Informing reproductive health policy through epidemiologic research: three papers on unintended pregnancy among women worldwide

Worldwide, women struggle to control the timing and spacing of childbearing, resulting in a high number of pregnancies that are unintended. In order to achieve many of the United Nations Millennium Development goals related to maternal and child health, gender equality and HIV prevention, the incidence of unintended pregnancy and its consequences must be significantly reduced. The three papers comprising this dissertation represent distinct analyses related to the general theme of unintended pregnancy among disadvantaged women, with a particular focus on research that is responsive to and can directly inform pressing policy questions./nPaper 1 synthesizes the observational evidence on the relationship between use of hormonal contraception (HC) and women's risk of HIV acquisition using quantitative meta-analysis. Given the central role of HC in preventing unintended pregnancy, policymakers and practitioners are struggling to translate an inconsistent body of observational evidence on this question into balanced contraceptive guidance for women, in particular in high prevalence HIV settings such as sub Saharan Africa. Pooled effect estimates from studies that use a comparable approach to identify the effect of use of various forms of HC on risk of HIV acquisition, and adequately address confounding and selection bias, suggest that use of certain forms of HC is associated with an elevated risk of HIV acquisition, but not of the magnitude that would merit complete withdrawal of these methods./nPaper 2 capitalizes on a unique study design to examine the role of an unintended birth on women's educational attainment in the United States. Despite over three decades of research, there remains debate over the extent to which reduced educational attainment among women with an unintended pregnancy is a function of childbearing itself, or a consequence of common selection factors that predispose women to both early childbearing and poor socioeconomic outcomes. By exploiting a discontinuity in the timing of presentation for abortion care, this paper compares the incidence of graduation or drop out from school among exchangeable groups of women, half of whom had an unintended birth and half of whom received an abortion. Unlike previous research, this analysis finds no difference in the educational achievements of women who experience an unintended birth and those that experience an unintended pregnancy that they do not carry to term./nFinally, paper 3 explores the extent to which minors seeking abortion in the U.S. involve parents and other important individuals in their decision-making process, and how these relationships influence their confidence in and projected coping with their abortion decision. Despite the fact that a majority of states require parental involvement in minors' abortion, little is known about the effect of involving a parent on minors' abortion decision-making and anticipated coping after abortion. This analysis reveals that in the absence of a law mandating involvement, a majority of minors involve parents, primarily mothers, and male partners in their abortion decisions. For a minority of minors, experiencing pressure or lack of support from mothers reduces confidence in their decision and increases their likelihood of anticipating poor coping after an abortion.

Advisor: Padian, Nancy