Overview

Unintended pregnancies are a significant occurrence in the United States. Around 45% of the 6 million annual U.S. pregnancies are unintended (Guttmacher, 2016). Research has shown that unintended pregnancies can have long-term implications for children and parents.  Births resulting from unintended pregnancies are associated with adverse maternal- and child- health outcomes such as delayed pre-natal care, premature birth, increases in the neonaticide rate (the killing of infants within 24 hours of birth) (Kaplan, 2014), and negative physical and mental health effects for children.

Pregnancy Intention

Most often pregnancies are defined as either intended or unintended.  An "unintended pregnancy" is defined as pregnancy that occurs either when a woman wanted to become pregnant in the future but not at the time  that she became pregnant, or one that occurred when she did not want to become pregnant then or at any time in the future

[1].  “Current definitions of intention assume that pregnancy is a conscious decision. However, given the complex emotional, psychological, and cultural factors at play, often behaviors do not align with intentions ( 10,  14 ,   , 14, 24–26 ), and intentions may change over time ( 27–29 ). Indeed many women express ambivalence regarding their pregnancy intentions ( 30–33 ), and formulating plans for a pregnancy may seem unrealistic for many women as they do not perceive themselves as having reproductive control ( 34). Health care providers may also have different perspectives regarding whether a couple is prepared for a pregnancy ( 35 –37), given that providers often want couples to conform to normative ideals regarding timing of pregnancy. Moreover, though the terms unplanned and unintended pregnancies are often used interchangeably, careful attention to terminology is important as the wording of questionnaires regarding pregnancy intention has been found to affect a woman’s assessment of her own pregnancy ( 38–40 ).” 

 

Several categories have been developed to further describe pregnancy intentions (Kost and Lindberg, 2015)[3]:

  • Intended (wanted at that time or sooner)
  • Mistimed by less than two years
  • Mistimed by two or more years
  • Unwanted (wanted no children or no additional children)

Using these four-category definitions, Kost and Lindberg found the following demographic characteristics of mothers across intention status groups:

  • Mothers of intended births are more often married and older than mothers of mistimed or unwanted births.
  • Greatly mistimed births have mothers who are younger and in less stable relationships than births in the other groups.
  • Unwanted births occur more often among older women and among women with greater numbers of previously completed pregnancies and are likely at a stage of life in which desired fertility is complete.

 Ambivalence

In addition to understanding pregnancy intention, it is important to consider ambivalence.  Feelings of ambivalence toward pregnancy can be a common occurrence.  When exploring this further, Gomez et al (2019)[4] found that for some participants who were described as ambivalent, a hypothetical unexpected pregnancy would clearly be unacceptable while for others, an unexpected pregnancy would be acceptable even if the timing might be less than ideal.

Cutler et al (2018)[5] interviewed 84 women aged 15 to 44 who were at less than 24 completed weeks of gestational age from urban, walk-in pregnancy testing clinics in New Haven, Connecticut.  When asked what they immediately felt after being told they were pregnant, women reported a range of feelings (happy, sad, scared, worried, mad, surprised, shocked).  Also reported were contradictory feelings (happy and sad) and mixed emotions such as “feeling in the middle”).

Ambivalence stemmed from various sources, such as:

  • Prior fertility and pregnancy experiences
  • Current children
  • Relationship status
  • Social support
  • Maternal–fetal health
  • Financial considerations
  • Fit with current life circumstances
  • Impact their current goals and dreams

Also important to consider is that entering menopause, irregular menstrual cycles and experiences of long periods of time between cycles prior to a final menstrual period can complicate a woman’s family planning and reproductive goals.

Aiken, Dillaway and Mevs-Korff (2015)[1] conducted in-depth interviews with 27 women that explored their pregnancy intentions and their feelings related to an unplanned pregnancy.  What they found included the following:

▶ A woman facing an unplanned, unintended pregnancy may have reached or surpassed her ideal number of children.

▶ In some cases, the woman may have been unable to obtain highly effective contraceptive methods (intrauterine devices, implants, or sterilization) and then is frustrated to find she is pregnant.

▶ Some women describe another child as being a “tipping point” that would have a negative impact on their lives.

▶ A woman might be in financially fragile circumstances and worry about how they will provide for another child.

▶ Financial considerations also apply to women with greater financial means, in terms of the potential lifestyle changes another child could bring (such as the need to delay retirement or the impact on career plans).

Implications for Practice

▶ Acknowledge and explore sources of ambivalence.  This will allow you to provide comprehensive support related to the woman’s experiences as well as their reproductive goals.

▶ Be mindful of ambivalence in all forms and points in time.

▶ Do not assume that expressions of ambivalence mean that women are necessarily unhappy about their pregnancies.

 

References

[1] Unintended Pregnancy in the United States. Guttmacher Institute. January 2019. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states; Retrieved September 28, 2020.

[2] Mumford, S. L., Sapra, K. J., King, R. B., Louis, J. F., & Buck Louis, G. M. (2016). Pregnancy intentions-a complex construct and call for new measures. Fertility and sterility, 106(6), 1453–1462. https://doi.org/10.1016/j.fertnstert.2016.07.1067

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5159192/pdf/nihms803878.pdf

[3] Kost, K., & Lindberg, L. (2015). Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography, 52(1), 83–111. https://doi.org/10.1007/s13524-014-0359-9.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734627/pdf/nihms708159.pdf

[4] Gómez, A. M., Arteaga, S., Villaseñor, E., Arcara, J., & Freihart, B. (2019). The Misclassification of Ambivalence in Pregnancy Intentions: A Mixed-Methods Analysis. Perspectives on sexual and reproductive health, 51(1), 7–15. https://doi.org/10.1363/psrh.12088

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476569/pdf/nihms-1013515.pdf

[5] Cutler, A., McNamara, B., Qasba, N., Kennedy, H. P., Lundsberg, L., & Gariepy, A. (2018). "I Just Don't Know": An Exploration of Women's Ambivalence about a New Pregnancy. Women's health issues : official publication of the Jacobs Institute of Women's Health, 28(1), 75–81. https://doi.org/10.1016/j.whi.2017.09.009

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223118/pdf/nihms-992140.pdf

[1] Aiken, A. R., Dillaway, C., & Mevs-Korff, N. (2015). A blessing I can't afford: factors underlying the paradox of happiness about unintended pregnancy. Social science & medicine (1982), 132, 149–155. https://doi.org/10.1016/j.socscimed.2015.03.038