3
Consequences of Unintended Pregnancy

Does it matter whether a pregnancy is unintended at the time of conception—mistimed or unwanted altogether? There is a presumption that it does—that unintended pregnancy has a major impact on numerous social, economic, and cultural aspects of modern life. But it is important to define what these consequences might be. Accordingly, this chapter examines five sets of information that help to answer this important question. The first section addresses elective termination of pregnancy, because about half of all unintended pregnancies in the United States are resolved by abortion. As such, abortion can be seen as one of the primary consequences of unintended pregnancy. The second section considers the fact that unintended pregnancy is more common among unmarried women and women at either end of the reproductive age span (Chapter 2)—demographic attributes which themselves carry increased medical or social risks for children and/or their parents.

The final three sections address additional consequences of unintended pregnancy. The third section analyzes a complex set of studies in which the intendedness of pregnancy itself is related to a variety of outcomes for both the child (such as birthweight and cognitive development) and parents (such as educational achievement). These studies allow one to consider whether pregnancy intention itself affects various child and parental outcomes. The fourth consequence explored is that opportunities for preconception health assessment and care are often missed when pregnancy occurs unintentionally. Preconception care is still a developing field of clinical practice, but its potential impact is important. The fifth section of the chapter analyzes how some dimensions of the childbearing population in the United States would change if unwanted pregnancies were eliminated altogether and mistimed ones were redistributed



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--> 3 Consequences of Unintended Pregnancy Does it matter whether a pregnancy is unintended at the time of conception—mistimed or unwanted altogether? There is a presumption that it does—that unintended pregnancy has a major impact on numerous social, economic, and cultural aspects of modern life. But it is important to define what these consequences might be. Accordingly, this chapter examines five sets of information that help to answer this important question. The first section addresses elective termination of pregnancy, because about half of all unintended pregnancies in the United States are resolved by abortion. As such, abortion can be seen as one of the primary consequences of unintended pregnancy. The second section considers the fact that unintended pregnancy is more common among unmarried women and women at either end of the reproductive age span (Chapter 2)—demographic attributes which themselves carry increased medical or social risks for children and/or their parents. The final three sections address additional consequences of unintended pregnancy. The third section analyzes a complex set of studies in which the intendedness of pregnancy itself is related to a variety of outcomes for both the child (such as birthweight and cognitive development) and parents (such as educational achievement). These studies allow one to consider whether pregnancy intention itself affects various child and parental outcomes. The fourth consequence explored is that opportunities for preconception health assessment and care are often missed when pregnancy occurs unintentionally. Preconception care is still a developing field of clinical practice, but its potential impact is important. The fifth section of the chapter analyzes how some dimensions of the childbearing population in the United States would change if unwanted pregnancies were eliminated altogether and mistimed ones were redistributed

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--> (typically, postponed). This statistical exercise helps provide an understanding of the consequences of current demographic patterns of unintended pregnancy and subsequent childbearing. Abortion as a Consequence Of Unintended Pregnancy As the Chapter 2 discussed, about half of all unintended pregnancies end in abortion. Accordingly, the occurrence of abortion can be seen as one of the primary consequences of unintended pregnancy. Voluntary interruption of pregnancy is an ancient and enduring intervention that occurs globally whether it is legal or not. The legalization of abortion in all of the United States, accomplished through the 1973 Supreme Court ruling Roe v. Wade, served in large part to replace illegal abortion (as well as abortion obtained outside of the United States) with legal abortion in this country. It is estimated that before the legalization of abortion, about 1 million abortions were being performed annually, few of them legally, and somewhere between 1,000 and 10,000 women died annually from complications following these often poorly performed procedures. Before the Supreme Court ruling, abortion was probably the most common criminal activity in this country, surpassed only by gambling and narcotics violations (Luker, 1984; Jaffe et al., 1981). A 1975 report by the Institute of Medicine documented the benefits to public health by the legalization of abortion. The Supreme Court decision was followed not only by a decline in the number of pregnancy-related deaths in young women (Cates et al., 1978) but also by a decline in hospital emergency room admissions because of incomplete or septic abortions, conditions that are more common with illegally induced abortions (Institute of Medicine, 1975). Given the long-standing reliance on abortion to resolve many unintended pregnancies, it is important to consider available information about the major medical and psychological risks that this procedure may pose (Centers for Disease Control and Prevention, Reproductive Epidemiology Unit, 1994; Frye et al., 1994; Lawson et al., 1994). From the voluminous data available for review, two important findings stand out that are often overlooked in the controversy over this procedure. First, whatever the risks associated with legal abortion in the United States, it remains a far less risky medical procedure for the woman than childbirth; over the 1979–1985 interval, for example, the mortality associated with childbirth was more than 10 times that of induced abortion (Council on Scientific Affairs, American Medical Association, 1992). Second, abortion in the first trimester of pregnancy carries fewer risks to health than abortion in the second trimester of pregnancy and beyond.

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--> Medical Complications As with any surgical procedure, abortion carries an inherent risk of medical complications, including death. Complications known to be directly related to the procedure include hemorrhage, uterine perforation, cervical injury, and infection, which is often due to incomplete abortion. Later complications that have been investigated include possible negative effects on subsequent pregnancy outcomes, particularly low birthweight, midtrimester spontaneous abortion, and premature delivery. The vast majority of abortions performed in this country are first-trimester vacuum aspiration procedures. Pregnancy outcomes among women who have had one vacuum aspiration abortion are no different than those among women who have not had an abortion. Results are mixed, however, as regards the influence on subsequent pregnancy outcomes of having had more than one abortion or having second-trimester abortions by vacuum extraction. At present, investigators are studying a possible relationship between abortion and an increased risk of developing premenopausal breast cancer (Daling et al., 1994). Rates of Complications To assess the frequency with which the well-documented complications of abortion occur, between 1970 and 1978 the Centers for Disease Control and the Population Council conducted the Joint Program for the Study of Abortion in three waves: 1970–1971, 1971–1974, and 1975–1978. These surveys showed that the risk of developing major complications 1 from legal abortion decreased greatly during the 1970s: from 1.0 percent in the first wave to 0.29 percent in the last (Buehler et al., 1985; Cates and Grimes, 1981; Grimes et al., 1977; Tietze and Lewit, 1972). Although the total complication rate2 increased from 9.0 to 14.8 percent over the three waves, this probably reflected an increased follow-up rate, a change in the distribution of firstand second-trimester abortions among the study populations, and an increase in reports of minor complications. Alternatively, the change may have been due to an actual increase in complications. More recent data show a total complication rate of induced abortion of less than 1 percent (Gold, 1990; Hakim-Elahi et al., 1990). 1   The major complications rate denotes the percentage of women sustaining 1 or more of 15 complications that include cardiac arrest, convulsion, fever for 3 or more days, hemorrhage necessitating blood transfusion, pneumonia, psychiatric hospitalization for 11 or more days, and death. 2   The total complication rate refers to the percentage of women who sustained one or more complications of any variety or severity.

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--> In all waves, the risk of all complications increased steadily with increasing gestational age, being lowest for women obtaining abortions at ≤ 8 weeks of gestation and increasing 2 to 10 times for procedures after 12 weeks of gestation. Complication rates were lowest among women whose abortions were performed using suction curettage and increased with more invasive procedures (those often used for more advanced pregnancies). Trend data are also available on mortality. The annual number of legal-abortion-related deaths decreased from 24 deaths in 1972 to 6 in 1987, and the mortality rate decreased from 4.1 per 100,000 abortions in 1972 to 0.4 in 1987. As with overall complication rates, the risk of mortality is lower for abortions performed by suction or sharp curettage during the first trimester and for pregnancies of lower gestational age (Lawson et al., 1994). The risk of mortality is higher, however, for nonwhite women, women 35 years of age and older, and for women of higher parity. The increased risk of both morbidity and mortality with increasing gestational age underscores the health risks averted by early rather than late abortion. At present, 11 percent of abortions are obtained after 12 weeks of pregnancy; these later abortions are obtained disproportionately by adolescents: for girls under age 15, 22 percent of abortions are done in the second trimester, whereas the comparable figure for women over age 20 is 9 percent (Rosenfield, 1994). Although late abortion may be due to delay in recognizing a pregnancy, in deciding what to do if the pregnancy is unwanted, or may be a consequence of a genetic defect not detected until the second trimester, public policies can also increase the chance that an abortion will be performed in the second rather than the first trimester. Policies that may discourage first-trimester abortions include mandatory waiting periods (now required in 13 states), parental involvement/judicial bypass laws (35 states), and various informed consent laws, many of which require that women be given antiabortion lectures and materials intended to discourage them from having an abortion (31 states) (National Abortion and Reproductive Rights Action League, 1994). Chapter 7 notes the important and related issues of insufficient training of providers in abortion techniques and of declining numbers of abortion providers. Psychological Issues Although the medical risks of abortion appear to be very small, the procedure may pose troubling moral and ethical problems to some women and providers as well. In addition, women (and those close to them) may find that confronting an unintended pregnancy and weighing the option of abortion are emotionally difficult experiences, and the procedure itself may involve appreciable pain and expense.

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--> Accordingly, numerous researchers have attempted to determine the extent to which abortion results in psychological problems in the weeks and months following the procedure. Some have investigated what has been called "post-abortion syndrome," hypothesizing that abortion may lead to a form of posttraumatic stress disorder, even though abortion does not meet the American Psychiatric Association's definition of trauma (Gold, 1990). Most of the 250 studies dealing with the psychological effects of induced abortion suffer from substantial methodological shortcomings and limitations (Council on Scientific Affairs, 1992; Adler et al., 1990; Gold, 1990; Koop, 1989). In light of these problems, former Surgeon General C. Everett Koop concluded in 1989 that data "were insufficient…to support the premise that abortion does or does not produce a post-abortion syndrome." He also concluded that emotional problems resulting from abortion are "minuscule from a public health perspective" (Koop, 1989). Similarly, Adler et al. (1990:42) concluded that "studies [of the psychological impact of abortion] are consistent in their findings of relatively rare instances of negative responses after abortion and of decreases in psychological distress after abortion compared to before abortion." Political Issues It is important to add that even though the medical and psychological consequences of abortion for individual women are largely minor, the consequences for the nation's political and social life are less benign. The legality and availability of abortion have been associated with important and painful divisions throughout the country, even overt hostility and violence, including several murders of health care personnel working for clinics that provide abortions. Controversy over abortion has affected public discourse on a wide range of issues—health care reform, fetal tissue research, and public funding for contraceptive services and research, among other topics. Views about abortion have colored state and local elections, Supreme Court nominations, political conventions, presidential politics, and many other issues as well. Polling data show that although a majority of Americans continue to support the basic legality of abortion, there remain many differences of opinion about the extent to which abortion should be available without restrictions, the acceptability of using government funds to pay for abortions, whether parental consent should be required when a minor seeks an abortion, and other issues as well (Blendon et al., 1993). It appears that social and political controversy over abortion will likely remain a divisive force in the United States—a reality that underscores the importance of reducing unintended pregnancy, which is the principal antecedent to abortion.

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--> Maternal Demographic Status As noted in Chapter 2, unintended pregnancy occurs among all populations of women. But the experience is relatively more common in several specific groups: women at either end of the reproductive age span and women who are unmarried. Although many of these unintended pregnancies are resolved by abortion, an appreciable number result in live births (see Table 2-2). Therefore, in assessing the consequences of unintended pregnancy, it is useful to review the available data on the extent to which these demographic attributes themselves carry increased risks for children and their parents. Information on both socioeconomic and medical risks are reviewed below; because poverty is intertwined with the issues of both age and marital status, as subsequent text reveals, it is not discussed as a separate issue. Data from selected developing countries on many of these issues have recently been reviewed but are not presented here (National Research Council, 1989a,b). This focus on selected groups is not meant to obscure a major point made in Chapter 2: although it is true that women who are unmarried or at either end of the reproductive age span are disproportionately represented among those having births that were unintended at conception, the majority of such births are to women without these attributes. Unintended pregnancy remains a widespread problem, whatever its pockets of concentration. Adolescent Childbearing: Socioeconomic Issues The negative associations between early childbearing and a host of economic, social, and health outcomes have been found in a variety of data sets over time. The association is strong, consistent, and persistent. The critical question has been that of causality. Births during the teenage years are concentrated among disadvantaged groups, whose members are likely to experience multiple disadvantages as adults whether or not they have children as teenagers. Thus, it has been argued that the association between early childbearing may reflect the disadvantaged backgrounds of those adolescents who become parents rather than any negative effects due to the timing of the birth itself (Geronimus, 1992; Luker, 1991). Before addressing the causality issue, it is important to note the strong association of teenage childbearing with various problems. The link to diminished socioeconomic well-being, for example, for both children and their mothers has been recognized for several decades (Bacon, 1974). Adolescents who have children are substantially less likely to complete high school than those who delay childbearing. In recent years, the proportion of teenage mothers with high school degrees has increased, in large part because many are able to complete requirements for the general equivalency diploma (Moore, 1992; Mott

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--> and Maxwell, 1981). However, few teenage mothers attend college, and less than 1 percent have been found to complete college by age 27 (Moore, 1992). Moreover, teenage mothers are more likely to be single parents or, if they are married, to experience marital dissolution (Hayes, 1987). Indeed, the proportion of teenagers who are single parents has increased substantially over the years. For example, in 1970, 30 percent of all births to teenage girls occurred outside of marriage, whereas 67 percent of births occurred outside of marriage in 1991 (National Center for Health Statistics, 1994). Larger families place greater demands on a family's economic assets. Although family sizes among younger as well as older mothers have declined over time, younger mothers continue to have more children than delayed childbearers (Moore, 1992). Because of their fewer years of schooling, larger families, and lower likelihood of being married, teenage mothers acquire less work experience, have lower wages and earnings, and are substantially more likely to live in poverty. Figure 3-1 illustrates the strong association between age at first birth and poverty. Although minority women generally face a higher probability of poverty regardless of their age at first birth, age at first birth is linked to lower economic well-being within each race/ethnicity group. A majority of Hispanic and black teenage mothers are poor; that is, the ratio of their family income to the poverty threshold is below 100 percent; less than one-fourth of women who delay childbearing into their 20s have such low incomes. Among whites, one-fourth of teenage mothers had family incomes below the poverty level, compared with less than 1 in 10 among delayed childbearers. The lesser likelihood of marriage and lower earning capacity of teenage mothers are also related to more frequent welfare receipt. Figure 3-2 illustrates the very strong association between a mother's age at the birth of her first child and the probability that she will receive payments from Aid to Families with Dependent Children (AFDC) during her first-born's preschool years. Again, though, there are important questions about whether these many associations are directly caused by the mother's young age. Untangling the question of causality is essential to understanding the impact of childbearing in adolescence on both the mother and her offspring and in designing remedial programs for the future. Specifically, if having a baby has no negative impact on socioeconomic status or health, then remedial efforts should focus less on delaying childbearing than on alleviating the disadvantages associated with and apparently contributing to teenage childbearing. Of course, for many service providers and policymakers confronted with the needs of young parents and their children, the causality issue is moot; teenage parents and their children represent a population with multiple and immediate needs who pose substantial public costs, and figuring out cause versus association has little urgency. Selectivity into early parenthood has long been recognized (Waite and Moore, 1978), and researchers have employed a variety of strategies to control for the effects of socioeconomic background differences. For example, Moore

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--> Figure 3-1 Percentage of mothers in poverty at age 27 by age at first birth. Source: Moore KA, Myers DE, Morrison DR, Nord CW, Brown B, Edmonston B. Age at first childbirth and later poverty. J Res Adol. 1993;3:393–422. and colleagues (1993) estimated structural equation models including numerous background factors as controls; Hoffman et al. (1993) and Geronimus and Korenman (1992) compared outcomes for sisters, one of whom was a teenage mother and one of whom was not; Grogger and Bronars (1994, 1993) compared teenagers whose first birth was to twins with teens who had single births; and Hotz and colleagues are now comparing teens who have miscarriages with teens who deliver and raise their children (J. Hotz, pers. com., 1994). Published results from these investigators find that the negative effects associated with teenage childbearing are much diminished when the mother's prepregnancy characteristics are accounted for. Nevertheless, virtually all researchers using varied approaches with varied data sets find that early childbearing is associated with negative outcomes over and above the effects of background. Put another way, there does appear to be a causal and adverse

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--> Figure 3-2 Percentage of mothers ever receiving Aid to Families with Dependent Children in the first 5 years after first birth by age at first birth, 1979 cohort National Longitudinal Survey of Youth. Source: Child Trends, Inc. based on public use files from the National Longitudinal Survey of Youth, 1979–1988 data, under Contract N01-HD-9-2919 from the National Institutes of Health. effect of early childbearing on the health and social and economic well-being of children; this effect is over and above the important effects of background disadvantages. Adolescent Childbearing: Medical Issues In addition to the socioeconomic burdens accompanying childbearing by teenagers, adolescent pregnancy often poses serious health risks as well to both

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--> mothers and infants. Young adolescents (particularly those under age 153) experience a maternal death rate 2.5 times greater than that of mothers aged 20–24 (Morris et al., 1993). Common medical problems among adolescent mothers include poor weight gain, pregnancy-induced hypertension, anemia, sexually transmitted diseases (STDs), and cephalopelvic disproportion (Stevens-Simon and White, 1991). It is also believed that teenagers are at greater risk of very long labor (American College of Obstetricians and Gynecologists, 1993), but whether this risk results in increased rates of labor abnormalities and cesarean deliveries has not been proven conclusively (Lubarsky et al., 1994). Less is known about the long-term physiological sequelae. Adolescent mothers tend to be at greater risk for obesity and hypertension in later life than older primiparas, but most studies have not clearly distinguished whether these conditions are linked to early childbearing or early maturation (Stevens-Simon and White, 1991). Although potential risks to the adolescent mother are quite serious, the risks to the infant she delivers are even greater. Infants born to mothers less than 15 years of age are more than twice as likely to weigh less than 2,500 grams (about 5.5 pounds) at birth and three times more likely to die in the first 28 days of life than infants born to older mothers (McAnarney and Hendee, 1989). After controlling for birthweight, the postneonatal mortality rate is approximately twice as high for infants born to mothers under 17 years of age than for infants born to older women. The incidence of sudden infant death syndrome is higher among infants of adolescents, and these infants also experience higher rates of illness and injuries (Morris et al., 1993). Many of these health risks derive from the demographic attributes of adolescents rather than from their physiological immaturity. For instance, pregnancy-induced hypertension appears to be connected more closely to low parity than to age. Several studies have indicated that very young adolescent mothers are underweight and give birth to smaller babies because of poor diets and inadequate or no prenatal care (Stevens-Simon and White, 1991). Similarly, the greater incidence of illness and injury in infants of adolescent mothers is more likely due to environmental factors such as poverty, poor health habits, and insufficient supervision than to the age of the mother per se (Stevens-Simon and White, 1991). 3   The number of births to girls under age 15 is small. In 1992 there were only 12,220 live births to women under age 15, representing 0.3 percent of all live births that year (National Center for Health Statistics, 1994).

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--> Childbearing at Older Ages: Socioeconomic and Medical Issues Unfortunately, few data are available to help provide an understanding of the socioeconomic consequences to parents or children of childbearing late in life, and the consequences may well differ by parity. Older parents having a first or second child may be better educated, may be more likely to be married, and may have higher incomes than younger parents, especially those parents in their teens or early 20s. On the other hand, a birth occurring to an older mother can also be a higher-order birth—for example, a fourth or fifth child or more—whose addition to the family may add appreciable strain. Moreover, elderly parents may have less physical energy and perhaps less flexibility in outlook, despite the presumption of increased wisdom. However, data are available to assess the important medical risks to the mother and her child that cluster at this end of the reproductive life span. In the aggregate, childbearing becomes riskier to both mother and infant as women get older. Maternal mortality rates are several times higher in women over age 40 than in younger women. From 1979 to 1986 the overall maternal mortality rate in the United States for women over age 40 was 56 deaths per 100,000 live births compared with only 9.1 deaths per 100,000 live births in the general population (Koonin et al., 1991). Maternal morbidity is also higher among women over 40 (Prysak at al., 1995). In a review of the literature on the effect that greater maternal age has on pregnancy outcome, Hansen (1986) found that the majority of studies show a two- to fourfold increase in the frequency of toxemia in older mothers compared with that in younger ones. Venous thrombosis, a serious condition usually occurring postpartum in 1 in 100 women, was reported in one study to occur in 1 in 12 women over age 40 (Lehmann and Chism, 1987). In addition, the incidence of chronic conditions that are aggravated by pregnancy, such as hypertension and diabetes mellitus, increase with maternal age. Unless these conditions are monitored closely, they can pose major maternal as well as perinatal health risks. Risks to the fetus and infant of a woman over age 40 include spontaneous abortion, chromosomal defects, congenital malformations, fetal distress, and low birthweight. Although the chances of miscarriage for a woman under age 25 are only 1 in 400, after the age of 35 the rate jumps to 40 in 100 pregnancies (Hotchner, 1990). Down syndrome, a chromosome disorder commonly associated with advanced maternal age, occurs at an approximate rate of 1 in 1,167 in pregnancies to women age 20; by age 40 the rate is 1 in 106 (Scott et al., 1989). It is believed that Down syndrome and other chromosomal disorders occur more frequently in older women because of their longer exposure to such environmental risks as X-rays and certain drugs. Medical conditions more common to older women affect their infants as well. For example, diabetes, if not carefully monitored, can lead to congenital malformations among other problems, and high blood pressure can cause fetal distress. Older women appear

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--> How much of a change in children's family contexts could possibly be achieved by reducing the number of births derived from unintended pregnancies? To address this question, information on the relationship between maternal marital status and whether births resulted from unwanted or mistimed pregnancies (using data on births from the 1982 and 1988 NSFG) was applied to the estimated proportion of births to unmarried women in 1994. Births from unwanted and mistimed pregnancies figure differently in this estimation. Births from unwanted pregnancies, by definition, would simply not occur, whereas births that were mistimed at conception would occur, but would occur later—some in marriage and some not. Logit simulation was used to model this redistribution of mistimed pregnancies, as described in more detail in Appendix E. The results of this simulation show that eliminating unintended pregnancy decreases dramatically the proportion of children who are born to unmarried women. Specifically, the proportion of all births in 1994 that were either to unmarried women or were the result of an unwanted pregnancy would decrease from 38 to 21 percent—a 45 percent reduction overall. The percentage of all births to teenage mothers would also decrease, given the disproportionate representation of teenagers in the pool of unmarried women giving birth, but the precise shape of the age redistribution was not calculated. The complete elimination of all unintended fertility is an unrealistic goal. However, this statistical exercise adds to the evidence presented earlier in this chapter that an appreciable reduction in the number of unintended pregnancies would improve the well-being of future generations. The fact that other industrialized countries report fewer unintended pregnancies than the United States suggests that progress in the desired direction is a realistic, feasible goal. Conclusion The data and perspectives presented in this chapter demonstrate that unintended pregnancy has serious consequences. these consequences are not confined only to unintended pregnancies occurring to teenagers or unmarried women and couples; in fact, unintended pregnancy can carry serious consequences at all ages and life stages. First, unintended pregnancy often leads to abortion, a fact that underscores a point made at the outset of this report: reducing unintended pregnancy would dramatically decrease the incidence of abortion. Although it is quite clear that abortion has few if any long-term negative consequences on a woman's medical or psychological well-being, it is nonetheless true that resolving an unintended pregnancy by abortion may be an emotionally difficult experience for a woman and others close to her; in particular, abortion providers, women, and their partners as well may find that abortion poses difficult moral or ethical problems; and there continue to be

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--> major political and social tensions, including violence and even murder, associated with abortion in the United States. Second, a disproportionate share of the women bearing children who were unintended at conception are unmarried and/or at either end of the reproductive age span. These demographic attributes themselves carry increased medical and social burdens for children and their parents. At the same time, it is important to reiterate that although women who are unmarried and/or at either end of the reproductive age span are disproportionately represented among those having births that were unintended at conception, the majority of such births are to women without these attributes (Chapter 2). Third, a complex and extensive group of studies has attempted to measure the impact of a pregnancy's intention status on a wide variety of child and parental outcomes. These studies show that unintended pregnancies—especially those that are unwanted (as distinct from mistimed)—carry appreciable risks for children, women, men, and families. That is, unintendedness itself poses an added, independent burden beyond whatever might be present because of other factors, including the demographic attributes of the mother in particular. For an unwanted pregnancy, prevention of ill effects on the child is not dependent on whether the unintendedness itself caused the negative outcome. If the unwanted pregnancy can be prevented, any associated ill effects will also be prevented. With an unwanted pregnancy especially, the mother is more likely to seek prenatal care after the first trimester or not to obtain care. She is more likely to expose the fetus to harmful substances by smoking tobacco and drinking alcohol. The child of an unwanted conception is at greater risk of weighing less than 2,500 grams at birth, of dying in its first year of life, of being abused, and of not receiving sufficient resources for healthy development. The mother may be at greater risk of physical abuse herself, and her relationship with her partner is at greater risk of dissolution. Both mother and father may suffer economic hardship and fail to achieve their educational and career goals. The health and social risks associated with a mistimed conception are similar to those associated with an unwanted conception, although they are not as great. For some risks, such as low birthweight, an independent effect of planning status cannot be established. That is, the milieu in which the mistimed conception occurs may be the causal link to the adverse outcome. For other risks, such as child abuse and neglect, assisting families in having their children when they are ready for them may attenuate the effects of resource deficits. Too little is known about the impact of unintended conceptions on family formation, parent-child interactions, and parental well-being. Much more research is needed into the role of family formation on parents' attainments as well as on the development of their children. Research should identify predictors of unintended childbearing within marriage that can be employed to develop programs designed to prevent unwanted pregnancies and assist parents in timing their wanted conceptions. Among married couples who experience unintended

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--> conceptions, more research is needed into the long-term consequences to the couples as well as their children. Fourth, it is also apparent that pregnancy begun without some degree of planning and intent often precludes individual women and couples from participating in preconception risk identification and management and may also mean that they are unable to take full advantage of the rapidly expanding knowledge regarding human genetics. Certain specific diseases and conditions with serious consequences, such as diabetes, are best managed among pregnant women when care is begun before conception. Increased access to such care and increased provider training in this field will help more individuals take advantage of this developing area of clinical practice. Finally, a recalculation of what the childbearing population in the United States would look like if unintended pregnancy did not occur (unwanted conceptions eliminated and mistimed ones redistributed) shows that a larger proportion of children would be the product of intended conceptions born to married women, thereby improving the life circumstances of children and contributing to the well-being of future generations. References Adams MM, Bruce C, Shulman HB, et al. Pregnancy planning and preconception counseling. Obstet Gynecol. 1993;82:955–959. Adler N, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological responses after abortion. Science. 1990;248:41–44. Altemeier WA, Vietze PM, Sherrod KA, Sandler HM, Falwey S, O'Connor SM. Prediction of child maltreatment during pregnancy. J Am Acad Child Psychiatry. 1979;18:201. American College of Obstetricians and Gynecologists. Special Needs of Pregnant Teens. ACOG Patient Education Pamphlet No. AP103. Washington, DC; 1993. Astone N, McLanahan S. Family structure, parental practices, and high school completion. Am Sociol Rev. 1991;56:309–320. Atrash HK, Koonin LM, Lawson HW, et al. Maternal mortality in the United States, 1979–1986. Obstet Gynecol. 1990;76:1055–1060. Bacon L. Early motherhood, accelerated role transition, and social pathologies. Social Forces. 1974;52:333–341. Baumrind D. Optimal Caregiving and Child Abuse: Continuities and Discontinuities. National Academy of Sciences Study Panel on Child Abuse and Neglect . Washington, DC: National Academy Press; 1993. Baydar N, Grady W. Predictors of Birth Planning Status and Its Consequences for Children. Seattle, WA: Battelle Public Health Research and Evaluation Center; 1993. Blendon RJ, Benson JM, Donelan K. The public and the controversy over abortion. JAMA. 1993;270:2871–2875. Blomberg S. Influence of maternal distress during pregnancy on postnatal development. Acta Psychiatr Scand. 1980;62:402–417.

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