By Rebecca Bowers

EXECUTIVE SUMMARY

In a just-published study, researchers used data from a nationwide survey to understand the relationships among intention about pregnancy, attitude toward a hypothetical pregnancy, and contraceptive use for women who are at risk for unintended pregnancy.

  • Women who participated in the study who indicated they “never” wanted to become pregnant were about three times more likely to report contraceptive use compared to women who said they intended to become pregnant in the next year.
  • Women who indicated that becoming pregnant would be the “worst” thing that could happen were almost three times as likely to use contraceptives as those who said becoming pregnant would be the “best” thing that could happen.

Recent research suggests that intentions regarding pregnancy do not completely explain whether and how women use contraception. In addition, women’s attitudes toward the idea of becoming pregnant also are a factor. In a just-published study, researchers used cross-sectional data from a nationwide survey of 858 women veterans receiving care in the Veterans Affairs Healthcare System to evaluate the relationships among pregnancy intention, attitude toward hypothetical pregnancy, and contraceptive use for women who are at risk for unintended pregnancy.1

Participants in the study who indicated that they never wanted to become pregnant were nearly three times more likely to report contraceptive use as women who indicated the intention to become pregnant in the next year. Women who considered becoming pregnant to be the “worst” thing that could happen also were almost three times as likely to report contraceptive use as those who considered pregnancy to be the “best” thing that could happen.1

Intentions regarding pregnancy and attitudes about a possible pregnancy do not always align, says Sonya Borrero, MD, MS, associate professor of medicine and director of the Center for Women’s Health Research and Promotion at the University of Pittsburgh. She also serves as a core faculty member at the Veterans Affairs’ (VA) Center for Health Equity Research and Promotion and as a staff physician in the VA Pittsburgh’s women’s health clinic. Reproductive health clinicians must be aware of the different thoughts and attitudes that may affect women’s behavior regarding contraceptive use, she notes.

Intentions and attitudes can change during the course of a few months because of factors such as relationship status, finances, or social support, noted Borrero in a press statement. Conducting routine or frequent assessments is necessary in helping women to make the best decisions for them about reproduction, she explained.

Understand Effects on Method Choice

According to the survey’s results, women who selected “never” as their pregnancy intention were more than three times as likely to use highly effective methods, as opposed to women who placed themselves in the “next year” category. Women who said that it would be the “worst thing” if they became pregnant, regardless of their plan, were more than twice as likely to use highly effective methods, compared to those in the group who indicated pregnancy would be the “best thing.” In the study, the researchers classified intrauterine devices and subdermal implants as “highly effective” methods of birth control. They listed the birth control pill, ring, patch, and injection as “moderately effective methods.” The least effective methods listed in the study were barrier devices (e.g., condoms, diaphragms, and cervical caps), fertility awareness, spermicides, and withdrawal.1

Cultural backgrounds also played a role in the attitudes toward unintended pregnancy. The results indicate that Hispanic women held more positive attitudes about unintended pregnancies than black or white women. Among black women, there was no significant link between intention or attitude and contraceptive use.1

Women’s Plans Can Change

In a 2017 study of a national sample of 2,894 women ages 18-39, researchers analyzed data regarding pregnancy avoidance and happiness about pregnancy to evaluate the associations between measures of attitude and consistent use of contraception.2

The figures suggest that although more than half of women (53%) considered avoiding pregnancy to be very important, 23% indicated they would be very unhappy to be pregnant. Using logistic regression models including both measures, researchers found that only pregnancy avoidance was associated with using contraception consistently. The analysis findings indicate that cognitive attitude was less likely to change over time than emotional attitude. The researchers found that changes in consistent contraception use were associated with a change in a woman’s pregnancy avoidance, but not in her happiness.2

One way to help patients in making individual choices is to aid in the development of a reproductive life plan (RLP). This plan consists of personal goals related to whether, when, and how individuals decide to have children. These goals are developed with consideration of a woman’s priorities, resources, and values.3

The Centers for Disease Control and Prevention recommends anyone capable of having a child should have an RLP.4 (Get more information for women and men at the agency’s website, www.cdc.gov/preconception.) The American College of Obstetricians and Gynecologists (ACOG) also “strongly supports women’s access to comprehensive and culturally appropriate reproductive life planning.”5

Working with patients on reproductive life planning involves asking a series of questions. This activity can be incorporated into healthcare visits to determine patients’ goals related to pregnancy and childbearing.

Examples of questions for creating an RLP include:

  • Do you plan to have children or more children at any time in the future?
  • How long would you like to wait before becoming a parent?
  • What can I do today to help you achieve your plan?

For those patients who do not wish to become pregnant, consider using these questions:

  • Which family planning method do you plan to use until you or your partner are ready to become pregnant?
  • How certain are you about using that method without problems?

The clinician can ask these questions and integrate the results into the electronic health record. Alternatively, the clinician can include the questions in intake materials so that answers can be part of a specific discussion in the limited time of an office healthcare visit. (Read more about RLPs; see the February 2017 “Teen Topics” column at https://bit.ly/2SOSBn8.

REFERENCES

  1. Wolgemuth T, Judge-Golden C, Callegari L, et al. Associations between pregnancy intention, attitudes, and contraceptive use among women veterans in the ECUUN Study. Womens Health Issues 2018;28:480-487.
  2. Jones RK. Change and consistency in US women’s pregnancy attitudes and associations with contraceptive use. Contraception 2017;95:485-490.
  3. Centers for Disease Control and Prevention. Reproductive Life Plan Tool for Health Professionals. Available at: www.cdc.gov/preconception. Accessed Dec. 19, 2018.
  4. Johnson K, Posner SF, Biermann J; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care — United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep 2006;55:1-23.
  5. American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women. Committee Opinion no. 654 summary: Reproductive life planning to reduce unintended pregnancy. Obstet Gynecol 2016;127:415.