Background

Unintended pregnancy occurs frequently in the U.S. and has health, social and economic costs. The 2001 National Survey of Family Growth (NSFG) estimated that 49% (3.1 million) of all U.S. pregnancies were unintended [1]. Unintended pregnancy is a term that includes mistimed pregnancy, defined as pregnancy that occurred sooner than a woman desired, and unwanted pregnancy, defined as pregnancy when a woman did not want to conceive at any time in the future. Low-income Hispanic women have one of the highest unintended pregnancy rates, compared to other groups by race/ethnicity and income. While the national unintended pregnancy rate is 51 per 1000 women of reproductive age, the rate among Hispanic women below the Federal Poverty Level is over three times higher [1].

Fewer than half of unintended pregnancies end in live births, and Hispanic women terminate a smaller percentage of unintended pregnancies (43%) than the national average (48%) due to limited access to abortion services, as well as cultural opposition and stigmatization [1–3]. Their high unintended pregnancy rate and lower than average percentage terminated give Hispanic women an unintended birth rate of almost twice the national rate [1]. This disparity is likely greater among the subset of Hispanic women who are low-income because of the relationship between poverty and unintended pregnancy. The NSFG estimates that 43% of Hispanic births are unintended, compared to 35% of all U.S. births [4]. The purpose of this study is to determine what sociodemographic characteristics are associated with an increased risk of unintended birth among a sample of Hispanic immigrant women who are at increased risk of depression.

Unintended birth is associated with adverse health behaviors, including delayed prenatal care and decreased breastfeeding [5]. There is also consistent evidence of an association between unintended pregnancy and infant and maternal physical abuse, though the number of studies is fewer [5]. Use of alcohol or tobacco in pregnancy and infant mortality are all hypothesized outcomes of unintended pregnancy, but empirical findings have been mixed [5–7]. A recent meta-analysis also confirmed associations between unintended pregnancy and low birth weight and preterm delivery [8]. These associations have not been widely studied specifically in a Hispanic population, but there is some evidence that there is an association between pregnancy intention and preterm birth among Hispanic immigrants, but not among U.S.-born Hispanics [9]. Considering its wide adverse health consequences, it is a Healthy People 2010 goal to reduce unintended pregnancies in the U.S. from 49 to 30%.

The NSFG provides good evidence of the demographic correlates of unintended pregnancy at a national level. The women most likely to report a recent unintended pregnancy (in the past 5 years) include younger women, unmarried and non-cohabiting women, African American and Hispanic women, low-income women, and women with low educational attainment [1, 10]. Mistimed births are most common among those having a first birth, and unwanted births are most common among those having a third or higher order birth [4].

These correlates have not been widely studied in a Hispanic population, projected to become the predominant ethnic group by the year 2020 [11], nor among Hispanic immigrants specifically. The few studies of unintended pregnancy in Hispanic immigrants have been conducted in Western states, such as Texas and California [12, 13], where the Hispanic population is predominantly Mexican and many of the Hispanics are U.S.-born. There is little to no previous research on pregnancy intendedness among other Hispanic groups, including more recent immigrants from Central and South America [14]. It is important to study unintended pregnancy among Central and South Americans in Washington, D.C. because they differ from those who have been the previous focus of research in terms of how many years they have been in the U.S. and whether there is a large Hispanic population in their region, both of which may influence degree of acculturation and family planning decision-making.

Hispanics are a heterogeneous group in terms of country of origin, length of time in the U.S. and degree of acculturation; little is known about how acculturation among Hispanic immigrants is related unintended pregnancy. Acculturation is broadly defined as the process by which one culture assimilates to another culture, in behaviors, beliefs, and values [15, 16]. Social scientists have studied and written on theories of acculturation for decades and, over time, have developed complex understandings of the process. The field of public health has developed a growing interest in the impact of acculturation on health behaviors in recent years, in particular, focusing on the health of Hispanic immigrants, who comprise approximately two-thirds of U.S. Hispanics [15]. The research methods of public health typically rely on variables that are easy to measure in large datasets, which has resulted in a simplified conceptualization of acculturation within much public health research. The proxy variables most often used to approximate the construct are: country of birth (U.S. vs. foreign born), generational status (first, second, third generation American), length of time in the U.S., and language usage (Spanish, English or a combination [15]).

Within reproductive and perinatal health research, higher acculturation levels have been associated with teen pregnancy, smoking and substance abuse during pregnancy, preterm birth, low birth weight, and neonatal mortality [16]. Few studies have been conducted on the impact of acculturation on unintended pregnancy. One state-representative sample of postpartum women in California showed that U.S.-born Hispanic women were more likely than Hispanic immigrants to report their most recent pregnancy as unintended [13]. Conversely, a clinic sample in Texas found no difference in ever having an unintended pregnancy between U.S.-born Hispanics (45%) and immigrant Hispanics (41%). The reported cause of the unwanted pregnancy also did not differ, with 81% of U.S.-born Hispanics and 75% of Hispanic immigrants attributing it to non-use of contraceptives, rather than method failure [12]. In a clinic sample of Hispanic youth in San Francisco, CA, U.S.-born Hispanics were more likely than immigrant Hispanics to have had an abortion [17]. However, this study cannot determine whether the higher abortion rate is due to a greater number of unintended pregnancies or just a difference in the percentage of unintended pregnancies that are aborted.

In order to lower the unintended pregnancy rate among Hispanic women in the U.S., it is important to know which groups of Hispanic immigrants are at greatest risk of unintended birth and therefore must be targeted and reached by family planning programs. To fill this gap in the literature, the aim of this paper is to determine the sociodemographic, including immigration-related, factors associated with unintended birth among an East Coast sample of low-income Hispanic immigrants predominantly from Central America. It was hypothesized that the demographic correlates of unintended pregnancy among Hispanic immigrant women would be the same as those in the general population. It was expected that unintended pregnancy would be more common among younger, unmarried and non-cohabiting, and less educated women. It was hypothesized that more highly acculturated women (those who had been in the U.S. for longer and those who had a higher language acculturation score) would be more likely to report unintended pregnancy because high acculturation has been linked to other negative reproductive health outcomes.

Methods

Sample

The data were collected for the baseline interview of an intervention trial to prevent perinatal depression in low-income Hispanic immigrants at high risk for depression [18]. A volunteer sample of pregnant predominantly Central American women (n = 217) was recruited from two prenatal clinics serving a predominantly low-income Hispanic population in Washington, D.C., between January 2005 and November 2006. Women were eligible for enrollment if they were 18–35 years old, Hispanic, and at high risk for major depression (i.e., a self-reported history of major depression and/or a high depressive symptom score) but not currently depressed [19]. Forty-one percent of women screened were eligible for the study (n = 310) and, of those, 70% participated in the baseline interview (n = 217). Baseline interviews occurred between the 1st and 2nd trimester (mean gestational age 17.6 weeks). All interviews were conducted in Spanish by bilingual researchers. Two participants were excluded from this analysis because they were born in the U.S., resulting in a total sample of 215.

Measures

Pregnancy intention was measured using a question modified from the NSFG: “In regard to your pregnancy, which of the following would you say? I was trying to get pregnant, I wanted to get pregnant but not at the present time, or I did not want to get pregnant” (translated from Spanish). Responses categorize pregnancies into intended, mistimed, and unwanted pregnancies, respectively. Population-based surveys, including the NSFG and the Pregnancy Risk Assessment Monitoring System (PRAMS) routinely measure pregnancy intention retrospectively, after the child’s birth. In this study, participants were interviewed during pregnancy at a mean of 17 weeks gestation, which may better classify their pre-conception pregnancy intentions.

The two immigration-related covariates in this dataset were length of time in the U.S. and language usage. Time in the U.S. was measured in years and modeled categorically, comparing women in the U.S. for less than one year, 1–4 years, and 5 or more years. The variable was categorized because time in the U.S. is not linearly associated with pregnancy intention, and therefore cannot be modeled continuously in regression models. The original categories we planned to use were: less than 5 years, 5–9 years and 10 or more years, as has been done in previous studies. However, we found that the majority of the sample were relatively recent immigrants, with 14% arriving within the last 12 months, so it was possible to further differentiate the lowest category by adding a ‘less than 1 year’ group. In cross-tabulations, this category’s pregnancy intentions differed in from the ‘1–4 years’ group, so we were justified in keeping the categorization for modeling purposes. In addition, we collapsed the upper two categories because only 18 women had been in the U.S. 10 or more years, and the associations with pregnancy intendedness were similar among the ‘5–9 years’ and ‘10 or more years’ categories. In the new collapsed category of ‘5 or more years,’ over three quarters of women had been in the U.S. for 5–9 years.

The Short Acculturation Scale was used to measure language acculturation [20]. This scale includes 4 items about the preferred language in different domains: language used regularly, language used at home, language used in thought, and language used with friends. Response options for each item are: only Spanish, more Spanish than English, both equally, more English than Spanish, or only English. Items are summed (0–16) and higher scale scores indicate greater language acculturation. In a psychometric evaluation among Central and South American immigrant WIC participants, the scale reliability was good (Cronbach’s α = 0.81), and validity was demonstrated by a strong correlation to length of time in the U.S. (r = 0.50, P < 0.01) [21]. Psychometric characteristics were similar in the current sample, with good internal reliability (Cronbach’s α = 0.71) and a significant correlation to years in the U.S. (r = 0.40, P < 0.001). The scale was modeled as a continuous variable.

Several demographic covariates were measured including: age, education, employment, marital and relationship status, parity, and health insurance status. In addition, social support was measured using the Social Support Apgar (SSA), which was developed specifically for use during pregnancy [22]. The original scale consists of 25 items that measure social support along 5 domains (adaptation, partnership, growth, affection, resolve), from 5 sources (partner, parents, other family, friends, other acquaintances). Scores are summed, with greater scores indicating more social support. A modified version of the SSA was used to assess types and providers of social support during and after pregnancy. Specifically, “Partner” was changed to “Baby’s Father” and “My Parents” was separated into “My Mother” and “My Father”, with the latter yielding five more questions to the SSA. Internal reliability was high in three psychometric studies (Cronbach’s α’s ranged from 0.88 to 0.93), and social support was shown to be negatively associated with life stress [22]. In the present sample, internal reliability of the SSA was similarly high (Cronbach’s α = 0.94). The scale was modeled as a continuous variable.

Analysis

To characterize the sample, descriptive statistics, including means and frequency tabulations, were run. Next, cross-tabulations with Chi-squared statistics were conducted in order to assess the unadjusted associations of covariates with pregnancy intendedness. Finally, multinomial logistic regression [23] was used to model the association between pregnancy intendedness (using the categories of intended, mistimed, unwanted) and the covariates: length of time in the U.S., language acculturation, age, marital/partner status, parity, social support, education, employment and health insurance. All covariates were selected a priori based on previous research and theory [4, 10]. All variables were entered into the model simultaneously. Variables that were not statistically significant were left in the final model because they serve as control variables. A variance inflation factor (VIF) test determined that the covariates in the model did not have significant correlations amongst themselves.

Results

The sample consisted of young (mean age = 25), recent immigrant women (mean 4 years in the U.S.), predominantly from Central America (Table 1). Most were married or cohabiting with an unmarried partner and had little formal education (mean = 9 years). For 41%, this was a first pregnancy and for just over a quarter, it was their third or higher order pregnancy. Two-thirds of the sample reported having health insurance: most commonly D.C. Health Care Alliance, a public means-tested insurance program for Washington, D.C. residents. Because the women were recruited to participate in the parent study to prevent postpartum depression, all women were selected to be at high risk for depression, but not currently depressed: approximately half of women had elevated depressive symptoms at baseline and 18% reported a history of a major depressive episode.

Table 1 Sample demographics (n = 215)
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Two-thirds of women reported that their current pregnancy was unintended (37% mistimed and 28% unwanted). Table 2 shows how the pregnancy intendedness distribution varied by key demographic variables. Pregnancy intendedness was significantly associated with years in the U.S., education level, partner status and parity. Mistimed pregnancies were more common among women residing in the U.S. for less than 1 year, unmarried women cohabiting with their partner and those without a partner, and women for whom this was a second birth. Non-significant trends showed that women under 25 and employed women reported more mistimed pregnancies. Unwanted pregnancies were most common among women without partners and women for whom this was a third or higher birth. Women who only spoke Spanish also reported higher rates of unwanted pregnancy than women who spoke some English, but this trend was not significant. Pregnancy intention was not significantly associated with the two depression risk variables that were used for selection into the study.

Table 2 Bivariate statistics: pregnancy intendedness distribution, by sociodemographic correlates, with χ2 tests of association
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The relative risk ratios in the multinomial logistic regression model (Table 3) represent the impact of each covariate on the risk of mistimed and unwanted pregnancy compared to intended pregnancy, adjusted for the other covariates in the model. Length of time in the U.S. was significantly associated with the risk of reporting the index pregnancy as mistimed: women who immigrated less than 1 ago had nearly 4 times the risk of mistimed pregnancy, compared to women who had resided in the U.S. for 1–4 years (RRR = 3.82; 95% CI: 1.09, 13.44; P-value <0.05). The risk among women in the U.S. 1–4 years and 5 or more years were similar. Language acculturation was not associated with the risk of a mistimed pregnancy.

Table 3 Multinomial logistic regression model (n = 205): Relative risk of mistimed and unwanted pregnancy, compared to intended pregnancy
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Mistimed pregnancies were less common among women ages 25–29 than women under 25, and much lower among married women than women without partners or with non-cohabiting partners. Parity was a very strong predictor of mistimed pregnancy; a second order pregnancy was over 5 times and a third or higher order pregnancy was over 7 times as likely to be reported mistimed, compared to a first pregnancy. Social support was marginally associated with mistimed birth, with higher social support decreasing the risk. Being employed doubled the risk of reporting a pregnancy as mistimed, although this trend was only marginally significant.

Neither length of time in the U.S. nor language acculturation was associated with the risk of reporting the pregnancy was unwanted (Table 3, column 3). The factor most strongly associated with unwanted pregnancy was parity. Second births were over 9 times as likely and third or higher births were over 25 times as likely to be reported as unwanted, compared to first births. Marriage and social support both decreased the risk of unwanted pregnancy. Cohabiting with a partner showed a trend of decreased risk, although this was only marginally significant. Also, women ages 25–29 were marginally less likely to have an unwanted pregnancy than women under 25.

Discussion

Previous research among the general U.S. population has shown that age, marital/partner status and parity are important correlates of unintended pregnancy. In the present study, these associations were also seen among a subpopulation of Hispanic immigrants. As hypothesized, unintended birth was more common among younger, unmarried and non-cohabiting women. Parity was also strongly associated with unintended birth among Hispanic immigrants.

Few studies have previously focused on unintended pregnancy correlates amongst Hispanic immigrants, so there is little information on associations between pregnancy intendedness and acculturation. This study provides some evidence that length of time in the U.S. is an important predictor of Hispanic immigrant women’s pregnancy intentions, but not in the direction hypothesized. It was expected that more highly acculturated women (those who had been in the U.S. for longer and those who had a higher language acculturation score) would be more likely to report unintended pregnancy, because high acculturation has been linked to other negative reproductive health outcomes. In this analysis, very recent immigrants (who arrived within the past 12 months) were the most likely to report at baseline that a pregnancy was mistimed.

While previous research has examined differences in intendedness by country of birth (U.S.-born vs. foreign-born [11, 12]), this study may be the first to examine the role of length of time in the U.S. and language usage on pregnancy intendedness among a sample of Hispanic immigrants. Additionally, while the previous studies use theories of acculturation, or conforming to the U.S. culture and customs, to explain potential differences in pregnancy intendedness among Hispanic women, the results of this study imply that immigration context also plays an important role. Women who have been in the U.S. less than a year are the group most likely to report that a pregnancy was mistimed. One might imagine that they were not ready for a pregnancy because in that first year they were busy getting settled into a new country—finding work, making money, developing a social network, and acclimating to a new language, location, and set of customs.

Many Hispanic women, particularly Central American women, emigrate with the intention of finding work [24]. Becoming pregnant shortly after immigrating may impede that goal. This hypothesis is supported by the marginal association seen in this study between being employed and reporting a mistimed pregnancy. These data suggest that, at least in this sample, women may have been more concerned with establishing themselves economically than starting a family. Unpublished qualitative interviews with women from the recruitment clinic support this idea. They undercut the stereotype that undocumented Hispanic women enter the U.S. with the intention to quickly deliver a so-called “anchor baby,” who automatically becomes a U. S. citizen and keeps them tied to this country [25–27]. Additionally, very recent immigrants may have more barriers to contraceptive use than highly acculturated immigrants and U.S.-born Hispanics, particularly in terms of access to family planning services and insurance coverage of contraception.

It is interesting that language acculturation was not significantly associated with pregnancy intendedness in this immigrant sample. The relationship between language acculturation and pregnancy intentions should be examined in future research among a sample of Hispanics that includes both U.S.-born women and immigrants who have been in the U.S. for a wide range of time. It is possible that no associations were seen in this study because the majority of our participants have low language acculturation, with half speaking only Spanish in all measured contexts. However, it is also possible that pregnancy intentions are driven more by life circumstances, such as relationships, current family size, employment, housing and finances, than by level of cultural assimilation. This explanation is supported by the fact that the strongest predictors of pregnancy intentions in this study were parity and marital status. Second and higher order births were more likely to be reported as mistimed, and third and higher order births were much more likely to be unwanted, compared to first births. In addition, married women reported two-thirds of their pregnancies were intended, versus 35% of cohabiting women and only 19% of non-cohabiting or non-partnered women (unadjusted).

These findings have implications for family planning programs. The highest-risk groups for unintended pregnancy are young women, women who have achieved their desired family size, and women who immigrated in the past year. It is important to develop targeted outreach strategies to link very recent Hispanic immigrants with family planning clinics and endorse the use of highly-effective contraceptives until the women are ready to conceive. Previous research found that among Spanish-speaking immigrants, length of time in the U.S. was positively associated with consistent contraceptive use, further supporting that recent immigrants are an underserved population in need of and who would be responsive to family planning services [28]. Clinics with Title X federal family planning funding need to develop culturally relevant outreach strategies to inform recent immigrant women, regardless of their legal status, of the family planning services available to them for free or at low cost. Peer outreach or lay health worker (promotora) programs may prove effective, as they have in other areas of health promotion to Hispanic women and adolescents [29–32]. Clinics may also have to offer significant enabling services, such as translation, transportation, childcare, and extended clinic hours.

A limitation of this analysis is that it investigates the correlates of unintended birth, rather than unintended pregnancy. Women were recruited at prenatal care appointments, so the sample does not include women who decided to terminate the pregnancy. The correlates of unintended pregnancy overall may differ from the correlates of unintended birth; however, this is a population with a relatively low usage of abortion because they have restricted access to services, payment for services, and cultural barriers and beliefs [3]. Another limitation is the lack of information on contraceptive use in this sample. Knowing whether or not women were using contraceptives around the time of conception would have implications for whether outreach messages should center on using contraception generally, or endorsing more effective methods.

The results of this study are limited in generalizability to the population of Hispanic immigrants because the data were collected for a randomized preventive intervention designed for women at high risk of depression. All women in this sample either have a past history of depression or currently elevated depressive symptoms that did not reach a threshold for clinical diagnosis. No participants had a current diagnosis of depression, none were in treatment for depression, and none were taking antidepressants. As a result of the inclusion criterion, this sample may be more likely to experience unintended birth. In the U.S. Hispanic population as a whole, 43% of births are unintended [4], versus 65% of births in this sample. It is unknown whether there were more unintended births in this sample because we interviewed women at risk for depression, or because our sample included only low-income foreign-born Hispanics. It is unclear if the correlates we reported would be the same in a general population of Hispanic immigrants who was not selected to have certain mental health characteristics. However, depression is very common and affects more women than men. It is estimated that 20% of women will experience at least one episode of depression in their lifetime [33], with similar incidence in pregnancy as other times during the reproductive years [34–38]. There is some evidence that perinatal depression is more common in Hispanic women than white, non-Hispanic women [39–41]. Based on this epidemiology, this sample may not differ greatly from a general low-income Hispanic immigrant population.

Despite these limitations, this analysis offers a unique perspective on an understudied and growing population at high risk for unintended birth. Few, if any, other studies have examined the associations between length of time in the U.S., language acculturation, and pregnancy intendedness. Future research must be devoted to understanding contraceptive use, unintended pregnancy rates, and perceptions of the consequences of unintended pregnancy among Hispanic immigrant women and their partners. As Foulkes et al. raise, it is also crucial to explore what the concept of unintended pregnancy means to Hispanic women [2]. The cross-cultural meaning of ‘pregnancy intendedness’ and ‘unintended pregnancy’ is not well-understood, and qualitative studies should be conducted to examine this in depth.

In order to make informed public health decisions it is necessary to gather more information about the correlates, cultural context, and perceived consequences of unintended pregnancy. There are many reasons why it is important to help Hispanic immigrants, in particular, avert unintended births, achieve their desired family size and birth spacing. In addition to the adverse health and behavioral consequences of unintended pregnancy, access to safe and effective family planning services is an issue of human rights and women’s rights. For Hispanic immigrants, unintended births may have unique consequences. Many of these women come to the U.S. in order to work, to support themselves as well as family members who still reside in their countries of origin. These goals may be impeded by an unintended birth, and low-income women are at greater risk for raising the next generation of new Americans in poverty. Additional research will help family planning programs to customize their messages and outreach programs in areas where large numbers of Hispanic immigrants reside. Without culturally informed and culturally appropriate family planning programs, there is little hope of achieving the Healthy People 2010 goal to reduce the percentage of pregnancies that are unintended.