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.

Depression and unwanted first pregnancy: longitudinal cohort study

OBJECTIVE

To examine the outcomes of an unwanted first pregnancy (abortion v live delivery) and risk of depression and to explain discrepancies with previous research that used the same dataset.

DESIGN

Longitudinal cohort study.

SETTING

Nationally representative sample of US men and women aged 14-24 in 1979.

PARTICIPANTS

1247 women in the US national longitudinal survey of youth who aborted or delivered an unwanted first pregnancy.

MAIN OUTCOME MEASURES

Clinical cut-off and continuous scores on a 1992 measure of the Center for Epidemiological Studies depression scale.

RESULTS

Terminating compared with delivering an unwanted first pregnancy was not directly related to risk of clinically significant depression (odds ratio 1.19, 95% confidence interval 0.85 to 1.66). No evidence was found of a relation between pregnancy outcome and depression in analyses of subgroups known to vary in under-reporting of abortion. In analyses of the characteristics of non-respondents, refusal to provide information on abortion did not explain the lack of detecting a relation between abortion and mental health. The abortion group had a significantly higher mean education and income and lower total family size, all of which were associated with a lower risk of depression.

CONCLUSIONS

Evidence that choosing to terminate rather than deliver an unwanted first pregnancy puts women at higher risk of depression is inconclusive. Discrepancies between current findings and those of previous research using the same dataset primarily reflect differences in coding of a first pregnancy.

Association of pregnancy intention with parenting difficulty in Fukushima, Japan

BACKGROUND

Our prior study revealed that nearly half of the Japanese women between the ages of 35 and 49 years experience an unintended pregnancy, many of which are carried to term. The present study is intended to investigate the association of the intention to become pregnant with parenting difficulty after birth.

METHODS

We distributed self-administered questionnaires to mothers of 317 randomly selected children aged 3 to 18 months who resided in Sukagawa City, Fukushima. The extent to which the unintended pregnancy is associated with the risk of negative attitude in parenting was examined by using multiple logistic regression analysis.

RESULTS

The response rate was 69% and the proportion of births, the outcome of an unintended pregnancy, 22%. When the pregnancy was unintended, the mother may not deny her feelings toward child abuse (odds ratio [OR] = 5.2). She was unlikely to have discussion about child rearing with her husband (OR=3.1) or family (OR=3.3); or the husband rarely participate in child rearing (OR=1.9).

CONCLUSION

To improve the child rearing environment, these findings provide preliminary evidence to underscore the importance of pregnancy planning and providing services to augment the parenting skills of couples who have an unintended pregnancy. A follow-up of pregnant women is currently underway to examine prospectively the effects on child rearing of one's intention to become pregnant.

Scaling up postabortion contraceptive service — results from a study conducted among women having unwanted pregnancies in urban and rural Tanzania

INTRODUCTION

It is well recognized that unwanted pregnancies and unsafe abortion are significant public health problems in sub-Saharan Africa. At the International Conference on Population and Development held in Cairo in 1994, postabortion care was prioritized as a means to reduce maternal morbidity and mortality associated with unsafe abortion. However, only a few postabortion care programs have been implemented and most of them have been confined to urban settings. The present study describes the magnitude of the problem of unwanted pregnancies among women with incomplete abortion in urban and rural Tanzania and evaluates the outcome of a postabortion care intervention.

METHODS

Data were collected among 781 women admitted with incomplete abortion in Dar es Salaam region (urban Tanzania) and 575 women in Kagera region (rural Tanzania).

RESULTS

Sixty-seven percent of the women in urban Tanzania and 42% in rural Tanzania stated that their pregnancy was unwanted. Contraceptive acceptance among women with unwanted pregnancies was high; 93% in urban Tanzania and 71% in rural Tanzania left with a contraceptive method.

CONCLUSION

The high proportion of women with unwanted pregnancies in urban and rural Tanzania underlines the need of scaling up postabortion contraceptive service.

"Planned" and "unplanned" pregnancy: deconstructing experiences of conception

This paper seeks to explore women's experiences of conception, and to deconstruct the dichotomy between the terms "planned" and "unplanned" pregnancy. It draws on interviews with 19 primagravidae conducted as part of a wider qualitative study of women's experiences of pregnancy and childbirth. Although the concept of pregnancy intention is widely regarded as ambiguous, and by some immeasurable, this paper draws on interview data to develop four categories of pregnancy intention. The first category (the planned pregnancy) is unambiguous and reflects the type of planned approach currently advocated by health professionals. The second category (the laissez-faire pregnancy) reflects the experiences of women who stop using contraception but adopt a more relaxed approach to pregnancy planning. The third category (the recalcitrant pregnancy) is far more ambiguous and describes the experiences of those who want to be pregnant but for whom it would not be socially acceptable to plan a pregnancy. The final category (the accidental pregnancy) is unambiguous and deals with pregnancies that could be described as unexpected, and arising due to genuine contraceptive failure. This paper concludes by highlighting the significance of pregnancy intention for health policy, health research, and for the health care providers. The importance of adopting a subjective approach to improve our understanding of women's experiences of conception is also highlighted.

Pregnancy intention from men's perspectives: does child support enforcement matter?

CONTEXT

Most research on pregnancy intention has focused on women's perspectives and characteristics. Because decisions about sexual activity and contraceptive use usually involve both men and women, it is important to understand factors associated with men's intentions-for example, child support enforcement-to maximize the potential for reducing unwanted pregnancies.

METHODS

Data from the 1982-2002 waves of the National Longitudinal Survey of Youth were used in multinomial logit analyses to examine the determinants of pregnancy intention from men's perspectives.

RESULTS

Forty-six percent of pregnancies reported by never-married men were unwanted, compared with 21% of those reported by married men. Stronger child support enforcement was marginally associated with men's decreased likelihood of being involved in an unwanted pregnancy compared with no pregnancy (coefficient, -0.14) and of being involved in an unwanted pregnancy compared with a wanted pregnancy (-0.15). Without the improvement of child support enforcement over the survey period, the rate of unwanted pregnancies would have been an estimated 7% higher than the observed rate.

CONCLUSIONS

Strengthening child support enforcement may have a positive impact on preventing unwanted pregnancies. Programs designed to reduce unwanted pregnancies and nonmarital births should include information on child support enforcement to increase their success.

Child murder by mothers: a critical analysis of the current state of knowledge and a research agenda

OBJECTIVE

Maternal filicide, or child murder by mothers, occurs more frequently in the United States than in other developed nations. However, little is known about factors that confer risk to children. The authors review the literature to identify predictors of maternal filicide and identify gaps in knowledge about maternal filicide.

METHOD

Databases were systematically searched for studies of maternal filicide and neonaticide (murder in the first day of life) that were conducted in industrialized countries and were published in peer-reviewed, English-language publications after 1980.

RESULTS

Women who committed filicide varied greatly by the type of sample studied. Neonaticide was often committed by young, poor, unmarried women with little or no prenatal care.

CONCLUSIONS

The results of the review suggest that little is known about the predictors of maternal filicide and that a systematic, focused program of research on reliable markers for maternal filicide is needed to better prevent these events.

Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy

OBJECTIVE

The primary objectives of this study were to explore maternal history of perinatal loss and pregnancy wantedness as correlates of substance use during pregnancy.

METHOD

The research design involved interviewing women who gave birth in Washington DC hospitals during 1992. Interview data included pregnancy history (prior births, induced abortions, miscarriages, and stillbirths), desire for the pregnancy (wanted, not wanted, mistimed), socio-demographic information, timing of onset of prenatal care, and substance use (cigarettes, alcohol, and drugs) during pregnancy.

RESULTS

A history of induced abortion was associated with elevated risk for maternal substance use of various forms; whereas other forms of perinatal loss (miscarriage and stillbirth) were not related to substance use. Unwanted pregnancy was associated with cigarette smoking during pregnancy, but not with any other forms of substance use.

CONCLUSIONS

Reproductive history information may offer insight to professionals pertaining to the likelihood of women using substances in a later pregnancy.

Providing options counseling for women with unintended pregnancies

Nearly half of the pregnancies in the United States are unintended, and nurses frequently encounter women with unintended pregnancies in the clinical setting. Nurses may be responsible for counseling these women on how to explore and decide between the options of parenting, adoption, and abortion. To date, little has been written about options counseling, despite the fact that unintended pregnancy is one of the most common health conditions that women face. This article presents epidemiological data on prevalence, outcomes, consequences, causes, and prevention of unintended pregnancy. It examines the conflicts that nurses may experience when providing care to women with unintended pregnancies and discusses the intersection of professional responsibilities and personal values. Finally, the article presents general strategies and specific suggested steps for providing options counseling.

Is unintended pregnancy a risk factor for depression in Iranian women?

A study was carried out to determine the association between unintended pregnancy and pre- and postpartum depression in 163 women in Kermanshah city, Islamic Republic of Iran. Using the self-administered Beck Depression Inventory for educated women and a special interview for illiterate women, 105 intended and 58 unintended pregnancies were studied. Of the 58 women with unintended pregnancy, 43% reported attempting to abort the fetus. Depression at 37 weeks' gestation was slightly higher in the unintended than the intended pregnancy group (53.4% versus 41.0%; relative risk = 1.3) and depression 10 days postpartum was much higher in the unintended group (48.7% versus 25.6%; relative risk = 1.9). Screening for depression is recommended for pregnant women with unintended pregnancy.

Is intimate partner violence associated with unintended pregnancy? A review of the literature

Although a substantial body of literature explores the adverse physical and mental health consequences associated with intimate partner violence, only a limited body of international research has explored the effect of intimate partner violence on women's fertility control. Yet a compelling argument can be made of the indirect mechanism through which the climate of fear and control surrounding abusive relationships could limit women's ability to control their fertility. Lack of fertility control can lead to unintended pregnancies, which are also associated with adverse outcomes for women's and infant health, especially in developing countries. The association between intimate partner violence and unintended pregnancy also suggests serious social effects spawned by a cycle of unintended childbearing in abusive households. Therefore, further investigation is warranted to explore the nature of the association as well as the mechanisms through which these phenomena operate in the United States and in developing countries.

Profile of Mood States and parental attitudes in motherhood: comparing women with planned and unplanned pregnancies

BACKGROUND

Despite the availability of various contraceptive options, in some Western countries most pregnancies are unplanned. The objective of this longitudinal study was to assess the influence of planned and unplanned pregnancy on women's psychological well-being and on maternal attitude toward parenting in the first years after giving birth.

METHODS

A sample of 119 primiparous women (88 planned and 31 unplanned pregnancies) with normal pregnancy, uncomplicated vaginal delivery, and a healthy living baby completed the Profile of Mood States (POMS) instrument in the ninth month of pregnancy, and at 1, 6, and 12 months after birth, and the Parental Attitude Research Instrument (PARI) 2 years after the birth. The POMS evaluates mood disturbance and the PARI assesses maternal attitudes toward parenthood in general.

RESULTS

Women with unplanned pregnancies demonstrated a significantly more disturbed mood, both in pregnancy and in the first year after the birth. However, at approximately 2 years after childbirth there was no difference between the two groups of women in their rejection of the maternal role, and repressive and punitive maternal attitudes.

CONCLUSIONS

In primiparas of middle socioeconomic levels, unplanned pregnancy is a risk factor for moderate mood disturbances rather than for an inadequate parental educational role. The study findings demonstrate the need to prevent unplanned pregnancies, and to offer immediate health assistance when particular conditions arise.

Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: a cohort study of the 1995 National Survey of Family Growth

The psychological consequences of induced abortion are complex and subject to both considerable controversy and methodological criticisms. While many women report feelings of relief immediately after the procedure, others report feelings of anxiety, which they attribute to their abortions. The purpose of the present study was to examine risk of generalized anxiety following unintended pregnancies ending in abortion or childbirth using a large representative sample of American women. Among all women, those who aborted were found to have significantly higher rates of subsequent generalized anxiety when controlling for race and age at interview. Implications of the findings are discussed. In particular, findings highlight the clinical relevance of exploring reproductive history in therapeutic efforts to assist women seeking relief from anxiety.

Predicting adolescent risk behaviors based on an ecological framework and assets

OBJECTIVES

To examine the relationship between an aggregate risk score (smoking, drinking, and number of sex partners) and measures of youth assets in a sample of 3439 youth aged 14-18 years.

METHODS

Linear regression models for African American and white males and females predicted an aggregate risk score.

RESULTS

After adjustments, the youth asset most predictive of risk was self/peer values regarding risk behaviors. Perceived school support was also predictive.

CONCLUSIONS

Taking an ecological approach to the measurement of adolescent health behaviors contributes to our understanding of these risk behaviors.

Maternal-fetal attachment: searching for a new definition

Maternal-fetal attachment is the purest source of the powerful attachment relationship, the gradual internalisation of the life within unspoilt by the realities and complexities of early parenting. This qualitative study searches for a definition of attachment utilising a phenomenological framework. An opportunity sample of 10 women in the final trimester of pregnancy was interviewed. Interviews were transcribed and analysed using Glaser & Strauss's (1967) constant comparative methodology. Thirteen key themes were identified, of these 4 were specific to parenting experience. A novel finding contrary to earlier studies was that women reported their overwhelming emotion was not love but an innate desire to protect. Protection, the developmental nature of attachment and importance of the emotional and physical support of a partner or parent form the kernel of an evolving paradigm.

Substance use associated with unintended pregnancy outcomes in the National Longitudinal Survey of Youth

Abortion is known to be associated with higher rates of substance abuse, but no studies have compared substance use rates associated with abortion compared to delivery of an unintended pregnancy. This study examines data for women in the National Longitudinal Survey of Youth whose first pregnancy was unintended. Women with no pregnancies were also used as a control group. Use of alcohol, marijuana, cocaine, and behaviors suggestive of alcohol abuse were examined an average of four years after the target pregnancy among women with prior histories of delivering an unintended pregnancy (n = 535), abortion (n = 213), or those who reported no pregnancies (n = 1144). Controls were instituted for age, race, marital status, income, education, and prepregnancy self-esteem and locus of control. Compared to women who carried an unintended first pregnancy to term, those who aborted were significantly more likely to report use of marijuana (odds ratio: 2.0), with the difference in these two groups approaching significance relative to the use of cocaine (odds ratio: 2.49). Women with a history of abortion also reported more frequent drinking than those with a history of unintended birth. With the exception of less frequent drinking, the unintended birth group was not significantly different from the no pregnancy group. Resolution of an unintended pregnancy by abortion was associated with significantly higher rates of subsequent substance use compared to delivering an unintended pregnancy. A history of abortion may be a useful marker for identifying women in need of counseling for substance use.

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.

Measuring factors underlying intendedness of women's first and later pregnancies

CONTEXT

Unintended pregnancy is associated with poor health outcomes for mothers and infants, and is indicative of gaps in family planning services. Conventional measures of pregnancy intendedness do not reflect the multiple factors affecting a woman's pregnancy-related intentions and attitudes.

METHODS

Data collected between March 2002 and February 2003 from 701 women in a public family planning clinic and 671 women in a public prenatal clinic in New Orleans were analyzed to examine factors underlying intendedness (including attitudes toward pregnancy and motivations to achieve or avoid pregnancy).

RESULTS

In factor analyses, variables measuring pregnancy intendedness were represented by a single latent factor, pregnancy desirability. For first pregnancy, variables that best captured desirability were those measuring happiness, effort in achieving the pregnancy, extent of looking forward to telling friends, whether the pregnancy was intended (i.e., came at the right time or later), and whether the woman wanted to have a baby with her partner. For last or current pregnancies that were second or higher order ones, they were happiness, pregnancy wantedness, effort in achieving the pregnancy, whether the pregnancy was planned and whether the woman wanted to have a baby with her partner. Among women younger than 18 at first pregnancy, happiness and whether a woman wanted a baby with her partner were the only items that captured pregnancy desirability.

CONCLUSIONS

Future surveys on pregnancy intendedness could reduce the number of questions used to capture pregnancy desirability. This should help standardize surveillance systems and permit better assessment of trends in pregnancy desirability over time.

Women's experiences in connection with induced abortion - a feminist perspective

Although abortions are common, few researchers have explored the experiences of women related to abortions. The aim of this qualitative study was to analyse women's experiences of induced abortion from a feminist perspective. Five women aged 19-33 years were interviewed about 1 month after their abortion. The interviews were analysed using thematic content analysis from which the following themes were identified: experiences connected with the decision-making process, experiences connected with the abortion and experiences after the abortion. Childhood experiences of divided families, financial problems, being too young, and an insecure partnership influenced the women's decision to have an abortion. Ambivalence about abortion was strongly expressed throughout the process. Despite positive attitudes towards abortion in general, the women had negative attitudes towards their own abortion. They described receiving most support from their mothers and friends, in the decision-making process, and least from their partners. After the abortion the women gained a feeling of maturity and experience although their ambivalence persisted. One conclusion drawn from our study is that nurses and midwives need to be aware of women's complex experiences with abortions in order to support and empower women who seek an abortion.

Barriers to Utilization of Prenatal Care Services in Turkey

PURPOSE

To identify barriers to utilization of prenatal care services in Turkey, including pregnant women's attitudes toward pregnancy and prenatal care.

DESIGN

Descriptive. The population was Turkish women who lived in Erzurum and had delivered their infants but were still hospitalised.

METHODS

The sample of 446 women had or had not received prenatal care, had no complications during pregnancy, carried their pregnancies to term, and were considered to have normal deliveries. Attitudes toward pregnancy and prenatal care and barriers to prenatal care services were measured by use of a questionnaire.

FINDINGS

Low education of pregnant women and unwanted pregnancy were barriers to use of prenatal care services. Additional barriers were negative attitudes toward pregnancy and attitudes toward prenatal care. These barriers decreased frequency of use and delayed early initiation of prenatal care. The most important barrier reported by the women was being too busy at home to seek care.

CONCLUSIONS

Although this sample was limited, the findings indicate barriers for attention by health care providers to ensure appropriate prenatal care and maternal and infant health.

Unintended pregnancy and induced abortion among unmarried women in China: a systematic review

Background

Until recently, premarital examination for both men and women was a legal requirement before marriage in China. Researchers have carried out surveys of attendees' sexual activity, pregnancy and abortion before their marriages, trying to map out reproductive health needs in China, according to this unique population-based data. To systematically identify, appraise and summarise all available studies documenting pregnancy and induced abortion among unmarried Chinese women attending premarital examinations.

Methods

We searched the Chinese Biomedical Literature Index from 1978 to 2002; PUBMED; and EMBASE. Trials were assessed and data extracted by two people independently.

Results

Nine studies, of which seven were conducted in the urban areas, one in the rural areas, and one in both urban and rural areas, met the inclusion criteria. In the seven studies in urban areas, the majority of unmarried women had experienced sexual intercourse, with estimates ranging from 54% to 82% in five studies. Estimates of a previous pregnancy ranged from 12% to 32%. Abortion rates were high, ranging between 11 to 55% in 8 studies reporting this, which exclude the one rural study. In the three studies reporting both pregnancy and abortion, most women who had become pregnant had an induced abortion (range 86% to 96%). One large rural study documented a lower low pregnancy rate (20%) and induced abortion rate (0.8%).

Conclusions

There is a large unmet need for temporary methods of contraception in urban areas of China.

Decision making and referral prior to abortion: a qualitative study of women's experiences

BACKGROUND

Despite abortion being one of the most common gynaecological procedures performed in the UK, significant regional variation exists in access to services.

OBJECTIVE

This study explores women's experience of referral for abortion in three inner London boroughs to determine if services met their expectations.

METHOD

In-depth interviews conducted with 21 women of varying ages, gestations and ethnicity, 3-9 weeks after termination of their pregnancy. The data were subjected to qualitative analysis.

RESULTS

Most women had made a decision to proceed with abortion before approaching the health service, and expected non-judgmental support, information and prompt referral. We found variations in the extent to which these expectations were met. Delays in referral occurred when health professionals either required women to have more thinking time, referred them elsewhere for pregnancy testing or avoided discussing abortion. This was further compounded by difficulties in making appointments via the centralised telephone booking service. The brief counselling session offered to most women by the abortion providers, although helpful to some women, was viewed as unnecessary and intrusive by others.

CONCLUSIONS

Most women seeking an abortion prefer not to discuss their decision but expect information and prompt referral. Delays in referral cause distress and later abortions and should be avoided. High-quality counselling should be targeted at those in need.

Adolescent abortion: trends and techniques

The adolescent years are often characterized by high-risk behaviors. These behaviors carry consequences with them, including pregnancy and abortion. Although the abortion rate for adolescents has been decreasing since 1990, not all groups have seen an equal drop; notably, those adolescents not in school and members of minority groups are experiencing slower rates of decline. Adolescents undergo the same methods of abortion as adults; however, they have unique psychosocial needs, such as parental involvement and the prevention of future unwanted pregnancies, which should be assessed.

Contraception before and after termination of pregnancy: can we do it better?

AIM

To compare contraceptive use pre- and post-therapeutic abortion in 1995, 1999 and 2002 in a New Zealand clinic.

METHODS

Retrospective, consecutive case review of women presenting for therapeutic abortion. Anonymous data included demographic details, contraception used at conception, and post-termination contraception.

RESULTS

Pre-conception contraceptive use is significantly declining, with post-termination condom choice increasing. This is predominantly due to increasing numbers of Asian women presenting for abortion. In 2002, 97% of Asian women used no contraception or only condoms pre-conception, and 62% chose condoms or abstinence post-termination. Oral contraceptives are used significantly less by Asian than European women both pre-termination (p = 0.0002) and post-termination (p = 0.00001). Other ethnic groups showed little change in contraceptive use over the study periods.

CONCLUSIONS

It is speculated that ethnic Chinese women lack adequate contraceptive education, demonstrate distrust of non-barrier methods, believe men should provide the prophylactic, and mistakenly believe contraception unnecessary for the first week following menstruation. Abortion may be used for family planning rather than as back up for contraceptive failure. Young Chinese arriving in New Zealand require immediate sexual health education including accurate contraceptive information. Liaison between primary healthcare sectors and policy makers of immigration and other services assisting overseas students is recommended to provide culturally appropriate education.

Teenage pregnancy experiences in rural Kenya

This community-based survey describes the socio-economic determinants of teenage pregnancy, experiences of health problems during pregnancy, and health care utilization patterns among adolescents (12-19 years old) in rural Kenya. Characteristics of adolescents with repeated pregnancy experiences were compared with first-time pregnancies. The survey covered 3,132 households from 32 randomly selected communities and 1,247 adolescents were interviewed. Data were collected retrospectively through quantitative and qualitative methods. Results showed that 572 (45.9%) adolescents had had sexual intercourse in the past, and of these, 245 (42.8%) had been pregnant at least once. A significant majority of adolescents who had been pregnant were not attending school during the survey period. Fifty-six percent of the first pregnancies occurred while the girl was single. Compared with repeat pregnancies, first pregnancies were more likely to be reported as unwanted (OR = 2.4; 95% CI = 1.1, 5.3). Antenatal care attendance, place of delivery and pregnancy outcomes were not significantly different for first-time and repeat pregnancies. Adolescents' reports on health problems during pregnancy, labour and in the post-partum period were not associated with parity or with age (< 16 years old). A lower proportion of younger primigravidae sought medical attention for health problems that arose during pregnancy (OR = 2.3; 95% CI = 1.1, 4.8) and labor (OR = 3.6; 95% CI = 1.5, 8.7). In conclusion, the study highlighted major unmet reproductive health needs of adolescents in this region. Age and gravida influenced health care seeking which could increase the chances of serious life threatening complications among young primigravidae.

Women's life cycle and abortion decision in unintended pregnancies

OBJECTIVE

To study the impact of sociodemographic, financial, and reproductive factors and of characteristics related to intimate relationships on the decisions of women in different age groups about whether or not to continue an unintended pregnancy.

DESIGN

Cross sectional population based survey.

SETTING

Telephone interview survey between September 2000 and January 2001 in France. From a representative sample (n=14704) of 18 to 44 year old women, those who in the past five years had an abortion or whose last pregnancy was unintended were oversampled (sampling fraction=100%, n=1034) while the other women were randomly selected (sampling fraction =19%, n=1829). Altogether, 2863 women answered the questionnaire.

PARTICIPANTS

All women whose last pregnancy was unintended and ended in induced abortion or birth (n=645).

MAIN RESULTS

Factors associated with the abortion decision varied strongly according to age. Younger women's abortion decisions were mainly related to being a student and being single. Wanting to stop childbearing when the desired number of children was achieved best explained the decision to have an abortion among 25 to 34 year old women. Older women chose abortion especially when childbearing did not fit their work situation or when the relationship with the partner was unstable. A high level of education of a woman and her partner increased the likelihood of abortion, especially among young women.

CONCLUSIONS

The impact of socioeconomic and relationship factors on the decision to have an abortion is not the same at different stages in life, and refers to the social representations and perceptions of what good conditions are for being a mother.

[Few teenage pregnancies in Sweden--a comparison between five Western industrialized countries. Support from and attitudes in the society explain the differences]

Cross-national comparisons of teenage sexual and reproductive behavior in five Western industrialized countries show vast differences in teenage pregnancy rates and birthrates. The lowest rates are found in Sweden and France, moderate rates in Canada and Great Britain, and the highest in the USA. Since age and frequency of sexual activity are similar across countries, the variations in pregnancy rate reflect young people's motivation and ability to prevent unwanted pregnancies. Sweden and France offer the most positive attitudes to sexuality combined with a clear expectation that teenagers can make responsible decision about sexuality and delay childbearing. Societal acceptance of teenage sexuality is reflected in open-minded sexuality education and easy access to contraceptive services. In contrast the official message in USA is to delay childbearing until marriage by abstinence only, and use of contraceptives is not supported. Differences in societal support for employment and education also played a major role.

Knowledge and perception of emergency contraception among female Nigerian undergraduates

CONTEXT

The reproductive health hazards of unintended pregnancies and unsafe abortions are well documented. The potential of emergency contraceptives to prevent unwanted pregnancy in developed countries has been described, but in Nigeria, the awareness about the method is poor and no study has looked at efficacy.

METHODS

Between September and October 2001, a randomly selected sample of female undergraduate students at the University of Benin, Nigeria, were surveyed about their demographic information, sexual history and contraceptive use, and their awareness and knowledge of emergency contraception.

RESULTS

Of the 880 respondents, 43% were sexually active, 39% had ever practiced contraception and 34% had ever had an induced abortion. Overall, 58% of respondents reported knowing about emergency contraception; sexually active respondents were significantly more likely than those who were not and those who had ever practiced contraception were more likely than those who had not to be aware of emergency contraceptives. However, only 18% of respondents who reported knowing about emergency contraception knew the correct time frame in which emergency contraceptives must be used to be effective.

CONCLUSION

There is an urgent need to educate Nigerian young people about emergency contraception, emphasizing available methods and correct timing of use.

Sociocultural determinants of induced abortion

OBJECTIVE

To determine the frequency of induced abortion and identify the role of sociocultural factors contributing to termination of pregnancy and associated morbidity and mortality in hospital setting.

DESIGN

Prospective observational study.

PLACE AND DURATION OF STUDY

The study was conducted in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi from January 1999 to June 2001.

SUBJECTS AND METHODS

The patients who were admitted for induced abortion were interviewed in privacy. On condition of anonymity they were asked about the age, parity, family setup and relationships, with particular emphasis on sociocultural reasons and factors contributing to induction of abortion. Details of status of abortionist and methods used for termination of pregnancy, the resulting complications and their severity were recorded.

RESULTS

Out of total admissions, 57(2.35%) gave history of induced abortion. All women belonged to low socioeconomic class and 59.6% of them were illiterate. Forty-three (75.5%) of these women had never practiced contraception. Twenty-four (42%) were grandmultiparae and did not want more children. In 29 women (50.9%) the decision for abortion had been supported by the husband. In 25 women (43.8%) abortion was carried out by Daiyan (traditional midwives). Serious complications like uterine perforation with or without bowel injury were encountered in 25 (43.8%) of these women. During the study period illegally induced abortion accounted for 6 (10.5%) maternal deaths.

CONCLUSION

Prevalence of poverty, illiteracy, grand multiparity and non-practice of contraception are strong determinants of induced abortion.

Pregnancy intendedness and the use of periconceptional folic acid

OBJECTIVE

Periconceptional use of folic acid can prevent birth defects, including at least 50% of neural tube defects. This study used an ongoing surveillance system to explore the association between pregnancy intendedness and women taking periconceptional folic acid.

METHODS

Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) surveys a stratified random sample of women after a live birth. In 1998-1999, 1867 women completed the survey (64.0% response rate); responses were weighted for nonresponse. Women were asked whether they took folic acid most days in the month before becoming pregnant.

RESULTS

Overall, 33.2% of women took folic acid most days in the month before becoming pregnant, and 39.9% said that their pregnancy was unintended. Adolescent mothers were less likely to take periconceptional folic acid (9.2%) and more likely to report unintended pregnancy (62.0%) than older women. Overall, women who said that their pregnancy was intended were more likely to report that they had taken periconceptional folic acid (odds ratio: 4.75; 95% confidence interval: 3.16-7.14); after controlling for maternal age and income the odds ratio was 3.70 (95% confidence interval: 2.38-5.56).

CONCLUSIONS

Women whose pregnancies were intended were more likely to have been taking periconceptional folic acid than women whose pregnancies were unintended. The importance of fertile women's taking daily multivitamins that contain 400 microg (0.4 mg) of folic acid should be stressed among women who are not contemplating pregnancy, especially adolescents and low-income women.

The biopsychosocial aspects of unwanted teenage pregnancy

Unwanted teenage pregnancy is a major health problem in Wales and perioperative nurses are frequently involved in caring for teenagers undergoing surgical termination of pregnancy. By providing such adolescents with holistic care--by taking into account both biological and psychological aspects of health--nurses can help reduce an adolescent's anxiety and pain.

Born unwanted. Observations from the Prague Study

The authors followed 220 children born in 1961-1963 to women twice denied abortion for the same pregnancy in Prague (Czech Republic) and 220 pair-matched controls, whose mothers were pair-matched for age and socioeconomic status and the partner's presence in the home. They were medically, psychologically, and socially assessed at ages 9, 14-16, 21-23, 30, and 35. Although differences in psychosocial development between the unwanted study participants and pair-matched controls were not dramatic and changed over time, the differences were consistently in disfavor of the unwanted pregnancy participants. When siblings were used as controls, the findings supported the hypothesis that being born from an unwanted pregnancy is a risk factor for poor mental health in adulthood.

Nursing care for pregnant adolescents

Although the physical care of pregnant adolescents is similar to that required by adult women, adolescents have additional unique needs. Adolescents often need more support and extensive teaching during pregnancy and the postpartum. Moreover, adolescents often have fewer life experiences than do adult women, making them less able to cope with the life changes they are experiencing related to pregnancy and birth. Nonjudgmental and developmentally appropriate interactions are essential to the care of pregnant adolescents. This article explores nursing care for the physical, emotional, and educational needs of adolescents during the prenatal, intrapartum, and postpartum periods.

Motivational antecedents to contraceptive method change following a pregnancy scare: a couple analysis

In this study we develop and then test a couple model of contraceptive method choice decision-making following a pregnancy scare. The central constructs in our model are satisfaction with one's current method and confidence in the use of it. Downstream in the decision sequence, satisfaction and confidence predict desires and intentions to change methods. Upstream they are predicted by childbearing motivations, contraceptive attitudes, and the residual effects of the couples' previous method decisions. We collected data from 175 mostly unmarried and racially/ethnically diverse couples who were seeking pregnancy tests. We used LISREL and its latent variable capacity to estimate a structural equation model of the couple decision-making sequence leading to a change (or not) in contraceptive method. Results confirm most elements in our model and demonstrate a number of important cross-partner effects. Almost one-half of the sample had positive pregnancy tests and the base model fitted to this subsample indicates less accuracy in partner perception and greater influence of the female partner on method change decision-making. The introduction of some hypothesis-generating exogenous variables to our base couple model, together with some unexpected findings for the contraceptive attitude variables, suggest interesting questions that require further exploration.

Pregnancy wantedness: attitude stability over time

In this analysis we have compared two attitudinal reports, from interviews two years apart, of the same event for consistency over time. We have looked at women's self-reports, and at their proxy reports for partners' attitudes as well. The inconsistent reports of women's own views tended to shift slightly toward more favorable reports at the second interview (15 percent more positive versus 10 percent more negative). More specifically, 7.5 percent of women who reported at Time 1 that their most recent births had been unwanted switched to more favorable reports at Time 2, and about the same percentage of women who reported Table 4, the findings would suggest that some of the groups typically considered to be most "at risk" were those who were also most apt to report inconsistently. This findings should signal some concern in the policy community. Net of other factors, there is no effect of income, but a number of at-risk groups remained significantly more likely than others to change their reports over time. Of particular concern is the finding that women who reported their pregnancies as mistimed or unwanted were so much more likely to change their reports over time than were women who initially said that their pregnancies had been well timed. When we look at the direction of change, it is clear that, with some exceptions, the more "at risk" groups were more likely to shift in a more negative direction, while the less "at risk" groups were less likely to do so; and at times they were more likely to report more favorably at the second interview. Although somewhat hampered by small sample sizes in the analysis of Time 1 mistimed and unwanted reports, results confirmed that certain subgroups were not only more apt to report inconsistently, they were also more likely to do so in specific directions. To the extent that future survey questions can emphasize to respondents that they should focus on the time of conception, and not on current status, inconsistency across groups may be reduced.

Unintended pregnancies: a call for nursing action

Unintended pregnancies occur in all age groups and socioeconomic strata of our society and represent significant social, medical, and economic costs. Nearly 50% of all pregnancies in the United States are classified as unintended, and approximately 48% of all women ages 15 to 44 have experienced at least one unintended pregnancy. Contributors to unintended conceptions in the U.S. included barriers to accessing contraception, fears about using it, errors in use, and lack of back-up plans when errors in use occur. As important proponents of women's health, nurses are in an ideal position to address each of these contributors to unintended pregnancy through health promotion activities including patient education and counseling, through public policy advocacy, and through a commitment to a research agenda.

The mental health of adults born of unwanted pregnancies, their siblings, and matched controls: a 35-year follow-up study from Prague, Czech Republic

This study tested the hypothesis that being born of an unwanted pregnancy is a risk factor for poor mental health in adulthood. Self-report and objective data were collected at ages 28 to 31 and 32 to 35 years in a cohort of nearly 200 "unwanted" subjects born after their mothers had been twice denied an abortion for the same pregnancy. The same data were collected in a sociodemographically matched control cohort of "accepted" subjects whose mothers had not requested an abortion, and from siblings of both the unwanted subjects and the accepted control subjects. Logistic regression analyses conducted with several indicators of poor mental health in adulthood as dependent variables brought partial support for the hypothesis. Specifically, unwanted subjects became psychiatric patients (especially psychiatric inpatients) more frequently than their siblings and the accepted controls. Criminality, alcohol-related disorders, and heavy smoking were not associated with unwanted pregnancy.

What is a 'planned' pregnancy? Empirical data from a British study

The terms "planned", "unplanned", "intended", "unintended", "wanted" and "unwanted" are often used in relation to pregnancy in health policy, health services and health research. This paper describes the findings relating to women's understanding of these terms from the qualitative stage of a British study. We found that when discussing the circumstances of their pregnancies, women tended not to use the above terms spontaneously. When asked to explain the terms, women were able to do so but there was considerable variation in understanding. Most, but not all, were able to apply the terms. Women applied the term "planned" only if they had met four key criteria. Intending to become pregnant and stopping contraception were not sufficient criteria, in themselves, to apply the term; partner agreement and reaching the right time in terms of lifestyle/life stage were also necessary. In contrast, "unplanned" was a widely applied term and covered a variety of circumstances of pregnancy. The other terms were less favoured, "unwanted" being positively disliked. We recommend that survey questions eliciting information on women's circumstances of pregnancy do not rely on the above terms in isolation and, further, that a more circumspect use of the terms in policy and clinical settings is required.

Contraceptive failure--results from a study conducted among women with accepted and unaccepted pregnancies in Denmark

Most studies focusing on contraceptive failure in relation to pregnancy have focused on contraceptive failure among women having induced abortions, thereby neglecting those women who, despite contraceptive failure, accept the pregnancy and intend to carry the fetus to term. To get a more complete picture of the problem of contraceptive failure, this study focuses on contraceptive failure among women with diverse pregnancy outcomes. In all, 3520 pregnant women attending Odense University Hospital were included: 373 had induced abortions, 435 had spontaneous abortions, 97 had ectopic pregnancies, and 2614 received antenatal care. The variables studied comprise age, partner relationship, number of births, occupational and economical situation, and contraceptive use.Contraceptive failure, defined as contraceptive use (condom, diaphragm, IUD, oral contraception, or another modern method) at the intercourse where conception most likely occurred, were reported by 315 women, 52% of these women had induced abortions, 10% had spontaneous abortions, 3% had ectopic pregnancies, and 36% received antenatal care. Women aged 15-24 years were more likely to have experienced contraceptive failure in relation to use of condom and oral contraception than women aged 25-34 years. In addition, contraceptive failure was found to be associated with being single, a student, and having given birth twice or more previously. Regarding pregnancy acceptance, being 25-34 years of age was positively associated, whereas being single and a student was negatively associated with pregnancy acceptance.

Consequences for infants of parental disagreement in pregnancy intention

CONTEXT

Despite the well-established literature on couples' pregnancy intentions and on the consequences of unintended pregnancy, the effects of parents' disagreement in fertility intentions has not been explored. Parental disagreement in pregnancy intention, as well as a father's pregnancy intention, may affect infant health.

METHODS

Logistic regression analyses using 1979-1992 data from the National Longitudinal Survey of Youth assess effects of unintendedness and parents' disagreement on outcomes related to infants' health and development. Analyses are conducted separately for married and unmarried women; for women of each marital status, one set of analyses includes extensive controls for socioeconomic background, and a second compares effects of intended and unintended pregnancies within the same family.

RESULTS

Infants whose conception was intended by their mother but not their father are at elevated risk of adverse health events. When a pregnancy was not intended by the mother, risks are higher than they are if both parents intended the pregnancy, but they differ little according to father's intention. Thus, it may be useful to classify pregnancies as intended by both parents or not intended by at least one. In comparisons of siblings, unintended fertility (so defined) is associated with delayed prenatal care and reduced initiation of breastfeeding.

CONCLUSION

Information on both parents' fertility intentions is needed to identify infants at risk of adverse health and developmental outcomes.

The extent of pregnancy mistiming and its association with maternal characteristics and behaviors and pregnancy outcomes

CONTEXT

The National Survey of Family Growth (NSFG) classifies pregnancies as intended, mistimed or unwanted. However, these categories could be too broad, as a woman's feelings about a pregnancy, her health behaviors during pregnancy and thus her pregnancy outcomes may vary according to whether her pregnancy is moderately or seriously mistimed. These relationships have not yet been explored.

METHODS

Data from the 1995 NSFG were examined to assess associations between pregnancy mistiming and maternal characteristics. Descriptive and multivariate analyses were conducted of the extent of mistiming for each maternal characteristic. Chi-square and F-tests were used to examine the associations between a pregnancy's intendedness--according to a four-category classification--and maternal characteristics, maternal happiness ratings, maternal behaviors and pregnancy outcomes.

RESULTS

Fifty-five percent of mistimed pregnancies were mistimed by 24 months or less, 32% were mistimed by 25-60 months and 13% were mistimed by more than 60 months. According to multivariate analyses, pregnancies among younger women, never-married women and black women were mistimed by significantly more months than those among other women. The distribution of moderately mistimed pregnancies differed significantly from those of both seriously mistimed and unwanted pregnancies according to most maternal characteristics; there were few differences between intended and moderately mistimed pregnancies, and between seriously mistimed and unwanted pregnancies.

CONCLUSIONS

Mistiming is not a unitary construct. Its extent is associated with maternal characteristics and behaviors. Future research on pregnancy intention should examine the extent of mistiming and consider alternatives to traditional definitions of intendedness.

Correlates of unintended pregnancy in Beheira governorate, Egypt

This study looked at the frequency and determinants of unplanned births among women in Beheira governorate, Egypt, and the effects on antenatal and postnatal care sought by the mother for herself and her child. Unintended births comprised 23.6%; 13.8% were unwanted and 9.8% were mistimed. Contraceptive failure accounted for 28.8% of unintended pregnancies; 47.1% of women who reported unintended pregnancy were not using [corrected] contraception. Age, education and parity were predictors of unwanted pregnancy. Contraceptive use and maternal employment status predicted mistimed pregnancy. Unintended pregnancy was a barrier to antenatal care, but not to child care. Our findings suggest that family planning programmes should help women of reproductive age achieve spacing and fertility limits.

Socio-demographic characteristics of adolescent post-abortion patients in Blantyre, Malawi

BACKGROUND

Unsafe sex, unwanted pregnancy and unsafe abortion are some of the emerging adolescent reproductive health challenges in Malawi.

OBJECTIVES

To study socio-demographic characteristics of adolescent post-abortion patients and that of their male partners, with the aim of better understanding the determinants of adolescent fertility in Malawi, thus facilitating design of appropriate intervention strategies.

DESIGN

A descriptive, cross-sectional study.

SETTING

The Queen Elizabeth Central Hospital, Blantyre, Malawi.

SUBJECTS

A total of 446 out of 465 eligible adolescents managed for incomplete abortion during the study period were enrolled from January 1st to December 31st 1997. RESULTS. Their mean age was 17.5 years (SD +/- 1.3), while that of their male partners was 22.4 years (SD +/- 3.4). The unmarried adolescents comprised 43.9% and students 38.6%. About 30.0% had attained secondary school level of education. The mean age at sexual debut was 15.7 years (SD +/- 1.75), about a year after that at menarche (14.3 years, (SD +/- 1.4)). The mean number of sexual partners they had had was 1.5 (SD +/- 0.86), the highest being 10. The index pregnancy was reportedly unwanted in 45. 1% of the total. The rate was higher among the young, single and students. They were also less likely to have informed their partners about the pregnancy or the abortion (p = 0.0001). About 52.8% of the female students were involved with fellow male students. Of the married adolescents, 4.4% reported having had extramarital affairs.

CONCLUSION

There is need to design appropriate programmes to promote safe sex and reduce unwanted pregnancy and unsafe abortion with its potential sequelae among adolescents in Malawi.