What does “unintended pregnancy” really mean and why does it matter?

By | January 15, 2020

INTRODUCTION

The “sexual revolution” of the late 1960s in the United States and Europe was based on the idea that the link between sex and pregnancy is opt-in rather than an opt-out. That is, one’s sexual behavior can be entirely independent of procreation, and that parenthood ought to be “planned.” As the United Nations Population Fund (UNFPA) frames it, human life occurs “by choice, not by chance.” 

Demographers, not just sexual revolutionaries, have had a longstanding interest in the degree of planning and intentionality that goes into human procreation.  It is well understood that pregnancies are somewhat predictable based on behavior—namely, sexual intercourse between presumably fertile men and women—but the intention to engage in sex and the intention to procreate are not always perfectly aligned.

This issue of Definitions explores the methods used to measure pregnancy intentions, the way it is framed as a global issue, and the way such measurements are used to promote specific policies related to human life and the family at the national and international level.

Evolution of a concept

In the early twentieth century the birth control movement, led by such figures as Margaret Sanger and Marie Stopes, promoted the idea that parenthood ought to be intentionally planned and controlled. These women characterized unplanned childbearing as catastrophic for mother and child alike.  But attempts to quantify unintended pregnancies and births at a large scale did not come until the 1940s and 1950s, when demographers developed fertility surveys conducted at the household level.1

The earliest surveys about the intendedness of pregnancy were conducted in the United States, beginning with a study in Indianapolis by demographers Claude V. Kiser and P.K. Whelpton. It was limited to married, native-born, white, Protestant couples.  The couples were independently asked, if they could begin their married life over again, how many children they would ideally like to have in total.  If the number of children in the family exceeded the “ideal” amount, this was measured as “unwanted” fertility.2

In the 1950s, fertility surveys were scaled up to measure population growth across the United States, the sampling was broadened to cover a more racially and religiously diverse group of respondents.   In 1963, Major General Frederick Osborn, characterized by the American Philosophical Society as “the respectable face of eugenic research in the post-war period,”3 summarized his analysis of national fertility survey data thusly: “American women are having almost 20% more children than they would have if they had only pregnancies wanted at the time or at a later date. These excess births are the result of failure to use contraception or failure to use it effectively.”4

On the one hand, fertility surveys exploring couples’ intended and ideal family sizes are a useful tool to predict future demographic trends, and can be used to predict future demands for housing, education, health care, and other services.  On the other hand, amid growing concerns about overpopulation, some policymakers reasoned that expanding access to voluntary family planning could potentially reduce fertility by as much as a fifth, without having to resort to more draconian measures to promote a small family norm.

Meanwhile, efforts were underway in the medical and psychological fields to determine whether children born as the result of unintended or unwanted pregnancies were uniquely disadvantaged throughout their lives.  It should be noted that, thanks to outspoken family planning advocates like Sanger and prominent psychiatrists like Karl Menninger, who shared her philosophy,5 there was already a widespread belief that “unwantedness” at the time of conception caused an indelible harm to children, even in the absence of any formal study to examine this hypothesis.6

Modern measurements of pregnancy intention

Since the early U.S.-based fertility surveys of the mid-twentieth century, the study of pregnancy intentions has been continuously developing, and survey methods have expanded internationally.  Within the United States, the National Survey of Family Growth has been conducted since 1973, and allows for individual pregnancies to be classified on the basis of whether they were intended at the time of conception.  International surveys such as the Demographic and Health Surveys conducted, with support from USAID, use a similar approach.7  Respondents are asked what their feelings were just prior to becoming pregnant, and generally speaking, the pregnancy is classified as “intended” or “unintended.”  Unintended pregnancies are further subdivided into “mistimed” (the respondent did report wanting another child, but not yet) or “unwanted” (the respondent did not want children at all, or did not intend to have any more children.)

Controversies and critiques

This “conventional” method is not without its critics: indeed, as one study well-stocked with citations points out, “the critiques of the conventional measure have become so numerous as to form their own body of research.”8  This is largely because there is wide variation in women’s and couples feelings about pregnancy and bearing children, as well as in their concrete efforts to avoid or achieve these outcomes.  Likewise, these measurements do not reflect the degree of change that can occur in people’s attitudes, even over a relatively short period of time.  One frequently cited critique of studies of pregnancy “wantedness” is the tendency of parents to change their answers from one survey to the next: a pregnancy classified as unintended or unwanted may later be characterized as intended or merely mistimed.  In such cases, the respondent is describing his or her feelings just prior to the same pregnancy, but characterizing it differently: rather than acknowledging a change of attitude, the parent cannot imagine (or, at least admit) that the child they now know and love was anything other than intended and wanted.  Similarly, respondents have been shown to “revise their ideal family size upwards based on the actual number of children they already have.”9

Importantly, surveys used to measure pregnancy intentions typically do not ask parents to choose from a list of terms to describe their past pregnancies (e.g. “unwanted,” “mistimed,” etc.)  These terms are applied based on the researchers’ definitions, based on the answers to questions which most likely do not include those words at all.  One U.K.-based qualitative study was based on interviews with women who were currently or recently pregnant, and the researchers found that “most did not use the terms ‘planned’, ‘unplanned’, ‘intended’, ‘unintended’, ‘wanted’ or ‘unwanted’ to classify their pregnancies.”  The word “unwanted” produced the most negative emotional response from the women surveyed, regardless of whether they had continued their pregnancy or had an abortion.  On the other hand, most of the women agreed that a pregnancy could become “wanted” regardless of whether it was “intended” or not.10

The study of pregnancy intentions is a complex project, inasmuch as it attempts to create clear categories around feelings that may differ between parents, change over time in individuals, and be composed of internally conflicting emotions and perceptions at any given time.  Less attention has been paid to the emotions, motivations, and perceptions of the researchers themselves, although a survey of the literature on this subject allows for several observations.  

Firstly, the policy prescriptions set forth by study authors are narrowly limited to encouraging the use of contraception for the prevention of unintended pregnancies, and of expanding the availability of abortion to address them if they occur.  Despite the frequently-mentioned confounding variable of after-the-fact rationalization of unintended pregnancies as wanted children, there is scant interest in studying what factors tend to enable this outcome, or how one might craft policies to encourage it.  Indeed, as the authors of one study put it, “the public health goal is not to help mothers change their attitudes so that those unintended births become intended ones; the goal is to delay those pregnancies until women move into a life stage when they do want to have a baby […]     Similarly, the negative consequences for an unwanted birth can be alleviated not by convincing mothers to want the births, but by preventing the unwanted pregnancies.”11  That this is a matter of opinion, not a self-evident fact, did not prevent its inclusion in a peer-reviewed research report.

Secondly, the discourse around fertility intention measurement relies on some unsupported assumptions.  In an article that details the subtle differences between such categories as “unintended,” “unplanned,” “mistimed,” and “unwanted,” a lengthy paragraph defining each in turn ends with the assertion: “All of these definitions assume that pregnancy is a conscious decision.”12 While the goal of contraceptive use is to transform the link between the sexual act and procreation from an opt-out to an opt-in (in which the necessary precursor to becoming pregnant is discontinuing one’s method of prevention), the fact remains that biology is a stubborn thing.  As of 2011, 45 percent of pregnancies in the U.S. are classified as unintended.13  Global numbers are similar: 44 percent of pregnancies worldwide were estimated to be unintended between 2010 and 2014.14  Despite this, knowledge of family planning methods is now near-universal, and access to methods is approaching a saturation point.15  That nearly half of this “conscious decision-making” is occurring unintentionally ventures beyond cognitive dissonance and into utter incomprehensibility.

Whose problem is it anyway?

In 2017, UNFPA published its annual “State of World Population” report with an infographic claiming “43% of pregnancies in the developing world are UNPLANNED.”16  Absent from the report was a corresponding figure for the developed world.  A few months later, The Lancet published the missing data, in a report by the Guttmacher Institute.17  To be more specific, the relevant data were included in an online-only supplementary file, not in the main body of the paper: 46 percent of pregnancies in the developed world were classified as unplanned, as compared to 43 percent in the developing world.

The unit of measure is important: most of the charts in the main publication focused on the rate of unintended pregnancy, expressed as the number of pregnancies classified as unintended per 1,000 women aged 15-44.  Unlike the percentage of pregnancies classified as unintended, this measurement is affected by the pregnancy rate overall among women of reproductive age.  Therefore, the rate of unintended pregnancy is lower in countries and regions with lower fertility, which tend to be high-income developed countries such as those in Western Europe (such as the U.K. and the Netherlands, who provided funding for the study).  By contrast, in higher-fertility countries, the unintended pregnancy rate is higher, but the percentage of all pregnancies classified as unintended is lower.  The region with the highest fertility—Africa—has the lowest percentage of unintended pregnancies: 39 percent.

Conclusion

The narrative that the developing world—and Africa in particular—have less of a problem with unintended pregnancy than the developed world runs counter to the narrative UNFPA and the Guttmacher Institute have dedicated themselves to promoting.  As such, the decision to relegate the percentage data to the online supplement of the Lancet article is not surprising—certainly not more so than the decision to publish it at all.  As for UNFPA’s choice to showcase only half of the relevant statistic, one may rightly call it misleading, if not exactly false.

In the end, as at the beginning, the study of pregnancy intentions has been driven by specific political interests: namely, the desire to reduce overall fertility by increasing the use of modern contraceptives. The definitions of terms, the research questions deemed to be interesting, and the manner of reporting findings are clearly aligned with these objectives, sometimes quite explicitly.

Nevertheless, buried in the fine print of countless studies is the fact that the unintended pregnancy can, and often does, become a very much wanted child.  Digging deeper into the ways in which this occurs, and how it might be assisted through policy interventions, is a worthy project for researchers willing to see “ex-post rationalization” by parents of unexpected children as a promising sign, and not a flaw in the data set.

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