2025 Theses Doctoral

Advancing the Understanding of Reproductive Coercion among Women in the United States

Hahn, Alexandria Louise

In the United States, over 8% of women have experienced reproductive coercion by a partner during their lifetime. Reproductive coercion involves deliberate behaviors that undermine reproductive decision-making and increase the risk of unintended pregnancy and sexually transmitted infections. These behaviors include pressuring a partner to become pregnant (pregnancy coercion), sabotaging birth control, such as removing or damaging a condom (condom manipulation), or forcing a partner to continue or end a pregnancy (controlling the outcome of a pregnancy). Despite its clinical relevance, addressing reproductive coercion has been hindered by conceptual ambiguity, lack of validated instruments, and limited research on the influence of community- and societal-level factors.

The purpose of this dissertation was to strengthen the evidence base on reproductive coercion to inform research, clinical practice, and policy. The aims of this dissertation were to: (1) synthesize and critically assess existing evidence on the prevalence and associated factors of reproductive coercion; (2) evaluate the validity and reliability of the Reproductive Coercion Scale; and (3) identify multilevel factors associated with reproductive coercion.

This dissertation comprised three studies: (1) a systematic review conducted in accordance with PRISMA guidelines to assess U.S.-based quantitative studies published through April 2024 on reproductive coercion prevalence and associated factors, with risk of bias evaluated using the Joanna Briggs Institute Critical Appraisal Tools; (2) a psychometric evaluation of the Reproductive Coercion Scale, including exploratory factor analysis, internal consistency assessment, and examination of convergent and discriminant validity; and (3) a cross-sectional analysis of baseline data from the American Women: Assessing Risk Epidemiologically cohort, geocoded and merged with publicly available datasets, to examine multilevel factors associated with reproductive coercion using bivariate and multivariable regression.

The systematic review synthesized findings from 23 studies that primarily examined demographic and behavioral factors associated with reproductive coercion. All studies were rated as having a moderate to high risk of bias due to their reliance on unvalidated measures of reproductive coercion, raising concerns about the trustworthiness of the evidence base. In the psychometric evaluation, exploratory factor analysis supported a two-factor solution of pregnancy coercion and condom manipulation, resulting in an 8-item Refined Reproductive Coercion Scale that demonstrated acceptable internal consistency, strong structural validity, and evidence of convergent and discriminant validity.

In the cross-sectional analysis, higher sexual self-efficacy, decision-making power, and communication ability were associated with reduced likelihood of reproductive coercion, whereas having a partner with a history of sexually transmitted infections was associated with increased likelihood. Greater perceived social support was associated with lower odds of reproductive coercion, while women affected by reproductive coercion were more likely to have engaged with women’s health specialists. No significant associations were observed for community- or societal-level factors.

This dissertation advances the study of reproductive coercion through validation of the 8-item Refined Reproductive Coercion Scale and the application of a multilevel approach to examine reproductive coercion across individual, interpersonal, community, and societal levels. Findings underscore the critical role of nurses in addressing reproductive coercion through clinical practice and advocacy. Future research should continue to examine how community resources and policy reforms influence reproductive coercion prevention and its impact on sexual and reproductive health. Sustained collaboration among nurses, researchers, clinicians, and community partners will be essential to translating this knowledge into evidence-based strategies.