The Pursuit of the Unwanted, part 1

By Rebecca Oas, Ph.D. | August 19, 2015

Margaret Sanger, the founder of Planned Parenthood, said that her guiding principle was that “every child should be a wanted child.”   In response, pro-life activists have said, “there are no unwanted children, only unwanting parents.” While I agree with the sentiment behind that second quote, I have to take issue with it for one important reason: it omits a major factor in the discussion of “unwantedness” that is too often overlooked: I’m speaking of the middlemen between women and Planned Parenthood, the ones who populate academic and policymaking circles, who, armed with a solution in search of a problem, seized on the purported “unwantedness” of children as a rationale to flood the world with abortion and contraceptives.

Earlier this year, two papers were published in the February issue of Demography that shed some light on the current state of “unwantedness” as a scholarly topic. But first, I should mention that I use scare quotes around the word because in the context of academia, it’s much more likely to be used by researchers than the mothers whose desires they are attempting to analyze. Women’s aversion to the word “unwanted” is well known and hardly surprising – perhaps the best illustration is this quote from an interviewee in a UK-based study in 2002:

“Unwanted child, it means it reminds me of something like the homeless children or orphans […] It’s like you are deserting your children.”

The history of attempts to define the scale of “unwantedness” and describe its consequences in human terms is a fascinating subject, and one I hope to discuss in depth another time, but the important thing to keep in mind is that the “conventional” measure of unwantedness does not involve the parents using the word “unwanted” or making any statement whatsoever on their current feelings regarding their child(ren). Instead, it relies on answers to survey questions asking if, shortly before they became pregnant, they wanted to have a baby. If the answer is a simple “no,” the pregnancy is classified as unwanted. If the answer is that they wanted a child, but not at that time, the pregnancy is classified as “mistimed.” Both of these fall into the broader category of “unintended pregnancy.”

With regard to the two papers from Demography, I want to focus less on the technical details and more on the framing of the findings – both studies deal with the issue of how statistical biases can affect computational outcomes, but statisticians have biases too.

The methods of measuring pregnancy intendedness are the subject of a paper by Kathryn Kost and Laura Lindberg which analyzes how these classifications affect the prenatal and postnatal care received by the child.  They begin with the following:

“The premise that unintended childbearing has significant negative effects on the behavior of mothers and on the health of infants strongly influences public health policy and much of current research on reproductive behaviors. Yet, the evidence base presents mixed findings.”

This notion that “strongly influences” policy not only predates its own evidence base, but is clearly in desperate need of one, hence it also “strongly influences” current research, which in turn churns out “mixed findings.” Nevertheless, the central notion remains firmly in place, largely because the researchers tasked with evaluating it are a self-selected group of people who think that showing how “unwanted” children suffer lifelong disadvantages is a) an interesting research question and b) something to be solved by preventing their lives rather than finding ways to improve them.

Among their findings, after adjusting certain aspects of the statistical model that had been used in prior studies:

“Mistimed and unwanted births were still less likely to be recognized early in pregnancy than intended ones. Fewer unwanted births received early prenatal care or were breast-fed and unwanted births were also more likely than intended births to be of low birth weight.”

I know that academic papers are full of jargon that can seem strange to the non-specialist reader, but the idea of a “birth” being breast-fed or recognized early in pregnancy would almost be funny if it weren’t for the sobering reality that the odd phrasing is being deployed to obscure a human life.

Kost and Lindberg conclude that their findings “support and extend research demonstrating strong demographic and socioeconomic differences in unintended childbearing,” although they note that it’s difficult to separate out women’s childbearing intentions from their life situations and stages, and “separating the effects is difficult not only in statistical terms but also in ways that are substantively meaningful.”

They go on to say:

“As scientists, we compare their [the women classified as having unwanted or mistimed births] behavior and infant outcomes with those of women having intended births, but the public health goal is not to help mothers change their attitudes so that those unintended births become intended ones; the goal is to delay those pregnancies until women move into a life stage when they do want to have a baby […] Similarly, the negative consequences for an unwanted birth can be alleviated not by convincing mothers to want the births, but by preventing the unwanted pregnancies.”

As scientists, one could argue it is not their job to determine what “the public health goal” is at all, much less dismiss a perfectly reasonably path toward achieving it without so much as a reason why. (It may also be worth mentioning that this study received funding support from the Guttmacher Institute.)

Moving on to the second paper, David Bishai and colleagues discuss the outcomes of the famous Matlab Project, which took place in Bangladesh during the 1990s and studied the impact of introducing family planning services in one area and comparing it to a control area that did not receive the interventions. In particular, the authors wanted to evaluate the purported link between “unwantedness” and child mortality in the Matlab cohort.

From the introduction:

“Many have sought evidence to assess the contribution of family planning services to child health. If there is a link, then money spent to help people avoid unintended births becomes a public health investment relevant to child survival.”

To be clear – the money is already being spent, but a stronger evidence base means the flow continues and possibly strengthens. And, family planning groups are already tapping into the vein of “family planning saves the lives of infants” without even bringing “unwantedness” into the mix.

But, to their credit, Bishai and colleagues were willing to be surprised by their findings:

“Contrary to our expectations, we found no relationship between a woman saying she did not want any more children and the risk of death of children who were conceived and born after that intention was expressed in 1990.”

Essentially, the study found that it was impossible to find a correlation between “unwantedness” and childhood death because of selection biases – for example, “more educated women were better able to realize their goal of not having unwanted children.” Once again, we see the effect of the intimate linkages between women’s fertility plans and their current life situations that Kost and Lindberg discussed.

“The inability to use Matlab as a quasi-experiment for wantedness is disappointing because the Matlab area is one of the world’s largest populations with a history of quasi-experimentally delivered family planning services.”

Color me quasi-sympathetic. Why should “wantedness” be such an important concept to promote, when this very paper demonstrates why its entire basis is riddled with biases? The authors conclude that:

“the heightened availability of family planning and abortion for women who wanted to limit their fertility played an insignificant role in improving child survival in the Matlab area of Bangladesh in the 1990s.”

Their recommendations: family planning groups should avoid making their case based on child survival because a) selection bias will make doing so extremely difficult, and b) child survival is already going up around the world based on other things. Therefore, arguing for funding for family planning based on other things is “ultimately more sustainable.”

It occurs to me that the mood of the authors of this study seemed awfully downcast considering the outcome: “unwanted” children are not statistically more likely to die! It also seemed a bit odd that their closing remarks seemed more concerned with the future of family planning programs than the future of child health – I know that as researchers we can get extremely specialized and see the world through our at-times-myopic perspective, but the good news of better child survival ought to trump the bad news of losing a potential argument in favor of contraception and abortion, right?

In closing, these two papers are entirely typical of the “unwantedness” literature these days, and they serve as an illustration of what’s wrong with the entire field. “Unwantedness” was a concept that was conceived of and defined by the very same group of scholars that includes the authors of these papers. Its very name is highly distasteful to the very women they attempt to speak for.   It’s not even terribly effective at doing the thing it was designed to do, namely provide strong evidence to promote abortion and birth control (although even the most paltry findings can be spun into policy gold given an enabling environment). But worst of all is the fact that the very kids whose lives and, potentially, deaths, form the basis of this literature are not intended to be the beneficiaries of the policies it promotes. Instead, they are meant to be held up as an example to others of lives not worth being lived.

Next: Why a series on “unwantedness?”