Perinatal Forum May 17, 2004

1. Unintended Pregnancy“All pregnancies should be intended-that is, they should be consciously and clearly desired at the time of conception.”- IOM Committee on Unintended Pregnancy Perinatal Forum May 17, 2004

2. Intendedness question Thinking back to just before you were pregnant, how did you feel about becoming pregnant? • You wanted to be pregnant sooner • You wanted to be pregnant later • You wanted to be pregnant then • You did not want to be pregnant then or any time in the future

3. Potential effects on response rates to intendedness question Individual-Level Effects • Misunderstand what is being asked • Language • Comprehension • Not able to answer • May refuse because question is intrusive • May refuse because suspicious of system Interviewer Effects • Not explain purpose of questions • Not ask question directly • Interviewer uncomfortable with question • Poor practices/ not following protocol

4. Response Categories • Women were defined as having “valid ” responses if they answered that their pregnancies were: • Wanted sooner • Wanted later • Wanted then • Not wanted at all • In addition, women were classified as “Don’t Know” if they indicated that they were unsure of their intentions at conception. • Finally, women were also classified as “Refused” if they refused the question, and “Missing” if no answer was recorded.

5. Refusing this question is associated with refusing other questions... 51% of the women who refused to answer the intendedness question refused to answer at least one the other questions

6. Most women who were missing this question were also missing the others... 98% of women missing the intendedness question also were missing the other questions

7. Implications Current ascertainment of unintended pregnancy may seriously underreport those groups with or at high risk for poor outcome, potentially diluting the observed associations between intendedness at conception and perinatal outcome.

8. Contraception use among American women, 1995 Source: National Survey of Family Growth, 1995

9. Contraception Failure Rates, 1995After 12 months of use Family Planning Perspectives, volume 31, No. 2, March/April 1999 , Contraceptive Failure Rates: New Estimates From the 1995 National Survey of Family Growth, By Haishan Fu, Jacqueline E. Darroch, Taylor Haas and Nalini Ranjit

10. Defining unintended pregnancy(from the IOM and NSFG) • Intended pregnancies • Wanted at the time of conception, regardless of use of contraception at the time. Women who indicate they wanted to be pregnant sooner, or at that time, are considered to have intended pregnancies. • Unintended pregnancies • Not wanted at the time conception occurred, regardless of contraception.

11. Defining unintended pregnancy • Unintended pregnancy categories • Unwanted pregnancies • Conception occurred when the woman did not want pregnancy at any time in the future. • Mistimed pregnancies • Conception occurred at a time when the woman did not plan to become pregnant, although she may have planned to do so in the future

12. Data Sources for Unintended Pregnancy Information • National Survey of Family Growth (US) • Pregnancy Risk Assessment Monitoring System (PRAMS) Project (NYS) • Regional Perinatal Data System (FLR) • NYS Vital Statistics - induced abortions

13. Ever had an unintended pregnancy? US women age 15-44, 1995 • Source: NSFG 1995

14. What is the basis for considering unintended pregnancy one of our leading public health problems? • Magnitude/ frequency of occurrence • Breadth of populations affected • Association with significant maternal and child morbidity • Costs to the public/private health care system • Sensitivity to primary prevention

15. Gazmararian JA, Adams MM, Saltzman LE, et al. The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995;85:1031-8. Intended Mistimed Impact of unintended pregnancy on physical violence • “…women with unwanted or mistimed pregnancies had a higher prevalence of physical violence than did women with intended pregnancies, regardless of other characteristics.” 14 12 10 8 6 4 2 0 Not Not wanted

16. Unintended Intended 20 18 16 14 12 10 8 6 4 2 Najman JM, Morrison J, Williams G, et al. The mental health of women six months after they give birth to an unwanted baby: a longitudinal study. Soc Sci Med 1991;32:241-247. 0 During During At birth At birth 6 months 6 months Impact of unintended pregnancy on depression • A gap persists in the rate of depression among women giving birth to unwanted babies during pregnancy, at delivery, and six months post-partum. pregnancy pregnancy after birth after birth

17. Wanted Mistimed Unwanted 100 90 80 70 60 50 40 30 20 10 0 Skill Skill Positive Positive Vocabulary Vocabulary Baydar N. Consequences for children of their birth planning status. Family Planning Perspectives 1995;27:228-234. development development mother-child mother-child relationship relationship Impact of unintended pregnancy on child development • Pre-schoolers who were unintended at conception were: 1) less likely to receive skills development opportunities, 2) less likely to have positive MCH relationships, and 3) scored lower on vocabulary scales, than did their intended counterparts.

18. Healthy People 2010 Objective 9.1: “Increase to 70% the proportion of pregnancies that are intended.”

19. Progress Toward Healthy People 2010 Objective 9.1: In 2000 in the Finger Lakes region, 54% of pregnancies were intended.

20. Pregnancy Intention in the United States, 1995 15.5% of pregnancies were mistimed and resulted in a live birth 25.1% of pregnancies were mistimed and unwanted and resulted in abortion 7.6% of pregnancies were unwanted and resulted in a live birth 51.7% of pregnancies were intended and resulted in live birth

21. Pregnancy intention in New York(not including NYC) , 1999 27.3% of pregnancies were mistimed and resulted in a live birth 20% of pregnancies were mistimed and unwanted and resulted in abortion 44.9% of pregnancies were intended and resulted in a live birth 7.8% of pregnancies were unwanted and resulted in a live birth

22. Intended and unintended pregnancies, FLR, 1999 14%ofpregnancies were mistimed and resulted in a live birth 20.9% of pregnancies were mistimed/ unwanted and resulted in abortion 4.6% of pregnancies were unwanted and resulted in a live birth 42.6% of pregnancies were Intended and resulted in a live birth

23. Summary: Unintended pregnancy in US, NYS (not NYC), FLR(percent)

24. Demographic associations with unintended pregnancies which result in a live birth

25. Unintended pregnancy by 5-year age category, FLR, 1998-2003 20-24 <15 15-19 25-29 30-34 35-39 40-44 45+ Not Wanted

26. Unintended pregnancy and maternal race, FL 1998 - 2003

27. Unintended pregnancy and prenatal public program participation, FL, 1998 – 2003

28. Unintended pregnancy and maternal education, FL 1998 - 2003among women age 20 and over

29. Unintended pregnancy and prenatal public program participation, FL, 1998 – 2003

30. Prenatal behaviors • Women with unintended pregnancies receive prenatal care later than women with intended pregnancies • Women with unintended pregnancies use alcohol, tobacco, and other drugs more frequently than women with intended pregnancies

31. Unintended pregnancy and early prenatal care entry, FL, 1998 - 2003 % starting prenatal care during first trimester

32. Drug use and unintended pregnancy, FL, 1998 - 2003

33. Alcohol use and unintended pregnancy, FLR, 1998-2003(percent)

34. Smoking and unintended pregnancy, FL, 1998-2003

35. Summary and Conclusions

36. Women at risk for unintended pregnancy • Mistimed and unwanted pregnancies occurred in every demographic group (by age, race, education) • Younger women are at higher risk of mistimed pregnancies • Older women are at higher risk of unwanted pregnancies

37. The “average” woman with an unintended pregnancy which resulted in birth... • Was not a teenager • Was of white, non-Hispanic heritage • Had Medicaid coverage • Had at least one pregnancy prior to this one • Lived in a non-urban area

38. Outcomes Infants born to women whose pregnancies were unintended are more likely to be: • low birth weight, • delivered preterm, • not breast fed, • placed in foster care/adoption.

39. Preterm delivery (<37 wks) and unintended pregnancy, FL, 1998 - 2003

40. Low birthweight (<2500 g.) and unintended pregnancy, FLR 1998-2003

41. Breast feeding and unintended pregnancy, FL, 1998 – 2003intend to breastfeed at 6 weeks

42. Public Health/Clinical Focus Through primary prevention, we are able to avoid the potentially disastrous effects and agonizing decisions that women with unintended pregnancies face

43. Implications of findings • Effect of unintended pregnancies on women’s lives? • Education • Employment • Family finances • Stress/ health • Cost of unintended pregnancy to society • Public funding now and in future • Child abuse/neglect

44. More information needed... • Barriers to effective contraception use • Methods that are reliable and acceptable • How to effectively address unintended pregnancy as a public health problem

45. Public Health/Clinical Focus Secondary and tertiary prevention of unintended pregnancy • Transition from unintended conception to intended birth • Particularly focus upon pregnancies unwanted at conception • Bonding interventions • Social support • Parenting education