Study reveals hidden reproductive pressure facing pregnant teens

Dr. Cheryl Kovar, an East Carolina University associate professor of nursing, is working to establish a baseline understanding of a bedeviling social dilemma that isn’t a common topic of discussion: reproductive coercion among 14- to 19-year-old pregnant or parenting girls.

Why, Kovar wants to know, do adolescent girls make the decisions they do surrounding reproduction, specifically birth control sabotage, pregnancy pressure from a male partner or others, and pregnancy outcomes? In short, what percentage of girls are being unduly influenced to get pregnant, and once pregnant are they being induced to either keep or end the pregnancy?

The Problem

A National Institutes of Health study found that reproductive coercion (RC) is more common among less-educated women and in non-white mothers. The study also found that RC occurs in 8-16% of populations in the U.S., which tracks with the findings from Kovar’s work.

Dr. Cheryl Kovar, who was recently inducted as a fellow of the American Academy of Nursing, has concluded a study on reproductive coercion among girls in North Carolina.

In a 2020 study of reproductive coercion in women 18 to 26, Kovar and a colleague from the Indiana University School of Medicine found an 8% prevalence of reproductive coercion among young adult women in North Carolina and Indiana. That cohort had results that were within the range that she expected.

For her most recent study, Kovar purposefully selected five North Carolina counties, spanning rural communities to urban centers, to prevent skewing of results due to economic or other social factors.

Many girls in difficult situations, Kovar has found, cling to the love they know they can get from a child of their own, regardless of how poorly they may be treated by the baby’s father.

Thirteen-year-old bodies are physically able to have babies, Kovar said, but are 13-year-old girls socially and psychologically prepared to be mothers? Not likely.

When young mothers make the decision to have and keep a child, Kovar said her peers can sometimes lose perspective. Very young new parents act like very young new parents: not understanding relatively basic caregiving for newborns or spending more time on their phones than holding the baby.

“I feel like I’m giving voice to those who don’t have one. We can’t make judgments. We have a new family unit here, and we’ve got to support them with equity, fairness, love and compassion,” Kovar said.

Study Findings

There is a difference between reproductive coercion and intimate partner violence, Kovar stressed.

“Intimate partner violence is just that, violent.” Kovar said. “Reproductive coercion is all about power and control within the relationship and nonviolent.”

Kovar said one of the challenges with pregnancies in girls just reaching their teens is that they are more likely to get pregnant again before they turn 20. Life for teen mothers is challenging, and with every subsequent pregnancy their lives can be that much harder. The goal, Kovar said, is to prevent the first pregnancy.

“But if you can’t prevent the first, let’s prevent the second. Or third,” Kovar said.

Kovar said her recent study — to her knowledge the first to be conducted with this population of pregnant and/or parenting adolescent females — ended up with some surprising results.

Contraceptive sabotage is usually the largest occurrence, but study participants reported that happening less than in previous studies. Pregnancy pressure was a bit higher, but the real heartbreak, Kovar said, was the number of respondents who reported pregnancy outcome pressure.

Kovar’s findings support past research into reproductive coercion and do not support some other broad assumptions. The prevalence of reproductive coercion, 13% in her study, was within the published range of 12-19% among adolescent females ages 14-19 years, and white girls reported higher rates of coercion than Black girls, despite more Black girls participating in the study.

The study also reaffirmed that most respondents reporting reproductive coercion were partnered with the baby’s father, which is outside of the norm for most teenage relationships.

Her 2020 study on reproductive coercion returned intuitive results — women who reported coercion were less likely to be happy than their peers. Kovar’s newest findings are puzzling. Her respondents said they were fairly or very happy despite the power and control dynamics at play in their relationship. She feels it might have something to do with a sense of stability and love.

“I think they’re equating having a place to live and a roof over their head for them and their baby as being a positive, so they’re happy. They’re not out on the street,” Kovar said.

Enlisting Community Support to Find Solutions

Kovar said her research would be nearly impossible if not for the strong relationships she has with health departments across the state.

On a recent Friday afternoon, Kovar finished a final draft of her report for the reproductive coercion study and sent it to her public health partners. By Monday morning, she already had responses with public health experts ready to use her findings to develop interventions that could be put into effect immediately.

Kovar’s study reflected the need in communities to address issues of disparity — in terms of wealth, class, and access to resources. She formed an advisory board which consisted of several people representing counties that had signed on to support her research. This led to the identification of a site champion, one person willing to lead efforts for their community in each of the five counties.

“We’ve now established that there’s a prevalence of reproductive coercion in pregnant and parenting adolescent females,” Kovar said.

Larger universities and research institutions have resources and relationships that make securing funding for studies easier. For universities like ECU, that are on the rise in terms of stature in the research circles, Kovar’s interpersonal relationships with peers at large universities and in health departments in rural North Carolina have been instrumental in her success.

Kovar’s next study will use an evidence-based intervention developed by former Ohio State University faculty member Dr. Bernadette Melnyk’s cognitive-behavioral skills building program — Creating Opportunities for Personal Empowerment, or COPE — with the girls represented in her study. The program offers a multi-step model that helps adolescents improve behavioral health and lifestyle outcomes.

“This model does not specifically address reproductive coercion, and maintaining fidelity to the model is critical. In order to address this issue, I’m going to ask her if we can include some information identifying reproductive coercion and its three components for the girls who have babies,” Kovar said.

Kovar said the findings from this study didn’t happen overnight. The work has taken years, mostly to build relationships with public health department leaders whose trust she gained.

Dr. Linda Bolin, Ph.D. program director and interim chair for the Department of Nursing Science, said nursing is unique among academic research efforts. Inherent in nursing is a dichotomy — care for the patient requires an incredibly broad approach, but within a nearly unlimited sea of human experience nurses can focus their research on very niche groups within a community.

“You take the basics for your BSN, and then once you get into your area of specialization and get into your area of nursing research, it’s just wide open,” Bolin said.

Bolin said health care research is increasingly a team effort, combining professionals from a range of backgrounds and specialties, and having a nurse as part of the team increases its productivity.

“Nurses are the consistent part of the health care team. We are the root of the tree, and everyone branches off our work,” Bolin said.

Kovar understands that she won’t be able to solve the challenge of reproductive coercion in young girls, but she hopes her research will at least give her peers in health care and public health a better understanding of the problems they face, and maybe a few ideas about how to lend a helping hand.

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