The relationship between violence and women's reproductive lives is a relatively new line of inquiry. In June 1999, the Centers for Disease Control and Prevention convened a national conference on the topic, with three main objectives: to assess the state of the research, to increase awareness and understanding of the possible associations between violence against women and their reproductive lives, and to lay the groundwork for future research and action. The conference addressed the association between violence and such specific topics as pregnancy intentions, contraceptive use, pregnancy termination and pregnancy outcomes.
Research reported at the conference indicated that violence is present during 4-8% of all pregnancies. In addition, violence is implicated in inconsistent contraceptive use and unintended pregnancy. Finally, evidence about the relationship between violence during pregnancy and pregnancy outcomes, particularly the likelihood of delivering a low-birth-weight infant, is inconclusive. Beside research findings, several methodological recommendations emerged from the conference: to broaden study populations beyond women in battered women's shelters, and include those attending family planning, abortion, and HIV and sexually transmitted disease clinics; to refine data collection methods to improve disclosure of victimization; to obtain additional data on the relationship between violence and intervening variables; and to develop and evaluate more effective screening and intervention programs. (1)
Most research on violence and women's reproductive lives has focused on adults. Whether this research is generalizable to adolescents remains to be seen. Research on maltreatment and adolescent pregnancy has not been as widespread as research on maltreatment and adult pregnancy because of access issues. (2) First, access brings with it complex legal and ethical issues related to obtaining permission from parents or guardians for minor adolescents to participate in research. Maltreated adolescents are not likely to be residing in domestic violence shelters, because the permission of the parent or guardian may be required, and the parent or guardian may be the perpetrator or may have knowledge about the maltreatment that he or she does not want to disclose. Second, access brings with it complex legal and ethical issues related to researchers as mandated reporters of child abuse, incest and statutory rape. Third, access is an obstacle because adolescents may hide or deny maltreatment for fear of being removed from their homes, alienating their partners or being placed in foster care.
The overall goal of this study was to determine if there is sufficient research evidence to support a causal link between childhood maltreatment (including physical, sexual and emotional abuse) and subsequent adolescent pregnancy. To address this goal, we conducted an extensive literature review to answer the following questions: What types of maltreatment have been addressed? How have types of maltreatment been defined? What types of research designs have been used? To what extent do the findings conflict or agree? What research questions remain unanswered? What are the implications for future research?
METHODOLOGY
For a study to be included in this literature review, it had to involve women who had become pregnant or given birth as adolescents. We limited the review to empirical studies that were published between 1980 and 2000. We excluded theoretical articles and those with no women who were 21 or younger during the cited research period or when they experienced maltreatment. Retrospective accounts from adult women concerning their maltreatment and pregnancies when they were 21 or younger were included. We examined three databases, covering three pertinent areas: medicine (Medline), psychology (PsychINFO) and sociology (SocioFile). One of the authors abstracted each article that met the criteria listed above, and a graduate student and a university faculty member in a related discipline reviewed each abstract for accuracy.
We found 15 empirical articles that addressed the relationship between maltreatment and adolescent pregnancy; all had been published since 1989. The sample sizes varied from fewer than 100 to more than 3,000 (Table 1, page 70). Sexual abuse was the dominant type of maltreatment of interest and was included in all 15 studies. Substance abuse, poor mental health and delinquent behaviors were often addressed as they related to maltreatment and pregnancy. No authors provided information about the perpetrator, and only four made comparisons between racial and ethnic groups in the prevalence or types of maltreatment.
RESULTS
The Studies
* Adams and East studied 100 females aged 12-24 who were attending a medical clinic. (3) Half of the women were pregnant; 23% were white, 34% were black, 25% were Mexican American and 18% were of some other race or ethnicity. A 186-item structured interview was used to elicit information about physical, sexual and emotional abuse.
Compared with adolescents who had not been maltreated, those who had been were more likely to report having been pregnant. In addition, the maltreated adolescents were more likely to report using alcohol and tobacco, not liking school, being involved in delinquent behavior, having suicidal thoughts, feeling depressed and not having a father in the home; they also had their first sexual experience at a younger age and had an older first partner. The three types of maltreatment (sexual, physical and emotional) were about equally prevalent across the four racial and ethnic groups. Finally, physical abuse was predictive of adolescent pregnancy, but sexual and emotional abuse were not.
* Boyer and Fine interviewed 535 pregnant or parenting females aged 13-21 from both urban and rural settings, to determine the extent of their sexual and physical abuse. (4) The types of sexual victimization that they had experienced ranged from noncontact molestation (e.g., being forced to view sexual films) to rape. Sixty-two percent had been molested or raped prior to their first pregnancy. Moreover, 67% had experienced at least one of the following types of physical abuse: being hit with an object, being thrown against a wall or being hit with a closed fist. When experiences related to both sexual and physical maltreatment (other than spanking) were included, the proportion of youth who had been victimized rose to 71%.
Adolescents who reported having been maltreated were more likely than were other adolescents to have exchanged sex for money (14% vs. 2%), for a place to stay (14% vs. 1%) or for drugs (11% vs. 1%). Furthermore, the children of maltreated mothers were more likely to have been maltreated than were the children of other women (7% vs. 2%). Twenty-one percent of the maltreated mothers said that they had been reported to child welfare authorities for allegedly abusing their children, compared with 8% of the others.
* In Butler and Burton's exploratory study, 41 young mothers were interviewed about their experiences, ranging from sexual coercion to rape. (5) Twenty-two reported a total of 37 incidents of maltreatment. The prevalence of sexual maltreatment in this sample was twice as great as the national estimate for the general population of females aged 18 or younger.
The authors proposed six possible links between early sexual maltreatment and adolescent pregnancy: The pregnancy might have resulted directly from maltreatment; it might have resulted from dysfunctional family patterns; it might have been related to gender and sexual socialization that teaches females that their worth is tied to their sexuality; it might have been the result of low self-esteem, feelings of powerlessness and poor mental health; it might have been planned, so the adolescent could escape an abusive situation; or it might have been related to an interruption in cognitive and emotional development caused by trauma.
* Chandy, Blum and Resnick used a nationally representative database to identify 1,011 females in grades 7-12 who reported that they had been sexually maltreated; a comparison group of 1,011 young women who did not report having been maltreated was randomly selected from the same data set. (6) The maltreated girls were more likely to have been pregnant and more likely to disclose the following adverse outcomes: poor school performance, thoughts about or attempts at suicide, eating disorders and substance use. Factors that were protective against maltreatment included a greater degree of religiosity, perceived good health, caring from adults, living with both biological parents, and having a clinic or nurse present at the school. Risk factors included perceiving that peers use substances in school, mother's use of alcohol, family stress during the last year and worry about sexual coercion.
