Rethinking the Pregnancy Planning Paradigm: Unintended Conceptions or Unrepresentative Concepts?

Abstract

Approximately half of pregnancies occurring each year in the United States are unintended: They either occurred too soon or were not intended at any time. 1 This commonly cited statistic is testament to the dominance of unintended pregnancy as a public health benchmark for measuring and improving women's reproductive health. 2 In addition to its use as a public health metric, this timing-based definition of unintended pregnancy is reflected in pregnancy planning paradigms in clinical practice. According to these paradigms, women are expected to map out their intentions regarding whether and when to conceive, and to formulate specific plans to follow through on their intentions. 3 CURRENT PLANNING PARADIGM While there is no evidence that planning benefits all women, it has been widely promoted as a universal ideal. The Centers for Disease Control and Prevention recommends reproductive life planning for women and assigns to health care providers the role and responsibility of helping women to define and implement pregnancy plans. 3 We propose, however, that public health and clinical efforts focused on reducing unintended pregnancy and improving pregnancy outcomes solely by promoting planning are subject to several important limitations. First, implicit in the planning ideal is the assumption that all women hold clear and unequivocal timing-based intentions. Yet rather than evoking a binary distinction between whether a pregnancy was "intended" or "unintended" at a certain time, women often describe their pregnancies as falling on a continuum between the two. 4 This characterization reflects an important conceptual facet of women's pregnancy preferences beyond intentions: desire to achieve or to avoid pregnancy. While some women hold strong desires either to achieve or to avoid pregnancy, others are ambivalent or indifferent, holding either some degree of desire to both achieve and avoid pregnancy or no strong desire either way. 5 Moreover, the strength and polarity of women's desires may fluctuate. 6 Current preventive strategies based on structured planning lack the flexibility to accommodate women with ambivalent, indifferent or fluctuating desires. Recommending effective contraceptive use as a means of avoiding pregnancy for a certain period of time does not fully address the complexity of these women's thoughts about conception and implies that their ambivalence or indifference can or must be resolved. In fact, only women with the strongest and most consistent desire to avoid pregnancy are likely to use contraceptives correctly and consistently over time. 6 For women with ambivalent, indifferent or fluctuating desires,