Table of Contents
Synopsis
Study question: How do pregnant adolescent women perceive and understand the pregnancy classification terms “planned,” “wanted,” and “unintended” used by the National Survey of Family Growth?
What is already known: The clinical relevance of measuring intended and unintended pregnancy in the National Survey of Family Growth (NSFG) is unclear, particularly to the adolescent population. While modernized measurements are available, more investigation is needed on how pregnant adolescent women conceptualize and relate to their pregnancies.
What this study adds: Pregnant adolescent women relate to the concepts of planning and wanting pregnancy as distinct and different concepts, while they do not relate to the terms intended or unintended pregnancy. The classifications used by NSFG may therefore not accurately capture the lived experience for adolescent women. This may cause pregnant adolescent women to inadvertently misclassify their pregnancies, thereby obscuring appropriate targets for intervention.
Abstract
Objective: To clarify how pregnant adolescent women relate to terms and concepts used by the National Survey of Family Growth (NSFG) regarding unintended pregnancies, specifically the classification terms of “planned,” “wanted,” and “intended” pregnancies. NSFG is a tool designed to measure pregnancy intendedness in order to inform health and social service programs.
Methods: We conducted in-depth interviews with 28 pregnant adolescent women. Interviews explored how each woman understood the classification terms used in the NSFG (intendedness, wantedness, and planned) and conceptualized her pregnancy.
Results: Most pregnant adolescent women designated their pregnancy as unintended and unplanned. While most women had a clear ideal for a planned and wanted pregnancy and did not currently experience these ideals, many still considered their pregnancy to be wanted. Partner and family support were associated with the wantedness of a pregnancy by the woman. Women experienced confusion about the term “intended” and offered varying interpretations thereof.
Conclusions: The NSFG classifications do not accurately capture the lived experience for pregnant adolescent women, who may consequently misclassify their pregnancy.
Implications: Findings support the continued development of tools that more accurately define and reflect the complexity of adolescents’ pregnancy experiences and provide more relevant classifications, such as pregnancy acceptability, for public health and clinical practice.
Introduction
Unintended pregnancies are more likely than intended pregnancies to result in low birth weight, pre-term birth, elective abortion, maternal depression, and child abuse and neglect.1, 2 Due to these poor outcomes, researchers and government agencies have attempted to measure unintended pregnancies in the United States for decades. The National Survey of Family Growth (NSFG), a cross-sectional survey, is a major avenue for collecting these data.3 In this survey, which is completed by women aged 15-49, pregnancies are classified as “intended” if the woman reports she got pregnant at a time of her choice or later, “mistimed” if the woman reports she wanted a pregnancy in the future but not at that particular time, or “unwanted” if the woman reports she never wanted any more children.4 Both unwanted and mistimed pregnancies are classified as “unintended.”
The validity of the data gathered from the NSFG has been called into question.1,5,6 Researchers argue that the cross-sectional, dichotomized nature of classifying pregnancies into two distinct categories—intended or unintended—misrepresents the complexity of the situation for many women.5,7–13 As a result, many pregnancies may be misclassified by the measurement, which may then obscure the appropriate targets for intervention to reduce associated negative outcomes.7,9,10,14–16
We conducted the current study to explore how pregnant adolescents perceive and understand the pregnancy classification terms from the NSFG. In this phenomenological, cross-sectional qualitative study, we explored pregnant adolescent women’s perceptions to generate hypotheses about the dimensions and determinants of adolescent pregnancy intendedness. Ultimately, we wish this study to contribute to more meaningful measurement and improved prevention and outcome interventions.
Methods
Sampling and Recruitment
Women were eligible for the study if they were (a) pregnant, (b) younger than 18 years, and (c) able to speak English. We used purposive sampling to ensure we enrolled women of varying ethnicities (Hispanic and non-Hispanic) and who made various decisions about their pregnancies (completing the pregnancy and either keeping the baby or adopting the baby out, having an abortion). We recruited women from several clinics in Salt Lake City, Utah: a university-affiliated teenage-mother program, a woman’s clinic, and a local adoption agency. Women were approached in the clinics and invited to participate in the study. An initial questionnaire screened for eligibility. Eligible women were asked to sign an informed consent document. For women who consented, interviews took place that same day, in a private room in the clinic of recruitment. All research activities were approved by the University of Utah’s Institutional Review Board.
Data Collection
We conducted 28 one-on-one interviews with pregnant women younger than 18 years. The interviews began with the standard questions used by the NSFG for pregnancy intendedness and then proceeded into open-ended questions (Table 1). Women were not told into which category they were classified by the NSFG questions. Interviews were conducted in Salt Lake City and surrounding suburbs from February 1996 to July 2003. Each interview was completed by a single interviewer (R.F. or D.H.). Both interviewers received training and feedback from senior study investigators, who included two psychologists and a family physician. All interviews utilized the same interview guide based on our previous research.10 This guide followed a semi-structured outline of points to cover and possible follow-up questions to address each point (see Appendix). The opening question for the semi-structured component of all interviews was “How do you feel about this pregnancy?”, with a follow-up question of “Why?” Each participant was asked if her pregnancy was planned, wanted, and intended, with follow-up questions of “Why?” The interviewer probed further to fully explore why the women answered the way they did and how they defined each NSFG term: intended, unintended, wanted, unwanted, planned, unplanned (Table 2). Participants were additionally asked what circumstances would make the pregnancy the opposite of what they answered (e.g., if their pregnancy was wanted, what would make it unwanted?). After each interview, basic demographic information was obtained. Interviews lasted between 30-45 minutes each and were transcribed verbatim. These transcripts were compared to the audio tape by the interviewer and corrected as needed. No compensation was provided to the participants.
Analysis
Our analysis followed a phenomenological analytic approach, as outlined by Moustakas17 and Creswell and Poth.18 The primary coder (D.E.) read the transcripts several times; memos with initial impressions and possible broader meanings were recorded. From each transcript, significant phrases that reflected how each woman conceptualized her pregnancy were identified. These significant statements were then organized into larger themes or clusters. A codebook was created to represent the common lived experience for women in this study. This codebook included both deductive codes based on the NSFG terms and inductive codes based solely on the themes that emerged from the transcripts.
Validation of this initial work was achieved through a second round of coding by more experienced researchers (J.S., L.G., and C.F.). Each read two complete transcripts, totaling 21% of the data. Multiple team meetings were conducted to discuss any discrepancies in the codebook and reach consensus.
Results
Sample Description
Twenty-eight women participated in the interviews; 65% identified as White Non-Hispanic (n=18) and 35% identified as White and Hispanic (n=10), with no other minorities represented. The average age was 15.9 years, with ages ranging from 14 to 17 years. All participants had less than a high school education. Participants were not asked about gender identity or expression. All stages of pregnancy gestational age were represented, ranging from 6 to 34.5 weeks. Five participants were choosing to abort the pregnancy (18%), 2 were choosing adoption after birth (7%), and 21 were planning to keep the baby after birth (75%).
Themes
Intendedness
Overwhelmingly, participants classified their pregnancy as unintended. (We include their statements below, with participants’ ages in parentheses.) When asked why, most women cited being too young, for instance: “Cause I’m too young, I think, to be having a child at this age” (17y). Participants also classified pregnancies as unintended when they perceived it as a mistake or accident, e.g.: “It was unintended. I didn’t mean to get pregnant. I mean, it was a mistake in the first place, but now I’ve made the mistake, I’m gonna undo it” (16y). A lack of planning or trying for a pregnancy was another reason for classifying pregnancy as unintended. A representative response: “I wasn’t planning on getting pregnant even though you could say we were asking for it because we weren’t using birth control or anything, so we weren’t planning it” (17y).
Participants offered varying meanings of the word intended. First, several participants expressed the idea that just having sex makes a pregnancy intended because the woman knows the consequences. One participant stated: “Well, because I knew what I was doing and so I knew that if I had sex, I would have a possible chance to get pregnant” (15y). A second interpretation of intended was that planned pregnancies were intended and accidental pregnancies were unintended. Intended was “wanting to have it and we planned it” and unintended was “that you didn’t want to have it, probably it was just an accident” (17y).
A third definition came from a 16-year-old participant. She believed that pregnancy was divinely intended or unintended, and stated:
I think if God intended you to have a child, then you’re intended to have it, then you should, and then you should be the one to take care of it. I think if you’re intended to have kids then you’re gonna have ‘em or there’s something that’s gonna stop that.
When asked what would make their pregnancy intended, many participants were unsure of what this term meant, with one bluntly stating: “I don’t know what that means” (16y). Several asked clarifying questions, such as: “What does intended mean—planned or unplanned?” (16y) or “What does that mean? Intended, like did we want it to happen?” (15y)
Planning
Most participants identified their pregnancy as unplanned. Many participants identified problems using birth control as the reason for the unplanned pregnancy—including birth control failure, not using birth control correctly, or not using birth control at all. Several women blamed condom failure, including a 15-year-old woman who became pregnant after her first sexual intercourse: “obviously it broke because that happened.” Inconsistent birth control usage was also named as a reason for an unplanned pregnancy. Several women stated that they just did not use birth control, resulting in an unplanned pregnancy: “But again, I knew the consequences and I knew about condoms. I knew about pills and everything, and I didn’t do it” (15y).
Participants also referred to a lack of preconception planning and preparedness with their partner or family as a reason for their unplanned pregnancy. One woman specified, “When you plan for it, you actually sit down and, well, this much money will go to the baby and try to like figure finances and stuff like that, but we didn’t do that. So, it was unplanned” (16y).
Almost universally, these adolescent women characterized their pregnancy as mistimed and expressed a desire to be older before pregnancy. One woman articulated: “I am going to be a senior in high school, and I don’t have any money. I have goals where I am going to be a big thing when I grow up and you know. You can’t have a baby and do all the stuff at the same time” (17y).
Nearly all participants expressed an unambiguous view of what an ideal planned pregnancy involves: being older, being financially secure, and planning with their partner beforehand. For most women, their actual situation was the opposite of their ideal. Many participants were facing very difficult financial situations: living with their parents and struggling to become financially independent with little education and little opportunity. When asked what she would do to plan a pregnancy, one woman expressed: “I’d make sure I was ready. Like financially and everything like that. I want to get an apartment before I have another kid” (15y).
Wantedness
The terms of wanted/unwanted pregnancy seemed to invoke a deeper emotional reaction and more nuanced feelings than the terms intended/unintended and planned/unplanned did. Responses around wantedness often moved away from the choices and circumstance surrounding conception and toward the ongoing pregnancy and birth. While nearly all participants described their pregnancy as unplanned, mistimed, and unintended, many still declared their pregnancy wanted. For instance, one participant replied: “I’ve just always wanted kids; so, to me, even if it came at bad timing and I wasn’t married or anything, it would still be wanted” (16y).
Wantedness could change throughout a pregnancy. Many adolescent women expressed initial unwantedness but, over the course of the pregnancy, came to want the pregnancy: “It’s not unwanted. Well, it was at first, but now, no” (16y).
Family and partner support were very influential for nearly all women. Participants expressed how much they needed and desired family support throughout their pregnancy, whether they were planning an abortion, adopting out, or keeping the baby: “I couldn’t ask for a better mother… she came home and we talked about it… and we both know it’s not right to abort a baby, but under the circumstances, there was really nothing we could do. I kind of relaxed when she told me it was alright to do” (15y).
Family support significantly affected wantedness. A family supportive of the woman and her pregnancy was associated with a wanted pregnancy, and a family unsupportive of the pregnancy was associated with an unwanted pregnancy: “I never planned it and I guess it’s more wanted now than unwanted because of all the support that his family is giving me and my sister and him, but I’ll still need more support from my family longer” (17y). Conversely, when asked what would make her pregnancy unwanted, one participant stated, “not having any support of people around me” (16y).
Partner support also affected whether a pregnancy was wanted. One participant expressed initial unwantedness, “but when I talked to him [the partner] about it, and he’s like, you know, don’t worry about it, I’m going to help you take care of it” (17y), she expressed deep wantedness and planned to keep the baby after birth. Conversely, when asked what would make their pregnancy wanted, one participant stated, “if my partner wasn’t such an asshole” (17y).
Our interviewers probed deeply into what exemplifies their ideal wanted pregnancy. The answers were similar across all clinics and pregnancy choices: having a supportive partner and family, being financially stable, graduating from school, and being older.
Initial Feelings About Pregnancy
All but two participants expressed negative, surprised, or shocked feelings when finding out about the pregnancy. One woman expressed her initial reaction as “shocked. Very shocked. I didn’t expect it” (17y).
Nearly all women expressed fear about their families’ reactions to the pregnancy, with one woman stating:
I was scared that maybe my mom, she didn’t want me to keep the baby, and she wanted me to get an abortion and I wouldn’t. I said no and she threatened me with lots of things and that was scary. I thought I would lose my mom through the whole thing because she was so upset. (16y)
Participants were also fearful of how their families’ perception of them would change and of losing their support. For example, one participant expressed: “Your parents think that you are a good kid. And all of a sudden, she is bad now, because look at what she did” (17y).
Discussion
We found that most adolescent pregnancies are unintended and unplanned but not necessarily unwanted. When discussing intendedness and planning, women focused on preconception circumstances; when discussing wantedness, women centered on support from others and their own feelings after conception. This finding is consistent with the conclusion of Gomez and colleagues that unplanned and unexpected pregnancies can sometimes still be welcomed.8 It is also consistent with our prior work that found a similar distinction between planning and wanting among adult women.10
The NSFG includes the following question: “Right before you became pregnant, did you yourself want to have a(nother) baby at any time in the future?”4 For most pregnant adolescent women, the answer is yes, but not currently. This response means the pregnancy will be classified as mistimed, and therefore also unintended. This classification fails to account for any differences in wantedness, which for most women in our sample was decided after conception. Important factors that help determine pregnancy outcomes—i.e., maternal acceptance of pregnancy, ceasing risky behaviors, and seeking prenatal care—are obscured in the overall classification of mistimed. Our findings are consistent with growing evidence that pregnancy acceptability might be an improved construct to better capture true lived experiences.11,12,19,20 Measuring pregnancy acceptability may classify adolescent pregnancies into more clinically relevant groups, distinct in varying levels of wantedness and resulting pregnancy actions, and provide a clearer picture of adolescent pregnancy and targets for intervention, both before and after conception.
Our study suggests that pregnant adolescent women use widely varying interpretations of the word intended regarding pregnancy. Several women thought simply having sex—with its resulting consequences—created an intended pregnancy. Others thought intended pregnancies were planned before conception. Yet others believed pregnancy was divinely intended. Additionally, many women were very confused about the meaning of this term and could not provide a definite response to questions regarding intendedness. Although the word pair intendent/unintended is used in the NSFG classifications, intended is not a term that seems clear to pregnant adolescent women.
Our findings highlight a chasm between the reality of pregnant adolescent women and their idealized views of a planned pregnancy. Most of our participants had goals around additional education, career development, stable relationships, and adequate finances; however, none of them experienced these ideals at the time of pregnancy and were facing situations of inadequate support and little opportunity. Other researchers suggest that preventing teenage pregnancy is a multifaceted, complex issue that involves more than just sexual education.21,22 Instead, it requires a collaborative conversation, a social determinants of health approach, and an examination of the root causes of teenage pregnancy.22 Rather than focusing purely on individual behavior change, a broader view is needed to improve the social, economic, and built environment pregnant adolescents inhabit. Our findings support these approaches.
Limitations
Our study faced several limitations. First, our sample was less diverse than the US population. However, our sample included both Hispanic and Non-Hispanic pregnant women younger than 18 years who represented the full spectrum of plans for pregnancy (keep, abort, or adopt). Second, our data were collected in the years 1996-2003. While some circumstances surrounding adolescent pregnancy have changed (i.e., more readily available contraceptives and a declining unintended pregnancy rate), current research suggests that very little has changed for the fundamental dynamics of planning or wanting a pregnancy.23 Our work adds to the limited availability of data in this field. Additionally, the core NSFG questions remain the same, and our results are consistent with research published recently, suggesting our data are relevant and reflect an ongoing need for this line of research.6 Third, as with the NSFG, our data are from a cross-sectional assessment of our participants’ views, and we do not have longitudinal assessments over time. However, several of our participants described significant shifts in their attitudes that had occurred prior to the interview.
Health Implications
Our results confirm that adolescent pregnancy is frequently fraught with social difficulties: initial apprehension, fear of others’ reactions, and difficult economic, living, and educational circumstances. Considering these difficulties, adolescent pregnancy prevention efforts should continue to be a major goal of health and social programs across the country. However, coupled with comprehensive sexual education and access to family planning, a more engaged conversation is needed: one that helps adolescent women envision a path toward their own ideals for future pregnancies, give them opportunity to succeed on this path, and help them see how current behavior affects their future.
In addressing the issues of adolescent pregnancy, the NSFG classification of mistimed (a subcategory of unintended) does not capture the range of lived experiences for many pregnant adolescent women or identify potential target factors for achieving better outcomes. Aiken and colleagues hypothesize that women who judge their pregnancies to be acceptable—independent of planning and intention—will have more positive outcomes.19 We recommend employing instruments that incorporate questions about pregnancy desire, post-conception wantedness, and/or acceptability. More relevant measures will enable researchers and practitioners to reach the ultimate goal behind pregnancy measurement: (1) improved pregnancy outcomes for mothers and children and (2) enhanced reproductive agency and empowerment for women.
Implications for Practice
Our study adds to the existing evidence supporting the development of more robust and relevant concepts of pregnancy for adolescents, such as pregnancy acceptability. However, further inquiry is needed into designing and validating instruments for pregnancy acceptability and related concepts. Moving forward, we believe qualitative data is needed to understand the determinants of pregnancy acceptability.
In addressing adolescent pregnancy clinically or in public health, we confirm that different adolescent women may have very different attitudes and behaviors during pregnancy, ultimately affecting outcomes for both the mother and the baby. Assessing the gap between the adolescents’ ideal and actual circumstances may provide insight for the individual adolescent pregnancy. Finally, partner and family support are extremely influential for pregnancy outcomes for adolescent women. Understanding and assessing partner support and pregnancy wantedness may provide effective avenues for intervention.
Acknowledgements
Drs. M. Jann Dewitt and Penny Jameson helped develop and implement the interview process. Rachel Fischer conducted some of the interviews for this study.
Sources of Funding
The research was funded in part by the Division for Reproductive Health, US Centers for Disease Control, under an agreement through the Association for Prevention Teaching and Research, TS-0785.
Disclosure of Potential Conflicts of Interest
None reported.
References
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Appendix
Interview Guide
CURRENT PREGNANCY
- How do you feel about this pregnancy?
- Did you expect this pregnancy?
- What was your reaction when you first found out you were pregnant?
- Did you and your partner discuss the possibility of you getting pregnant before it happened?
- [When you first started having sex? What did you do? What did you talk about?]
- [At the time you had sex that led to this pregnancy, were you thinking that you might get pregnant?]
- What is your partner’s attitude about this pregnancy?
- What kind of support are you getting from others about the pregnancy?
- [Explore: financial, material, emotional, social, moral]
- In what ways is your life changing with this pregnancy?
- In your opinion, is this a (planned/unplanned) pregnancy? Why?
- [What would have to be different in your life to make this an (unplanned/planned) pregnancy? What does unplanned/planned mean to you?]
- In your opinion, is this a (wanted/unwanted) pregnancy? Why?
- [What would have to be different in your life to make this an (unwanted/wanted) pregnancy? What does wanted/unwanted mean to you?]
GENERAL ATTITUDES
- In your opinion, what are some reasons women get pregnant when they aren’t planning to?
- In your opinion, what are some reasons that men get women pregnant when the men aren’t planning to?
- If a woman has an unexpected pregnancy, do you think she should continue the pregnancy or not?
- What role do you think men play in preventing pregnancy?
- What role do you think men play in planning pregnancy?
- Are there any other comments you would like to make on these issues?
Citation
D Elzinga, LH Gren, CJ Frost, D Hobbins, LM Ord, & JB Stanford. (2022). Exploring the Dimensions of Adolescent Pregnancy Intendedness, Wantedness, and Planning. Utah Women’s Health Review. doi: 10.26054/0d-3w3x-1c80.
