Despite attempts to expand access to contraceptive technologies and to encourage family planning, unintended pregnancy remains a major public health problem in the United States. African American women are at particularly high risk compared with women of other races and ethnicities. In our study population of pregnant women already enrolled in antenatal care, which primarily consists of women who have elected to continue their pregnancy, we were able to confirm this disparity in one behavioral dimension of pregnancy intent—whether or not the woman was trying to get pregnant.
Although we expected that higher levels of fatalism might mediate the higher rate of not trying to get pregnant noted among African American women, we were not able to demonstrate this in this study, nor did we see interactions in these relationships by race/ethnicity. This is in contrast to our previous findings in prenatal testing, in which levels of fatalism were found to mediate differences in testing strategy between women of different races/ethnicities.19
Of note, we regard with interest the mitigation of the significant effect of fatalism on the outcome once race/ethnicity was accounted for. Our findings might suggest that the effect of race/ethnicity is mediated by a construct related to fatalism, although one that was not measured in this study. Perhaps with a measure of fatalism more specifically related to pregnancy, we might have discovered a stronger effect or evidence of mediation.
We did observe that subjective social standing was an independent predictor of not trying to get pregnant in our overall prediction model. However, further exploration revealed that this construct was only a significant predictor among white women and among women born in the United States. This finding is consistent with a prior study that documented that after adjustment for objective measures of SES (such as income and education), subjective social standing was related to self-rated health among white women but not among African Americans or Latinas.21
This finding should be taken into account as we examine target populations' efforts to reduce unintended pregnancy. Many programs are aimed toward women of lower SES via public financing streams, but more attention should be paid to racial and ethnic minorities of higher social standing. Although they are not typically the focus of public health campaigns, these women remain at higher relative risk of unintended pregnancy than others and may need to be considered separately as health messages are developed and marketed. Similarly, in the clinical arena, patients who seek care should be evaluated for their individual risk of unintended pregnancy regardless of their SES, social standing, or insurance type.
The current study is not without its limitations. The study sample was drawn from the San Francisco Bay area and was limited to women enrolled in prenatal care; thus, this group may not be representative of the entire population of reproductive-aged women at risk for unintended pregnancy in this country. However, we believe our study provides a unique view of a special population not often studied in examinations of unintended pregnancy, specifically, women who have elected to continue their pregnancies. Women who have unintended pregnancies but choose to continue their pregnancies should be of particular interest to clinicians and public health practitioners. These women, specifically those with unwanted pregnancies (as contrasted with mistimed pregnancies), have been shown to have increased risks of high-risk behaviors during pregnancy, such as use of tobacco, alcohol, and illicit drugs, coming late to prenatal care, and not breastfeeding.30,31
They are also probably more likely to have unintended pregnancies in the future. Identification of these women during the course of pregnancy may provide valuable opportunities for counseling and intervention.
In terms of reproductive history, the proportion of women with unplanned pregnancies in our cohort is similar to other quoted U.S. rates, although the proportion of women reporting having undergone an abortion in this cohort is higher than the U.S. average.32
The initial design of the study sought to oversample women from minority backgrounds, which may partly account for the higher abortion rate, but the recruitment of this diverse sample is also clearly a strength of this study population. The parent investigation was designed to study prenatal testing decision making, and, thus, we were limited to those attitudes explored as part of this original research question.
Our outcome measure has not been validated previously, nor did the retrospective nature of the study allow for a validation within this population. We believe, however, that the phrasing of the survey question allowed for an unbiased account of behaviors and planning related to the index pregnancy. We did note a correlation between the outcome as measured and women reporting being “very happy” about their pregnancy (AOR, 95% CI for the outcome 0.46, 0.25-0.86 among women who were “very happy”), a suggestion that our measure may track with intent. Santelli et al.33
recently reported a moderate correlation between trying to get pregnant and happiness about pregnancy and described “trying” as one cognitive factor predictive of pregnancy intent.34
Other measures have endured varied criticisms of their ability to measure unintended pregnancy as well, and currently there is no gold standard for the determination of pregnancy intent.35,36
Many measures in current use are quite transparent in their attempts to glean information on wantedness of pregnancies; responses to these measures may be skewed toward social desirability. The measure used in the current study may carry an advantage in that it would seem to be probing a more clinical and behavioral construct. It may prove to be the case that pregnancy planning is not a meaningful construct for all women, and further exploration of this within diverse populations is warranted.
Continued efforts to develop effective means of preventing unintended pregnancy are needed. Improving the ability of all women to seek healthcare outside of the context of pregnancy to promote health, prevent disease, and allow for healthy pregnancy timing will be key to improving the health of women and children in the United States. Our findings suggest, however, that the populations of women traditionally thought of as being in need of services may not represent the entire population of women at risk for unplanned pregnancy. Racial and ethnic minorities, regardless of subjective socioeconomic standing, are at high risk of unintended pregnancy. Expanding access to family planning for low-income women is clearly laudable, but limiting efforts to these strategies will not serve all women at risk. Future investigations should continue to focus on the role of cultural and reproductive attitudes on unintended pregnancy risk to allow for better tailored behavioral and educational interventions.