Public reproductive health and 'unintended' pregnancies: introducing the construct 'supportability'

Predictive ability of the Desire to Avoid Pregnancy scale

BACKGROUND

A longstanding gap in the reproductive health field has been the availability of a screening instrument that can reliably predict a person's likelihood of becoming pregnant. The Desire to Avoid Pregnancy Scale is a new measure; understanding its sensitivity and specificity as a screening tool for pregnancy as well as its predictive ability and how this varies by socio-demographic factors is important to inform its implementation.

METHODS

This analysis was conducted on a cohort of 994 non-pregnant participants recruited in October 2018 and followed up for one year. The cohort was recruited using social media as well as advertisements in a university, school, abortion clinic and outreach sexual health service. Almost 90% of eligible participants completed follow-up at 12 months; those lost to follow-up were not significantly different on key socio-demographic factors. We used baseline DAP score and a binary variable of whether participants experienced pregnancy during the study to assess the sensitivity, specificity, area under the ROC curve (AUROC) and positive and negative predictive values (PPV and NPV) of the DAP at a range of cut-points. We also examined how the predictive ability of the DAP varied according to socio-demographic factors and by the time frame considered (e.g., pregnancy within 3, 6, 9 and 12 months).

RESULTS

At a cut-point of 2 on the 0-4 range of the DAP scale, the DAP had a sensitivity of 0.78, a specificity of 0.81 and an excellent AUROC of 0.87. In this sample the cumulative incidence of pregnancy was 16% (95%CI 13%, 18%) making the PPV 43% and the NPV 95% at this cut-point. The DAP score was the factor most strongly associated with pregnancy, even after age and number of children were taken into account. The association between baseline DAP score and pregnancy did not differ across time frames.

CONCLUSIONS

This is the first study to assess the DAP scale as a screening tool and shows that its predictive ability is superior to the limited pre-existing pregnancy prediction tools. Based on our findings, the DAP could be used with a cut-point selected according to the purpose.

"If I Am Ready": Exploring the relationships between masculinities, pregnancy, and abortion among men in James Town, Ghana

The ability to exercise full sexual and reproductive health and rights is shaped by the contextual environment, meaning that women and pregnant people must navigate patriarchal norms when seeking care. Despite growing evidence that men are able to influence pregnancy outcomes, there remains a paucity of research on how and why men are able to involve themselves in pregnancy and abortion decision-making. This study interrogates the mechanisms that drive men's involvement in pregnancies and abortions in James Town, Ghana. Data from a survey (n = 296) and in-depth interviews (n = 37) were collected between July 2020 and January 2021. The mixed-method analysis critically examined the relationship between men's support for a pregnancy or abortion and their constructions of masculinities. Findings framed sex and reproduction as both a facilitator and a threat to men's masculinity. Reproduction was an essential component of being a man. Men discussed the need to fulfil masculine ideals of being independent, provide financially, and be in an acceptable relationship in order to be 'ready' for fatherhood. However, men similarly operationalised the notion of 'readiness' as the driving force behind their involvement in abortion decision-making. As being a father without being ready could lead to social ostracism and derision, men discussed forcing their abortion desires onto their sexual partners and other pregnant people. Achieving masculine ideals, therefore, was a critical motivation for controlling women and pregnant people's bodies. Understanding the role of masculinities is critical in acknowledging the contextual and environmental factors that women and pregnant people navigate, which contribute to continued reproductive injustices.

Contraception knowledge and uptake among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Background: South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods: A baseline cross sectional survey was conducted among 3432 grade 8s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results: In total, 2383 learners, completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion: This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

Knowledge, uptake and patterns of contraception use among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Background: South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods: A baseline cross sectional survey was conducted among 3432 grade 8’s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results: In total, 2383 learners, completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion: This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions

CONTEXT

Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use.

METHODS

We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy.

RESULTS

After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively).

CONCLUSIONS

Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

Revisiting the Association between Race, Ethnicity, and Beliefs about Pregnancy

Objective

Black and Latinx individuals are often the focus of health educational efforts to 'correct' perceived flawed beliefs about pregnancy, in order to increase contraceptive use and reduce unintended pregnancies. We sought to revisit the association between race, ethnicity, and beliefs about pregnancy.

Methods

We administered a web-based survey to 2,099 heterosexual men and women aged 21-44 years, using non-probability quota sampling. We analyzed a subset who were not currently pregnant (n=1,884) and conducted chi-square tests to examine the association between race/ethnicity and beliefs about avoiding pregnancy (can be avoided, determined by fate/God, 'just happens,' and is a natural process). We then performed a two-stage multinomial logistic regression, modeling the belief that pregnancy can be avoided. The first model included sociodemographic characteristics and the second model added feelings about pregnancy.

Results

Bivariate analyses revealed that, compared with Whites, those who identified as Black/African American or Latinx were significantly more likely to believe that pregnancy was determined by fate/God (15%,13% vs 9%, respectively) or a natural process (13%,13% vs 9%, respectively) and less likely to report that it can be avoided (57%,56% vs 67%, respectively; P=.001). In the first regression model, these differences persisted. However, in the second model, being Black/African American or Latinx was not significantly associated with beliefs about avoiding pregnancy.

Conclusions

Our findings suggest that once more nuanced beliefs about pregnancy prevention are considered, Black and Latinx individuals do not hold strongly different beliefs than Whites. Efforts that exclusively focus on people of color to change beliefs about pregnancy appear unwarranted.

Examining Women's and Men's Ideal Criteria Before Forming Families

In the United States, family formation decision-making is more complex than the predominant models that have been used to capture this phenomenon. Understanding the context in which a pregnancy occurs requires a more nuanced examination. In-depth interviews were conducted with 60 men and women, aged 18-35, who had children or were pregnant. Using grounded theory analysis, themes emerged that revealed participants' ideal criteria desired before pregnancy. We stratified by those who met and did not meet these criteria. Almost universally, participants shared ideal criteria: to graduate, gain financial stability, establish a relationship, and then become pregnant. Many participants did not accomplish these goals. Those who had not met their criteria had experienced traumatic childhoods and suffered economic concerns. For this group, having children prompted positive changes within their control, but financial stability remained limited. Efforts should focus on improving circumstances for all individuals to fulfill their criteria before pregnancy.

A qualitative assessment of perspectives on getting pregnant: the Social Position and Family Formation study

BACKGROUND

Intentions-oriented approaches to measuring pregnancy do not necessarily align with how people view and approach pregnancy. Our objective was to obtain an in-depth understanding of the notions women and men hold regarding pregnancy.

METHODS

We conducted semi-structured in-depth interviews with 176 heterosexual women and men ages 18-35, in the United States. Data were analyzed using grounded theory methodology.

RESULTS

Participants described notions of getting pregnant in one of three ways. One group of participants used language that solely described pregnancy as a deliberate process, either premeditated or actively avoided. Another described pregnancy as a predetermined phenomenon, due to fate or something that 'just happens.' The third group represented a blending of both notions.

CONCLUSIONS

Our findings underscore the need to shift the current paradigm of deliberate intentions to one that recognizes that pregnancy can also be viewed as predetermined. These findings can be used to improve measurement, health services, and better direct public health resources.

Expanding reproductive justice through a supportability reparative justice framework: the case of abortion in South Africa

Theoretical refinement of the concept of reproductive justice has been called for. In this paper, I propose the use of a supportability reparative justice approach. Drawing on intra-categorical intersectionality, the supportability aspect starts from the event of a pregnancy to unravel the interwoven embodied and social realities implicated in women experiencing pregnancy as personally supportable/unsupportable, and socially supported/unsupported. The reparative justice aspect highlights the need for social repair in the case of unsupportable pregnancies and relies on Ernesto Verdeja's critical theory of reparative justice in which he outlines four reparative dimensions. Using abortion within the South African context, I show how this framework may be put to use: (1) the facilitation of autonomous decision-making (individual material dimension) requires understanding women within context, and less emphasis on individual-driven 'choice'; (2) the provision of legal, safe state-sponsored healthcare resources (collective material dimension) demands political will and abortion service provision to be regarded as a moral as well as a healthcare priority; (3) overcoming stigma and the spoiled identities (collective symbolic dimension) requires significant feminist action to deconstruct negative discourses and to foreground positive narratives; and (4) understanding individual lived experiences (individual symbolic dimension) means deep listening within the social dynamics of particular contexts.

Towards a critical epidemiology approach for applied sexual health research

Critical approaches may benefit epidemiological studies of sexual health. This article proposes a critical approach, reconcilable with social epidemiological enquiry. Key aims of critical epidemiology for sexual health are identified, from which three criticisms of practice emerge: (1) lack of attention to socio-cultural contexts, (2) construction of ‘risk’ as residing in the individual and (3) enactment of public health agendas which privilege and pathologise certain behaviours. These reflect and construct an apolitical understanding of population health. This article proposes features of a critical epidemiology that represent a morally driven re-envisioning of the focus, analysis and interpretation of epidemiological studies of sexual health.

The Best of Intentions: A Structural Analysis of the Association between Socioeconomic Disadvantage and Unintended Pregnancy in a Sample of Mothers from the National Longitudinal Survey of Youth (1979)

OBJECTIVES

Births to less educated women are more likely to be classified as unintended than other births. We question a common interpretation that this association reflects a lack of contraceptive knowledge or self-efficacy among less educated women. We theorize that differences in early life educational advantages structure pregnancy desires and the salience and opportunity costs of precise fertility timing. We hypothesize that net of covariates indicative of early educational disadvantage, mothers with less education are not more likely to report births as unintended compared with mothers who have attained higher levels of education before becoming mothers.

METHODS

Using multivariate regression, we analyze a sample of women in the National Longitudinal Survey of Youth (1979) who had their first births by 1994. We test whether an index measure of educational advantage in youth predicts unintended first birth.

RESULTS

Unadjusted results confirm well-documented associations between educational disadvantage and greater likelihood of unintended pregnancy. However, once covariates are controlled, those with high educational advantage in youth are more likely to report their first birth as mistimed (relative risk ratio, 1.57).

DISCUSSION

Educational advantage captures expectations about how much education a young woman will obtain before giving birth and is a structural dynamic that precedes proximate factors related to family planning access and behaviors.

CONCLUSIONS

These findings highlight the need to incorporate structural factors that condition perceptions of pregnancy intention in the study of unintended pregnancy and to critically reevaluate the conceptualization and interpretation of pregnancy intention measures.