Unintended pregnancy

Unintended pregnancies are those in which conception was not intended by the female sexual partner. Worldwide, 38% of pregnancies were unintended in 1999 (some 80 million unintended pregnancies in 1999).^[1][2] Unintended pregnancies are the primary cause of induced abortion,^[3] resulting in about 42 million induced abortions per year.^[1] Unintended pregnancy is also linked to higher rates of maternal and infant deaths.

The use of modern contraceptive methods has greatly reduced the incidence of unintended pregnancy, particularly in more developed countries. However the United States has an unusually high rate of unintended pregnancy, especially among the poor.

Unintended pregnancies may arise within a committed relationship, such as marriage, as well as resulting from casual sexual activity, or as a result of rape.

Family planning

Becoming pregnant and having a baby are major events in a female's life, as well as that of her partner and family. Couples desire to control not just the number of children, but also the timing.^[4] Health outcomes for the child and for the mother are improved by not starting to have children too early, and by allowing adequate spacing between births. Economic and social factors, such as completing education and achieving a level of economic security, also play roles in desires when to have children.

Causes

• Not using contraception.^[1]
• Using contraception inconsistently or incorrectly.^[1]
• Contraceptive failure (the method was used correctly, but did not work.)^[1] Accounts for relatively small fraction of unintended pregnancies when modern highly effective contraceptives are used.

Reasons contraceptives might not have been used or been used incorrectly include:

• Coercion. Rape or involuntary sex which sometimes happens in the context of domestic violence. Unintended pregnancies are more likely to be associated with abuse than intended pregnancies.^[5] This may also include birth control sabotage - manipulation of someone's use of birth control to undermine efforts to prevent pregnancy.
• Lack of knowledge about sex and reproduction. Including erroneous beliefs.
• Lack of knowledge or experience with the contraceptive, or lack of motivation to use it correctly.
• Lack of planning or ambivalence about whether to have a child.

Results

Unintended pregnancies result in poorer outcomes for the mother and for the child, if birth occurs. Unintended pregnancy precludes pre-conception counseling, and pre-conception care, and delays initiation of prenatal care.^[6] The great majority of abortions result from unintended pregnancies.

Results of unintended pregnancy include:

• Prenatal care initiate later, and less adequate.^[3] Adversely affects health of woman and of child and less preparation for parenthood.^[3] Delay from unintended pregnancy is in addition to that from other risk factors for delay.^[3] Unwanted pregnancies have more delay than mistimed.^[3]
• Unintended pregnancies preclude chance to resolve sexually transmitted diseases (STD) before pregnancy.^[3] Untreated STD in pregnant woman can result in premature delivery, infection in newborn or infant death.^[3]
• Preclude use of genetic testing to help make decisions about whether to become pregnant.

• Women with an unintended pregnancy are more likely to suffer depression during or after pregnancy.^[6][7]
• Poorer maternal mental health^[6]
• Increased risk of physical violence during pregnancy^[6]
• Reduced likelihood of breastfeeding, resulting in less healthy children^[6]
• Lower mother-child relationship quality^[6] (see also Maternal bond)
• More likely that mother smokes tobacco (about 30% more likely in the US) or drinks during pregnancy.^[3] Which results in poorer health outcomes and additional costs for welfare system.^[3] (see also Fetal alcohol syndrome, Fetal alcohol spectrum disorder)

Children whose births were unintended are:

• Greater liklihood of low birth weight, particularly for unwanted pregnancies.^[3][8] In US eliminating all unwanted pregnancies would reduce rate of low birth weight by 7% for blacks, and 4% for whites, helping to decrease the large disparity in rates for whites vs. blacks.^[3] May be through increased risk preterm delivery.^[3]
• Greater infant mortality.^[3][8] If all sexually active couples in the US had routineley used effective contrectiption in 1980, there would have been 1 million fewer abortions, 340,000 fewer live births that were unintended at conception, 5,000 fewer infant deaths, and the infant mortality rate would have been 10% lower.^[3]
• likely to be less mentally and physically healthy during childhood,^[9]
• at higher risk of child abuse and neglect,^[3][10]
• less likely to succeed in school,^[11]
• more likely to live in poverty,^[11]
• more likely to need public assistance,^[11]
• more likely to have delinquent and criminal behavior.^[11] (see also Legalized abortion and crime effect)

Unintended pregnancies lead to higher rates of maternal morbidity, and threaten the economic viability of families.^[8]

Women with unintended pregnancies have less education and participate less in the workforce than women whose pregnancies are intended.^[11]

Induced abortions

Main article: Abortion

A woman who finds herself pregnant may terminate the pregnancy by an abortion.^[3] A large proportion of induced abortions worldwide are due to unwanted or mistimed pregnancy.^[12][13] Unintended pregnancies result in about 42 million induced abortions per year worldwide.^[1] In the United States, over 92% of abortions are the result of unintended pregnancy.^[11]

Abortion carries few health risks when performed in accordance with modern medical technique.^[3] It is far safer than child birth.^[3] However where safe abortions are not available, abortion can contribute significantly to maternal mortality and morbidity.

While decisions about abortion may cause some individuals psychological distress, some find a reduction in distress after abortion.^[3] There is no evidence of widespread psychological harm from abortion.^[3][14] Unwanted pregnancy and unwanted birth are also psychologically distressing, so considerations of psychological impact of abortion should be in comparison to potential harm from these stressors.

Some find abortion morally objectionable.^[3]

Maternal deaths

Main article: Maternal death

Over the six years between 1995 and 2000 there were an estimated 338 million pregnancies that were unintended and unwanted worldwide (28% of the total 1.2 billion pregnancies during that period).^[15] These unwanted pregnancies resulted in nearly 700,000 maternal deaths (approximately one-fifth of maternal deaths during that period).^[15] More than one-third of the deaths were from problems associated with pregnancy or childbirth, but the majority (64%) were from complications from unsafe or unsanitary abortion.^[15] Most of the deaths occurred in less developed parts of the world, where family planning and reproductive health services were less available.

Pre and postnatal depression contributes to increased risk of suicide among pregnant women and mothers. Suicide contributes to the rate of maternal mortality; where the rate of maternal deaths from physical causes is reduced by medically safe abortions and child delivery, the proportion from psychological problems can become more significant.

In cultures that practice honor killing, unintended pregnancy may increase the woman's chance of being killed.

Unwanted births

Infants whose births were not wanted are more likely to die of infanticide. Unwanted children may also be abandoned, especially where social structures to handle adoption are not available. Unwanted children are sometimes put up for adoption. (Related MeSH M01.111, Unwanted child.)

Prevention

Main article: family planning

Prevention includes comprehensive sexual education, availability of family planning services, including access to a range of effective birth control methods. Most unintended pregnancies result from not using contraception, many more result from using contraceptives inconsistently or incorrectly. Increasing use of long-acting reversible contraceptives (such as IUD and contraceptive implants) decreases the chance of unintended pregnancy by decreasing the chance of incorrect use. Method failure is relatively rare with modern, highly effective contraceptives, and is much more of an issue when such methods are unavailable, unaffordable, or not used. (See comparison of contraceptive methods).

In the United States, women who have an unintended pregnancy are more likely to have subsequent unplanned pregnancies.^[7] Providing family planning and contraceptive services as part of prenatal, postpartum and post abortion care can help reduce recurrence of unintended pregnancy.

Providing contraceptives and family planning services at low or no cost to the user helps prevent unintended pregnancies. Many of those at risk of unintended pregnancy have little income, so even though contraceptives are highly cost-effective,^[16] up front cost can be a barrier. Subsidized family planning services improve the health of the population and saves money for governments and health insurers by reducing medical,^[6] education and other costs to society.

Providing modern contraceptives to the 201 million women at risk of unintended pregnancy in developing countries who do not have access to contraception would cost an estimated US$3.9 billion per year.^[17] This expenditure would prevent an estimated 52 million unintended pregnancies annually, preventing 1.5 million maternal and child deaths annually, and reduce induced abortions by 64% (25 million per year).^[17] Reduced illness related to pregnancy would preserve 27 million healthy life years, at a cost of $144 per year of healthy life.^[17]

It is theorized that preventing unintended pregnancies could help break the cycle of poverty.^[18]

Affordable contraceptive services should form the basis for child abuse prevention.^[3] "The starting point for effective child abuse programming is pregnancy planning" US Surgeon General C. Everett Koop^[3]

Epidemiology

Note: Numbers and rates are for detected pregnancies. A large proportion of pregnancies miscarry before the woman is aware of the pregnancy.

Incidence

The global rate of unintended pregnancy was 55 per 1,000 women aged 15–44 in 2008, of which 26 per 1,000 ended in abortion.^[19] The rate of intended pregnancy was 79 per 1,000.^[19] The estimated 208 million pregnancies in 2008 resulted in 102 million intended births, 41 million induced abortions, 33 million unintended births, and 31 million miscarriages.^[19]

Globally, the proportion of married women practicing contraception increased from 54% in 1990 to 63% in 2003.^[19] The global rate of unintended pregnancy declined from 69 per 1,000 women in 1995.^[19] The decline was greatest in the more developed world.^[19]

Worldwide, 38% of pregnancies were unintended in 1999 (some 80 million unintended pregnancies in 1999).^[1][2] In developed world an estimated 49% of pregnancies were unintended, 36% in the developing world.^[2]

Unintended pregnancy is more likely among the poor, who have less access to contraceptives, less education about sexuality and family planning, and may have fewer career opportunities. In the United States, teen pregnancies are more likely than others to be unintended. Often as a result of lack of knowledge about sexuality and contraceptives, inexperience using contraceptives, difficulty getting contraceptives, or lack of planning. Women nearing menopause also have an increased risk of unintended pregnancy; as periods become less regular, a woman may assume that she can no longer have children, and stop using contraceptives, or use them less consistently.

By country/region

Europe

In France, 33% of pregnancies are unintended. Of women at risk for unintended pregnancy, only 3% do not use contraception, and 20% use Intrauterine devices (IUDs).^[20]

United States of America

The United States rate of unintended pregnancies is higher than the world average, and much higher than that in other industrialized nations.^[21] Almost half (49%) of U.S. pregnancies are unintended, more than 3 million unintended pregnancies per year.^[22] Over 92% of abortions are the result of unintended pregnancy,^[11] unintended pregnancies result in about 1.3 million abortions/year.^[1] The rate of abortions is high in the United States than in other developed countries because of the higher rate of unintended pregnancies in the US.^[4] In 2001, 44% of unintended pregnancies resulted in births, and 42% resulted in induced abortion and the rest in miscarriage.^[21] It is estimated that more than half of US women have had an unintended pregnancy by age 45.^[23]

History

US birth rates declined in the 1970s. Factors that are likely to have led to this decline include: The introduction of the birth control pill in 1960, and its subsequent rapid increase in popularity; the completion of legalization of contraceptives in the 1960s and early 1970s; the introduction of federal funding for family planning in the 1960s and Title X in 1970; and the legalization of abortion, which was completed in 1973. The decline in birth rate was associated with reductions in the number of children put up for adoption and reduction in the rate of neonaticide.

• It is unclear to what extent legalization of abortion may have increased the availability of the procedure.^[3] It is estimated that before legalization about 1 million abortions were performed annually.^[3] Before legalization, aboriton was probably one of the most common criminal activities.^[3] Before legalization, an estimated 1,000 to 10,000 women died each year from complications of poorly preformed abortions.^[3] Legalization was followed by a decrease in pregnancy related deaths in young women, as well as decrease in hospital admissions for incomplete or septic abortions, conditions more common than induced abortion.^[3]

• The infanticide rate during the first hour of life dropped from 1.41 per 100,000 during 1963 to 1972 to 0.44 per 100,000 for 1974 to 1983; the rate during the first month of life also declined, whereas the rate for older infants rose during this time.^[24]

The rate of unintended pregnancy declined significantly from 1987 until 1994, due to increased contraceptive use^[25][26] Since then until 2001 the rate has remained relatively unchanged.^[26]

Unintended pregnancies and births in the United States^[25]
Rate per 1000 women.

Year	Unintended pregnancies	Unintended births
1981	54.2 [25]	25 [25]
1987	53.5 [25]	27 [25]
1994	44.7 [25]	21 [25]
2001	51 [26]

Among poor women, the rate of unintended pregnancy and unintended birth rose from 1994 to 2001, while it declined for the more affluent women (those >200% of federal poverty level).^[26] (Unintended pregnancy rose almost 30% and unintended births rose 50% for those below federal poverty level.) Contraceptive use had been increasing for years, but stopped in the 1990s, and began to decline among poorer women.^[27] Cuts in federal and state family planning programs may account for the decreased use of contraceptives and increase in unintended pregnancies.^[27]

Costs and potential savings

The public cost of unintended pregnancy is estimated to be about 11 billion dollars per year in short term medical costs.^[11] This includes costs of births, one year of infant medical care and costs of fetal loss.^[11] Preventing unintended pregnancy would save the public over 5 billion dollars per year in short term medical costs.^[11] Savings in long term costs and in other areas would be much larger.^[11] By another estimate, the direct medical costs of unintended pregnancies, not including infant medical care, was $5 billion in 2002.^[28]

Teens

See also: Adolescent sexuality in the United States

Of the 800,000 teen pregnancies per year,^[29] over 80% were unintended in 2001.^[1] One-third of teen pregnancies result in abortion.^[29] In 2002, about 9% of women at risk for unintended pregnancy were teenagers,^[20] but about 20% of the unintended pregnancies in the United States are to teenagers.^[30] A somewhat larger proportion of unintended births are reported as mistimed, rather than unwanted, for teens compared to women in general (79% mistimed for teens vs. 69% among all women in 1998).^[31]

Prevention

In the US it is estimated that 52% of unintended pregnancies result from couples not using contraception in the month the woman got pregnant, and 43% result from inconsistent or incorrect contraceptive use; only 5% result from contraceptive failure, according to a report from the Guttmacher Institute.^[1] Contraceptive use saved an estimated $19 billion in direct medical costs from unintended pregnancies in 2002.^[28]

In 2006, publicly funded family planning services (Title X, medicaid, and state funds) helped women avoid 1.94 million unintended pregnancies, thus preventing about 860,000 unintended births and 810,000 abortions.^[32] Without publicly funded family planning services, the number of unintended pregnancies and abortions in the United States would be nearly two-thirds higher among women overall and among teens; the number of unintended pregnancies among poor women would nearly double^[32] The services provided at publicly funded clinics saved the federal and state governments an estimated $5.1 billion in 2008 in short term medical costs.^[32] Nationally, every $1.00 invested in helping women avoid unintended pregnancy saved $3.74 in Medicaid expenditures that otherwise would have been needed.^[32]

Reducing unintended pregnancy in the United States would be particularly desirable since abortion is such a politically divisive issue.^[3]

Rape

A longitudinal study in 1996 of over 4000 women in the United States followed for 3 years found that the rape-related pregnancy rate was 5.0% among victims aged 12–45 years. Applying that rate to rapes committed in the United States would indicate that there are over 32,000 pregnancies in the United States as a result of rape each year.^[33]

History

See also: History of abortion, History of condoms, and Timeline of reproductive rights legislation

Early ways of preventing unwanted pregnancy included withdrawal and various alternatives to intercourse; they are difficult to use correctly and, while much better than no method, have high failure rates compared to modern methods.^[4][34] Various devices and medications thought to have spermicidal, contraceptive, abortifacient or similar properties were also used.

Abortions have been induced to prevent unwanted births since antiquity,^[3] abortion methods are described in some of the earliest medical texts.^[34] The degree of safety of early methods relative to the risks of child birth is unclear.^[34]

Infanticide (‘customary neonaticide’) or abandonment (sometimes in the form of exposure) are other traditional way of dealing with babies that were not wanted or that a family could not support.^[34] Opinions on the morality or desirability of the practices have changed through history.

Where modern contraceptives are not available, abortion has sometimes been used as a major way of preventing unwanted birth. For instance in much of Eastern Europe and the former Soviet republics in the 1980s, desired family size was small, but modern contraceptive methods were not readily available, so many couples relied on abortion, which was legal, safe, and readily accessible, to regulate births.^[4] In many cases, as contraceptives became more available the rate of unintended pregnancy and abortion dropped rapidly during the 1990s.^[4]

In the 19th and 20th century, the desired number of pregnancies has declined as reductions in infant and childhood mortality have increased the probability that children will reach adulthood. Other factors, such as level of education and economic opportunities for women, have also lead to reductions in the desired number of children.^[4] As the number of desired number of children decreases, couples spend more of their reproductive lives trying to avoid unintended pregnancies.^[4]

In society and culture

Unintended pregnancy can be an indicator of premarital sex, which may carry social stigma, result in persecution or honor killing. Sometimes, in order to prevent illegitimate children, forced marriages result. Such marriages typically have poorer outcomes than voluntary marriage.

In many industrialized nations there is increasing acceptance of premarital sex, single parenting, and children born outside wedlock.

Unintended pregnancy is common as a cause of stress or social stigma in fictional works. It plays a role in many portrayals of illegitimacy and teen pregnancy.

See also

• Demographic dividend
• Epidemiology of teenage pregnancy
• International Conference on Population and Development
• Legalized abortion and crime effect
  • The Impact of Legalized Abortion on Crime
• Miscarriage
• Millennium Development Goals
• Nutrition and pregnancy
• Religious views on birth control
• Reproductive life plan
• Take Charge
• Wrongful birth - legal cause of action by parents of congenitally diseased child who would have chosen not to have the pregnancy or child had their practitioner followed the standard of care in informing them of the risks of the congenital disease.

References

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2. ^ ^{a b c} [http://www.guttmacher.org/pubs/archive/Sharing-Responsibility.pdf Sharing Responsibility:Women, Society and Abortion Worldwide] (Report). 1999. http://www.guttmacher.org/pubs/archive/Sharing-Responsibility.pdf. 
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4. ^ ^{a b c d e f g} "Abortion in Context: United States and Worldwide". Alan Guttmacher Institute. May 1999. http://www.guttmacher.org/pubs/ib_0599.html. Retrieved 2011-08-28. 
5. ^ J.E. Hathaway, L.A. Mucci and J.G. Silverman et al., Health status and health care use of Massachusetts women reporting partner abuse, Am J Prev Med 19 (2000), pp. 302–307.
6. ^ ^{a b c d e f g} "Family Planning - Healthy People 2020". http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=13. Retrieved 2011-08-18. "Which cites:
   • Logan C, Holcombe E, Manlove J, et al. (2007 May [cited 2009 Mar 3]). The consequences of unintended childbearing: A white paper. Washington: Child Trends, Inc.. http://www.childtrends.org/Files/Child_Trends-2007_05_01_FR_Consequences.pdf. 
   • "Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors". Contraception 79 (3): 194-8. 2009 Mar. 
   • Kost K, Landry D, Darroch J. (1998 Mar–Apr). "Predicting maternal behaviors during pregnancy: Does intention status matter?". Fam Plann Perspectives 30 (2): 79-88. 
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13. ^ Lawrence B. Finer, Lori F. Frohwirth, Lindsay A. Dauphinee, Susheela Singh, and Ann M. Moore (September 2005). "Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives". Perspectives on Sexual and Reproductive Health 37 (3): 110–118. http://www.guttmacher.org/pubs/journals/3711005.pdf. 
14. ^ "More on Koop's study of abortion". Fam Plann Perspect 22 (1): 36–9. 1990. doi:10.2307/2135437. JSTOR 2135437. PMID 2323405. 
15. ^ ^{a b c} Promises to Keep: The Toll of Unintended Pregnancies on Women's Lives in the Developing World. http://www.globalhealth.org/news/article/2319. Retrieved 2009-01-22. 
16. ^ James Trussell, Anjana Lalla, Quan Doan, Eileen Reyes, Lionel Pinto, Joseph Gricar (2009). "Cost effectiveness of contraceptives in the United States". Contraception 79 (1): 5–14. doi:10.1016/j.contraception.2008.08.003. PMID 19041435. 
17. ^ ^{a b c} Susheela Singh, Jacqueline E. Darroch, Michael Vlassoff, Jennifer Nadeau (2003). Adding it Up: The Benefits of Investing In Sexual and Reproductive Health Care (Report). The Alan Guttmacher Institute and UNFPA. ISBN 0-939253-62-3. http://www.guttmacher.org/pubs/covers/addingitup.html. 
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23. ^ Rameet Singh, Jennifer Frost, Beth Jordan, and Elisa Wells (January 2009). "Beyond A Prescription: Strategies for Improving Contraceptive Care". Contraception. http://www.arhp.org/publications-and-resources/contraception-journal/january-2009. 
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27. ^ ^{a b} Marc Kaufman (May 5, 2006). "Unplanned Pregnancy Increases among Poor". San Francisco Chronicle. http://www.commondreams.org/headlines06/0505-07.htm. Retrieved 2011-08-23. 
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29. ^ ^{a b} Dragoman M, Davis A (June 2008). "Abortion care for adolescents". Clin Obstet Gynecol 51 (2): 281–9. doi:10.1097/GRF.0b013e31816d72ee. PMID 18463459. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00003081-200806000-00012. 
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External links

• CDC:Unintended Pregnancy Prevention