Exploring the Dynamic Relationship Between Life Stressors and Reproductive Decision-Making

Background: High rates of unintended and unplanned pregnancies in the United States result in challenges to quality of life, negative maternal and neonatal outcomes, and increased federal spending. While several socioeconomic and environmental factors have been associated with increased risks of unintended pregnancy, limited research has been conducted to evaluate the relationship between life stressors and reproductive outcomes such as unintended and unplanned pregnancies. Additionally, fertility intentions and reproductive decision-making are understudied in relation to stressors experienced by vulnerable populations in the United States. Specifically, the stressors associated with uprooting and flight experienced by Syrian refugees who have resettled in the United States, and the impact of these stressors on reproductive decision-making, has yet to be studied. Purpose: The purpose of this dissertation is to deepen the scientific understanding of the dynamic process of pregnancy intention and planning in women experiencing major life stressors, both in the United States and in the context of forced migration. Paper One: A secondary analysis of longitudinal data from 1,730 women following their first birth was conducted. A total of 1,552 pregnancies were experienced in the 36-month follow-up period. An Andersen-Gill survival analysis was used to assess how changes in stress over time relate to risk of pregnancies that are unintended, unplanned, or both unintended and unplanned. Minor (HR 1.66 and HR 1.68) and major (HR 2.34 and HR 1.90) decreases in stress, as well as minor increases (HR 1.60 and HR 1.40) in stress, were associated with an increased risk of unintended and unplanned pregnancies respectively. Increases in risk were not seen in major increases in stress over time. Major increases in stress may be associated with improved vigilance in contraceptive use, or stress-related decreases in intercourse. Clinical and policy interventions to reduce unintended pregnancy should take into consideration the impact that changes in stress may have on reproductive outcomes. Paper Two: A mixed-methods evaluation of reproductive decision-making with 36 women from Syria who resettled in southeast Michigan was conducted. Women completed a quantitative survey for every pregnancy experienced since the start of the Syrian Civil War, followed by a qualitative interview structured around a timeline. Participants described factors influencing fertility intentions over time including the facilitators and barriers to accessing reproductive healthcare and contraception. Findings will be used to improve reproductive healthcare access and uptake for women that are refugees in the United States and globally. Paper Three: Interviews with women from Syria were utilized to reconstruct a gender-informed migrant theory using extended case methodology. These interviews enabled deeper theorization of the work of women and the temporality of the refugee. This theory will be used to guide future research, policy, and clinical interventions for women who are refugees, specifically with the goal of improving reproductive healthcare access and uptake. Future Directions: The results of this dissertation aim to improve understanding of the relationship between life stressors and pregnancy intention and planning, and to identify barriers to providing quality reproductive healthcare to vulnerable populations. Results will be used to inform future work to develop policy and healthcare interventions aimed at assisting women in seeking congruence between their reproductive intentions and outcomes both in the United States and globally.PhDNursingUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/151631/1/meachuey_1.pd