The U.S. Department of Health and Human Services’ Healthy People 2020 objectives call for a 10% reduction in unintended pregnancy over the next 10 years (1). Obstetrician–gynecologists can help to achieve this goal if they
- take advantage of each patient visit as an important teachable moment to assess each woman’s short- and long-term reproductive plans.
- engage each patient in supportive, respectful conversation about her pregnancy intentions and provide preconception or contraceptive counseling based on the woman’s desires and preferences.
- discuss the range of contraceptive methods and the perceived barriers to contraception, and engage in shared decision making to optimize contraceptive choices with women who desire to avoid pregnancy.
- educate women about the importance of pregnancy planning and child spacing to reduce adverse pregnancy outcomes.
- maintain awareness of the Affordable Care Act’s contraception coverage provisions as well as local community initiatives that improve women’s knowledge of how to access low- or no-cost contraception.
- support initiatives that reduce poverty and racial and ethnic health inequities, both of which are major drivers of unintended pregnancy.
Public Health Burden of Unintended Pregnancy
An unintended pregnancy is defined as a pregnancy that is mistimed or unwanted (2). The 3.4 million unintended pregnancies each year in the United States account for approximately one half of all pregnancies (3) and can result in negative health consequences for women and children and an enormous financial burden to the health care system (4, 5). Unintended pregnancy can be associated with maternal depression, an increased risk of physical violence to the pregnant woman, late prenatal care, and undue financial burdens in many families (6). Short interpregnancy (preceding birth to subsequent pregnancy) intervals of less than 18 months because of unintended pregnancy can be associated with poor obstetric outcomes (7, 8). Unintended pregnancies account for most of the 1.1 million abortions that occur annually (3, 9, 10). Infants born as a result of unintended pregnancies are at greater risk of birth defects, low birth weight, and poor mental and physical functioning in early childhood (8).
Initiatives to Promote Effective Reproductive Life Planning
A reproductive life plan is a set of personal goals regard-ing whether, when, and how to have children based on individual priorities, resources, and values (11). Practitioners often limit discussions about reproductive life planning to appointments for contraception or to the well-woman visit. But there are a number of opportunities to integrate reproductive life planning into other clinical encounters, including acute care and prenatal visits. Dr. Jeanne Conry launched the initiative “Every Woman, Every Time” in 2013 during her American College of Obstetricians and Gynecologists’ presidential address (12). The campaign encourages clinicians to address reproductive health choices every time a woman has contact with the health care system. Obstetrician–gynecologists and other health care providers should use every encounter not only to discuss women’s preferences for contraception, but also to counsel women about healthy lifestyle changes they can make to improve their health status before pregnancy to help ensure healthy future pregnancies. Every patient encounter, regardless of the chief reason for the visit, is an important “teachable moment” (13) to reduce unintended pregnancy, promote maternal health, and improve pregnancy outcomes. The first step in helping women plan their pregnancies is asking the right questions.
The One Key Question® Initiative promotes direct screening for women’s pregnancy intentions as a core component of high quality, primary preventive care services (14). The initiative proposes (see Box 1) that clinicians begin every conversation with women, aged 18–50 years, with the following question, “Would you like to become pregnant in the next year?” If the answer is “no,” clinicians can discuss pregnancy prevention, including education and counseling on all available contraceptive options, and help each woman arrive at an appropriate choice based on her health status, personal values, and preferences. Counseling should include guidance on the correct use of the chosen contraceptive method and the need for consistent use. If the response is “yes,” clinicians can provide preconception counseling and discuss evidence-based lifestyle modifications to optimize health status in preparation for future pregnancies.
Box 1. Questions to Assess Women’s Pregnancy Intentions Cited Here...
One Key Question ®
- • Would you like to become pregnant in the next year?
The Centers for Disease Control and Prevention’s Quality Family Planning Recommendations
- • Do you have any children now?
- • Do you want to have (more) children?
- • How many (more) children would you like to have and when?
The Providing Quality Family Planning Services report (15), published by the U.S. Centers for Disease Control and Prevention and the Department of Health and Human Services, provides evidence-based recommendations on how to prevent or achieve pregnancy based on the preferences and desires of women, their partners, and couples. The report supports the need for effective and efficient patient–practitioner communication about reproductive life planning using a series of three questions (see Box 1) and emphasizes the specific need for respectful engagement of women across demographic spectrums. Some women, particularly minority women, lower income women, and adolescents, can be mistrustful of health care practitioners and, therefore, reluctant to discuss their sexual activities or fully express their contraceptive needs and reproductive goals. This brief series of questions can help patients and obstetrician–gynecologists or other health care providers to have open, honest discussions about pregnancy intentions, whether care is being provided in a family planning clinic, a private or public health care setting, or during an acute care visit.
The Providing Quality Family Planning Services report encourages clinicians to offer a full range of reproductive life planning services, such as pregnancy testing and counseling, helping women to achieve pregnancies, basic infertility services, preconception health, and services to prevent and treat sexually transmitted infections. Providing preventive health services for women during family planning visits is strongly recommended and designated as a high-value component of quality family planning services.
Disparities in Unintended Pregnancy
Minority and low-income women are two to three times more likely to experience an unintended pregnancy compared to white or higher income women (2). Limited availability of the broad range of contraceptive methods in underserved areas or communities of color accounts for much of the disparity (16). Financial barriers can further reduce access and consistent use of women’s contraceptive method of choice and contributes to income disparities in unintended pregnancy and abortion rates. The Institute of Medicine recommends patient education and counseling on all U.S. Food and Drug Administration-approved contraceptive methods as part of the core elements of preventive care services (17). Although the Affordable Care Act (18) includes the provision of comprehensive contraceptive services for most insured reproductive-aged women without deductibles or co-pays, there remain significant populations of women without coverage who cannot access these services (19–21).
Promoting Knowledge About Access and Consistent Use of Contraception
At the core of unintended pregnancy is the unmet need for contraception, inconsistent or incorrect use of contraceptive methods, and misperceptions about adverse effects, particularly for hormonal methods or long-acting reversible contraceptives. At least 52% of unintended pregnancies occur among women who are not using any contraception, and 43% occur because of inconsistent or incorrect use of contraceptive methods. The Contra-ceptive Choice Project (22), a prospective study of nearly 10,000 reproductive-aged women, evaluated the effect of structured contraception counseling and financial coverage on women’s use of long-acting reversible contraceptives. The study found that structured counseling could be delivered effectively in a busy clinical setting and could improve a woman’s knowledge and consistent use of her contraceptive method of choice. Findings from the study also indicate that when contraceptive methods are provided at no cost, women are more likely to choose the most effective methods, which results in lower rates of unintended pregnancy, abortion, and births among adolescents (23). Additional organized efforts to provide access and coverage for contraception, such as statewide initiatives in Iowa (24) and Colorado (25), have demonstrated similar results with regard to low- or no-cost access and women’s consistent use of their method of choice. The American College of Obstetricians and Gynecologists strongly supports state and national efforts to improve and sustain access to contraception and encourages Fellows to support initiatives in their local communities that help provide low- or no-cost access to effective contraceptive methods.
Every woman who is capable of having a child should have a reproductive life plan. In order to reduce the rate of unintended pregnancy, obstetrician–gynecologists must focus on having respectful, meaningful conversations with patients about pregnancy intentions and must be willing to support efforts that promote access and consistent use of all contraceptive methods.
For More Information
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resources. The resources may change without notice.
ACOG has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/UnintendedPregnancy.
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