Definition and Epidemiology

The term unplanned pregnancy is defined as a pregnancy that is undesired at the time of conception or that is mistimed (occurs earlier than desired).^1,2 However, use of a single term to refer to unplanned pregnancies masks some of the differences between women with mistimed pregnancies and those with unwanted pregnancies. Women with unwanted or unintended pregnancies are more likely to have health risks that could negatively affect pregnancy outcomes. Unintended pregnancies are associated with greater unfavorable maternal behaviors and increased health risks for both mother and child than mistimed pregnancies are. Therefore, clarification of the difference between mistimed pregnancy and unintended pregnancy may help guide clinicians as they provide direct services to women and infants.²

Women with unintended pregnancies are less likely to receive the appropriate prenatal care, take prenatal vitamins and supplements, exercise during pregnancy, become vaccinated, eat a healthy diet, and gain the recommended amount of weight.³ In addition, they are more likely to engage in high-risk sexual behaviors, smoke cigarettes, drink alcohol, and abuse drugs and have a higher risk for developing mental health issues.³ Some but not all studies suggest that there is an increased risk of negative perinatal outcomes, such as low birth weight, preterm birth, and lower breastfeeding rates, associated with unintended pregnancies. Infants born to a mother with an unintended pregnancy are more likely to be readmitted to the hospital after discharge home. One study suggests that the emotions associated with having a child who was not planned for have long-term negative consequences for the parent-child relationship.⁴ In addition, significant social and economic costs, at both the personal and community levels, are associated with unintended pregnancies.⁵ In 2002, the medical costs associated with unplanned pregnancies in the United States totaled close to 5 billion dollars.⁶

The overall pregnancy rate for women 15 to 44 years of age in recent years is about 100 pregnancies per 1000 women; that is, approximately 10% of women of reproductive age become pregnant in any single year. Approximately 50% of those pregnancies are unintended. The rate of unintended pregnancies varies on the basis of several factors, including ethnicity, education, income, and marital status. Approximately 35 per 1000 white women have unintended pregnancies, compared with 78 per 1000 Hispanic women and 98 per 1000 black women. Unintended pregnancies occur in 26 per 1000 college graduates and in 76 per 1000 women who do not have a high school diploma.^7,8 One in 10 women aged 18 to 24 will have more than one unintended pregnancy.⁹ This is twice the rate for all women of childbearing age.⁹ Women whose income level is below 100% of the federal poverty level have an unintended pregnancy rate of 112 per 1000 women. Women whose income is twice the poverty level have an unintended pregnancy rate of 29 per 1000 women.¹⁰ Adolescent women have the highest proportion of unintended pregnancies, with at least 75% of pregnancies in women younger than 19 years being unintended.¹ Approximately 750,000 adolescents in the United States become pregnant each year, and most of these pregnancies are unintended.¹¹ Thirty-five percent of these adolescents will have a rapid repeat pregnancy, which is a pregnancy within 2 years of a previous pregnancy. Of these rapid repeat pregnancies in adolescents, 35% are unplanned.¹² The United States has one of highest rates of adolescent pregnancies among developed countries.

Approximately 14% of unintended pregnancies end in miscarriage. There are no official statistics kept on the number of children adopted each year, but estimates range from 1% to 3% of unplanned pregnancies.¹³ This number remains low despite changes to the adoption system over the past several decades that have resulted in an increase in support for birth parents.¹⁴

The high prevalence of unintended pregnancy is surprising, given that contraception is widely available in the United States. Although approximately 62% of women aged 15 to 44 years used contraception in 2006 to 2008, the proportions were significantly lower in four groups: teenagers 15 to 19 years of age (28%); never married, non-cohabitating women, some of whom are teens (39%); childless women (44%); and women who intend to have (more) children in the future (47%).⁷ Reasons for contraceptive nonuse differ according to the age of the woman and the circumstances surrounding the event. For example, contraceptive nonuse at first intercourse and hence unintended pregnancy were most often related to concerns that parents would find out about sexual activity. Older women with a second or higher-order pregnancy were more likely to discontinue contraception because of its side effects and medical complications.¹ Interestingly, experts estimate that 48% of the unintended pregnancies in the United States occur in women who use contraception but are not using it correctly.¹⁵

Although three fourths of reproductive-age women see a health care provider annually, less than 50% receive contraceptive or family planning services.¹³ Because women receive most of their preventive care from nongynecologic providers, primary care providers (PCPs) have a unique opportunity to provide contraceptive counseling to prevent unintended pregnancy.¹⁶ Studies suggest that PCPs vary in their knowledge and perceived competence in providing contraceptive counseling. In addition, PCPs may inaccurately assess a woman’s need for contraceptive counseling, misunderstand reasons for contraceptive nonuse, relegate the responsibility for contraceptive counseling to a subspecialist, or wait for the patient to initiate the discussion about contraception.¹⁶ PCPs should ask women about their reproductive life plan. This includes an assessment of how many children they have, if they want more children, and when they want more children. The answers to these questions can help guide appropriate care for women of childbearing age.¹⁷

Clinical Presentation

Patients may visit a provider because of signs and symptoms of possible pregnancy, without having taken a pregnancy test. These signs and symptoms may include a missed period, nausea and vomiting, breast pain, dizziness, and fatigue. Patients who feel especially vulnerable and are in denial about a pregnancy may not take a test at home and may want to take the test in a health care setting so that they have immediate guidance. Taking a test in a provider’s office can prove to be beneficial for patients who have minimal support at home and those with mental health problems.

A positive result of a pregnancy test can generate a variety of responses. For some patients, the news brings joy and excitement; for others, the news can be a crisis of varying proportions. Given this, the provider should use neutral language when delivering the news of a positive pregnancy test result. Although many personal and socioeconomic factors may affect a woman’s individual reaction, one common denominator is ensured: the woman’s life is changed.

The health care provider is often the patient’s first confidant in the first few minutes after delivery of the news of an unplanned pregnancy and is in a unique position to assist her in meeting her total health and wellness needs. For women for whom the pregnancy represents a crisis, several types of reactions can occur. With an unplanned pregnancy, the health care provider’s response is critical in establishing and maintaining an environment that feels safe and supportive to the patient. The provider’s initial role is to listen; both verbal and nonverbal communications provide information that is useful in developing the care plan. The patient needs to be allowed time to express her feelings. It is important that the provider not congratulate the patient or console her until the patient’s feelings have been assessed.

Patients feel especially vulnerable and pressured to find a quick and easy solution. Many report feeling as though they are racing against the clock, and they look to the significant people in their life for support and advice. Support may be lacking, or advice from these sources may differ from what the patient desires. A study by Joyce and colleagues found that the parents’ disagreement over the pregnancy was the most important predictor of instability in the mother’s intention regarding the pregnancy.¹⁸ In addition, a woman’s intentions regarding the pregnancy are not fixed and may change, depending on where she is on the continuum from preconception to postpartum.

In many cases, the pregnancy is not the only issue that concerns the patient. In fact, the patient’s reaction to the pregnancy may conceal her real concerns—finances, relationship problems, domestic violence, sexual abuse, or other issues. A woman’s reaction to an unplanned pregnancy is in part based on her evaluation of the obstacles she faces in life. Nelson and O’Brien found that women who decide to continue with pregnancy and have trouble organizing and coping with their emotions are at risk for developing a pattern of negativity that will affect the quality of the parent-child relationship.⁴ Assessment of these concerns is essential in the decision-making process for healthy outcomes.

Management and Counseling

Counseling of a woman with an unplanned pregnancy can be challenging and emotionally difficult for both the health care provider and the woman involved. This challenge is accentuated by the personal feelings that each provider may have about unplanned pregnancy, the options available, and the fact that an unplanned pregnancy can be a crisis in a woman’s life.¹¹ Health care providers need to understand and accept that a woman’s perspective and her goals and way of achieving them may conflict with their own. Before a provider can put aside his or her own beliefs and biases about reproductive choices and options, he or she needs to thoughtfully reflect on what those beliefs might be and how they might influence the education and counseling provided to a woman with an unplanned pregnancy. It is virtually impossible for a provider to rid himself or herself of personal values and biases, but the provider must be committed to and vigilant about keeping those biases out of the interaction with the woman and other people involved in the situation. If a provider feels that he or she is unable to put personal beliefs and values aside, the patient should be referred to someone else for counseling and management.¹⁴

Every woman has the right to factual and unbiased information about reproductive choices to make an informed decision about the pregnancy. Based on this, it is important for the provider to keep in mind that the woman is responsible for defining how the unplanned pregnancy is a problem for her, and she is responsible for her own exploration, assessing her options, and ultimately making a decision and acting on it. The provider’s role is to actively listen to the woman, to provide information and support, and to help the woman assess her options. A patient may ask the provider what she should do or what the provider would do if he or she were in the woman’s situation. It is important for the provider to remind the patient that it is her decision and that the provider will support her through that decision, whatever it may be. Patients often ask health care providers what they would do, often deeming a provider’s answer to be “the right answer.” The solution to the unplanned pregnancy lies with the woman.¹³

After the patient has expressed herself, the health care provider can assist with prioritizing the patient’s concerns and needs by focusing on one issue at a time. By exhibiting a willingness to listen and help, the provider helps build the patient’s confidence. An exploration of the patient’s feelings about pregnancy, the child, abortion, and abortion alternatives provides an opportunity to further process the situation. It is also helpful for the provider to know whether the patient has previously experienced an unplanned pregnancy or whether she knows anyone who has dealt with an unplanned pregnancy and the decision to have an abortion, to raise the child, or to surrender the child for adoption. A critical piece of information concerns the woman’s support system and the role of the child’s father in the woman’s life and in the decisions about this pregnancy. Although patients seek a rapid solution to the crisis of an unplanned pregnancy, the provider should encourage the patient to take the time necessary to make an informed decision about this life-changing situation because even a decision to end the pregnancy can have long-term effects.

Patients may need time to process their emotions and to discuss the pregnancy with the significant people in their lives. A scheduled follow-up visit provides an opportunity to further discuss with the patient her reactions and their effect on decision-making as well as to provide information and available support services. These initial meetings play an important role in how patients react to their pregnancy and assist with the decision-making process.

The health care provider should inform the patient of the full range of available options. For someone experiencing an unplanned or a crisis pregnancy, abortion is often viewed as the only solution. However, other viable options do exist. Referrals to crisis pregnancy centers can provide patients with the expertise of trained staff and can broaden their options. If the patient does not want to go to a crisis pregnancy center or if one is not accessible to her, a referral to a professional counselor is appropriate. The provider should keep in mind that in some cultures abortion is illegal, so a patient may need be forthcoming about her true wishes.¹⁹ The more informed the patient is, the less likely it is that she will regret the eventual decision. It is important to assure the patient that all information discussed will be kept confidential. Regardless of the decision, continued and unconditional acceptance of and compassion toward the patient will contribute to her overall wellness at this critical time.

Counseling a patient who is experiencing a crisis pregnancy can be very challenging. The following framework, which contains lists of questions for the health care provider to ask the patient, may help make this interaction fruitful for both patient and provider.

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