- 1Department of Community Health Sciences, University of California, Los Angeles School of Public Health, Los Angeles, CA 90095-1772, USA
- 2Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
Among the most important decisions that individuals and couples face during their reproductive years is if and when to have a child, and how many children to have. Ideally, pregnancy occurs if and when it is desired. However, reproductive outcomes commonly occur that are contrary to plans and desires. Infertility affects 15-25% of couples worldwide, while four of every 10 pregnancies that occur globally are considered to be unintended.1 2
In the linked study (doi:10.1136/bmj.d4473), Carson and colleagues assess cognitive abilities (verbal, non-verbal, and spatial) in children of women who considered their pregnancies to be unplanned, mistimed, and planned, as well as women who were subfertile, needed ovulation induction, or had assisted reproductive technology.3
Many studies have linked unintended pregnancies with negative health and social outcomes for mothers and children, including delayed and insufficient antenatal care, lower likelihood and shorter duration of breast feeding, and higher rates of depression and anxiety among mothers.4 In the United States, almost half of unintended pregnancies end in abortion.5 In countries (particularly developing nations) where abortion is illegal or restricted, the consequences of an unintended pregnancy can be particularly devastating (for example, maternal death from unsafe abortion).6 Likewise, infertility can have physical and mental health consequences, as well as social repercussions, such as divorce and abandonment.1
In Carson and colleagues’ prospective study, 41% of women reported a mistimed (26%) or unplanned (15%) pregnancy, even though the study was conducted in the United Kingdom, where contraceptive services and abortion are readily available and financially supported through the NHS. Bivariate models indicated significantly lower scores on cognitive outcomes in 3 year old and 5 year old children born after unplanned and mistimed pregnancies compared with planned pregnancies; however, these differences disappeared in adjusted models that controlled for sociodemographic characteristics, such as family income, maternal age, and social class. These findings point to the role of adverse sociodemographic and family level factors in both the occurrence of unintended pregnancies and poorer cognitive outcomes in the children who result from these pregnancies.
Carson and colleagues present a well constructed analysis of the impact of pregnancy planning status on children’s cognitive outcomes using nationally representative data with an extensive set of sociodemographic and life course factors, thereby allowing deeper examination of causal pathways and greater external validity than studies that include limited control variables and that focus solely on clinic based samples. Further work is needed in subsequent studies, however, to better define and understand pregnancy planning, to assess a broader range of health and social consequences of unintended pregnancy, to assess consequences across study populations and sociopolitical contexts, and to disentangle the consequences of unintended pregnancy from consequences attributable to pre-existing social conditions.
Recent analyses comparing intended and unintended siblings from the same family have helped separate the effects of family level characteristics from pregnancy planning status and determine the “spillover” effects of an unintended birth on other children in the family.7 8 Studies that incorporate prospective assessments of pregnancy planning may improve the measurement of pregnancy intentions and minimise rationalisation bias caused by respondents being hesitant to characterise a pregnancy as unwanted after the birth of the child.9 Lastly, given evidence that the health consequences of unintended pregnancy seem to be more pronounced in children who were considered unwanted by both parents compared with those whom only one parent reported as unwanted,10 studies that incorporate both parents’ pregnancy intentions are needed.
The high prevalence of unintended pregnancy in Carson and colleagues’ study—despite universal access to reproductive healthcare—highlights the continued importance of primary and secondary prevention of unintended pregnancy. Primary prevention can be improved through consistent use of effective contraception. Comprehensive contraceptive counselling can help women and couples in selecting an acceptable contraceptive method and finding a suitable alternative in the event that side effects or dissatisfaction with the method arise.11 Greater reliance on highly effective methods, including long acting reversible contraception (such as the intrauterine device) and greater use of emergency contraception, could further reduce unintended pregnancy and abortions.12 Secondary prevention, including the provision of safe and legal abortion and comprehensive prenatal care to promote healthy behaviours during and after pregnancy, can help to mitigate the detrimental effects of unintended pregnancy on women’s and children’s health and wellbeing. These combined efforts are needed to support women and their partners in achieving the number and timing of pregnancies they desire, a basic human right to which women and families throughout the world are entitled.
Cite this as: BMJ 2011;343:d4996
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.