Adverse Childhood Experiences and Unintended Pregnancy: Evidence From North Dakota PRAMS, 2017-2020.

Introduction: Unintended pregnancy remains a significant public health issue with lasting consequences. Adverse childhood experiences are linked to risky behaviors and poor reproductive outcomes; however, limited research has examined optimal approaches to measuring adverse childhood experience exposure in rural populations. This study examines the relationship between adverse childhood experiences and pregnancy intendedness in North Dakota from 2017 to 2020. Methods: This cross-sectional study used North Dakota Pregnancy Risk Assessment Monitoring System data (N=2,973). A cumulative adverse childhood experience score was calculated. Exploratory factor analysis identified 2 adverse childhood experience groupings (abuse/neglect and household dynamics). Pregnancy intendedness was dichotomized as intended or unintended; a sensitivity analysis supported this categorization. Multivariable logistic regression assessed the associations between adverse childhood experiences and unintended pregnancy, controlling for sociodemographic and behavioral factors. The models compared the cumulative adverse childhood experience score, factor-based groupings, and individual adverse childhood experience items. Results: Unintended pregnancy was more common among women with ≥4 adverse childhood experiences (51%) than among women with no adverse childhood experiences (32%). A dose-response relationship was observed, with increasing adverse childhood experience exposure associated with increased odds of unintended pregnancy. In adjusted models, younger age, being unmarried, higher parity, marijuana use before pregnancy, and higher adverse childhood experience exposure were independently associated with unintended pregnancy, whereas no significant differences were observed by residence or maternal race. The cumulative adverse childhood experience score showed greater predictive value than factor-based or item-only models. Sensitivity analyses revealed consistent adverse childhood experience gradients across subcategories of unintended pregnancy. Conclusions: Higher cumulative adverse childhood experience exposure is associated with a greater risk of unintended pregnancy. Findings support the use of cumulative adverse childhood experience measures in reproductive health research and highlight the importance of trauma-informed care and upstream strategies that address childhood adversity.