Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda

Unintended pregnancies account for about half of all pregnancies in the United States and, in 1995, numbered nearly 3 million pregnancies. They pose appreciable medical, emotional, social and financial costs on women, their families and society. The US is not attaining national goals to decrease unintended pregnancies, and little is known about effective means for reducing unintended pregnancy rates in adults or adolescents.To examine the evidence about the effectiveness, benefits and harms of counseling in a clinical setting to prevent unintended pregnancy in adults and adolescents and to use the evidence to propose a research agenda.We identified English-language articles from comprehensive searches of the MEDLINE, CINAHL, PsychLit and other databases from 1985 through May 2000; the main clinical search terms included pregnancy (mistimed, unintended, unplanned, unwanted), family planning, contraceptive behavior, counseling, sex counseling, and knowledge, attitudes and behavior. We also used published systematic reviews, hand searching of relevant articles, the second Guide to Clinical Preventive Services and extensive peer review to identify important articles not otherwise found and to assure completeness. Of 673 abstracts examined, we retained 354 for full article review; of these, we used 74 for the systematic evidence review and abstracted data from 13 articles for evidence tables. Four studies addressed the effectiveness of counseling in a clinical setting in changing knowledge, skills and attitudes about contraception and pregnancy; all had poor internal validity and generalizability and collectively did not provide definitive guidance about effective counseling strategies. Nine studies (three in teenage populations) addressed the relationship of knowledge on contraceptive use and adherence. Knowledge of correct contraceptive methods may be positively associated with appropriate use, but reservations about the method itself, partner support of the method, and women's beliefs about their own fertility are important determinants of method adherence that may attenuate the knowledge effect. Many factors influence contraceptive use and adherence; among them are age, marital status, ambivalence about becoming pregnant, attitudes of partner, side effects, satisfaction with provider and costs; however, the impact of such factors may not be consistent across populations defined by cultural, age or other factors. The studies themselves differed materially in outcome variables, populations and methodologies and did not yield a body of work that can reliably identify specific influences on contraceptive use and adherence. No literature reports on harms of counseling or on the costs or cost-effectiveness of different approaches to counseling about unintended conceptions in the primary care setting.Virtually no experimental or observational literature reliably answers questions about the effectiveness of counseling in the clinical setting to reduce rates of unintended (unwanted, mistimed) pregnancies in this country. Existing studies suffer from appreciable threats to internal validity and loss to follow-up and are extremely heterogeneous in terms of populations studied and outcomes measured. The quality of the existing research does not provide strong guidance for recommendations about clinical practice but does suggest directions for future investigations. Numerous issues warrant rigorous investigation.     

The cost of unintended pregnancy in the United States

INTRODUCTION: Despite the many contraceptive options available in the United States, nearly half (49%) of the 6.4 million pregnancies each year are unintended; these represent a significant cost to the health care system. METHODS: The total number of unintended pregnancies and their outcomes were obtained from the literature. Direct medical costs were estimated for each unintended pregnancy outcome. RESULTS: The direct medical costs of unintended pregnancies were US$5 billion in 2002. Direct medical cost savings due to contraceptive use were US$19 billion. DISCUSSION: Unintended pregnancies are a costly problem in the United States. Contraceptive use can reduce direct and indirect costs; hence, payers may realize cost savings by providing coverage of contraceptive products.     

Contraceptive use and risk of unintended pregnancy in California

California is home to more than one out of eight American women of reproductive age. Because California has a large, diverse and growing population, national statistics do not necessarily describe the reproductive health of California women. This article presents risk for pregnancy and sexually transmitted infections among women in California based on the California Women's Health Survey. Over 8900 women of reproductive age who participated in this survey between 1998 and 2001 provide estimates of access to care and use of family-planning methods in the state. We find that 49% of the female population aged 18-44 in California is at risk of unintended pregnancy. Nine percent (9%) of women at risk of an unintended pregnancy are not using any method of contraception, primarily for method-related reasons, such as a concern about side effects or a dislike of available contraceptive methods. Among women at risk for unintended pregnancy, we find disparities by race/ethnicity and education in use of contraceptive methods.     

青岛市未婚女性意外妊娠心理和行为研究

目的:了解青岛市未婚女性意外妊娠的心理和行为等情况,为采取积极措施降低未婚意外妊娠的发生率提供科学依据.方法:采用问卷方式对青岛市2012年5～8月因意外妊娠来院进行流、引产或生育的未婚女性进行心理、行为、避孕知识等因素的调查,采用EpiData软件建立数据库,应用SAS软件进行卡方分析和多因素分析.结果:共调查未婚女性1 1 12例,有34.35％的女性认为是被诱惑发生性行为导致意外妊娠,69.06％认为社会性文化开放导致未婚性行为,71.67％未婚女性认为缺乏避孕知识而造成意外妊娠,48.29％女性因未避孕而妊娠,其中73.29％认为不可能妊娠而未采取紧急避孕措施.不同年龄组对未婚性行为的看法无差异.年龄越小,未避孕的比例越高,各年龄组之间差异有统计学意义(P＜0.01).引流产组和生育组对于妊娠的第一感觉和流产危害的认识差异有统计学意义(P＜0.01).不同文化程度各组间避孕知识的知晓情况差异有统计学意义,文化程度越高了解越全面(P＜0.01).多因素广义线性模型分析结果显示现居地(农村→镇街→市区)、贞操观念、是否缺乏紧急避孕知识组间妊娠次数差异有统计学意义.结论:青岛市未婚女性生殖健康和避孕知识欠缺,被诱惑发生性行为情况较严重,应加强性道德、生殖健康、避孕知识的教育,减少未婚意外妊娠的发生.     

产后抑郁与非计划妊娠的关系

目的探讨非计划妊娠对产后抑郁的影响,为预防产后抑郁提供科学依据,方法选取2013年2月-2014年2月在该院进行42 d体检的1 139例产妇为研究对象,采用爱丁堡产后抑郁量表(EPDS)评估产妇的抑郁情绪,将评分≥10分界定为有抑郁情绪。收集产妇的社会人口学资料、妊娠计划性、不良孕产史等情况,采用二元非条件Logistic回归模型进行分析。结果意外妊娠者198例(17.4%),顺其自然妊娠608例(53.4%),计划妊娠333例(29.2%),意外妊娠,顺其自然妊娠妇女较计划妊娠妇女年龄小、受教育程度和家庭收入低,并且农村户口占的比例很高。意外妊娠产妇产后抑郁的检出率高于其他两组。调整相关混杂因素后,经二元Logistic回归模型分析显示:意外妊娠、顺其自然妊娠是产后抑郁的危险因素,OR值(95%CI)分别为1.982、1.420,差异具有统计学意义(P<0.05)。结论非计划妊娠会增加产后抑郁的风险。     

意外妊娠终止后继发不孕的原因及影响因素分析

目的:探讨意外妊娠终止后继发不孕的原因及影响因素。方法:以2006年8月～2008年8月到怀化市第一人民医院就诊的82例意外妊娠后继发不孕的妇女作为观察组,进行问卷调查,以同期入院的58例原发性不孕妇女作为对照组,采用SPSS13.0软件进行统计分析。结果:观察组初次性生活年龄早于对照组(P0.001);避孕失败原因依次为未避孕(占57.32%)、避孕套失败(占18.29%)、安全期避孕(10.98%)、体外排精(9.76%);避孕失败后终止妊娠的方式主要为人工流产、药物流产,而输卵管妊娠后继发不孕者亦占一定比例;继发不孕的原因居前4位的分别是输卵管梗阻、慢性输卵管炎、慢性盆腔炎、输卵管积水。结论:意外妊娠终止后继发不孕的主要原因是盆腔炎性疾病后遗症,导致输卵管梗阻或不通畅。初次性生活年龄过早,未避孕或避孕方法不当,多次人工流产、药物流产、输卵管妊娠史是意外妊娠后继发不孕的重要影响因素。     

Measuring pregnancy intention and its relationship with contraceptive use among women undergoing therapeutic abortion

BACKGROUND: Most pregnancies ending in therapeutic abortion are assumed to have been unintended. In the developed world, most arise from inconsistent or incorrect contraceptive use. Ambivalence about pregnancy might be associated with less effective contraceptive use. METHODS: Three hundred sixteen women undergoing abortion in Scotland were interviewed about contraceptive use at the time of conception. A modified measure of pregnancy intendedness was used to determine ambivalence. RESULTS: Pregnancy appeared to be clearly unintended for 92% of women. Sixteen percent were not using contraception and had higher intendedness scores (p<.001) than those using a method. Forty-four percent were using contraception inconsistently or incorrectly, almost always condoms or oral contraception, but method choice was not linked to pregnancy intendedness. DISCUSSION: Women who are ambivalent about the desire for pregnancy are less likely to use contraception. The challenge for reducing abortion rates lies in improving contraceptive use among the much larger group of women who do not intend to get pregnant but use contraception imperfectly.     

Unintended pregnancy risk in an emergency department population

OBJECTIVE: To assess unintended pregnancy risk and associated factors among female urban Baltimore emergency department (ED) attendees. METHODS: A cross-sectional anonymous questionnaire study was completed by 790 women, sufficient to detect a 5% difference of unintended pregnancy risk in the national population and a 10% intersite difference with 80% power. The results were analyzed with chi-square tests, univariate and multivariate logistic regression analyses. RESULTS: Female ED attendees are at greater risk for unintended pregnancy (33.5%), particularly those of lower income (p=.006) and without a primary care provider (p=.003). Unintended pregnancy risk did not vary between sites by any variable except young age despite the fact that sites varied significantly by race, insurance and income measures. CONCLUSION: Women using the ED are at increased risk for unintended pregnancy and are less likely to have access to a regular medical care source; thus, the ED represents a possible contraceptive provision site.     

Contraceptive nonuse among US women at risk for unplanned pregnancy

BACKGROUND: This study was conducted to assess risk factors for contraceptive nonuse among a nationally representative sample of US women and explored the influence of future pregnancy intentions on contraceptive nonuse. STUDY DESIGN: Using data from the 2002 National Survey of Family Growth (NSFG), we analyzed 12 months of contraceptive behavior among 3687 women at risk for unplanned pregnancy. RESULTS: Compared with contraceptive users, contraceptive nonusers were more likely to be older than 40 years (OR 6.3, 95% CI 2.7-14.7), black (OR 1.8, 95% CI 1.2-2.8), less educated (OR 2.4, 95% CI 1.4-4.0), uninsured (OR 1.6, 95% CI 1.1-2.4), Medicaid recipients (OR 1.9, 95% CI 1.2-2.9) or having infrequent intercourse (OR 3.8, 95% CI 2.7-5.3). We found no significant association between future pregnancy intentions and contraceptive behavior. CONCLUSIONS: While family planning efforts have traditionally focused on disadvantaged women, older women and women who have infrequent sex are also at high risk for nonuse. Future pregnancy intentions, as currently assessed by the NSFG, is not a useful indicator of contraceptive behavior.     

Unintended pregnancy and postpartum contraceptive use in women with and without chronic medical disease who experienced a live birth

Background

Maternal chronic medical disease and unintended pregnancies increase the risk of maternal and infant morbidity and mortality. Little is known regarding the relationship between chronic medical disease status and pregnancy intendedness or contraceptive use.

Study Design

We compared pregnancy intention and postpartum contraception use in women with and without chronic medical disease who experienced a live birth using data from the Florida Pregnancy Risk Assessment Monitoring System 2004–2005.

Results

Women aged ≥20 years with chronic medical disease were more likely to report that the index pregnancy was unintended (odds ratio [OR]=1.56, 95% confidence interval [CI] 1.28–2.03) and reported similar postpartum contraception nonuse (OR=0.85, 95% CI 0.60–1.19) compared to those without chronic medical disease. Women aged <20 years with chronic medical disease were less likely to report that the index pregnancy was unintended (OR=0.50, 95% CI 0.28–0.88) and reported similar postpartum contraception nonuse (OR=0.99, 95% CI 0.54–1.82) compared to those without chronic medical disease.

Conclusions

In our study population, age and chronic medical disease were associated with different risks of pregnancy intention in the index pregnancy. Women with and without chronic disease in both age groups reported similar postpartum contraception use.     

Couple perspectives on unintended pregnancy in an area with high HIV prevalence: A qualitative analysis in Rakai,Uganda

Understanding how couples perceive a recent unintended pregnancy in the context of HIV infection and high levels of gender inequality may provide insights for prevention of undesired pregnancy. We used data from 24 in-depth interviews with 8 HIV-serodiscordant and 4 seroconcordant couples living in rural Uganda and interviewed separately; between 15 and 49 years and one or both identified the pregnancy as unintended. A dyadic analysis was performed to understand each partner’s perspectives on experiences of a specific pregnancy. We used the social-ecological model to guide the analysis. Issues of agency were commonly invoked in describing pregnancy. Women often cited factors that demonstrated a lack of control when making decisions about continuing the pregnancy. Men often expressed a lack of agency or control over preventing their female partner from becoming pregnant. There was much disagreement between partners about intentions regarding the specific pregnancy. Likewise, lack of communication about child spacing and pregnancy intentions was common among couples. HIV serostatus played a role in some discussions of pregnancy intention among serodiscordant couples. This qualitative analysis supports prior quantitative research on the complexity of pregnancy intentions. A lack of agency at the individual level was compounded by a lack of communication between partners.     

某高校学生婚前性行为、意外妊娠的发生及影响因素分析

目的了解大学生的生育健康知识、态度及行为,探索影响大学生发生性行为的因素,使未来的健康教育活动更有针对性。方法抽取北京市某高校1～4年级大学生698名,采用自行设计的问卷对大学生进行高校学生婚前性行为、意外妊娠的发生及影响因素现场调查。结果知晓适宜的流产时间、认为在大学期间可以接受婚前性行为、对待避孕的态度是消极者分别占16．8％、60．5％和29．7％;20．2％的人发生过性行为,在发生性行为的学生中,43．5％的男生使女友妊娠过,37．9％的女生意外妊娠过。Logistic回归结果显示男生（OR=7．302）、高年级（DR=2．076）及中度抑郁的（OR=2．537）学生发生性行为的风险增加。结论被调查人群的生育健康知识不足,大学生群体中性行为及意外妊娠的发生率较高,未来的教育活动应该多关注男生、高年级学生以及学牛的心弹。     

Unintended pregnancy in the United States: incidence and disparities, 2006

Background

The incidence of unintended pregnancy is among the most essential health status indicators in the field of reproductive health. One ongoing goal of the US Department of Health and Human Services is to reduce unintended pregnancy, but the national rate has not been estimated since 2001.

Study Design

We combined data on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth with a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US Census Bureau.

Results

Nearly half (49%) of pregnancies were unintended in 2006, up slightly from 2001 (48%). The unintended pregnancy rate increased to 52 per 1000 women aged 15–44 years in 2006 from 50 in 2001. Disparities in unintended pregnancy rates among subgroups persisted and in some cases increased, and women who were 18–24 years old, poor or cohabiting had rates two to three times the national rate. The unintended pregnancy rate declined notably for teens 15–17 years old. The proportion of unintended pregnancies ending in abortion decreased from 47% in 2001 to 43% in 2006, and the unintended birth rate increased from 23 to 25 per 1000 women 15–44 years old.

Conclusions

Since 2001, the United States has not made progress in reducing unintended pregnancy. Rates increased for nearly all groups and remain high overall. Efforts to help women and couples plan their pregnancies, such as increasing access to effective contraceptives, should focus on groups at greatest risk for unintended pregnancy, particularly poor and cohabiting women.     

武汉市青山区已婚育龄妇女意外妊娠状况调查

目的 探索武汉市青山区不同年龄队列已婚育龄妇女意外妊娠发生状况及影响因素.方法 采用横断面调查,于2010年3月以整群抽样抽取青山区18～49岁已婚育龄妇女3256人,应用自编调查表调查意外妊娠史及有关影响因素.结果 3256人中,53.8％报告有意外妊娠史,9.1％报告过去一年有意外妊娠,3个年龄队列(18～30岁、31～40岁和41～49岁)报告过去一年意外妊娠史的比例依次为31.8％、10.5％和1.8％.3个年龄队列均报告最近一次妊娠的主要原因是“没有采取避孕措施”(报告比例分别为69.7％、51.1％和42.4％);其次是“传统避孕法失败”(18～30岁为13.0％)和“环脱落或带环怀孕”(31～ 40岁为23.4％,41 ～49岁为37.0％).各年龄组队列报告“没有采取避孕措施”的主要原因是“存在侥幸心理”(59.6％).年龄大、初婚年龄小、初次性交年龄小是已婚育龄妇女意外妊娠发生相关危险因素.结论 青山区已婚育龄妇女报告意外妊娠者的比例较高.生育健康服务和干预应区别对待不同年龄队列的已婚育龄妇女,尤其重点关注年轻的妇女.     

武汉市青山区已婚育龄妇女意外妊娠状况调查

目的 探索武汉市青山区不同年龄队列已婚育龄妇女意外妊娠发生状况及影响因素.方法 采用横断面调查,于2010年3月以整群抽样抽取青山区18～49岁已婚育龄妇女3256人,应用自编调查表调查意外妊娠史及有关影响因素.结果 3256人中,53.8％报告有意外妊娠史,9.1％报告过去一年有意外妊娠,3个年龄队列(18～30岁、31～40岁和41～49岁)报告过去一年意外妊娠史的比例依次为31.8％、10.5％和1.8％.3个年龄队列均报告最近一次妊娠的主要原因是“没有采取避孕措施”(报告比例分别为69.7％、51.1％和42.4％);其次是“传统避孕法失败”(18～30岁为13.0％)和“环脱落或带环怀孕”(31～ 40岁为23.4％,41 ～49岁为37.0％).各年龄组队列报告“没有采取避孕措施”的主要原因是“存在侥幸心理”(59.6％).年龄大、初婚年龄小、初次性交年龄小是已婚育龄妇女意外妊娠发生相关危险因素.结论 青山区已婚育龄妇女报告意外妊娠者的比例较高.生育健康服务和干预应区别对待不同年龄队列的已婚育龄妇女,尤其重点关注年轻的妇女.     

The relationship between body mass index and unintended pregnancy: results from the 2002 National Survey of Family Growth

BACKGROUND: The study was conducted to characterize the relationship between body mass index (BMI) and unintended pregnancy, contraceptive use patterns, and perceived fertility. METHODS: This study employed a cross-sectional, nationally representative database (2002 National Survey of Family Growth). Unintended pregnancy was compared among BMI groups [normal (<25 m/kg(2)), overweight (25-30 m/kg(2)) and obese (>30 m/kg(2))]. Analyses also evaluated the association between demographic, socioeconomic, behavioral and health-related variables and BMI. Multiple logistic regression with adjustment for sampling design was used to measure associations of interest. RESULTS: BMI data were available from 6690 nonpregnant women. Of these, 3600 (53.6%) were normal weight, 1643 (25%) were overweight and 1447 (21.4%) were obese. Compared to women with normal BMIs, the risk of unintended pregnancy in the last 5 years did not differ among overweight [adjusted OR 0.95 (95% CI 0.77-1.17)] or obese [adjusted OR 0.87 (95% CI 0.70-1.09)] women. There were no differences in contraceptive use patterns or perceived fertility among BMI groups. CONCLUSION: Data from the 2002 NSFG do not support an association between obesity and unintended pregnancy.     

Not seeking yet trying long-acting reversible contraception: a 24-month randomized trial on continuation,unintended pregnancy and satisfaction

Objectives

To measure the 24-month impact on continuation, unintended pregnancy and satisfaction of trying long-acting reversible contraception (LARC) in a population seeking short-acting reversible contraception (SARC).