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 regarding 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.
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
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 Contraceptive 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.
- Department of Health and Human Services. Healthy People 2020 topics and objectives: family planning. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/family-planning. Retrieved October 27, 2015. ⇦
- Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001–2008. Am J Public Health 2014;104(suppl 1):S43–8. [PubMed] [Full Text] ⇦
- Guttmacher Institute. Unintended pregnancy in the United States. Fact Sheet. New York (NY): GI; 2015. Available at: http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html. Retrieved October 27, 2015. ⇦
- Sonfield A, Kost K. Public costs from unintended pregnancies and the role of public insurance programs in paying for pregnancy-related care: national and state estimates
for 2010. New York (NY): Guttmacher Institute; 2015. Available at: http://www.guttmacher.org/pubs/public-costs-of-UP-2010.pdf. Retrieved October 28, 2015. ⇦
- Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Stud Fam Plann 2008;39:18–38. [PubMed] ⇦
- Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plann 2010;41:241–50. [PubMed] ⇦
- Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol 2007;196:297–308. [PubMed] [Full Text] ⇦
- Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006;295:1809–23. [PubMed] [Full Text] ⇦
- Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol 2011;117:1358–66. [PubMed] [Obstetrics & Gynecology] ⇦
- Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84:478–85. [PubMed] [Full Text] ⇦
- Centers for Disease Control and Prevention. Reproductive life plan tool for health professionals. Available at:
http://www.cdc.gov/preconception/rlptool.html. Retrieved October 27, 2015. ⇦
- Conry JA. Every woman, every time. Obstet Gynecol 2013;122:3–6. [PubMed] [Obstetrics & Gynecology] ⇦
- McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003;18:156–70. [PubMed] [Full Text] ⇦
- Bellanca HK, Hunter MS. ONE KEY QUESTION®: Preventive reproductive health is part of high quality primary care. Contraception 2013;88:3–6. [PubMed] [Full Text] ⇦
- Gavin L, Moskosky S, Carter M, Curtis K, Glass E, Godfrey E, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2014;63(RR-4):1–54. [PubMed] [Full Text] ⇦
- Frost JJ, Frohwirth L, Zolna MR. Contraceptive needs and services, 2013 update. New York (NY): Guttmacher Institute; 2015. Available at: http://www.guttmacher.org/pubs/win/contraceptive-needs-2013.pdf. Retrieved October 27, 2015. ⇦
- Institute of Medicine. Clinical preventive services for women: closing the gaps. Washington, DC: National Academies Press; 2011. ⇦
- Health Resources and Services Administration. Women’s preventive services guidelines. Available at: http://www.hrsa.gov/womensguidelines. Retrieved October 27, 2015. ⇦
- Brief for Physicians for Reproductive Health, American College of Obstetricians and Gynecologists et al. as Amici Curiae Supporting Petitioners, Kathleen Sebelius, Secretary of Health and Human Services, et al. v. Hobby Lobby Stores, Inc. et al. 134 S.Ct. 2751 (2014) (No. 13–354). ⇦
- National Family Planning and Reproductive Health Association. Medicaid family planning expansion programs: essential coverage post-ACA implementation. Washington, DC: NFPRHA; 2013. Available at: http://www.nationalfamilyplanning.org/document.doc?id=782. Retrieved October 28, 2015. ⇦
- Frost JJ, Gold RB, Frohwirth L, Blades N. Variation in service delivery practices among clinics providing publicly funded family planning services in 2010. New York (NY): Guttmacher Institute; 2012. Available at: http://www.guttmacher.org/pubs/clinic-survey-2010.pdf. Retrieved October 27, 2015. ⇦
- Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception 2013;88:243–9. [PubMed] [Full Text] ⇦
- Secura GM, Madden T, McNicholas C, Mullersman J, Buckel CM, Zhao Q, et al. Provision of no-cost, long-acting contraception and teenage pregnancy [published erratum appears in N Engl J Med 2014;372:297]. N Engl J Med 2014;371:1316–23. [PubMed] [Full Text] ⇦
- Biggs MA, Rocca CH, Brindis CD, Hirsch H, Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception 2015;91:167–73. [PubMed] [Full Text] ⇦
- Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health 2014;46:125–32. [PubMed] [Full Text] ⇦