Unintended pregnancies represent almost 50% of all pregnancies with approximately 40% ending in abortion.2
The remaining proportion of unintended pregnancies that are carried to term are associated with deleterious maternal and infant/child health outcomes.14-18
That nearly 50% of women who have an abortion report having had a previous abortion2
underscores how commonly unintended pregnancies recur. Elucidating the risk factors for repeated unintended pregnancies, leading either to abortion or delivery, is an important objective in advancing women’s health and in providing novel opportunities for intervention at the time of the first unintended pregnancy. In the current investigation, adverse circumstances in childhood were examined in relation to a woman’s probability of having repeat abortions during adolescence and adulthood. Results showed that women who had 2+ abortions were more likely to have been exposed to adverse events in childhood compared to women who had 0 or 1 abortion. These associations were independent of correlates of repeat abortion, including increased age, non-White ethnicity, lower childhood socioeconomic status, and a greater number of pregnancies. Additionally, the study hypotheses regarding the salience of abuse as well as non-abuse events were confirmed. That is, in addition to experiences of abuse, non-abuse adverse events were also shown to confer risk for repeat abortions, re-defining by broadening the group of women considered to be at risk.
Consistent with previous research linking abuse to deleterious reproductive outcomes,3 8-10
results highlight the role of abuse histories in relation to risk for repeat abortions. For every 1-unit increase in reported abuse history (i.e., having no abuse history vs. reporting physical or
sexual abuse vs. reporting both
physical and sexual abuse) the likelihood of having 2+ abortions was 2.6 times greater than for never having had an abortion and almost 6 times greater than for having 1 abortion. Additionally, non-abuse adverse events were also found to relate to risk for repeat abortion with adverse events pertaining to personal safety appearing to be especially problematic. For every 1-unit increase in personal safety-related events, the likelihood of having 2+ abortions versus no abortion and 1 abortion was 2.7 times and 2.2 times greater, respectively. This is the first study to demonstrate that abuse events as well as experiences that are stressful but not abusive play a role in predisposing some women to have repeat abortions.
difficult life circumstances in childhood relate to a woman’s risk of having repeat abortions in adolescence and adulthood is an important area for future investigation. Women who are exposed to significant levels of stress in childhood may experience a variety of barriers to the prevention of repeated unintended pregnancies. For example, childhood adversity, including abuse history, has been linked to risky sexual practices,19-21
poorer mental health outcomes,22-24
and problems forming successful intimate relationships,21 25-27
, all experiences that have potential implications for effective contraceptive use. Previous research suggests that aspects of a woman’s self-concept, such as perceiving oneself as incompetent or ineffective –correlates of low self-esteem and/or low self-efficacy– may underlie adulthood outcomes of childhood adversity.28-31
Because women with such self-attributes lack confidence in their ability to exert control over their environments, problems related to feelings of being out of control or misguided attempts to take control (e.g., sexual risk-taking behaviors) can arise. Future studies should consider how the negative influences of childhood adversity on a woman’s self-concept in adulthood, may mediate effects of adverse events on risk for repeat abortion by impeding a woman’s ability to negotiate appropriate contraceptive use following an initial abortion.
A strength of the current study was that the reliability of abortion history information was enhanced by collecting these data through an extensive in-person interview in the context of a comprehensive medical history interview. Weaknesses were that the study was cross-sectional and relied upon women’s self-reports of their experiences in childhood and their reproductive medical history over periods of adolescence and adulthood. Underreporting in particular has been shown to be a problem when conducting research on sensitive topics such as abortion.32-33
In the current study, although we cannot specifically quantify effects of potential underreporting, there did not appear to be differential underreporting among the women who reported no abuse/event histories which could have artificially inflated observed associations between adversity experiences in childhood and abortion history. That is, approximately one-third of women who reported not having experienced abuse or any stressful life events reported having 1+ abortion, a figure that is consistent with national estimates.34
Additionally, the sample size was relatively small and the confidence intervals for some of the effect sizes were wide. The current sample was similar, however, to other larger samples in terms of the proportion of women reporting repeat abortions and the socio-demographic correlates of repeat abortions.2-3 6-7
The limited sample size also precluded secondary analyses stratified by race to determine whether relations between childhood adversity and abortion history may vary by cultural factors.
Because the sample was relatively small in size, well-educated with 70% of women having a college or graduate degree, and were participating in a study of reproductive aging, the generalizability of the current findings may also be limited. In addition, the selection requirement that the women not be currently pregnant or breastfeeding may not only have further enhanced the non-representativeness of the sample but also precluded opportunities to assess alternative pregnancy outcomes. In fact, the current study was limited to the examination of self-reported abortion history and did not collect information pertaining to pregnancy intention or desire. Therefore, the examination of early life adversity in relation to repeat unintended pregnancies that were carried to term rather than terminated could not be examined. This alternative outcome remains an important area for future investigation as almost half of all unintended pregnancies are carried to term with approximately one-third specifically classified as being unwanted.34
The consequences of unintended pregnancies carried to term are significant, including delayed use of prenatal care, continued maternal smoking and alcohol use, pre-term and low birthweight births, developmental delays in infancy, and increased risk for abuse in childhood.14-18
In conclusion, increased exposures to adverse events in childhood distinguish women with repeat abortions from women with 0 or 1 abortion. Correlates of repeat abortion, including increased age, non-White ethnicity, lower childhood socioeconomic status, and greater number of pregnancies do not account for this difference. Findings are consistent with previous research linking adverse childhood experiences, and in particular childhood abuse, to a variety of negative outcomes (e.g., sexual risk-taking behaviors), impeding effective contraceptive use. Clinical implications are that women who have initial abortions should be screened for abuse history as well as exposures to adverse events more generally to determine who may benefit from specialized interventions. Such interventions should target the specific barriers that make it difficult for women with adverse childhood backgrounds to prevent subsequent unintended pregnancies; current standard of care practices limited to providing counseling on contraceptive use may be inadequate in this population.