Critiquing the Unintended Pregnancy Framework

Assessing Parenting Attitudes Among Adolescents Seeking Healthcare with a Brief Pregnancy and Parenting Attitudes Questionnaire

PURPOSE

To use modified Parenthood/Pregnancy Attitude, Timing and How important is pregnancy prevention (PATH) questions to assess parenting attitudes and reproductive desires in adolescents and young adults (AYAs).

METHODS

Between November 2020 and January 2022, we recruited participants 13-22 years old via a convenience sample from an Adolescent Medicine outpatient clinic at an urban children's hospital to participate in a cross-sectional survey. The survey was self-administered on a tablet and was adapted from the original PATH questions.

RESULTS

300 adolescents completed the survey. Median age 17 years, 87.3% identified their assigned sex at birth as female, 43.0% identified as Black, and 55.3% had public insurance. 61.3% reported ever being sexually active. 62.7% reported a desire for future children, 70.2% listed a time frame or specific age when they would like children. Those who had ever had sexual activity were more likely to desire future children. Most participants (68.5%) reported pregnancy prevention was very important or important.

CONCLUSIONS

To our knowledge, this is the first study assessing parenting attitudes and reproductive desires of AYA patients assigned sex female at birth and assigned sex male at birth in a clinical setting. Most AYAs reported they were sexually active, had a desire for future children, had a certain time frame in mind for having children, and would want to prevent pregnancy until that time. Assessing AYA's parenting attitudes and reproductive desires supports the use of shared decision making and the provision of reproductive health counseling aligned with patients' preferences and priorities.

Risk Factors for Contraceptive Failure and Unintended Pregnancy Among Women With Inflammatory Bowel Disease

Among pregnant women with IBD, risk factors for unplanned pregnancy from contraceptive failure included low socioeconomic status, low education level, no domestic partner, and racial/ethnic minority status. Active disease and corticosteroid use were not uncommon among those with unplanned pregnancy.

Changes in contraceptive method use, access, and experiences of care during a statewide contraceptive initiative

OBJECTIVE

To examine changes in contraceptive use, access, and care experiences during a statewide contraceptive access initiative, Delaware Contraceptive Access Now.

STUDY DESIGN

We used responses from the Delaware/Maryland Survey of Women at the early wave (November, 2016-March, 2017) and late wave (February, 2021-October, 2021). Our cross-sectional sample included 6467 respondents at risk of unintended pregnancy. We used logistic regression to examine changes in contraceptive outcomes, controlling for age, race/ethnicity, income, education, marital status, and employment. Using interaction terms between state and survey wave, we compared population-level changes in outcomes in Delaware to changes in Maryland, which did not implement a similar contraceptive initiative.

RESULTS

The change in long-acting reversible contraceptive (LARC) use in Delaware compared to Maryland was estimated as a 2.8% point increase, but was not statistically significant (95% CI: -2.8, 8.3). Knowing where to get free LARC increased by 6.2% points (95% CI: 0.4, 12.1; p < 0.05) in Delaware compared to Maryland. Both Delaware and Maryland indicated substantial within-state decreases in reporting their doctor asked about plans for pregnancy (Delaware: -8.9% points; Maryland: -15.1% points), but the decrease in Delaware was significantly smaller: 5.6% points (95% CI: -0.9, 12.1; p < 0.1). Delaware also had a net decrease of 4.7% points (95% CI: -9.9, 0.5; p < 0.1), compared to Maryland, among those very or somewhat satisfied with their current method.

CONCLUSIONS

We observed a mixed picture of changes in contraceptive use, access, and care experiences during the program. Our findings will be useful to Delaware program administrators and others, including the federal government, as they adopt similar reforms.

IMPLICATIONS

We found that the Delaware contraceptive access initiative substantially increased knowledge of free LARC access and led to a relative increase in respondents reporting they had been asked about their pregnancy plans, compared to Maryland, but was not associated with other outcomes.

Nonuse of Contraception at Conception Due to Partner Objection and Pregnancy-Related Health Care Utilization, Postpartum Health, and Infant Birth Outcomes

Objective: Reproductive coercion has been associated with adverse reproductive health experiences. This study examined the relationship between nonuse of contraception due to partner objection, one aspect of reproductive coercion, and selected pregnancy-related outcomes. Methods: We used 2016-2020 data from the Pregnancy Risk Assessment Monitoring System in 22 jurisdictions to assess the prevalence of nonuse of contraception due to a partner objection by select characteristics among individuals with a recent live birth who reported an unintended pregnancy. We calculated adjusted prevalence ratios (aPRs) to understand associations with health care utilization, postpartum behaviors and experiences, postpartum contraceptive use, and infant birth outcomes. Results: Among people with a recent live birth in the study jurisdictions (n = 29,071), approximately 5% reported nonuse of contraception due to a partner objection and unintended pregnancy. This experience was associated with lower prevalence of attending a health care visit before pregnancy (aPR 0.8, 95% confidence interval [CI] 0.7-0.9), first trimester prenatal care, and attending a postpartum checkup (aPR 0.7, 95% CI 0.6-0.9 for both). Higher prevalence was observed for postpartum depressive symptoms (aPR 1.3, 95% CI 1.1-1.6) and partner objecting to using birth control postpartum (aPR 2.8, 95% CI 2.1-3.9). Conclusions: Nonuse of contraception due to a partner objection at conception was associated with poor mental health and lower health care utilization around the time of pregnancy. Prevention efforts may include strategies that ensure provider screening for intimate partner violence, and evidence-based approaches that teach about healthy relationships, enhance self-efficacy, and address underlying drivers of violence.

The need for preconception care: Australian women's health beliefs, expectations, and trust in healthcare

INTRODUCTION

Preconception care aims to improve the health outcomes of parents and their children by optimising health prior to pregnancy. However, inconsistent adoption of preconception care guidelines and low uptake among women highlights the need for further exploration.

AIM

This study aims to explore women's perceptions of the need for preconception care and the factors influencing these perceptions, including competing demands and expectations perceived by women while planning for pregnancy.

METHODS

A participatory, qualitative approach was used, involving in-depth semi-structured interviews with reproductive-aged women in Australia. Reflexive thematic analysis was conducted on interview transcripts, including Synthesised Member Checking to verify findings.

RESULTS

Interviews were conducted with 38 women. Three major themes emerged: (1) "Advice from trusted people will go a long way" emphasized the value of trusted connections and expertise; (2) "A bit of a baby factory" highlighted women's sense of sole responsibility for pregnancy outcomes requiring their extensive efforts to avoid subsequent feelings of guilt and blame; (3) "If people knew" described women's preference for privacy to avoid scrutiny and judgment.

DISCUSSION

Women's perception of the need for preconception care is shaped by intersecting issues of trust, individualised responsibility, and privacy. In the absence of relationship-based care with a trusted primary care provider, women seek lived experience and formal expertise online. Individual responsibility for preconception health is disempowering to women. Relationship-based models of primary maternity care, including midwifery models of care, and parasocial connections with experts may better meet women's health needs in the preconception period.

Pregnancy Intendedness by Presence and Extent of Disability in the USA, 2019-2020

CONTEXT

Over 40% of pregnancies in the United States are unintended. Women with unintended pregnancies may be less likely to receive timely prenatal care and engage in healthy behaviors immediately before and during pregnancy. Limited research suggests that women with disabilities are more likely to have an unintended pregnancy, but to date no studies have assessed whether intendedness varies by extent of disability.

METHODS

We analyzed 2019-2020 PRAMS data from 22 sites that included the Washington Group Short Set of Questions on Disability (n = 37,832). We examined associations of extent of disability (none, some difficulty, or a lot of difficulty) with pregnancy intendedness (classified as intended, mistimed, unwanted, or unsure). We used multinomial logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) while controlling for sociodemographic characteristics.

RESULTS

Overall, 60.1% of pregnancies were intended, 18.2% mistimed, 6.4% unwanted, and 15.3% unsure. Compared to respondents with no difficulty, respondents with some difficulty or a lot of difficulty were more likely to report a mistimed pregnancy (aOR = 1.55, 95%CI 1.40,1.71; aOR = 1.62, 95%CI 1.34,1.95), an unwanted pregnancy (aOR = 1.92, 95%CI 1.66,2.24; aOR = 2.20; 95%CI 1.72,2.82), and unsure intendedness (aOR = 1.61, 95%CI 1.45,1.79; aOR = 1.75, 95%CI 1.45,2.11), respectively.

CONCLUSIONS

People with disabilities who give birth, regardless of extent of disability, had elevated odds of mistimed and unwanted pregnancy and of being unsure of their pregnancy intendedness. Our findings support the use of more inclusive measures of disability and emphasize the need for equitable reproductive healthcare that respects the childbearing potential and choices of individuals with disabilities.

Motivations for Abortion or Continuation of an Unwanted Pregnancy: A Scoping Review of the Global Literature

CONTEXT

The aim of this scoping review was to provide an overview of recent studies in peer reviewed journals investigating self-reported motivations to have an abortion or to continue an unwanted pregnancy in different countries and settings, including both qualitative and quantitative results.

METHODS

We searched for English language publications published between 2008 and 2023 indexed in four scientific databases. We included studies if they captured people's own motivations for abortion and/ or for continuing an unwanted pregnancy.

RESULTS

Of the included 19 studies, all focused on abortion, and four also included motivations to carry an initially unwanted pregnancy to term. Motivations for abortion often related to family planning (e.g., complete family, no desire for children, not the right time), the relationship with the person involved in the pregnancy, and life or material circumstances (such as financial resources, housing or future plans), and sometimes with stigma, shame, or expected negative reactions. Motivations to continue an unwanted pregnancy were having a supportive partner and personal beliefs about the pregnancy. Despite different settings, different methods, and methodological limitations, studies showed similar multifactorial and interrelated motivations in decision making around unwanted pregnancies.

CONCLUSIONS

This research showed that in different places throughout the world multiple interrelated motivations play a role in a decision to have an abortion or to continue an unwanted pregnancy. The findings mainly provide insight into retrospective explanatory accounts, which may be biased because respondents may feel the need to justify their choice. Future research should discontinue asking people to rationalize unwanted pregnancy decisions.

Clinician Perspectives on Adolescent Contraceptive Counseling Following Dobbs v. Jackson: Implications for Young People's Contraceptive Autonomy

OBJECTIVE

The objective of this study is to understand whether clinicians who provide contraceptive counseling to adolescent patients perceive that the Dobbs decision has influenced their counseling.

STUDY DESIGN

We conducted in-depth interviews with a convenience sample of 16 clinicians who provide contraceptive counseling to adolescents at the American Academy of Pediatrics annual conference in October 2022. We used thematic content analysis and an iterative process of constant comparison to identify themes inductively. This analysis focused on participants' perception of if and how the Dobbs decision has or will influence their contraceptive counseling with adolescents.

RESULTS

Most clinicians in our study reported that the Dobbs decision influenced their contraceptive counseling. This included promoting long-acting reversible methods more so than pre-Dobbs, and explicitly considering changing state-level abortion laws and restrictions. Many clinicians openly noted that their personal preferences influence their counseling, such as prioritizing pregnancy prevention and encouraging patients to use particular methods.

CONCLUSION

We found that most clinicians in our sample acknowledged that the Dobbs decision has influenced their contraceptive counseling practices with adolescents. Clinicians' responses demonstrate that, in many instances, the Dobbs decision motivated them to focus on method effectiveness, leading to tiered and directive contraceptive counseling. We recommend practice changes to support comprehensive contraceptive care provision, provider trainings in unbiased counseling, and developmentally tailored decision aids are needed to ensure that adolescent patients' autonomy is prioritized over a singular focus on pregnancy prevention.

Exploring Postpartum Pregnancy Prevention Behaviors Among Women Experiencing Homelessness: A Mixed-Methods Analysis

INTRODUCTION

Women experiencing homelessness are at higher risk of unintended pregnancy than women who are stably housed and may have unique reasons for not engaging in postpartum pregnancy prevention. This sequential explanatory mixed-methods study aimed to examine reasons women experiencing homelessness may not engage in pregnancy prevention during the postpartum period.

METHODS

Quantitative 2016-2019 Pregnancy Risk Assessment Monitoring System data regarding postpartum pregnancy prevention among recently pregnant women experiencing homelessness and women stably housed (n = 99,138) were analyzed with complex survey-weighted bivariate analysis. Primary outcomes included whether women engaged in postpartum contraception and key reasons for not engaging in postpartum contraception. Qualitative data from semistructured interviews with north Texas women (n = 12) recently pregnant and homeless were coded and thematically analyzed. Findings were triangulated using a woman-centered conceptual framework that facilitates meeting reproductive goals.

RESULTS

Women experiencing homelessness reported several statistically significant (P < .05) reasons for not using postpartum pregnancy prevention: currently pregnant, currently abstinent, cannot afford contraception, and partner not liking contraception. Key themes from interviews were related to internal factors (eg, perceived risk of pregnancy is high, current situation not good for having children); external factors (eg, my partner wants to have another child); perceptions of pregnancy (eg, children would be joyful, I want to get pregnant soon after I get housing), and salience of planning (eg, doesn't matter if we plan).

DISCUSSION

Findings highlight several key reasons for not engaging in postpartum pregnancy prevention among women experiencing homelessness. Findings lay the groundwork for interventions seeking to support individualized and evolving sexual and reproductive health goals within the context of needed housing and family resources.

Mental health risks in pregnancy and early parenthood among male and female parents following unintended pregnancy or fertility treatment: a cross-sectional observational study

BACKGROUND

Unintended pregnancy at higher risk of perinatal mood disorders; however, concurrent factors such as socioeconomic conditions may be more critical to mental health than pregnancy intention. Mental health risks among individuals undergoing fertility treatment are inconsistent. We investigated mental health risks during pregnancy and parenthood in parents who conceived unintentionally or through fertility treatment compared to those who conceived naturally and intentionally.

METHODS

We conducted a web-based study with 10,000 adults ≥ 18 years old, either pregnant or with a child aged < 2 years. Male and female respondents weren't couples. We analyzed 1711 men and 7265 women, after filtering out invalid responses. We used a questionnaire including conception methods (e.g., naturally conceived intended/unintended pregnancies, fertility treatment such as scheduled intercourse or ovulation inducers [SI/OI], intrauterine insemination [IUI], and in-vitro fertilization or intracytoplasmic sperm injection [IVF/ICSI]) and mental health risks (e.g., psychological distress, chronic pain, death fantasies). Using a modified Poisson regression, we estimated relative risks (RR [CI]) for mental health risks compared to those with intended pregnancies.

RESULTS

Unintended pregnancy showed higher mental health risks during pregnancy in both genders, with women having significantly higher psychological distress, chronic pain, and death fantasies (RR 1.63 [1.05-2.54], RR 1.63 [1.14-2.33], and RR 2.18 [1.50-3.18], respectively). Women's death fantasies risk remained high in parenthood: RR 1.40 (1.17-1.67). In relation to fertility treatments, men using SI/OI during their partner's pregnancy showed higher mental health risks, especially for chronic pain (RR 1.75 [1.01-3.05]). Men who underwent IUI showed higher mental health risks during parenthood, notably death fantasies (RR 2.41 [1.13-5.17]). Pregnant women using SI/OI experienced higher mental health risks, with a significant risk of chronic pain (RR 1.63 [1.14-2.33]). Pregnant women using IVF/ICSI had a significantly lower risk of chronic pain (RR 0.44 [0.22-0.87]), but women who used IVF/ICSI had a significantly higher risk of death fantasies during parenthood (RR 1.40 [1.04-1.88]).

CONCLUSIONS

Mental health risks vary by parenting stage (pregnancy or early parenthood) and gender, especially for those who conceived unintentionally or through fertility treatment. Both stages require adaptable mental health support for all parents.

TRIAL REGISTRATION

N/A (non-interventional study).

Decision-making in case of an unintended pregnancy: an overview of what is known about this complex process

Introduction: Unintended pregnancies are a worldwide health issue, faced each year by one in 16 people, and experienced in various ways. In this study we focus on unintended pregnancies that are, at some point, experienced as unwanted because they present the pregnant person with a decision to continue or terminate the pregnancy. The aim of this study is to learn more about the decision-making process, as there is a lack of insights into how people with an unintended pregnancy reach a decision. This is caused by 1) assumptions of rationality in reproductive autonomy and decision-making, 2) the focus on pregnancy outcomes, e.g. decision-certainty and reasons and, 3) the focus on abortion in existing research, excluding 40% of people with an unintended pregnancy who continue the pregnancy. Method: We conducted a narrative literature review to examine what is known about the decision-making process and aim to provide a deeper understanding of how persons with unintended pregnancy come to a decision.Results: Our analysis demonstrates that the decision-making process regarding unintended pregnancy consists of navigating entangled layers, rather than weighing separable elements or factors. The layers that are navigated are both internal and external to the person, in which a 'sense of knowing' is essential in the decision-making process. Conclusion: The layers involved and complexity of the decision-making regarding unintended pregnancy show that a rational decision-making frame is inadequate and a more holistic frame is needed to capture this dynamic and personal experience.

Providing Quality Family Planning Services in the United States: Recommendations of the U.S. Office of Population Affairs (Revised 2024)

This update, titled Providing Quality Family Planning Servicesa in the United States: Recommendations of the U.S. Office of Population Affairs (Revised 2024), provides recommendations developed by the Office of Population Affairs (OPA) within the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services (HHS). These recommendations represent an update to Providing Quality Family Planning (QFP) Services: Recommendations of the Centers for Disease Control and Prevention (CDC) and the U.S. Office of Population Affairs (OPA), originally published in 2014. The updated recommendations outline how to provide quality sexual and reproductive health (SRH) services for people of reproductive age but can also be used to guide the care of people of any age when the content is relevant to their needs, including family-building services, contraception, pregnancy testing and counseling, early pregnancy management, sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) prevention and testing services, and other preventive health services. The recommendations aim to enable health care providers with the knowledge, skills, and attitudes to ensure that all people, regardless of individual characteristics such as sex, sexual orientation and gender identity, age, disability, or race, can have their SRH needs met. The primary audience for these recommendations is providers and potential providers of SRH services to people of reproductive age, such as providers working in clinical settings dedicated to SRH service delivery, including those funded by the Title X family planning programb as well as primary care providers and other subspecialty providers who may identify SRH needs and make referrals. During the past decade, several changes have taken place in the United States that have affected SRH care delivery, including technological advances, recognition of long-standing inequities, and other legal and regulatory changes. This broader context has been considered in designing the updated recommendations. This update of the QFP aims to provide guidance on the provision of person-centered SRH care focused on individuals' needs, values, and preferences. The update offers specific recommendations for how to provide high-quality SRH care and connects users to relevant guidelines, primary research, and other resources to inform best practices. In addition to incorporating new evidence, this update incorporates newer approaches to care, including adopting a health equity lens that recognizes the impact of structural and interpersonal racism, classism, ableism, and bias based on sexual orientation and/or gender identity on health and the provision of quality SRH care. OPA will update these QFP recommendations periodically to reflect new findings in the scientific literature and revisions to the clinical guidelines referenced in this update.

Long-term effects of unintended pregnancy on children: Findings from the Dutch prospective birth-cohort Amsterdam born children and their development study

Several studies investigated short-term risks of children born from unintended pregnancies, however evidence about long-term risks is lacking. We aimed to examine whether children born from unintended pregnancies experience psychosocial problems up into adolescence. This study is based on the longitudinal birth cohort study 'Amsterdam Born Children and their Development' (n = 7784). Unintended pregnancy was measured as a multidimensional construct, based on self-reports on the extent of pregnancy mistiming ('This pregnancy happened too soon'), unwantedness ('I did not want to be pregnant (anymore)') and unhappiness ('I am happy to be pregnant'; recoded). Further, children's psychosocial problems were measured with the Strengths and Difficulties Questionnaire, at 5-6, 11-12 and 15-16 years old. Multiple over-time associations between unintended pregnancy and children's psychosocial problems were analysed using Structural Equation Modelling, while controlling for confounders. Results showed that pregnancy mistiming was a significant predictor of internalizing (β = 0.10, p < 0.001) and externalizing problems (β = 0.07, p = 0.006) and unwanted pregnancy of internalizing problems (β = 0.13, p < 0.001) at 5-6 years. These associations were substantially mediated by maternal mental health and poorer maternal bonding. Associations were no longer present at 11-12 and 15-16 years. Thus, we conclude that children born from unintended pregnancies experience more psychosocial problems at 5-6 years, but no longer at 11-12 and 15-16 years. Unintended pregnancies often coincide with maternal mental health problems and socioeconomic factors. Most importantly, the associations between unintended pregnancy and children's psychosocial problems are influenced by maternal mental health and poorer bonding. Therefore it is important to improve maternal mental health and bonding for the benefit of both mother and child, rather than on the isolated effect of unintended pregnancy per se.

The Association Between Unintended Pregnancy and Perinatal Outcomes in Low-Risk Pregnancies: A Retrospective Registry Study in the Netherlands

INTRODUCTION

People with unintended pregnancies might be at increased risk of adverse perinatal outcomes due to structural factors, distress, or delayed prenatal care. Existing studies addressing this association yielded inconsistent findings. Using contemporary data from a large Dutch midwifery care registry, we investigated the association between unintended pregnancy ending in birth and neonatal outcomes, parental morbidity, and obstetric interventions. We extend previous research by exploring whether delayed initiation of prenatal care mediates these associations.

METHOD

This study used data (N = 9803) from a Dutch nationally representative registry of people with low-risk pregnancies receiving primary midwife-led care in the Netherlands between 2012 and 2020. Using logistic (mediation) regression analyses adjusted for potential confounders we investigated associations between unintended pregnancy and neonatal outcomes (low Apgar score, small for gestational age, and prematurity), parental morbidity (hypertension and gestational diabetes mellitus), and obstetric interventions (induction of labor, pain medication, assisted vaginal birth, and cesarean birth) and whether delayed initiation of prenatal care mediated these associations.

RESULTS

Unintended pregnancies were associated with increased odds of low Apgar scores (odds ratio [OR], 1.68; 95% CI, 1.09 -2.59), preterm birth (OR, 1.27; 95% CI, 1.02-1.58), small for gestational age (OR, 1.19; 95% CI, 1.00-1.41), and induction of labor (OR, 1.14; 95% CI, 1.01-1.28). Conversely, unintended pregnancy was associated with a decreased odds of cesarean birth (OR, 0.83; 95% CI, 0.71-0.97). The timing of prenatal care initiation did not mediate any of these associations.

DISCUSSION

Our findings suggest that people in primary midwifery-led care with unintended pregnancies ending in birth are at increased risk for adverse perinatal health outcomes and that structural factors might underlie this link. Health care professionals and policy makers should attend to their own biases and offer nonjudgmental, tailored preventive preconception care and antenatal care strategies for people with higher vulnerabilities.

Integrating Sexual and Reproductive Health Equity Into Public Health Goals and Metrics: Comparative Analysis of Healthy People 2030's Approach and a Person-Centered Approach to Contraceptive Access Using Population-Based Data

BACKGROUND

The Healthy People initiative is a national effort to lay out public health goals in the United States every decade. In its latest iteration, Healthy People 2030, key goals related to contraception focus on increasing the use of effective birth control (contraceptive methods classified as most or moderately effective for pregnancy prevention) among women at risk of unintended pregnancy. This narrow focus is misaligned with sexual and reproductive health equity, which recognizes that individuals' self-defined contraceptive needs are critical for monitoring contraceptive access and designing policy and programmatic strategies to increase access.

OBJECTIVE

We aimed to compare 2 population-level metrics of contraceptive access: a conventional metric, use of contraceptive methods considered most or moderately effective for pregnancy prevention among those considered at risk of unintended pregnancy (approximating the Healthy People 2030 approach), and a person-centered metric, use of preferred contraceptive method among current and prospective contraceptive users.

METHODS

We used nationally representative data collected in 2022 to construct the 2 metrics of contraceptive access; the overall sample included individuals assigned female at birth not using female sterilization or otherwise infecund and who were not pregnant or trying to become pregnant (unweighted N=2760; population estimate: 43.9 million). We conducted a comparative analysis to examine the convergence and divergence of the metrics by examining whether individuals met the inclusion criteria for the denominators of both metrics, neither metric, only the conventional metric, or only the person-centered metric.

RESULTS

Comparing the 2 approaches to measuring contraceptive access, we found that 79% of respondents were either included in or excluded from both metrics (reflecting that the metrics converged when individuals were treated the same by both). The remaining 21% represented divergence in the metrics, with an estimated 5.7 million individuals who did not want to use contraception included only in the conventional metric denominator and an estimated 3.5 million individuals who were using or wanted to use contraception but had never had penile-vaginal sex included only in the person-centered metric denominator. Among those included only in the conventional metric, 100% were content nonusers-individuals who were not using contraception, nor did they want to. Among those included only in the person-centered metric, 68% were currently using contraception. Despite their current or desired contraceptive use, these individuals were excluded from the conventional metric because they had never had penile-vaginal sex.

CONCLUSIONS

Our analysis highlights that a frequently used metric of contraceptive access misses the needs of millions of people by simultaneously including content nonusers and excluding those who are using or want to use contraception who have never had sex. Documenting and quantifying the gap between current approaches to assessing contraceptive access and more person-centered ones helps clearly identify where programmatic and policy efforts should focus going forward.

Meeting people's pregnancy prevention needs: Let's not force people to state an "Intention"

Pregnancy intention screening does not identify need for pregnancy prevention and ignores the nuances of lived experiences while reinforcing white middle-class normative expectations. Asking about desire for contraception is a patient-centered approach to meeting people's needs.

Welcomed Pregnancies: Characteristics and Patterns of Adjusting to Unwanted, Unplanned, Untimely or Otherwise Difficult Pregnancies

Background Women facing problematic pregnancies, defined as "unplanned, mistimed, unwanted, or otherwise difficult," either have abortions or make adjustments to welcome these pregnancies. These adjustments are understudied. Pregnancy resource centers that provide counseling and services to assist in the process of welcoming pregnancies have been the focus of controversy due to their refusal to counsel or refer for abortions. This survey of a national population of women seeks to quantify changes in attitudes toward problematic pregnancies that are not aborted and to gauge levels of contact with pregnancy help centers and perceptions of harm or benefits attributed to those contacts. Methodology A national research firm was enlisted to obtain 1,000 surveys completed by female residents of the United States aged 41-45, inclusive. Women reporting a history of abortion were surveyed along one path. For those who did not have abortions but reported a problematic pregnancy, questions were presented to assess changes in attitude toward their pregnancy from the date they first learned they were pregnant to 90 days later, their considerations of abortion, whether they had contact with a pregnancy help center, and their assessment of that contact on either harming or improving their lives. Results Among 275 respondents who had no history of abortion but had ultimately welcomed a problematic pregnancy, 112 (40.7%) had been at higher risk of abortion. Positive attitudes toward their pregnancies increased most rapidly for women who had been at higher risk of abortion but were lower on the day they first learned they were pregnant. Overall, 34 (12.4%) reported they had contacted a pregnancy help center that did not refer for abortions. Another 37 (13.5%) were uncertain if they had contacted an organization fitting that description. Both groups reported the contact improved their lives, on average. Negative assessments were uncommon and all were of a small degree. Conclusions Women facing problematic pregnancies who did not choose abortion experienced rapid improvements in feelings of wantedness, timeliness, acceptance, welcoming, and desirability toward the pregnancy. The rate of improvement was most rapid among those who had investigated and considered abortion. Women reporting contact with pregnancy help centers almost always assess it as having improved their lives.

PROTOCOL: Abortion and mental health outcomes: A systematic review and meta-analysis

This is a protocol for a systematic review and meta-analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta-analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies' methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re-analysis.

The role of a community health worker-delivered preconception and pregnancy intervention in achieving a more positive pregnancy experience: the Bukhali trial in Soweto, South Africa

BACKGROUND

A patient-centered, human-rights based approach to maternal care moves past merely reducing maternal mortality and morbidity, towards achieving a positive pregnancy experience. When evaluating an intervention, particularly in the context of the complex challenges facing maternal care in South Africa, it is therefore important to understand how intervention components are experienced by women. We aimed to qualitatively explore (i) factors influencing the pregnancy and postpartum experience amongst young women in Soweto, South Africa, and (ii) the influence of Bukhali, a preconception, pregnancy, and early childhood intervention delivered by community health workers (CHWs), on these experiences.

METHODS

Semi-structured, in-depth interviews were conducted with 15 purposively sampled participants. Participants were 18-28-year-old women who (i) were enrolled in the intervention arm of the Bukhali randomized controlled trial; (ii) were pregnant and delivered a child while being enrolled in the trial; and (iii) had at least one previous pregnancy prior to participation in the trial. Thematic analysis, informed by the positive pregnancy experiences framework and drawing on a codebook analysis approach, was used.

RESULTS

The themes influencing participants' pregnancy experiences (aim 1) were participants' feelings about being pregnant, the responsibilities of motherhood, physical and mental health challenges, unstable social support and traumatic experiences, and the pressures of socioeconomic circumstances. In terms of how support, information, and care practices influenced these factors (aim 2), four themes were generated: acceptance and mother/child bonding, growing and adapting in their role as mothers, receiving tools for their health, and having ways to cope in difficult circumstances. These processes were found to be complementary and closely linked to participant context and needs.

CONCLUSION

Our findings suggest that, among women aged 18-28, a CHW-delivered intervention combining support, information, and care practices has the potential to positively influence women's pregnancy experience in South Africa. In particular, emotional support and relevant information were key to better meeting participant needs. These findings can help define critical elements of CHW roles in maternal care and highlight the importance of patient-centred solutions to challenges within antenatal care.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201903750173871, 27/03/2019.

Characteristics Associated With Physician Bias in Contraceptive Recommendations

OBJECTIVE

We aimed to examine associations between obstetrician-gynecologist (OBGYN) contraceptive recommendations and sociodemographic characteristics of patients and recommending physicians.

METHODS

OBGYNs affiliated with residency programs across the United States were recruited via email to participate in an online exploratory survey depicting scenarios of reproductive-age women of differing race and socioeconomic status, all other factors identical, and were asked to provide contraceptive recommendations. The χ2 test, Fisher's exact tests, and logistic regression were used to analyze recommendation differences based on physician and patient characteristics.

RESULTS

Of 172 physician respondents, large proportions self-identified as white (74%) and attending physicians (56%) from the Mid-Atlantic (42%). In multivariate logistic regression, self-administered methods (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2-0.8) and condoms (OR, 0.5; 95% CI, 0.3-0.9) were recommended significantly less to Black high SES patients compared with white high SES patients. Non-white physicians recommended tubal ligation (OR, 0.7; 95% confidence interval [CI], 0.5-0.9) significantly less than white physicians, and recommended long-acting reversible contraception (OR, 3.3, CI 2.2-5.2) and condoms (OR, 1.4; 95% CI, 1.1-1.9) significantly more. Trainee physicians recommended self-administered methods (OR, 0.3; 95% CI, 0.2-0.4), condoms (OR, 0.2; 95% CI, 0.2-0.3), and tubal ligation (OR, 0.4; 95% CI, 0.3-0.6) significantly less than attending physicians.

CONCLUSIONS

OBGYN contraceptive recommendations differed based on patients' perceived race and SES. Recommendations also differed based on race, training level, and geographic location of the recommending physician. Results suggest that physician bias contributes to contraceptive recommendations. OBGYNs should receive education about contraceptive coercion and patient-centered decision-making so that they provide high-quality counseling to all patients.

Association between pregnancy planning or intention and early child development: A systematic scoping review

The Sustainable Development Goals have a specific target to "ensure that all girls and boys have access to quality early childhood development" by 2030. There is sparse literature regarding the impact of pregnancy intention (wantedness and timing) or planning on child development. We aimed to summarize the evidence measuring the association between unintended or unplanned pregnancy and child development for children aged 3 to 5. We included studies that compared developmental outcomes of children from unwanted, unplanned, or mistimed pregnancies to those of children from wanted or planned pregnancies. In April 2022, we searched Ovid MEDLINE (from 1946), EMBASE (from 1974), and SCOPUS (from inception) without language restrictions. One reviewer tabulated data on country and year of study, population, sample and sampling method, age of participants, exposure, date of exposure retrieval, developmental outcome(s), assessment (direct or through third parties), statistical methods (including covariate selection methods), and effect estimates into bespoken data tables. Our scoping review identified 12 published studies reporting on 8 "cohorts" (range: 1963-2016) with information on approximately 39,000 children born mostly in developed countries. Overall, unwanted/unplanned pregnancies seemed to be associated with poorer child development when compared with wanted/planned pregnancies. Mistimed or delayed pregnancies correlated with weaker effects in the same direction. We concluded that achieving the target for SDG 4, related to child development, might entail policies that create environments supportive of wanted conception and access to safe abortion.

Exploring Contraceptive Experiences of Abortion-Fund Clients in the Rocky Mountain Region of the United States from a Reproductive Justice Lens

Objective

This study focuses on the contraceptive experiences of abortion fund applicants to draw attention to various elements that restrict the realization of reproductive justice in the Rocky Mountain Region of the United States.

Methods

This study uses qualitative data from 830 applications to an abortion fund submitted between 2013 and 2022.

Results

Our findings highlight a range of experiences, from contraceptive failure and side effects, to diminished access and reproductive coercion.

Conclusion

Abortion fund applicants described individual, interpersonal, and structural factors that shaped their access to contraception. This study calls for various interventions, including implementing comprehensive sex education, to ensure reproductive justice.

Carrying an unintended pregnancy to term and long-term maternal psychological distress: Findings from the Dutch prospective Amsterdam Born Children and their Development study

BACKGROUND

Given the estimated high rate of unintended pregnancies, it is important to investigate long-term effects on psychological distress in women carrying an unintended pregnancy to term. However, research into associations between unintended pregnancies carried to term and psychological distress postpartum is mixed, and especially, evidence on long-term associations is scarce.

OBJECTIVE

To examine whether carrying an unintended pregnancy to term is associated with maternal psychological distress later in life, up to 12 years postpartum.

DESIGN

This study is based on the population-based birth cohort study 'Amsterdam Born Children and their Development' study, which included pregnant people in 2003 (n = 7784) and followed them up until 12 years postpartum.

METHODS

Unintended pregnancy was measured as a multidimensional construct, based on self-reported data around 16 weeks gestation on pregnancy mistiming, unwantedness and unhappiness. Symptoms of maternal psychological distress were assessed around 3 months, 5 years and 12 years postpartum using multiple questionnaires measuring symptoms of depression, anxiety and stress. Multiple structural equation modelling models were analysed, examining the associations between dimensions of unintended pregnancy and maternal psychological distress per time point, while controlling for important co-occurring risks.

RESULTS

Pregnancy mistiming and unhappiness were significant predictors of more maternal psychological distress around 3 months postpartum. Around 5 years postpartum, only pregnancy mistiming was positively associated with maternal psychological distress. Dimensions of unintended pregnancy were no longer associated with maternal psychological distress around 12 years postpartum. Strikingly, antenatal psychological distress was a much stronger predictor of maternal psychological distress than pregnancy intention dimensions.

CONCLUSION

Those who carried a more unintended pregnancy to term reported more symptoms of psychological distress at 3 months and 5 years postpartum. People carrying an unintended pregnancy to term may benefit from extra support, not because of the pregnancy intentions per se, but because they may be related to antenatal psychological distress.