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The Sensitivity of Measures of Unwanted and Unintended Pregnancy Using Retrospective and Prospective Reporting: Evidence from Malawi

DOI:10.1007/s10995-015-1669-2
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Sara Yeatman at University of Colorado
Sara Yeatman
Christie Sennott at Purdue University
Christie Sennott
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A thorough understanding of the health implications of unwanted and unintended pregnancies is constrained by our ability to accurately identify them. Commonly used techniques for measuring such pregnancies are subject to two main sources of error: the ex post revision of preferences after a pregnancy and the difficulty of identifying preferences at the time of conception. This study examines the implications of retrospective and prospective measurement approaches, which are vulnerable to different sources of error, on estimates of unwanted and unintended pregnancies. We use eight waves of closely-spaced panel data from young women in southern Malawi to generate estimates of unwanted and unintended pregnancies based on fertility preferences measured at various points in time. We then compare estimates using traditional retrospective and prospective approaches to estimates obtained when fertility preferences are measured prospectively within months of conception. The 1,062 young Malawian women in the sample frequently changed their fertility preferences. The retrospective measures slightly underestimated unwanted and unintended pregnancies compared to the time-varying prospective approach; in contrast the fixed prospective measures overestimated them. Nonetheless, most estimates were similar in aggregate, suggesting that frequent changes in fertility preferences need not lead to dramatically different estimates of unwanted and unintended pregnancy. Greater disagreement among measures emerged when classifying individual pregnancies. Carefully designed retrospective measures are not necessarily more problematic for measuring unintended and unwanted fertility than are more expensive fixed prospective ones.
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The Sensitivity of Measures of Unwanted and Unintended
Pregnancy Using Retrospective and Prospective Reporting:
Evidence from Malawi
Sara Yeatman and
Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
Christie Sennott
Department of Sociology, Purdue University, West Lafayette, IN, USA
Sara Yeatman: sara.yeatman@ucdenver.edu; Christie Sennott: csennott@purdue.edu
Abstract
A thorough understanding of the health implications of unwanted and unintended pregnancies is
constrained by our ability to accurately identify them. Commonly used techniques for measuring
such pregnancies are subject to two main sources of error: the ex post revision of preferences after
a pregnancy and the difficulty of identifying preferences at the time of conception. This study
examines the implications of retrospective and prospective measurement approaches, which are
vulnerable to different sources of error, on estimates of unwanted and unintended pregnancies. We
use eight waves of closely-spaced panel data from young women in southern Malawi to generate
estimates of unwanted and unintended pregnancies based on fertility preferences measured at
various points in time. We then compare estimates using traditional retrospective and prospective
approaches to estimates obtained when fertility preferences are measured prospectively within
months of conception. The 1,062 young Malawian women in the sample frequently changed their
fertility preferences. The retrospective measures slightly underestimated unwanted and unintended
pregnancies compared to the time-varying prospective approach; in contrast the fixed prospective
measures overestimated them. Nonetheless, most estimates were similar in aggregate, suggesting
that frequent changes in fertility preferences need not lead to dramatically different estimates of
unwanted and unintended pregnancy. Greater disagreement among measures emerged when
classifying individual pregnancies. Carefully designed retrospective measures are not necessarily
more problematic for measuring unintended and unwanted fertility than are more expensive fixed
prospective ones.
Keywords
Unintended pregnancy; Unwanted pregnancy; Fertility preferences; Measurement; Malawi
© Springer Science+Business Media New York 2015
Correspondence to: Sara Yeatman, sara.yeatman@ucdenver.edu.
HHS Public Access
Author manuscript
Matern Child Health J. Author manuscript; available in PMC 2016 July 01.
Published in final edited form as:
Matern Child Health J. 2015 July ; 19(7): 1593–1600. doi:10.1007/s10995-015-1669-2.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Introduction
The concepts of unwanted and unintended pregnancy are central to the fields of public
health and demography where they are used to explain the disconnect between stated
fertility intentions and actual fertility [1, 2] and to argue for family planning resources [3–5].
Unwanted pregnancies are pregnancies that occur after a woman wants no more children.
Unintended pregnancies, on the other hand, include unwanted pregnancies and pregnancies
that were mistimed (i.e., wanted at a later time) [6, 7]. Unwanted and unintended
pregnancies are often linked to negative health outcomes for women and children1 [8–10]
and frequently end in abortion [11], which in much of the world remains illegal and unsafe.
Despite the utility of unwanted pregnancy and unintended pregnancy as constructs, their
measurement is less than straightforward [1, 4, 12]. Accurate measurement is important at
the aggregate level to understand the extent of the issues and to budget resources to address
unmet need for family planning. At the individual level, accurate measurement is vital for
targeting family planning programs and for carefully assessing the maternal and child health
consequences.
In this paper, we use closely-spaced panel data from Malawi to examine how the timing of
measures of fertility preferences affects estimates of unwanted and unintended pregnancy.
Background
Three techniques are commonly used for measuring unwanted and unintended pregnancy
(and fertility, which refers specifically to pregnancies that end in births) in survey research.
The first, direct retrospective recall, is widely used in a variety of settings [9]. This method
uses cross-sectional data on pregnancy (or birth) histories and asks women pregnancy by
pregnancy whether or not the pregnancy was wanted at the time of conception. Some
variants also ask whether a pregnancy was wanted at that time or at a later time to
distinguish between mistimed and unwanted pregnancies.
Direct retrospective recall assumes accurate retrospective reporting of pregnancy desires at
the time of conception after the pregnancy in question has occurred, and often after the
resulting child has been born. As outlined in Fig. 1, respondents are asked at time t about the
wantedness of a conception that occurred at time t−y. When respondents’ reports of
wantedness at time t are the same as they were at time t−y, this method will yield unbiased
estimates. A substantial body of literature, however, suggests that this type of retrospective
measure is subject to ex post rationalization [2, 13–16]. In other words, women are reluctant
to label an existing child as unwanted and thus preferences reported at time t are not
necessarily good indicators of true preferences at time t−y. In general, this practice should
lead to an underestimation of unintended pregnancies, and explains a shift away from using
direct retrospective recall for the measurement of unintended fertility in surveys such as the
Demographic and Health Surveys (DHS) [4, 15]. Nonetheless, estimates of unintended
pregnancy from the US National Survey for Family Growth (NSFG) and the US Pregnancy
1See Gipson et al. [9] for a detailed review of this literature and its limitations.
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Risk Monitoring Assessment System (PRAMS) continue to use this approach [17, 18], as
does the DHS in its estimates of unmet need for contraception [19].
A second method for measuring unwanted fertility2 uses cross-sectional data on
respondents’ current ideal number of children and compares it to respondents’ number of
living children at the time of conception for births recorded in a birth history. This method is
currently used by the DHS to calculate unwanted fertility [20]. The method assumes an
individual’s ideal family size is stable: respondents are asked their ideal family size at the
time of interview, time t, which is inferred to be their ideal family size at the time of
conception, time t−y. When a respondent’s ideal family size changes over time, however, the
measure will result in biased estimates of unwanted fertility. Additionally, ex post
rationalization remains a concern because individuals may revise their ideal family size
upwards based on the actual number of children they already have, leading to a possible
underestimate of unwanted fertility. Indeed, a study from Malawi found that young women
increased their reported ideal family size following the birth of a child that would otherwise
have been considered unwanted [21].
The third method for measuring unwanted and unintended pregnancy uses a prospective
design. Although generally thought to be more accurate, this method is rarely used because
of its substantial data demands. Respondents are asked about their desire to continue
childbearing and/or their desired timing of next birth before a pregnancy occurs. For
example, suppose the initial interview takes place at time t−x−y. Respondents are then
followed up x + y years later at time t. Pregnancies (or births) are classified as wanted or
unwanted (or intended or unintended) at the time of conception (t−y) based on reports from
the initial interview. Unlike the earlier methods, this design does not suffer from recall bias
but does rely on the assumption that preferences are stable. In other words, if a woman
reports her preferences at time t−x−y but changes them before the conception occurs at time t
−y, the pregnancy will be misclassified.
Two main sources of error potentially affect measurements of unwanted and unintended
pregnancy. The first comes from respondents who may not always report their preferences
honestly. Retrospective measures are particularly vulnerable to ex post revisions, but
prospective measures may also suffer if respondents are unwilling to report socially
undesirable preferences. The second source of error is related to survey design and the issue
that researchers are measuring preferences at a point in time that never corresponds with the
precise time of conception. Certain retrospective measures are less susceptible to this error
because they ask specifically about preferences at the time of conception. In contrast,
prospective measures ask about preferences before a conception occurred. A growing body
of evidence demonstrates that, in response to changes in life circumstances, women change
their fertility preferences including ideal family size [13, 21–24], desired timing of next birth
[25, 26], and desire for additional children [2, 25]. The risk of misclassifying a pregnancy
increases with the length of time between surveys, which is often a period of years [e.g., 13,
15, 16, 27].
2Although it could be used to measure unwanted pregnancy using a pregnancy history, we are not aware of any studies (beside the
present one) that have used a pregnancy history in this way.
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Data and Methods
Our data come from Tsogolo la Thanzi (TLT),3 a panel study designed to investigate how
HIV/AIDS affects the family formation strategies of young Malawians. Malawi is a high
fertility country in southeastern Africa with a median age of first birth of 19 years and a total
fertility rate of 5.7 children per woman [28]. In 2009, TLT drew a simple random sample of
1,505 women between the ages of 15 and 25 living within a seven-km radius of the southern
Malawian town of Balaka. This analysis uses eight waves of TLT data, each spaced 4
months apart. The first wave was collected between June and August 2009 and the eighth
between October and December 2011. 97 % of contacted and eligible women completed a
baseline interview and 80 % of women ever interviewed were reinterviewed at Wave 8. TLT
research assistants interviewed respondents in Chichewa, the dominant local language, in
private rooms at the TLT research center so that sensitive information could not be
overheard.
At each wave TLT interviewers asked respondents a series of questions about their fertility
preferences and fertility behavior:
Ideal Family Size (IFS)
“People often do not have exactly the same number of children they want to have. If you
could have exactly the number of children you want, how many children would you want to
have?”
Want More
“Would you like to have a (nother) child?” Respondents who were currently pregnant were
asked: “Would you like to have another child after the child you are expecting is born?”
Desired Timing of Next Birth
“How long would you like to wait before having your first/next child?” Response categories
include: as soon as possible, <2, 2–3, 3–4, 4–5, 5+ years, no preference/whenever, don’t
want a(nother) child, and don’t know. Currently pregnant women were asked about the
desired timing of their next birth. No preference and “don’t know” were set to missing. We
combined the first two responses to create a dichotomous variable indicating a desire to get
pregnant in the near future; all other responses were considered a desire to delay pregnancy.
Retrospective Preference
Women identified as pregnant during the survey or through post-survey pregnancy testing
were given a special pregnancy questionnaire in which they were asked whether the
pregnancy was wanted.
We focus on the wantedness and intendedness of pregnancy rather than birth for three
reasons. First, the reported intendedness of a pregnancy can change over the course of the
3Tsogolo la Thanzi is a research project designed by Jenny Trinitapoli and Sara Yeatman and funded by grant (R01-HD058366) from
the National Institute of Child Health and Human Development.
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pregnancy itself [29]. Therefore, we want to capture prospective preferences before
conception to avoid measuring preferences that are affected by knowledge of the pregnancy.
Second, the TLT study design allows for the measurement of conceptions with reasonable
accuracy (see details below). Third, for purposes of family planning programs, particularly
in a context where abortion is almost always unsafe, unintended pregnancies are a better
marker of the unmet need for contraception than are unintended births.
Following TLT protocol, interviewers offered respondents rapid urine pregnancy tests at
each wave after completion of the survey. We consider a respondent to have experienced a
new pregnancy between waves if she was not pregnant at the previous wave and either
tested pregnant or reported being pregnant and refused the pregnancy test. We investigated
and manually confirmed cases where women experienced more than one pregnancy over the
two-year period to prevent erroneous double counting of the same pregnancy.
In order to assess the implications of retrospective and prospective measures on estimates,
we compare seven methods of measuring unwanted and unintended pregnancies in our
sample. Four methods are variants of commonly used measures (“classic”) and the other
three allow for changes in preferences by capturing preferences within 4 months prior to
conception (“new”).
Methods for Measuring Unwanted Pregnancies
M1 Retrospective IFS (classic): comparing IFS at Wave 8 with number of living
children at time of conception.
M2 Time-varying IFS (new): comparing IFS from wave prior to conception with
number of living children at time of conception.
M3 Fixed prospective wanting more (classic): using desire for more children from
Wave 1.
M4 Time-varying wanting more (new): using desire for more children from wave
prior to conception.
Methods for Measuring Unintended Pregnancies
M5 Retrospective timing4 (classic): using reported intendedness at wave after
conception.
M6 Fixed prospective timing (classic): using desired timing of next child from Wave
1 to assess intendedness of subsequent conceptions. On average, women in the
sample are followed for approximately 28 months (range 26–31, mean: 28).
Therefore, in this measure, we classify a conception as unintended through
Wave 5 if a respondent stated at baseline that she would like to wait more than 2
years before her next birth. Conceptions that are captured at Waves 6 through 8
4The question in Chichewa, nanga mimbayi mumayifuna, translates to “did you want this pregnancy?” Although not explicitly
describing timing, responses to the question suggest that respondents interpreted it that way. Nonetheless, the wording remains a
limitation of the measure.
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are considered unintended if the respondent indicated at baseline that she would
like to wait three or more years before her next birth.
M7 Time-varying timing (new): using desired timing of next child from wave prior
to conception to assess intendedness.
We assess agreement in aggregate estimates using t tests and assess sensitivity, specificity,
and positive and negative predictive value of the classic approaches when compared to the
new time-varying approaches.
The sample consists of 1,062 women who were interviewed at all eight waves. Women who
were pregnant at baseline stayed in the sample if that pregnancy resulted in a live birth;
however, the initial pregnancy was not used in estimates. Over the two and a half year
period, we captured a total of 590 new conceptions among these women. 44 women had two
separate confirmed conceptions and one woman had three. One conception was dropped
because of a missing value for ideal family size. An additional 48 conceptions were dropped
for estimates of pregnancy intendedness because of missing values on timing preferences.5
Tsogolo la Thanzi received ethical approval from the Penn State University Office for
Research Protections and the Malawi National Health Sciences Research Committee.
Results
Table 1 presents the sociodemographic characteristics of the sample at baseline.
Respondents’ mean age was 19.6 years. 45 % were married and an additional 15 % reported
a steady nonmarital partner. Half of the sample had a primary school education or less and
37 % were enrolled in school. 48 % had no living children at baseline and the remainder had
between one and five. Ideal family size preferences ranged from one to seven but were
heavily clustered between two and four children. The vast majority of women in the sample
(92 %) wanted more children. Only 13 % of women wanted a birth within 2 years, and 30 %
within 3 years, although 51 % of women would experience a pregnancy within the two and a
half year study period (not shown).
Young Malawian women frequently changed their ideal family size preferences and desired
timing of next child across each four-month wave (approximately 27 and 14 % at each
wave, respectively). The reported desire for a (nother) child was most stable, which is
unsurprising given the young age range of the sample. Nonetheless, approximately 6 % of
respondents changed their response to this question across sequential waves, mostly in ways
not easily explained by a new pregnancy (not shown).
Table 2 presents estimates of the percent of pregnancies classified as unwanted (first two
columns) or unintended (last two columns) using the seven different methods of estimation.
The first column presents estimates based on variants that compare reported ideal family
size and living children. As expected, more conceptions were classified as unwanted using
5Thirty-six of the 48 missing cases were due to women missing pregnancy questionnaires. The additional 12 were due to “don’t
know” or “no preference/whenever” responses to questions on the desired timing of next child. We conducted a sensitivity analysis in
which we classified “don’t know” responses as a desire to delay and “no preference/whenever” responses as a desire to have a child
soon (<2 years). Neither our estimates nor the differences between estimates changed significantly.
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the time-varying method that does not suffer from problems of ex post rationalization. The
retrospective method [M1], which measures ideal family size after conception, estimated
that 2.6 % of pregnancies were unwanted, while the time-varying variant [M2], which
measures ideal family size fewer than 4 months before conception, estimated that 3.2 % of
pregnancies were unwanted. The differences in aggregate estimates, however, were not
statistically different.
The second column compares estimates of unwanted pregnancies using the wanting more
measure. The fixed prospective measure of wantedness [M3] based on the respondent’s
report at baseline classified more than twice as many conceptions as unwanted as did the
time-varying method [M4] (5.3 vs. 2.6 %). These estimates were statistically different in
aggregate (p<0.01). Despite the larger difference in aggregate estimates in this comparison,
when compared to the time-varying estimates, the fixed prospective approach had higher
sensitivity (i.e., probability of identifying a conception as unwanted if the time-varying
approach identified it as such) than did the retrospective IFS measure. Both classic methods
of estimating unwanted pregnancies had high specificity and negative predictive value,
which is unsurprising given the low prevalence of unwanted conceptions in this young
sample.
Lastly, we present and compare estimates of unintended pregnancies—pregnancies that were
wanted later or not at all. The estimates of unintendedness ranged from 64 to 69 %. As with
measures of unwantedness, the highest estimate was derived from the fixed prospective
method [M6]. The most similar estimates occurred among methods that captured
preferences in closest proximity to conception (i.e., the wave before [M7] and the wave
following [M5]), which differed in their estimates of unintended pregnancy by 2.0 % points.
Despite these differences, neither classic method differed statistically in aggregate from the
time-varying approach although they were statistically different from one another (p =
0.026). At the individual level, the retrospective and fixed prospective methods correctly
identified 77 and 81 %, respectively, of unintended pregnancies; however, the former
correctly identified more intended pregnancies.
Childbearing during the study period could explain some of the change in fertility
preferences observed, and therefore the differences in prospective estimates. In our data,
multiple conceptions did not explain any of the inconsistencies in the prospective measures
of unwanted pregnancy but did contribute to some for unintended pregnancies. The latter
occurred when women reported a baseline desire for a rapid pregnancy, and then revised
their timing preference to a desire to delay following a pregnancy. In these circumstances,
the fixed prospective method would underestimate unintended pregnancy because the
second pregnancy would be classified as wanted based on the preference that actually
corresponded with the first. When we limited our sample to respondents’ first conceptions
during the study period, the estimate of unintended pregnancy using the fixed prospective
measure increased from 69.3 to 71.1 %, while the time-varying estimate stayed consistent at
65.6 %.
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Discussion
In this paper, we calculated seven different estimates of unwanted and unintended pregnancy
over a two-year period using prospective and retrospective measures of fertility preferences
from young Malawian women. Our estimates were generally similar in the aggregate; only
the fixed prospective estimate of unwanted pregnancy was statistically different from our
time-varying approach. Although prospective measures are generally considered better than
retrospective ones, our findings call for some qualification. We found that prospective
measures of unwanted and unintended pregnancy overestimated these outcomes. Women in
our sample changed their preferences in both directions—from not wanting any more
children to wanting more, and from wanting more to not wanting more—but more
conceptions occurred after women changed their preferences in a pronatal direction leading
to an overestimation of unwanted and unintended pregnancy when compared to time-
varying estimates. A shift from wanting to not wanting to have another child is likely to
occur after a birth, which can be accounted for in estimates of unwanted pregnancy, or as
women age or end a relationship, both of which would reduce a woman’s risk of pregnancy.
In contrast, changes in preferences that are pronatal (e.g., wanting more children, wanting
the next child sooner) are more likely to follow changes in life circumstances that make a
pregnancy more likely, such as acquiring a new partner. Consequently, estimates of
unwanted or unintended pregnancy that are based on prospective measures with long lags
between the measurement of pregnancy intention and conception risk overestimating the
prevalence of these outcomes.
In contrast, retrospective measures trended towards underestimating unwanted and
unintended pregnancy, which is consistent with concerns about ex post rationalization of
preferences. Nonetheless, the aggregate retrospective estimates did not differ statistically
from the time-varying prospective ones. We found the highest aggregate agreement in the
measures of unintended pregnancy that were captured in closest proximity to conception
[see also 13]. In other words, our time-varying prospective estimate based on desired
pregnancy timing measured at the interview before the conception and the retrospective
measure captured at the interview immediately after conception yielded the most consistent
aggregate estimates of unintended pregnancy.
The similarity in aggregate estimates of unwanted and unintended pregnancy masks
disagreement at the individual level. This finding is consistent with that of other researchers
[13, 16, 29–32] that aggregate agreement in measures of pregnancy intendedness can occur
despite disagreement at the individual level based on how and when questions are asked. To
the extent that researchers and policymakers are interested in aggregate estimates of
unwanted and unintended pregnancy, the proximity of our estimates should provide comfort.
On the other hand, if our interest is in characterizing the women who are most at risk of
having an unwanted or unintended pregnancy, then differences at the individual level will
matter to the extent that they are systematic rather than stochastic.
Our analyses are subject to important limitations. First, given the small number of women
who had achieved their ideal family size in our young sample, our estimates of unwanted
fertility are small and not particularly robust. Second, given the complicated timing issues at
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play, we limit our analyses to women interviewed at each wave. Sample attrition is a
problem with all panel data, and while relatively low in TLT, it introduces bias into our
estimates. Women who attrited from the sample or missed interviews, for example, may be
different from the analytic sample in ways that are relevant to questions of pregnancy intent.
Additionally, while we maintain that our time-varying estimates are more accurate than the
alternatives, they too are vulnerable to social desirability and a gap (albeit small)6 between
measurement of preferences and conception.
Careful measurement is essential for understanding the true impact of unwanted and
unintended pregnancies on maternal and child health outcomes, and for informing family
planning programs. Our objective was not to argue for a proliferation of intensive studies
similar to TLT. Such studies are complex and expensive. Rather, we sought to offer insight
into the relative size of errors associated with retrospective and prospective approaches to
the measurement of unwanted and unintended pregnancies. Our findings support the
conclusions of others that retrospective measures of unwanted and unintended pregnancy are
likely to be underestimates. Although in our sample, where retrospective estimates are
captured close to conception, the underestimates are small. Until now, relatively little
attention has been given to the problem that changes in preferences before a conception can
have on prospective estimates of unwanted and unintended pregnancies. Our findings that
fixed prospective measures overestimated these outcomes should insert a degree of
uncertainty into this approach. Even interviews that are 2 years apart may be sufficiently
long for fertility preferences to change such that we as researchers no longer know what it is
that we are measuring. Prospective studies of fertility intendedness should consider the
dynamics and variability of preferences in their design, and it may be that carefully designed
retrospective measures are not necessarily more problematic than more expensive fixed
prospective ones.
Acknowledgments
An earlier version of this article was presented at the 2013 IUSSP International Population Conference in Busan,
Republic of Korea. The data used in this study and the time afforded to the authors for this research were supported
by grants from the National Institute of Child Health and Human Development (R01-HD058366; R01-HD077873).
For valuable feedback on earlier drafts, we are grateful to Ilene Speizer, John Casterline and the journal’s
reviewers; any errors are our own. The research was made possible by the Tsogolo la Thanzi team, particularly
Abdallah Chilungo, Sydney Lungu, Hazel Namadingo, and Jenny Trinitapoli.
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Malawi. International Perspectives on Sexual and Reproductive Health. 2012; 38:34–42.
[PubMed: 22481147]
27. Gipson JD, Hossain MB, Koenig MA. Measurement of and trends in unintended birth in
Bangladesh, 1983–2000. Journal of Health, Population and Nutrition. 2011; 29:400–405.
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28. MDHS: Malawi Demographic and Health Survey 2010. Zomba, Malawi and Calverton, Maryland,
USA: National Statistical Office (NSO) and ICF Macro; 2011.
29. Poole VL, Flowers JS, Goldenberg RL, Cliver SP, McNeal S. Changes in intendedness during
pregnancy in a high-risk multiparous population. Maternal and Child Health Journal. 2000; 4:179–
182. [PubMed: 11097505]
30. Kaufmann RB, Morris L, Spitz AM. Comparison of two question sequences for assessing
pregnancy intentions. American Journal of Epidemiology. 1997; 145:810–816. [PubMed:
9143211]
31. Joyce T, Kaestner R, Korenman S. The stability of pregnancy intentions and pregnancy-related
maternal behaviors. Maternal and Child Health Journal. 2000; 4:171–178. [PubMed: 11097504]
32. Guzzo, KB.; Hayford, SR. Revisiting retrospective reporting of birth intendedness. Bowling Green
State University, Center for Family and Demographic Research; 2013. Working Paper Series
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Fig. 1.
Timeline depicting the relationship between data collection and events used to measure
unwanted and unintended pregnancies
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Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Yeatman and Sennott Page 13
Table 1
Descriptive statistics of analytic sample at baseline, 2009
Characteristic % (N = 1062)
Age (range 15–25)
15–19 49.5
20–25 50.5
Marital status
Married 45.4
Nonmarital partner 15.2
No partner 39.5
Education
Primary or less 51.3
Some secondary 41.4
Finished secondary 7.3
Enrolled in school
No 63.0
Yes 37.0
Number of living children (range 0–5)
0 47.7
1 26.7
2 18.6
>3 7.1
Ideal family size (range 1–7)
1 2.3
2 28.1
3 24.3
4 37.1
5 5.8
6+ 2.3
Missing 0.2
Want a(nother) child
No 8.5
Yes 91.5
Desired timing of next birth
<2 years 13.3
2–3 years 16.6
3+ years 68.5
Missing 1.7
Matern Child Health J. Author manuscript; available in PMC 2016 July 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Yeatman and Sennott Page 14
Table 2
Percent of pregnancies classified as unwanted or unintended using different measurement strategies
Unwanted pregnancies (%) Unintended pregnancies (%)
Ideal family size (N =
589) Want a (nother) (N =
589) Desired timing (N =
541)
Classic
Retrospective 2.6 [M1]a63.6 [M5]
Fixed prospective 5.3 [M3] 69.3 [M6]
New
Time-varying 3.2 [M2] 2.6 [M4] 65.6 [M7]
Percentage point difference in
estimates (new-classic) 0.6 −2.7*2.0 −3.7
Diagnostic tests (compared to new)
Sensitivity 0.211 0.667 0.769 0.806
Specitivity 0.981 0.963 0.618 0.522
Positive predictive value 0.267 0.323 0.794 0.763
Negative predictive value 0.974 0.991 0.584 0.584
aMethods: (M1) Retrospective IFS; (M2) Time-varying IFS; (M3) Fixed prospective wanting more; (M4) Time-varying wanting more; (M5)
Retrospective timing; (M6) Fixed prospective timing; (M7) Time-varying timing
*p<0.01
Matern Child Health J. Author manuscript; available in PMC 2016 July 01.
... Women who re port not want ing fu ture births may at a later time have a birth and re port it as wanted, es pe cially as the child ages. Two stud ies based on eight waves of data over two years for young Malawian women found dy namic fam ily size pref er ences at the in di vid ual level but rel a tive sta bil ity in the ag gre gate (Yeatman and Sennott 2015;Yeatman et al. 2013). One of these stud ies (Yeatman and Sennott 2015) found that pro spec tive clas si fi ca tion pro duces a higher per cent age of un wanted births among re spon dents than ret ro spec tive questioning. ...
... Two stud ies based on eight waves of data over two years for young Malawian women found dy namic fam ily size pref er ences at the in di vid ual level but rel a tive sta bil ity in the ag gre gate (Yeatman and Sennott 2015;Yeatman et al. 2013). One of these stud ies (Yeatman and Sennott 2015) found that pro spec tive clas si fi ca tion pro duces a higher per cent age of un wanted births among re spon dents than ret ro spec tive questioning. The post hoc rationalization of birth wantedness has also been ex am ined for preg nan cies reported as intended fol lowing con tra cep tive fail ure or dis con tin u a tion (Curtis et al. 2011). ...
... Perhaps the male part ner's at ti tudes and pref er ences about con tra cep tion and child bear ing ex ert strong prox i mate in flu ences on those of his fe male part ner's, al though not nec es sar ily in sim i lar di rec tions. Male part ner concor dance with fe male fer til ity pref er ences has largely been stud ied rel a tive to her de sire for ad di tional births and their num ber (e. g., Bankole and Singh 1998;Becker 1996;Yeatman and Sennott 2015) and gen der (e. g., Short and Kiros 2002;Vlassoff 1990), whereas for con tra cep tive de ci sions, the fo cus has been on his aware ness and sup port for or op po si tion to her use (Prata et al. 2017). Male part ners' ob jec tions to fe male con tra cep tive prac tice of ten cen ter on con trol of her sex u al ity and fer til ity (e. g., Biddlecom and Fapohunda 1998;Kabagenyi et al. 2014). ...
A Panel Study of Fertility Preferences and Contraceptive Dynamics in the Presence of Competing Pregnancy Risks in Uganda
Article
Full-text available
  • Jan 2021
Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.
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... We evaluate if a woman's most recent birth was wanted or unwanted by comparing the number of children a woman wanted in 2005 to the total number of children that were born between 2005 and 2012. If the total number of additional children a woman wanted in 2005 was greater than or equal to the number of children born between 2005 and 2012 (including those who died within this period), then the most recent birth was labeled as wanted [see also 6,60]. In contrast, if the number of additional children a woman desired in 2005 was less than the number of children born between 2005 and 2012, then the last birth was labeled as unwanted. ...
... First, the data we analyse come from the IHDS-the first nationally representative survey from India-which enhances the generalizability of our results. Additionally, our prospective measure of fertility intentions enables us to mitigate some of the bias found in the retrospective measures that are typically used [40,60]. In terms of our results, although several studies have investigated the relationship between unintendedness and breastfeeding, past results have been mixed, including among studies set specifically in India [36,37]. ...
Fertility intentions and child health in India: Women’s use of health services, breastfeeding, and official birth documentation following an unwanted birth
Article
Full-text available
This study examines the relationship between women’s prospective fertility intentions and child health, measured via access to healthcare facilities for children and postpartum maternal behaviors that are indicative of future child health. We analyze two waves of nationally representative data (2005 and 2012) from the India Human Development Survey (IHDS). The analytic sample includes 3,442 non-pregnant, currently married women aged 18–40 in 2005 who participated in both rounds of the IHDS, and had at least one birth between 2005 and 2012. We investigate the influence of women’s prospective fertility intentions on access to benefits from the Integrated Child Development Services (ICDS), indicators of breastfeeding as recommended by the World Health Organization, and official documentation of births via birth certificates or registration. We find that 58 percent of births among women in the sample were labeled as unwanted. We use an adaptation of propensity score matching—the inverse-probability-weighted regression adjustment (IPWRA) estimator—and show that, after accounting for maternal and household characteristics that are known to be associated with maternal and child health, children who resulted from unwanted births were less likely to obtain any benefits or immunizations from the ICDS, to be breastfed within one hour of birth, and to have an official birth certificate. Results from this study have direct policy significance given the evidence that women’s fertility intentions can have negative implications for child health and wellbeing in the short and longer term.
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... Studying the outcomes of negative reproductive intentions is directly connected with the concept of childbearing intendedness. It is a highly complex construct, the meaning and the correct measurement of which have been debated for decades (Joyce et al., 2000;Pohlman, 1968;Santelli et al., 2003;Trussell et al., 1999;Westoff, 1980;Westoff & Ryder, 1977;Yeatman & Sennott, 2015). Demographers typically assume that when a woman becomes pregnant after engaging in voluntary sexual intercourse, the pregnancy is based on a rather conscious decision (Casterline & El-Zeini, 2007) and can be classified as intended (coming at the right time or later than desired), mistimed (coming earlier than desired), or unwanted (occurring despite being undesired). 1 Thus, in a prospective set-up of a panel study, respondents who declared that they did not intend to have a child at the first survey wave, but who reported having a child by the second wave, are classified as having experienced an unintended (unwanted) or a sooner-than-intended (mistimed) birth. ...
... Arteaga et al., 2017;Santelli et al., 2003). Unlike in the United States, very few panel surveys aimed at analysing childbearing intendedness have been conducted in Europe (Baschieri et al., 2017;Koenig et al., 2006;Williams et al., 1999;Yeatman & Sennott, 2015). The current study employs cross-national panel data from the Generations and Gender Survey (GGS) to examine female and male respondents who experienced an unintended or soonerthan-intended 2 birth between two survey waves in three European post-socialist countries (East) and three European countries without the state-socialist experience (West). ...
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... Studying the outcomes of negative reproductive intentions is directly connected with the concept of childbearing intendedness. It is a highly complex construct, the meaning and the correct measurement of which have been debated for decades (Joyce et al., 2000;Pohlman, 1968;Santelli et al., 2003;Trussell et al., 1999;Westoff, 1980;Westoff & Ryder, 1977;Yeatman & Sennott, 2015). Demographers typically assume that when a woman becomes pregnant after engaging in voluntary sexual intercourse, the pregnancy is based on a rather conscious decision (Casterline & El-Zeini, 2007) and can be classified as intended (coming at the right time or later than desired), mistimed (coming earlier than desired), or unwanted (occurring despite being undesired). 1 Thus, in a prospective set-up of a panel study, respondents who declared that they did not intend to have a child at the first survey wave, but who reported having a child by the second wave, are classified as having experienced an unintended (unwanted) or a sooner-than-intended (mistimed) birth. ...
... Unlike in the United States, very few panel surveys aimed at analysing childbearing intendedness have been conducted in Europe (Baschieri et al., 2017;Koenig et al., 2006;Williams et al., 1999;Yeatman & Sennott, 2015). The current study employs cross-national panel data from the Generations and Gender Survey (GGS) to examine female and male respondents who experienced an unintended or soonerthan-intended 2 birth between two survey waves in three European post-socialist countries (East) and three European countries without the state-socialist experience (West). ...
Didn’t Plan One but got One: Unintended and sooner-than-intended Parents in the East and the West of Europe
Article
Full-text available
The realisation rates of short-term childbearing intentions are known to be consistently lower in post-socialist countries than in the rest of Europe. However, the East–West differences in the outcomes of intentions to postpone or forego (further) childbearing have not been previously examined. We employ two panel waves of the Generations and Gender Survey in six countries (three from Eastern and three from Western Europe), and, based on the short- and long-term fertility intentions expressed by respondents at the first survey wave, we classify the births occurring between two waves as intended, sooner-than-intended, or unintended. We find that in our study population of non-teenage respondents who had the same partner at both survey waves and a child between the two survey waves, between around 10% (Western European countries) and 30% (Eastern European countries) experienced an unintended or a sooner-than-intended birth. The East–West divide is largely driven by the share of unintended parents which is clearly higher in the post-socialist countries. However, the geographical pattern fades away once we control for the anticipated costs of having a child. Our study gives insight into East–West differences in attitudes to childbearing and into how they affect reproductive behaviour. It also offers methodological improvements of cross-national panel surveys designed to examine childbearing intentions that would allow for a more accurate assessment of childbearing intendedness.
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... An alternative way of assessing pregnancy intention in surveys is to compare desired family size with actual number of surviving children; any pregnancy that occurs after the desired size has been reached is defined as undesired (referred to here as desired-versus-actual family size) (Fig. 1). Both methods are widely used notably in the Demographic and Health Surveys (DHS) which have been undertaken in more than 90 countries [14,18]. However, very few studies have comprehensively assessed these methods, including the level of agreement between them. ...
... However, very few studies have comprehensively assessed these methods, including the level of agreement between them. In their study of pregnancy intention, Yeatman and Sennott assessed prevalence of unwanted and unintended pregnancies among young women in Malawi using seven measurement approaches, including both methods mentioned here; however, the level of agreement between these two approaches was not directly assessed [18]. This paper is part of a series of papers from the Every Newborn-International Network for the Demographic Evaluation of Populations and their Health (EN-INDE PTH) study in five Health and Demographic Surveillance System (HDSS) sites in sub-Saharan Africa and Asia. ...
Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study
Article
Full-text available
  • Feb 2021
Background: An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes. Methods: The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight. Results: Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention. Conclusions: We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.
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... Assessment is ideally asked when a woman is pregnant or as soon after the end of pregnancy as possible, before long periods of time, or feelings about post-pregnancy circumstances affect recall. 37,38 For nonbiased population level assessment, it should be asked of all women attending for early pregnancy services, termination services, or antenatal care regardless of partner or contraception status, or of whether a pregnancy was achieved through assisted reproductive technology means. When asked in antenatal care, this has traditionally been with a dichotomous question of if a pregnancy was planned or unplanned. ...
Measures of Pregnancy Intention: Why Use Them and What Do They Tell Us?
Article
  • Feb 2023
Understanding pregnancy intention is an important public health measure that captures the ability of individuals to access information, resources, and services needed to plan the timing and spacing of pregnancies. Pregnancy intention is a complex construct impacted by social, emotional, financial, cultural, and contextual factors. In this review, we will examine the range of available tools for individuals and populations to evaluate pregnancy intention, the timing of the tools in relation to pregnancy, their interpretation, and use for policy and practice. Traditionally, pregnancy intention was only assessed in population health surveys; however, more sophisticated tools and measures have been developed. These tools can be used at several time points: before pregnancy, during pregnancy, or after the pregnancy has ended. It is important to appreciate the varied contexts globally for women and their partners when assessing pregnancy intention, and the ability of a given tool to capture this when used retrospectively or prospectively. These tools can inform targeted delivery of services for a person or couple before, during, and after pregnancy. This knowledge can inform strategies at an individual, community, and population level as an indicator of access to sexual and reproductive health information and knowledge and uptake of preconception health.
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... Even though this measurement strategy is practical, and often necessary given the cross-sectional nature of most data, scholars have long emphasized that it is problematic. Retrospective reports of pregnancy planning and desirability often differ from women's initial, pre-birth reports about the same pregnancy (Bankole & Westoff, 1998;Guzzo & Hayford, 2014;Joyce et al., 2002;Koenig et al., 2006;Rackin & Morgan, 2018;Rosenzweig & Wolpin, 1993;Williams & Abma, 2000;Yeatman & Sennott, 2015). ...
Women’s Life Experiences and Shifting Reports of Pregnancy Planning
Article
Full-text available
Background Unplanned pregnancy is associated with adverse consequences for women. Yet, these associations are typically based on women’s reports of pregnancy planning provided post birth. Therefore, women’s recollection of their pregnancy planning may be influenced by their adverse life circumstances following the pregnancy, artificially driving these associations. Methods To understand how post-birth experiences pattern women’s recall of their pregnancy planning, we conducted 17 in-depth interviews with young women (24–34 years old) enrolled in a longitudinal study in southern Malawi. Respondents who were pregnant at the time of data collection in 2015 answered close-ended questions about the planning of their pregnancy. During in-depth interviews three years later, women discussed their life experiences since the pregnancy and were re-asked a subset of the same questions about the planning of the 2015 pregnancy. We thematically coded respondents’ narratives about their relationships, parenting, and economic situations in the three years following their pregnancy and mapped these onto changes in women’s pre- and post-birth reports of their pregnancy planning. Results More than one-half of respondents recalled their pregnancy planning differently than they did pre-birth—some as more planned, others as less planned. The presence and direction of women’s changing reports were patterned by the quality of their relationship with the child’s father, the father’s involvement as a partner and parent, and their economic situation. Conclusions Women’s life experiences following a birth correspond with changes in their pregnancy planning reports, emphasizing the limitations of using retrospective measures to study the consequences of unplanned fertility.
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... One crucial feature of the repeated cross-sectional design of the NSFG is that it must assess a woman's desire for each of her pregnancies retrospectively, after the pregnancy (or birth) has occurred. It is unknown how accurately women can recall their pre-conception desire for a pregnancy after the conception (or birth) occurs, in part because their post-conception experiences may get in the way of accurately remembering their pre-conception feelings (Yeatman and Sennott 2015). This possible ex post facto rationalization has led researchers to question whether mothers who have negative experiences remember their pregnancies as undesired as a result of those negative experiences, regardless of their actual desire for the pregnancy before it was conceived (Guzzo and Hayford 2014;Joyce, Kaestner, and Korenman 2002). ...
The Social Context Of Retrospective-prospective Changes In Pregnancy Desire During The Transition To Adulthood: The Role Of Fathers And Intimate Relationships
Article
Background Researchers have questioned the accuracy of retrospective measures of unintended pregnancy, which ask women whether they wanted a pregnancy before it was conceived. Objective We investigated whether pregnant women’s retrospective recollections of their pre-conception desires for pregnancy were shaped by intimate relationships, their own reactions, and their perceptions of their partners’ reactions to their pregnancies. Methods We used the Relationship Dynamics and Social Life (RDSL) study, which included weekly survey interviews with 971 young women, of whom 175 experienced 203 pregnancies during the 2.5-year study period. We estimated logistic regression models of whether women’s retrospective recollections of their pre-conception desires were stable, shifted positive, or shifted negative compared to their prospectively reported desires, along with formal mediation tests of potential mechanisms. Results Women were more likely to remember their undesired pregnancies as desired before conception if they themselves reacted happily to the pregnancy, they were married or engaged, or they perceived their partner as reacting positively. The association with perceiving her partner as positive was mediated by her own happiness about the pregnancy.Conclusion Retrospective recollections of pre-conception desire at least partially represent women's current feelings about a pregnancy. Post-conception happiness about a pregnancy may identify mothers and children whose health and well-being are at risk, but prospective measures are necessary to evaluate whether women got what they wanted.
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... Should a divorce occur, one's fertility regains importance to solidify a new relationship (Reniers 2003). Even within a single partnership, pregnancy intentions and desired family size can change frequently (Yeatman and Sennott 2015;Yeatman, Sennott, and Culpepper 2013;Gibby and Luke 2019). ...
Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi
Article
  • Apr 2021
Infertility and unintended pregnancy are dual burdens in Malawi, where 41% of pregnancies are unintended and approximately 20% of people report infertility. Although preventing unintended pregnancy has been a focus in public health, infertility has rarely been explored as a factor that may be associated with contraceptive use. Using cross‐sectional survey data (2017–2018; N = 749), we report on the prevalence of and sociodemographic characteristics associated with infertility and certainty of becoming pregnant among women in Malawi. We conducted multivariable logistic regressions examining the relationship between infertility, certainty of becoming pregnant, and contraceptive use. Approximately 16% of women experienced infertility, and three‐quarters (78%) were certain they could become pregnant within one year. Women who experienced infertility had lower odds of contraceptive use than women who did not (Adjusted Odds Ratio [AOR]: 0.56; 95% Conficence Interval [CI]: 0.39–0.83). Women who said there was “no chance” or they were “unlikely” to become pregnant also had lower odds of contraceptive use compared to women who were certain they would become pregnant (AOR: 0.30; 95% CI: 0.10–0.92). Our findings indicate that experiences and perceptions surrounding fertility are associated with contraceptive use, underscoring their importance in understanding how people manage their fertility to reach their reproductive goals.
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Measuring Fertility Intentions During Times of Crisis: An Example Using Survey Data Amid the Covid‐19 Pandemic
Article
  • Feb 2023
Fertility intentions—intentions regarding whether and when to have children—predict reproductive health outcomes. Measuring fertility intentions is difficult, particularly during macrostructural shocks, for at least two reasons: (1) fertility intentions may be especially volatile during periods of uncertainty and (2) macrostructural shocks may constrain data collection. We propose a set of indicators that capture how a macrostructural shock directly alters fertility intentions, with a particular focus on the Coronavirus disease 2019 (Covid‐19) pandemic. We advance the conceptualization and construct of fertility intentions measures in three ways. First, we demonstrate the value of direct questions about whether women attributed changes in fertility intentions to the pandemic. Second, we highlight the importance of a typology that delineates fertility postponement, advancement, foregoing, and indecision. Third, we demonstrate the importance of incorporating a granular time window within a two‐year period to capture short‐term changes to fertility intentions. We exemplify the value of our proposed measures using survey data from a probabilistic sample of women aged 18–34 in Pernambuco, Brazil. We discuss the self‐reported change in intentions due to Covid in wave 1 as well as panel change across waves. We further ground our contributions by uncovering important variations by social origin and parity.
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Revising Unmet Need for Family Planning
Article
Full-text available
  • Jan 2012
Unmet need for family planning is defined using survey data as the percentage of women who do not want to become pregnant but are not using contraception. Though the concept seems straightforward, the calculation is extraordinarily complex and has changed over time. To address these issues, DHS revised the definition of unmet need in 2012. Using the revised definition: Unmet need is calculated the same way in all DHS surveys. Unmet need is calculated the same way in DHS and the Multiple Indicator Cluster Surveys (MICS). Unmet need can be used to reliably track trends over time and compare estimates across countries. This paper describes the rationale, process, and results of revising the definition of unmet need, and compares estimates of unmet need using the original and revised definitions for all DHS surveys from 1990- 2010. The study also estimates unmet need for spacing and limiting, unmet need by background characteristics, total demand for family planning and the proportion of demand satisfied, and unmet need for sexually active unmarried women, all using the revised definition.
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Are Individuals’ Desired Family Sizes Stable? Evidence from West German Panel Data
Article
Full-text available
  • Jun 2008
Using West German panel data constructed from the 1988 and 1994/1995 wave of the DJI Familiensurvey, we analyze the stability and determinants of individuals’ total desired fertility. We find considerable variation of total desired fertility across respondents and across interviews. In particular, up to 50% of individuals report a different total desired fertility across survey waves. Multivariate analysis confirms the importance of background factors including growing up with both parents, having more siblings, and being Catholic for preference formation. Consistent with the idea that life course experiences provide new information regarding the expected costs and benefits of different family sizes, the influence of background factors on total desired fertility is strong early in life and weakens as subsequent life course experiences, including childbearing, take effect. Accounting for unobserved individual heterogeneity, we estimate that an additional child may increase the total desired fertility of women with children by 0.14 children, less than what conventional estimates from cross-sectional data would have suggested.
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The Consequences of Unintended Pregnancy for Maternal and Child Health in Rural India: Evidence from Prospective Data
Article
Full-text available
To investigate the relationship between pregnancy intendedness and utilization of recommended prenatal care for mothers and vaccinations for children against six vaccine preventable diseases in rural India using a prospective dataset. To examine the association between pregnancy intention and neonatal and infant mortality in rural India. The study is based upon a prospective follow-up survey of a cohort selected from the National Family Health Survey 1998-1999, carried out in 2002-2003 in rural areas of four Indian states of Bihar, Jharkhand, Maharashtra and Tamil Nadu. Data for 2108 births for which pregnancy intendedness was assessed prospectively was analyzed using bivariate analysis, logistic regressions and discrete-time survival analysis. Mothers reporting unwanted births were 2.32 (95 % CI: 1.54-3.48) times as likely as mothers reporting wanted births to receive inadequate prenatal care. Moreover, unwanted births were 1.38 (95 % CI: 1.01-1.87) times as likely as wanted births to receive inadequate childhood vaccinations. Likewise, births that were identified as mistimed/unwanted had 83 % higher risk of neonatal mortality compared to wanted births. The association between pregnancy intendedness and infant mortality was only marginally significant. This is the first study of its kind which has investigated the relationship between prospectively assessed pregnancy intendedness and early childhood mortality in rural India. The study provides additional and more conclusive evidence that unwanted births are disadvantaged in terms of maternal and child health outcomes. Findings argue for enhanced focus on family planning to reduce the high prevalence of unintended pregnancy in rural India.
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The Measurement of Wanted Fertility
Article
  • Sep 1990
A review of existing approaches to the estimation of wanted fertility concludes that these measures typically contain an upward bias. An alternative methodology is therefore proposed to estimate wanted fertility from survey questions about women's desire to continue childbearing. This new methodology is applied to data from 48 surveys in developing countries. The results from this exercise indicate that in these populations on average 26% of fertility is unwanted, which is substantially more than estimated derived with other methods. The proportion unwanted apparently varies systematically over the course of the fertility transition: it is lowest at the beginning and end and highest among countries in mid-transition. -Author
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The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families
Article
  • Jan 1998
Experts estimate that nearly 60 percent of all U.S. pregnancies--and 81 percent of pregnancies among adolescents--are unintended. Yet the topic of preventing these unintended pregnancies has long been treated gingerly because of personal sensitivities and public controversies, especially the angry debate over abortion. Additionally, child welfare advocates long have overlooked the connection between pregnancy planning and the improved well-being of families and communities that results when children are wanted. Now, current issues--health care and welfare reform, and the new international focus on population--are drawing attention to the consequences of unintended pregnancy. In this climate The Best Intentions offers a timely exploration of family planning issues from a distinguished panel of experts. This committee sheds much-needed light on the questions and controversies surrounding unintended pregnancy. The book offers specific recommendations to put the United States on par with other developed nations in terms of contraceptive attitudes and policies, and it considers the effectiveness of over 20 pregnancy prevention programs. The Best Intentions explores problematic definitions--"unintended" versus "unwanted" versus "mistimed"--and presents data on pregnancy rates and trends. The book also summarizes the health and social consequences of unintended pregnancies, for both men and women, and for the children they bear. Why does unintended pregnancy occur? In discussions of "reasons behind the rates," the book examines Americans' ambivalence about sexuality and the many other social, cultural, religious, and economic factors that affect our approach to contraception. The committee explores the complicated web of peer pressure, life aspirations, and notions of romance that shape an individual's decisions about sex, contraception, and pregnancy. And the book looks at such practical issues as the attitudes of doctors toward birth control and the place of contraception in both health insurance and "managed care." The Best Intentions offers frank discussion, synthesis of data, and policy recommendations on one of today's most sensitive social topics. This book will be important to policymakers, health and social service personnel, foundation executives, opinion leaders, researchers, and concerned individuals. May
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Do Reproductive Intentions Matter?
Article
Data from 18 countries with Demographic and Health Surveys show that the average fertility rate of married women who want no more children is 43% below the rate observed among women who have not yet completed their desired childbearing. These two groups of women also differ in their average level of contraceptive use--49% among the former and 24% among the latter. A systematic pattern of differences in these variables exists among countries at different stages of the fertility preference transition: In societies where relatively few women want to limit childbearing, reproductive intentions have only a modest impact on contraceptive use and fertility; in countries where large proportions of married women want no more births, most of these women practice contraception to control their fertility. The strength of a country's family planning program is also an important determinant of levels of contraceptive prevalence and of fertility among women who want to stop childbearing.
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Revisiting Retrospective Reporting of First-Birth Intendedness
Article
Because birth intendedness is typically measured retrospectively, researchers have raised concerns about the accuracy of reporting. Our objective was to assess the stability of intendedness reports for women asked about the same birth at different times. We used data from Wave III (2001-2002; ages 18-24) and Wave IV (2007-2008; ages 25-32) of the National Longitudinal Study of Adolescent Health, a nationally representative school-based sample first surveyed in 1995. For the 1,463 women who reported a first birth by Wave III that could be matched with the same birth reported at Wave IV, we examined whether intendedness was characterized consistently at both waves. We constructed descriptive measures of consistency in reporting and estimated logistic regression models predicting changes in reports. Nearly four-fifths of young mothers did not change their reports across waves, with about 60 % reporting their first birth as unintended. However, 22 % of women changed the intendedness categorization of their first birth between surveys. Women who initially reported the birth as intended were more likely to recategorize the birth as unintended than vice versa. With the exception of race and employment, most socioeconomic and demographic characteristics were unrelated to the likelihood of recategorizing first birth intendedness in multivariate models. Most reports of birth intentions are stable, but there is a nontrivial degree of inconsistency. Cross-sectional reports may either under- or overestimate the prevalence of unintended fertility. It remains to be seen whether, and how, consistency of reports is linked to maternal and child health and well-being.
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Young Women’s Dynamic Family Size Preferences in the Context of Transitioning Fertility
Article
  • Apr 2013
Dynamic theories of family size preferences posit that they are not a fixed and stable goal but rather are akin to a moving target that changes within individuals over time. Nonetheless, in high-fertility contexts, changes in family size preferences tend to be attributed to low construct validity and measurement error instead of genuine revisions in preferences. To address the appropriateness of this incongruity, the present study examines evidence for the sequential model of fertility among a sample of young Malawian women living in a context of transitioning fertility. Using eight waves of closely spaced data and fixed-effects models, we find that these women frequently change their reported family size preferences and that these changes are often associated with changes in their relationship and reproductive circumstances. The predictability of change gives credence to the argument that ideal family size is a meaningful construct, even in this higher-fertility setting. Changes are not equally predictable across all women, however, and gamma regression results demonstrate that women for whom reproduction is a more distant goal change their fertility preferences in less-predictable ways.
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