National Partnership for Women & Families

Monthly Women's Health Research Review

Study reviews stigma, social norms for unintended pregnancy in Ala.

Summary of "Social norms and stigma regarding unintended pregnancy and pregnancy decisions: A qualitative study of young women in Alabama," Smith et al., Perspectives on Sexual and Reproductive Health, June 2016.

"Women aged 18-24 have the highest rate of unintended pregnancy among all age-groups in the United States," but little is known about how social norms and stigma around unintended pregnancy influence young women's pregnancy decisions, according to Whitney Smith, a doctoral candidate in the Department of Health Care Organization and Policy at the University of Alabama-Birmingham's School of Public Health, and colleagues.

The researchers defined social norms as "behavior [that] is accepted and expected in a community," while stigma is "social disgrace or disapproval" and serves "as an informal control mechanism for individuals who do not adhere to socially defined norms."

Noting that few recent studies have analyzed social norms and stigmas regarding unintended pregnancy, particularly among different races and in the South, the researchers wrote that they aimed "to explore perceptions of norms and stigmas related to unintended pregnancy, parenthood, adoption and abortion, and to examine racial and ethnic differences in these perceptions, among young, low-income women in Birmingham, Alabama."

According to the researchers, "Birmingham is a socially conservative city with marked levels of poverty, racial residential segregation and health disparities." In Birmingham, 30 percent of "residents live in poverty." In Alabama overall, researchers noted, the average rates of unintended pregnancy are "considerably higher" among women of color and low-income women. Despite such economic and health disparities in the area, the Alabama "government did not expand Medicaid under the Affordable Care Act [PL 111-148] and has enacted restrictive abortion policies," which has limited "access to reproductive health care."

The researchers wrote, "Studying reproductive norms and stigmas in Birmingham may provide insight into the situation in other urban and rural environments."

Study methods

The researchers collected data between December 2013 and July 2014. They recruited participants from two public health department centers and a community college in the area, all of which "served mainly low-income populations." Eligible participants included those who used one of the "study venues," were between ages 19 and 24, were English-speaking and were not pregnant.

The researchers conducted six focus groups, with a total of 34 participants. Groups were separated by race, with three groups of white participants and three groups of black participants. The moderators asked questions and shared standardized anecdotes about unintended pregnancies "to elicit views on norms and stigma related to unintended pregnancy and pregnancy options." In addition, the researchers interviewed a separate control group of 12 participants of different racial and ethnic backgrounds to ensure that a variety of unique experiences were represented.

The researchers then analyzed the interviews to determine "perceptions of other people's behavior (descriptive norms) and behaviors expected by others (normative expectations), as well as expressions of favor or disfavor (attitudes) and assigned responsibility (blame) regarding a stigmatized behavior or decision."

Results

In total, the study sample included 46 participants with a mean age of 21. About 52 percent identified as black, while 41 percent identified as white and 7 percent identified as another race or ethnicity. Among all participants, 46 percent reported a previous pregnancy.

The 12 participants in the interview group, compared with those in the focus groups, had more education, were less likely to have had a prior pregnancy or given birth and more likely to be in a non-marital relationship. Nonetheless, they noted that participants in both categories "shared many of the perceptions of reproductive norms and stigma."

Unintended pregnancy

The researchers found that participants of different racial backgrounds shared "common expectations for educational attainment, financial stability and personal maturity prior to getting pregnant and during pregnancy." However, they noted that unintended pregnancies were common among those in their communities and "often occurred before these expectations had been met." The participants also said unintended pregnancies at a young age were increasingly common.

According to the study, "One of the few areas where findings differed by race or ethnicity was male involvement and marriage." Expectations about relationships and pregnancy varied among black participants, but were more consistent among nonblack participants.

The researchers noted that "[c]ommon manifestations of social norms and stigma emerged from discussions when participants tried to reconcile community expectations about the circumstances of pregnancy with experiences of unintended pregnancy." For example, the researchers noted that study participants said if they were to experience an unintended pregnancy, they expected others to be "'mad,' 'worried,' 'disappointed,' 'upset' and 'unhappy.'" Study participants also brought up "common stereotypes of the 'kind of woman' in that situation," noting that friends and family members might expect an unintended pregnancy to occur "because of poor upbringing, promiscuity, irresponsibility and lack of contraceptive use."

Participants also said "women can be the target of accusations and gossip regardless of their pregnancy decision." According to the researchers, such "[j]udgment and blame for getting pregnant can affect a woman's self- perception." Further, the researchers noted that "women who experienced unintended pregnancy may be shunned by friends and family members, even though they live in tight-knit communities." They also noted that multiple participants discussed how young women who experience unintended pregnancy "try to keep their pregnancies secret for fear of backlash."

Parenting

According to the study, participants largely believed those facing an unintended pregnancy should opt to parent, and that this choice was made by most young women in their communities. The researchers wrote, "The perception of parenting as an inevitability repeatedly emerged in discussions of decision making following an unintended pregnancy."

The researchers found that "[p]arenting norms were also manifested in family and community reactions to the decision to parent, which most women described as positive, despite often mixed reactions to the pregnancy initially." Further, the researchers noted that many participants said they themselves would opt to parent if they faced an unintended pregnancy, citing "the expectation of personal fulfillment from overcoming the challenges of early parenting" and not "miss[ing] out on motherhood experiences."

Nonetheless, the researchers noted that participants recognized the "trying socioeconomic circumstances that young mothers faced," such as difficulty finishing college. In addition, although most participants said choosing to parent was a sign of "selflessness, strength and responsibility," some noted that there can be judgment for "parent[ing] outside of the expected contexts," including the belief that it is selfish to raise a child in an unstable environment.

Adoption

Participants said that while "formal adoption" was a rare decision in their communities, many either had lived in foster care or with a different family member, or knew someone who had. They said such situations were different from legal adoption and were "difficult and emotionally trying, particularly when the child was displaced from one or more homes."

According to the researchers, some participants said they would not consider or support "adoption because of personal beliefs, an expectation of emotional connection to the fetus or concern about the well-being of the child."

The study participants described women who opt for adoption "using diverse and sometimes contradictory terms," ranging from "difficult" and "brave" to "selfish." The researchers noted that while participants "generally viewed motivations for alternatives to parenting as an 'an excuse,'" some said women may choose adoption "to protect themselves and their families from shame, or to protect the child from emotional harm." According to the study, participants believed women should "cherish the ability to get pregnant," and echoed community values that prioritized parenting before adoption as "morally acceptable options."

Abortion

The researchers found that the choice to end the pregnancy was "far less visible" in communities than a young person's choice to parent. However, black participants were more likely than white participants to consider abortion a common experience and white participants acknowledged that "abortion may happen 'more often than people realize.'"

Several participants said they would not have an abortion if they had an unintended pregnancy, although a minority of respondents said they would. According to the researchers, most participants considered abortion "acceptable only in 'real trying circumstances,' which encompassed rape, drug abuse, severe mental illness and homelessness," or other exceptional circumstances, such as to save the life of the woman.

They also noted that respondents expected community members to "react negatively to finding out that a young woman had had an abortion" and felt that women who chose abortion, as well as others involved with such services, "were perceived as irresponsible, selfish, weak, cold-hearted and immoral."

Some white participants recounted experiences with antiabortion-rights crisis pregnancy centers, noting that they push women not to have abortions. Respondents also said they knew of people who did not disclose their abortion, in part because of perceived social stigma. In some cases, respondents shared stories of parents of young women forcing them to obtain an abortion in order to prevent their community from learning about the pregnancy.

Discussion

"Our study revealed a number of themes related to social expectations as perceived by low-income young women" regarding unintended pregnancy, the researchers wrote.

The researchers touched on the study's key findings, including the frequency of unintended pregnancy despite social disapproval, social expectation to carry the unintended pregnancy to term and parent, and "perceived stigma toward unintended pregnancy." They noted, "Overall, our results indicate that young women in this setting share perceptions of reproductive norms and stigma that are similar to those held by other low-income women in the United States, regardless of age or location." However, the researchers noted that "the stigma surrounding nonnormative behaviors may be more salient in the South than in other regions, as evidenced by the hostile climate for access to abortion and related public misinformation."

The researchers also pointed to "some racial differences in expectations for male involvement following unintended pregnancy and in norms pertaining to abortion" in their findings. Specifically, they noted that "[m]ore black participants than whites expressed expectations for single parenthood," while "white participants were less familiar than blacks with the occurrence of abortion in their communities." In addition, according to the researchers, "only white participants discussed experiences with crisis pregnancy centers, despite reported efforts by antiabortion activists to discourage black women from having abortions." Nonetheless, the researchers wrote that "black and white women in our study perceived similar manifestations of stigma regarding unintended pregnancy and pregnancy decisions." The researchers added that the "findings are unique, as previous studies have not explored racial variation in norms and stigmas regarding unintended pregnancy and pregnancy decision options in the South."

According to the researchers, "Understanding reproductive norms and stigma has important programmatic consequences for professionals who support women's pregnancy-related decision making." For example, they noted, "By learning about the manifestations of reproductive stigma, and employing compassion in interactions with clients, practitioners can use this research to counteract and help women cope with this stigma." They recommended strategies such as "[i]ndividual-level interventions ... to target women who experience reproductive stigma and offer them education and counseling to help restore their sense of integrity," as well as interventions for "the broader community [that] may involve educational approaches that incorporate critical thinking about the alignment of social expectations, women's experiences and related stigma."

Noting that the study's findings illuminate low-income women's perception of pregnancy and parenting social expectations, as well as their susceptibility to social stigma for violating those expectations, the researchers conclude, "Thus, social norms and stigma may influence young women's health decision making, particularly the disclosure of an unintended pregnancy and nonconformist pregnancy decisions."