Unintended Pregnancy as a Risk-Factor for Child Maltreatment Kai Guterman Casey Family Programs June 9, 2011

1. Unintended Pregnancy as a Risk-Factor for Child MaltreatmentKai Guterman Casey Family Programs June 9, 2011

2. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • But for all that I didn’t know and wasn’t told about who I was, a feeling of being unwanted and not belonging had been planted in me from a time that came before my memory. And it wasn’t long before I came to the conclusion that I was an uninvited guest. It was my hardest, earliest truth that to be legitimate, you had to be invited to be on this earth by two people—a man and a woman—who loved each other. Them just having sex wasn’t enough to get you invited. Each had to agree to invite you. A mother and a father. Antwone Fisher

3. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • When children enter the world “unwanted” by a primary caregiver, what are the particular risks to their development and general well-being? • To date, the research literature has provided a very incomplete answer to this question. 1. Perhaps these children receive lesser quality and quantity of inputs necessary for optimal child development including • Less positive parental behaviors, in terms of time and nurturing • Fewer resource investments, in terms of nourishment and educational investments.  • (Neglect)

4. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • When children enter the world “unwanted” by a primary caregiver, what are the particular risks to their development and general well-being? 2. Additionally, they may also be given an excess of negative parental behaviors • More severe discipline • The child becomes an object of resentment and ridicule • (Abuse) • Consciously or unconsciously, parents may demonstrate their commitment to their child’s life chances, and resources may be distributed accordingly.

5. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • To better meet the needs of children and families, practitioners and policy-makers must begin to consider a more complete picture of the circumstances surrounding the pregnancy. • These early circumstances set the stage for all following developmental processes that unfold from this developmental moment. • All parenting decisions may be understood within the context of these original circumstances. • Depending upon the degree of wantedness, the child’s developmental trajectory begins to follow down a particular pathway.

6. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Conceptual framework: • Looking upon maltreatment from a Public Health perspective, we can use a prevention framework, where interventions are designed to target critical time-points to interrupt mediating pathways that unfold into sequences of pathological events.

7. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Public Health perspective: • In the case of child maltreatment, delivering effective services before risks accumulate into maltreating behaviors provides the opportunity for the child and family to switch tracks onto healthier developmental trajectories. • For such a process to work, researchers must adequately understand the complex pathways leading toward maltreatment, by understanding the antecedents in the chain of events leading toward worse outcomes.

8. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • The evidence-base has established the following risk-factors for child maltreatment: • (1) child characteristics including prematurity and difficult temperament • (2) parent characteristics including teenage childbearing, single motherhood, social isolation, low SES, authoritarian parenting style, substance-abuse, depression, and family-of-origin abuse or neglect

9. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • The evidence-base has established the following risk-factors for child maltreatment: (continued) • (3) neighborhood or community-level characteristics including social distrust, negative views of the community, and low levels of collective efficacy • (4) societal characteristics including cultural norms that reinforce corporal punishment and cultural beliefs of parental “ownership” of children, as well as the concern for “private matters” in the home

10. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Risk for Maltreatment: • Particularly in American society, these risk-factors are known to accumulate and bundle together • As a result, many children grow up in severely disadvantaged homes with few resources to adapt to these environments—a double blow to healthy child development • These accumulated risks take on a certain momentum, and this momentum can continue to build over the course of generations. • Therefore, practitioners, researchers, and policy-makers should be particularly concerned with the ways that risk is transmitted from one generation to the next

11. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Research Question: Can unwantedness, or a measure of low pregnancy intention predict worse parenting behaviors and outcomes for those children?

14. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Risk-Factor Vs. Causal Variable • Because low pregnancy intention is a characteristic of some families and children, it cannot be understood as a causal treatment than can universally be applied to an entire population. • In the same way, characteristics of children (difficult temperament, etc) cannot be said to cause abuse. • Instead, these characteristics, when aggregated, can place children at greater risk for maltreatment • As a result, we can explore associational and predictive relationships, to determine if, and to what extent low pregnancy intention precedes and predicts later maltreatment behaviors with any degree of precision.

15. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Hypothetical Process: • Upon learning the news of pregnancy, some parents question: • whether the timing is right, or • their ability to provide for a child, or • the stability of their partner relationship. • Uncertain about their readiness, these parents may delay their decision . . .

16. Unintended Pregnancy as a Risk-Factor for Child Maltreatment Hypothetical Process: • In their postponement, the developing pregnancy continues to progress, and begins to reach a point where it becomes too late to turn back. • Mothers may soon feel as if a decision has already been made for them, and become resigned to their (and their child’s) fate.   • During this period of uncertainty, mothers may be continuing to use substances, and delay seeking prenatal care.

17. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Definitions and Measurement: • Unintended pregnancy encompasses 2 concepts: (approximately 40% of all pregnancies) • 1. Mistimed pregnancies, whereby women wanted a child, but they became pregnant either too early or too late • approximately 30% of all pregnancies • 2. Unwanted pregnancies include the more severe cases of unintended pregnancy, where the woman does not desire a child at all, or any more children • approximately 10% of all pregnancies

18. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Measurement and Meaning of Unintended Pregnancy (Santelli et al, 2003) • Traditionally used measures of unintended pregnancy were designed to be reliable and predictive at a population-level, not an individual-level. • As a result, the predictive power of these intentions is not high • Human behavior is more complex than a yes/no answer. • Ideally, such information should be captured along a continuum between wanted and unwanted, etc.

19. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Measurement and Meaning of Unintended Pregnancy • Information about child bearing intentions is most accurate when collected closer in time to conception. • Over time, “unwanted” pregnancies are more likely to be reported as “wanted” • As a result, retrospective studies seeking information on pregnancy intention are subject to error, increasing with time

20. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Measurement and Meaning of Unintended Pregnancy • Pregnancy intentions involve cognitive, emotional and cultural factors, and measurement strategies should take these factors into account • Motivations to engage in sexual activity are often distinct from childbearing intentions • Ambivalence and failure to form intentions around pregnancy planning behaviors are common. • One study found that 60% of inner-city women had not considered the possibility of becoming pregnant—the last time they conceived

21. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Measurement and Meaning of Unintended Pregnancy • “The focus on whether a woman intends a pregnancy implies that her intentions count the most. However, for millions of women in the United States and around the world, the power to translate these intentions into practice is circumscribed by limited access to resources or health services, or by limited control of their own bodies (Santelli et al, 2003).”

22. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Measurement and Meaning of Unintended Pregnancy • Some women frequently do not control the circumstances of intercourse, much less the decision of whether to bear a child. • Attitudes and behaviors of male partners often influence women’s intentions, sexual behavior, contraceptive use, and parenting practices. • Disagreement between the intentions of partners is common. • As a result, the perspectives of male partners are important to capture for any study addressing pregnancy intentions.

23. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Qualitative Research on Pregnancy Intention: • Edin, England, Shafer, & Reed, 2007, “Forming Fragile Families: Was the Baby Planned, Unplanned, or In Between.” • TLC3 (Time, Love, and Cash among Couples with Children) Qualitative Data using a subsample of Fragile Families (N=202) • Edin et al. propose understanding the propensity to conceive through 2 parallel, but independent continua: • (1) Scale ranging from high to low pregnancy intention, and • (2) Scale is organized in terms of personal efficacy • Family Planning Efficacy : • The ability or inclination to organize the complex set of behaviors required to avoid pregnancy, such as making and keeping doctor’s appointments to get the pill or patch, going to the drug store to fill a prescription or purchase over-the-counter contraceptives, and using the pill or condoms regularly (Edin et al., 2007, 26).

24. Unintended Pregnancy as a Risk-Factor for Child Maltreatment Pregnancy Intentions Efficacy

25. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Qualitative Research on Pregnancy Intention (Edin et al., 2007): • For most families, pregnancy planning behaviors fall fairly consistently into alignment with their position on the pregnancy intention scale; couples strongly desiring/not desiring a pregnancy act in such a way • Pregnancy Intentions match Pregnancy Planning Behaviors • Preferences are revealed through contraceptive practices • However, Edin et al., identify one group for whom pregnancy intentions fall out of alignment with behaviors, totaling about 25% of these pregnancies. • “Unplanned, not contracepting,” does not desire a pregnancy, yet they are not to take any precautions.

26. Unintended Pregnancy as a Risk-Factor for Child Maltreatment Pregnancy Intentions Unplanned, Not Contracepting Families Efficacy

27. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Unplanned, Not Contracepting Group: • “I just asked her what she was going to do, was she gonna have it, or what…? I was thinking to myself, I don’t want [a] child…. She didn’t want… one neither…. But she had it anyway.” • “I wasn’t trying to get pregnant, but it just happened…. I had stopped using the pill. That’s my problem.” (Edin et al., 2007, 42)

28. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Does low pregnancy planning efficacy translate into low parenting efficacy once the child is born? • Burton Mindick (1982) theorized that the conception of an unwanted pregnancy and child maltreatment are in fact the same problem. • Both exhibit the same underlying difficulties: poor interpersonal skills and coping abilities. • If unintended pregnancy is part of a larger problem of interpersonal functioning, how can we define it, measure it, and treat it?

29. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence Base Addressing Pregnancy Intention and Maltreatment: • Scattered and undeveloped: • Most studies define terms and operationalize concepts differently. • Lack of precise definitions and measurement techniques prevents comparability and duplicability of findings • Small sample sizes • Limited population-based studies • Many studies lack adequate demographic controls • Retrospectively attained pregnancy intention status

30. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence Base Addressing Pregnancy Intention and Maltreatment: • Multiple calls to better develop the field have gone unheeded: • The consequences of unintended pregnancy are serious, imposing appreciable burdens on children, women, men, and families. [Therefore the Institute of Medicine, Committee on Unintended Pregnancy] urges, first and foremost, that the nation adopt a new social norm: All pregnancies should be intended (Brown and Eisenberg, 1995, 4).

31. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence: • Zuravin (1987) • N= 518 urban, single mothers receiving welfare • Finds a statistically significant positive coefficient between unplanned conceptions and abuse and neglect scores. • Limited demographic controls

32. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence: • Zuravin (1991) • N=198 female headed families receiving child protective services compared with a matched control sample • Finds that the relationship between unplannedness and maltreatment is actually mediated through the effect of pregnancy upon family size.   • Limited demographic controls  

33. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence: • Rosenzweig and Wolpin (1993) • N= 3,233 young mothers • Analyze the retrospectively attained wantedness of the child upon birth outcomes • They find a statistically significant negative relationship between a measure of wantedness and well-child care, which includes non-neglectful parenting behaviors, among others.

34. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence: • Sidebotham (2003) (United Kingdom) • N= 14,256 children using longitudinal data (the only population-based study) • Finds a statistically significant odds-ratio of 2.92 for unintended pregnancy between children registered and unregistered for child protective services. • As a result, children on the protective service registry were 3 times as likely to have been unintended as their peers.

35. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Evidence: • Goto, Yasumura, and Yabe (2005) (Japan) • N= 317 mothers using a mail-in survey and compares differences between unintended and intended pregnancy outcomes. • They find an odds-ratio of 5.2 for a self reported question (“I feel I am abusing my child.”) between unintended pregnancy and intended pregnancy groups.

36. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Research: • Rodriguez (2009) • N= 77 expectant mothers, recruited for an online survey • She finds an association between low pregnancy desire and child abuse potential, but identifies passive parental coping styles as fully mediating the relationship.

37. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Research: • David, et al (2006) • The Prague Study followed 220 children for over 30 years, exploiting an ideal natural experiment. • These children were born to mothers who were twice rejected abortion access in the early 1960’s living under Soviet rule. • Medical commissions made decisions to accept or reject abortion applications based upon an “acceptable” set of criteria. • These women who twice sought abortion and were twice rejected could be seen as extreme cases of unwantedness, representing 2% of women seeking abortion at that time • Of 501 women in this category, 316 carried the child to term. Out of these, 6 children died (5 in the first year), a proportion exceeding the national average by over 30 times.

38. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Research: • David, et al (2006) (continued) • Early on, these children closely matched their comparison group in terms of intelligence, birth-weight, and other primarily genetic endowments. • However, researchers noted that unwanted children were breast-fed for less time, and in school they received lower grades, were rated lower by their teachers in terms of behavior and diligence, and were significantly more “rejected as a friend,” among peers. • As adolescents and adults, these unwanted children experienced much higher rates of in-patient psychiatric treatment, criminal behaviors, and failed intimate relationships.

39. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Existing Research: • David, et al (2006) (continued) • For our purposes, these children appeared more or less the same as typical Czech children at birth and shortly thereafter, yet as they grow, environmental factors—including parenting behaviors, veer them off on a developmental trajectory leading toward comparatively worse outcomes. • These disparities continue to grow over time, compounding disadvantage over the life-course. • While the Prague study did not specifically measure child maltreatment, from using known proxies for maltreatment, we have good reason to believe that these children experienced a worse home environment, specifically higher rates of abuse and neglect.

40. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Data: • Fragile Families and Child Well-Being Study: • N= 4,898 couples • Rich longitudinal birth-cohort survey, began in the baseline year 2000. • Participants were randomly sampled from 75 public hospitals in 20 US cities of over 200,000 residents, forming a nationally representative set of cities randomly selected based upon maximum variation in policy regimes (Reichman, Teitler, Garfinkel, & McLanahan, 2001).

41. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Data: • Fragile Families and Child Well-Being Study: • Indicative of its name, the Fragile Families study sought to learn important information about lower-income, and primarily unmarried couples who have children • Designed to better elucidate 3 primary areas of interest: • Non-marital childbearing • Welfare reform • The role of fathers in these families

42. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Data: • Fragile Families and Child Well-Being Study: • Sought to describe the forces that draw fragile families closer together, as well as further apart. • As a result, the surveys reflect a rich set of questions designed to understand these processes from both mothers’ and fathers’ perspectives.

43. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Fragile Families and Child Well-Being Study: • Contrary to nearly all previous datasets, Fragile Families undertook considerable efforts to capture the experience of fathers. • Whereas nearly all previous research into child maltreatment and low-income families relied upon mother reports and administrative data, the views of fathers can yield important information about the internal dynamics of these families. • Interviewers were comparatively successful at tracking down these fathers. For those who did not attend the birth, interviewers were able to speak with many of them in the following months, • N= 3,830 fathers captured in baseline year.

44. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Fragile Families and Child Well-Being Study: • As a result of these design elements of the study, the surveys reflect a rich set of questions designed to understand these parental relationships from both the mothers’ and fathers’ perspectives. • The circumstances and later outcomes of these families and their children tend to reflect a deeper set of personal disadvantages. • For this reason, such a dataset is especially appropriate for studying risk-factors for child maltreatment, as these families display propensities for maltreatment at higher rates than the general population.

45. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Fragile Families and Child Well-Being Study: • 24% Married at Baseline • 52-55% in Steady relationship at Baseline • 3% of mothers have no relationship with father at Baseline (in hospital for birth) • Average age of 25.3 for Mothers, 27.9 for Fathers • Both parents average slightly above a Diploma/GED • Mothers income averages 222% of the poverty line • Fathers average 276% of poverty

47. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Independent Variables • Primary Survey Questions capturing Pregnancy Intention (Asked of Both Mother and Father): • When you found out [Baby’s Mother] was pregnant, did you think about having an abortion? • Did [Baby’s Father] suggest that [Baby’s Mother] have an abortion? • After you found out [Baby’s Mother] was pregnant, would you say your relationship with [Baby’s Father/ Mother] got better, worse, or stayed the same?

50. Unintended Pregnancy as a Risk-Factor for Child Maltreatment • Findings: • Note that mothers are far more likely to consider abortion than fathers, and for fathers who do consider abortion, a large percentage of them suggest abortion. • Fathers are more likely to say that their relationship became worse upon hearing the news of pregnancy, whereas mothers are about equally likely to say that the relationship became better than worse.