attributing to VLBW
might infact be a result of unmeasured factors (risky behavior
during pregnancy as a result of an unhappy marriage) that are
correlated with both VLBW and marital dissolution. To alle-
viate some of these concerns, we included separate dummy
variables for whether or not the mother drank or smoke dur-
ing pregnancy as proxy variables for maternal risky behavior.
We observed that our VLBW estimates changed very little
as a result of this modification in the model specification.
Beyond alleviating some concern about bias from unknown
confounders, understanding the possible underpinnings of
these findings (e.g., are lower divorce risks related to lower
long-run psychological and monetary costs?) will require
further research, which may lead to improvements in our
ability to adequately counsel patents making decisions about
infants born at the limit of viability or with little chance of
survival. An important caveat in this study is that one third
of births in the U.S. take place outside of marriage and un-
married mothers have higher rates of VLBW than married
mothers. The burdens of VLBW may be particularly high
for unmarried mothers. However, we do not consider these
women in our analysis because the focus of this paper is on
the transition from marriage to divorce/separation.
Finally, this paper uses data from the 1988–1990 period
and is thus not using current data. These data are among
the few available data sets with the necessary structure and
variables required for this research. Moreover, we have not
identified persuasive reasons to expect that the costs or stress
associated with caring for a VLBW infant have declined over
the last decade. Nevertheless, this is a concern for further
investigation with national surveys that might emerge in the
future.
These study results indicate that families with VLBW
infants exhibit a multi-fold risk of marital instability and di-
vorce, which may further increase in the presence of other
factors, including pregnancy wantedness. As divorce in these
circumstances likely has broad long-term consequences for
these infants and their siblings and parents, there is a need to
counsel and support families with VLBW children on mecha-
nisms to cope with the initial stressors that can be anticipated
to arise. We are cognizant of the fact that a significant pro-
portion of the VLBW babies go on to lead perfectly normal
lives. Yet, our results suggest that parents are often mak-
ing divorce/separation decisions within the first 2 years after
delivery of the VLBW infant. Thus, informed counseling
about the chances of the VLBW, premature child regaining
normal physical and mental functioning over the medium
to long-run may could prove extremely useful in reducing
divorce rates. For families employing artificial reproductive
technology, which may increase the risk of multiple and
VLBW births, disclosure of the potential risks of divorce
may well be indicated. Given the rising rate of VLBW births
and their increasing survival, family-oriented policies and
programs are indicated to assure that families with VLBW
infants have more reasonable prospects of staying intact and
being self-sufficient.
Acknowledgement This work was supported in part by DHHS,
HRSA, MCHB grant 5T76MC00008.
References
1. Arias E, MacDorman MF, Strobino DM, Guyer B. Annual sum-
mary of vital statistics – 2002. Pediatr 2003;112:1215–30.
2. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F,
Munson ML. Births: Final Data for 2002. Natl Vital Stat Rep
2003;52:1–116.
3. MacDorman MF, Martin JA, Matthews TJ, Hoyert DL, Ventura SJ.
Explaining the 2001–2002 infant mortality increase: data from the
linked birth/infant death data set. Natl Vital Stat Rep 2005;53:1–
24.
4. McCormick MC. The contribution of low birth weight to infant
mortality and childhood morbidity. N Engl J Med 1985;312:82–
9.
5. Allen MC. Limits of viability in the newborn. In: Burg FD, In-
gelfinger JR, Wald ER, Polin RA (eds.). Current Pediatric Therapy.
Philadelphia, PA: WB Sauders Co.; 1999:368–71.
6. Allen MC, Donohue PK, Dusman AE. The limit of viability
neonatal outcome of infant born at 22 to 25 weeks’ gestation. N
Engl J Med 1993;329:1597–1601.
7. McCormick MC, Brooks-Gunn J, Workman-Daniels K, Turner J,
and Peckham GJ. The health and developmental status of very low
birth weight children at school age. JAMA 1992;267:2204–8.
8. Seidman DS, Laor A, Gale R, Stevenson DK, et al. Birth weight
and intellectual performance in late adolescence. Obstet Gynecol
1992;79:543–6.
9. LaPine TR, Jackson JC, Bennett FC. Outcome of infants weigh-
ing less than 800 grams at birth: 15 years experience. Pediatr
1995;96:479–83.
10. Lorenz JM, Wooliever DE, Jetton JP, Paneth N. A quantita-
tive review of mortality and development disability in extremely
premature newborns. Arch Pediatr Adolesc Med 1998;152:425–
35.
11. Vohr BR, Wright LL, Dusick AM, et al. Neurological and func-
tional outcomes of extremely low birth weight infants in the Na-
tional Institute of Child Health and Human Development Neonatal
Research network, 1993–1994. Pediatr 2000;105:1216–26.
12. Hack M, Klein NK, Taylor G. Long-term developmental outcomes
of low birth weight infants. Future Child 1995;5:176–96.
13. Darling RB. The Economic and Psychosocial Consequences
of Disability: Family-Society Relationships. Marriage Fam Rev
1987;11:45–61.
14. Yura MT. Family Subsystem Functions and Disabled Children:
Some Conceptual Issues. Marriage Fam Rev 1987;11:135–51.
Springer
Matern Child Health J
15. Lee SK, Penner PL, Cox MC. Comparison of the attitudes of health
care professionals and parents toward active treatment of very low
birth weight infants. Pediatr 1991;88:110–4.
16. Singer LT, Salvator MS, Guo S, Collin M, Lilien L, Baley J.
Maternal psychological distress and parenting stress after the birth
of a very low birth weight infant. JAMA 1999;281:799–805.
17. Becker GS, Landes EM, Michael RT. An economic analysis of
marital instability. J Political Economy 1977;85:1141–88.
18. Powers ET. New estimates of the impact of child disability on
maternal employment. AEA Pap Proc 2001;91:135–39.
19. Rankin RP, Maneker JS. The duration of marriage in a divorcing
population: the impact of children. J Marriage Fam 1985;47:43–
52.
20. Sabbeth BF, Leventhal JM. Marital adjustment to chronic child-
hood illness: a critique of the literature. Pediatr 1984;73:762–
8.
21. Lansky SB, Cairns NU, Hassanein R, Wehr J, Lowman JT. Child-
hood cancer: parental discord and divorce. Pediatr 1978;62:184–
88.
22. Joesch JM, Smith KR. Children’s health and their mother’s risk of
divorce or separation. Soc Biol 1997;44:159–69.
23. Taanila A, Kokkonen J, Javelin MR. The long-term effects of chil-
dren’s early onset disability on marital relationships. Dev Med
Child Neurol 1996; 38:567–677.
24. Corman H, Kaestner R. The effects of child health on marital status
and family structure. Demography 1992;29:389–408.
25. Mauldon J. Children’s risk of experiencing divorce and remar-
riage: do disabled children destabilize marriages? Popul Stud
1992;46:349–62.
26. Reichman NE, Corman H, Noonan K. Effects of child health on
parents’ relationship status. Demography 2004;41:569–84.
27. Saigal S, Burrows E, Stoskopf BL, Rosenbaum PL, Streiner D. Im-
pact of Extreme Prematurity on Families of Adolescent Children.
J Pediatr, 137(5):701–6.
28. National Maternal and Infant Health Survey, U.S. Department of
Health and Human Services, National Center for Health Statis-
tics, Inter-University Consortium for Political and Social Research
9730.
29. Sanderson M, Placek PJ, Keppel KG. The 1988 National Maternal
and Infant Health Survey: design, content, and data availability.
Birth 1991;18(1):26–32.
30. STATA Statistical Software [computer program]. Release 8.0. Col-
lege Station, Tex: Stata Corp; 2004.
31. Singer JD, Willet JB. Applied Longitudinal Data Analysis: Model-
ing Change and Event Occurrence. Oxford University Press, 2003.
New York. Chapters 11 &12.
32. Efron B. Logistic Regression, Survival Analysis, and the Kaplan-
Meier Curve. J Am Stat Assoc 1988;83:414–25.
Springer
VLBW_divorce2006.pdf
304.45 KB
  • Article
    Full-text available
    A body of literature has investigated female mate choice in the pre-mating context (pre-mating sexual selection). Humans, however, are long-living mammals forming pair-bonds which sequentially produce offspring. Post-mating evaluations of a partner's attractiveness may thus significantly influence the reproductive success of men and women. I tested herein the theory that the attractiveness of putative sons provides extra information about the genetic quality of fathers, thereby influencing fathers' attractiveness across three studies. As predicted, facially attractive boys were more frequently attributed to attractive putative fathers and vice versa (Study 1). Furthermore, priming with an attractive putative son increased the attractiveness of the putative father with the reverse being true for unattractive putative sons. When putative fathers were presented as stepfathers, the effect of the boy's attractiveness on the stepfather's attractiveness was lower and less consistent (Study 2). This suggests that the presence of an attractive boy has the strongest effect on the perceived attractiveness of putative fathers rather than on non-fathers. The generalized effect of priming with beautiful non-human objects also exists, but its effect is much weaker compared with the effects of putative biological sons (Study 3). Overall, this study highlighted the importance of post-mating sexual selection in humans and suggests that the heritable attractive traits of men are also evaluated by females after mating and/or may be used by females in mate poaching.
  • Article
    We aimed to identify mothers at risk for poorer maternal mental health (MMH) one month post-partum and to determine changes in MMH over four years in relation to birth circumstances (singleton/twins, full-term/pre-term infant/s, first/non-first child), internal resources (adult attachment styles), and external resources (marital quality and maternal grandmother’s support) at one month post-partum. The mediating effects of external resources were also investigated. Questionnaires were completed between 2001 and 2012 by 561 Israeli mothers. Shortly after birth, mothers at risk for poorer MMH were those who gave birth prematurely or were characterized by insecure attachment styles, lower marital quality, younger age, or a higher level of education. The mothers with a good prognosis for improvement in MMH were those who had given birth prematurely or were younger, more highly educated, or multiparous. Women with insecure attachment or lower marital quality reported lower MMH one month after delivery that did not improve over time, and the MMH of older or less educated mothers deteriorated over time. Marital quality mitigated or exacerbated the effects of birth circumstances and insecure attachment style on MMH shortly after giving birth. Findings suggested that early interventions may be important to help identify women at risk.
  • Objective: To examine how parents describe the distress of early preterm birth in the months and years after the infant's hospital discharge. Design: Discourse analysis of in-depth interviews and photo elicitation. Setting: Homes or cafés in the Pacific Northwest United States. Participants: Parents of premature infants born between 24 and 30 weeks gestation (N = 10) who experienced significant distress in and out of the hospital. Parents participated in the study when their children were between 15 months and 8 years old. Methods: Participants described dealing with prematurity, emotional distress, and parenting in individual interviews and returned for second interviews in which they further described their distress using photographs. Data were analyzed using discourse analysis. Results: Parents described preterm birth, hospitalization, and the aftermath as ongoing traumatic events. Discourses of distress included the Perfect Child, the Good Mother, and the Good Father. Parents used these discourses to reconcile the loss of an idealized birth and parenting after the birth of a premature child. Isolation and Medicalized Parenting were used to explain how parents struggled to interact within their social networks and to parent under challenging circumstances. Conclusion: Participants described their trauma and distress in ways not captured by psychiatric diagnoses such as depression and anxiety. Findings may help nurses be aware of the negative effects of preterm birth and respond to parents' emotional needs.
  • Hintergrund: Die Prävention und Behandlung der Frühgeburt gehört auch heute noch zu den ungelösten Problemen der Geburtshilfe. Progesteron entfaltet eine Vielzahl von Wirkungen auf Myometrium und Zervix, u. a. eine Hemmung der Myometriumkontraktion und eine zervixstabilisierende Wirkung durch Inhibition proinflammatorischer Zytokine und konsekutiv der Produktion von Prostaglandinen sowie durch die Reduktion der Expression von Proteinen, die für die Wehentätigkeit von Bedeutung sind. Daher ist Progesteron ein vielversprechender Kandidat zur Prävention der Frühgeburt. Material und Methode: In PubMed wurde eine Literaturrecherche des Zeitraumes 1956–August 2014 durchgeführt, der folgende Suchbegriffe zugrunde lagen: Frühgeburt und Progesteron oder 17-OHPC oder Progestin. Ergebnisse: (i) Frauen mit Einlingsschwangerschaften sollten nach vorangegangener Frühgeburt täglich vaginales Progesteron (200 mg Kapsel oder 90 mg Gel) von der 16+0 bis 36+0 SSW erhalten (alternativ: 250 mg 17-OHPC intramuskulär wöchentlich): Level of Evidence Ia, Empfehlungsgrad ++ . Die prophylaktische Applikation von Progesteron führt zu einer signifikanten Senkung der Rate an Frühgeburten <34 und < 37 SSW sowie zu einer Verminderung der perinatalen Mortalität. (ii) Frauen mit Einlingsschwangerschaften und einer sonografisch gemessenen Zervixlänge von ≤25 mm vor der 24+0 SSW sollten täglich Progesteron vaginal (200 mg Kapsel oder 90 mg Gel) bis zur 36+6 SSW erhalten: Level of Evidence Ia, Empfehlungsgrad ++ . Dieses Vorgehen führt zu einer signifikanten Senkung der Rate an Frühgeburten < 28, < 33 und < 35 SSW sowie zu einer Reduktion der neonatalen Morbidität. (iii) Es fehlen bisher Evidenz-basierte Daten, um Progesteron oder 17-OHPC zur primären Tokolyse oder in Kombination mit konventionellen Tokolytika (adjunktive Tokolyse) zu empfehlen. (iv) Es besteht eine zunehmende Evidenz, dass vaginales Progesteron (400 mg/Tag) nach initialer Tokolyse mit Sistieren der Wehen als Erhaltungstherapie zu einer signifikanten Verlängerung der Schwangerschaft führt: Level of Evidence Ib, Empfehlungsgrad +. (v) Die Datenlage zur Anwendung von vaginalem Progesteron nach vorzeitigem Blasensprung und als perioperative Maßnahme im Rahmen einer Zerklage ist unzureichend, um hieraus Evidenz-basierte Empfehlungen ableiten zu können. (vi) Die vaginale Applikation von Progesteron wird von den Schwangeren gut toleriert ohne signifikante Nebenwirkungen, die intramuskuläre Applikation von 17-OHPC intramuskulär ist dagegen mit einer deutlich höheren Rate an mütterlichen Nebenwirkungen (z. B. lokale Schmerzen, Übelkeit, Diarrhoe) assoziiert, die Frauen sind über den off-label use von Progesteron in der Schwangerschaft aufzuklären. Diskussion: Die prophylaktische Gabe von Progesteron ist eine evidenzbasierte Maßnahme zur Prävention der Frühgeburt bei Frauen mit Einlingsschwangerschaft nach vorangegangener Frühgeburt und bei Schwangeren mit sonografisch verkürzter Zervix (≤ 25 mm) vor der 24. SSW. Die vaginale Applikation von Progesteron ist der intramuskulären Injektion von 17-OHPC insbesondere aufgrund der geringeren Rate maternaler NW vorzuziehen. Ob Progesteron zur primären oder adjunktiven Tokolyse oder zur Erhaltungstherapie nach initialer Tokolyse mit Sistieren der Wehen eine effektive Option zur Behandlung der Frühgeburt darstellt, muss in weiteren gut konzipierten randomisierten klinischen Studien mit ausreichender statistischer Power geklärt werden.
  • Article
    Full-text available
    Streszczenie Ciąża jest sytuacją bar dzo ważną i znaczącą w życiu kobiety i jej męża/partnera. Wiąże się z podejmowaniem przez nich nowej roli rodzicielskiej oraz ze zmianami emocjonalnymi i zmianami w funkcjonowaniu systemu rodzinnego. Oczekiwanie na potomka może zbliżać rodziców do siebie bądź też wpływać na pogorszenie relacji między nimi. Istotna jest akceptacja ciąży przez ojca dziecka, jego wsparcie oraz dzielenie doświadczeń związanych z ciążą, co pomaga kobiecie w przygotowaniu się do roli matki. Szczególną sytuacją wydaje się być ciąża mnoga, która wiąże się z koniecznością zaakceptowania więcej niż jednego dziecka oraz z obawami (lękiem, strachem) wywołanymi możliwością wystąpienia powikłań prenatalnych i okołoporodowych. Cel: Celem pracy była ocena jakości związku małżeńskiego kobiet z ciążą jednopłodową i wielopłodową. Materiał i metody: Przebadanych zostało 111 kobiet z ciążą jedno-płodową (N = 74) i wielopłodową (N = 37). W badaniu zastosowano Kwestionariusz wywiadu własnego autorstwa oraz Skalę G.B. Spaniera DAS służącą do oceny jakości związku małżeńskiego. Wyniki: Wyniki ujawniły, że zarówno kobiety w ciąży jednopłodowej jak i mnogiej oceniają jakość swojego związku małżeńskiego na poziomie średnim, przy czym kobiety z ciążą pojedynczą uzyskały wyniki bliskie progu wysokiej oceny jakości związku, a matki z ciążą mnogą bliskie progu niskiej oceny tej jakości. Nie uzyskano istot-nych różnic między ogólnymi wskaźnikami jakości związku w obu badanych grupach, jak również między ich aspektami (zgodność, spójność, satysfakcja, ekspresja emocjonalna). Korelacje skali DAS i Kwestionariusza wywiadu ujawniły, że istnieją istotne związki dla całej grupy badanej i grupy z ciążą pojedynczą miedzy liczbą posiadanych dzieci a satysfakcją i wynikiem ogólnym jakości związku. W ciąży mnogiej zależności te obejmują satysfakcję i liczbę posiadanych dzieci, satysfakcję oraz skalę Apgar, zgodność i wa-gę urodzeniową oraz zestawienie wyniku ogólnego jakości związku z terminem rozwiązania porodu i wyniku ogólnego z wagą urodze-niową. Wnioski: Relacje z partnerem i rodzaj ciąży w jakiej jest kobieta ma/może mieć znaczenie dla odczuwanej satysfakcji z włas
  • Article
    In this study, the researchers examined, from an attachment theory perspective, changes in mothers’ (n = 707) perception of the marital relationship over the course of the two years following childbirth. We found a decline in perceived quality of mothers’ marital relationship over time, as well as several significant associations between birth circumstances (assisted reproductive technology, first/non-first baby), insecure attachment, and certain forms of support from the grandmothers on the one hand, and marital quality immediately after childbirth and over time on the other. Some forms of support served as partial mediators between attachment orientation and marital quality. We believe that the current findings can assist in designing interventions aimed at improving the spousal relationship after childbirth and decreasing potential stressors for both parents and newborns.
  • Article
    Full-text available
    Parenting a preterm infant is more challenging than a full-term one. Parent involvement in early intervention programs seems to have positive psychosocial effects on both the child and parent. CareToy is an innovative smart system that provides an intensive individualized home-based family-centred EI in preterm infants between 3 and 9 age-corrected months. A RCT study, preceded by a pilot study, has been recently carried out to evaluate the effects of CareToy intervention on neurodevelopmental outcomes with respect to Standard Care. This study aims at evaluating the effects of CareToy early intervention on parenting stress in preterm infants. Parents (mother and father) of a subgroup of infants enrolled in the RCT filled out a self-report questionnaire on parenting stress (Parenting Stress Index-Short Form (PSI-SF)) before (T0) and after (T1) the CareToy or Standard Care period (4 weeks), according to the allocation of their preterm infant. For twins, an individual questionnaire for each one was filled out. Results obtained from mothers and fathers were separately analysed with nonparametric tests. 44 mothers and 44 fathers of 44 infants (24 CareToy/20 Standard Care) filled out the PSI-SF at T0 and at T1. CareToy intervention was mainly managed by mothers. A significant ( p<0.05 ) reduction in Parental Distress subscale in the CareToy group versus Standard Care was found in the mothers. No differences were found among the fathers. CareToy training seems to be effective in reducing parental distress in mothers, who spent more time on CareToy intervention. These findings confirm the importance of parental involvement in early intervention programs. This trial is registered with Clinical Trial.gov NCT01990183 .
  • Article
    Full-text available
    Objective The objective of this study was to investigate both the effects of low gestational age and infant’s neurodevelopmental outcome at 2 years of age on the risk of parental separation within 7 years of giving birth. Design Prospective. Setting 24 maternity clinics in the Pays-de-la-Loire region. Participants This study included 5732 infants delivered at <35 weeks of gestation born between 2005 and 2013 who were enrolled in the population-based Loire Infant Follow-up Team cohort and who had a neurodevelopmental evaluation at 2 years. This neurodevelopmental evaluation was based on a physical examination, a psychomotor evaluation and a parent-completed questionnaire. Outcome measure Risk of parental separation (parents living together or parents living separately). Results Ten percent (572/5732) of the parents reported having undergone separation during the follow-up period. A mediation analysis showed that low gestational age had no direct effect on the risk of parental separation. Moreover, a non-optimal neurodevelopment at 2 years was associated with an increased risk of parental separation corresponding to a HR=1.49(1.23 to 1.80). Finally, the increased risk of parental separation was aggravated by low socioeconomic conditions. Conclusions The effect of low gestational age on the risk of parental separation was mediated by the infant’s neurodevelopment.
  • Chapter
    This chapter examines the clinical dimension of preterm birth as it reflects guiding interpretative paradigms in Western medicine. The chapter examines current clinical beliefs about the triggers for two types of early delivery, the type that occurs when pregnant women spontaneously go into labor before their pregnancy reaches 37 weeks gestation, and the type that occurs when physicians intervene to deliver a baby early, in order to avoid complications anticipated if the pregnancy is allowed to continue. It also describes the therapies that have been tried to prevent preterm births, and notes that nearly all of them have failed. Treatment for newborns born preterm is more successful than preventive interventions, but still, a significant portion of infants born very prematurely die or suffer serious long-term consequences. It is not possible, at the point of delivery, to determine with certainty what the outcome will be for any given preterm infant. After a discussion of alternative ways to think about preterm birth besides as a single syndrome or disease-like phenomenon, this chapter concludes with a discussion of the clinical perspective on the reasons that the U.S. preterm birth and preterm survival rates are higher than those in Canada, Great Britain, and Western Europe.
  • Article
    Full-text available
    Background: Mothers caring for children with disability experience a number of challenges. Aim: The aim of the study was to explore the challenges that mothers who cared for children with cerebral palsy (CP) living in Zambia experienced. Methods: During a qualitative study the experiences of 16 conveniently sampled mothers of children with CP, from the Ndola district in Zambia, were explored by means of interviews. The responses were thematically analysed. All the necessary ethical considerations were upheld. Results: Mothers experienced social isolation and marital problems, as well as negative attitudes from family, friends, community members and health care professionals. The physical environment created access challenges because of a lack of sidewalks, ramps, functioning lifts and small indoor spaces. Conclusion: Mothers of children with CP feel socially isolated owing to a lack of support from family, community members, and health care providers. This social isolation was exacerbated by attitudes of others towards the mothers; it was felt that mothers were responsible for their children’s condition. Mothers also experienced marital problems as a result of having a child with CP.
  • Article
    Objective. —To assess the effect of improved survival of increasingly premature infants by examining the outcomes at school age of a large group of children born at different birth weights. Design. —Inception cohort. Setting/Participants. —Participants were selected from two previously studied multisite cohorts: very low—birth-weight (≤1500 g) children referred to participating intensive care units and heavier birth-weight children drawn from a stratified random sample of births in geographically defined regions. Follow-up at 8 to 10 years of age was by a combination of telephone interview and home/clinic visits for 65.1% (1868) of those eligible. Main Outcome Measures. —The presence or absence of 17 specific conditions, limitations in activities of daily living due to health, mental health (affective health, behavior problems), and, for a subset, IQ scores. Results. —Decreasing birth weight was associated with an increased morbidity for all measures except affective health; those with birth weights of 1500 g or less were more likely to experience multiple health problems. Maternal educational attainment did not influence the association of birth weight with morbidity except for IQ among children whose birth weight was above 1000 g, for which socioeconomic disadvantage worsened the status of all children irrespective of birth weight. Conclusions. —Children born at lower birth weights experience increased morbidity at early school age. These results reinforce the importance of postdischarge, early intervention programs to reduce the risk of these later health problems.(JAMA. 1992;267:2204-2208)
  • Article
    Two hypotheses were tested by means of multiple regression and elaboration relative to the duration of marriage in the 1977 divorcing population of 11,559 families in northern California—counties of Butte, Marin, Sacramento, and San Francisco. The first hypothesis that the presence of children is associated with longer duration (five years or more) was supported even when we controlled for spouses' education, age at marriage, previous divorce, race, length of stay in California, and spouse filing for divorce. The second hypothesis that the presence of children younger than age 2 was also associated with longer marital duration was not supported. This latter finding prompts ideas for further research and suggestions for marriage education and divorce counseling.
  • Book
    Change is constant in everyday life. Infants crawl and then walk, children learn to read and write, teenagers mature in myriad ways, and the elderly become frail and forgetful. Beyond these natural processes and events, external forces and interventions instigate and disrupt change: test scores may rise after a coaching course, drug abusers may remain abstinent after residential treatment. By charting changes over time and investigating whether and when events occur, researchers reveal the temporal rhythms of our lives. This book is concerned with behavioral, social, and biomedical sciences. It offers a presentation of two of today's most popular statistical methods: multilevel models for individual change and hazard/survival models for event occurrence (in both discrete- and continuous-time). Using data sets from published studies, the book takes you step by step through complete analyses, from simple exploratory displays that reveal underlying patterns through sophisticated specifications of complex statistical models.
  • Article
    We discuss the use of standard logistic regression techniques to estimate hazard rates and survival curves from censored data. These techniques allow the statistician to use parametric regression modeling on censored data in a flexible way that provides both estimates and standard errors. An example is given that demonstrates the increased structure that can be seen in a parametric analysis, as compared with the nonparametric Kaplan-Meier survival curves. In fact, the logistic regression estimates are closely related to Kaplan-Meier curves, and approach the Kaplan-Meier estimate as the number of parameters grows large.
  • Article
    To assess the effect of improved survival of increasingly premature infants by examining the outcomes at school age of a large group of children born at different birth weights. Inception cohort. Participants were selected from two previously studied multisite cohorts: very low-birth-weight (less than or equal to 1500 g) children referred to participating intensive care units and heavier birth-weight children drawn from a stratified random sample of births in geographically defined regions. Follow-up at 8 to 10 years of age was by a combination of telephone interview and home/clinic visits for 65.1% (1868) of those eligible. The presence or absence of 17 specific conditions, limitations in activities of daily living due to health, mental health (affective health, behavior problems), and, for a subset, IQ scores. Decreasing birth weight was associated with an increased morbidity for all measures except affective health; those with birth weights of 1500 g or less were more likely to experience multiple health problems. Maternal educational attainment did not influence the association of birth weight with morbidity except for IQ among children whose birth weight was above 1000 g, for which socioeconomic disadvantage worsened the status of all children irrespective of birth weight. Children born at lower birth weights experience increased morbidity at early school age. These results reinforce the importance of postdischarge, early intervention programs to reduce the risk of these later health problems.
  • Article
    In this paper, U.S. data from the 1981 Child Health Supplement are used to estimate the effect of a child's disability or serious chronic illness on: (1) the risk of the parents' divorcing before the child reaches the age of 11, and (2) the mother's chances of remarriage after divorce. Divorce is significantly more common among the parents of disabled or sickly children than among those of healthy children, and these disruptive effects of a child's frailty are even stronger when children are between six and nine years old than when they are younger. Possibly, divorce only becomes a viable option for some parents once a sickly child has started to spend part of the day away from home, in school. In contrast, a child's health status does not predict the mother's waiting time to remarriage. A range of potentially confounding demographic factors are controlled in the models, and their effects on children's chances of experiencing parental divorce are as expected. For example, having a mother who married young significantly predicts parental divorce.