The World Bank thinks “unintended pregnancy” is a big problem…but why?

By Rebecca Oas, Ph.D. | April 27, 2016

The World Bank has highlighted “unwanted pregnancy” as a key issue in the latest update to its volume on disease control priorities in the area of reproductive, maternal, newborn, and child health (RMNCH).

The World Bank begins its treatment of unwanted/unintended pregnancy by praising the general benefits of contraception:

[C]ontraception has a wide range of social, economic, and environmental benefits, in addition to its well-documented health advantages for women and children…Contraception has wider social and economic benefits, but its immediate purpose is to avoid unintended pregnancies.

The majority of [unintended] pregnancies stem from the non-use of contraceptive methods among women wishing to avoid or postpone childbearing.

I think sex is also involved, but I digress.

The obvious question is why aren’t women using contraceptives if they want to avoid becoming pregnant? The answer varies, of course, but one thing should be emphasized: for the vast majority of them, it isn’t lack of access to modern family planning methods.

To return to the World Bank, they devote extensive space to discussing how unintended pregnancy is measured, focusing on three approaches:

  • Women are asked what is their “total desired family size,” and any births in excess of that number are “defined as unwanted.” This method has a “serious problem”:

the likelihood that desired total family sizes are, in part, a rationalization of actual family sizes, with the consequence that unwanted births are likely to be underestimated.”

  • Women are asked prospectively whether another child is wanted. This method is “described as severely limited by the lack of studies.” Moving on…
  • Women are asked whether recent births were wanted, unwanted, or mistimed. Once again:

estimates are vulnerable to post factum rationalization due to an understandable reluctance of mothers to report children as unwanted or mistimed.”

It’s important to note that not all “unintended pregnancies” are “crisis pregnancies.” In fact, the high levels of so-called “rationalization” suggest that many of these pregnancies pose a greater crisis to the authors of the World Bank publication than to the parents.

The authors conclude that the approaches described above yield “very different results” and “no consensus exists on how best to obtain valid estimates of unintended births.” (This after more than half a century of attempting to do just that.) In summary, we have a measurement that produces inconsistent data, has no agreed methodology, and is systematically undercut by the fact that women reject the labels these surveys threaten to affix to their children.

So why is “unintended pregnancy” such a priority issue again?

They’re not claiming that children born from unintended pregnancies are inherently at a disadvantage:

“Insufficient data exist to indicate whether unintended pregnancies carried to term are disadvantaged in health or schooling, compared with intended births.”

That’s actually a huge admission there – a great deal of research has been done to prove that being “unwanted” has harmful effects on children, with underwhelming results (see some discussion of that here). However:

“Other effects of unintended pregnancies on family health are easier to document. A reduction in the number of unintended pregnancies is the greatest health benefit of contraception. In 2008, contraception prevented an estimated 250,000 maternal deaths, and an additional 30 percent of maternal deaths could be avoided by fulfillment of the unmet need for contraception.”

As I’ve written previously, this World Bank document relies heavily on the false notion that “unmet need” can be “fulfilled” in anything approaching a straightforward manner. But when it claims that the greatest health benefit of contraception is the reduction of “unintended” pregnancies, it really just means the number of pregnancies—presuming that a pregnancy averted by contraception must logically be unintended. What is not being claimed here is that the “unintended” pregnancy is inherently less safe than the “intended” one. But calling for the reduction of pregnancies in general starts to look like population control, and we can’t have that, right?

They go on to say that contraception can reduce high-parity or high-risk pregnancies and increase the spacing between pregnancies, but it doesn’t draw a direct line between a pregnancy being unintended and falling into one of those categories. After all, many very desired pregnancies are high-risk, high-parity, or happen close together. And again, it’s not as if large family size is necessarily a bad thing:

With respect to perinatal and child health and survival, evidence of an adverse effect of large family sizes is weak.”

The bottom line is that the women of the world do not consult the World Bank to determine the most auspicious time to become pregnant, or the number of children to have. When surveys attempt to force them to express their fertility desires in exact, methodological terms, they then turn around and create their families in non-laboratory conditions, and confound the surveyors by their willingness to accept life as it comes.

For some women, especially those who are poor or live in poor regions, that acceptance can entail great risk to her health and financial stability. This is why we cannot divert resources away from improving maternal health around the world.  After all, when a woman dies in childbirth, her death was not an “intended” event, regardless of whether her pregnancy was intended or not.