C 2006) Maternal and Child Health Journal, Vol. 10, No. 3, May 2006 ( DOI: 10.1007/s10995-005-0049-8
A Positive Orientation Toward Early Motherhood Is Associated with Unintended Pregnancy Among New Orleans Youth Aimee Afable-Munsuz, PhD,1,5 Ilene Speizer, PhD,2 Jeanette H. Magnus, MD, PhD,3 and Carl Kendall, PhD4 Received 7 April 2005; accepted 25 October 2005 Published online: 28 December 2005
Objective: Characterizing young women’s willingness to enter motherhood is critical to understanding the high rates of unintended pregnancy among women under 20 years. Our objectives were to discuss a measure called Positive Orientation towards Early Motherhood (POEM), and investigate its association with self-reported unintended pregnancy experience. Methods: We used data from 332 African-American women 13–19 years old recruited at public family planning and prenatal clinics in New Orleans. Using a series of ANOVAs and multinomial logistic regression, we assessed differences in POEM between four different outcome groups: women who were never pregnant and those who had only intended pregnancies, only unintended pregnancies and both unintended and intended pregnancies. Results: The data suggested that young women perceive pregnancy as an opportunity to assert responsibility, become closer with their families and achieve greater intimacy with their boyfriends. Multiple regression analysis indicated that this positive orientation toward early motherhood independently raised the likelihood that young women experienced unintended pregnancies. In particular, the perception that a pregnancy makes a young woman feel more responsible was associated with an increased likelihood that a young woman had only unintended pregnancies compared to no pregnancies at all. Interestingly, this perception did not differentiate young women who had only intended pregnancies from those who were never pregnant. Conclusion: When interpreting reports of unintended pregnancy, more attention should be given to young women’s orientation toward early motherhood. Doing so will inform policies that address both personal and structural factors that contribute to persistently high rates of unintended pregnancy among adolescents. KEY WORDS: pregnancy intentions; unintended pregnancy; adolescent pregnancy; measurement; social disparities.
INTRODUCTION 1
Center for Reproductive Health Research and Policy, University of California, San Francisco, San Francisco, California. 2 University of North Carolina at Chapel Hill School of Public Health, Department of Maternal and Child Health, Chapel Hill, North Carolina. 3 Tulane University School of Public Health and Tropical Medicine, Department of Community Health Sciences, New Orleans, Louisiana. 4 Tulane University School of Public Health and Tropical Medicine, Department of International Health and Development, New Orleans, Louisiana. 5 Correspondence should be addressed to Aimee Afable-Munsuz, PhD, Center for Reproductive Health Research and Policy,
Nationally, 35% of all births are unintended, according to the 2002 National Survey of Family Growth (NSFG) (1). However, the prevalence of unintended births reaches 49% among all African-American women and 80% among AfricanAmerican teens 15–19 years of age (1). In a University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94143-0936; e-mail:
[email protected].
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266 country where modern contraception is commonly used (2), the disproportionately high prevalence of unintended births among these sub-groups of women challenge us to think about what these estimates really indicate. According to the conventional definition, unintended births more commonly referred to as unintended pregnancies, are those that are mistimed (occurring earlier than wanted) and unwanted (not wanted at the time of conception or any time in the future). Estimates of unintended pregnancy rates are usually based on retrospective reports, collected in surveys some time after the birth of an infant and (or when) the pregnancy is resolved. However, this approach as well as the concept of “intending a pregnancy” has been subject to some debate. The authors of studies and reviews of unintended pregnancy measurement have all agreed that pregnancy intentions are multi-dimensional (3–11). Many question the utility of grouping together mistimed and unwanted pregnancies because they argue that timing and wantedness of pregnancy are two distinct dimensions (8–11). Luker (1999), commenting on the findings of Trussel et al. (1999), suggests that estimates of unintended pregnancy from different decades are not comparable because of the different circumstances between women surveyed from those with completed fertility to those initiating childbearing (3, 6). To an earlier generation of men and women, an unintended pregnancy was often an additional pregnancy after they reached desired family size (12). Today, with the inclusion of unmarried and adolescent women in reproductive health research, an unintended pregnancy increasingly refers to pregnancies occurring early in a woman’s reproductive years and her willingness to enter a new social role, motherhood. When the measure captures unexpected pregnancies at the beginning of a woman’s reproductive life course, rather than “excess” births at the end, Luker argues, what the measure really captures is her willingness to enter a new social role, motherhood (6). In the present study, we discuss a measure that captures some of the features that define young women’s willingness to enter motherhood. With this measure called Positive Orientation towards Early Motherhood (POEM), we investigated whether adolescent women perceive pregnancy as an event that signals greater responsibility and an opportunity to become closer to their family and boyfriends. We also investigated POEM’s association with adolescent women’s self-reported current and previous experience with unintended pregnancy, according to
Afable-Munsuz, Speizer, Magnus, and Kendall the conventional definition, using data from New Orleans.
STUDY METHODOLOGY Sample Women were recruited for this present study as part of the Determinants of Unintended Pregnancy Risk in New Orleans (DUPR) Study, a collaboration between Tulane University and the Centers for Disease Control and Prevention (CDC). Our study had two phases—the ethnographic phase, to collect data on which to base the POEM measure, and the quantitative phase, to field the POEM measure. In the ethnographic phase of the study, we conducted 77 in-depth interviews with women (aged 14–38 years old) between February and August 2001. Of these women, 73 out of 77 were African American; and more than 85% had completed high school or were still attending at the time of interview (13). In the second phase of the study, between March 13, 2002 and February 28, 2003, we surveyed 1,374 women (13– 49 years old) at the same clinics. Because this study focuses on understanding young women’s entry into motherhood and related unintended pregnancy experience, only data on 332 women aged 13–19 years old are presented here. All women in this sub-group were African American. The sample included women attending an innercity public prenatal clinic for an obligatory screening and education session before their first prenatal appointment and women visiting a nearby familyplanning clinic. The prenatal clinic we selected is the primary provider of free prenatal care services in New Orleans; the family planning clinic was selected because of its proximity to the prenatal clinic and because it served low-income women. Women who visited the family planning clinic attended a re-visit with a nurse to obtain a contraceptive update or refill, an annual check-up with a doctor to review contraceptive use, or a visit with a doctor to discuss a problem with a contraceptive (including side-effects and requests to change contraceptive methods). Clients of all ages (including adolescents) in the waiting area of each clinic were approached and asked to participate in the study. Using the appointment book, trained interviewers called out the name of the woman who was third or fourth in line to allow the 30-min survey to be started before her appointment. If a client was unwilling to participate in
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Table I. Variables Used to Measure Positive Orientation Toward Early Motherhood (POEM), Determinants of Unintended Pregnancy Risk in New Orleans Study, 2002–2003 Statement wording
Variable label
A child gives me more of a reason to work towards my career goals Having a baby makes me feel more acceptable among my friends Having a baby makes me feel more like an adult A child gives me more of a reason to complete my education A child gives me more of a reason to stay away from trouble (excessive parties, drinking, drugs, etc.) Having a baby gives me more attention from my boyfriend/husband Having a child brings my family closer together Having a baby makes me feel more responsible
CAREER FRIENDS ADULT EDUCATION TROUBLE PARTNER FAMILY RESPONSIBLE
Note: Respondents rate each item on a scale of 1–5, indicating the extent of agreement (1 = strongly disagree, 2 = disagree, 3 = don’t know, 4 = agree, 5 = strongly agree).
the study, the next name in the appointment book was called. Willing clients were escorted to a separate room to take the survey. Clients completed consent forms that explained study goals and survey content. The survey was administered by interviewers who read the questions and entered the replies into a computer. When the surveys were complete, clients were given tote bags as honoraria. The study protocol and consent procedures were approved by the Institutional Review Boards of Tulane University Health Sciences Center, the Centers for Disease Control and Prevention, Charity Hospital in New Orleans, and the Department of Health and Human Services (DHHS), which oversees the family-planning clinic as one of the New Orleans Office of Public Health clinics. Study staff did not collect information on women who were eligible but refused to participate. To assess how representative the surveyed samples were of all women seen in the clinics, we compared the demographic characteristics of the women interviewed to the characteristics of all women who visited the clinics during the study period using data from clinic records and data from DHHS records. This comparative analysis indicated that the interviewed women in the family planning clinic were significantly younger than all women visiting the family planning clinic; there were no significant differences in age between the women interviewed in the prenatal clinic and all women visiting the prenatal clinic (14).
tify POEM, we developed eight items on the basis of sentiments articulated by women who had ever been pregnant and women who had never been pregnant during the ethnographic phase of the DUPR study (13). A primary research aim of the ethnographic phase was to understand perceptions of teen pregnancy, which we refer to as early motherhood. To the extent possible, POEM was created to capture young women’s perceptions of early motherhood. Thus, items were worded to capture concepts that were specifically discussed by teen mothers such as motherhood as an event that signaled greater responsibility, motherhood as a way to become closer with their families and motherhood as an opportunity to achieve greater intimacy with their boyfriends. While not an a priori objective, it is important to recognize that some of the POEM items may reflect how motherhood is perceived among women at any age or parity. To determine POEM, the interviewer read eight statements (see Table I for statements) aloud, and women were asked to indicate their extent of agreement on a scale of 1 – 5, where 1 = strongly disagree and 5 = strongly agree. Higher scores for each item were interpreted as a more positive orientation toward early motherhood. In addition, we collected information on respondent’s current age, age at first sexual intercourse, contraceptive use at first sex, respondent’s educational level, and whether the respondent’s mother had any college education (which served as a proxy for the respondent’s socioeconomic background).
Independent Variables Outcome Variable This study investigated POEM and its relation to young women’s likelihood of self-reporting current or previous pregnancies as unintended. To quan-
We created four mutually exclusive outcome groups to indicate young women’s self-reported
268 pregnancy experience: (1) never pregnant women, which included only women recruited from the family planning clinic (six of these women reported never having sex); (2) women who reported having only intended pregnancies (included women recruited from the prenatal or family-planning clinic); (3) women who reported having only unintended pregnancies (included women recruited from both clinics); and (4) women who reported having a combination of unintended and intended pregnancies (included women recruited from both the prenatal or family planning clinics). This latter group included 27 women reporting up to 5 teen pregnancies; 23 of the 27 women reported their first pregnancy as unintended. In order to interpret our findings in light of national data, we used the conventional definition of unintended pregnancy, used by the National Survey of Family Growth (NSFG), which includes both mistimed and unwanted pregnancies.
Analysis We performed all statistical analyses using SAS software (Windows 8.0) (15). To assess differences in women’s sociodemographic characteristics according to unintended pregnancy experience groups (never pregnant, had only intended pregnancies, had only unintended pregnancies, had both unintended and intended pregnancies), we conducted one-way analyses of variance (ANOVAs) for continuous variables and Chi-square analyses for categorical variables. To determine if there were significant differences in each POEM-item mean among the unintended pregnancy experience groups, we conducted a series of ANOVAs and Tukey-multiple comparison tests, where appropriate. We then performed exploratory factor analysis (with an oblique PROMAX rotation) to investigate multidimensionality of the POEM measure (16). We examined eigenvalues to determine the number of factors resulting from each model (an eigenvalue that exceeds 1.0 denotes the presence of an underlying factor). On the basis of the eigenvalues, we determined that POEM can be explained by two factors. We used a factor loading criteria of 0.7 to determine which items were assigned to each factor. Two continuous measures of POEM were constructed which composed of 2–3 items each; each measure was the sum of the contributing items. We repeated the ANOVA to assess differences in the two POEM measures as well as the complete 8-item POEM
Afable-Munsuz, Speizer, Magnus, and Kendall measure among the outcome groups. To assess whether these findings were robust, we performed multinomial logistic regression to adjust for differences in sociodemographic characteristics between each unintended pregnancy experience group.
RESULTS Socio-Demographic Characteristics Fertility and sociodemographic information on these women according to unintended pregnancy experience is provided in Table II. Overall, the mean age of the sample was 17.5 years old and the mean age of first sex was 15.4 years old. Almost 60% were currently in high school or had not completed high school, about 21% completed high school or had a GED, and about 21% were in college. With regard to the respondent’s mother’s educational level, more than 60% reported that their mother was not college educated and over 32% reported that their mother had at least one year of college education. Over 80% of the young women reported using contraception during their first sexual intercourse. Fiftysix percent of the sample was recruited in the prenatal clinic. About 28% of the sample had never been pregnant, over 34% were currently pregnant for the first time, 14% had one prior pregnancy, 23% were either currently pregnant with their 2nd or higher-order pregnancy or had two or more pregnancies already. Among those women who were ever pregnant, 14% reported having only intended pregnancies, 75% reported having only unintended pregnancies, and 11% reported having both unintended and intended pregnancies. Unintended pregnancy outcome groups were significantly different with regard to several of the characteristics presented in Table II. Notably, both women who had only intended pregnancies and women who had both unintended and intended pregnancies were considerably older than the women who were never pregnant or who experienced only unintended pregnancies; post-hoc Tukey comparison tests indicated that the two former groups were significantly different from the latter two groups. For women who had both unintended and intended pregnancies, this finding is not surprising given that they also report higher parity. Interestingly, there was a significant difference by mother’s education level across the outcome groups. Almost half of the women who were never pregnant reported that their
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Table II. Characteristics of 332 African-American Female Study Participants, 13–19 years Old, Recruited from Public Prenatal and Family Planning Clinics According to Self-Reported Current and Previous Unintended Pregnancy Unintended pregnancy experience
Variable Age (mean) Education (%) Still in high school/incomplete high school Complete high school/GED In college Mother had some college education (%)∗∗∗ No Yes Unknowna Age at first sexual intercourse (mean) Contraceptive use at first sex (%)b No Yes Clinic (%) Family planning Prenatal Pregnancy experience (%) Never pregnant/never had sex Pregnant for the first time 1 previous pregnancy (not currently pregnant) 2 + pregnancies (including current) Total N
Never pregnant
Only intended
Unintended and intended
Only unintended
Full sample
17.2
18.2∗
18.5∗
17.5
17.5
50.5 20.4 29.0
60.6 24.2 15.2
58.3 20.8 20.8
61.5 20.7 17.8
58.4 20.8 20.8
49.5 47.3 3.2 15.8∗∗
54.6 33.3 12.1 15.7
79.2 20.8 0.0 14.8
67.2 26.4 6.3 15.1
61.5 32.7 5.8 15.4
13.6 86.4
24.2 75.8
25.0 75.0
20.1 79.9
18.9 81.2
100.0 n/a
27.3 72.7
3.7 96.3
23.6 76.4
44.0 56.0
100.0 n/a n/a n/a 94
n/a 63.6 27.3 9.1 33
n/a n/a n/a 100.0c 27
n/a 52.3 21.4 26.4 178
28.1 34.7 14.1 23.1 332
a
This category includes responses “don’t know,” “no response” and “not in contact.” Excludes five women who never had sex. c Of the 27 women in this category, 23 reported their first pregnancy as unintended. ∗ p < .05 (different from never pregnant and only unintended groups). ∗∗ p < .05 (different from unintended & intended and only unintended groups). ∗∗∗ p < .005 (chi-square). b
mother had had at least one year of college education, followed by one-third of the women who had only intended pregnancies, one-fifth of the women who had both unintended and intended pregnancies and about one-quarter of the women who had only unintended pregnancies. Thus, both the women who were never pregnant and those who reported only intended pregnancies seemed to be slightly more advantaged with regard to their mother’s educational level. Finally, both women who were never pregnant and women who reported having only intended pregnancies reported an older age at first sexual intercourse than women who experienced unintended pregnancies; only the never pregnant group was significantly different from women who experienced unintended pregnancies with regard to age at first sex according to post-hoc Tukey comparison tests. Descriptive Analysis of the POEM Items The overall mean scores of each POEM item (listed in Table I) and the scores according to un-
intended pregnancy experience are presented in Table III. Overall, women tended to agree with CAREER (A child gives me more of a reason to work towards my career goals), EDUCATION (A child gives me more of a reason to complete my education), TROUBLE (A child gives me more of a reason to stay away from trouble—excessive parties, drinking, drugs, etc.) and RESPONSIBLE (Having a baby makes me feel more responsible), as their mean scores were above 3.0; and they tended to disagree with items ADULT (Having a baby makes me feel more like an adult), FAMILY (Having a child brings my family closer together), FRIENDS (Having a baby makes me feel more acceptable among my friends) and PARTNER (Having a baby gives me more attention from my boyfriend/husband) as their mean scores were below 3. Examining the scores according to unintended pregnancy experience group, mean scores for all of the items (except FRIENDS) differed significantly across groups. Notably, women who had been pregnant (including those who reported both intended and unintended pregnancies)
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Afable-Munsuz, Speizer, Magnus, and Kendall Table III. Positive Orientation Toward Early Motherhood (POEM) Item Means According to Unintended Pregnancy Experience Among the 332 African American Female Study Participants, 13–19 Years Old Unintended pregnancy experience
Only intended
Unintended and intended
Only unintended
∗
3.3 3.1∗∗ 3.8∗ 1.6∗∗ 1.7 1.9∗∗ 1.8∗∗ 2.8∗∗
3.9 3.9 4.0 2.5 2.0 2.9 3.2 4.1
4.5 4.3 4.8 2.5 2.1 2.9 3.1 4.4
4.3 4.3 4.6 2.2 2.1 2.7 2.7 4.1
4.0 3.9 4.3 2.1 2.0 2.5 2.6 3.7
20.1∗∗ 10.2∗ 3.4∗∗ 93
26.6 11.8 5.6 33
28.7 13.6 5.7 24
27.0 13.2 5.0 174
25.1 12.2 4.7 324d
Never pregnant CAREER EDUCATION TROUBLE PARTNER FRIENDS ADULT FAMILY RESPONSIBLE Summary indices POEM (all)a POEM-goalsb POEM-supportc Total N
Total
a
Score range: 8–40. Score range: 3–15 (CAREER, EDUCATION, TROUBLE). c Score range: 2–10 (PARTNER, FAMILY). d POEM data missing for 8 women. ∗ p
