Special Issue: The Future of Womens Reproductive Health: Evidence, Policy, and Politics

Analyses of Social Issues and Public Policy, Vol. 00, No. 00, 2013, pp. 1--21

Reproductive Rights and Informed Consent: Toward a More Inclusive Discourse

Debra Mollen*
Department of Psychology and Philosophy, Texas Womans University

In the past 2 years, a record number of abortion restrictions have been proposed and enacted in the United States. Such restrictions include parental notification and consent laws, mandatory waiting periods, preabortion counseling, sonogram requirements, and restrictions on late-term abortions. These restrictions are often positioned in the language of informed consent with legislators and policymakers asserting that women regret abortions, are physically and psychologically harmed by them, and are advantaged by continuing their pregnancies to term. In this paper, I position these restrictions, as well as ideas about parenting, within a framework of pronatalism, an ideology that venerates parenting as normative and desirable, and generally disparages other choices surrounding reproductive choices, particularly for women. Research about the incidence and impact of abortion on womens lives, as well as the physiological, psychological, financial, and other effects of pregnancy, childbirth, and parenting on adults well-being, is presented. Myths pertaining to abortion and parenting are explored. Recommendations for psychologists conclude the article.

In the last 2 years in the United States, a record number of abortion restrictions have been proposed and enacted in the United States (State Legislative Trends at Midyear 2012). Hsieh and Armstrong (2011) noted that the pro-life incrementalist approach of chipping away at abortion rights has been markedly successful in the past few years and that by increasing the number and type of obstacles to access abortion, opponents of abortion impede womens constitutionally protected right to choose to terminate a pregnancy. Restrictions on the access to abortion include parental notification and consent laws, mandatory waiting periods, preabortion

Correspondence concerning this article should be addressed to Debra Mollen, Department of Psychology and Philosophy, Texas Womans University, P.O. Box 425470, Denton, TX 76204 [e-mail: dmollen@mail.twu.edu].

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DOI: 10.1111/asap.12027
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2013 The Society for the Psychological Study of Social Issues

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counseling, sonogram requirements, and restrictions on late-term abortions (Gee, 2011). Such legislation has significant consequences for womens access to the full spectrum of reproductive services. For example, parental notification laws have resulted in increases in later-term abortions for young women who become pregnant at 17 and choose to wait until later in their pregnancies to terminate (Althaus, 2006), as well as prompting some adolescents to travel to neighboring states without such legislation to obtain abortions (Ralph & Brindis, 2008). Although it was not passed, the Personhood Amendment proposed in Mississippi in 2011 and similarly proposed legislation would render nearly all abortions illegal; prohibit some common forms of birth control, including IUDs and emergency contraception (EC); outlaw some fertility treatments; and treat women who obtain abortions as murderers (Armstrong, 2013; Eckholm, 2011). Indeed, an Idahoan woman was prosecuted for taking RU-486 (mifepristone, a common medication used to induce abortions) in 2011 (Hsieh & Armstrong, 2011). Undergirding the legal restrictions to abortion in a political climate increasingly hostile to women are assertions that women regret abortions, are physically and psychologically harmed by them, and are advantaged by continuing their pregnancies to term (Annas, 2007; Beckner, 2012, Manninen, 2010; Medoff, 2009). Many of the proposed and enacted legislations are based on the notion of informed consent such that pro-life advocates and lawmakers argue that all women ought to have detailed information about fetal development and about the physical and mental health risks of abortion before being able to terminate a pregnancy. Beliefs about abortion occur within the sociopolitical context of the pronatalist ideology that is currently dominant in the United States. Pronatalism promulgates the notion that a persons social worth is inherently linked to her or his ability to procreate and raise children (Parry, 2005b). People in pronatalist countries tend to believe that raising children is necessary for happiness and fulfillment, that children contribute to well-being, and that adults without children are selfish, immature, and hedonistic (Hansen, 2012). Because of the biological, social, and cultural realities of reproduction, pronatalism holds particular significance for women (Rice & Else-Quest, 2005). The desire and ability to biologically mother are generally idealized, with those who cannot or choose not to have children considered deficient, incomplete, or unfulfilled (Parry, 2005a, p. 134). Women who have abortions are often stigmatized because they violate the ideals of pronatalism (Kumar, Hessini, & Mitchell, 2009; Norris et al., 2011). Furthermore, pronatalism enacted may promote misconceptions about birth control that deter women from using it (Black, Lotke, Buhling, & Zite, 2012; Diamond-Smith, Campbell, & Madan, 2012), prompt physicians to dissuade women from obtaining permanent methods of contraception such as sterilization (Borrero et al., 2008), and discourage physicians from performing abortions (Freedman, Landy, Darney, & Steinauer, 2010). Simultaneously, although generally well-documented in the

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literature, the psychological and physical risks and financial costs associated with pregnancy, childbirth, and parenting are notably absent from much of the national discourse. Consequently, we seldom hear about informed consent for parenting, while it is commonplace in discussions about legal access to abortion. In this paper, I will present information about the prevalence of abortion, its safety, and consequences for women within the context of the pronatalist culture of contemporary United States. I will position the data about abortion and its consequences within the current political climate, exploring the assertions by prolife legislators that abortion is necessarily psychologically and physically harmful to women, as well as in light of current public opinion and related beliefs about abortion and its concomitants. Next, I will explore the literature on pregnancy, childbirth, and parenting, identifying factors that impact mortality, well-being, and relationship satisfaction for parents, particularly mothers. I conclude the paper with recommendations for psychologists regarding practice, research, public policy and advocacy, and education as they pertain to pregnancy and parenting.

Abortion Incidence, Safety, and Consequences Abortion is one of the most commonly obtained medical procedures in the United States. Between 2005 and 2008, about 22 abortions were performed for every 100 pregnancies (Jones & Kooistra, 2011). Worldwide, about 43.8 million abortions occurred in 2008; women in North America accounted for 19% of all abortions performed across the globe (Sedgh et al., 2012). In 2008, approximately 1.21 million abortions were performed in the United States (Jones & Kooistra). Kumar and colleagues (2009) noted that although 81 women experience an abortion every minute worldwide, it remains significantly underreported due to stigma and shame. In the United States, between one-third and one-half of all women will have an abortion by midlife (Henshaw, 1998). In countries where abortion is legal, it is one of the safest medical procedures practiced, especially when it is performed in the first trimester of pregnancy, as is most often the case in the United States. Rowlands (2011) reviewed mortality rates for pregnancy outcomes in the United States and reported that the risk of death for a surgical abortion performed in the first 9 weeks of pregnancy was .1 per 100,000 outcomes, compared with 7 in 100,000 for those who gave birth. In their review, Rubin and Russo (2004) remarked that legal abortion is safer than a penicillin shot (p. 73). By contrast, The World Health Organization (WHO) has estimated that nearly half of all abortions performed in 2008 worldwide were unsafe, a woman dies every 8 minutes due to the effects of unsafe abortion, and approximately 13% of maternal deaths occur annually due to the consequences of

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unsafe abortion practices (Gupta, Chauhan, Goel, & Mishra, 2011; Sedgh et al., 2012). A large body of literature regarding the consequences of abortion also reflects the psychological safety of the procedure. For example, Major, Appelbaum, Beckman, Dutton, Russo, and West (2009) reviewed 58 articles over a 19-year (19892008) period in the United States and 12 additional studies conducted internationally and concluded that the majority of adult women who terminate a pregnancy do not experience mental health problems (p. 885). Longitudinally examining the impact of abortion among 442 women, Major et al. (2000) noted that most women reported satisfaction with their decision to have abortions for the 2-year duration of the study, rates of post-traumatic stress disorder (PTSD) were actually significantly lower than in the general population, and self-esteem increased from the time period prior to the abortion through the postabortion period. Rubin and Russo (2004) noted that the greatest experience of distress occurs prior to an abortion and tends to dissipate in the days, weeks, and months that follow and other research indicates that, although variation in responses occur, the typical response to abortion is relief rather than regret (Matlin, 2003). Researchers who have examined the impact of abortion on adolescents provide similar results, namely that there is no increased risk of mental health problems following abortion among teenagers (Adler, Ozer, & Tschann, 2003), and in fact that abortion among adolescents may be correlated with increases in self-esteem and decreases in depression (Pope, Adler, & Tschann, 2001). Other studies have examined related factors and found similar results. For example, Fergusson, Boden, and Horwood (2007) investigated life outcomes for 492 young women in New Zealand and found that adolescent women who had abortions achieved better educational outcomes compared to those who had been pregnant but not had an abortion, after controlling for confounding variables including parental education, living standards, socioeconomic status, childhood behavioral problems, cognitive abilities, and school achievement. Bradshaw and Slade (2003) reviewed 8 studies that examined relationship issues and 24 studies that investigated emotional issues following an abortion and found that anxiety, depression, and overall distress tend to decrease in the month after the procedure and that for most women, romantic relationship and sexual satisfaction are largely unaffected following abortion occurrence. Myths and Misconceptions In spite of the ubiquity and safety of abortion in the United States, myths and misinformation abound and persist. The proliferation of misconceptions about abortion and other related issues (e.g., EC) may be understood in part as the results of pronatalism, which glorifies parenting in a sociocultural context that simultaneously denigrates issues related to womens sexuality (Stotland, 1996), particularly

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those involving womens agency. Norris and colleagues (2011) proffered that the current sociocultural climate that is hostile to abortion occurs in part due to the stigma that arises from womens sexual agency coupled with rejection of the mothering role. Recent research underscores that neither female college students nor medical providers are immune from the myths associated with reproductive health. For example, among a sample of 609 women attending a private university in a Mid-Atlantic state, Hickey (2009) found that while nearly all reported having heard of EC, one-third erroneously believed they needed a prescription to obtain it and almost 40% believed that EC was equivalent to RU-486. Among a group of 430 clinical practitioners in the Society for Adolescent Health and Medicine, more than three-quarters of whom had completed a fellowship in adolescent medicine, almost one-quarter underestimated the safety of medication abortion, nearly 40% underestimated its efficacy, and more than one-third overestimated the chance of serious complication resulting from medication abortion (Coles, Makino, & Phelps, 2012). Myths about abortion have intensified and persisted over the past several years. Particular myths that misinform the public also have a pronounced impact on the legislation that has been proposed and in many cases enacted, particularly since 2010 in the United States, since such myths form the crux of the argument for informed consent for American women pursuing abortion services. Examples of such myths include a disproven causative link between abortion and breast cancer, a medically unsubstantiated relationship between early fetal development and pain, fallacious claims of enduring medical complications such as impaired fertility, and erroneous assertions that abortion causes persistent deleterious mental health problems, such as suicide, traumatic stress response, and depression (Manninen, 2010; Medoff, 2009; Stotland, 1996; Weitz, 2010). Assertions that abortion causes traumatic responses in women have resulted in the propagation of a manufactured postabortion syndrome, not recognized by the American Psychological Association (APA) nor by the American Psychiatric Association, and based on claims . . . [that are] clearly unsubstantiated (Dadlez & Andrews, 2009, p. 447). Major (2003) and Dadlez and Andrews (2009) noted that researchers often distort scientific claims about the effects of abortion by inferring causation from correlation, relying on biased samples, failing to control for confounding variables, and ignoring important contextual information that may impact a womans response to abortion. In a review of 21 studies of abortion and mental health, Charles, Polis, Sridhara, and Blum (2008) found that the highest-quality studies generally reported no negative mental health outcomes, while those with significant methodological concerns did assert long-term negative mental health outcomes related to abortion. Consequences of misleading research are grave, both in terms of perpetuating myths that may result in decreased support for and increased stigmatization of abortion rights among the general public (Benson, 2010; Pew Research Center, 2009; Saad, 2009) and in terms of misinforming lawmakers who propose and enact restrictive legislation for women seeking abortions.

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Informed Consent Restrictive legislation based substantially on misinformation about abortion serves to hamper womens access to reproductive care, particularly access to abortion services. Examples of such legislation include parental notification and consent laws, mandatory waiting periods, and preabortion counseling in which women are read a state-prepared script meant to warn them of the dangers of abortion (Manninen, 2010, p. 34) and which is intended to create feelings of guilt, anxiety, and powerful emotional reactions to the recognizable form of a human fetus (Woodcock, 2011, p. 497). Pro-life legislators often propose restrictions under the semblance of informed consent. For example, Texas Governor Rick Perry, in explaining the rationale for the state-mandated sonogram law, noted, We . . . created a law that will prevent abortions in Texas until the mother has a sonogram because we believe women deserve to have all the information before making such a life-ending decision (Perry, 2012, para 11). Similarly, Associate Supreme Court Justice Anthony Kennedy noted that while no reliable data [exist] . . . it seems unexceptionable to conclude some women come to regret their choice to abort the infant . . . severe depression and loss of esteem can follow (cited in Annas, 2007, p. 2204). Neither of these assertions by policymakers is based on the most rigorous, peer-reviewed science, both are couched in the language of informed consent, and both reflect ideology designed to dissuade women from choosing to terminate their pregnancies. While the process of informed consent is grounded in respect for an individuals autonomy to freely choose and assent to medical and psychological treatment, it is evident that much of the proposed and enacted legislation that is presented as informed consent may be more accurately conceptualized as stateinduced pressure to abstain from abortion without consideration of the substantial medical and psychological science that renders legal abortion a safe procedure (Gee, 2011; Woodcock, 2011). Of particular relevance, required waiting periods, mandated education about fetal development, and other limitations and proscriptions apply only when pregnancy is to be terminated, and not in the equally critical decision to bring a pregnancy to term (Stotland, 1996, p. 243). In fact, in light of the substantial financial, medical, and psychological risks associated with pregnancy, childbirth, and parenting, when it comes to reproductive rights, the issue of informed consent appears markedly unilateral. Pregnancy, Childbirth, and Parenting Physical and Psychological Risks and Financial Costs Pregnancy is often a vulnerable time for womens health and well-being. For example, although much research reflects the problems associated with postpartum

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depression (PPD), some research has reflected higher rates of depression among pregnant women compared to women in the postpartum period (Evans, Heron, Francomb, Oke, & Golding, 2001; Joseffson, Berg, Nordin, & Sydsj o, 2001) and depression and anxiety during pregnancy are associated with adverse birth outcomes such as preterm delivery, preeclampsia, and low birth weight (Halbreich, 2005). Rates of intimate partner violence (IPV) affecting pregnant women are difficult to ascertain due to varying definitions of abuse and a lack of adequate screening by medical providers, but researchers believe it is likely underreported and have found that abusive male partners often engage in reproductive control by sabotaging contraception, forcing unwanted and unprotected sex, and controlling their partners pregnancy outcomes (Moore, Frowirth, & Miller, 2010; Silverman et al., 2010). IPV has been correlated with preterm birth and low birth weight (Shah & Shah, 2010; Taillieu & Brownridge, 2010). Globally, childbirth has consistently been one of the leading causes of death and disability for women, with one woman dying each minute of every day from consequences related to childbirth (Kantrowitz, 2007) and increasing numbers of women in the United States experiencing high rates of obstetric near-death experiences (King, 2012; Wilson & Salihu, 2007). McNeil (2011) noted that although death rates of infants, pregnant women, and young mothers have been declining for the past 12 years, the rate is slower than had been anticipated. In 2010, Amnesty International (2010) issued Deadly Delivery: The Maternal Health Care Crisis in the USA, a report based on 2 years of research. It found that women in the USA have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries (p. 1), including Greece, Germany, and Spain. Moreover, it noted that serious complications that nearly resulted in womens death increased 25% between 1998 and 2005. Its report also noted that the federal Agency for Healthcare Research and Quality (AHRQ), which is charged with managing healthcare effectiveness, has produced guidelines for maternal healthcare that fail to address the most prevalent causes of maternal death, which include embolism, hemorrhage, hypertensive disorders, and infections (2010). Outcomes for Black women and their children in the United States are particularly grave. Black women experience particularly high rates of diabetes, hypertension, and hydramnios, and Black infants are substantially more likely to experience preterm birth, low birth weight, and death compared to White infants (Zhang, Cox, Graham, & Johnson, 2011). Masho and Archer (2011) identified an intergenerational pattern, in which those Black women living in Mississippi who themselves had been born prematurely and with low birth weights were significantly more likely to give birth to infants who were similarly impacted who were at subsequent risk for death within their first year of life. The postpartum period is often a time of psychological vulnerability for women. While the majority of women experience a brief period typically referred

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to as the baby blues after giving birth, a small but sizable percentage1020% meet the criteria for a diagnosis of PPD (Nydegger, 2006; OHara & Swain, 1996; Reck, Stehle, Reinig, & Mundt, 2009). Reck et al. (2009) found a positive relationship between the baby blues and the development of PPD or an anxiety disorder. A lack of support, troubled relationship with ones partner, a previous and/or familial history of depression, difficult labor or delivery, and low income are associated with PPD (OHara & Swain, 1996). A much smaller percentage of women, 0.1.2%, experiences postpartum psychosis (Nydegger, 2006). Postnatal mood disturbances have been documented across countries and cultures (Oates et al., 2004) and among lesbian and bisexual women (Maccio & Pangburn, 2011). In spite of the prevalence of postpartum mood disorders, some researchers have expressed concern that they remain underdiagnosed, undertreated, and stigmatized (Nydegger, 2006; Wood, Middleton, & Leonard, 2010). Stigma may result in part from pronatalist ideology that venerates womens identities as mothers. Having and raising children also represents a significant financial commitment. In the most recent United States Department of Agriculture (USDA) report, Expenditures on Children by Families, Lino (2012) reviewed housing, food, transportation, clothing, healthcare, childcare, educational, and miscellaneous expenses and noted that average costs for raising children relate positively to household income, with annual costs in a household with two children ranging from $8,760 to $9,970 for those in the lowest income bracket to between $20,420 and $24,510 for those with the highest incomes. Lino also noted that expenses increase as children grow up, that expenses for raising children are highest in the urban Northeast, and that expenses for raising children comprise an even more significant proportion of incomes in households headed by single parents, which are overwhelmingly headed by women whose incomes are lower relative to two-parent families. Costs related to raising children represent between one-fifth and one-third of household expenditures for households with one child and from 38% to 57% of household expenses for families with three children (Lino). Estimating future costs for raising a child born in 2011 yields expenses through age 17 as $212,370 for those in the lowest income group to $295,560 for households in the middle income bracket, to $490,830 for the wealthiest families. Psychological Consequences of Parenting While many adults aspire to be parents and anticipate raising children to be an emotionally rich and rewarding experience, research conducted across more than half a century provides a more cautionary note (Simon, 2008). McLanahan and Adams (1989) compared 2,460 parents and nonparents in 1957 with 2,204 parents and nonparents in 1976 to determine how being a parent may have changed subjective well-being over the span of two decades and found that parents with children at home worry more, feel less efficacious and are less happy with their

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marriages than non-parents (p. 141). They speculated that the increase in divorce rates and increased opportunities for career development among women may have contributed to increased distress among parents over the course of the investigation. Perhaps increased opportunities for paid employment coupled with ongoing expectations that women perform the majority of childcare and household responsibilities contributed to these results (Ross & Willigen, 1996). In a longitudinal study, Nomaguchi and Milkie (2003) studied 1,933 adults and while they found that parents reported greater social integration than adults who did not become parents, they also determined that women who became mothers increased the number of hours of housework they performed by more than 9 hours weekly (compared with just 1 hour of housework performed by new fathers), that mothers reported more frequent disagreements with their male partners than women who did not become mothers, and that unmarried men who became parents may be particularly vulnerable to depression. While increasingly flexible gender roles have resulted in an increased valuing of family roles among men (Perrone, Wright, & Jackson, 2009), household labor remains persistently divided along traditionally gendered lines (Lachance-Grzela & Bouchard, 2009, p. 777). Using a sample of 13,017 diverse adults, including married, single, cohabitating adults who were childfree, parents, and stepparents and controlling for variables including gender, race, age, education, income, marital and employment status, Evenson and Simon (2005) found that parents reported much higher rates of depression than adults who were not parents regardless of gender and that even parents with adult children living independently did not experience improved mental health outcomes compared to adults who never had children. Through a framework of connecting perceived inequality to personal distress, Ross and Van Willigen (1996) studied 2,031 adults and controlled for age, educational achievement, relationship status, employment, and race. They found that mothers perform more than twice as much childcare than fathers and that higher rates of childcare were related to increased levels of anger, which women often expressed by yelling. Additionally, the authors found a positive relationship between the number of children in the family and anger among women. Utilizing the Day Reconstruction Method, Kahneman, Krueger, Schkade, Schwarz, and Stone (2004) studied a sample of 909 diverse employed women and found that of 16 daily activities, taking care of ones children ranked 12th in terms of enjoyment, ahead of using the computer, performing housework, working, and commuting but behind activities such as socializing, eating, exercising, preparing food, and shopping. Such data belie pronatalist ideals about the pervasive enjoyment and reward of having and raising children. As one researcher who studied the experiences of new mothers remarked as she observed a disconnect between idealized notions and the realities of motherhood, mothering consisted of much repetitive, frustrating, arduous labour that often lacked reward or recognition and

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from which it was difficult to escape because of the good mother ideal (Lupton, 2000, p. 58). Eibach and Mock (2011) conducted two innovative studies to help explain why parenting continues to be idealized in light of substantial evidence that parents do not benefit psychologically compared to those who do not become parents. They found that when participants were primed to the economic costs of having children, they tended to idealize parenting more than when they were presented with a compensating condition in which participants were told adult children provide tangible support to their elderly parents or in a control condition. In addition, when presented with the costs model, participants expressed experiencing greater enjoyment and intention of spending time with their children than in the compensating and control conditions. The authors suggested that their results could be interpreted through dissonance theory, whereby being presented with the costs associated with having children engenders discomfort that prompts participants to compensate for these costs. Perhaps reflecting the gendered implications of pronatalism, women idealized parenting more than men did across both studies.

Relationship Satisfaction and Parenting A substantial amount of literature contributes to our knowledge about relationship trajectories and satisfaction over the course of time, particularly regarding the transition to parenthood. At the 2010 APA annual convention, in a keynote speech, Daniel Gilbert acknowledged that happiness declines for men and women after the birth of the first child, a fact, he admitted, that contrasted his intuition (Munsey, 2010). Lawrence, Rothman, Cobb, and Bradbury (2010) reviewed a number of studies and noted that, although relationship satisfaction may decrease among all couples regardless of the addition of children, parenthood appear[s] to hasten marital declineeven among relatively satisfied couples who select themselves into this transition (p. 105). They noted that marital dissatisfaction seems especially pronounced for women. Cox, Paley, Burchinal, and Payne (1999) observed 136 couples during the prenatal period and again at 3, 12, and 24 months after childbirth. Participants completed measures of depression and marital self-report, as well as noting the sex of their child and whether the pregnancy was planned or unplanned. The couples also engaged in a problem-solving discussion that was recorded and analyzed. Cox et al. noted decreases in marital satisfaction over time that peaked during the third data collection period when the child was about 1 year old; they found that planned pregnancy was related to small gains in marital satisfaction, and that having a daughter and depressive symptoms in parents were associated with more marital dissatisfaction over time.

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In a 2-year longitudinal study of 71,504 married and cohabitating pregnant women in Norway, researchers assessed relationship status, relationship satisfaction, and whether or not the pregnancy was planned (Mortensen, Torsheim, Melkevik, & Thuen, 2012). They found a significant decrease in relationship satisfaction after the birth of the baby and that being married versus cohabitating was related to greater relationship satisfaction when the baby was born but appeared not to serve the same protective factor in relationship satisfaction over time. Similar to Cox et al. (1999), they found that a planned pregnancy had a small positive relationship with satisfaction. Of note, Mortensen et al. remarked that relationship dissatisfaction appears to function similarly as in the United States, in spite of the greater government support for parents in Norway compared to the United States. Lawrence, Nylen, and Cobb (2007) studied the role that expectations play in marital satisfaction among a group of 172 couples. Participants were assessed four times during the study, once prenatally within the first 6 months of marriage, once during the third trimester of pregnancy, and twice in the first year postpartum. The researchers found that marital satisfaction sharply declined in the postpartum period, that women had higher expectations for parenting than men, and that both women and men who had higher expectations for parenting, emotional support from their partners, and the division of childcare labor experienced steeper declines after the birth of their babies compared to those with lower expectations. Utilizing a sample in Sweden, Moller, Hwang, and Wickberg (2008) studied 251 women and men with infants who ranged from 2 to 20 weeks. They examined marital satisfaction, participants feelings about the division of household work, stress levels, perceptions about the infant, social support, and the transition to parenting. They found a significant relationship between womens feelings about household work and their satisfaction with their marriages. They noted a similar relationship between the division of household labor and marital satisfaction was not found for men. Studies of couples who become parents offer important information about the trajectory in the lives of couples, particularly when they are conducted longitudinally. However, they are limited when they omit a control group of similar adults who do not have children. An increasing number of studies that examine relationship satisfaction through the parenting transition are beginning to include control groups, though because many do not distinguish among those who choose not to become parents, those who do not become parents due to issues with infertility but wish to do so, and those who become parents post data collection, caution is necessary when interpreting the results. For example, Mitnick, Heyman, and Slep (2009) conducted a meta-analysis of 41 studies, only 4 of which included adults without children and did not specify whether the nonparents had chosen not to have children, and found that marital dissatisfaction decreased similarly for all couples regardless of whether they became parents during data collection.

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Somers (1993) compared 74 intentionally childfree adults with 127 parents on measures of stereotype perception, marital satisfaction, life satisfaction, and decision-making. They found that the childfree participants reported higher levels of marital satisfaction when controlling for age, and that childfree individuals evidenced substantially higher levels of cohesion compared to parents. Childfree adults also reported higher life satisfaction when controlling for religious affiliation. Shapiro, Gottman, and Carr` ere (2000) studied 82 couples for 6 years, including 39 couples who remained childfree. They conducted semistructured interviews using a coding system and administered a measure of marital satisfaction. They found that women who became mothers became significantly more dissatisfied with their marriages over time compared to women who did not. They noted that mothers dissatisfaction was often undetected until 12 years following the birth of their first child. Lawrence, Rothman, Cobb, Rothman, and Bradbury (2008) studied 156 married couples, including 52 adults who were intentionally childfree, and examined the impact of marital satisfaction and, for parents, whether their pregnancies were planned. They collected data at four points for all couples. They found couples who reported initially high marital satisfaction tended to have children earlier in their marriages and tended to plan their pregnancies and that while satisfaction declined for all couples over time, the decline was particularly steep for parents compared to nonparents. They noted, declines in satisfaction among parents observed across the transition to parenthood are a function of the transition itself . . . as opposed to those declines in satisfaction being normative for all couples married for similar lengths of time (p. 47). Similarly, Doss, Rhoades, Stanley, and Markman (2009) studied 218 couples, including 132 couples who had children during the 8 years in which the investigators collected data. In the first study with those participants who became parents, they collected data annually, including measures of marital satisfaction, relationship confidence, relationship dedication, conflict management, and problem intensity, as well as through videotaped problem-solving discussions. They noted that all measures that assessed relationship quality over the transition to becoming parents captured deterioration of the couples relationships, including marital satisfaction and, for women, problems with conflict management. A minority (7% of mothers, 15% of fathers) of parents experienced improvement in their relationships after becoming parents. Consistent with the findings of Cox et al. (1999), Doss et al. found that mothers marital satisfaction was more negatively impacted by the birth of daughters compared to sons, which may be due to the relative greater involvement by fathers with sons. They noted that, for the average couple, no aspect of the relationship functioning showed a positive effect of the transition to parenthood (Doss et al., 2009, p. 15) and found that none of the variables of interest improved for parents over time. In the second study,

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they studied the remaining 86 couples without children and found that, while relationship satisfaction generally decreased over time, there was no evidence of sudden deterioration as there had been with parents, and no reported difficulties with problem intensity and conflict management. Employing a meta-analysis, Twenge, Campbell, and Foster (2003) investigated the results of 97 studies representing 47,692 participants that included both parents and adults without children. They found that parents marital satisfaction was substantially lower than those without children and that this effect was more pronounced for womens satisfaction. In addition, consistent with the findings by McLanahan and Adams (1989), Twenge et al. noted that parenting seemed especially deleterious on marital satisfaction in studies conducted more recently, further noted that children had a particularly negative impact on parents of higher socioeconomic status, and that there was an inverse relationship between the number of children a couple had and their marital satisfaction. In sum, while most adults become parents, and while some advantages to parenthoodfor example, greater social integrationhave been observed, there exist health, financial, psychological risks and costs that may substantially impact well-being and relationship satisfaction over time. In spite of these cautionary data, there remains a lack of sustained, public, national, and disciplinary discourse on making a cogent decision to become a parent as well as a relative marginalization of those adults who intentionally refrain from becoming parents.

Myths and Misconceptions Consistent with myths and misconceptions about abortion and other forms of reproductive control (i.e., EC), myths persist about parenting as well as the decision not to have children. These may also be situated within pronatalism, as the crux of these myths lies in the assumption that parenting, particularly biological parenting, is necessarily a desirable and advantageous role for adults especially womento pursue. As such, research suggests that adults who choose not to become parents are subject to marginalization and negative stereotypes (i.e., LaMastro, 2001; Mollen, 2006; Park, 2002) compared to parents. Rothrauff and Cooney (2008) studied 2,507 adults including 289 adults without biological, adopted, or stepchildren and controlled for age, education, and income. They examined psychological well-being, generativity, the psychological need to care for and give back to the next generation (p. 148), and recalled parental affection and generosity. They found a positive direct impact of generativity on psychological well-being but no difference in this relationship for childfree adults as compared to parents. The authors concluded that parenthood appears to be only one route to achieving psychological well-being . . . [and] is not as vital for womens development and well-being as is often presumed (p. 155).

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Myths also persist regarding the empty nest syndrome, the culturally sanctioned notion that parents, particularly mothers, experience depressive symptoms when their children are grown and leave home. Research generally has not supported evidence of an empty nest syndrome, however. For example, Gorchoff, John, and Helson (2008) conducted a study of 123 married women over 18 years and examined marital satisfaction, marital quality, and the transition to the empty nest. They found that in contrast with women who had children at home at midlife, those whose children had left home experienced increased marital satisfaction and enjoyment with their partners. Similarly, Dennerstein, Dudley, and Guthrie (2002) tracked 381 Australian women over 9 years and found that participants happiness increased and reports of daily hassles decreased once the last child had left home. Studies of elderly childless people have generally found no elevated risks on measures of psychological well-being, care provision, loneliness, or depression (Chang, Wilber, & Silverstein, 2010; Zhang & Hayward, 2001). Recommendations Myths and misinformation about parenting and reproductive issues, situated within a pronatalist culture, persist and contribute to a climate in which many people become parents without being fully informed of the realities and nuances of their decisions. Additionally, the current political climate is characterized by increasing restrictions for reproductive healthcare, which decreases the likelihood that women will be able to make fully informed choices about the decision to parent. Moreover, persistent depictions and portrayals of motherhood as inherently and necessarily satisfying and gratifying likely inhibit women from being able to acknowledge the full range of complex feelings and reactions they have about their roles as parents. Psychologists are in unique positions in their roles as practitioners, researchers, educators, and advocates to help people make more informed choices about their decisions to become parents as well as to inform policy discussions and advocate for educational programs that are based on the most current, rigorous scientific findings. As such, the following recommendations are based on findings in the literature regarding sexuality, pregnancy, and parenting. 1. Psychologists can help clients, students, and others with whom they work make thoughtful, informed choices about whether, when, and how to parent by discussing the positive effects and potential costs of a myriad of choices for adults regarding their reproductive lives (APA, 2007). Options include biological, step-, surrogate, adoptive, and foster parenting, as well as refraining from parenting. Choosing to provide care to elderly people and animals, volunteering with organizations for at-risk youth, and pursuing meaningful work such as teaching may be viable options for those who wish to support others development without parenting.

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2. In their interactions with students, clients, and colleagues, psychologists should dispel myths and correct misinformation about parenting, contraception, and abortion. 3. Psychologists can conduct research to address issues that may be understudied in light of pronatalist assumptions and values, such as the benefits of choosing not to have children. Psychologists should help educate others about the ways science can be misused to undermine advances in reproductive justice and minimized to advance pronatalist positions. 4. Psychologists can advocate for comprehensive sexuality education programs that teach young people how to make thoughtful, informed choices about sexuality. Research has shown that abstinence-only education has little positive impact on sexual behaviors among adolescents and may be associated with higher rates of sexual risk-taking behaviors, while adolescents who receive comprehensive sexuality education are less likely to become pregnant as teenagers, more likely to delay sexual activity with partners, and more likely to use condoms and other contraception (APA, 2005; Kirby, 2008; Kohler, Manhart, & Lafferty, 2008; Perrin & DeJoy, 2003). 5. Support programs that help people plan and space their pregnancies. Currently, nearly half (49%) of all pregnancies in the United States are unplanned (Guttmacher Institute, 2012). Unplanned pregnancies are related to higher rates of maternal depression, lower levels of happiness, and higher levels of stress; delayed prenatal care; and poorer outcomes for children (Bouchard, 2005; Gipson, Koenig, & Hindin, 2008; Lachance-Grzela & Bouchard, 2009). The most effective family planning programs include widespread access to affordable and safe contraception (Mwaikambo, Speizer, Schurmann, Morgan, & Fikree, 2011). 6. Spearhead comprehensive programs that help couples manage not only the process of caring for a newborn, but also navigating the transition to parenting as individuals and as a couple. While childbirth classes have become normative in the United States and include information about labor and delivery, most fail to address mens or womens adjustment to pregnancy and parenthood or changes in marriage associated with the birth of a child (Schulz, Cowan, & Cowan, 2006, p. 21). Some promising studies that evaluate such interventions indicate their initial effectiveness (Cowan & Cowan, 1995; Schulz et al.; Shapiro, Nahm, Gottman, & Content, 2011). Conclusion The current political and social landscape in the United States reveres biological parenting without promoting a reasoned discussion about the physiological, psychological, financial, and other effects of pregnancy, childbirth, and

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parenting on adults lives. Simultaneously, access to abortion has been hampered by restrictions often presented in terms of informed consent but that are not based on science. Particularly as barriers to reproductive rights continue to escalate, psychologists are called to take action to support the full range of options available to women and to champion the cause of reproductive justice.

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DEBRA MOLLEN is Associate Professor in Counseling Psychology and Affiliate Faculty in Womens Studies at Texas Womans University in Denton, Texas. She earned her PhD. in Counseling Psychology with a minor in Gender Studies from Indiana University. Her research interests include womens sexuality with emphases on childfree women and reproductive justice; multiculturalism; and professional development and training issues for psychologists. She is Chair-Elect for APA Division 17s Section for the Advancement of Women.