Cupids Health

Unintended conceptions leading to wanted pregnancies – an integral perspective on pregnancy acceptance from a mixed-methods study in Germany


Introduction

Unintended pregnancies are associated with social problems and health risks for mother and child [1]. However, differentiation is called for as there is some evidence that not all unintended pregnancies imply the same adverse consequences to the same extent. Especially, ‘the paradox of happiness about unintended pregnancy’ [2,p.149] is discussed as a predictor of positive development after unintended conception [2]. Depending on the scope and measures of surveys, approximately every second to fourth woman with an unintended pregnancy carried to term reported positive feelings [3–8]. The differentiation requires a clarification of the dimensions of the umbrella term ‘unintended’ and should also discuss the response to pregnancy.

Differentiation of ‘unintended’ as ‘unwanted’ or ‘mistimed’ is provided by the timing-based measure introduced in 1965 in the US-National Survey of Family Growth (NSFG) and well established as a standard later [9–11]. The ‘London Measure of Unplanned Pregnancy’ (LMUP, defined in the 1990s) goes beyond that by proposing a continuum between strictly planned and strictly unplanned pregnancy rated in six dimensions. Efforts to avoid a pregnancy – for example, by using contraceptives – are included as a dimension [12–14]. As a critique of the prevailing ‘planning paradigm’ [15,p.148], research was carried out on the ambivalence concerning pregnancy (with varying definitions: [16–18]), on the impact of emotions and affective attitudes, and on intendedness ‘in between wanted and unwanted’ [6,11,19–24].

The focus on intention and desire before conceiving was widened by including feelings and considerations after the pregnancy was confirmed [9; for NSFG: 5,25]. Stanford et al. [26,p.185] defined a ‘postconception desire for pregnancy’ and ‘adaptation to pregnancy and baby’ as two out of the five dimensions of ‘pregnancy intendedness’. Aiken et al. [15] defined the ‘perception of pregnancy’ and ‘pregnancy acceptability’ as indicators of pregnancy wantedness. Judging a pregnancy as acceptable can turn an unintended conception into a wanted pregnancy [2,15]. Gomez et al. defined pregnancy acceptance as a measure ‘which captures whether individuals anticipate considering an unexpected pregnancy welcome, manageable, or okay’ [22,p.408]. However, the terms ‘happiness’, ‘pregnancy acceptability’, and ‘postconception desire’ are neither clarified nor well-founded in theory.

Aiken et al. [2] explored happiness about the prospect of a pregnancy in the next few months among women who wanted no more children. In the semi-structured interviews, one of the reasons underlying this paradox was a ‘deep and heartfelt feeling about children taking precedence over practical consideration’ [p.159]. Some evidence is provided that in the United States this attitude is more pronounced among Latina [2] respectively women with a low income [11,20]. In retrospective studies, mistimed pregnancies and pregnancies after omitting contraceptives were welcome more frequently compared to unwanted pregnancies, respectively those due to contraceptive failure [6,9]. Correlations were observed between positive feelings and the decision to keep the baby [5,27]. Interrelations between more or less favourable living conditions and general attitudes towards motherhood at the time of pregnancy and their respective impact on the response to pregnancy and pregnancy acceptance remain unclear. Furthermore, the impact of the pregnancy itself as a trigger for changes and the subsequent process of adaptation to pregnancy have not been explored.

First, more insight into the heterogeneity of ‘unintended’ pregnancy carried to term is provided with a main focus on differentiating between positive and negative responses, and the determinants of the response such as attitudes and living conditions are explored. The more or less ‘happy’ unintended pregnancies are discussed based on whether they share some features with intended pregnancies (acceptance assumed a priori) and pregnancies ending in abortion (no acceptance assumed). Second, five types of pathways of emerging acceptance in the course of unintended pregnancy – sooner or later, more easy or difficult – are derived from the qualitative interviews.

Methods

The cross-sectional mixed-methods study ‘Women’s lives: family planning in the life course’ was conducted in 2012–2018 in 12 Federal States of Germany. The standardised, population-based CATI survey includes a random sample of n = 14,522 women who were 20–44 years old. All participants who ever experienced an unintended pregnancy were asked for their willingness to give an additional in-depth interview. From those agreed, n = 116 were selected by purposeful sampling: one case was chosen after the other in contrast to the previous cases concerning age, education, and family situation. As no statistical generalisability is intended in the qualitative analysis, the quality criterion of the sample is maximal heterogeneity concerning relevant features. The design provides the option to merge standardised and qualitative data for 116 women.

The analyses are restricted to first pregnancies in the life course carried to term or aborted. As the dynamics of unintended pregnancies differ in the succession of first and further pregnancies [6], this restriction generates a more homogeneous sample. Standardised data on n = 2,306 unintended and n = 6050 intended pregnancies leading to a first baby, and n = 620 first pregnancies ending in abortion are available. In accordance with the second research question, the qualitative interviews were selected out of the 116 in-depth interviews which recounted a first pregnancy that occurred unintentionally and resulted in a first baby (n = 59) or an abortion (n = 33), providing subjective reports of sufficient quality for analysis.

The standardised questionnaire collected retrospective data on all pregnancies. Intendedness was unintended according to the time-based measure of NSFG by combining desire and timing [10]. Five categories were offered: (1) ‘wanted and the time was right’, (2) ‘wanted, but should have happened earlier’, (3) ‘wanted, but should have happened later’, (4) ‘I was ambivalent/did not make up my mind’, and (5) ‘unwanted’. Pregnancies at the right time or overdue were recoded as ‘intended’ (1, 2). The label ‘not strictly unwanted’ pools both ‘mistimed’ and ‘ambivalent, not decided’ (3, 4), as they express the idea of some kind of desire coinciding with lacking intention. Abortions are set as ‘unwanted’ [10]. The label ‘unintended’ pools items 3–5. The first spontaneous response to pregnancy was measured with a scale ranging from one (very welcome) to six (not at all welcome). Analysis groups 1–2 were marked as ‘(very) welcome, positive’, 3–4 as ‘ambiguous’, and 5–6 as ‘not welcome (at all), negative’. Contraceptive use was reported as ‘yes’ (contraceptive failure, information on kind of contraception) or ‘no’ (contraceptive negligence).

Living conditions at the time of pregnancy were measured via a set of items which are known to influence the probability of unintended pregnancies [6,28–30] including age < 20 years, difficulties in relationship and in the professional or economic situation, summarised in a variable each. The item ‘I always wanted to have children’ captures a positive attitude towards children (full, partial, and no agreement). The statistical analyses are limited to bivariate contingency tables.

The guiding question in in-depth interviews prompted a free narration of the biography covering all pregnancies. The ‘cases’ are the narrated episodes of the process of emerging acceptance of an unintended first pregnancy. They start at the time before conception, locate the pregnancy in the context of living conditions at that time, and narrate all that happened since they discovered about the pregnancy and made a decision about it, resulting in positive feelings towards the baby (‘unplanned, but someday I was glad about it’). Qualitative analysis used a procedure of repeated contrasting of cases. Similar to the steps of coding in the grounded theory, a key category of ‘acceptance of pregnancy’ was developed. By this, a typology of five patterns was achieved.

SoFFI F./FIVE has established guidelines for ethical standards and data security and employs a data protection officer. He assessed the procedures according to the rules. As social science research (not medical research), an ethical approval by an external board was not required.

Results

Heterogeneity within the category ‘unintended pregnancy, carried to term’ and determinants of response

Unintended first pregnancies carried to term are heterogeneous as they show different manifestations of response, quality of ‘unintendedness’, and efforts to avoid the pregnancy. A total of 40.5% of the participants gave a positive response and 40.7% gave an ambiguous response, while only one-fifth reported negative feelings (18.9%). Further, 67.3% were declared as not strictly unwanted and 32.7% as unwanted. In 61.6% of the cases, contraceptives were omitted; 38.4% occurred while using contraceptives – among those the majority use the pill (63.9%) and/or condoms (29.5%). Only a few cases of contraceptives with low efficacy were mentioned.

Table 1 shows that the response is interrelated with pregnancy intention and efforts to avoid the pregnancy: Pregnancies which are declared as ‘not strictly unwanted’ are more often ‘(very) welcome’ compared to ‘unwanted’ pregnancies. This also applies to those pregnancies reported as a result of no contraceptive use compared to those which occurred while using contraception. Thus, the unintended pregnancies that were welcome share some features we would rather expect in intended pregnancies, such as no contraceptive use or some kind of preconception desire. Unintended pregnancies which were not welcome resemble abortion in the contexts of a higher rate of ‘unwanted’ pregnancies and contraceptive failure.

Table 1. Response to the pregnancy (unintended pregnancies carried to term, first pregnancy in life).

Table 1 confirms an impact of adverse living conditions with the response being less positive if these living conditions were difficult. Most important are difficulties in relationship and an age younger than 20 years rather than a difficult job and/or financial situation. A generalised orientation towards children shows little if any association. School education does not show any influence.

Five types of pathways: emerging acceptance in the course of an unintended pregnancy

On the one hand, qualitative analysis offers the opportunity to identify different pathways and meanings of ‘acceptance’ hidden behind a statistical correlation between pregnancy intention and efforts to avoid the pregnancy. On the other hand, the response helps to understand the attitudes and subjective perspectives on living conditions. Comparing the different narratives and discussing similarities and differences, three main dimensions of differences were identified: the moment (sooner or later) of emerging acceptance, attitudes towards the prospect of having a baby, and the plot of the story. Five pathways of emerging acceptance were identified. Some cases might show features of more than one type, and a few cases do not fit into the scheme because of individual traits (Table 2).

Table 2. Qualitative typology of emerging acceptance of a first pregnancy, unintended and carried to term: Moment of emergence, attitude towards the prospect to have a baby and plot of the story.

• Type 1: deliberate planning was not necessary: acceptance before conception

This type of narrative starts with a readiness for having a child as a deeply-rooted attitude in life or that emerges later, for example, related to ‘appropriate age’. Living conditions made the prospect of a baby at least manageable if not desirable. Behaviour is described as ‘it was clear that we take a chance’. Contraceptives were omitted or used irregularly. A positive response is plausible as any outcome of the risk behaviour was welcome and accepted: ‘If it happens, it happens’.

At that point it was irrelevant, we did not mind anymore. (…) we consciously stopped using contraceptives (…) it came as a surprise one day (…), but it was okay.

Although the question arises as to whether the pregnancy was really unwanted, there are reasons for not classifying the pregnancy as intended. Planning is considered as not necessary or the desire remains rather vague and lacks the necessary clarity to deliberately take steps to prepare for pregnancy.

I would have used contraceptives properly if I did not want children at all.

• Type 2: deliberate planning was not possible: acceptance when pregnancy was confirmed

A second type of narrative characterises the time before pregnancy as a conflict between the desire for a child and the counteracting obstacles with the metaphor of ‘heart’ and ‘feeling’ versus ‘head/rationality’ and ‘reason’. In light of the living conditions, it appears unreasonable or unjustifiable to get pregnant. Therefore, a pregnancy should not be planed deliberately. A specific no-go is the explicit rejection of a child by the partner, as no woman should force a man to become a father. It is underlined that the pregnancy occurred ‘without intention’ (=not the fault of the women), ‘was impossible, actually’, or was caused by something beyond control such as contraceptive failure.

I would not have dared to get pregnant – at least not at that time.

I cannot say I did it deliberately. (…) But I do not know, probably the body did it anyhow. Actually, it was a time when it should not happen at all.

To be pregnant created a new reality or a fact and the desire for a child was suddenly fulfilled, causing positive feelings. New light is shed on this situation.

We did not really discuss our future at that time. The idea that children might be a part of it only came up at the very moment we knew I was pregnant.

At this stage, problems were subordinated to the priority of becoming a mother (‘the child was more important to me. Then I cancelled my vocational training’) and the future was clarified.

• Type 3: acceptance when, spontaneously, the moral decision was made to keep the baby

The third type of narration reports acceptance of the pregnancy despite a lack of desire to have a baby and a negative response 1 . They refer to moral reflections rather than emotions. Three main arguments were as follows. First was that it was a social norm (‘the normal, clear step’), which implied that, in general, any pregnancy should be accepted as a fact. Hence, women should take responsibility and give birth to the child. Second argument was that abortion is no option in general or is regarded as impossible and is no option even in a concrete situation. Third, a positive identification as a ‘saving’ and ‘protecting’ hero-mother is presented.

I somehow had decided instinctively before deciding consciously: Yes, now that it is here, I am going to protect it somehow.

Women either expressed optimism concerning the living conditions (‘somehow it is working’) or acceptance of the pregnancy despite adverse conditions. In this case, the narration of difficulties highlights the social costs, courage, and strength of the women who decide in favour of the child.

• Type 4: acceptance later: change of mind due to a change of perspectives

The fourth type of narrative is structured as a story of a personal conversion after a turning point. Negative aspects – rejection of pregnancy, negative response, and consideration or even initiation of steps to get an abortion – were abandoned and positive feelings emerged. While the ultrasound image of the foetus served as a trigger in some cases, it was the newly discovered opportunities in the other cases.

I never wanted children (…). At first, I was shocked, because I did not want it. However, after seeing the first ultrasound image you are totally happy (laughing).

• Type 5: acceptance later after working out uncertainty and ambivalence

Finally, the fifth type represents stories of clarifying emotions. Acceptance and positive response emerge as a result of this process. This type includes complex ambivalent feelings after conception such as happiness, desire, or confidence mixed with anxiety, fear of failure, or stress, and the difficulties in making a decision (‘an inner struggle: I thought I do not want it, actually, or I do not want it yet’).

Discussion

The analysis supports previously demonstrated results [3–5,7,8,22] that not all unintended pregnancies follow a clear pattern of ‘no intention/desire to have a child, efforts to avoid the pregnancy, negative response to the pregnancy (and decision for an abortion)’. The standardised and qualitative analysis explores pregnancy acceptance indicated by positive response as the central category, with the power to differentiate between unintended pregnancies with a positive or negative response and to identify different meanings and pathways to ‘acceptance’. The quantitative analysis shows that for first unintended pregnancies carried to term, the response as ‘(very) welcome’ is related to features such as ‘not strictly unwanted’ and no contraceptive use we would rather expect as aspects of intended pregnancies – only the deliberate intention to plan a pregnancy was lacking. Altogether we might think of a continuum of first pregnancies ranging from intended/at the right time or overdue – unintended but welcome – unintended and not welcome – abortions.

The qualitative typology represents a continuum, too, ranging from pregnancies accepted soon and easily to pregnancies accepted late and with many conflicts. Type 1 and 2 are about pregnancies that were accepted early and easily and resemble intended pregnancies concerning the desire, the weak efforts to avoid the pregnancy – they said that a deliberate intention was unnecessary or impossible. These pregnancies might be seen as manifestations of ‘happy’ unintended pregnancies. The pathways of type 4 and 5 rather share features of first pregnancies resulting in an abortion and correspond with unintended pregnancies ‘not welcome (at all)’. This typology adds two more dimensions: the moment and contradiction of emerging acceptance.

The typology seems apt to integrate some findings of previous research into a systematic analytical framework. In the first type of pathways, the label ‘unintended’ rather meant that a deliberate ‘planning’, based on a clear intention, is unnecessary. This corresponds to Earle’s findings of ‘laissez faire pregnancy’ [21] and ‘passive proceptive behaviour’, as described by Stanford et al. [26]. The second pathway says that deliberate intention was not possible, desirable, or justifiable, reflecting the stigmatisation of a pregnancy at the wrong time. These stories of unintended victory of the heart over the head do not present the pregnancies ‘bad luck’ or ‘unhappy ones’ as they do not meet the standards of deliberate planning, which are too high, as found in previous research [24]. Earle [21] and Aiken et al. [15] described a desire for a pregnancy associated with a social stigma to go deliberately forward for it (‘recalcitrant pregnancy’), if women look for a pregnancy ‘outside the expected ideals regarding social and economic readiness’ [15,p.148]. Especially in Germany, the definition of social and economic readiness as a precondition for raising children is ambitious [31]. The third type shows the combination of spontaneous negative response changing to acceptance if the pregnancy is seen in the light of social and moral norms as an obligation to give birth. Acceptance is also obligatory, as no child should be unwanted even if the circumstances are adverse. Yet, only a few studies have explored the relationship between decision-making and happiness about pregnancy [26]. In the fourth and fifth types, the focus is on refraining from abortion. These stories of ‘late acceptance’ can be related to the results of research on decision-making in case of unintended pregnancy [6,30].

The quantitative and qualitative analyses underline the impact of (the subjective evaluation of) living conditions and some aspects of attitudes towards having a baby/an abortion. This has not been well explored until now. A positive response was significantly more frequent if living conditions were favourable or if women conceived at an older age. As all these factors are known to increase the likelihood that the first pregnancy in the life course occurred unintentionally [6], the influence might be direct or indirect (via pregnancy intention). Attitudes and conditions might be interrelated; once the pregnancy occurs, the conditions are judged via the lens of desire; however, these conditions and norms of social readiness for children also in turn influence the desire. The inclusion of living conditions implies that pregnancy acceptance is not understood only in a culturalistic approach as socio-culturally rooted ‘heartfelt feelings’ [2]. This is especially important as, unlike in the United States [2], in Germany, less educated women more often experience unintended first pregnancies [6], but the acceptance of these pregnancies is not a question of education (Table 1).

A second impulse can be worked out. The analytic framework as a qualitative typology integrates the importance of conception as forwarding a new situation that demands adaptation.

Strength and weakness of the study

Since the analysis is restricted to first pregnancies carried to term or being aborted, these results cannot be generalised for unintended pregnancies. The inclusion of still births would provide a complete picture. Another limitation is the retrospective nature of standardised and qualitative data. However, while analysing the narratives, we discussed the impact of strategies of self-presentation, justifications, and social norms. The strength of the study is the mixed-methods-design, which offers the opportunity to relate standardised and qualitative data to the same case.

Conclusions

The findings substantiate the demand for a measure of ‘wantedness’ that includes preconception pregnancy intention and postconception pregnancy acceptance. This would be a promising and useful tool to differentiate unintended respectively unplanned pregnancies carried to term according to social and health problems they involve respectively positive developments after conception. The usual standardised ‘unintended’ measures such as the NSFG measure or the ‘unplanned’ ones such as LMUP capture only insufficiently first, that lacking intention and deliberate planning is not always a problem per se and does not strictly exclude a positive attitude towards a child and, second, that the desire for a child might change in the course of the pregnancy. Some proposals for relevant dimensions to be covered by such a measure can be drawn from our findings, that is, time and ease of emerging acceptance. The impact of attitudes, adverse living conditions, support, guidance, and counselling in case of unintended pregnancy carried to term could be explored in more detail using such a measure.



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