"A mistake that wasn’t totally a mistake": a study on the incidence of pregnancy, identity, and constructing belonging in street youth

Rationale: Pregnancy is common in street youth and has a profound impact on their lives. While service providers report cases where pregnancy was the impetus for youth to leave street life, spontaneous abortion, therapeutic abortion and apprehension of a child by the foster care system are more common outcomes. This thesis addresses the following research questions: 1) What is the incidence of pregnancy and reproductive outcomes in female street youth in Toronto as compared to low-income housed youth? 2) What life experiences and socio-cultural contextual elements influence street-involved young women’s contraception use and pregnancy-related decisions?Methods: A parallel mixed methods research design was utilized. The quantitative sub-study estimated the prevalence and incidence of pregnancy and pregnancy outcomes in female street youth under the age of 25 and compared it to an age- and sex-matched housed cohort. Algorithms were created to identify pregnancies from administrative data and time not at risk for pregnancy was subtracted from the person-time denominators. The duration of prenatal and postnatal care and risk factors for pregnancy were described. The qualitative sub-study used in-depth interviews, focus groups, and extended community engagement to understand the meaning of contraception, conception and pregnancy in street-involved young women with diverse pregnancy outcomes. Semi-structured interview guides were developed in consultation with community members. Themes and concepts were identified and refined using line-by-line coding, constant comparison, and analytic memos. Symbolic interactionism and Erving Goffman’s theory of stigma were found to be useful lenses through which to view the data.Results: 158 homeless youth and 540 housed youth were included in the quantitative sub-study and followed for an average of four years. The incidence of pregnancy in single homeless youth was 23.2 per 100 person-years, 2.3 times higher than the rate in housed youth. The incidence in homeless youth with children in their care was 39.7 per 100 person-years. Single homeless youth were more likely to experience a delivery than a therapeutic abortion. The prevalence of pregnancy at recruitment was 14% in single homeless youth, 34% of homeless youth with children in their care and 6% in housed youth. In the multivariate model, prior pregnancies and having children in their care at the time of recruitment was associated with an increased rate of pregnancy.Ambivalence regarding pregnancy and contraception were key findings in the qualitative sub-study. While many women recounted preferring to wait to have children until they had achieved educational, career and housing goals, they also reported not using birth control effectively at the time they became pregnant. The isolation, stigma, the need for belonging and a positive identity were key elements that appeared to contribute to this ambivalence. The women’s accounts suggested that having a child and being with a partner were very meaningful for them and appeared to be ways of creating family, a sense of belonging and a more positive identity. Once pregnant, women recounted making decisions regarding the fate of their pregnancy based on their desire and ability to take on the role and identity of mother. Their previous experiences, their feelings regarding abortion and adoption, their partner’s preferences and characteristics, and their assessment of the consequences for their unborn child were also described as weighing heavily in their decisions. Finally, the young women’s accounts shed light on how they constructed identity and belonging in their other relationships, such as with partners. Conclusion: A complex network of socio-cultural contextual elements, including isolation, identity, and belonging impacts street youth’s pregnancy and birth control-related decisions. These elements may contribute to the high incidence and prevalence of pregnancy in this population.

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