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Consideration of Abortion in Pregnancy: Demographic Characteristics, Mental Health, and Protective Factors a
Amy M. Claridge MEd & Casey L. Chaviano MSW
a
a
Department of Family and Child Sciences , College of Human Sciences, The Florida State University , Florida , USA Accepted author version posted online: 07 Aug 2013.Published online: 11 Nov 2013.
To cite this article: Amy M. Claridge MEd & Casey L. Chaviano MSW (2013) Consideration of Abortion in Pregnancy: Demographic Characteristics, Mental Health, and Protective Factors, Women & Health, 53:8, 777-794, DOI: 10.1080/03630242.2013.831018 To link to this article: http://dx.doi.org/10.1080/03630242.2013.831018
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Women & Health, 53:777–794, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2013.831018
Consideration of Abortion in Pregnancy: Demographic Characteristics, Mental Health, and Protective Factors
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AMY M. CLARIDGE, MEd and CASEY L. CHAVIANO, MSW Department of Family and Child Sciences, College of Human Sciences, The Florida State University, Florida, USA
This study examined demographic characteristics, available resources, and mental health outcomes of women who did and did not consider abortion in pregnancy. Using data collected between 1998 and 2000 from 2,937 mothers recruited for the Fragile Families and Child Well-Being Study, this study examined whether women who did and did not consider abortion differed in terms of sociodemographic characteristics and resources at the birth of their children and mental health outcomes when their children were one year old. This study further examined protective factors associated with low parenting stress at one year postpartum, despite initial abortion consideration. Compared to women who did not consider abortion, women who did consider abortion tended to be younger, have less education and lower income, and report higher levels of substance use, higher perceived support, and lower received support. A subset of women who had higher education, more income, and lower substance use reported lower parenting stress at year one despite abortion consideration in pregnancy. Promotion of education and employment assistance may
Received December 15, 2012; revised July 26, 2013; accepted July 29, 2013. The authors thank the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) through grants R01HD36916, R01HD39135, and R01HD40421, as well as a consortium of private foundations for their support of the Fragile Families and Child Well-Being Study. An earlier version of this article was presented at the 2012 American Association for Marriage and Family Therapy Annual Conference. Address correspondence to Amy M. Claridge, MEd, Department of Family and Child Sciences, The Florida State University, College of Human Sciences, 225 Sandels Building, Tallahassee, FL 32306-1491. E-mail: [email protected] 777
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be particularly important among women experiencing unplanned pregnancies as these services may contribute to lower parenting stress and improved child outcomes.
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KEYWORDS health
abortion, pregnancy, protective factors, women’s
Existing research on mothers or couples who consider abortion has examined the impact of deciding to terminate pregnancy on women’s mental health. We propose a shift toward the context surrounding pregnancy decisions, which may be a better indicator of future outcomes than the decision itself. Pregnancy may be more stressful when it is unplanned (Geller, 2004; Hohmann-Marriott, 2009). Therefore, the present study examined the contextual factors surrounding those who likely experienced unplanned pregnancy, and specifically reported considering abortion, in comparison to those who did not consider abortion. The study also examined protective factors at baseline that were related to positive outcomes at one year postpartum. Understanding the context surrounding individuals who considered abortion in pregnancy but did not experience the typical negative outcomes associated with unplanned pregnancy will help clinicians serve pregnant women and their families better.
BACKGROUND Pregnancy Intention Unplanned pregnancy is prevalent in the United States and worldwide with 41% of pregnancies worldwide unplanned in 2008 (Singh, Sedgh, & Hussain, 2010), and 49% of U.S. pregnancies unplanned in 2001 (Centers for Disease Control and Prevention, 2013). Among the unplanned pregnancies in the United States, around 38% end in abortion, 14% end in miscarriage, and 48% result in live births (Singh et al., 2010). Many studies have examined the women who have undergone abortion. However, the majority of unplanned pregnancies are carried to term, and researchers should also explore the experience of the individuals and couples involved in unplanned pregnancies who ultimately become parents. Various demographic variables have consistently been associated with unplanned pregnancy. Unplanned pregnancy rates are higher among racial and ethnic minorities (Maxson & Miranda, 2011), and women who are unmarried (Finer & Henshaw, 2006; Maxson & Miranda, 2011), young (Finer & Henshaw, 2006; Kost & Forrest, 1995), do not have a high school diploma (Finer & Henshaw, 2006), or who are socioeconomically disadvantaged (Forrest, 1994; Kost & Forrest, 1995). Outcomes associated with unplanned pregnancy may also be related to these demographic characteristics.
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On the other hand, the actual experience of an unplanned pregnancy may affect later outcomes. Pregnancy generally is a stressful experience for women (Cohen & Roth, 1984; Olson, 1980) and is likely additionally stressful when facing the risk factors associated with an unplanned pregnancy (Geller, 2004) or when partners’ perceptions about the pregnancy conflict with each other (Hohmann-Marriott, 2009). Longitudinally, unplanned pregnancy is associated with negative outcomes among children, including poor physical health and delayed development among three-year-olds (Crissey, 2005) and internalizing and externalizing behaviors among adolescents (Hayatbakhsh et al., 2011) and young adults (Axinn, Barber, & Thornton, 1998). Mothers of unplanned pregnancy are more likely to experience postpartum depression (Miller, Sable, & Beckmeyer, 2009; Sayil, Güre, & Uçanok, 2007), anxiety (East, Chien, & Barber, 2012), perceived stress, (Miller et al., 2009) low self-efficacy (Sayil et al., 2007), and engage in harsh parenting behaviors (East et al., 2012) than mothers who have had planned pregnancies. Limited research, with a small, socioeconomically advantaged sample, suggested that unplanned pregnancy may also be associated with lower relationship satisfaction among pregnant couples (LaChance-Grzela & Bouchard, 2009). However, these findings related to unplanned pregnancy have several limitations. Most studies failed to distinguish between mistimed (the pregnancy is wanted eventually, but at a later time) and unwanted (the pregnancy is not wanted at any time) unplanned pregnancies (Kaufmann, Morris, & Spitz, 1997; Petersen & Moos, 1997), which is an important distinction given the more severe negative outcomes associated with unwanted pregnancies (Maxson & Miranda, 2011). Also, many studies have relied on retrospective reports of pregnancy intention, which may be subject to social desirability bias (East et al., 2012), and may not capture changing intentions throughout pregnancy and the postpartum (Petersen & Moos, 1997). Finally, most studies have measured pregnancy intention with a single item that may not reflect the complexities of unplanned pregnancy (Petersen & Moos, 1997; Santelli et al., 2009).
Consideration of Abortion Unplanned pregnancy subsequently entails a decision to continue the pregnancy and parent, place the child for adoption, or terminate the pregnancy (Cohan, Dunkel-Schetter, & Lydon, 1993). Abortion has been associated with poor communication in couple relationships (Freeman et al., 1980), partner aggression (Amaro et al., 1990; Hedin & Janson, 2000), sexual dysfunction (Bradshaw & Slade, 2003; Miller, 1992; Rue et al., 2004), and poor relationship quality in current and future relationships (Coleman, Rue, & Coyle, 2009; Coyle, Coleman, & Rue, 2010). Although couples may consider abortion as an option for unplanned pregnancies; many couples ultimately decide to
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carry their pregnancies to term (Singh et al., 2010). Scant research has examined the outcomes associated with consideration of abortion in pregnancy and ultimately deciding to parent. Only recently have researchers studied pregnancy decision-making from a systemic perspective to explore fathers’ involvement in the process (Coleman, Rue, & Coyle, 2009; Coyle et al., 2010; Naziri, 2007). Results suggested that men want to be part of the pregnancy decision-making process (Hallden & Christensson, 2010; Lindell & Olsson, 1993); however, pregnancy decision-making is stressful and can have negative impacts on partner relationships (Rue et al., 2004; Schelotto & Arcuri, 1986). Coyle and colleagues (2010) found that perceptions of inadequate abortion counseling in the decision-making process were related to relationship problems and posttraumatic stress symptoms reported by both partners. They also found that incongruence in the decision to terminate pregnancy was associated with men’s perceptions of poorer relationship quality. Absent from the present literature is research about the maternal mental health outcomes associated with couple consideration of abortion in pregnancy.
THE CURRENT STUDY The purpose of this study was to compare differences in couples who did and did not consider abortion with regard to several demographic variables and resources at childbirth and maternal mental health outcomes at one year postpartum. We also examined protective factors at baseline which were associated with positive outcomes at one year postpartum regardless of considering abortion.
METHOD Sample Data for this study came from the Fragile Families and Child Well-Being Study (FFCWS) (Reichman et al., 2001), which followed a birth cohort of 4,898 children born in twenty large U.S. cities between February 1998 and September 2000. The FFCWS used a stratified random sample of all U.S. cities with more than 200,000 people to select twenty cities for the study, and then sampled hospitals within cities and births within hospitals. At each hospital, births were randomly sampled until preset quotas of married and unmarried parents were reached to oversample purposely children born to unmarried parents (75.8%; n = 3,712). Approximately 85% of sampled mothers and 76% of sampled fathers completed interviews at baseline. Participants were excluded if they planned to place the child for adoption, if the child’s father was deceased at the birth, if they did not speak English or Spanish, if the
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mother was too ill to complete the interview, or if the child died prior to the interview. Researchers obtained approval for the study protocol from each participating hospital’s Institutional Review Board, and all participants provided written informed consent to participate in the study. Trained FFCWS field staff interviewed biological mothers and fathers at the birth of the index child and also when the child was one-, three-, five-, and nine-years. By age 9, 71.7% (n = 3,515) of mothers and 54.1% (n = 2,652) of fathers participated in interviews. At each time point, parents were asked about attitudes toward marriage, relationships, social support networks, neighborhood characteristics, parenting, and involvement in programs. For the purpose of this study, we drew variables from interviews with mothers and fathers at baseline and one year. Baseline interviews were conducted in the hospital with mothers within 48 hours of the focal child’s birth and with fathers as soon as possible after the birth, both in person and telephonically. Year one interviews were conducted between June 1999 and March 2002 when the children were approximately one-year-old. Approximately 70% were conducted in person and the rest were conducted by telephone. Only mothers that completed all items of interest for this study were included in analyses. At baseline, 76.7% (n = 3,757) of mothers completed all items, and at year one, 60% (n = 2,937) of mothers completed all items.
Baseline Measures CONSIDERATION
OF
ABORTION
To measure whether the individuals or couples considered abortion, mothers’ and fathers’ responses were used to create three subgroups: (a) couples in which both partners considered abortion; (b) couples in which both partners did not consider abortion; and (c) couples in which only one partner considered abortion. Two items, each drawn from Section B: Father-Mother Relationships of the Fragile Families Baseline Questionnaire, were used to determine the three levels of abortion consideration. One item was reported by mothers (“When you found out you were pregnant, did you think about having an abortion?”) and one item was reported by fathers (“When you found out the baby’s mother was pregnant, did you think about her having an abortion?”). Responses were dichotomous for each item. One variable was created that indicated to which of the three groups the family belonged. RECEIVED SUPPORT A 7-item scale was constructed to measure mothers’ received support at baseline. Items were drawn from Sections E: Relationships with Extended Kin and F: Environmental Factors and Government Programs of the Fragile Families
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Baseline Mother Questionnaire. Items addressed actual support mothers received in the past year from family, friends, and the government. Three items addressed financial support over the past year (e.g., “In the last year did you have income from family or friends?”), and three addressed social support during pregnancy (e.g., “During pregnancy, did you receive child care?”). The final item assessed received governmental support related to housing (“Is the fed/state/local government helping to pay for your rent?”). Responses were dichotomous for all seven items. The items were added together to produce a scale (Cronbach’s α = .67) with possible scores ranging from 0 to 14, with higher scores indicating more support received. PERCEIVED SUPPORT The constructed perceived support scale consisted of three items, each reported by mothers at baseline and drawn from Section E: Relationships with Extended Kin of the Fragile Families Baseline Mother Questionnaire. Items assessed respondents’ perceptions of availability of support in the next year, including financial support (“In the next year, would someone in your family loan you $200?”) and social support (“In the next year, would someone in your family give you a place to stay?”). The dichotomous-response items were added together to produce a scale (Cronbach’s α = .83) with possible scores ranging from 0 to 6, and higher scores indicating more perceived support. RELIGIOUS INVOLVEMENT Religious involvement was assessed using one item (“How often do you attend religious services?”), drawn from Section F: Environmental Factors and Government Programs of the Fragile Families Baseline Mother Questionnaire. The item had five categorical response choices ranging from “once a week or more” to “not at all.” Responses ranged from 1 to 5, with higher scores indicating more religious involvement. SUBSTANCE USE Substance use was measured by three FFCWS-developed items asking mothers how often they had used cigarettes, alcohol, or other drugs during their pregnancy. Items were drawn from Section G: Health and Health Behavior of the Fragile Families Baseline Mother Questionnaire, and were recoded as dichotomous variables in which 0 indicated that mothers had not used the particular substance and 1 indicated that they had used the substance during pregnancy. Responses to these three items were added together and entered into the model as the total number of substances mothers used during pregnancy, with a possible range from 0 to 3.
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Year One Measures
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PARENTING STRESS Scales were constructed to describe mothers’ perceived stress related to parenting at one year. Items were drawn from Section B: Child Well-Being & Mothering of the one year mother questionnaire. Mothers were asked to respond to four statements (e.g., “I feel trapped by my responsibilities as a parent”). Each statement used a four-point forced response scale containing “strongly agree,” “somewhat agree,” “somewhat disagree,” and “strongly disagree.” Responses to the four items were added together to form a maternal stress scale (Cronbach’s α = .66) with scores ranging from 4 to 16 and higher scores indicating higher levels of maternal parenting stress. MATERNAL MENTAL HEALTH Maternal depressive symptoms were measured using an item constructed by the FFCWS, from Section J: Health and Health Behavior of the one year mother questionnaire. In a structured interview conducted by trained FFCWS staff, mothers were asked 15 items drawn from the Composite International Diagnostic Interview Short Form (CIDI-SF; Kessler et al., 1998), including whether they had feelings of dysphoria or anhedonia (e.g., “During the past 12 months, has there ever been a time when you felt sad, blue, or depressed for two or more weeks in a row?”). Probability scores were calculated based on the participant endorsing symptoms related to dysphoria or anhedonia, and participants were classified as either meeting or not meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) major depression criteria. The FFCWS calculated this classification in two ways, using either liberal or conservative guidelines (Walters et al., 2002). This study used the conservative classification, which required participants to endorse all of the symptoms related to either dysphoria or anhedonia as occurring “most of the day” for at least two weeks. Among mothers in this study, 15.4% (n = 452) met criteria for major depression at one year postpartum. Maternal anxiety was measured using an item constructed by the FFCWS from Section J: Health and Health Behavior of the one year mother questionnaire. Mothers were asked 20 items drawn from the CIDI-SF, assessing whether they felt worried for at least 6 months; whether the worry was excessive, lasted more days than not, and involved worrying about more than one thing; and whether they felt lack of control of the anxiety. Probability scores were calculated based on endorsement of DSM-IV generalized anxiety disorder (GAD) criteria, and mothers were classified as either meeting or not meeting criteria. Among mothers in this study, 4.2% (n = 124) met criteria for GAD at one year postpartum.
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SUBSTANCE USE
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Substance use was measured by four FFCWS-developed items asking mothers if they had used cigarettes, alcohol, marijuana, or hard drugs in the past month. Items were drawn from Section J: Child Well-Being & Mothering of the one year mother questionnaire. These items were coded as dichotomous variables in which 0 indicated that mothers had not used the particular substance in the past month and 1 indicated that they had used the particular substance in the past month. Responses to these four items were added together to represent the total number of substances mothers used in the past month, with a possible range of 0 to 4.
Data Analysis A one-way multivariate analysis of variance (MANOVA) was conducted to examine the significant demographic differences at baseline between couples who jointly considered abortion, couples who jointly did not consider abortion, and couples who were discrepant in consideration of abortion. This analysis examined correlates of unplanned pregnancy, including education, age, income, and substance use, in addition to perceived and received support. Second, a one-way multivariate analysis of covariance (MANCOVA) was conducted to examine differences in overall well-being at one year among the three groups of abortion consideration at baseline. All characteristics which significantly (p < .05) varied among groups in the first MANOVA analysis were included as covariates in the analysis of the year one data. Finally, a one-way MANOVA was conducted to examine within group differences among participants who considered abortion. The analysis examined differences in baseline characteristics between the subgroups of mothers who reported either high or low parenting stress at one year. To determine which subgroups of abortion consideration contributed to the significant omnibus effects in each analysis, a series of analyses of variance (ANOVAs) were conducted using Bonferroni correctional procedures for multiple tests.
RESULTS Baseline Characteristics Among participating mothers, 45.4% (n = 1,706) reported their race as African American, 27.3% (n = 1,026) reported their race as Hispanic, and 22.9% (n = 860) reported their race as White. Mothers’ ages at baseline ranged from 15 to 43 years with a mean age of 25.31 years, and 39.5% (n = 1,484) of mothers reported having less than a high school education. Among fathers, 47.4% (n = 1,781) reported their race as African American, 27.8%
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(n = 1,044) as Hispanic, and 20.3% (n = 763) as White. Fathers’ ages at baseline ranged from 15 to 53 years (M = 27.91), and 31.8% (n = 1,195) of fathers reported having less than a high school education. Supplemental analyses indicated that loss of participants at one year was not random: Mothers in the one year analytic sample, compared to those in the full baseline sample were significantly (p < .05) more likely to have completed high school or general educational development (GED) and reported higher income and less anxiety. In 65.8% (n = 2474) of cases, neither mothers nor fathers reported considering abortion; in 8.6% (n = 323) both mothers and fathers reported considering abortion, and in 25.6% (n = 960) only one parent reported considering abortion. A MANOVA was conducted to compare the three abortion consideration groups on the seven demographic baseline measures and two social support scales. A significant multivariate main effect was revealed for abortion consideration, Wilks’ λ = .924, F (16, 7412) = 18.77, p < .001, supporting our first hypothesis that the three abortion consideration groups would differ significantly at baseline in terms of demographic and social support characteristics. Due to the significance of the multivariate test, univariate effects were examined for each variable, revealing significant differences in group means on all nine variables (Table 1).
Year One Maternal Well-Being We computed a MANCOVA to compare one-year maternal well-being outcomes among the three abortion consideration groups, while controlling for the significant baseline characteristics from the first analysis. The test revealed a significant multivariate main effect for abortion consideration, Wilks’ λ = .991, F (8, 5844) = 3.43, p < .001, supporting our second hypothesis that the three abortion consideration groups would demonstrate different one year well-being outcomes. Baseline household income, perceived support, and substance use also each demonstrated significant multivariate main effects. Univariate tests revealed significant differences between abortion consideration groups in parenting stress, depression, and substance use (Table 2).
Protective Factors Although results suggested that as a whole those who considered abortion at baseline reported poorer outcomes at one year, some participants’ outcomes were similar to those who did not consider abortion. Thus, we next explored factors at baseline that were different between those who reported typical, high parenting stress outcomes versus atypical, low parenting stress despite having considered abortion. Using the mean parenting stress score among those who did not consider abortion (8.44), we used a cut-off score of 8 to differentiate high and low stress. The cut-off criteria resulted in
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1.93 (.88) 2.07 (.82) 24.02 (5.77) 26.65 (6.98) $27,552 (1798) 2.69 (1.29) 3.33 (.77) 11.50 (1.90) 2.97 (.11)
Dependent variablea
Mother’s education Father’s education Mother’s age (years)
Father’s age (years)
Annual household income
Religious Involvement Perceived support
Received support
Substance use
2.98 (.15)
11.65 (1.63)
2.86 (1.34) 3.32 (.76)
$26,429 (1043)
27.06 (7.43)
1.94 (.96) 1.97 (.88) 24.42 (6.00)
Discrepantly considered n = 960
2.99 (.06)
12.23 (1.80)
3.16 (1.38) 3.22 (.65)
$37,831 (650)
28.41 (7.03)
2.18 (1.09) 2.18 (1.04) 25.82 (6.07)
Did Not consider n = 2474
9.41∗∗∗
52.43∗∗∗
29.05∗∗∗ 10.34∗∗∗
50.62∗∗∗
18.20∗∗∗
23.32∗∗∗ 15.63∗∗∗ 27.07∗∗∗
F (2, 3752)
2 < 3∗ 2 < 3∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 < 3∗ 2 > 3∗∗ 1 > 3∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 > 3∗∗∗ 2 > 3∗∗∗
Post hoc comparisonsb
Higher scores indicate higher education (range: 1–4), increased age (years), higher annual household income, more religious involvement (range: 1–5), more perceived support (range: 0–6), more received support (range: 0–14), and more substance use during pregnancy (range: 0–3). b Bonferroni post hoc comparisons were used. Group 1 = Joint consideration of abortion; Group 2 = Discrepant consideration of abortion; Group 3 = No consideration of abortion. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
a
Jointly considered n = 323
Abortion consideration group means (SD)
TABLE 1 Means of Baseline Characteristics by Abortion Consideration Groups
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9.06 (2.73) .74 (.78) .15 (.33) .04 (.20)
Dependent variablea
Parenting stress
Substance use
Depression Anxiety
.15 (.36) .04 (.19)
.71 (.79)
9.05 (2.71)
Discrepantly considered n = 749
.10 (.31) .003 (.16)
.57 (.69)
8.44 (2.55)
Did Not consider n = 1927
3.87∗ .76
10.78∗∗∗
10.93∗∗∗
F (2, 2934)
1 > 3∗∗ 2 > 3∗∗∗ 1 > 3∗∗ 2 > 3∗∗∗ 2 > 3∗∗
Post hoc comparisonsb
Note: Baseline variables entered as covariates: Mother’s education (range: 1–5), father’s education (range: 1–5), mother’s age (years), father’s age (years), annual household income, religious involvement (range: 1–5), perceived support (range: 0–6), received support (range: 0–14), and substance use during pregnancy (range: 0–3). a Higher scores indicate higher parenting stress (range: 4–16), more substance use (range: 0–4), and higher prevalence of depression and anxiety. b Bonferroni post-hoc comparisons were used. Group 1 = Joint consideration of abortion; Group 2 = Discrepant consideration of abortion; Group 3 = No consideration of abortion. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
Jointly considered n = 261
Abortion consideration group means (SD)
TABLE 2 Means of Year One Outcomes by Abortion Consideration Groups Controlling for Baseline Characteristics
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two groups of mothers who considered abortion at baseline: those who reported typical, high parenting stress at one year (9 or above; n = 548) and those who reported lower-than-typical parenting stress (8 or less; n = 453). A MANOVA examining differences in baseline characteristics between the typical and atypical stress groups of mothers revealed a significant multivariate main effect, Wilks’ λ = .967, F (9, 991) = 3.73, p < .001, indicating that the two groups were significantly different in terms of baseline characteristics. Univariate tests revealed that there were significant differences in group means in terms of education, income, and substance use. However, no significant group differences were observed for age, received support, or perceived support (Table 3).
DISCUSSION We examined couples’ demographic characteristics and resource availability, as well as maternal well-being at one year postpartum depending on whether they considered abortion. Additionally, we identified protective factors at baseline among mothers who considered abortion but reported atypical, low parenting stress at one year.
Baseline Characteristics Baseline characteristics were similar among those who considered abortion jointly and discrepantly, however, they were significantly different among those who did not consider abortion. Participants who did not consider abortion had more education, were older, had higher income, and had more received support than those who jointly or discrepantly considered abortion. They also reported less perceived support and less substance use. These findings were consistent with existing literature, suggesting those who experience unplanned pregnancies tend to be economically disadvantaged (Kost & Forrest, 1995), young (Finer & Henshaw, 2006), to have less education (Finer & Henshaw, 2006), and to use substances (Than et al., 2005). Interestingly, although those who considered abortion reported low received support, they also reported high perceived support. This finding could be related to the fact that the sample included individuals who all decided to parent when faced with a pregnancy decision. It is possible that those who decided on abortion made that decision in part because of their low perceived support (Makenzius et al., 2012). The finding is also consistent with literature that suggests perceived and received support may be two separate sub-constructs with distinctly separate functions (Norris & Kaniasty, 1996).
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2.07 (.93) 2.09 (.89) 24.14 (5.59) 26.47 (7.16) $29,674 (1258) 2.85 (1.28) 3.26 (.72) 11.87 (1.92) 2.97 (.19)
Dependent variablea
Mother’s education Father’s education Mother’s age (years) Father’s age (years) Annual household income Religious involvement Perceived support Received support Substance use
1.86 (.92) 1.87 (.89) 24.02 (5.97) 26.64 (7.03) $25,428 (1006) 2.83 (1.34) 3.26 (.70) 12.02 (1.83) 2.99 (.07)
Typical, high stress outcomes n = 548
12.85∗∗∗ 16.52∗∗∗ .10 .15 7.12∗∗ .05 .03 1.76 5.70∗
F (1, 1017)
Higher scores indicate higher education (range: 1–5), increased age (years), higher annual household income, more religious involvement (range: 1–5), more perceived support (range: 0–6), more received support (range: 0–14), and more substance use during pregnancy (range: 4–15). ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
a
Atypical, low stress outcomes n = 453
Year one outcome group means (SD)
TABLE 3 Means of Baseline Characteristics for Year One Typical and Atypical Parenting Stress Outcomes Among Participants Who Considered Abortion
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Year One Maternal Well-Being Next, we examined maternal well-being at one year postpartum among the abortion consideration groups. Findings were similar to the baseline analysis in that the groups of individuals who considered abortion did not significantly differ from one another. However, those who did not consider abortion reported lower parenting stress, depression, and substance use at one year. Previous research suggested that these outcomes were associated with unplanned pregnancies (Miller et al., 2009; Sayil et al., 2007; Than et al., 2005); however, these findings expand the existing literature by specifically examining abortion consideration. These outcomes are important as maternal depression and parenting stress have been linked to insecure attachment among infants and toddlers (Coyl, Roggman, & Newland, 2002). Future studies should further investigate the impact of considering abortion on maternal mental health outcomes.
Protective Factors Given the significant findings from the first two analyses, we next examined protective factors among mothers with atypical, low parenting stress at one year despite initially considering abortion. Mothers who considered abortion yet reported low parenting stress at one year were more educated, had higher income, and reported less substance use at the birth of their children. Therefore, these potential protective factors should be promoted among women facing pregnancy decisions.
LIMITATIONS This study had several limitations. First, limitations of the dataset rendered it impossible to compare those who actually experienced abortion and those who did not. It was also not possible to examine pregnancy intention directly. Although it is likely that those who considered abortion were experiencing an unplanned pregnancy (Thorp, Hartmann, & Shadigian, 2003), they may not represent others who experienced unplanned pregnancies and did not consider abortion, and may include some planned pregnancies. Coleman, Coyle, and Rue (2010) found that women who considered abortion and decided to terminate their pregnancies later than the first trimester had more ambivalence and poorer mental health outcomes over time. We were not able to assess when in the pregnancy participants considered abortion or made their decision not to terminate the pregnancy, but the issue of timing should be examined in future studies. Second, common to other studies examining unplanned pregnancy, this study relied on retrospective report of abortion consideration. Parents
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reported their abortion consideration approximately 48 hours after the birth of the focal child, thus the report may have been subject to “postbirth rationalization,” resulting in under-reporting of consideration (East et al., 2012). Abortion concealment rates also tend to be high, around 65% (Jones & Forrest, 1992), and it is likely some participants did not disclose their consideration of abortion due to social desirability pressures. Conversely, “maternity blues” also often occur during this period and could have influenced mothers’ responses, perhaps resulting in an overestimation of abortion consideration (Pitt, 1973). Further, this study was limited to examining maternal outcomes one year postpartum. One year was chosen because of the importance of maternal depression and stress early in children’s lives in the formation of secure attachment (Coyl et al., 2002); however, future studies should examine these factors longitudinally. The generalizability of the findings is also limited in that the majority of the FFCWS sample was unmarried at the birth of their child, and almost 40% of the original FFCWS sample was lost to follow-up at one year. The participants in the current study were more likely to have completed high school, have higher annual incomes, and report less anxiety than participants who dropped out. Furthermore, we used a series of FFCWS-developed items to assess substance use rather than a standard established scale; so, the reliability and validity of the construct is unknown. Finally, although we identified potential confounding variables based on common covariates of unplanned pregnancy in the literature, it is possible that not all confounding variables were included in the analyses so that residual confounding is possible.
IMPLICATIONS AND CONCLUSIONS Despite the limitations, the results of this study contribute to the literature in several ways. Although other studies have examined the differences between individuals who experience planned and unplanned pregnancies and outcomes associated with the decision to terminate pregnancy, few studies have specifically examined consideration of abortion in pregnancy. The findings suggest that considering abortion is associated with poorer outcomes at one year and that protective factors contribute to low parenting stress among mothers who considered abortion. The results of this study suggest that more education and income, and lower substance use may be associated with more positive outcomes for mothers who considered abortion. This has implications for both policy and clinical practice. This study provides rationale for promoting programs that support women in pregnancy decision-making, as well as providing education and employment assistance for new parents. Although current policy often emphasizes intervention with children of at-risk families, the results of this study suggest that intervening with mothers early on and
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specifically providing resources to promote education, employment, and substance use prevention may serve to decrease maternal parenting stress, and subsequently, improve child outcomes. Intervention may be particularly important for women experiencing unplanned pregnancies and who have considered abortion.
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REFERENCES Amaro H., L. W. Fried, H. Cabral, and B. Zuckerman. 1990. Violence during pregnancy and substance use. Am J Public Health 80:575–9. Axinn, W. G., J. S. Barber, and A. Thornton. 1998. The long-term impact of parents’ childbearing decisions on children’s self-esteem. Demography 35:435–43. Bradshaw, Z., and P. Slade. 2003. The effects of induced abortion on emotional experiences and relationships: A critical review of the literature. Clin Psychol Rev 23:929–58. Centers for Disease Control and Prevention. 2013. Unintended pregnancy prevention. Atlanta: National Center for Chronic Disease Prevention and Health Promotion. Cohan, C. L., C. Dunkel-Schetter, and J. Lydon. 1993. Pregnancy decision making: Predictors of early stress and adjustment. Psychol Women Quart 17: 223–39. Cohen, L., and S. Roth. 1984. Coping with abortion. J Hum Stress 10:140–5. Coleman, P. K., C. T. Coyle, and V. M. Rue. 2010. Late term elective abortion and susceptibility to posttraumatic stress symptoms. J Pregnancy 2010:1–10. Coleman, P. K., V. M. Rue, and C. T. Coyle. 2009. Induced abortion and intimate relationship quality in the Chicago Health and Social Life Survey. Public Health 123:331–8. Coyl, D. D., L. A. Roggman, and L. A. Newland.2002. Stress, maternal depression, and negative mother-infant interactions in relation to infant attachment. Infant Mental Hlth J 23:145–63. Coyle, C. T., P. K. Coleman, and V. M. Rue. 2010. Inadequate preabortion counseling and decision conflict as predictors of subsequent relationship difficulties and psychological stress in men and women. Traumatology 16:16–30. Crissey, S. R. 2005. Effect of pregnancy intention on child well-being and development: Combining retrospective reports of attitude and contraceptive use. Popul Res Policy Rev 24:593–615. East, P. L., N. C. Chien, and J. S. Barber. 2012. Adolescents’ pregnancy intentions, wantedness, and regret: Cross-lagged relations with mental health and harsh parenting. J Marriage Fam 74:167–85. Finer, L. B., and S. K. Henshaw. 2006. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Repro H 38:90–6. Forrest, J. D. 1994. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynecol 170:1485–9. Freeman, E. W., K. Rickels, G. R. Huggins, C. Garcia, and J. Polin. 1980. Emotional distress patterns among women having first or repeat abortions. Obstet Gynecol 55:630–6.
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Geller, P. A. 2004. Pregnancy as a stressful life event. CNS Spectr 9:188–97. Haber, M. G., J. L. Cohen, T. Lucas, and B. B. Baltes. 2007. The relationship between self-reported received and perceived social support: A meta-analytic review. Am J Commun Psychol 39:133–44. Hallden, B., and K. Christensson. 2010. Swedish young men’s lived experiences of a girlfriend’s early induced abortion. Int J Mens Health 9:126–43. Hayatbakhsh, M. R., J. M. Najman, M. Khatun, A. A. Mamun, W. Bor, and A. Clavarino. 2011. A longitudinal study of child mental health and problem behaviours at 14 years of age following unplanned pregnancy. Psychiat Res 185:200–4. Hedin, L. W., and P. O. Janson. 2000. Domestic violence during pregnancy: The prevalence of physical injuries, substance abuse, abortions and miscarriages. Acta Obstet Gyn Scan 79:625–30. Hohmann-Marriott, B. 2009. The couple context of pregnancy and its effects on prenatal care and birth outcomes. Matern Child Healt J 13:745–54. Jones, E. F., and J. D. Forrest. 1992. Contraceptive failure rates based on the 1988 NSFG. Fam Plann Perspect 24:12–9. Kaufmann, R. B., L. Morris, and A. M. Spitz. 1997. Comparison of two question sequences for assessing pregnancy intentions. Am J Epidemiol 148:810–6. Kessler, R. C., G. Andrews, D. Mroczek, B. Ustun, and H. Wittchen. 1998. The world health organization composite international diagnostic interview short-form (CIDI-SF). Int J Method Psych 7:171–85. Kost, K., and J. D. Forrest. 1995. Intention status of U.S. births in 1988: differences by mothers’ socioeconomic and demographic characteristics. Fam Plann Perspect 27:11–7. Lachance-Grzela, M., and G. Bouchard. 2009. The well-being of cohabiting and married couples during pregnancy: Does pregnancy planning matter? J Soc Pers Relat 26:141–59. Lindell, M. E., and H. M. Olsson. 1993. Swedish students’ attitudes toward abortion. Health Care Women In 14:281–91. Makenzius, M., T. Tyden, E. Darj, and M. Larsson. 2012. Risk factors among men who have repeated experience of being the partner of a woman who requests an induced abortion. Scand J Public Healt 40:211–6. Maxson, P., and M. L. Miranda. 2011. Pregnancy intention, demographic differences, and psychosocial health. J Womens Health 20:1215–23. Miller, W. B. 1992. An empirical study of the psychological antecedents and consequences of induced abortion. J Soc Issues 48:67–93. Miller, W. B., M. R. Sable, and J. J. Beckmeyer. 2009. Preconception motivation and pregnancy wantedness: Pathways to toddler attachment security. J Marriage Fam 71:1174–92. Naziri, D. 2007. Man’s involvement in the experience of abortion and the dynamics of the couple’s relationship: A clinical study. Eur J Contracep Repr 12:168–74. Norris, F. H., and K. Kaniasty. 1996. Received and perceived social support in times of stress: A test of the social support deterioration deterrence model. J Pers Soc Psychol 71:498–511. Olson, L. 1980. Social and psychological correlates of pregnancy decisions among adolescent women. Am J Orthopsychiat 50:432–45.
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Petersen, R., and M. K. Moos. 1997. Defining and measuring unintended pregnancy: Issues and concerns. Women Health Iss 7:234–40. Pitt, B. 1973. Maternity blues. Brit J Psychiat 122:431–3. Reichman, N., J. Teitler, I. Garfinkel, and S. McLanahan. 2001. Fragile families: Sample and design. Child Youth Serv Rev 23:303–26. Rue, V. M., P. K. Coleman, J. J. Rue, and D. C. Reardon. 2004. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monitor 10:SR5–SR16. Santelli, J. S., L. D. Lindberg, M. G. Orr, L. B. Finer, and I. Speizer. 2009. Toward a multidimensional measure of pregnancy intentions: Evidence from the United States. Stud Family Plann 40:87–100. Sayil, M., A. Güre, and Z. Uçanok. 2007. First time mothers’ anxiety and depressive symptoms across the transition to motherhood: Associations with maternal and environmental characteristics. Women Health 44:61–77. Schelotto, G., and C. Arcuri. 1986. Supposing it hurts me too? Abortion: The anguish experienced by men. Planned Parenthood Europe Regional Information Bulletin 15:25–34. Singh, S., G. Sedgh, and R. Hussain. 2010. Unintended pregnancy: Worldwide levels, trends, and outcomes. Stud Family Plann 41:241–50. Than, L. C., M. A. Honein, M. L. Watkins, P. W. Yoon, K. L. Daniel, and A. Correa. 2005. Intent to become pregnant as a predictor of exposures during pregnancy: is there a relation? J Reprod Med 50:389–96. Thorp, J. M., K. E. Hartmann, and E. Shadigian. 2003. Long-term physical and psychological health consequences of induced abortion: Review of the evidence. Obstet Gynecol Surv 58:67–79. Walters, E. E., R. C. Kessler, C. B. Nelson, and D. Mroczek. 2002. Scoring the World Health Organization’s composite international diagnostic interview short form (CIDI-SF). Unpublished manuscript.
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Consideration of Abortion in Pregnancy: Demographic Characteristics, Mental Health, and Protective Factors a
Amy M. Claridge MEd & Casey L. Chaviano MSW
a
a
Department of Family and Child Sciences , College of Human Sciences, The Florida State University , Florida , USA Accepted author version posted online: 07 Aug 2013.Published online: 11 Nov 2013.
To cite this article: Amy M. Claridge MEd & Casey L. Chaviano MSW (2013) Consideration of Abortion in Pregnancy: Demographic Characteristics, Mental Health, and Protective Factors, Women & Health, 53:8, 777-794, DOI: 10.1080/03630242.2013.831018 To link to this article: http://dx.doi.org/10.1080/03630242.2013.831018
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Women & Health, 53:777–794, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2013.831018
Consideration of Abortion in Pregnancy: Demographic Characteristics, Mental Health, and Protective Factors
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AMY M. CLARIDGE, MEd and CASEY L. CHAVIANO, MSW Department of Family and Child Sciences, College of Human Sciences, The Florida State University, Florida, USA
This study examined demographic characteristics, available resources, and mental health outcomes of women who did and did not consider abortion in pregnancy. Using data collected between 1998 and 2000 from 2,937 mothers recruited for the Fragile Families and Child Well-Being Study, this study examined whether women who did and did not consider abortion differed in terms of sociodemographic characteristics and resources at the birth of their children and mental health outcomes when their children were one year old. This study further examined protective factors associated with low parenting stress at one year postpartum, despite initial abortion consideration. Compared to women who did not consider abortion, women who did consider abortion tended to be younger, have less education and lower income, and report higher levels of substance use, higher perceived support, and lower received support. A subset of women who had higher education, more income, and lower substance use reported lower parenting stress at year one despite abortion consideration in pregnancy. Promotion of education and employment assistance may
Received December 15, 2012; revised July 26, 2013; accepted July 29, 2013. The authors thank the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) through grants R01HD36916, R01HD39135, and R01HD40421, as well as a consortium of private foundations for their support of the Fragile Families and Child Well-Being Study. An earlier version of this article was presented at the 2012 American Association for Marriage and Family Therapy Annual Conference. Address correspondence to Amy M. Claridge, MEd, Department of Family and Child Sciences, The Florida State University, College of Human Sciences, 225 Sandels Building, Tallahassee, FL 32306-1491. E-mail: [email protected] 777
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be particularly important among women experiencing unplanned pregnancies as these services may contribute to lower parenting stress and improved child outcomes.
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KEYWORDS health
abortion, pregnancy, protective factors, women’s
Existing research on mothers or couples who consider abortion has examined the impact of deciding to terminate pregnancy on women’s mental health. We propose a shift toward the context surrounding pregnancy decisions, which may be a better indicator of future outcomes than the decision itself. Pregnancy may be more stressful when it is unplanned (Geller, 2004; Hohmann-Marriott, 2009). Therefore, the present study examined the contextual factors surrounding those who likely experienced unplanned pregnancy, and specifically reported considering abortion, in comparison to those who did not consider abortion. The study also examined protective factors at baseline that were related to positive outcomes at one year postpartum. Understanding the context surrounding individuals who considered abortion in pregnancy but did not experience the typical negative outcomes associated with unplanned pregnancy will help clinicians serve pregnant women and their families better.
BACKGROUND Pregnancy Intention Unplanned pregnancy is prevalent in the United States and worldwide with 41% of pregnancies worldwide unplanned in 2008 (Singh, Sedgh, & Hussain, 2010), and 49% of U.S. pregnancies unplanned in 2001 (Centers for Disease Control and Prevention, 2013). Among the unplanned pregnancies in the United States, around 38% end in abortion, 14% end in miscarriage, and 48% result in live births (Singh et al., 2010). Many studies have examined the women who have undergone abortion. However, the majority of unplanned pregnancies are carried to term, and researchers should also explore the experience of the individuals and couples involved in unplanned pregnancies who ultimately become parents. Various demographic variables have consistently been associated with unplanned pregnancy. Unplanned pregnancy rates are higher among racial and ethnic minorities (Maxson & Miranda, 2011), and women who are unmarried (Finer & Henshaw, 2006; Maxson & Miranda, 2011), young (Finer & Henshaw, 2006; Kost & Forrest, 1995), do not have a high school diploma (Finer & Henshaw, 2006), or who are socioeconomically disadvantaged (Forrest, 1994; Kost & Forrest, 1995). Outcomes associated with unplanned pregnancy may also be related to these demographic characteristics.
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On the other hand, the actual experience of an unplanned pregnancy may affect later outcomes. Pregnancy generally is a stressful experience for women (Cohen & Roth, 1984; Olson, 1980) and is likely additionally stressful when facing the risk factors associated with an unplanned pregnancy (Geller, 2004) or when partners’ perceptions about the pregnancy conflict with each other (Hohmann-Marriott, 2009). Longitudinally, unplanned pregnancy is associated with negative outcomes among children, including poor physical health and delayed development among three-year-olds (Crissey, 2005) and internalizing and externalizing behaviors among adolescents (Hayatbakhsh et al., 2011) and young adults (Axinn, Barber, & Thornton, 1998). Mothers of unplanned pregnancy are more likely to experience postpartum depression (Miller, Sable, & Beckmeyer, 2009; Sayil, Güre, & Uçanok, 2007), anxiety (East, Chien, & Barber, 2012), perceived stress, (Miller et al., 2009) low self-efficacy (Sayil et al., 2007), and engage in harsh parenting behaviors (East et al., 2012) than mothers who have had planned pregnancies. Limited research, with a small, socioeconomically advantaged sample, suggested that unplanned pregnancy may also be associated with lower relationship satisfaction among pregnant couples (LaChance-Grzela & Bouchard, 2009). However, these findings related to unplanned pregnancy have several limitations. Most studies failed to distinguish between mistimed (the pregnancy is wanted eventually, but at a later time) and unwanted (the pregnancy is not wanted at any time) unplanned pregnancies (Kaufmann, Morris, & Spitz, 1997; Petersen & Moos, 1997), which is an important distinction given the more severe negative outcomes associated with unwanted pregnancies (Maxson & Miranda, 2011). Also, many studies have relied on retrospective reports of pregnancy intention, which may be subject to social desirability bias (East et al., 2012), and may not capture changing intentions throughout pregnancy and the postpartum (Petersen & Moos, 1997). Finally, most studies have measured pregnancy intention with a single item that may not reflect the complexities of unplanned pregnancy (Petersen & Moos, 1997; Santelli et al., 2009).
Consideration of Abortion Unplanned pregnancy subsequently entails a decision to continue the pregnancy and parent, place the child for adoption, or terminate the pregnancy (Cohan, Dunkel-Schetter, & Lydon, 1993). Abortion has been associated with poor communication in couple relationships (Freeman et al., 1980), partner aggression (Amaro et al., 1990; Hedin & Janson, 2000), sexual dysfunction (Bradshaw & Slade, 2003; Miller, 1992; Rue et al., 2004), and poor relationship quality in current and future relationships (Coleman, Rue, & Coyle, 2009; Coyle, Coleman, & Rue, 2010). Although couples may consider abortion as an option for unplanned pregnancies; many couples ultimately decide to
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carry their pregnancies to term (Singh et al., 2010). Scant research has examined the outcomes associated with consideration of abortion in pregnancy and ultimately deciding to parent. Only recently have researchers studied pregnancy decision-making from a systemic perspective to explore fathers’ involvement in the process (Coleman, Rue, & Coyle, 2009; Coyle et al., 2010; Naziri, 2007). Results suggested that men want to be part of the pregnancy decision-making process (Hallden & Christensson, 2010; Lindell & Olsson, 1993); however, pregnancy decision-making is stressful and can have negative impacts on partner relationships (Rue et al., 2004; Schelotto & Arcuri, 1986). Coyle and colleagues (2010) found that perceptions of inadequate abortion counseling in the decision-making process were related to relationship problems and posttraumatic stress symptoms reported by both partners. They also found that incongruence in the decision to terminate pregnancy was associated with men’s perceptions of poorer relationship quality. Absent from the present literature is research about the maternal mental health outcomes associated with couple consideration of abortion in pregnancy.
THE CURRENT STUDY The purpose of this study was to compare differences in couples who did and did not consider abortion with regard to several demographic variables and resources at childbirth and maternal mental health outcomes at one year postpartum. We also examined protective factors at baseline which were associated with positive outcomes at one year postpartum regardless of considering abortion.
METHOD Sample Data for this study came from the Fragile Families and Child Well-Being Study (FFCWS) (Reichman et al., 2001), which followed a birth cohort of 4,898 children born in twenty large U.S. cities between February 1998 and September 2000. The FFCWS used a stratified random sample of all U.S. cities with more than 200,000 people to select twenty cities for the study, and then sampled hospitals within cities and births within hospitals. At each hospital, births were randomly sampled until preset quotas of married and unmarried parents were reached to oversample purposely children born to unmarried parents (75.8%; n = 3,712). Approximately 85% of sampled mothers and 76% of sampled fathers completed interviews at baseline. Participants were excluded if they planned to place the child for adoption, if the child’s father was deceased at the birth, if they did not speak English or Spanish, if the
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mother was too ill to complete the interview, or if the child died prior to the interview. Researchers obtained approval for the study protocol from each participating hospital’s Institutional Review Board, and all participants provided written informed consent to participate in the study. Trained FFCWS field staff interviewed biological mothers and fathers at the birth of the index child and also when the child was one-, three-, five-, and nine-years. By age 9, 71.7% (n = 3,515) of mothers and 54.1% (n = 2,652) of fathers participated in interviews. At each time point, parents were asked about attitudes toward marriage, relationships, social support networks, neighborhood characteristics, parenting, and involvement in programs. For the purpose of this study, we drew variables from interviews with mothers and fathers at baseline and one year. Baseline interviews were conducted in the hospital with mothers within 48 hours of the focal child’s birth and with fathers as soon as possible after the birth, both in person and telephonically. Year one interviews were conducted between June 1999 and March 2002 when the children were approximately one-year-old. Approximately 70% were conducted in person and the rest were conducted by telephone. Only mothers that completed all items of interest for this study were included in analyses. At baseline, 76.7% (n = 3,757) of mothers completed all items, and at year one, 60% (n = 2,937) of mothers completed all items.
Baseline Measures CONSIDERATION
OF
ABORTION
To measure whether the individuals or couples considered abortion, mothers’ and fathers’ responses were used to create three subgroups: (a) couples in which both partners considered abortion; (b) couples in which both partners did not consider abortion; and (c) couples in which only one partner considered abortion. Two items, each drawn from Section B: Father-Mother Relationships of the Fragile Families Baseline Questionnaire, were used to determine the three levels of abortion consideration. One item was reported by mothers (“When you found out you were pregnant, did you think about having an abortion?”) and one item was reported by fathers (“When you found out the baby’s mother was pregnant, did you think about her having an abortion?”). Responses were dichotomous for each item. One variable was created that indicated to which of the three groups the family belonged. RECEIVED SUPPORT A 7-item scale was constructed to measure mothers’ received support at baseline. Items were drawn from Sections E: Relationships with Extended Kin and F: Environmental Factors and Government Programs of the Fragile Families
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Baseline Mother Questionnaire. Items addressed actual support mothers received in the past year from family, friends, and the government. Three items addressed financial support over the past year (e.g., “In the last year did you have income from family or friends?”), and three addressed social support during pregnancy (e.g., “During pregnancy, did you receive child care?”). The final item assessed received governmental support related to housing (“Is the fed/state/local government helping to pay for your rent?”). Responses were dichotomous for all seven items. The items were added together to produce a scale (Cronbach’s α = .67) with possible scores ranging from 0 to 14, with higher scores indicating more support received. PERCEIVED SUPPORT The constructed perceived support scale consisted of three items, each reported by mothers at baseline and drawn from Section E: Relationships with Extended Kin of the Fragile Families Baseline Mother Questionnaire. Items assessed respondents’ perceptions of availability of support in the next year, including financial support (“In the next year, would someone in your family loan you $200?”) and social support (“In the next year, would someone in your family give you a place to stay?”). The dichotomous-response items were added together to produce a scale (Cronbach’s α = .83) with possible scores ranging from 0 to 6, and higher scores indicating more perceived support. RELIGIOUS INVOLVEMENT Religious involvement was assessed using one item (“How often do you attend religious services?”), drawn from Section F: Environmental Factors and Government Programs of the Fragile Families Baseline Mother Questionnaire. The item had five categorical response choices ranging from “once a week or more” to “not at all.” Responses ranged from 1 to 5, with higher scores indicating more religious involvement. SUBSTANCE USE Substance use was measured by three FFCWS-developed items asking mothers how often they had used cigarettes, alcohol, or other drugs during their pregnancy. Items were drawn from Section G: Health and Health Behavior of the Fragile Families Baseline Mother Questionnaire, and were recoded as dichotomous variables in which 0 indicated that mothers had not used the particular substance and 1 indicated that they had used the substance during pregnancy. Responses to these three items were added together and entered into the model as the total number of substances mothers used during pregnancy, with a possible range from 0 to 3.
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Year One Measures
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PARENTING STRESS Scales were constructed to describe mothers’ perceived stress related to parenting at one year. Items were drawn from Section B: Child Well-Being & Mothering of the one year mother questionnaire. Mothers were asked to respond to four statements (e.g., “I feel trapped by my responsibilities as a parent”). Each statement used a four-point forced response scale containing “strongly agree,” “somewhat agree,” “somewhat disagree,” and “strongly disagree.” Responses to the four items were added together to form a maternal stress scale (Cronbach’s α = .66) with scores ranging from 4 to 16 and higher scores indicating higher levels of maternal parenting stress. MATERNAL MENTAL HEALTH Maternal depressive symptoms were measured using an item constructed by the FFCWS, from Section J: Health and Health Behavior of the one year mother questionnaire. In a structured interview conducted by trained FFCWS staff, mothers were asked 15 items drawn from the Composite International Diagnostic Interview Short Form (CIDI-SF; Kessler et al., 1998), including whether they had feelings of dysphoria or anhedonia (e.g., “During the past 12 months, has there ever been a time when you felt sad, blue, or depressed for two or more weeks in a row?”). Probability scores were calculated based on the participant endorsing symptoms related to dysphoria or anhedonia, and participants were classified as either meeting or not meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) major depression criteria. The FFCWS calculated this classification in two ways, using either liberal or conservative guidelines (Walters et al., 2002). This study used the conservative classification, which required participants to endorse all of the symptoms related to either dysphoria or anhedonia as occurring “most of the day” for at least two weeks. Among mothers in this study, 15.4% (n = 452) met criteria for major depression at one year postpartum. Maternal anxiety was measured using an item constructed by the FFCWS from Section J: Health and Health Behavior of the one year mother questionnaire. Mothers were asked 20 items drawn from the CIDI-SF, assessing whether they felt worried for at least 6 months; whether the worry was excessive, lasted more days than not, and involved worrying about more than one thing; and whether they felt lack of control of the anxiety. Probability scores were calculated based on endorsement of DSM-IV generalized anxiety disorder (GAD) criteria, and mothers were classified as either meeting or not meeting criteria. Among mothers in this study, 4.2% (n = 124) met criteria for GAD at one year postpartum.
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SUBSTANCE USE
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Substance use was measured by four FFCWS-developed items asking mothers if they had used cigarettes, alcohol, marijuana, or hard drugs in the past month. Items were drawn from Section J: Child Well-Being & Mothering of the one year mother questionnaire. These items were coded as dichotomous variables in which 0 indicated that mothers had not used the particular substance in the past month and 1 indicated that they had used the particular substance in the past month. Responses to these four items were added together to represent the total number of substances mothers used in the past month, with a possible range of 0 to 4.
Data Analysis A one-way multivariate analysis of variance (MANOVA) was conducted to examine the significant demographic differences at baseline between couples who jointly considered abortion, couples who jointly did not consider abortion, and couples who were discrepant in consideration of abortion. This analysis examined correlates of unplanned pregnancy, including education, age, income, and substance use, in addition to perceived and received support. Second, a one-way multivariate analysis of covariance (MANCOVA) was conducted to examine differences in overall well-being at one year among the three groups of abortion consideration at baseline. All characteristics which significantly (p < .05) varied among groups in the first MANOVA analysis were included as covariates in the analysis of the year one data. Finally, a one-way MANOVA was conducted to examine within group differences among participants who considered abortion. The analysis examined differences in baseline characteristics between the subgroups of mothers who reported either high or low parenting stress at one year. To determine which subgroups of abortion consideration contributed to the significant omnibus effects in each analysis, a series of analyses of variance (ANOVAs) were conducted using Bonferroni correctional procedures for multiple tests.
RESULTS Baseline Characteristics Among participating mothers, 45.4% (n = 1,706) reported their race as African American, 27.3% (n = 1,026) reported their race as Hispanic, and 22.9% (n = 860) reported their race as White. Mothers’ ages at baseline ranged from 15 to 43 years with a mean age of 25.31 years, and 39.5% (n = 1,484) of mothers reported having less than a high school education. Among fathers, 47.4% (n = 1,781) reported their race as African American, 27.8%
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(n = 1,044) as Hispanic, and 20.3% (n = 763) as White. Fathers’ ages at baseline ranged from 15 to 53 years (M = 27.91), and 31.8% (n = 1,195) of fathers reported having less than a high school education. Supplemental analyses indicated that loss of participants at one year was not random: Mothers in the one year analytic sample, compared to those in the full baseline sample were significantly (p < .05) more likely to have completed high school or general educational development (GED) and reported higher income and less anxiety. In 65.8% (n = 2474) of cases, neither mothers nor fathers reported considering abortion; in 8.6% (n = 323) both mothers and fathers reported considering abortion, and in 25.6% (n = 960) only one parent reported considering abortion. A MANOVA was conducted to compare the three abortion consideration groups on the seven demographic baseline measures and two social support scales. A significant multivariate main effect was revealed for abortion consideration, Wilks’ λ = .924, F (16, 7412) = 18.77, p < .001, supporting our first hypothesis that the three abortion consideration groups would differ significantly at baseline in terms of demographic and social support characteristics. Due to the significance of the multivariate test, univariate effects were examined for each variable, revealing significant differences in group means on all nine variables (Table 1).
Year One Maternal Well-Being We computed a MANCOVA to compare one-year maternal well-being outcomes among the three abortion consideration groups, while controlling for the significant baseline characteristics from the first analysis. The test revealed a significant multivariate main effect for abortion consideration, Wilks’ λ = .991, F (8, 5844) = 3.43, p < .001, supporting our second hypothesis that the three abortion consideration groups would demonstrate different one year well-being outcomes. Baseline household income, perceived support, and substance use also each demonstrated significant multivariate main effects. Univariate tests revealed significant differences between abortion consideration groups in parenting stress, depression, and substance use (Table 2).
Protective Factors Although results suggested that as a whole those who considered abortion at baseline reported poorer outcomes at one year, some participants’ outcomes were similar to those who did not consider abortion. Thus, we next explored factors at baseline that were different between those who reported typical, high parenting stress outcomes versus atypical, low parenting stress despite having considered abortion. Using the mean parenting stress score among those who did not consider abortion (8.44), we used a cut-off score of 8 to differentiate high and low stress. The cut-off criteria resulted in
786
1.93 (.88) 2.07 (.82) 24.02 (5.77) 26.65 (6.98) $27,552 (1798) 2.69 (1.29) 3.33 (.77) 11.50 (1.90) 2.97 (.11)
Dependent variablea
Mother’s education Father’s education Mother’s age (years)
Father’s age (years)
Annual household income
Religious Involvement Perceived support
Received support
Substance use
2.98 (.15)
11.65 (1.63)
2.86 (1.34) 3.32 (.76)
$26,429 (1043)
27.06 (7.43)
1.94 (.96) 1.97 (.88) 24.42 (6.00)
Discrepantly considered n = 960
2.99 (.06)
12.23 (1.80)
3.16 (1.38) 3.22 (.65)
$37,831 (650)
28.41 (7.03)
2.18 (1.09) 2.18 (1.04) 25.82 (6.07)
Did Not consider n = 2474
9.41∗∗∗
52.43∗∗∗
29.05∗∗∗ 10.34∗∗∗
50.62∗∗∗
18.20∗∗∗
23.32∗∗∗ 15.63∗∗∗ 27.07∗∗∗
F (2, 3752)
2 < 3∗ 2 < 3∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 < 3∗ 2 > 3∗∗ 1 > 3∗ 1 < 3∗∗∗ 2 < 3∗∗∗ 1 > 3∗∗∗ 2 > 3∗∗∗
Post hoc comparisonsb
Higher scores indicate higher education (range: 1–4), increased age (years), higher annual household income, more religious involvement (range: 1–5), more perceived support (range: 0–6), more received support (range: 0–14), and more substance use during pregnancy (range: 0–3). b Bonferroni post hoc comparisons were used. Group 1 = Joint consideration of abortion; Group 2 = Discrepant consideration of abortion; Group 3 = No consideration of abortion. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
a
Jointly considered n = 323
Abortion consideration group means (SD)
TABLE 1 Means of Baseline Characteristics by Abortion Consideration Groups
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9.06 (2.73) .74 (.78) .15 (.33) .04 (.20)
Dependent variablea
Parenting stress
Substance use
Depression Anxiety
.15 (.36) .04 (.19)
.71 (.79)
9.05 (2.71)
Discrepantly considered n = 749
.10 (.31) .003 (.16)
.57 (.69)
8.44 (2.55)
Did Not consider n = 1927
3.87∗ .76
10.78∗∗∗
10.93∗∗∗
F (2, 2934)
1 > 3∗∗ 2 > 3∗∗∗ 1 > 3∗∗ 2 > 3∗∗∗ 2 > 3∗∗
Post hoc comparisonsb
Note: Baseline variables entered as covariates: Mother’s education (range: 1–5), father’s education (range: 1–5), mother’s age (years), father’s age (years), annual household income, religious involvement (range: 1–5), perceived support (range: 0–6), received support (range: 0–14), and substance use during pregnancy (range: 0–3). a Higher scores indicate higher parenting stress (range: 4–16), more substance use (range: 0–4), and higher prevalence of depression and anxiety. b Bonferroni post-hoc comparisons were used. Group 1 = Joint consideration of abortion; Group 2 = Discrepant consideration of abortion; Group 3 = No consideration of abortion. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
Jointly considered n = 261
Abortion consideration group means (SD)
TABLE 2 Means of Year One Outcomes by Abortion Consideration Groups Controlling for Baseline Characteristics
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two groups of mothers who considered abortion at baseline: those who reported typical, high parenting stress at one year (9 or above; n = 548) and those who reported lower-than-typical parenting stress (8 or less; n = 453). A MANOVA examining differences in baseline characteristics between the typical and atypical stress groups of mothers revealed a significant multivariate main effect, Wilks’ λ = .967, F (9, 991) = 3.73, p < .001, indicating that the two groups were significantly different in terms of baseline characteristics. Univariate tests revealed that there were significant differences in group means in terms of education, income, and substance use. However, no significant group differences were observed for age, received support, or perceived support (Table 3).
DISCUSSION We examined couples’ demographic characteristics and resource availability, as well as maternal well-being at one year postpartum depending on whether they considered abortion. Additionally, we identified protective factors at baseline among mothers who considered abortion but reported atypical, low parenting stress at one year.
Baseline Characteristics Baseline characteristics were similar among those who considered abortion jointly and discrepantly, however, they were significantly different among those who did not consider abortion. Participants who did not consider abortion had more education, were older, had higher income, and had more received support than those who jointly or discrepantly considered abortion. They also reported less perceived support and less substance use. These findings were consistent with existing literature, suggesting those who experience unplanned pregnancies tend to be economically disadvantaged (Kost & Forrest, 1995), young (Finer & Henshaw, 2006), to have less education (Finer & Henshaw, 2006), and to use substances (Than et al., 2005). Interestingly, although those who considered abortion reported low received support, they also reported high perceived support. This finding could be related to the fact that the sample included individuals who all decided to parent when faced with a pregnancy decision. It is possible that those who decided on abortion made that decision in part because of their low perceived support (Makenzius et al., 2012). The finding is also consistent with literature that suggests perceived and received support may be two separate sub-constructs with distinctly separate functions (Norris & Kaniasty, 1996).
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2.07 (.93) 2.09 (.89) 24.14 (5.59) 26.47 (7.16) $29,674 (1258) 2.85 (1.28) 3.26 (.72) 11.87 (1.92) 2.97 (.19)
Dependent variablea
Mother’s education Father’s education Mother’s age (years) Father’s age (years) Annual household income Religious involvement Perceived support Received support Substance use
1.86 (.92) 1.87 (.89) 24.02 (5.97) 26.64 (7.03) $25,428 (1006) 2.83 (1.34) 3.26 (.70) 12.02 (1.83) 2.99 (.07)
Typical, high stress outcomes n = 548
12.85∗∗∗ 16.52∗∗∗ .10 .15 7.12∗∗ .05 .03 1.76 5.70∗
F (1, 1017)
Higher scores indicate higher education (range: 1–5), increased age (years), higher annual household income, more religious involvement (range: 1–5), more perceived support (range: 0–6), more received support (range: 0–14), and more substance use during pregnancy (range: 4–15). ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
a
Atypical, low stress outcomes n = 453
Year one outcome group means (SD)
TABLE 3 Means of Baseline Characteristics for Year One Typical and Atypical Parenting Stress Outcomes Among Participants Who Considered Abortion
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Year One Maternal Well-Being Next, we examined maternal well-being at one year postpartum among the abortion consideration groups. Findings were similar to the baseline analysis in that the groups of individuals who considered abortion did not significantly differ from one another. However, those who did not consider abortion reported lower parenting stress, depression, and substance use at one year. Previous research suggested that these outcomes were associated with unplanned pregnancies (Miller et al., 2009; Sayil et al., 2007; Than et al., 2005); however, these findings expand the existing literature by specifically examining abortion consideration. These outcomes are important as maternal depression and parenting stress have been linked to insecure attachment among infants and toddlers (Coyl, Roggman, & Newland, 2002). Future studies should further investigate the impact of considering abortion on maternal mental health outcomes.
Protective Factors Given the significant findings from the first two analyses, we next examined protective factors among mothers with atypical, low parenting stress at one year despite initially considering abortion. Mothers who considered abortion yet reported low parenting stress at one year were more educated, had higher income, and reported less substance use at the birth of their children. Therefore, these potential protective factors should be promoted among women facing pregnancy decisions.
LIMITATIONS This study had several limitations. First, limitations of the dataset rendered it impossible to compare those who actually experienced abortion and those who did not. It was also not possible to examine pregnancy intention directly. Although it is likely that those who considered abortion were experiencing an unplanned pregnancy (Thorp, Hartmann, & Shadigian, 2003), they may not represent others who experienced unplanned pregnancies and did not consider abortion, and may include some planned pregnancies. Coleman, Coyle, and Rue (2010) found that women who considered abortion and decided to terminate their pregnancies later than the first trimester had more ambivalence and poorer mental health outcomes over time. We were not able to assess when in the pregnancy participants considered abortion or made their decision not to terminate the pregnancy, but the issue of timing should be examined in future studies. Second, common to other studies examining unplanned pregnancy, this study relied on retrospective report of abortion consideration. Parents
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Abortion Consideration
791
reported their abortion consideration approximately 48 hours after the birth of the focal child, thus the report may have been subject to “postbirth rationalization,” resulting in under-reporting of consideration (East et al., 2012). Abortion concealment rates also tend to be high, around 65% (Jones & Forrest, 1992), and it is likely some participants did not disclose their consideration of abortion due to social desirability pressures. Conversely, “maternity blues” also often occur during this period and could have influenced mothers’ responses, perhaps resulting in an overestimation of abortion consideration (Pitt, 1973). Further, this study was limited to examining maternal outcomes one year postpartum. One year was chosen because of the importance of maternal depression and stress early in children’s lives in the formation of secure attachment (Coyl et al., 2002); however, future studies should examine these factors longitudinally. The generalizability of the findings is also limited in that the majority of the FFCWS sample was unmarried at the birth of their child, and almost 40% of the original FFCWS sample was lost to follow-up at one year. The participants in the current study were more likely to have completed high school, have higher annual incomes, and report less anxiety than participants who dropped out. Furthermore, we used a series of FFCWS-developed items to assess substance use rather than a standard established scale; so, the reliability and validity of the construct is unknown. Finally, although we identified potential confounding variables based on common covariates of unplanned pregnancy in the literature, it is possible that not all confounding variables were included in the analyses so that residual confounding is possible.
IMPLICATIONS AND CONCLUSIONS Despite the limitations, the results of this study contribute to the literature in several ways. Although other studies have examined the differences between individuals who experience planned and unplanned pregnancies and outcomes associated with the decision to terminate pregnancy, few studies have specifically examined consideration of abortion in pregnancy. The findings suggest that considering abortion is associated with poorer outcomes at one year and that protective factors contribute to low parenting stress among mothers who considered abortion. The results of this study suggest that more education and income, and lower substance use may be associated with more positive outcomes for mothers who considered abortion. This has implications for both policy and clinical practice. This study provides rationale for promoting programs that support women in pregnancy decision-making, as well as providing education and employment assistance for new parents. Although current policy often emphasizes intervention with children of at-risk families, the results of this study suggest that intervening with mothers early on and
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specifically providing resources to promote education, employment, and substance use prevention may serve to decrease maternal parenting stress, and subsequently, improve child outcomes. Intervention may be particularly important for women experiencing unplanned pregnancies and who have considered abortion.
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