Partner Disengagement from Pregnancy and Adverse Maternal and Infant Outcomes

Abstract

Objective:

To assess whether partner disengagement from pregnancy is associated with adverse maternal and infant outcomes.

Materials and Methods:

We analyzed data from the 2006–2007 Canadian Maternity Experiences Survey, comprising a cross-sectional representative sample of 6,421 childbearing women. Multiple logistic regression assessed the association between adverse outcomes and three indicators of partner disengagement: (1) partner did not want the pregnancy, (2) partner argued more than usual in the year prior to the baby's birth, and (3) partner was absent at the delivery.

Results:

Of all respondents, 3.8% had partners who did not want the pregnancy, 16.1% argued more than usual with their partner in the past year, and 7.6% had partners who were absent at the delivery. Women whose partner did not want the pregnancy were more likely to report intimate partner violence (IPV) (adjusted odds ratio [AOR] 3.55; 95% confidence interval [95% CI] 2.36–5.14), elevated depressive symptoms in the extended postpartum period (AOR 2.56, 95% CI 1.70–3.83), and nonroutine child healthcare visits after birth (AOR 1.54, 95% CI 1.13–2.11). Women whose partner argued more in the past year had higher odds of IPV (AOR 4.82, 95% CI 3.69–6.30), elevated depressive symptoms in the extended postpartum period (AOR 3.63; 95% CI 2.84–4.64), and nonroutine child healthcare visits (AOR 1.49, 95% CI 1.26–1.77), after adjustment for potential confounders.

Conclusions:

Partner disengagement is common and is associated with adverse maternal and infant outcomes. Affected women may benefit from special assistance during pregnancy and after delivery.

Introduction

The perinatal period is a critical transitional time that can have significant effects on the mother and her child's well-being beyond pregnancy. Not only are the physical changes accompanying pregnancy substantial but also several psychosocial vulnerabilities often are revealed.¹ Research has often focused on maternal prenatal care and behaviors and their influence on pregnancy health and adverse outcomes. However, interpersonal relationships during the prenatal and postnatal period can profoundly affect maternal psychosocial well-being.^2

–6 Family structure has changed over the last century, and an increasing proportion of babies are born to one parent or cohabitating couples;⁶ accordingly, interest has increased in the study of paternal involvement in pregnancy and its influence on pregnancy outcomes. Recent population-based research in the United Kingdom suggests that a large majority of fathers report being happy in response to their partner's pregnancy and that paternal engagement with pregnancy is positively associated with several indicators of healthy childbearing.⁴ In contrast, partner disengagement may be associated with higher maternal stress, escalation of conflict,^7,8 substance use,⁵ and maternal depressive symptoms.^3,5 Little research has been done on the association between partner disengagement and maternal and newborn morbidity, as well as healthcare seeking behaviors.

In this study, we analyzed data from the 2006 to 2007 Canadian Maternity Experiences Survey (MES), a nationwide sample representative of childbearing women in Canada. The objective of this study was to evaluate the association between partner disengagement from pregnancy and adverse maternal and newborn outcomes assessed in the MES. We used three indicators of partner's disengagement: (1) not wanting the pregnancy, (2) arguing more than usual in the year prior to the baby's birth, and (3) absence at the baby's birth.

Materials and Methods

Procedures and participants

This study utilized data from the MES, conducted by the Public Health Agency of Canada. The MES is a national survey designed to provide information on Canadian women's knowledge, experiences and practices during pregnancy, delivery, and the early and extended postpartum period.⁹ A stratified random sample of 8,542 women was drawn from a sampling frame of 58,972 women who had completed the 2006 Canadian Census of Population and were 15 years of age and over, had delivered a live singleton infant in the 3 months prior to the Census, and were living with their newborn infant at the time of the interview. The survey was conducted by trained female callers from Statistics Canada through computer-assisted telephone interviews, and over 96% of mothers were interviewed between 5 and 9 months postpartum, with a final response rate of 78% (n = 6421). Details of the survey methodology and data quality are reported elsewhere.^9

–12 A total of 71 women with unknown marital status, widowed, or with no partner around the time of labor/delivery were excluded, leaving 6,350 mother-child pairs for analysis, weighted to represent 75,793 new mothers across Canada.

The current study was approved by St. Michael's Hospital Research Ethics Board and the Research Data Centre Access Granting Committee of Statistics Canada.

Variables

We defined characterized partner disengagement using three indicators as follows: (1) Having a partner who did not want the pregnancy (“In the 12 months before the baby was born… your husband or partner said he did not want you to be pregnant?”), (2) If the woman and her partner argued more than usual in the past year (“In the 12 months before the baby was born…you and your husband or partner argued more than usual?”), and (3) If the woman's partner was absent during the birth of the baby (“Did you have your husband or partner with you during the birth of your baby?”).

Study outcomes included four measures of maternal psychosocial and physical morbidity and four measures of newborn healthcare use. We defined intimate partner violence (IPV) as an episode in which the partner threatened to, or carried out, an act of harm—physical or sexual—within a 2-year period preceding the postpartum interview. The MES administered 10 questions about abuse and violence, adapted from the Violence Against Women Survey.¹³ Elevated symptoms suggesting postpartum depression in the extended postpartum period (within 1 year postpartum) were measured using the Edinburgh Postnatal Depression Scale, a 10-item screening tool.¹⁴ A score ≥13/30 suggests a high probability of postpartum depression at the time of the interview, with over 80% of cases correctly classified as having major depression at that threshold.¹⁵ We defined substance use in pregnancy as smoking 10 or more cigarettes per day in the last 3 months of pregnancy, consuming 2 or more alcoholic drinks on at least 1 occasion during pregnancy, or using street drugs during pregnancy. A new medical condition arising in pregnancy was defined as a new condition requiring medication for more than 2 weeks, special care, or extra tests. Delivery complications were defined by having complications or health problems during labor or the birth that required special care, extra tests, or a longer stay in a hospital. Infant outcomes included admission to neonatal intensive care unit, preterm delivery <37 weeks gestation, hospital readmission within 5 months after birth, and nonroutine newborn healthcare visits. The latter included any visit to a doctor or other healthcare provider for a problem or illness other than a routine checkup.

Data analysis

The MES was based upon a sample design involving stratification and unequal probabilities of selection of respondents. Survey weights were used to restore the representativeness of the sample and obtain unbiased point estimates for the Canadian population. Special procedures for the analysis of survey data (SURVEYFREQ and SURVEYLOGISTIC) were used to obtain weighted proportions and odds ratios (ORs) with 95% confidence intervals (95% CIs) using the Taylor Series method of variance estimation.¹⁶ Descriptive measures included weighted proportions and mean. The Rao-Scott chi square test was used to assess statistically significant differences between proportions.

Missing data were very low for most variables and, therefore, were not considered in the analyses, except for household income, for which we created an “Unknown” indicator category to prevent a significant drop in the sample size. The MES reporting guidelines prohibit the reporting of estimates based on counts of less than five, and they also recommend the reporting of weighted counts.¹²

The analytic strategy included the reporting of the prevalence of the outcomes according to the presence or absence of each of the three indicators of partner disengagement and their association with the eight adverse maternal and infant outcomes. The associations were expressed as crude and adjusted ORs (AORs) and 95% CIs. Using multivariable logistic regression analysis, the ORs were adjusted for marital status (married, common-law, single or never married, divorced or separated), maternal age (<20, 20–34, ≥35 years), education (less than high school, high school diploma, postsecondary diploma, university diploma), household income (at or below the low income cutoff, above, or unknown),¹⁷ parity (primiparous or not), foreign born (yes or no), and ethnicity (North American, European, non-Western, Other). In sensitivity analyses, we further controlled for a woman's reported wantedness of pregnancy (sooner or when it occurred, later, or not at all), reaction to pregnancy (somewhat happy or very unhappy vs. very happy, somewhat happy or indifferent), and low support during pregnancy (none or little of the time vs. some, most, or all of the time).

Results

Among all recent mothers surveyed, 3.8% had a partner who did not want the pregnancy, 16.1% argued more than usual with their partner in the year prior to the delivery, and 7.6% had a partner who was not present at the baby's birth (Table 1). The majority of women were married or in a common-law relationship. Among women who had an indicator of partner disengagement, a greater proportion was single or divorced/separated. Women reporting partner disengagement were about 2 years younger than the total sample of women. Low income and low education status were more commonly reported among women who indicated partner disengagement from pregnancy. While in the overall sample 73% of women had an intended pregnancy, this proportion fell to 28% among women whose partners did not want the pregnancy. A small fraction of the overall sample of women were unhappy about the pregnancy, although higher proportions were seen among women reporting any type of partner disengagement. Similarly, measures of low overall support were highest among those with disengaged partners (Table 1).

Table 1.

Characteristics of All New Mothers and Those Women Whose Partners Had Indicators of Disengagement

		Those who reported a marker of partner disengagement
Maternal characteristics	All women	Partner did not want the pregnancy	Partner argued more than usual in the past year	Partner was absent at the delivery of the baby
Weighted No. (%)	75,793 (100.0)	2,860 (3.8)	12,230 (16.1)	5,778 (7.6)
Marital status
Married	67.8	31.3	50.4	43.7
Common-law	24.4	26.3	27.8	19.0
Single, never married	6.0	31.4	15.5	30.3
Divorced or separated	1.8	11.0	6.3	7.0
Maternal age (years)
Mean (SD)	29.6 (18.0)	27.7 (23.0)	28.3 (20.6)	28.3 (19.1)
Median (IQR)	30 (26–33)	28 (22–33)	28 (24–33)	28 (23–33)
Primiparity	55.1	56.3	57.7	55.2
Maternal education
Less than high school	7.5	18.0	12.2	16.3
High school diploma	19.3	26.5	26.3	26.6
Postsecondary diploma	37.5	34.6	36.3	37.3
University diploma	35.7	20.9	25.2	19.8
Low-income cutoff (LICO-AT)
At/below	18.2	40.4	30.4	40.3
Above	73.3	46.0	59.7	43.6
Unknown	8.5	13.6	9.9	16.1
Ethnicity/identity
North American	34.8	27.7	31.8	24.7
European	35.4	36.1	34.8	28.8
Non-Western	20.1	25.8	22.3	33.4
Other	9.7	10.4	11.1	13.1
Foreign born	24.1	21.8	21.8	28.1
Mother's pregnancy intentions
Sooner or when it occurred	73.3	28.8	57.6	52.3
Later	19.9	38.4	31.1	31.8
Not at all	6.8	32.8	11.3	15.9
Mother's reaction to pregnancy: Unhappy about pregnancy	2.8	14.1	6.0	6.7
Low support during pregnancy	5.1	8.6	9.4	5.1
Edinburgh postnatal depression scale, mean (SD)	5.3 (15.3)	7.8 (17.9)	8.0 (18.0)	6.1 (15.8)
Edinburgh postnatal depression scale, median (IQR)	4 (2–8)	7 (3–11)	7 (4–11)	5 (2–8)

Data are from the Canadian Maternity Experiences Survey, 2006–2007, whose weighted sample represents 75,793 pregnancies. All data are presented as a weighted frequency (%) unless otherwise indicated.

IQR, interquartile range; LICO-AT, low-income cut-off, after taxes; SD, standard deviation.

Adverse maternal outcomes

The prevalence of adverse maternal outcomes was higher among women whose partners did not want the pregnancy, who argued more than usual with their partner in the past year, and those whose partner was absent during the baby's birth (Table 2). Specifically, 27.6% of women whose partners disagreed with the pregnancy experienced IPV within the 2-year period preceding the interview, compared to 4.7% among those whose partner agreed with the pregnancy (AOR 3.55, 95% CI 2.36–5.14) (Table 3). An even stronger association was seen among the 16.1% of women whose partner argued more than usual in the year before the child's birth (AOR 4.82, 95% CI 3.69–6.30). A moderate AOR for partner violence was reported among women whose partner was absent from the delivery (AOR 1.54, 95% CI 1.07–2.20).

Table 2.

Weighted Prevalence (%) and Bivariate Analysis of Adverse Maternal and Infant Outcomes in Association with Indicators of Partner Disengagement

	Partner did not want the pregnancy			Partner argued more than usual in the past year			Partner was absent at delivery of the baby
	Yes (n = 2,860)	No (n = 72,933)	p^a	Yes (n = 12,230)	No (n = 63,563)	p^a	Yes (n = 5,778)	No (n = 70,015)	p^a
Adverse maternal outcomes
Intimate partner violence	27.6	4.7	<0.01	18.6	3.0	<0.01	14.5	4.8	<0.01
Elevated depressive symptoms in the extended postpartum period	19.6	7.0	<0.01	17.8	5.5	<0.01	10.0	7.28	0.048
Substance use	11.3	3.6	<0.01	8.7	3.01	<0.01	8.0	3.6	<0.01
New medical condition arising in pregnancy	25.4	24.5	0.76	29.6	23.5	<0.01	26.0	24.4	0.45
Delivery complications	16.6	15.5	0.40	16.8	14.2	0.05	19.9	14.2	<0.01
Adverse infant outcomes
Admission to a neonatal intensive care unit in the birth hospitalization	10.3	12.8	0.25	13.9	12.5	0.28	19.4	12.2	<0.01
Preterm birth <37 weeks gestation	7.8	6.1	0.33	6.7	6.1	0.51	10.8	5.8	<0.01
Readmission to hospital within 5 months after birth hospitalization	7.7	6.7	0.55	7.9	6.5	0.15	7.5	6.7	0.48
Nonroutine healthcare visits after birth hospitalization	36.2	28.0	0.01	34.3	27.1	<0.01	27.6	28.4	0.40

Rao-Scott chi square test for difference between proportions.

Table 3.

Adverse Maternal and Infant Outcomes in Association with Indicators of Partner Disengagement

	Partner did not want the pregnancy		Partner argued more than usual in the past year		Partner was absent at delivery of the baby
	OR (95% CI)	AOR (95% CI) ^a	OR (95% CI)	AOR (95% CI) ^a	OR (95% CI)	AOR (95% CI) ^a
Adverse maternal outcomes
Intimate partner violence	7.66 (5.53–10.62)	3.55 (2.36–5.14)	7.46 (5.89–9.46)	4.82 (3.69–6.30)	3.37 (2.53–4.50)	1.54 (1.07–2.20)
Elevated depressive symptoms in the extended postpartum period	3.33 (2.30–4.81)	2.56 (1.70–3.83)	3.80 (3.04–4.75)	3.63 (2.84–4.64)	1.41 (0.99–2.01)	0.86 (0.58–1.29)
Substance use	3.47 (2.23–5.39)	2.13 (1.29–3.51)	3.21 (2.41–4.27)	2.09 (1.51–2.89)	2.41 (1.68–3.47)	1.46 (0.98–2.20)
New medical condition arising in pregnancy	1.05 (0.76–1.44)	1.13 (0.81–1.57)	1.40 (1.19–1.64)	1.49 (1.25–1.77)	1.10 (0.88–1.38)	1.17 (0.92–1.49)
Delivery complications	1.15 (0.79–1.67)	1.16 (0.77–1.72)	1.23 (1.01–1.49)	1.28 (1.03–1.58)	1.52 (1.18–1.95)	1.82 (1.38–2.40)
Adverse infant outcomes
Admission to a neonatal intensive care unit in the birth hospitalization	0.79 (0.51–1.22)	0.75 (0.47–1.20)	1.14 (0.93–1.41)	1.16 (0.93–1.46)	1.76 (1.36–2.28)	1.89 (1.41–2.53)
Preterm birth <37 weeks gestation	1.33 (0.79–2.26)	1.33 (0.75–2.34)	1.12 (0.83–1.52)	1.11 (0.81–1.53)	2.04 (1.45–2.88)	2.27 (1.56–3.30)
Readmission to hospital within 5 months after birth hospitalization	1.18 (0.72–1.95)	0.93 (0.53–1.62)	1.25 (0.96–1.64)	1.19 (0.89–1.59)	1.16 (0.80–1.68)	1.08 (0.71–1.66)
Nonroutine healthcare visits after birth hospitalization	1.38 (1.03–1.85)	1.54 (1.13–2.11)	1.37 (1.17–1.60)	1.49 (1.26–1.77)	0.91 (0.73–1.14)	1.00 (0.78–1.28)

Adjusted for marital status (married, common-law, single or never married, divorced or separated), maternal age (<20, 20–34, ≥35 years), parity (primiparous or not), low income (at or below the low income cutoff, above, or unknown), education (less than high school, high school diploma, postsecondary diploma, university diploma), immigrant status (foreign born or Canadian born), and ethnicity (North American, European, non-Western, or Other).

Values in bold are statistically significant with p-values < 0.05.

95% CI, 95% confidence interval; AOR, adjusted odds ratio.

Elevated symptoms suggesting postpartum depression in the extended postpartum period were more common among women whose partners did not want the pregnancy (AOR 2.56, 95% CI 1.70–3.83), or who had argued more than usual (AOR 3.63, 95% CI 2.84–4.64), but not with a partner's absence from the delivery (Table 3). A similar pattern was observed for substance use in pregnancy. A new medical condition arising in pregnancy was significantly associated with greater arguing in the prior year (AOR 1.49, 95% CI 1.25–1.77), as were delivery complications (AOR 1.28, 95% CI 1.03–1.58) (Table 3). Delivery complications were also related to partner absence from the delivery (AOR 1.82, 95% CI 1.38–2.40).

Sensitivity analyses showed no substantial change in most associations after further adjusting for a mother's wantedness of her pregnancy, her reaction to the pregnancy, and her overall support during the pregnancy (data not shown). In the models focusing on elevated depressive symptoms in the extended postpartum period, further adjustment for history of depression (i.e., being diagnosed with depression or taking antidepressants before pregnancy) minimally decreased the associations for women whose partners did not want the pregnancy (AOR 1.92, 95% CI 1.23–3.00), or who had argued more than usual (AOR 3.14, 95% CI 2.43–4.04), but had no impact for those whose partners were absent at the delivery.

Adverse newborn outcomes

Admission to neonatal intensive care unit and preterm birth were each higher among women whose partners were absent during the baby's birth (Tables 2 and 3). Infant hospital readmission within 5 months of birth was not associated with any of the three indicators, but nonroutine child health visits were for women whose partners did not want the pregnancy (AOR 1.54, 95% CI 1.13–2.11) and with greater arguing in the year preceding the birth (AOR 1.49, 95% CI 1.26–1.77) (Table 3).

Discussion

In a representative sample of recent mothers in Canada, partner disengagement in pregnancy and peripartum was associated with a significantly higher risk of common adverse maternal and newborn outcomes, such as IPV and nonroutine infant care visits. These findings remained after adjusting for sociodemographic characteristics and women's pregnancy intentions.

Our finding of a higher occurrence of IPV among women with disengaged partners may reflect different possible pathways. Women who are in the process of separating from their partners may be more likely to report violence and partner disengagement.^6,18 The cross-sectional nature of the MES, and the broad time window during which IPV and partner disengagement may have occurred, limited our ability to determine the temporal nature of the observed relations. Many women may medically terminate a pregnancy given their partner's opposition to the pregnancy or to avoid bringing children into abusive relationships.¹⁹ Accordingly, the findings reported herein likely underestimated the true association between partner disengagement adverse outcomes, and certainly do not represent those women who terminated a pregnancy, and, thus, are not included in the MES.

We found that women with indicators of partner disengagement had higher rates of symptoms suggesting depression in the extended postpartum period. Some research suggests that an unintended or unwanted pregnancy is associated with a higher incidence of postpartum depression, as are low social supports.^7,20,21 However, in our sensitivity analyses, these associations persisted upon accounting for a woman's pregnancy intendedness or lack of social support. It is also plausible that a partner's disagreement with the pregnancy could be due to their dissatisfaction with the relationship. The quality of a woman's relationship with her partner, and measured marital satisfaction, has been associated with postpartum depression^3,22 and other indicators of poor mental health.⁵ Our finding that both disagreement with the pregnancy and greater arguing in the past year were linked with elevated depressive symptoms in the extended postpartum period aligns with this hypothesis; however, this hypothesis could not be directly tested herein, as the MES did not obtain information about the quality of a couple's relationship. It has been suggested that a problematic relationship may more negatively impact maternal mental health than the state of single motherhood.² Finally, in the current study, some women had a history of depression prior to pregnancy. However, adjustment for prior depression did slightly reduce, but did not eliminate the observed associations, suggesting that the occurrence of elevated depressive symptoms in the extended postpartum period may be relatively independent of existing depression.

Both a new medical condition arising during pregnancy and a complication of the recent delivery were each associated with arguing in the past year the partner's absence at the birth. This suggests that partner disengagement may be adversely associated not only with psychological well-being but also with physical health.

The indicators of partner disengagement behaved differently in relation to newborn outcomes. Admission to a neonatal intensive care unit and preterm birth were only higher among women whose partners were not present at the delivery. This finding may simply reflect the reality that an unanticipated onset of labor or the need for cesarean delivery preempted the partner's arrival to hospital, a maternal transfer from a rural to an urban center, or out of a cultural preference in which the father does not attend the birth. Notwithstanding the latter points, the absence of the partner at birth was significantly associated with partner violence, suggesting that, in some cases, partner absence may truly reflect a high risk relationship. To clarify the relationship between partner's absence at delivery and adverse outcomes, future studies may benefit from collecting information regarding the reasons and timing of a partner's absence. Nonroutine healthcare visits of the infant were associated with a partner not wanting the pregnancy and increased arguing, suggesting that partners' disengagement from the pregnancy may also be linked with an infant's health. Given the above, the family unit—comprising mother, her partner, and their newborn—may be compromised in the presence of markers of partner disengagement.

As a limitation, the cross-sectional nature of this study does not permit to establish a causal sequence in the exposure–outcome relations. As mentioned earlier, women who terminated a pregnancy or had a stillbirth or an early infant death were not included herein, yet, these outcomes too are linked to IPV.²³ Third, all variables in the MES were self-reported several months postpartum and may be subject to recall bias. Fourth, the MES does not contain information about the partner, it does not survey the partner directly, nor does it collect information about health behaviors or the quality of the couple's relationship. Fifth, the survey did not inquire about whether the infant had congenital anomalies, which may impact on an infant's healthcare utilization and pose an extra burden to their caregivers. There is also emerging evidence of an association between stressful life events during pregnancy and gastroschisis.^24,25 Future planned maternity surveys should strive to include these informative dimensions.

Without denying the importance of screening for domestic violence, it may be worth considering expanding the inquiry to other indicators of partner disengagement, such as ours, but not limited to them. A broader focus on the quality of the relationship may offer opportunities to provide more timely support and prevent the escalation of conflict and related adverse outcomes in the family unit. Front line healthcare workers—physicians, nurses, midwives, and social workers—are key agents in detecting and offering help to a woman or couple who are experiencing adversity in their relationship. Detection can occur at the first antenatal visit,²⁶ at the time of a delivery, or at the time of a routine or unplanned infant health visit. In addition, health personnel (social workers, nurses, etc.) may help detect and address women's lifetime risk of depression through intervention at this critical time period. The absence of the partner at a delivery may serve as a flag for further inquiry regarding the reasons for their absence. Nonroutine newborn visits, in some cases, may also be an indication of underlying problems within the family unit. The pregnant or new mother with a disengaged partner can be referred to existing social and family services or other options to lessen the potential consequences of having a disengaged partner.

In conclusion, partner disengagement may be associated with adverse maternal and infant health outcomes and nonroutine healthcare visits. Further research is needed to develop accurate indicators of a troubled relationship, to tease out the timing of that discord in relation to the pregnancy and the period thereafter, and to portray partners' characteristics and their experiences.

Footnotes

Acknowledgments

This research was supported by funds to the Canadian Research Data Centre Network (CRDCN) from the Social Science and Humanities Research Council, the Canadian Institute for Health Research (CIHR), and the Canadian Foundation for Innovation and Statistics Canada. Although the research and analysis are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada or the CRDCN. The authors thank the Maternity Experiences Study Group of the Public Health Agency of Canada's Canadian Perinatal Surveillance System who developed and implemented the Maternity Experiences Survey. M.L.U. holds a CIHR New Investigator Award, A.P. holds a Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Award, and J.G.R. holds a CIHR Chair in Reproductive and Child Health Services and Policy Research.

Author Disclosure Statement

No competing financial interests exist.

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