Structural Inequity and Pregnancy Desires in Emerging Adulthood

Measuring non-events: infertility estimation using cross-sectional, population-based data from four countries in sub-Saharan Africa

STUDY QUESTION

Does the prevalence of 12-month infertility in Burkina Faso, Côte d'Ivoire, Kenya, and Uganda differ between women trying to conceive and the broader population of women exposed to unprotected sex, and how are prevalence estimates affected by model assumptions and adjustments?

SUMMARY ANSWER

Estimates of 12-month infertility among tryers ranged from 8% in Burkina Faso to 30% in Côte d'Ivoire, increasing substantially among a larger population of women exposed to unprotected intercourse.

WHAT IS KNOWN ALREADY

While having a child is a fundamental human experience, the extent to which women and couples experience infertility is a neglected area of research, particularly in sub-Saharan Africa. Existing estimates of infertility in this region vary widely from 2% to 32%, however, potential impacts of variability in study populations and model assumptions have not been well-examined.

STUDY DESIGN, SIZE, DURATION

We used cross-sectional nationally representative survey data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda. We employed a multi-stage cluster random sampling design with probability proportional to the size selection of clusters within each country to produce representative samples of women aged 15-49. Samples ranged from 3864 in Côte d'Ivoire to 9489 in Kenya.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We created two analytic samples in each country-tryers and a broader sample of women exposed to unprotected sex-exploring differences in population characteristics and estimating the period prevalence of 12-month infertility using the current duration (CD) approach. We also examined the impact of several model assumptions within each of the two analytic samples, including adjustments for recent injectable contraceptive use, unrecognized pregnancy, infertility treatment, underreported contraceptive use, and sexual activity.

MAIN RESULTS AND THE ROLE OF CHANCE

Employing the CD approach among tryers produced an overall 12-month infertility prevalence of 7.9% (95% CI 6.6-12.7) in Burkina Faso, 29.6% (95% CI 15.3-100.0) in Côte d'Ivoire, 24.5% (95% CI 16.5-34.6) in Kenya, and 14.7% (95% CI 8.1-22.4) in Uganda. Results among women exposed to unprotected intercourse indicated much higher levels of infertility, ranging from 22.4% (95% CI 18.6-30.8) in Uganda to 63.7% (95% CI 48.8-87.9) in Côte d'Ivoire. Sensitivity analyses suggest infertility estimates are particularly sensitive to adjustments around pregnancy recognition timing and sexual activity, with little impact of adjustments for recent injectable contraceptive use, infertility treatment, and underreporting of traditional and coital dependent contraceptive use.

LIMITATIONS, REASONS FOR CAUTION

There was substantial digit preference in responses at 12 months, particularly among the tryers, which could introduce bias. Data quality concerns in the reproductive calendar may impact the accuracy of the CD approach among the broader sample of women exposed to unprotected sex, particularly with regard to underreported contraceptive use, induced and spontaneous abortions, and unrecognized pregnancies. Lastly, we lacked information on postpartum amenorrhea or abstinence.

WIDER IMPLICATIONS OF THE FINDINGS

Understanding the inconsistencies in definition and analytic approach and their implications for infertility estimation is important for reliably monitoring population-level infertility trends, identifying factors influencing infertility, improving prevention programs, and ensuring access to quality treatment and services.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Cohort profile: the ADAPT study, a prospective study of pregnancy preferences, pregnancy, and health and well-being in the southwestern USA

PURPOSE

Significant methodological shortcomings limit the validity of prior research on pregnancy decision-making and the effects of 'unintended' pregnancies on people's health and well-being. The Attitudes and Decisions After Pregnancy Testing (ADAPT) study investigates the consequences for individuals unable to attain their pregnancy and childbearing preferences using an innovative nested prospective cohort design and novel conceptualisation and measurement of pregnancy preferences.

PARTICIPANTS

This paper describes the characteristics of the ADAPT Study Cohort, comprised of 2015 individuals aged 15-34 years, assigned female at birth, recruited between 2019 and 2022 from 23 health facilities in the southwestern USA.

FINDINGS TO DATE

The cohort was on average 25 years old. About 59% identified as Hispanic/Latine, 21% as white, and 8% as black, 13% multiracial or another race. Over half (56%) were nulliparous. About 32% lived in a household with income <100% of the federal poverty level. A significant minority (37%) reported a history of a depressive, anxiety or other mental health disorder diagnosis, and 30% reported currently experiencing moderate or severe depressive symptoms. Over one-quarter (27%) had ever experienced physical intimate partner violence, and almost half (49%) had ever experienced emotional abuse. About half (49%) had been diagnosed with a chronic health condition, and 37% rated their physical health as fair or poor. The 335 (17%) participants who experienced incident pregnancy over 1 year were similar to selected non-pregnant matched comparison participants in terms of age, racial and ethnic identity, and parity but were more likely to live with a main partner than comparison participants.

FUTURE PLANS

We will continue to follow participants who experienced incident pregnancy and non-pregnant comparison participants until 2026. Analyses will examine pregnancy decision-making and investigate differences in health and well-being by prepregnancy pregnancy desires and feelings after the discovery of pregnancy, offering new insights into the consequences of not attaining one's reproductive preferences.

TRIAL REGISTRATION NUMBER

NCT03888404.

Integrating Sexual and Reproductive Health Equity Into Public Health Goals and Metrics: Comparative Analysis of Healthy People 2030's Approach and a Person-Centered Approach to Contraceptive Access Using Population-Based Data

BACKGROUND

The Healthy People initiative is a national effort to lay out public health goals in the United States every decade. In its latest iteration, Healthy People 2030, key goals related to contraception focus on increasing the use of effective birth control (contraceptive methods classified as most or moderately effective for pregnancy prevention) among women at risk of unintended pregnancy. This narrow focus is misaligned with sexual and reproductive health equity, which recognizes that individuals' self-defined contraceptive needs are critical for monitoring contraceptive access and designing policy and programmatic strategies to increase access.

OBJECTIVE

We aimed to compare 2 population-level metrics of contraceptive access: a conventional metric, use of contraceptive methods considered most or moderately effective for pregnancy prevention among those considered at risk of unintended pregnancy (approximating the Healthy People 2030 approach), and a person-centered metric, use of preferred contraceptive method among current and prospective contraceptive users.

METHODS

We used nationally representative data collected in 2022 to construct the 2 metrics of contraceptive access; the overall sample included individuals assigned female at birth not using female sterilization or otherwise infecund and who were not pregnant or trying to become pregnant (unweighted N=2760; population estimate: 43.9 million). We conducted a comparative analysis to examine the convergence and divergence of the metrics by examining whether individuals met the inclusion criteria for the denominators of both metrics, neither metric, only the conventional metric, or only the person-centered metric.

RESULTS

Comparing the 2 approaches to measuring contraceptive access, we found that 79% of respondents were either included in or excluded from both metrics (reflecting that the metrics converged when individuals were treated the same by both). The remaining 21% represented divergence in the metrics, with an estimated 5.7 million individuals who did not want to use contraception included only in the conventional metric denominator and an estimated 3.5 million individuals who were using or wanted to use contraception but had never had penile-vaginal sex included only in the person-centered metric denominator. Among those included only in the conventional metric, 100% were content nonusers-individuals who were not using contraception, nor did they want to. Among those included only in the person-centered metric, 68% were currently using contraception. Despite their current or desired contraceptive use, these individuals were excluded from the conventional metric because they had never had penile-vaginal sex.

CONCLUSIONS

Our analysis highlights that a frequently used metric of contraceptive access misses the needs of millions of people by simultaneously including content nonusers and excluding those who are using or want to use contraception who have never had sex. Documenting and quantifying the gap between current approaches to assessing contraceptive access and more person-centered ones helps clearly identify where programmatic and policy efforts should focus going forward.

Reproductive Justice as an Alternative to the Pregnancy Planning Paradigm for Teens

In this critical commentary, we describe the many limitations of the pregnancy planning paradigm as applied to pregnant and parenting teens. We describe how this paradigm, in characterizing pregnancies as intended or unintended, has shaped campaigns to prevent teen pregnancy and remains largely embedded in formal sex education and family planning programs in the United States. We argue that a paradigm shift is long overdue and describe how the reproductive justice framework addresses the limitations of the pregnancy planning paradigm. Although reproductive justice is endorsed by a growing number of organizations, recommended policies face formidable obstacles given that comprehensive sex education, contraception, and legal abortion are increasingly at risk in a post-Dobbs world.

Navigating work and motherhood: exploring the link between career orientation and childbearing motivations in emerging adulthood

BACKGROUND

Difficulties in reconciling work and family life are recognised as one of the major reasons for women delaying or even forgoing childbearing. Nonetheless, there are different mechanisms through which women's engagement in the labour market can impact their choices regarding having children. The current study focuses on the relationship between women's career orientation and the childbearing motivation of young, childless women. Additionally, we examine the moderating effect of women's self-esteem.

METHODS

Questionnaires to assess women's childbearing motivation, career orientation (career commitment and career centeredness), and self-esteem were administered online to Polish childless women aged 18-25 (N = 358). Multivariate regression was performed to verify how professional aspirations determine childbearing motivation. Moderation analysis included self-esteem in the equation.

RESULTS

Women's desire to be employed over their life course (career commitment) was associated with perceiving childbearing as less strenuous. However, women who placed a higher value on professional development perceived more costs and barriers related to parenthood. Women with higher self-esteem demonstrated a generally more negative view of childbearing, yet their perceived costs of having children increased along with rising professional aspirations.

CONCLUSIONS

Our results demonstrate that career aspirations are a highly complex construct, and their relationship to childbearing motivation may differ depending on how women perceive their future in the labour market. The mere desire to engage in professional work is not detrimental to childbearing motivation, but the anticipated costs of having children become greater the more a woman is career-centred and the lower her self-esteem.

The role of legal status and uncertainty in the reproductive aspirations of 1.5 and second generation Mexican-origin immigrant young women: An exploratory study

Background

The 1.5 generation, brought to the U.S. prior to age 16, faces barriers that the second generation, U.S.-born to immigrant parents, does not, including only temporary legal protection through the Deferred Action for Childhood Arrivals (DACA) Program. Little is known about how legal status and uncertainty shape cisgender immigrant young women's reproductive aspirations.

Methods

Drawing on the Theory of Conjunctural Action with attention to the immigrant optimism and bargain hypotheses, we conducted an exploratory qualitative study using semi-structured interviews with seven 1.5 generation DACA recipients and eleven second generation Mexican-origin women, 21-33 years old in 2018. Interviews focused on reproductive and life aspirations, migration experiences, and childhood and current economic disadvantage. We conducted a thematic analysis using a deductive and inductive approach.

Results

Data resulted in a conceptual model on the pathways through which uncertainty and legal status shape reproductive aspirations. Participants aspired to complete higher education and have a fulfilling career, financial stability, a stable partnership, and parents' support prior to considering childbearing. For the 1.5 generation, uncertainty of their legal status makes the thought of parenting feel scary, while for the second generation, the legal status of their parents makes parenting feel scary. Achieving desired stability before childbearing is more challenging and uncertain for the 1.5 generation.

Conclusions

Temporary legal status constrains young women's reproductive aspirations by limiting their ability to achieve desired forms of stability prior to parenting and making the thought of parenting frightening. More research is needed to further develop this novel conceptual model.

What a (Young) Woman Wants: Concurrent Effects of Desire to Avoid Pregnancy and Desire for Sex on Sexual Intercourse and Contraceptive Use

Of all pregnancies among young women in the United States, more than 60% are undesired, yet explanations for this phenomenon remain elusive. While research has investigated how pregnancy desires and intentions shape pregnancy-related behavior, only recently have scholars noted that desire for sex influences these same behaviors. Many young women simultaneously experience strong desires for sex alongside a strong desire to avoid pregnancy, but few studies have considered the extent to which young women adapt their reproductive behaviors in response to these potentially competing desires. Using novel weekly panel data, this analysis assesses how desires for sex may moderate the effect of the desire to avoid pregnancy on a young woman's sexual behavior and contraceptive use. Findings suggest that when a woman strongly wants to avoid pregnancy, she is less likely to have sex and more likely to use hormonal or coital contraceptives. As her desire for sex increases, however, she is instead more likely to have sex and use hormonal contraceptives. If she does not use hormonal methods, she is less likely to use coital contraceptives when she has intercourse. These findings highlight the importance of recognizing the desire for sex as a behavioral modifier for avoiding undesired pregnancy in the transition to adulthood.

A Latent Class Analysis: Identifying Pregnancy Intention Classes Among U.S. Adolescents

PURPOSE

Few studies have captured the multidimensionality of pregnancy intentions for adolescents on a national level, particularly missing the perspectives of male adolescents. Therefore, this study aimed to identify and describe pregnancy intention profiles among U.S. adolescents.

METHODS

Latent class analysis was conducted using data from two cycles of the National Survey of Family Growth (2015-2017 and 2017-2019) among U.S. adolescents 15-19 years old (N = 3,812). Stratified by sex, six National Survey of Family Growth indicators around desires, feeling, timing, and social acceptability were included. Multinomial logistic regression was used to identify the correlates of class membership.

RESULTS

Three latent classes of pregnancy intention were identified for each sex, which were distinguished by immediate and future desires, feelings, timing, and social acceptability. For both females and males, Delayed Pro-pregnancy (53% vs. 82%) and Near Pro-pregnancy (28% vs. 8%) were identified. Ambivalent-pregnancy (14%) and Anti-pregnancy (10%) were specific to females and males, respectively. Near Pro-pregnancy females and Anti-pregnancy males were more likely to be sexually active, older, of Hispanic descent, report receiving public assistance, and have a teen mother than adolescents classified as Delayed Pro-pregnancy. Females with a pregnancy history were more likely to be classified as Ambivalent than Delayed Pro-pregnancy.

DISCUSSION

While most adolescents intend to delay or avoid childbearing, there are subsets of adolescents whose pregnancy intentions are in favor of early childbearing, which is often dismissed in adolescent sexual and reproductive health. Current efforts can use these distinct pregnancy intention classes to tailor sexual and reproductive health services specifically for diverse adolescent populations.

Doctor Knows Best? Provider Bias in the Context of Contraceptive Counseling in the United States

OBJECTIVES

The study examined how clinicians described their patients in relation to their practices of contraceptive counseling.

STUDY DESIGN

This qualitative study involved individual interviews with 15 clinicians working in obstetrics and gynecology in South Carolina about their approaches to contraceptive counseling. We analyzed the data using a combination of deductive and inductive approaches.

RESULTS

Clinicians attributed challenges of working with diverse patient populations to patients' race/ethnicity, socioeconomic status, and age. Clinicians often interpreted patient concerns about or refusal to use effective contraceptive methods as a problem with patients themselves. When clinicians described patients in disparaging ways, they often focused on adolescent patients.

CONCLUSION

Bias informed by structural inequalities and power relations influences how clinicians perceive their patients and approach counseling them about contraception. Such practices may limit patients' informed decision-making and autonomy when making decisions about initiating or continuing contraceptive use.