At the end of the Thanksgiving weekend in 1992, I woke up with contractions. It was 4 am, and I was facing my first labor with a mix of anxiety and excitement. A few hours later, my husband and I headed for the Maryland hospital we had selected, hitting the absolute height of rush hour traffic on the famous Washington D.C. beltway. My contractions were coming strongly and frequently as we moved at a snail's pace, bumper to bumper with all the other commuters. The guy in the car next to ours was working his cell phone. I started to wonder what it would be like to deliver a baby in the front seat of a Ford Escort.
Once at the hospital, things progressed very quickly. Apparently my body knew how to get this baby out, and by 11 am I could hardly catch my breath between the relentless waves of contractions. The anesthesiologist with the epidural was my new best friend.
And then suddenly came the urge to push, and with that, a burning desire simply to get the baby out. But I wasn't ready, said the nurses. Superhuman patience was needed for another half hour or so, while ligaments stretched the final millimeters, membranes ripped and contractions as charged as lightning struck again and again. The hospital could have caught fire and I wouldn't have noticed.
Around noon I finally got the go-ahead, and I pushed so hard that colored circles danced before my eyes. Finally my son was born, looking a bit confused and featuring a big black eye. But he was perfectly healthy.
He had a lot of things going for him right from the beginning: He had two parents, his mom had received prenatal care and she wasn't a substance abuser or a teenager. But the very best thing he had going for him, according to the latest medical research, might surprise you: He was planned.
"HONEY, I'M LATE..." -- Those are the dreaded words announcing the more than 3 million unintended pregnancies that occur every year in the United States. In Spokane County, 53 percent of all pregnancies are unintended -- that number is split with 21 percent ending in abortion and 32 percent in live births. Statewide about 55 percent of all pregnancies are not planned, according to the Washington State Health Department.
Babies who start out as surprises have more health challenges than babies who are planned. A Spokane Regional Health District (SRHD) report has found that with unintended pregnancies, mothers are less likely to seek prenatal care, less likely to breastfeed and more likely to expose the fetus to alcohol and tobacco -- all circumstances that make for a less-than-optimal start on life.
If, on top of everything else, Mom is under 15 years old, her baby is more likely to be of low birth weight, is at higher risk of dying right after birth or of suffering sudden infant death syndrome. Later in life, these babies face a higher risk of child abuse, neglect and behavioral problems that may lead to drug use and other criminal behavior. In other words, these children are more likely to become a strain on society. Meanwhile, kids who were planned by their parents are more likely to become well-adjusted citizens. Ultimately, unintended pregnancies are everyone's problem.
"Our numbers here in Spokane are consistent with the rest of the country," says Zynthia Fine, program coordinator for the unintended pregnancy prevention program at SRHD. "It wasn't until the last couple of generations that people had access to contraception, and most of us know of a 'mistake' in the family, so maybe the number shouldn't be such a big surprise."
But not all unintended babies are doomed. "Families sometimes cope very well -- but we can statistically say that there are poor outcomes for unintended pregnancies. If an unintended pregnancy happens to a teenager, it can be a disaster," says Fine. "I have discovered over time that there is this interconnectedness between child abuse and neglect, domestic violence, substance abuse and unintended pregnancy -- those areas are so interconnected."
Leyli Woodfield is a public health nurse with SRHD. She has worked with the First Steps program since she was hired in 1990. Woodfield has enormous experience dealing with some of the most challenged expectant mothers. When she first meets with a client, she asks if the pregnancy was planned.
"It's a parenting question to me," says Woodfield. "Parenting starts a bit before conception. If you are doing drugs, smoking, getting caffeine or drinking and all that stuff, you need to take care of that before you get pregnant."
But what if the woman is pregnant, and she wants to keep the baby?
"That's a fact. We're here, we're pregnant, what are we going to do now?" says Woodfield. "I ask if the client has considered putting the child up for adoption. Some place the child up for adoption, but not many."
State of DENIAL -- Women with the lowest incomes have the highest rates of unintended pregnancy. Married women often have better resources and a better support system to deal with an unintended pregnancy, lessening the negative impact on the child and themselves.
But unintended pregnancies happen more frequently to women who are young and poor.
"I deal with people who fall within 185 percent of the Federal Poverty level," Woodfield says. "Some are working poor, some are high school students, some are college students, some have mental problems." She says it takes four times as long for women with two children to get off welfare as it does for those with no children.
Woodfield says that for some women who are already poor, on welfare and perhaps addicted to drugs or alcohol, a pregnancy in itself may be too much to handle -- they slip into denial.
"For some, the denial is the only way they can deal with it. Some become very depressed and do things that are suicidal," says Woodfield. "Others continue to use drugs and attend wild parties as another, slower, form of self-destruction. They seem to think that if I don't believe I'm pregnant, I can act like life is going on as it always was."
Receiving adequate prenatal care is paramount when it comes to insuring the health of both mother and baby throughout the pregnancy and the delivery. Without regular checkups to follow the growth and position of the baby -- and screenings for birth defects or other complications -- many unintended babies enter the world with health problems that could have been treated or prevented during pregnancy. Both maternal and infant illness and death are closely associated with unintended pregnancy.
If Mom is using drugs, a pregnancy can be an incentive to come clean, but some drug users swing the other way: They continue to take more drugs, and in some documented cases, have tried to provoke a miscarriage.
"It's important for me to get across that no woman wakes up pregnant one day and then decides to go and use drugs," says Woodfield, adding that it's all too easy to inflame public perception about this issue. "In some cases, the personal demons are simply bigger than the pregnancy."
If Mom is living in an abusive relationship where domestic violence is the order of the day -- violence often escalates if the woman becomes pregnant and her partner doesn't want to have anything to do with it -- that can have a devastating impact on the baby as well.
"Some babies are steeped in high-stress hormones throughout the pregnancy," says Woodfield. "Not only is domestic violence often aimed at the abdomen of the pregnant woman, but low birth weight is now attributed to domestic violence as well, because of the impact of the stress hormones." Babies with low birth weight have trouble thriving, they may get frequent infections and end up spending a large amount of their childhood in the hospital.
Some mothers suffer from trauma stemming from their own childhood. "Some [of the women] are caught up in their own personal trauma. This isn't the kind of trauma like, 'I was grounded for shoplifting,' " says Woodfield. "This is 'My mom's old man has been molesting me since I was 7' kind of trauma."
If the pregnancy itself is the result of trauma -- of rape or the result of the woman being molested by an acquaintance or a family member -- the powerlessness resulting from the original trauma is likely to follow the woman throughout the pregnancy.
"Every doctor's exam and ultrasound is a reminder of the pregnancy itself being an invasion," says Woodfield. "For some women, even going to the dentist is revisiting that trauma. Yes, the denial can be very ugly."
Facing REALITY -- At some point, a woman with an unintended pregnancy finds herself in the delivery ward with contractions. If she hasn't received adequate prenatal care, there are no medical records indicating special circumstances about her or her pregnancy. This is also the time when reality hits like a ton of bricks.
"If you have a mom that [mentally] checked out already before the delivery, you are much more likely to have problems after the birth or to have a baby with special needs," says Woodfield. "Fetal alcohol syndrome is forever. How would you like to think like a 3-year-old the rest of your life?"
And then there's the love myth, which often crashes and burns once the baby arrives.
"Some kids think that it will solve everything to have a baby. They think, 'Yes, it will fill that hole,' but they are not responsible enough to deal with all the stuff they need to do when they become moms," says Woodfield. "You just try single parenting on welfare and get daycare and try to work and go to school and find a place to live -- it's unbelievably hard."
The correlation between unintended pregnancy and a higher risk for Sudden Infant Death Syndrome, developmental problems and personal problems such as learning disabilities and difficulty relating to other people later in life is a cycle that's hard to break. Girls who are the result of an unintended pregnancy are more likely to become pregnant unintentionally when they grow older.
"Quite often, I'd say that the mothers we deal with weren't nurtured very well themselves, and they have many other issues," says Mary Ann Murphy, director of Casey Family Partners. "If this was a foot race, then the planned pregnancy gets a head start. But unintended pregnancy does not have life-long effects. There is no evidence that because things go wrong from the start that they will always go wrong."
Murphy's organization, Casey Family Partners, was formed in 1988 as a hospital-based center for abused and neglected children, supported both by Deaconess and Sacred Heart Medical Center.
"Parents who didn't get very good parenting themselves -- that has a huge impact on their own kids," says Murphy. "If you add that to not having planned the pregnancy and not having a model of how to nurture a child because you experienced the opposite yourself -- that can be a very difficult situation."
Social workers and therapists at Casey Family Partners use videotaping to help challenged parents realize how they deal with their kids. "One mom had a new baby come home from the hospital, so here we are, taping this very exciting day," explains Murphy. "On the tape, the mom saw her 7-year-old taking care of the baby, holding the baby, carrying the baby around." This was the same 7-year-old who had taken care of this mother when she had a drug problem.
"Something shifted inside this mom when she saw it for herself, that the 7-year-old was still taking care of things. She had this new baby and she wanted to do everything right with this one, yet things were still the same," says Murphy. "It helps us to see it for ourselves instead of having someone lecture us. These young mothers feel so judged, like the assumption is that they are not doing it right. When they see it for themselves, they understand, gain insight, they don't feel like they are being judged."
Another new mom had herself been raised by a very depressed mother. When she watched a tape of her own interactions with her kids, she recognized her mother's expression on her own face.
"That was an expression that used to scare her so much," says Murphy. "And now she could see she was using it with her own children. She really got religion from that."
The families that end up in counseling at Casey Family Partners often face very serious challenges, such as poverty, chemical dependency issues and family violence of all kinds, says Murphy. When a new and unintended baby is added to this volatile mix, parents often lose the last bit of coping skills they have left. Frustrated over crying, they hurt their kids trying to quiet them or they leave their babies with people who have no childcare skills -- sometimes with tragic results, as we have seen in the heartbreaking stories of babies being killed by parents or guardians in Spokane County.
"You know what it's like, your baby is crying in the night and you are feeling sleep-deprived and feeling like the baby is trying to get to you," says Murphy. "But then they see the tape and they see how much the child is responding to them, trying to look happy, trying to smile. And sometimes they realize how much their children are really trying to please them -- not trying to get to them."
Mothers who are in denial about their pregnancy often struggle when time comes to bond with the baby -- a process that begins during pregnancy.
"Active intervention to strengthen the bond with the parents is very important," says Murphy. "Sometimes we need to make the child real to the mom. For instance, knowing the gender can facilitate the awareness of the child as a separate person." The process of separation -- of the parent forming a stable base and the child struggling for independence -- is a long process that all parents and kids face.
But no matter how much parents may struggle with forming a secure attachment to their children, there is one thing they all have in common, no matter how desperate their situation may seem.
"They all want to do better for their children than what was done for them," says Murphy. "I think that is universal, no matter how hard you struggle to figure things out. And how much should we judge this person who is looking for love? This person who has a child thinking it will love them? Aren't we all looking for love in one way or the other?"
PLAN to succeed -- The Spokane Regional Health District's Healthy People 2010 objective is to increase the proportions of pregnancies that are intended from 47 percent today to 70 percent by 2010. The key to achieving that goal is family planning. When the Spokane Regional Health District did its unintended pregnancy survey, it found that more than 20 percent of the women who reported they didn't intend to get pregnant said they simply didn't think about it beforehand. Another 17 percent said it was luck or fate that they got pregnant, and 13 percent said they didn't think they could get pregnant at the time of conception. An equal number (12 percent) said they didn't want to use birth control -- some are afraid of side effects, while others say birth control is too expensive -- or that their partners didn't want to use birth control. But 7 percent of women admit to not using contraceptives at all; these women account for 47 percent of the unintended pregnancies.
Woodfield, the public health nurse, advises her clients on family planning. Sometimes her careful support and advice won't benefit the client's current pregnancy, but she never gives up trying to impact her clients' decision-making when it comes to future pregnancies.
"I'm not always successful. One of my things is, just because a woman can have a baby doesn't mean she should have one," says Woodfield. "We talk about family planning both before and after the baby is born, and I follow up on birth control month after month."
It's difficult to reach developmentally disabled people with a message about birth control and family planning, she says.
"There is a really fine line between what you can tell them and what you can't tell them. You can't say, 'Hey, go in and get your tubes tied.' That's an infringement on their civil liberties," says Woodfield. "The sad part is that someone with a low IQ may get pregnant over and over again, and the kids many times are taken away over and over again. Mom doesn't understand why the baby is taken away, but can you imagine the mourning and the despair that they don't get to keep their baby? Some respond by saying, 'I'll keep making them until I get to keep one.' That is devastating to me."
Nationally, a little less than half of all unintended pregnancies end in abortion. Both the abortion rate and the teenage pregnancy rate have been declining in the United States for the last 15 years, but we still see one abortion for every three live births -- a ratio that is four times higher than that in most other Western industrialized countries. Cutting the number of unintended pregnancies is also expected to bring the number of abortions down.
Many women who find themselves unexpectedly pregnant stop by Planned Parenthood. "We go over all the options the women have, and we answer all their questions," says Michele Stafford, Planned Parenthood's assistant clinical services director. "We ask what she has thought about -- we'll explain both adoption and abortion, and that they need to get prenatal care going if they decide to keep the baby."
If the pregnancy is terminated, Stafford says the women always leave with information about family planning. "We try to never have a patient leave us without birth control after a termination," she says. "We even have some things here we can give them, like condoms and emergency contraception, so at least they can leave with that."
Often a near-miss -- when a woman thinks she is pregnant but turns out not to be -- gets their attention. "They are so relieved to find out that they are not pregnant, that that time is a really good time to talk about birth control," says Stafford. "They don't want to find themselves in that situation again."
To prevent unintended pregnancy, the Spokane Regional Health District is especially focusing on at-risk middle school girls and people between the ages of 18 and 24.
"The prevention of unintended pregnancy is a multifaceted issue," says Fine. "We are doing a public information campaign just to raise awareness even for people who aren't at risk themselves. We just want to put it on the radar screen, because some people still seem to think that babies just come when they come."
Fine is optimistic that the goal can be reached. Because of the interconnectedness among child abuse and neglect, domestic violence, substance abuse and unintended pregnancy, any positive impact on any of these areas will cut the number of unintended pregnancies.
"Any place in this cycle where we can have an impact is a good thing," says Fine. "These are controversial issues. Some people don't like to talk about family planning or sex education, but who can argue [about whether] it's a good thing to plan your pregnancies when we know that planned pregnancies are just better off? I don't think anyone can seriously argue with that."
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Publication date: 01/23/03