Primary prevention of child maltreatment should include family planning

Primary prevention is the phrase of the day in child welfare. As Jerry Milner, Associate Commissioner of the Children’s Bureau of the Department of Health and Human Services put it in a letter attached to the program for the recent NCCAN conference, “Right now, our child welfare system typically responds only after families have lost much of their protective capacity and children have been harmed. We need to create environments where families get the support they need before harm occurs. This calls for an intensified focus on primary prevention and a reconceptualization of the mission and functioning of child welfare systems.”

Primary prevention refers to the prevention of abuse and neglect before it occurs through universal approaches. This is distinguished from secondary prevention, which focus on those at risk for a problem like child maltreatment, or tertiary prevention, which focuses no preventing on recurrence of a problem that has already occurred. (The much touted Family First Act allows funds to be used only for tertiary prevention, which is perhaps why it was not mentioned at the conference and why the Children’s Bureau has been dragging its feet on issuing guidance to states and counties.)

Yet, discussions of primary prevention (including those at NCCAN) often leave out the most primary of all–encouraging people to delay childbearing until they are ready to be parents, to wait at least 18 months between pregnancies, and to curb the overall number of children they have.

The connection between teen pregnancy and child maltreatment is well-known, but adolescence is lasting longer than ever, and even mothers aged 20 to 25 are more likely to abuse or neglect their children than older mothers. California researchers Emily Putnam-Hornstein and Barbara Needell found that babies born to mothers who were under 20 were twice as likely to be reported to child protective services (CPS) by the child’s fifth birthday as those born to mothers 30 or older. Among children referred to CPS by age five, almost 18 percent were born to a teenage mother and 50 percent were born to a mother younger than 25. Among children with no CPS contact, only 8 percent were teen births and 30 percent were born to a mother under 25.

Less well-known or discussed is the consistent evidence that larger family size and closer child spacing are correlated with child maltreatment. The Fourth National Incidence Study of Child Abuse and Neglect found that households with four or more children had a maltreatment rate of 21.2 per thousand, compared with 11.9 per thousand for families with two children. Putnam-Hornstein and Needell found that children who fell third or higher in the birth order were more than twice as likely to be the subject of a maltreatment report as first children.

Not surprisingly, research suggest that the interaction between birth order and maternal age creates the highest risk for a child maltreatment fatality. A study using linked birth and death certificates for all births in the U.S. between 1983 and 1991 found that the most important risk factors for infant homicide were a second or subsequent infant born to a mother less than 17 years old. These infants had 11 times the risk of being killed compared with a first infant born to a mother 25 years old or older. A second or subsequent infant born to 17 to 19-year-old mother had nine times the homicide risk of the first infant born to the older mother.

And setting the research aside for a moment, anyone who has worked for or with CPS, or in foster care, knows the prevalence of larger families with closely-spaced children in the system, often with a mother that started childbearing as a teen. This blogger has observed the same pattern as a member of the District of Columbia’s Child Fatality Review Committee, and it has been observed in other jurisdictions as well.¹  

If it is not the lack of research, why do supporters of child maltreatment prevention fail to include family planning and contraception in their suggestions? Judging from the reactions this blogger has received when raising this issue,  it is our country’s shameful history of attempting to restrict childbearing by women of color through means including forced sterilization and the promotion of birth control methods like Norplant.

But advocates for children of color should not allow this racist history to prevent thinking clearly about what is best going forward. There are few if any policies that could be more helpful to the future of black children and the elimination of racial disproportionality in foster care placement than ensuring that black women have access to the most effective methods of contraception so that they can determine their own futures.

Family planning and contraception need to be included in the discussion about child maltreatment prevention. Research suggests that media messaging, better information, and use of more effective contraceptive methods contributed to the drastic decline in the teen birth rate from 61.8  per thousand in 1991 to 18.8 per thousand in 2017. However, it is still high among certain populations, including Black (27.5 per thousand) and Hispanic (28.9 per thousand) teens.

We now have safe, effective long-lasting reversible methods of contraception. Known as LARC’s, for “Long Lasting Reversible Contraceptives, these methods provide long-lasting contraception without requiring action by the user. They include IUD’s and contraceptive implants. But LARC’s are not universally available, and even when available, women desiring these methods may have to return for a second appointment. Moreover, health care professionals are often not trained to address myths and misconceptions concerning longer-lasting contraception. The Colorado Family Planning Initiative improved access to LARC’s by training public health providers, supporting family planning clinics, and removing financial barriers. As a result of this initiative, the state’s teen birth rate was cut in half in just five years.

The Colorado initiative could be adopted nationwide, combined with a mass media campaign to explain the benefits to both children and parents of planning and spacing of pregnancies and births. We know that such campaigns can change people’s health-related behavior, as in the case of smoking cessation and HIV prevention. 

The omission of pregnancy prevention from the primary prevention toolkit is particularly upsetting because very few programs have been shown to be effective in preventing abuse or neglect after a baby is born. Jerry Milner and other proponents of primary prevention in child welfare argue that we should help families before they maltreat their children. How much more efficient and humane it would be to postpone the birth of children who are likely to be maltreated and help troubled adults address their problems before they have a first or subsequent child rather than afterwards?

1. Testimony of Dr. Angela Diaz, CECANF, August 6-7, 2015), https://slideblast.com/cecanf-nyc-meeting-transcriptfinal_59767e8e1723ddc0e0eedc5d.html ↩