A Qualitative Assessment of Unintended Pregnancy in South King County

Background and Purpose

Unintended pregnancy remains a significant public health problem in King County despite multi-agency efforts to reduce the rate of unplanned conceptions. An estimated 55% of pregnancies to King County residents were unintended from 1994-1998. This is higher than the national estimate of 49% and falls far short of the Healthy People 2010 goal of 30%. Studies have shown that unintended pregnancy is associated with risk for a range of negative social and health consequences. While unintended pregnancy occurs among all age, income, race, and ethnic groups, low-income women have higher rates and may face greater challenges when it occurs.

Historically, most unintended pregnancy prevention efforts at both the local and national levels have focused on expanding knowledge about contraception and access to contraceptive services. Many ongoing efforts in King County stem from this approach, such as administering the federal Title X program, which makes the full range of family planning services available to low-income men and women; increasing access to emergency contraception; and implementing the Take Charge program to expand family planning coverage to all women and men at or below 200% of the federal poverty level.

However, while knowledge and access are essential to effective contraceptive use, there is growing recognition that efforts to reduce rates of unintended pregnancy might not succeed without addressing the complex array of desires, motivations, and pressures both to conceive and avoid conception. Indeed, one reason for persistently high rates of unintended pregnancy may be our failure to adequately understand the meaning, relevance, and experience of "pregnancy intention" among the women we target for family planning services.

In recent years, researchers have begun to explore some of the fundamental assumptions that underlie the way we think about unintended pregnancy. Do women value "intendedness" as it relates to pregnancy?¹What meaning do women assign to commonly used terms, such as wanted, intended, planned, and prepared?²Qualitative studies that explored how women conceptualize pregnancy planning suggest that (1) the concept may not be relevant and salient to all women and (2) unplanned pregnancies may carry distinct advantages as well as disadvantages.

The purpose of this study was to explore three major areas:

Ultimately, we hope to use the findings to inform family planning practice, community health education messages, and future research on pregnancy intention. We believe that a deeper understanding of this public health issue will lead to more relevant, meaningful, and effective unintended pregnancy prevention efforts in King County.

¹	Moos M et al. Pregnant Women's Perspectives on Intendedness of Pregnancy. Women's Health Issues 1997; (7)6: 385-92.
²	Fischer R et al. Exploring the Concepts of Intended, Planned, and Wanted Pregnancy. The Journal of Family Practice 1999; (48)2: 117-122.

Methods

A qualitative approach was utilized for this study to allow an inductive and in-depth exploration of how women think about becoming pregnant. Data were collected through semi-structured individual interviews, guided by a series of open-ended questions that allowed women to describe their experiences in context and in their own words. The sample consisted of 30 low-income adult women living in the suburban city of Federal Way (King County, Washington). Participants were recruited at two agencies serving low-income women of reproductive age: the Federal Way Community Service Office and the Federal Way Public Health Center (the Women, Infant and Children [WIC] program and the family planning clinic).

Key Findings

The language of pregnancy intention

The wantedness of a pregnancy is not fixed at conception. It can change over time.
The term "intended" pregnancy carried highly negative connotations for a substantial group of participants.
Pregnancies described as "unplanned" or "unprepared" were viewed neutrally and were not necessarily considered problematic.
Participants generally did not see the terms "unintended," "intended," "planned," and "prepared" as reflective of their personal experiences.
Participants introduced the term "being ready" and used it often. "Being ready" described an emotional state or a positive life situation in which to have a child.

Pregnancy motivations and timing

Relationships and the desire for love and connection are at the heart of women's primary motivations to conceive.
Men's pregnancy-related attitudes and desires, as perceived by their female partners, provided additional motivation to get pregnant.
Social and economic hardship was tightly interwoven with women's pregnancy experiences.
Participants felt that pregnancy should occur, ideally, after one is in a stable, marital relationship; has a steady job and some degree of economic security; and is emotionally "ready" to handle the responsibilities of parenting.
The vast majority of women interviewed stated that they were currently delaying pregnancy until a later time.

Beliefs and experiences with planning pregnancy

Women's belief in both their own control over pregnancy and the role of fate (and other external factors) coexist without apparent contradiction.
While valued to a degree, the notion of planning for pregnancy (clearly, consciously deciding to get pregnant) was rarely part of women's experiences.
Participants' comments suggested that pregnancy planning has considerable drawbacks.
The phrase "if it happens, it happens" was expressed throughout the interviews as a widely held stance towards pregnancy.

Discussion of Major Themes

Conflicting pregnancy motivations

The women who spoke with us reported having coexisting and conflicting motivations both to get pregnant and to avoid pregnancy. Relationships with male partners and the need for love and attachment with a child serve as strong, compelling motivations to conceive. At the same time, women described important prerequisites to childbearing, including financial security, a stable (preferably marital) relationship, finishing an education, and starting a career. Most participants expressed a strong desire to postpone pregnancy until at least some of these life conditions are met.

Though the women in the study saw the value of delaying pregnancy until a better time in their lives, most of their pregnancies had occurred under less than optimal conditions: in poverty and often without a partner. For low-income women facing the uncertainty of when (or even if) they will reach a better time in their lives, postponing pregnancy until their economic situation improves poses the risk of waiting indefinitely. Under these circumstances, we wonder whether women may allow pregnancy to happen if they have met some, but not all, of the prerequisite conditions (e.g., stable partner, but not financial security), believing that it might be their best opportunity.

Planning pregnancy is valued in the abstract but has distinct drawbacks

While planning pregnancy (in the sense of explicitly deciding to become pregnant) was an infrequent experience among the participants in the study, women spoke of the importance of planning and expressed the desire to plan future pregnancies. However, we also heard about the distinct disadvantages to clearly and consciously planning to conceive: it undermines nature and fate, it can lead to disappointment, and it may remove the element of surprise - a seemingly positive and valued experience. In addition, for women who want to achieve certain life conditions prior to childbearing, the incentive to overtly plan pregnancy may be weak. Planning to get pregnant in the absence of economic stability (and other valued conditions) not only contradicts widely held societal values about childbearing and poverty, it means opposing personal values as well.

If it happens, it happens: an alternative to planning?

Taken as a whole, our findings lead us to think that planning pregnancy, while valued in the abstract, is not the most relevant or salient concept for the women in our study. This may help explain why we heard so little expressed desire for pregnancy, in spite of the compelling motivations and pressures to conceive described by participants.

Instead of explicitly planning pregnancy, our data suggest that women's intent toward becoming pregnant is more often expressed as "if it happens, it happens." Though a seemingly casual, noncommittal stance toward pregnancy, "if it happens, it happens" carries important meaning. It allows for the possibility that God plays a role, honors the mystery of conception, and resolves ambivalence toward pregnancy (conflicting, coexisting feelings) by attributing the outcome to fate ("it was meant to be").

More importantly, adopting the stance "if it happens, it happens" and letting pregnancy happen (as opposed to overtly planning it), circumvents the difficulty of seeking pregnancy at a less than optimal point in life. We believe that letting pregnancy happen, instead of planning for it, is a logical response to the bind of wanting to become pregnant but knowing that it is not the best time. When viewed through these lenses, it is not difficult to understand the high rates of unintended pregnancy among this group of women.

Sub-intended: neither fully intended, nor fully unintended

Are these pregnancies unintended? Does leaving oneself open to the possibility of pregnancy, without explicitly seeking it, constitute an intention to conceive? Clearly, women's experiences of pregnancy are fraught with far more ambiguity than the simple intended versus unintended dichotomy allows. These terms capture neither the gradations of desire nor the conflicting desires expressed by the participants in our study.

It is conceivable that the categories of pregnancies we think of as "intended" and "unintended" are quite heterogeneous with similarities across the groups. Developing more precise and refined measures of pregnancy intention - measures that account for degree of intention and allow for ambivalence - seems a necessary prerequisite for a fuller understanding of the risks and outcomes of this complex phenomenon. Perhaps, as some researchers have suggested, a category of "sub-intended" is needed to describe pregnancies that do not fall into either category.

The term "intended pregnancy" carries negative connotations for some

This study revealed that the terms commonly used to discuss pregnancy intention and planning frequently held different meanings for the women we interviewed than they do for public health professionals. Notably, "intended" pregnancy carried very negative connotations for many of the respondents (e.g., plotting, trapping, malicious), while "unintended" pregnancy was viewed neutrally (e.g., an accidental, but potentially positive, pregnancy). This finding reinforces the importance of grounding our prevention messages and interventions in formative research.

Implications for Future Research

Adapt questions about pregnancy intention (for research, data collection, and client interactions) in ways that capture women's complex, and sometimes contradictory, feelings towards pregnancy. In recent years, some national surveys, such as the National Survey on Family Growth, have modified their questions on pregnancy intention to capture nuanced and ambivalent feelings. State and local measures of pregnancy intention, including Washington State PRAMS, would be strengthened by similar adaptations.

Investigate the notion that "if it happens, it happens" is a more relevant and salient stance toward pregnancy than "intention" or "planning."

Explore the role that current relationships play in women's pregnancy desires, especially the "partner-specific" nature of pregnancy intention.

Conduct and use formative research to inform the development of prevention messages, programs, and terminology related to unintended pregnancy.

Determine to what extent the findings of this report hold true for women in other economic groups who experience unintended pregnancy.

Conclusions

The findings of this report reveal a discrepancy between current frameworks for understanding unintended pregnancy and the beliefs and experiences of women most at risk for unintended pregnancy. Closing this gap is a key to effective prevention strategies. It is our hope that researchers will continue to seek deeper understanding of pregnancy-related beliefs and experiences, and come together with program planners, policy makers, providers, reproductive health advocates, and community members to develop effective approaches to preventing unintended pregnancy that promote healthy families, personal dignity, and self-determination.

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