What is a ‘planned’ pregnancy? empirical data from a British study

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Abstract

The terms “planned”, “unplanned”, “intended”, “unintended”, “wanted” and “unwanted” are often used in relation to pregnancy in health policy, health services and health research. This paper describes the findings relating to women's understanding of these terms from the qualitative stage of a British study. We found that when discussing the circumstances of their pregnancies, women tended not to use the above terms spontaneously. When asked to explain the terms, women were able to do so but there was considerable variation in understanding. Most, but not all, were able to apply the terms. Women applied the term “planned” only if they had met four key criteria. Intending to become pregnant and stopping contraception were not sufficient criteria, in themselves, to apply the term; partner agreement and reaching the right time in terms of lifestyle/life stage were also necessary. In contrast, “unplanned” was a widely applied term and covered a variety of circumstances of pregnancy. The other terms were less favoured, “unwanted” being positively disliked. We recommend that survey questions eliciting information on women's circumstances of pregnancy do not rely on the above terms in isolation and, further, that a more circumspect use of the terms in policy and clinical settings is required.

Introduction

The desirability of ‘planned’ pregnancies has been an accepted tenet of family planning and maternal and child health policy in Britain and elsewhere in the world (RCOG, 1991; Department of Health, 1992; UNICEF, 1993; Brown & Eisenberg, 1995; Lee & Stewart, 1995). The assumption of such policy is that there are a number of costs to the individual and society from unplanned pregnancies. Unplanned pregnancies which result in abortion carry a financial cost to the health care system and/or the woman herself, as well as a potential personal/emotional cost and physical risk (albeit small with legal abortion) to the woman. Further, women who have unplanned pregnancies which continue to term have fewer opportunities to benefit from pre-conceptual and early antenatal care (e.g. taking folic acid, giving up smoking), and unplanned pregnancies have been linked to poor infant outcomes (Fergusson & Horwood, 1983; Baydar, 1995). Hence the importance of good population estimates of the prevalence of unplanned pregnancy and the numerous attempts to gather such information in the 40 years since reliable contraception made pregnancy planning a realistic concept (Freedman, Whelpton, & Campbell, 1959; Ryder & Westoff (1970), Ryder & Westoff (1976), Cartwright (1988); Ryder & Westoff, 1971; Westoff & Ryder (1973), Bone (1978); Westoff & Ryder, 1977; Dunnell, 1979; Cleland & Scott, 1987; Fleissig, 1991; Macro International, 1994).

In much research literature, the terms “planned”, “unplanned”, “intended”, “unintended”, “wanted”, “unwanted” and the concepts of “planning” or “intending” are treated as self-evident and unproblematic (e.g. Chow, Rider, & Hou, 1987; Metson, 1988; O’Campo, Faden, Gielen, Kass, & Anderson, 1993; Smith & McElnay, 1994; Warner, Appleby, Whitton, & Faragher, 1996; Mayer, 1997; McGovern, Moss, Grewal, Taylor, Bjornsson, & Pell, 1997). The approach taken in large national surveys (cited above) has been less crude; planning or intention status has tended to be elicited by means of multi-dimensional questions probing not only intentions, but also contraceptive use, reactions to pregnancy, timing of pregnancy plans and family size intentions. However, these questions have been used in various combinations and in different forms, suggesting a lack of clarity about this concept. Most of the questions have been concerned with the circumstances of births rather than abortions, the assumption being that all abortions are unplanned/unintended, despite evidence to the contrary (Price, Barrett, Smith, & Paterson, 1997). Further, most of the questions were developed for use with married women and measures are now urgently needed which take account of rapidly changing demographic trends—the increasing proportion of birth outside marriage and more fluid patterns of family formation. In the United States particularly, there has been growing concern over the validity of the survey questions used (London, Peterson, & Piccinino, 1995; Kaufmann, Morris, & Spitz, 1997; Bachrach & Newcomer, 1999; Luker, 1999; Peterson & Mosher, 1999; Sable, 1999; Trussell, Vaughan, & Stanford, 1999).

Research on how women themselves understand terms such as “planned”, “unplanned”, “intended”, “unintended”, and “wanted”, “unwanted” is limited. One US study, carried out in 1996 with 18 pregnant women using depth interviews, provided information on how women understood these terms (Fischer, Stanford, Jameson, & DeWitt, 1999) Moos, Petersen, Meadows, Melvin, & Spitz (1997) investigated concepts of planning using focus groups of young pregnant African–American women and white women of low or marginal income status in North Carolina, and in Britain the Family Planning Association commissioned a market research company to carry out focus groups and interviews with women of different ages and socioeconomic status to explore attitudes to planning (FPA, 1999). Previous studies have also found that it is not always possible to fit women's pregnancies into the dichotomous categories of “planned” and “unplanned” (e.g. Ineichen, 1986; Lester & Farrow, 1988; Macintyre & Cunningham-Burley, 1993; Katbamna, 2000), and Finlay (1996) questioned whether young women would use these terms at all if not prompted by researchers.

In this paper, we will present findings from the initial qualitative stage of a British study, which aims to develop a new measure1 of pregnancy planning/intention. The main focus of our paper will be to outline women's use and definitions of terms (e.g. planned, unplanned, etc) when talking about pregnancy, and consider the implications of these findings for survey measurement.

Section snippets

Methods

The overall aim of the study was to develop a new measure of pregnancy planning/intention. In order to do this we had to be begin by finding out whether women used particular concepts or terms when discussing pregnancy and if there was consensus on any particular term which could then inform the develop of the measure. In order to do this we chose an inductive (qualitative) approach, which allowed women to describe their own ideas.

Findings and discussion

We present and discuss our findings in four main sections. The first describes women's spontaneous use of terms during the interviews and factors related to this. The second, largely descriptive, section presents women's explanations of the terms. The third describes how women applied the terms to their pregnancies when asked to do so and how these applied terms fitted with the actions and feelings they described earlier in the interview; and the fourth section reflects on women's attitudes

Limitations

In this qualitative stage of our study, we asked pregnant women to reflect on the circumstances of their pregnancies. It is possible that by the time they talked to us, women may have recast their thoughts in light of an ongoing pregnancy or subsequent abortion. However, there are obvious methodological difficulties in interviewing women about their feelings towards pregnancy before they are pregnant. Interviewing a sample of women and following up those who become pregnant could be achieved in

Conclusions

Awareness that there may be significant problems of validity relating to questions used in national and international studies to elicit pregnancy planning/intention status (e.g. Cleland & Scott, 1987; Cartwright, 1988; Macro International, 1994) provided the impetus to this study. Our primary purpose, as stated above, was to establish how terms such as “planned” and “intended” were understood and used by women. We found that the terms tended not to be used spontaneously. When presented to the

Acknowledgements

We wish to acknowledge the valuable contribution of our project collaborators: Karen Dunnell, Penny Edgington, Anna Glasier, Isaac Manyonda, Catherine Paterson, Connie Smith, and R. William Stones. We would also like to thank the many others who helped with this project, including: Audrey Brown, Rolla Khadduri, Sunethra Kossine, Jan Sanders, Margaret Thorogood, and Maddy Ward.

This project was supported by a Medical Research Council/London Region special training fellowship in health services

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