Date

September 2013

Document Type

Dissertation

Degree Name

Ph.D.

Institution

Oregon Health & Science University

Abstract

While pregnancy, birth, and childrearing represent fulfillment of significant life goals, unintended pregnancy has been associated with a host of unfavorable health, social, achievement, and economic outcomes. Despite decades of study and intervention, rates of unintended pregnancy have remained relatively unchanged for over three decades and continue to elude researchers, clinicians, and policymakers. Unintended pregnancy and its outcomes disproportionately impact women of socioeconomic disadvantage, racial minorities, unmarried cohabitating women, and women 18 to 24 years old. Increasingly, researchers have recognized pregnancy intention as a nuanced, multidimensional phenomenon, with limited sensitivity to conventional measurement strategies and ambivalence toward childbearing and contraception holding a key role in unintended pregnancy. The purpose of this study was to expand the knowledge and understanding of factors and forces that influence sexually active women in their pregnancy decision-making, including the initiation and use of contraception. This study analyzed previously collected data from the TAKE CHARGE Final Evaluation: A Study of Recently Pregnant Women study, conducted by Washington State Department of Social and Health Services. There were 1,292 women in the total sample, with qualitative subsamples of 593 and 258, the latter emphasized in this study. All women had a Medicaid-funded birth in spring 2005 and were surveyed two years later, with many volunteering additional comments, totaling over 2400. This descriptive study maintained a naturalistic viewing position, implementing a concurrent nested mixed methods design with qualitative priority and integration during analysis. A novel characteristic of this study was the transformation of forced choice survey responses into qualitative statements which were subsequently integrated with volunteered participant comments and birth history data to create participant narratives amenable to a process of pattern-coding. Analysis uncovered four major themes: achieving childbearing goals, traditional values, multifaceted ambivalence, and insurance and finances matter, but not for pregnancy. These themes and seventeen subthemes were integrated with existing literature to yield two thematic messages. The first message asserts that participants were like everybody else, but living on the edge. Women in this study revealed that they represented a cross-section of the population with characteristics, goals, interests, values, and childbearing desires that could characterize the general population of Washington women, with economic security as the significant exception. The second message is that ambivalence is prevalent, multifaceted, and perhaps self-protective. This affirmed that ambivalence toward pregnancy and childbearing is not a one-dimensional phenomenon, but arises and evolves in various contexts, has a significant association with subsequent birth, and may offer a protective mechanism for responding to a multitude of conflicting attitudes, social norms, and control beliefs that surround pregnancy and childbearing. For many women, it may not be possible to form or express intentions even when pregnancy is considered desirable and ambivalence may be a mechanism for moderating decisional conflict. Health care and social services providers would be well served to remain alert to their personal/professional orientations, biases, and potentially stigmatizing behaviors. Implementation of screening and intake strategies that elicit the values, interests, and life situations of their clients may assist with goal alignment, improved trust, and mutual plans that may lead to prevention of unwanted pregnancy and improved health outcomes for women who desire pregnancy and childbearing. Current public policies that afford insurance access for pregnant women and children as well as access to family planning appear to be fulfilling a critical need, and may be enhanced by the Affordable Care Act. The unique approach to analyzing survey data employed in this study may be applied to other large fertility-focused studies, particularly when the integration of volunteered comments is possible. This study supports the ongoing critique of retrospective pregnancy intention measurement and reinforces the need for prospective and longitudinal fertility research, as well as additional qualitative and integrated methods study.

Identifier

doi:10.6083/M4KW5D2T

School

School of Nursing

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