Unintended Pregnancy in a Commercially Insured Population

Objectives: While much attention has been focused on unintended pregnancy in disadvantaged populations, few studies have focused on women in lower risk groups. This study, conducted in a national managed care organization, reports the prevalence of unintended pregnancy resulting in live births and examines associated factors. Methods: Women ages 18–49 who delivered a live infant during a 6-month interval were eligible for the study. Telephone surveys were conducted after delivery. We report the rate of unintended pregnancy resulting in a live birth, and describe its association with sociodemographic and pregnancy-related factors, partner's intention status, and contraceptive use. Results: Of 1173 births, 29% were unintended. Women who reported that the partner did not want the pregnancy were 7.4 times more likely than women whose partner wanted the pregnancy to regard the pregnancy as unintended. Only 40% of the women with an unintended birth used birth control and 64% of those used less effective methods such as condoms and diaphragms. Conclusions: In a population where the majority of women were married, educated, and with incomes over $40,000, almost 1/3 of the births resulted from unintended pregnancies. Future research is needed to help us better understand contradictions in pregnancy intention and contraceptive behavior. Comprehensive efforts are needed to promote consistent and correct use of contraception by women at risk for unintended pregnancy, and to involve male partners in family planning.     

Reasons for unprotected intercourse: analysis of the PRAMS survey

OBJECTIVES: This study was conducted to identify reasons why women had unprotected intercourse that led to an unintended pregnancy. METHODS: As part of the Pregnancy Risk Assessment Monitoring System (PRAMS) survey, women with a recent unintended viable pregnancy were asked after the birth why they had not used birth control. RESULTS: Of 7856 respondents, 33% felt they could not get pregnant at the time of conception, 30% did not really mind if they got pregnant, 22% stated their partner did not want to use contraception, 16% cited side effects, 10% felt they or their partner were sterile, 10% cited access problems and 18% selected "other." Latent class analysis showed seven patterns of response, each identifying strongly with a single reason. CONCLUSIONS: Almost half of women with viable unintended pregnancies ending in a birth felt they could not/would not get pregnant at the time of conception. Most women identified with a single reason for having unprotected intercourse.     

How contraceptive use patterns differ by pregnancy intention: implications for counseling.

To increase awareness of issues to include in contraceptive counseling-the objectives of this study were to evaluate: 1) how contraceptive use patterns (eg, non-use), level of effectiveness of contraceptive method, and sociodemographic characteristics may be associated with the occurrence of unintended pregnancy; 2) patterns of health care use for women with intended and unintended pregnancy; and 3) the association between contraceptive use patterns and sociodemographic characteristics. In-person interviews were conducted with 279 women enrolled in a Medicaid managed care health plan who had been pregnant in the last 5 years. Self-reported measures of pregnancy intention, contraceptive use, and health care use were collected. The relationships of pregnancy intention with contraceptive use patterns, level of effectiveness of contraceptive method used, and patterns of recent health care use were assessed. Differences in contraceptive use patterns by sociodemographic groups were assessed. Seventy-eight percent of women reported an unintended pregnancy. Non-use of birth control the month before conception was reported by 57% of women with unintended pregnancies and 84% of women with intended pregnancies. Use of birth control of low effectiveness was reported by 20% of women with unintended pregnancies and 8% of women with intended pregnancies. Non-use or use of contraceptive methods of low effectiveness did not differ for women in different sociodemographic groups regardless of pregnancy intention status. A majority of women reported recent health care use. Health care providers should be aware that women who have no intention for pregnancy may not be using an effective contraceptive method NOR have an effective pattern of contraceptive use.     

Female Perceptions of Male Versus Female Intendedness at the Time of Teenage Pregnancy

Teen pregnancy is a major public health concern and the majority of these pregnancies are unintended. The study population included women whose first pregnancy occurred at age 19 or younger (n?=?2,142). Data from the 2002 National Survey of Family Growth was used to determine whether women??s reports of her own pregnancy intentions differed from her perception of her male partner??s pregnancy intentions at the time of conception. Chi-square tests and multinomial logistic regression were used to examine perceived discrepant pregnancy intent. Most (55.4%) reported that the pregnancy was unintended by both, 22.1% indicated only he intended the pregnancy, 5.6% indicated only she intended the pregnancy, and 16.9% reported both intended the pregnancy. Compared to adolescent pregnancies respondents recalled being unintended by both her and her partner, Black and Hispanic respondents were more likely than whites to indicate the pregnancy was intended and were more likely to indicate that she did not intend the pregnancy but believed her partner did. Respondents who were older at the time of conception were more likely to indicate that the pregnancy was intended by both her and her partner. There are differences in recall of pregnancy intentions as perceived by respondents. Female adolescents perceived that the male who fathered the pregnancy intended to get pregnant at that time more often than she did. Teen pregnancy prevention efforts should consider both females and males intentions to become pregnant.     

The correspondence between intention to avoid childbearing and subsequent fertility: a prospective analysis

CONTEXT: Retrospective studies of pregnancy intendedness have revealed some characteristics that can help identify which women are more likely than others to experience an unintended birth. A comparison of these findings with those from a prospective analysis may shed greater light on the characteristics associated with unintended pregnancy. METHODS: Data were taken from the 1988 National Survey of Fertility Growth and a telephone reinterview of respondents conducted in 1990. Separate analyses were conducted of women intending to postpone childbearing for at least three years and of women intending to forgo all future childbearing. Logistic regression models were used to identify the effects of social and demographic characteristics, as well as change in marital status and certainty of intentions, on the odds of experiencing a birth in the interval between interviews. RESULTS: Only 10% of women intending to postpone pregnancy for more than three years and 8% of respondents seeking to forgo future childbearing had a birth in the interval between interviews. (These births, referred to as unpredicted births in this article, are roughly analogous to those labeled unintended in retrospective analyses.) Women with incomes below the poverty level were 2-3 times as likely as women with incomes between 100% and 199% of poverty to experience an unpredicted birth. Race was not a significant factor among women intending to avoid future childbearing, and became nonsignificant among those intending to postpone when change in marital status and contraceptive status were taken into account. Women aged 35 and older who wanted no more children were significantly less likely than women aged 20-29 to have an unpredicted birth. Women aged 30-34 who wanted to postpone childbearing were roughly 70% less likely than women aged 20-29 to experience an unpredicted birth. Overall, women who were at risk for a pregnancy but not practicing contraception were 2-3 times more likely than women using an effective method to have an unpredicted birth. CONCLUSIONS: There are at least two potential explanations for instances where the correlates of unintended births in the prospective analysis differ from those identified in retrospective studies. Certain subgroups of women may be more likely to classify births as wanted when they are asked retrospectively; alternatively, they may be more likely to experience changes in their living conditions that alter their fertility intentions.     

Teen contraceptive decisions: childbearing intentions are the tip of the iceberg

OBJECTIVE: To validate a model we developed while trying to understand why pregnant teens so often report that they did not want to become pregnant and could have obtained contraceptives before they conceived. METHOD: The study enrolled a racially/ethnically diverse group of 351 teenagers. Participants completed a questionnaire that asked about teen pregnancy risk factors, the expected effects of childbearing, the desire to remain non-pregnant, deterrents to contraceptive use, and contraceptive plans. RESULTS: Most participants were capable of using contraceptives but at high risk for unintended conception because they exhibited numerous sociodemographic risk factors, were unsure that pregnancy would affect their lives adversely, and were ambivalent about remaining non-pregnant. Believing a boyfriend wanted a baby and the anticipated effect of childbearing on 5 specific aspects of life explained 63% of the variance in the desire to remain non-pregnant, which, in conjunction with fears about using contraceptives, explained 20.5% of the variance in future contraceptive plans. CONCLUSIONS: Our new findings that expectations about the effect of childbearing explain the desire to remain non-pregnant may well help providers determine why teenagers who do not plan to conceive are often willing to allow themselves to do so by default. Further research is needed, as the model did not explain contraceptive decision-making adequately.     

Short Interpregnancy Intervals: Results from the First Baby Study

BackgroundShort interpregnancy interval (SIPI), defined as 18 months or fewer between delivery and subsequent conception, has become an independent marker of maternal and child health.MethodsWe performed a secondary analysis of 18 months of data from The First Baby Study, a prospective cohort of women followed from pregnancy through 3 years after their first birth. Women with SIPIs by 6, 6 to 12, and 12 to 18 months were compared with those without conceptions at those times. We then analyzed pregnancy intention of the subpopulation of women with a SIPI of 18 months or fewer. Logistic regression analyses determined associations between maternal characteristics, including sociodemographic and reproductive indicators, and SIPI incidence and intention.FindingsOf 3,006 participants, 795 (26.5%) had a repeat pregnancy within 18 months: 58 (1.9%) occurred within 6 months, 242 (8.1%) between 6 and 12 months, and 495 (16.5%) between 12 and 18 months. Incidence of SIPI at each interval differed by maternal characteristics, including income, marital status, and intention. Most women (84%) with a SIPI of 6 months or less classified them as unintended. Less than 2% of women with SIPIs of 18 months or fewer reported any contraceptive use in the postpartum period and no pregnancies occurred with the use of very effective methods, including long-acting reversible contraception.ConclusionsThe population of women at risk for SIPI is not homogenous. Among those with SIPIs, there is a stark contrast in intention between those who conceive early (≤6 months) versus later (≥12 months). Given that almost no pregnancies occurred when women used postpartum contraception, contraceptive counseling and unfettered access should be available for those at greatest risk for an early, repeat, unintended pregnancy.     

Differences between mistimed and unwanted pregnancies among women who have live births

CONTEXT: Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes. METHODS: Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and women's behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks. RESULTS: The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed. CONCLUSION: Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.     

Knowledge of likely time of ovulation and contraceptive use in unintended pregnancies

This investigation analyzed social and demographic characteristics of women having an unwanted or mistimed pregnancy (unintended pregnancies at the current time) in South America.A sample of 5135 women having had a normal non-malformed live-born infant were interviewed immediately postpartum at 18 hospitals participating in the Latin American Collaborative Study of Congenital Malformations (Spanish acronym: ECLAMC). Half (2568/5135 = 50%) reported that their pregnancies had been unintended, and, of those, 59.3% (1522/2568 = 59.3%) declared that they were trying to avoid conception. The latter group (n = 1522) was the main sample for this study.Patients were asked about their knowledge of when during the menstrual cycle conception is most likely to occur, their biomedical and social characteristics, the type of contraceptive methods used, their opinion of reasons for contraceptive failure, and their reasons for not using contraceptive methods.Women with unintended pregnancies who had not attempted to avoid conception were younger, often primigravid, less educated, and less knowledgeable concerning when during the cycle pregnancy is most likely to occur. Thus, reproductive health policies should be aimed at this target group.     

Intimate Partner Violence Among Economically Disadvantaged Young Adult Women: Associations With Adolescent Risk-Taking and Pregnancy Experiences

CONTEXT: Intimate partner violence negatively impacts the health of substantial proportions of young women in economically disadvantaged communities, where sexual initiation, aggressive behaviors, unintended pregnancies and childbearing are common among adolescents. It is therefore important to assess how adolescent risk behaviors and pregnancy experiences are linked to such violence during young adulthood.
METHODS: Data from 526 participants in the Reach for Health Longitudinal Study who were surveyed during middle school (in 1995–1996 and 1996–1997) and at ages 22–25 (in 2005–2007) provided information on adolescent risk behaviors and pregnancy experiences, as well as experiences of intimate partner violence during young adulthood. Bivariate and multivariate analyses were conducted to identify correlates of intimate partner violence involvement.
RESULTS: As young adults, 29% of women reported having been victims of intimate partner violence in the past 12 months; 21% reported having perpetrated such violence. In multivariate analyses, victimization and perpetration in the last year are positively associated with aggressive behavior in middle school (odds ratios, 1.9 and 2.5, respectively), lifetime number of sex partners (1.3 for both) and having a history of unintended pregnancy or pregnancy problems (1.3 for both). Perpetration also is associated with early sexual initiation (0.5) and living with a partner (1.8).
CONCLUSIONS: It is important to consider women's pregnancy histories in programs aimed at preventing the adverse outcomes of relationship violence and in screening for partner violence in sexual and reproductive health services. Early intervention may help women develop the skills needed for resolving conflicts with peers and partners.     

HIV-status disclosure and depression in the context of unintended pregnancy among South African women

Depressive symptoms are common among pregnant women living with HIV, and an unintended pregnancy may heighten vulnerability. HIV-status disclosure is thought to improve psychological well-being, but few quantitative studies have explored the relationships among disclosure, pregnancy intention and depression. Using multivariable linear regression models, we examined the impact of disclosure on depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) during pregnancy and postpartum among women who tested HIV-positive during the pregnancy in South Africa; and explored the role of pregnancy intention in this relationship. Among 350 women (median age: 27 years; 70% reporting that their current pregnancy was unintended), neither disclosure to a male partner nor disclosure to ≥1 family/community member had a consistent effect on depressive symptoms. However, pregnancy intention modified the association between disclosure to a male partner and depression during pregnancy: disclosure was associated with higher depression scores among women who reported that their current pregnancy was unintended but was associated with lower depression scores among women who reported that their pregnancy was intended. During the early postpartum period, disclosure to ≥1 family/community member was associated with higher depression scores. Counselling around disclosure in pregnancy should consider the heightened vulnerability that women face when experiencing an unintended pregnancy.     

Pregnancy Intention and Pregnancy Happiness: Are They Different?

Objectives: This study examines the relationship among pregnancy intention and attitudes, inconsistent contraceptive use, and plans for potential pregnancy among 311 women who presented at local health departments to seek a pregnancy test and for whom a pregnancy would be unintended. Methods: Women were surveyed prior to receiving pregnancy tests. Pregnancy intention was measured using traditional classifications of mistimed and unwanted pregnancies. Frequency distributions and chi-square tests were computed to examine and compare rates of happiness about the pregnancy among women with mistimed or unwanted pregnancy and to compare rates of inconsistent contraceptive use and plans for the pregnancy by intention and level of happiness. Results: Although all of the women selected for our sample stated that their pregnancies would be unintended, almost half (46%) were inconsistent contraceptive users. Further, 48% reported that they would be somewhat or very happy about a pregnancy. The proportion of women who were uncertain about the future of a pregnancy and who considered adoption or abortion was highest among those for whom a potential pregnancy was mistimed and who were unhappy about the pregnancy. Conclusions: Differentiating between pregnancy intention and happiness has practice implications for family planning and prenatal providers. Additional research should further elaborate these distinctions.     

Pregnancy Outcomes by Pregnancy Intention in a Managed Care Setting

Objectives Published studies show poor pregnancy outcomes associated with unintended pregnancies are disproportionately higher than in planned pregnancies and place a burden on the health care system. This study was designed to compare pregnancy intention rates, compare sociodemographic characteristics of women by pregnancy intention and compare pregnancy outcomes in a managed care setting. Methods A large managed health care organization in California conducted a retrospective medical record review of 1,784 women seeking prenatal care in 2002 to learn how women self-reported their pregnancy intention, compare pregnancy intention rates between this health plan to the national data, and to compare antecedents and pregnancy outcomes based on pregnancy intention. Results Overall, 62.1% of pregnancies were self-reported as intended with 26.4% mistimed and 11.4% unwanted. Being young, single, having lower educational attainment, having other living children, consuming alcohol and being a woman of color were the greatest predictors of having an unintended pregnancy. Despite these predictors, birth outcomes for unintended pregnancies in this setting showed no statistical difference from planned pregnancies. Conclusion Awareness of pregnancy intention of the women who are at greatest risk may be an important contributor to improving birth outcomes and health plan decisions about reproductive care services. Early entry to prenatal care and integrated services that decrease substance abuse and support high-risk pregnancy management are important contributors to reducing poor pregnancy outcomes.     

The Association Between Body Weight,Unintended Pregnancy Resulting in a Livebirth,and Contraception at the Time of Conception

Objectives: Annually, 3 million pregnancies in the United States are classified as unintended, with many of these unintended pregnancies occurring to women who use some type of contraceptive. Obesity may be affecting the biological effectiveness of contraceptives. We investigated whether there is an association between body weight and unintended pregnancy and whether this association differs by a woman's contraceptive status at the time of conception. Methods: We conducted a case–control study using multistate data from the 1999 Pregnancy Risk Assessment Monitoring System. A total of 18,445 women provided complete information on pregnancy intention, contraceptive use at the time of conception, weight, height, and other covariates. Multivariable logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs). Results: Among contraceptors, overweight and obese women had nearly twice the odds of having an unintended pregnancy as compared to women with normal body mass indices (OR=1.73 [95% CI: 1.20, 2.36] and OR=1.75 [95% CI: 1.21, 2.52], respectively) after adjustment for age, marital status, education, socioeconomic status, Medicaid, race/ethnicity, and parity. No association was found between heavier weight and unintended pregnancy among noncontraceptors. Conclusions: Though the observed associations could be the result of selection bias or unmeasured confounding, the findings suggest that the effect of obesity on unintended pregnancy is limited to contraceptive failure. Prospective studies designed specifically to examine a body weight–contraceptive failure association are needed to determine if heavier women should be advised to use contraceptive methods other than hormonal contraceptives to prevent unintended pregnancy.     

The resolution of teenage first pregnancies

First conceptions occuring in tennage women in the U.S., the outcomes of the pregnancies, the marital status of the teenage women at conception and at the outcome, whether the pregnancy was intended or not, and whether contraception was used to prevent the pregnancy are discussed. It was determined that 30% of a cross section of teenage women have had premarital intercourse and 58% of those married had premarital intercourse. Of those experiencing premarital intercourse, 30% were pregnant before marriage, i.e., fewer than 10% of all females 15-19. Twice as many blacks have premarital intercourse than whites, and twice as many of these become pregnant. 35% of those who have a premarital first pregnancy marry before the baby is born. 64% of premarital first pregnancies are unintended. Of those who did not want to become pregnant, 13-16% used contraception to prevent the premarital pregnancy. 86% of births to blacks from first pregnancies are illegitimate compared with 23% for whites. More than 1/5 of the women who do not marry end the pregnancy by induced abortion. White teenagers who do not marry prior to the outcome of the pregnancy are 7 times more likely to have an induced abortion than blacks. 18% of the whites who have illegitimate births from first pregnancies give up their children for adoption compared with 2% blacks. Fewer than 30% of postmarital first pregnancies of teenage women are unintended. Blacks appear to display less anxiety than whites over illegitimate births. It may be that escape via abortion and marriage is less accessible to blacks than to whites both economically and psychologically.     

Pregnancy Intentions,Pregnancy Attitudes,and the Use of Prenatal Care in Missouri

Objectives: This study uses data from 2378 mothers of live-born infants from the NICHD/Missouri Maternal and Infant Health Survey to examine the relationship between pregnancy intention and adequacy of prenatal care. Methods: Pregnancy intention was measured using traditional classifications of mistimed and unwanted pregnancies as well as additional measures of women's attitudes about their pregnancies. Odds ratios for inadequate prenatal care and its component parts (initiation of care and receipt of services) were calculated using multiple logistic regression in separate models and in a combined model for the measures of intention and attitude. Results: Women's attitudes about their pregnancies were associated with inadequate prenatal care, including both inadequate initiation of care and inadequate receipt of services. Traditional measures of intendedness were significantly related only to inadequate initiation of care. Women who were unhappy about the pregnancy (OR = 1.44), unsure that they wanted to be pregnant (OR = 2.81), or denied their pregnancies (OR = 4.82) were more likely to have inadequate prenatal care than women who did not have these attitudes. Women who were unhappy about being pregnant (OR = 1.86), unsure that they wanted to be pregnant (OR = 3.44), or who denied the pregnancy (OR = 6.69) were more likely to have inadequate initiation of care. Women who were unsure that they wanted to be pregnant (OR = 1.95) or who denied their pregnancies (OR = 2.47) were more likely to have received inadequate care once they had entered care. Conclusions: This study suggests that attitudes about pregnancy may be a psychosocial barrier to women obtaining early and continuous prenatal care. Pregnancy attitudes should be assessed and appropriate services provided to improve women's utilization of prenatal care. New measures of pregnancy attitude, beyond the traditional intention measures, can be useful in assessing pregnancy wantedness and identifying women to target for these services.     

Unintended pregnancy and breast-feeding behavior.

OBJECTIVES: This study assessed the effect of unintended pregnancy on breast-feeding behavior. METHODS: All women delivering a live birth between January 1, 1995, and July 31, 1996 (n = 33,735), in the 15-county central New York region were asked whether they had intended to become pregnant and their breast-feeding plans. RESULTS: Women with mistimed pregnancies, and pregnancies that were not wanted were significantly less likely to breast-feed than were women whose pregnancies were planned. After adjustment for confounding variables and contraindications for breast-feeding, the odds ratios of not breast-feeding remained significant. CONCLUSIONS: Promoting breast-feeding among women with unintended pregnancies is important to improve health status.     

Alignment between Desires and Outcomes among Women Wanting to Avoid Pregnancy: A Global Comparative Study of “Conditional” Unintended Pregnancy Rates

Since childbearing desires, and trends in these desires, differ across populations, the inclusion of women who want to become pregnant in the denominator for unintended pregnancy rates complicates interpretation of intercountry differences and trends over time. To address this limitation, we propose a rate that is the ratio of the number of unintended pregnancies to the number of women wanting to avoid pregnancy; we term these conditional rates. We computed conditional unintended pregnancy rates for five-year periods from 1990 to 2019. In 2015–2019, these conditional rates per 1,000 women per year wanting to avoid pregnancy ranged from 35 in Western Europe to 258 in Middle Africa. Rates with all women of reproductive age in the denominator have concealed stark global disparities in the ability of women to avoid unintended pregnancies, and they have understated progress in regions where the fraction of women wanting to avoid pregnancy has increased.     

Unintended Childbearing and Knowledge of Emergency Contraception in a Population-Based Survey of Postpartum Women

Objectives We examined the relationship between unintended childbearing and knowledge of emergency contraception. Methods The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) is a population-based survey of postpartum women. We analyzed data from the 2001 PRAMS survey using logistic regression to assess the relationship between unintended childbearing and emergency contraception while controlling for maternal characteristics such as age, race/ethnicity, education, marital status, family income, and insurance coverage before pregnancy. Results In 2001, 1,795 women completed the PRAMS survey (78.1% weighted response proportion). Of the women who completed the survey, 38.2% reported that their birth was unintended and 25.3% reported that they did not know about emergency contraception before pregnancy. Unintended childbearing was associated with a lack of knowledge of emergency contraception (OR 1.43, 95% CI 1.00, 2.05) after controlling for marital status and age. Conclusions Women in Oregon who were not aware of emergency contraception before pregnancy were more likely to have had an unintended birth when their marital status and age were taken into account. Unintended birth was more likely among women who were young, unmarried, lower income, and uninsured. Given that emergency contraception is now available over-the-counter in the US to women who are 18 years of age or older, age- and culturally-appropriate public health messages should be developed to expand women’s awareness of, dispel myths around, and encourage appropriate use of emergency contraception as a tool to help prevent unintended pregnancy and birth. An erratum to this article can be found at