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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2004.049296
RESEARCH AND PRACTICE |
Michelle DeKlyen, Sara McLanahan, and Jean Knab are with the Center for Research on Child Wellbeing, Princeton University, Princeton, NJ. Jeanne Brooks-Gunn is with the Teachers College and the College of Physicians and Surgeons, Columbia University, New York, NY.
Correspondence: Requests for reprints should be sent to Michelle DeKlyen, PhD, 288 Wallace Hall, Office of Population Research, Princeton University, Princeton, NJ 08544 (e-mail: mdek-lyen{at}princeton.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We compared recent parents (married, cohabiting, not cohabiting but romantically involved, and not romantically involved) to examine the association between mental health problems and relationship status.
Methods. We analyzed data from the Fragile Families and Child Wellbeing Study that followed a cohort of approximately 4900 births in large US cities. Our study included a large oversample of nonmarital births (n=3700) and interviews with both mothers and fathers. We used the Composite International Diagnostic Interview Short Form to assess depression and generalized anxiety 1 year after the birth. Self reports were used to measure heavy drinking, illicit drug use, incarceration, and partner violence.
Results. Unmarried parents reported more mental health and behavioral problems than did married parents, and unmarried parents whose relationships ended before the birth reported more impairment compared with other groups of unmarried parents.
Conclusions. A substantial number of children are born to unmarried parents and are at risk for poor parenting and poor developmental outcomes. Government initiatives aimed at increasing marriage rates among low-income couples need to consider the mental health status of unmarried parents.
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INTRODUCTION |
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Mental health problems are a major public health concern. They affect more than a quarter of all Americans each year1 and take an enormous toll on families in terms of economic well-being,2 intimate relationships,3,4 parenting quality, and child health and development.5–7 The mental health of parents and children is a particular concern for researchers and public health professionals because of recent trends in marriage and fertility. Non-marital childbearing (i.e., childbearing outside marriage) has increased dramatically in the United States during the past 4 decades, especially among minorities and couples with limited education.8,9 Whereas 1 out of 3 births in 2000 were to unmarried mothers, nearly 70% of Black births and 43% of Hispanic births occurred outside marriage.10 Because nonmarital childbearing is associated with low socioeconomic status—an established risk factor for mental disorder—the mental health problems of families may be increasing.11–13
Unfortunately, we know very little about parents who have children outside marriage. Although past research has shown that marriage is associated with positive mental health,14 most of this research does not distinguish between divorced and never-married parents. This research also does not distinguish between the different types of never-married parents. According to a recent estimate, about 50% of unmarried parents are cohabiting at the time of birth, 30% are in a romantic relationship, and 20% are not in a romantic relationship.15 Because of the diversity of relationships, there may be considerable variation in the mental health of unmarried parents. For example, cohabiting parents may resemble married parents, and parents who are no longer romantically involved may resemble divorced parents, with noncohabiting romantic parents falling somewhere in between.
Mental health problems and the variation in mental health across relationship types are also of interest to policymakers. Congress has proposed spending $1.6 billion during the next 5 years on programs that seek to promote "healthy" marriage among unmarried parents.16 These programs are based on the assumption that educating parents about the benefits of marriage and strengthening their communication and relationships skills will increase marriage rates and thus, improve child well-being. The mental health status of these parents is important for several reasons. First, assuming that marriage improves mental health, this information may tell us something about the potential benefits of the new programs and how the benefits may vary across subgroups. Because causality is likely to be bidirectional—with marriage improving mental health and better mental health increasing marriage—the difference between married and different types of unmarried parents should be viewed as an upper-bound estimate of the potential benefits of marriage. Second, assuming that poor mental health is one of the reasons people do not marry, knowing more about the problems of unmarried parents can tell us something about the obstacles that practitioners will face when trying to implement the new marriage programs. Moreover, information on mental health differences across relationship types will help professionals identify and target services for those who need them most. Finally, to ensure that the new marriage programs "do no harm," practitioners need to know more about the prevalence of antisocial behavior and domestic violence among different groups of unmarried parents. Research has shown that partner violence is a relatively common experience among low-income single mothers17,18 and that living with a violent or antisocial father is more harmful to children than living with no father.19 Again, in order to know how to target the marriage programs, we need more information on which groups of mothers and children are most at risk.
We examined the prevalence of mental health problems among mothers and fathers of infants, and we assessed the association between mental health and a variety of relationship statuses. We focused on 4 types of relationships—married, cohabiting, noncohabiting romantic, and nonromantic—and 6 indicators of mental health—depression, anxiety, alcohol use, illicit drug use, incarceration history, and partner violence. Although our data did not allow us to examine whether mental health is associated with the transition to parenthood, they did provide information about a new and rapidly growing population of interest to public health professionals and policymakers.
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METHODS |
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Sample
We used data from the Fragile Families and Child Wellbeing Study, a longitudinal study of approximately 4900 births (including an oversample of nonmarital births) in 75 hospitals within 20 large US cities between 1998 and 2000. Details about city and hospital selection and other sampling procedures have been published elsewhere.20 The Fragile Families sample differs somewhat from the population of all births in large cities because of the oversample of nonmarital births. Within marital status groups, however, demographics were similar to the characteristics for all births as reported by the National Center for Health Statistics (NCHS). The mothers in our study were somewhat more likely to be Black, younger, and more educated than the mothers in the NCHS data.
Mothers were screened in the hospital shortly after the birth of their child to determine whether they were eligible for the study. A mother was eligible if the child’s father was alive, if she planned to keep her baby, if she spoke English or Spanish well enough to complete the interview, and if she was well enough to complete the interview. Fewer than 5% of mothers were ineligible for 1 of these reasons. Mothers who were younger than 18 years were excluded in some hospitals (about half) because of legal restrictions. Births to mothers younger than 18 years accounted for only 4% of all births in 199910; thus, we did not expect this exclusion to affect our results.
Baseline response rates for mothers were high: 82% among married mothers, and 87% among unmarried mothers (the denominator was eligible births). After the interview, mothers were asked to provide information about the father of their child, and fathers were then contacted for an interview. Response rates for fathers also were high: 89% among married fathers, and 75% among unmarried fathers (the denominator was mothers who had been interviewed). Mental health assessments were conducted during the first follow-up interview, when the child was aged 12 to 18 months. Eighty-nine percent of mothers and 82% of fathers in the original sample participated in the follow-up interview. Our study included 4327 mothers and 3213 fathers for whom mental health data and key covariates were available.
Measures
To measure relationship status at birth, we asked mothers whether they were married, whether they were romantically involved, and whether they were living with the father. This information was used to sort parents into 1 of 4 relationship categories (married, cohabiting, noncohabiting romantic, and noncohabiting nonromantic). We also created indicators for several demographic characteristics expected to be associated with both mental health and relationship status, including age, race/ethnicity, immigrant status, education, low-income status (measured by whether Medicaid paid for the birth), and whether parents had other children together and/or with other partners.
To measure depression and anxiety, we administered the Composite International Diagnostic Interview Short Form (CIDI-SF), Version 1.0 November 1998,21 during the 1-year follow-up. Scoring followed procedures outlined by the developers of the CIDI-SF to yield 12-month Diagnostic and Statistical Manual of Disorders, Fourth Edition, diagnoses of major depressive episode and generalized anxiety disorder.22,23 To measure heavy drinking and illicit drug use, we asked respondents how many times they had 5 or more alcoholic drinks in 1 day during the past month and how often they had used illicit drugs during the past month. We also created a summary measure for each parent—whether he/she reported at least 1 of these problems—and 2 couple-level summary measures—whether either parent reported a problem and whether both parents reported problems.
Finally, to measure fathers’ antisocial behavior, we examined incarceration histories and domestic violence histories. To measure fathers’ incarceration, we asked both parents whether the father had ever spent time in jail. Previous research has shown that mothers’ reports of fathers’ incarceration are more accurate than fathers’ reports.24 To measure partner violence, we asked mothers whether they had been "seriously injured" or "slapped, kicked, hit with a fist or object, cut, or bruised" by the child’s father before or during the pregnancy. Our measure of partner violence is conservative because it did not include behaviors such as pushing, shoving, and throwing things, which are more common and are often included in other surveys of domestic violence.
Data Analysis
We began by examining differences in the prevalence of mental health problems among parents in different relationship categories. We tested the mean differences across groups with analyses of variance followed by pairwise tests with Bonferroni corrections for multiple comparisons. Next, we used multivariate analyses (ordinary least squares and logistic regression) to examine the prevalence of mental health problems while controlling for parents’ demographic characteristics (age, education level, race/ethnicity, immigrant status, other children by this or another partner, and whether Medicaid paid for child’s birth). We used the results from these models to obtain adjusted means and proportions for parents in each of the 4 relationship categories. These analyses allowed us to determine whether relationship status was an important predictor of mental health status after we accounted for demographic differences.
As discussed in the documentation on the Fragile Families Web site,22 our scoring procedures for major depressive episode were derived from 1994 and 1997 memos by Kessler et al. These procedures are more liberal than those subsequently outlined by Walters et al.25 We also analyzed these data using the more conservative scoring procedures. Although the prevalences that resulted from these more conservative procedures were somewhat lower, particularly among women, our analyses comparing mental health by relationship status remained substantially the same. Tables that used the more conservative scoring are available from the authors upon request.
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RESULTS |
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Table 1
shows the demographic characteristics of our sample by relationship status. Twenty-five percent of the mothers in our sample were married at the time of their child’s birth, 36% were cohabiting, 26% were romantic but not cohabiting, and 13% were nonromantic. The small proportion of married mothers is a consequence of our sampling design, which called for oversampling unmarried mothers by a ratio of 3 to 1.
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Mothers’ relationship status was strongly associated with mothers’ demographic characteristics (Table 1
). Married mothers were predominately White, and unmarried mothers were predominately Black and Hispanic. Married mothers also were older, more educated, and more likely to be immigrants compared with unmarried mothers. The high proportion of immigrants was attributable to the high fertility rates within this population. Twenty-nine percent of the fathers in our sample were married, 41% were cohabiting, 24% were romantic but not cohabiting, and 6% were nonromantic. Fathers were less likely than mothers to report a nonromantic relationship. This difference is attributable to the lower response rate of fathers within this particular category. The demographic differences among fathers were very similar to those among mothers. Married fathers were more likely than unmarried fathers to be White, older, and more educated.
Married parents were more likely than unmarried parents to have other children together (shared children), and unmarried parents were more likely to have children with other parents (nonshared children) (Table 1). Finally, unmarried parents were nearly 3 times more likely than married parents to have used Medicaid to pay for the birth. Medicaid covers families with incomes up to 133% of the poverty level (or, in many states, up to 185% of the poverty level) and thus, it is a good indicator of socioeconomic status.
Table 2 shows the (unadjusted) prevalence of mental health problems by relationship status. According to these estimates, 12% of married mothers experienced a major depressive episode during the year after the child’s birth compared with 15% of cohabiting mothers, 17% of noncohabiting romantic mothers, and 19% of nonromantic mothers. Postpartum depression affects some mothers during the year after their child’s birth and might have increased the prevalence of depression in our sample. Although this potential distortion may affect prevalence, it should not affect differences across groups, unless there is an interaction between postpartum depression and relationship status.
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The prevalence of generalized anxiety disorder was much lower than the prevalence of depression. The ratio of the prevalence among nonromantic and married mothers, however, was similar to that for depression. Heavy alcohol and illicit drug use also were relatively rare among mothers, with cohabiting, romantic, and nonromantic mothers reporting substantially higher substance use than married mothers did. After we combined all 3 of these indicators—depression, anxiety, and substance use—we found that nonromantic mothers were twice as likely as married mothers to report at least 1 type of problem (mostly depression), with cohabiting and noncohabiting romantic mothers falling in between.
The overall prevalence of depression and anxiety disorders was lower among fathers than among mothers, but the relationship patterns were similar. Married fathers reported the lowest prevalence of depression and anxiety, and nonromantic fathers reported the highest. Most remarkably, nonromantic fathers reported depression and anxiety levels as high as, or higher than, any of these groups of mothers, despite the well-established finding that women are more likely than men to suffer from depression and anxiety disorders. More fathers than mothers reported substance use. About 24% of married fathers reported having 5 or more drinks at least once a month compared with 30% of cohabiting fathers and 23% of other unmarried fathers. Interestingly, cohabiting fathers reported more heavy drinking than noncohabiting romantic fathers.
The likelihood of "any problem" was higher among fathers than among mothers, with 31% of married fathers and 46% of nonromantic fathers reporting a problem. Among fathers, this measure was primarily driven by heavy drinking, whereas among mothers, it was driven by depression. Once again, the significant difference was between married fathers and all 3 types of unmarried fathers.
There also were important marital status differences in the proportion of couples that were problem free and the proportion that included at least 1 parent with a mental health problem. Nonromantic couples were significantly more likely than any other group to include at least 1 parent with a problem.
We examined 2 additional behavioral problems among fathers: whether a father had ever been incarcerated, and whether he had hit or seriously hurt the mother before the child’s birth. Relationship status is strongly associated with both incarceration and partner violence. Fewer than 9% of married fathers had ever been incarcerated compared with 43% of nonromantic fathers. Similarly, the prevalence of partner violence was 5 times greater among nonromantic fathers compared with married fathers.
To ensure that the association between relationship status and mental health was not spurious, we estimated regression models that controlled for demographic characteristics, and we used the coefficients from these models to obtain adjusted prevalence levels for each relationship category (Table 3). A comparison of Tables 2 and 3 shows how much of the association between relationship status and mental health was accounted for by demographic factors. For example, the sizes of differences in mothers’ depression prevalence were reduced. In Table 2, the difference between married and nonromantic mothers was 7.5 percentage points; in Table 3, it was only 4.7 points (a 37% reduction). The difference was still statistically significant, but the disparity was substantially smaller. We saw an even greater reduction for generalized anxiety disorder, and the difference between married and nonromantic mothers was no longer significant in the regression models with demographic controls.
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These findings show that demographic factors account for much of the relationship status difference in depression and anxiety among mothers. In contrast, the demographic factors account for very little of the difference in mothers’ heavy drinking and illicit drug use. Adjusting for demographic characteristics also did little to attenuate the differences in fathers’ mental health, and in some instances, it actually increased these differences. This was true for fathers’ incarceration and partner violence as well. Thus, the estimates in Table 3
show that, with the exception of mothers’ anxiety, the mental health differences across relationship categories were not simply attributable to differences in demographic characteristics or socioeconomic status. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Our study makes several contributions to what is known about the association between relationship status and mental health among parents of infants. First, we found that mental health is strongly associated with marital status for both mothers and fathers. Married parents reported better health and fewer behavioral problems than all categories of unmarried parents. Second, we found significant differences among different types of unmarried parents, which have not been previously documented. As we expected, nonromantic parents (who are more similar to divorced and separated couples) had more mental health problems than cohabiting and romantic parents (who are more similar to married parents). Third, we found differences across categories in the prevalence of previous incarceration and partner violence. Cohabiting fathers were more than twice as likely, and nonromantic fathers were more than 3 times as likely, as married fathers to have been in jail after we accounted for other demographic characteristics. Domestic violence differences also were large, with nonromantic fathers the most likely to have been violent and married fathers the least likely. Finally, children born to unmarried parents were more likely than their peers to have 1 or both parents report mental health problems.
Limitations
Our study has several limitations. First, our data were cross-sectional; therefore, we could not determine whether relationship status affects mental health or mental health affects relationship status. The direction of the effect has very important implications for the new marriage initiatives. If marriage leads to better mental health, marriage programs are likely to benefit both parents and children. Conversely, if mental health problems are a barrier to marriage, then marriage is unlikely to solve these problems. Indeed, they will likely undermine the success of marriage programs. The difference between these 2 possible outcomes underscores the need for further research on the nature of these causal relationships before particular interpretations are selected by advocates of particular interventions.
Second, although fathers’ participation in the study was high overall, it was lower among those who were no longer romantically involved with the mother of their child. To examine just how much this problem may have affected our results, we compared mothers with and without a father interview. The mothers with a father interview reported slightly better mental health than all the mothers combined. If mothers and fathers are similar with respect to mental health problems, this suggests that our estimates of fathers’ problems are conservative.
Third, our mental health indicators have limitations. Some researchers have questioned whether the CIDI-SF does a good job of identifying cases of depression and anxiety.26,27 Postpartum depression may have inflated our estimates of depression among mothers.28 Our measures of alcohol and illicit drug use, incarceration, and partner violence also were limited because these behaviors are likely to be underreported by parents.
Finally, our measure of relationship status was taken at birth, whereas mental health status was assessed during the 12-month follow-up interview. To make sure that this did not affect our results, we reran our models and controlled for changes in relationship status. Although change was associated with depression and several indicators of father’s mental health, including it in the model did not affect our conclusions (analyses are available from the authors upon request).
Conclusions
The findings of our study are of interest to public health professionals because they highlight important distinctions within a growing and understudied segment of our population—unmarried parents who have recently had a child together. They also are of interest to the policymakers and practitioners who are involved in the new marriage initiatives for several reasons. First, we found that parents who were not romantically involved had the most mental health problems, which may help to explain why they were no longer together. Although these couples are unlikely to participate in marriage programs, some of these fathers are likely to pay child support and to help raise the child. Addressing the mental health needs of these parents is important, especially because of the high prevalence of problems among these fathers. Second, although cohabiting and romantic parents were similar in many respects, they differed in 2 areas: romantic fathers were more likely to have experienced a major episode of depression and to have spent time in jail. These differences are potentially important and must be considered when designing the new marriage programs. Moreover, because non-response was greater among romantic fathers compared with cohabiting fathers, the differential is likely to be even larger than reported here. Addressing the depression of romantic fathers is likely to be important to the success of marriage programs. Third, we found that partner violence was twice as high among romantic couples compared with married couples. These findings reinforce the concerns of advocates who argue that marriage programs may put some mothers and children at risk unless the programs effectively screen out violent men.
Finally, the high level of previous incarceration among unmarried fathers has important implications for marriage. Incarceration has increased dramatically since 1980 as a result of changes in sentencing policies, especially for drug-related offenses.29 Although the increase in incarceration is unlikely to be a major cause of the increase in nonmarital childbearing, it is likely to have critical feedback effects on marriage. Research has shown that employers discriminate against men who have been incarcerated, which makes it more difficult for them to find steady employment, a prerequisite for a stable marriage.30 Furthermore, prison life is likely to undermine the types of relationship skills that are the focus of the government’s new marriage initiative. Because of these effects, current incarceration policies may be at odds with policies to increase marriage.
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Acknowledgments |
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This research was made possible by grants to Sarah McLanahan from the National Institute of Child Health and Human Development (grant 1 R01 HC36916) and a consortium of government and private foundations. Jeanne Brooks-Gunn also acknowledges the support of the NICHD Research Network on Child and Family Well-Being, the NIMH-ASPE Consortium on Young Children’s Mental Health, the Center for Health and Child Wellbeing at Princeton University, and the Virginia and Leonard Marx Foundation. Michelle DeKlyen is grateful for the continuing support of the dean’s office of Princeton University.
We especially wish to thank the 75 hospitals that generously provided access to their maternity wards and the many mothers and fathers who allowed us into their lives. This research would not have been possible without their cooperation.
Human Participant Protection
This study was approved by the institutional review boards of Princeton University, Columbia University, and each of the 75 hospitals involved in participant recruitment.
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Footnotes |
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Peer Reviewed
Contributors
All the authors interpreted the data and contributed to the writing. M. DeKlyen conducted data analyses and wrote the initial draft. J. Knab conducted additional data analyses. S. McLanahan and J. Brooks-Gunn helped design and direct the Fragile Families and Child Wellbeing Study, supervised analyses, and edited subsequent drafts.
Accepted for publication April 26, 2005.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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