Race/Ethnicity and Pregnancy Decision Making: The Role of Fatalism and Subjective Social Standing
Rates of unintended pregnancy in the United States differ by race and ethnicity. We examined whether these differences might be explained by maternal fatalism and subjective social standing. We used data from 1070 pregnant women of sociodemographically diverse backgrounds enrolled in prenatal care in the San Francisco Bay area. Logistic regression was used to explore the relationship between attitude variables and a measure of pregnancy decision making ("not trying to get pregnant"). African American women were more likely than others to report not trying to get pregnant with the current pregnancy (adjusted odds ratio [AOR] 2.04, 95% confidence interval [95% CI] 1.22-3.43, p = 0.007). Higher subjective social standing was associated with a lower likelihood of not trying among white and U.S.-born women only (AOR 0.67, p = 0.001 and AOR 0.75, p < 0.001, respectively. Fatalism was associated with not trying in bivariate but not multivariable analyses. In this population, the likelihood of reporting not trying to get pregnant was higher among racial/ethnic minorities regardless of subjective social standing. Programs aimed at reduction in unintended pregnancy rates need to be targeted to a broader population of women.
Race=Ethnicity and Pregnancy Decision Making:
The Role of Fatalism and Subjective Social Standing
Allison S. Bryant, M.D., M.P.H.,
Sanae Nakagawa, M.A.,
Steven E. Gregorich, Ph.D.,
and Miriam Kuppermann, Ph.D., M.P.H.
Objective: Rates of unintended pregnancy in the United States differ by race and ethnicity. We examined
whether these differences might be explained by maternal fatalism and subjective social standing.
Methods: We used data from 1070 pregnant women of sociodemographically diverse backgrounds enrolled in
prenatal care in the San Francisco Bay area. Logistic regression was used to explore the relationship between
attitude variables and a measure of pregnancy decision making (‘‘not trying to get pregnant’’).
Results: African American women were more likely than others to report not trying to get pregnant with the
current pregnancy (adjusted odds ratio [AOR] 2.04, 95% conﬁdence interval [95% CI] 1.22-3.43, p¼0.007).
Higher subjective social standing was associated with a lower likelihood of not trying among white and U.S.-
born women only (AOR 0.67, p¼0.001 and AOR 0.75, p<0.001, respectively. Fatalism was associated with not
trying in bivariate but not multivariable analyses.
Conclusions: In this population, the likelihood of reporting not trying to get pregnant was higher among
racial=ethnic minorities regardless of subjective social standing. Programs aimed at reduction in unintended
pregnancy rates need to be targeted to a broader population of women.
Unintended pregnancy is a major public health problem
in the United States; in 2001, approximately one half of all
pregnancies were either unwanted or mistimed, and, overall,
these rates have changed little over the past two decades.
Women belonging to racial=ethnic minority groups are gen-
erally at greater risk of unintended pregnancy, as are women
who are poor, young, and single and who have lower levels of
Some, though not all, studies have demon-
strated an increased risk of perinatal outcomes, such as low
birth weight, preterm birth, and lower breastfeeding rates,
associated with unplanned pregnancies.
Women with un-
intended pregnancies are less likely to seek early prenatal care
and may have health behaviors during pregnancy that are
associated with adverse outcomes.
There are also nu-
merous social and economic costs, at the personal and com-
munity levels, to unplanned pregnancy.
Although efforts to decrease rates of unintended pregnancy
through increased contraceptive access and education have
been modestly successful, the risk of unplanned pregnancy
among minority women remains particularly high.
2001, 69%, 48%, and 42% of all pregnancies to African
American, Latina, and white women, respectively, were un-
Relatively few studies have investigated the role of
attitudes and social standing in the prediction of unintended
Reproductive decision making and pregnancy intent are
complex constructs; one element of such decision making
involves conscious behaviors on the part of women and their
partners. Here, we explore whether a woman reports having
tried to get pregnant with her current pregnancy as one di-
mension of pregnancy intendedness.
We sought to examine if subjective social standing or the
endorsement of a speciﬁc maternal attitude, namely, fatalism,
mediates differences in the risk of not having tried to get
pregnant among women of different race=ethnicities enrolled
in prenatal care, as a means to explain the prevalent racial=
ethnic disparities in unintended pregnancy. We have previously
demonstrated that fatalism, or a belief that outcomes are pre-
determined or controlled by external forces, is associated with
and, in some cases mediates, various reproductive values and
We, therefore, set out to test the hypothesis that
the decision by a higher proportion of women reporting not
Department of Obstetrics, Gynecology and Reproductive Sciences,
Medical Effectiveness Research Center for Diverse Populations,
Department of Medicine, and
Department of Epidemiology and Biostatistics, University of California, San Francisco, California.
JOURNAL OF WOMEN’S HEALTH
Volume 19, Number 6, 2010
ªMary Ann Liebert, Inc.
having tried to get pregnant among African Americans would
be mediated or modiﬁed by higher levels of fatalism, believing
that women whose locus of health control is more external than
internal would be less likely to report proactive reproductive
In addition, we tested the hypothesis that the effect of
subjective social standing, a measure of relative social status,
on trying to get pregnant would vary by race=ethnicity.
Subjective social standing has been measured in diverse
populations, and has been found to be associated with self-
physiological and psychological functioning,
depression, and chronic disease.
It often acts independently
of other more traditional measures of socioeconomic status
(SES), such as income and education.
Stewart et al.
proposed that examination of nontraditional measures of SES
might be prudent among their population of young pregnant
women, in whom educational attainment to date and current
income might not accurately describe true SES. They found
relatively low correlations between subjective social standing
and maternal income or education, with higher correlations
among white women. Given the known associations between
SES and unintended pregnancy, we hypothesized that lower
subjective social standing would be an independent predictor
of our outcome of interest.
Materials and Methods
We used baseline data collected as part of a longitudinal
investigation of predictors of prenatal test use, in which a
diverse group of pregnant women were recruited for partic-
ipation from obstetrical clinics and practices in the San Fran-
cisco Bay area in 1997 and 1998.
The study was approved by
the Committee on Human Research at the University of Ca-
lifornia, San Francisco, the San Francisco General Hospital,
and Kaiser Permanente Northern California Institutional Re-
As part of the original study, women completed a demo-
graphic and attitudinal questionnaire that included a number
of items related to reproductive history. The questionnaire
was completed in written form by the participant or was
administered orally by ﬂuent bilingual interviewers if the
participants preferred. The outcome of interest, ‘‘not trying to
get pregnant,’’ was assessed with the following question:
How difﬁcult was it for you to get pregnant? Responses in-
cluded needed medical assistance, difﬁcult, easy, and was not
trying. To measure fatalism, a two-item scale measured cul-
tural, religious, and fatalistic attitudes. Respondents were
asked to rate the following statements on a 7-point scale
(range 0–6, from strongly disagree to strongly agree): ‘‘God
would not give me more than I can handle,’’ and ‘‘In my
culture, we learn to accept what we are given.’’ Scale scores
were calculated by averaging each respondent’s item score.
These items have been used previously in multiple studies
among diverse populations.
To measure subjective social standing, we used a social
ladder, in which participants were asked to place an X on the
rung of a graphic representation of a ladder with a 1–9 rung
scale, where they think they stand relative to other people in
the United States. This tool was created as a measure of sub-
jective social standing and has been shown to be associated
with self-rated health, physiological functioning, and psycho-
logical functioning in women from diverse backgrounds.
The top rung of the ladder (9) is meant to represent those in the
United States who are the best off, with ‘‘the most money, the
most education and the most respected jobs.’’ The bottom rung
(1) represents those who are the least well off, with ‘‘the least
money, the least education, and the worst jobs or no job.’’
cases in which women marked spaces between rungs, a mid-
point score was assigned to approximate the position of the X
on the ladder (e.g., 5.5).
The primary outcome for this analysis was the response
‘‘not trying to get pregnant’’ to the question: How difﬁcult was
it for you to get pregnant? The primary predictor was ma-
ternal self-reported race=ethnicity. We used logistic regres-
sion models to estimate the effect of sociodemographic
characteristics, including subjective social standing, repro-
ductive history, and attitudes on the likelihood of the out-
come. Variables were considered to be signiﬁcant predictors
of the outcome if their effects had pvalues of <0.05. If fa-
talism or subjective social standing proved a signiﬁcant
predictor in the adjusted model, we then tested its potential
as a mediator by exploring the signiﬁcance of the indirect
effect of race=ethnicity on the outcome, via the predictor in
question. Lastly, we tested whether either fatalism or sub-
jective social standing modiﬁed the effect of race=ethnicity
on ‘‘not trying to get pregnant’’ by modeling interaction
terms. When a signiﬁcant interaction ( p<0.10) was detected,
the effect of the attitude within each race=ethnicity group
was reported separately.
Because the data contained missing values, each substan-
tive model was ﬁt to 20 multiply imputed datasets created
with SAS PROC MI (SAS Institute, Cary, NC). Imputed values
for binary and categorical variables were rounded and trun-
cated to the nearest category.
All covariates were included
in the imputation models, in addition to interaction terms
between race=ethnicity and fatalism, healthcare distrust,
happiness about the pregnancy, abortion view, unintended
pregnancy, subjective SES, and religion. Values for the re-
productive history variables were highly skewed and were
log transformed before imputation and back-transformed for
analyses. All parameter estimates and signiﬁcance tests were
calculated by combining results across the imputed 20 data-
All analyses were conducted using SAS v.9.1.
We used data from the 1070 women who reported that their
racial=ethnic category was white (32.0%), Asian (27.0%), La-
tina (22.6%), or African American (18.4%). Those choosing the
‘‘other’’ category (n¼11) were excluded. The mean age was
32.7 years (range 16–47 years). The mean gestational age at
enrollment was 17.0 5.8 weeks. Table 1 presents socio-
demographic, reproductive history, and attitudinal charac-
teristics of the overall population, and by the outcome of
Over a third (34.6%) of the women in this cohort indicated
that they had not been trying to become pregnant with
the current pregnancy. The proportion was highest among
1196 BRYANT ET AL.
African Americans (62.1%) and lowest among white women
(23.1%). African Americans represented 18.3% of the total
sample yet accounted for 32.9% of women who indicated that
they were not trying to get pregnant. As compared with all
other women, women who were not trying to get pregnant
had higher fatalism scores ( p<0.001) and lower levels of
subjective social standing ( p<0.001) (Table 1).
Point estimates for the adjusted effects of race=ethnicity on
the outcome are shown in Table 2. All models were adjusted
for the covariates presented, in addition to marital status,
education, occupation, and income. Signiﬁcant predictors of
not trying to get pregnant include maternal age, race=
ethnicity, nativity, religion, ever having had a live birth, and
subjective social standing. In adjusted models, fatalism was
not signiﬁcantly associated with not trying to get pregnant;
thus, we determined that it was unlikely to mediate the effect
of race=ethnicity on this outcome. Of note, the measure of fa-
talism was highly associated with the outcome in unadjusted
analyses; however, when we adjusted for race=ethnicity, the
effect of fatalism was statistically nonsigniﬁcant.
When we tested for effect modiﬁcation among race=
ethnicity, fatalism, and subjective social standing, a signiﬁcant
interaction between race=ethnicity and subjective social
standing ( pvalue for the interaction term ¼0.04) emerged.
Speciﬁcally, we found that subjective social standing was
signiﬁcantly associated with the ‘‘not trying to get pregnant’’
response only among white women. For these women, each
step up the social ladder was associated with a lower odds of
this outcome (adjusted odds ratio [AOR] ¼0.67, 95% conﬁ-
dence interval (CI) 0.54-0.82, p¼0.001). For women of other
race=ethnicities, however, there was no signiﬁcant effect of
subjective social standing (Table 3). To further explore the role
of subjective social standing on ‘‘not trying to get pregnant,’’
we performed a post hoc analysis and found a signiﬁcant in-
teraction between being U.S.-born and subjective social
standing in predicting the outcome ( p¼0.02). That is, among
women born in the United States, increased subjective social
standing was associated with decreased risk of not trying to
get pregnant (AOR 0.75, 95% CI 0.66-0.85, p<0.001), whereas
for foreign-born women, there was no relationship between
subjective social standing and not trying (AOR 0.92, 95% CI
Despite attempts to expand access to contraceptive tech-
nologies and to encourage family planning, unintended
pregnancy remains a major public health problem in the
Table 1. Study Population
Not trying to get pregnant
Maternal age 32.7 0.2 31.0 0.4 33.7 0.2 <0.001
African American 18.3 32.9 10.6
Asian 27.0 24.9 28.1
Latina 22.6 20.7 23.7
White 32.0 21.4 37.6
Less than high school education 12.8 15.6 11.2 <0.001
Family income <$25,000 per year 34.8 44.6 29.6 <0.001
Occupational category <0.001
Unemployed 5.9 8.5 4.5
Blue collar 6.9 7.0 6.8
Less skilled administrative 13.9 15.5 13.1
More skilled administrative 21.1 27.1 18.0
White collar 34.7 31.9 36.1
Professional 17.5 10.0 21.4
Married or living with partner 83.8 74.4 88.7 <0.001
U.S. born 56.1 64.9 51.5 <0.001
Religious afﬁliation <0.001
Catholic 32.0 29.3 33.5
Christian (other than Catholic) 24.8 34.9 19.5
Other religion 15.4 10.4 18.0
No religious afﬁliation 27.7 25.5 29.0
Previous pregnancy 73.3 74.9 72.4 0.38
Previous live birth 49.9 56.9 46.2 <0.001
Previous abortion 50.2 53.8 48.3 0.13
2.0 0.05 3.0 0.10 2.5 0.07 <0.001
Subjective social standing
5.1 0.06 4.7 0.1 5.4 0.07 <0.001
Values are listed as percent of total (column percent) or mean standard error.
Values range from 0 (least fatalistic) to 6 (most fatalistic).
As measured by the social ladder tool. Values range from 1 (lowest rung on ladder, or lowest relative social standing) to 9 (highest rung on
ladder, or highest relative social standing).
MATERNAL ATTITUDES AND PREGNANCY DECISION MAKING 1197
United States. African American women are at particularly
high risk compared with women of other races and ethnicities.
In our study population of pregnant women already enrolled
in antenatal care, which primarily consists of women who
have elected to continue their pregnancy, we were able to
conﬁrm this disparity in one behavioral dimension of preg-
nancy intent—whether or not the woman was trying to get
Although we expected that higher levels of fatalism might
mediate the higher rate of not trying to get pregnant noted
among African American women, we were not able to dem-
onstrate this in this study, nor did we see interactions in these
relationships by race=ethnicity. This is in contrast to our
previous ﬁndings in prenatal testing, in which levels of fa-
talism were found to mediate differences in testing strategy
between women of different races=ethnicities.
Of note, we
regard with interest the mitigation of the signiﬁcant effect of
fatalism on the outcome once race=ethnicity was accounted
for. Our ﬁndings might suggest that the effect of race=
ethnicity is mediated by a construct related to fatalism, al-
though one that was not measured in this study. Perhaps with
a measure of fatalism more speciﬁcally related to pregnancy,
we might have discovered a stronger effect or evidence of
We did observe that subjective social standing was an in-
dependent predictor of not trying to get pregnant in our
overall prediction model. However, further exploration re-
vealed that this construct was only a signiﬁcant predictor
among white women and among women born in the United
States. This ﬁnding is consistent with a prior study that
documented that after adjustment for objective measures of
SES (such as income and education), subjective social stand-
ing was related to self-rated health among white women but
not among African Americans or Latinas.
should be taken into account as we examine target popula-
tions’ efforts to reduce unintended pregnancy. Many pro-
grams are aimed toward women of lower SES via public
ﬁnancing streams, but more attention should be paid to racial
and ethnic minorities of higher social standing. Although they
are not typically the focus of public health campaigns, these
women remain at higher relative risk of unintended preg-
nancy than others and may need to be considered separately
as health messages are developed and marketed. Similarly, in
the clinical arena, patients who seek care should be evaluated
for their individual risk of unintended pregnancy regardless
of their SES, social standing, or insurance type.
The current study is not without its limitations. The study
sample was drawn from the San Francisco Bay area and
was limited to women enrolled in prenatal care; thus, this
group may not be representative of the entire population of
reproductive-aged women at risk for unintended pregnancy
in this country. However, we believe our study provides a
unique view of a special population not often studied in ex-
aminations of unintended pregnancy, speciﬁcally, women
who have elected to continue their pregnancies. Women who
have unintended pregnancies but choose to continue their
pregnancies should be of particular interest to clinicians and
public health practitioners. These women, speciﬁcally those
with unwanted pregnancies (as contrasted with mistimed
pregnancies), have been shown to have increased risks of
high-risk behaviors during pregnancy, such as use of tobacco,
alcohol, and illicit drugs, coming late to prenatal care, and not
They are also probably more likely to have
unintended pregnancies in the future. Identiﬁcation of these
women during the course of pregnancy may provide valuable
opportunities for counseling and intervention.
In terms of reproductive history, the proportion of women
with unplanned pregnancies in our cohort is similar to other
quoted U.S. rates, although the proportion of women re-
porting having undergone an abortion in this cohort is higher
than the U.S. average.
The initial design of the study sought
to oversample women from minority backgrounds, which
may partly account for the higher abortion rate, but the re-
cruitment of this diverse sample is also clearly a strength of
this study population. The parent investigation was designed
to study prenatal testing decision making, and, thus, we were
limited to those attitudes explored as part of this original re-
Table 2. Multivariable Prediction Model
for Not Trying to Get Pregnant
(95% CI) pvalue
African American 2.04 (1.22-3.43) 0.007
Asian 1.61 (1.02-2.54) 0.042
Latina 0.73 (0.43-1.25) 0.26
Maternal age, years <0.0001
17 7.06 (1.48, 33.6) 0.014
18–24 3.47 (2.13, 5.67) <0.001
25–29 1.76 (1.18, 2.62) 0.005
U.S. born 1.64 (1.11, 2.43) 0.013
Less than high school
1.20 (0.70, 2.04) 0.51
Married or living with
0.69 (0.44, 1.09) 0.11
Occupational category 0.94
Unemployed 0.99 (0.42, 2.30) 0.97
Blue collar 0.96 (0.42, 2.22) 0.93
Less skilled administrative 0.99 (0.49, 1.98) 0.98
More skilled administrative 1.23 (0.67, 2.25) 0.50
White collar 1.26 (0.709, 1.94) 0.56
Family income <$25,000 per
1.58 (0.76, 3.28) 0.57
Religious afﬁliation 0.006
Catholic 0.92 (0.60, 1.42) 0.72
Other Christian 1.22 (0.79, 1.87) 0.37
Other religion 0.50 (0.30, 0.83) 0.007
No religion 1.00
Previous pregnancy 0.98 (0.64, 1.51) 0.87
Previous live births <0.0001
1 1.47 (0.97, 2.23) 0.07
2 3.53 (2.16, 5.77) <0.0001
Previous abortion 1.20 (0.83, 1.73) 0.33
0.99 (0.90, 1.08) 0.81
Subjective social standing
0.82 (0.74, 0.91) 0.0001
Adjusted for all other covariates in the model.
AOR associated with 1 point increase in 7-point scale item, where
0¼least fatalistic and 6 ¼most fatalistic.
AOR associated with 1 point increase in 9-point scale item, where
1 represents the bottom rung of the social ladder tool and 9
represents the top rung.
AOR, adjusted odds ratio; CI, conﬁdence interval.
1198 BRYANT ET AL.
Our outcome measure has not been validated previously,
nor did the retrospective nature of the study allow for a vali-
dation within this population. We believe, however, that the
phrasing of the survey question allowed for an unbiased ac-
count of behaviors and planning related to the index preg-
nancy. We did note a correlation between the outcome as
measured and women reporting being ‘‘very happy’’ about
their pregnancy (AOR, 95% CI for the outcome 0.46, 0.25-0.86
among women who were ‘‘very happy’’), a suggestion that
our measure may track with intent. Santelli et al.
reported a moderate correlation between trying to get preg-
nant and happiness about pregnancy and described ‘‘trying’’
as one cognitive factor predictive of pregnancy intent.
measures have endured varied criticisms of their ability to
measure unintended pregnancy as well, and currently there is
no gold standard for the determination of pregnancy in-
Many measures in current use are quite transparent
in their attempts to glean information on wantedness of
pregnancies; responses to these measures may be skewed
toward social desirability. The measure used in the current
study may carry an advantage in that it would seem to be
probing a more clinical and behavioral construct. It may
prove to be the case that pregnancy planning is not a mean-
ingful construct for all women, and further exploration of this
within diverse populations is warranted.
Continued efforts to develop effective means of preventing
unintended pregnancy are needed. Improving the ability of
all women to seek healthcare outside of the context of preg-
nancy to promote health, prevent disease, and allow for
healthy pregnancy timing will be key to improving the health
of women and children in the United States. Our ﬁndings
suggest, however, that the populations of women tradition-
ally thought of as being in need of services may not represent
the entire population of women at risk for unplanned preg-
nancy. Racial and ethnic minorities, regardless of subjective
socioeconomic standing, are at high risk of unintended preg-
nancy. Expanding access to family planning for low-income
women is clearly laudable, but limiting efforts to these strat-
egies will not serve all women at risk. Future investigations
should continue to focus on the role of cultural and repro-
ductive attitudes on unintended pregnancy risk to allow for
better tailored behavioral and educational interventions.
A.S.B. is supported by the National Institutes of Health
grant 1 KL2 RR024130-01 as a UCSF Multidisciplinary Clinical
Research K12 Scholar and by the Robert Wood Johnson
Foundation as a Harold Amos Medical Faculty Development
This research was supported by grants from the National
Center for Human Genome Research (R01 HG01255) and the
Agency for Healthcare Research and Quality (P01 HS 10856).
The authors have no conﬂicts of interest to report.
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Address correspondence to:
Allison S. Bryant, M.D., M.P.H.
Department of Obstetrics, Gynecology
and Reproductive Services
University of California, San Francisco
505 Parnassus Avenue, Box 0132
San Francisco, CA 94143-0132
1200 BRYANT ET AL.