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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: Public Health Nurs. 2021 May 3;38(5):801–809. doi: 10.1111/phn.12920

Social Support Reduces the Risk of Unintended Pregnancy in a Low-Income Population

Hartley Feld 1, Sheila Barnhart 2, Amanda T Wiggins 3, Kristin Ashford 4
PMCID: PMC8419072  NIHMSID: NIHMS1705127  PMID: 33938034

Abstract

Almost half of all pregnancies (45%) in the United States (US) are unintended, with the highest concentration in women with low incomes. Targeted research is warranted to identify risk and protective factors that influence pregnancy intention to improve maternal/child health.

Purpose:

To identify individual and interpersonal level associations to pregnancy intention to use as leverage points to build resilience.

Method:

A cross-sectional, secondary analysis of Medicaid eligible pregnant women in Kentucky (n=309).

Results:

Sixty-two percent reported their current pregnancy was unintended. Older age, partnered, negative drug screen, and increased social support were associated with decreased odds of unintended pregnancy. For every 1 unit increase of belonging and tangible social support, women were 13% and 14% (respectively) less likely to have an unintended pregnancy (OR=.87, 95% CI=0.78–0.97, p=.011, OR=.86, 95% CI=0.77–0.95, p=.005). A positive drug screen was associated with an almost 3-fold increase in the odds of unintended pregnancy (OR=2.88, 95% CI=1.49–5.58, p=.002).

Conclusion:

Public health nurses can play a critical role in reducing unintended pregnancy rates by promoting social support, inclusion, and acceptance. There remains a critical need to identify barriers and facilitators to pregnancy planning for persons who use illicit drugs.

Keywords: Social Support, Vulnerable populations, Reproductive Health, Quantitative Research, Pregnancy, Maternal-child health, Cross-sectional studies, Substance use

INTRODUCTION

The United States (US) consistently has the highest rates of infant and maternal morbidity and mortality of all high-income countries (MacDorman, et al., 2014). Healthy People 2030 (2020) seeks to address these poor maternal-child health outcomes in part by preventing unintended pregnancies and improving women’s health prior to conception. Unintended pregnancy is associated with adverse health outcomes and is a costly public health issue (Finer & Zolna, 2016; Sonfield & Kos, 2015). Almost half of all pregnancies in the US (45%) are unintended, and socially disadvantaged women are at even higher risk (Finer & Zolna, 2016). Low socio-economic status, minority race/ethnic identity, having poor psychosocial health, being unmarried/cohabitating, having a history of victimization by an intimate partner, and struggling with substance use issues are all risk factors for unintended pregnancy (Finer & Zolna, 2016; Heil et al., 2011, Dietz et al., 1999, Maxson & Miranda, 2011). Having an unintended pregnancy followed by an unintended birth has been identified as both a consequence and a cause of low socio-economic status and income inequality (Bearak et al., 2018). More research is warranted to understand the social context of pregnancy intention of women living in or near poverty.

This paper explores the association of psychosocial and behavioral factors in relation to pregnancy intention in a sample of Medicaid eligible pregnant women in Kentucky. The primary aim of the study is to identify key individual and interpersonal associations to pregnancy intention to serve as leverage points to build resilience in marginalized populations.

Conceptual Framework

The social environment influences how women navigate contraception, internalize stressors, and communicate with friends and partners regarding the decision and timing of pregnancy. We utilized the social ecological model whereby an individual is nested in their social environment with dynamic levels of influence on human behavior (DiClemente et al., 2013). This paper focuses on individual and interpersonal levels to understand proximal psychosocial and behavioral issues and their role in pregnancy intention, but the larger social values and gendered norms of a community contribute greatly these outcomes as well (Price & Hawkins, 2007).

Individual level.

Overall, unintended pregnancy rates have improved in the US in the last decade, but these gains were not equitably distributed. The majority of unintended pregnancies are now largely concentrated in younger, non-partnered women living in poverty (Finer & Zolna, 2016; Sedgh, 2014). Consistent with the failure of systems across the US that support and promote the health of women of color, Hispanic and Black women have also been disproportionately affected by high rates of unintended pregnancy (Finer & Zolna, 2016).

Researchers have established that substance use is a behavioral risk for unintended pregnancy over the last several decades; women who use illicit drugs have the highest rates of unintended pregnancy. Women who use opioids, have consistently reported unintended pregnancy rates greater than 75% (Black et al., 2012; Heil et al., 2011). Women who inject drugs are also significantly more likely to become pregnant and more likely to have an abortion than the general population of women in a national sample (as cited in Heil et al., 2011). Similarly, marijuana use was found to be associated with non-use of contraception and unintended pregnancy (Casola, et al., 2017; Lundsberg, et al., 2018). As compared to women not using drugs, women with substance use issues were twice as likely to express ambivalence regarding pregnancy planning or the perception that they did not think they could get pregnant at the time of conception (Macafee et al., 2019).

Adverse psychosocial health profiles appear to be a risk factor or co-occurring issue for those with an unintended pregnancy (Orr & Miller, 1997); however, findings are inconsistent and may be more dependent on the context. The results of a meta-analysis indicated that the prevalence of perinatal (prenatal and post-partum) depression is twice as high in those with an unintended pregnancy and birth (Abajobir et al., 2016). Most of the recently published literature in this area focuses on the effects of the unintended pregnancy on the mental health of the mother and the associated post-partum maternal-child health outcomes, whereas we are interested in whether co-occurring poor mental health contributes to a women’s ability to control her desired fertility. Depression and stress have been correlated with higher rates of unintended or unwanted pregnancy, but when controlling for socioeconomic, demographic or other psychological variables it has not demonstrated significance (Maxson & Miranda, 2011). Young women who report both high levels of stress and depression were more likely to have inconsistent contraceptive use and contraceptive failure (Stidham-Hall et al., 2013). Additional research suggests that mental health plays a role in pregnancy planning, as adverse life course experiences and toxic stress have demonstrated an increased the risk of an unintended first pregnancy in some populations (Ditez et al., 1999, Hall et al., 2019).

Interpersonal level.

The social environment can both support and limit a women’s ability to plan a pregnancy. Intimate partner violence (IPV) and a history of violence or dysfunction in the home serve to erode fertility control and increase unintended pregnancies (Dietz et al., 1999; Pallitto et al., 2005). While positive and resilient social environments have demonstrated increased control over fertility and pregnancy intention, the findings in the literature are inconsistent or context specific regarding the role, mechanism, or measure of social support and pregnancy intention. Indeed, social support is a complex construct, generally organized as measuring the structure and existence of relational support or the perceived function and extent of resourceful relationships, which include emotional, informational, and instrumental domains (Cohen, et al., 1985). There is existing evidence to suggest structural social support (social influence, networks, frequency of contact, capacity) improves the likelihood of intended pregnancies and contraception use, but scant evidence regarding the role functional social support (Choi et al., 2019; Barton et al., 2017, Anderson et al., 2014; Levy et al., 2015).

Evidence from one study by Moseson, et al. (2018) demonstrated one form of functional support (the emotional domain), ‘not having anyone to turn to’ significantly increased the odds of an undesired pregnancy for non-Black women, but there was not an association for young Black women. However, the social support measure was limited to one question, there was a small sample of women who became pregnant (n=65), and no other mental health data was included in the analysis (Moseson et al., 2018). Loll et al. (2020) also found that providing informational social support is a promising clinical practice, when directed towards the promotion of sexual health, young women were found to increase their ability to navigate communication regarding the use of contraception. Maxson and Miranda (2011) used a comprehensive functional interpersonal social support tool and found that women with mistimed or unwanted pregnancies had lower mean scores of support than those who reported wanted pregnancies in a descriptive analysis. However, when they controlled for demographic and other covariates in a fully adjusted model these differences were not significant, only low levels of paternal support from another tool was associated with the unwanted pregnancy in the adjusted models (Maxson & Miranda, 2011). Similarly, descriptive research by Orr and Miller (1997) with low income, Black women and found that those who had low mean scores of instrumental and emotional support, specifically from the father of the baby, were more likely to report their pregnancy was unwanted. The contribution of this study is clarifying whether functional social support was protective in terms of planning a pregnancy in spite of other socio-economic, psychosocial and demographic issues previously identified in the literature, and if so what domains of support demonstrated the strongest relationship.

This study takes place in Kentucky, one of the states with the highest rates of poverty and teen births in the US (American Community Survey, 2015). Further, parents struggle to care for their children after birth, as the state consistently leads the nation in child maltreatment and children raised by grandparents or other relatives (US Census Bureau, 2018). Additionally, Kentucky has high rates of preterm birth, low birth weight infants, obesity and diabetes in pregnancy, and some of the highest rates smoking and opioid use in pregnancy (March of Dimes, 2017). Many adverse birth outcomes and social conditions in the state are associated with modifiable issues that could be mitigated if identified and addressed prior to conception, hence warranting the rationale for this study.

METHODS

Design and Sample

This investigation is a cross-sectional design using secondary data obtained from a prospective multicenter intervention study funded by the Center for Medicaid and Medicare Innovations (CMMI) program. Human subjects’ research protection was provided for the parent study by a university Institutional Review Board (IRB).

The sample consisted of Medicaid eligible pregnant women (N=309) from three regions of Kentucky, who were seen for their first prenatal visit between 2012 and 2016. The inclusion criteria were as follows: answered the pregnancy intention item, at least 75% of the psychosocial measures, all demographic questions, and were drug screened. Additional criteria from the parent study included only pregnant women ≥ 14 years of age, Medicaid eligible (138% to 195% of the federal poverty level depending on the year of enrollment), and less than 30 weeks gestation. Further information about the recruitment and enrollment procedures were reported in the parent study (Hieronymus et al., 2016).

Measures

Demographic and clinical factors.

Demographic variables included self-reported age, race/ethnicity, marital status/partnered, food security (as a proxy for low-income and poverty status), employment, and previous pregnancy.

Anxiety.

The Generalized Anxiety Disorder measure (GAD), a 7-item survey, using a Likert scale. GAD is a tool to identify uncontrollable worry and chronic or excessive anxiety (Hirsch, et al., 2013). The GAD-7 is a reliable measure for assessing symptom severity and generalized anxiety in pregnant populations (Zhong et al., 2015). Cronbach’s alpha for this sample was .90.

Social support.

Perceived social support was measured by the Interpersonal Support Evaluation List (ISEL). The 12-item ISEL has three subscales representing functional aspects of social support; appraisal (informational, advice), belonging (connectedness and acceptance), and tangible (instrumental and material) domains. The subscales are used to identify a specific component of support as it relates to an outcome of interest (Cohen, & Hoberman, 1983; Cohen et al., 1985). The ISEL uses a 4-point scale ranging from ‘definitely false’ (1) to ‘definitely true’ (4) with summed total score ranging from 0-36 and is a reliable and valid measure (Merz et al., 2014). Cronbach’s alpha for the total score was .85.

Depression.

The Center for Epidemiologic Studies Depression Scale (CES-D 10) is a 10-item survey, using a 4-point Likert scale. CES-D is a screening tool to identify current depressive symptomology. Scores range from 0 to 30, with high scores indicating greater depressive symptoms. The CES-D 10 has demonstrated high internal consistency and validity (Van Dam & Earleywine, 2011). Cronbach’s alpha for this study was .87.

Intimate partner violence.

The Slapped, Things or Threatened (STaT) tool is a simple and brief measure used to assess whether an individual had exposure to one or more physical aspects of intimate partner violence (IPV) in their lifetime. The 3-item, dichotomous (yes/no) tool demonstrated sensitivity (96%, CI: 90–100%) and specificity (75%, CI: 59%–91%) with a range of 0-3 (Paranjape & Liebschutz, 2003). A positive screen has a cut-off point of 1, which was used for this analysis.

Drug screening.

Each participant was screened for 13 different illicit drugs or their metabolites in their first prenatal visit in the form of a urine sample as part of routine care. The research staff obtained this data from the medical record, a positive screen included one or more substances found in the sample.

Pregnancy intention.

An unintended pregnancy is one that characterized as not planned, mistimed (not at the right time), or unwanted (wanted no children or no more children) (Kost & Lindberg, 2015). The measure of unintended pregnancy takes many forms, as there is no consistent tool used to determine intention (Santelli et al., 2009). The Center for Medicaid and Medicare Innovations (CMMI) funded studies simply asks a yes/no question if the woman was ‘trying to become pregnant’ as a proxy for intention when low literacy is a concern (Hill, 2016). Women answered this question in reference to their current pregnancy, those who answered no were considered unintended for this analysis and is the CMMI designation.

Analytic Strategy

Descriptive statistics, including means and standard deviations or frequency distributions, as appropriate, were used to summarize characteristics of the sample. Bivariate analysis, including the two-sample t-test, chi-square test of association or Mann-Whitney U test were used to examine associations between demographic and psychosocial variables and unintended pregnancy. Logistic regression modeling was used to identify which psychosocial characteristics (anxiety, social support, depression) were most strongly linked to the binary outcome (unintended/intended), while controlling for the demographic factors. Next, because social support was the only significant psychosocial factor in the primary model, a series of three independent logistic regression models were used to further assess the associations of specific forms of social support with unintended pregnancy. All data analysis was conducted using SAS, version 9.4 (Cary, NC), with an alpha level of .05 throughout.

RESULTS

The sample consisted of 309 pregnant women, of whom 191 (62%) reported their current pregnancy was unintended (Table 1). The mean age of the sample was 27 years (SD ± 5.4), with the majority being Caucasian/white (57%), unemployed (69%), and reported residing with their partner or being married (68%). Many left the reported income section blank or unknown but were all determined to be Medicaid eligible in order to participate. Food security was used as a proxy for income, with one-third (33%) reporting insecurity sometimes or often. Overall, women had low to moderate scores in the psychosocial measures and over a quarter of the women (27%) reported at least one type of IPV in their lifetime, scoring one or higher in the screening tool. Over a third (36%) were pregnant for the first time (primigravida).

Table 1.

Self-reported pregnancy intention demographic and psychosocial data from pregnant women in the sample (N = 309)

Characteristic Total sample
n (%) or M ± SD 		Unintended pregnancy
(n = 191)
n (%) or M ± SD 		Intended pregnancy
(n = 118)
n (%) or M ± SD 		P
Age (years) 27.2 ± 5.4 26.5 ± 5.6 28.4 ± 4.9 .002
Race/Ethnicity
 Non-Hispanic
  White 175 (57%) 114 (65%) a 61 (35%) <.001
  Black 36 (12%) 30 (83%) b 6 (17%)
  Other 14 (5%) 9 (64%) a,b,c 5 (36%)
 Hispanic 84 (27%) 38 (45%) c 46 (55%)
Relationship status
 Partnered 209 (68%) 112 (54%) 97 (46%) <.001
 Non-partnered 100 (32%) 79 (79%) 21 (21%)
Food Insecure
 Never 209 (68%) 123 (59%) 86 (41%) .26
 Sometimes 88 (29%) 59 (67%) 29 (33%)
 Often 12 (4%) 9 (75%) 3 (25%)
Drug screen
 Positive 90 (29%) 72 (80%) 18(20%) <.001
 Negative 219 (71%) 119 (54%) 100 (46%)
Employed
 Yes 95 (31%) 61 (64%) 34 (36%) .56
 No 214 (69%) 130 (61%) 84 (39%)
Gravida
 Primigravida 11 (36%) 69 (36%) 42 (36%) .92
 Multigravida 198 (64%) 122 (64%) 75 (64%)
Psychosocial Factors
Anxiety (potential range 0- 21) 4.9 ± 4.8 5.8 ± 5.0 3.6 ± 4.2 <.001
Depression (potential range 0-30) 8.1 ± 5.7 9.1 ± 6.1 6.4 ± 4.7 <.001
Intimate partner violence
 Positive 82 (27%) 59 (72%) 23 (28%) .027
 Negative 227 (74%) 132 (58%) 95 (49%)
Social support (potential range 0-36) 27.4 ± 7.0 26.3 ± 7.2 29.1 ± 6.4 <.001
 Subscales (0-12)
 Appraisal 9.3 ± 2.7 9.0 ± 2.7 9.9 ± 2.5 0.007
 Belonging 9.1 ± 2.7 8.7 ± 2.7 9.8 ± 2.4 <.001
 Tangible 8.9 ± 2.7 8.7 ± 2.7 9.5 ± 2.4 <.001
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Note: Groups with the same letter are not significantly different in post-hoc analysis

In the bivariate analysis, women who reported that their pregnancy was unintended were significantly younger (p = .002), less likely to be married or residing with a partner (p < .001) and have a positive drug screen (p < 0.001). Hispanic women were the only demographic more likely to have planned their pregnancy (55% intended), compared to non-Hispanics. Black women had the highest rate of unintended pregnancy (83%), followed by White women (65%), and the other race (64%). Twenty-nine percent had a positive drug screen, of whom 80% experienced an unintended pregnancy. The majority used cannabis/marijuana (52%), followed by opioids (32%). There were no significant differences in pregnancy intention based on employment status, food security or gravida.

At the individual level, women who reported an unintended pregnancy had significantly higher rates of depression and anxiety (both p < 0.001). While at the interpersonal level women who reported greater levels of social support overall were more likely to plan their pregnancy (p < 0.001), and this was true for each subscale of interest. Women who reported a history of exposure to intimate partner violence were significantly more likely to have an unintended pregnancy (p = 0.027).

The overall logistic regression model was significant (Chi-square = 67.6, p <0.001). Older age, partnered status, negative drug screen and increased social support were all associated with decreased odds of unintended pregnancy in the adjusted model. Every one-year increase in age was associated with a 7% decrease in the odds of unintended pregnancy (OR = 0.93, 95% CI = 0.88 – 0.97; p = .003; see Table 2), and partnered women were 57% less likely to report unintended pregnancy (OR = 0.43. 95% CI = 0.23 – 0.80; p = .008). A positive drug screen was associated with an almost 3-fold increase in the odds of unintended pregnancy (OR = 2.88, 95% CI= 1.49 – 5.58, p =.002). Every one-unit increase in overall social support (range 0-36) was associated with a 6% decrease in the odds of unintended pregnancy (OR = .94, 95% CI= 0.91 – 0.98, p =.006).

Table 2.

Adjusted associations among demographic, clinical and psychosocial factors and unintended pregnancy (n = 309)

Adjusted odds ratio (OR) 95% confidence interval for OR p
Age (years) 0.93 0.88 – 0.97 .003
Race/Ethnicity
 Non-Hispanic
  White 1.00
  Black 2.07 0.73 – 5.91 .17
  Other 0.89 0.38 – 2.08 .79
  Hispanic 0.60 0.30 – 1.20 .15
Relationship status
 Partnered 0.43 0.23 – 0.80 .008
 Non-partnered 1.00
Drug screen
 Positive 2.88 1.49 – 5.58 .002
 Negative 1.00
Anxiety 1.03 0.94 – 1.12 .58
Intimate partner violence
 Positive 1.03 0.53 – 2.00 .92
 Negative 1.00
Social support 0.94 0.91 – 0.98 .006
Depression 1.02 0.95 – 1.10 .59
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Race/ethnicity, depression, anxiety and intimate partner violence were not associated with pregnancy intention. The Hosmer-Lemeshow test was non-significant (Chi-square = 10.7, p=.22), suggesting the model fit the data well. All variance inflation factors were less than 3.6, suggesting multicollinearity was not distorting parameter estimates.

We then ran the same adjusted model with each subscale of social support independently (see Table 3), the one most strongly associated with planning a pregnancy was Tangible support, for every one-unit increase in the subscale (range 0-12), women were 14% less likely to have an unintended pregnancy (OR = .86, 95% CI= 0.77 – 0.95, p =.005). Belonging was also strongly associated; with every one-unit increase women were 13% less likely to have an unintended pregnancy (OR = .87, 95% CI= 0.78 – 0.97, p =.011). The third social support subscale, Appraisal was not associated with pregnancy intention in this study.

Table 3.

Associations among social support subscales from three separate logistic regression modelsa and unintended pregnancy.

Adjusted odds ratio (OR) 95% confidence interval for OR p
Appraisal 0.91 0.82 – 1.01 .09
Tangible 0.86 0.77 – 0.95 .005
Belonging 0.87 0.78 – 0.97 .011
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a

Each logistic regression model adjusted for age, race/ethnicity, relationship status, drug screen, anxiety, intimate partner violence and depression.

DISCUSSION

Demographic and psychosocial risks reflected in the rates of unintended pregnancy (Table 1) revealed that those with higher rates of depression, anxiety, victimization by an intimate partner violence, as well as being Black or White conferred the highest risk prior to adjusting for covariates. While older age, partnered status, avoiding illicit drugs, and greater social support improved the ability of women living in or near poverty to plan their pregnancy. Other individual and interpersonal characteristics such as race/ethnicity, depression, anxiety and intimate partner violence were not significantly associated with pregnancy intention in the final model.

Social support is a complex phenomenon, and to our knowledge this is the first study to focus on low-income women in the US, using a comprehensive quantitative tool to identify that social support, specifically belonging and tangible support are strongly associated with pregnancy intention. Despite other socio-economic, psychosocial, demographic and behavioral characteristics, the results indicate that higher levels of social support help women plan pregnancy. Consistent with the literature regarding the prenatal and post-partum period, social support has been identified as a meaningful measure associated with various forms of perinatal health; low social support is associated with poor health during and after pregnancy as well as a factor in delaying prenatal care (Webster et al., 2000). Cohen & Hoberman et al. (1983) developed the interpersonal support tool to identify the functional aspects of social networks to study how support can serve as a buffer to protect people from stressful events. We further analyzed the three subscales used in this study (tangible, belonging and appraisal) to identify which components of social support were most salient buffers.

Tangible interpersonal support refers to perceived availability of material, instrumental, or financial aid and assistance, and was most strongly associated with pregnancy planning (Cohen et al., 1985). Tangible support among women in the study may have manifested in the form of transportation to appointments, assistance with childcare, and finding affordable contraception when trying to avoid pregnancy. This form of social support has the potential to also improve birth outcomes for vulnerable families, perinatal researchers have cited the protective effects of prenatal tangible and emotional support (but not informational support) on birth outcomes for women who experienced moderate childhood trauma (Appleton et al., 2019).

Belonging as a social support subscale refers to the perceived availability of others to spend time with, and it also denotes social companionship, acceptance, trust (Cohen et al., 1985). Belonging and connectedness are consistently identified in the literature as protective factors to numerous health outcomes. Increased sense of belonging to a community was found to demonstrate a dose-response relationship to positive health behavior changes in population studies (Hystad & Carpiano, 2012). More specific to adolescents, connectedness in the form of bonding and emotional attachment to family or a partner were protective factors for adolescent sexual and reproductive health outcomes (Markham et al., 2010). Conversely, those without a secure emotional attachment or perception of belonging may take sexual risks that fill a perceived void as a means to compensate for social exclusion (Morsünbü, 2009).

Appraisal refers to the perceived availability of confidants, from whom one seeks advice, affirmation, information, guidance or feedback (Cohen et al., 1985). Support in the form of appraisal did not serve to protect or buffer women from an unintended pregnancy. Based on prior global research of women living in poverty, we hypothesized that peer advice would be a central contributor to the decision-making process involved in contraceptive use and family planning. Perhaps in the US, women do not rely on each other to discuss contraception and family planning as they may in more collective societies or those with different social norms about sex. Women also may not seek out information or advice from interpersonal support networks but rather rely on online information. Moreover, life course researchers suggest the chaos and stress related to living in poverty leads to future discounting, that is when the future is unpredictable higher levels of risk-taking behaviors occur (Hill et al., 2008). While women living in poverty may have close confidants with whom they seek advice, if they also perceive the future as unpredictable, the advice given may encourage sexual risk-taking behaviors.

Illicit drug use is a risk-taking behavior also associated with future discounting. In this study women who screened positive were almost 300% times more likely to report the current pregnancy was unintended. While this relationship has been previously established in the literature over the last several decades, this finding is a stark reminder that women who use marijuana and opioids continue to struggle with reproductive health and may have unmet needs for contraception.

Limitations

Santelli, et al. (2009) found that a multi-dimensional measure which includes whether the pregnancy was desired, mistimed, or unwanted is a better indicator of women who later seek an abortion than those who had only the choice of the CMMI dichotomous measure that was used in this study. Future studies may benefit from including a more robust measure of pregnancy intention, one that incorporates ambivalence and is validated in diverse populations.

While this study reflected approximately the same proportion of Black/African-Americans in the state of Kentucky, the limited sample size in this subgroup may have influenced the ability to determine group differences.

Intimate partner violence was not associated with pregnancy planning status in the final model. However, previous researchers have suggested that pregnant women may under-report the incidence of IPV, particularly women in poverty, who are underemployed or unemployed (70% of our sample was unemployed) (Bailey, 2010). The growing family may be dependent on the partner for financial support so women may minimize the IPV or deny it outright for self-preservation. Also measures of violence directly related to contraception use were not included in the study, reproductive coercion tools and interviews with clinical social workers and more screening tools may have led to more accurate reporting.

CONCLUSION

Women living in or near poverty have less success with pregnancy planning compared to their more affluent peers, it is critical to find sources of resilience that assuage the threats associated with low socio-economic circumstances. This is among the first studies to demonstrate that interpersonal support is central to planning a pregnancy, belonging and tangible support both had a strong dose response relationship as a protective factor against unintended pregnancy. Functional social support serves as a buffer that may mitigate misinformation, lack of access, or relational barriers to pregnancy planning among women living in poverty. In addition to reducing barriers to reproductive planning, social support may also serve as a buffer for other risk factors associated with unintended pregnancy, it may lessen the effects of depression or intimate partner violence. Conversely, lacking social support leads to isolation, cutting off women from feedback to mitigate high risk sexual behaviors, and further impair their reproductive planning efforts.

Public health nurses can play a critical role in reducing unintended pregnancy rates by promoting social support, inclusion, and acceptance. Advocacy efforts focused on increasing tangible support both from within social networks and from safety net programs also serve to reduce the risk of unintended pregnancy for marginalized women.

Implications for practice include identifying avenues for social inclusion for marginalized women, those that promote resilience through policies and interventions which aim to galvanize women to collectively work on improving their circumstances. The parent study employed a Centering pregnancy™ group support prenatal care model that promotes empowerment through active engagement in care (Centering Healthcare Institute, 2020). A similar nurse-led, empowerment model could be developed to build resilience in young women living in poverty prior to or between pregnancies, focusing on relationship skills, social support, reproductive life planning, and contraception options. These models could also be tailored to specifically guide women (and men) with substance use issues by partnering with criminal justice, recovery, and risk reduction programs. More research is warranted related to the protective factors in the larger social environment, such as the role of social engagement, social capital and policies that support disadvantaged women and families.

Acknowledgments

This publication was made possible by Grant Number 1D1CMS331140-04-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted as a secondary analysis of the parent study, the awardee of the parent study was the co-author Dr. Kristin Ashford. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

Additionally, the project utilized RedCap as a data collection tool and this was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Also the lead author was funded by the Robert Wood Johnson, Future of Nursing Scholars during the period of data collection and analysis. A small portion of this paper originally appeared in her dissertation, Reproductive Autonomy Social Context of Pregnancy Intention; A Global to Local Approach.

The data that supports the findings of this study are available from the corresponding author upon reasonable request.

Contributor Information

Hartley Feld, University of Kentucky, College of Nursing, Lexington, Kentucky.

Sheila Barnhart, University of Kentucky, College of Social Work, Lexington, Kentucky.

Amanda T. Wiggins, University of Kentucky, College of Nursing, Lexington, Kentucky.

Kristin Ashford, University of Kentucky, College of Nursing, Lexington Kentucky.

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