A Blessing I Can’t Afford: Factors Underlying the Paradox of Happiness about Unintended Pregnancy

Abstract

An unresolved paradox in the measurement and interpretation of unintended pregnancy is that women frequently report feeling happy about pregnancies they also classify as unintended (i.e. they have incongruent intentions and feelings). This study explores the underlying reasons why women profess such happiness and how these relate to their motivations to avoid pregnancy. Between September 2013 and February 2014, semi-structured in-depth interviews were conducted with 27 women (8 white, 19 Latina) selected from a longitudinal study measuring prospective pregnancy intentions and feelings among 403 women in Austin, Texas. Women were selected for interview on the basis of wanting no more children and consistently professing either happiness (n=17) or unhappiness (n=10) at the prospect of pregnancy. Interviews were coded and analyzed following the principles of grounded theory. We found that it is possible for women to express happiness at the idea of pregnancy while simultaneously earnestly trying to prevent conception. Happiness at the idea of an unintended pregnancy was explained as the result of deep and heartfelt feelings about children taking precedence over practical considerations, the perception that the psychosocial stress resulting from another child would be low, and the ability to rationalize an unintended pregnancy as the result of fate or God’s plan. The major exception to the sincerity of professed happiness was that conveyed as a result of social pressure despite truly negative feelings, predominantly expressed by foreign-born Latina women. Overall, equating incongruence with ambivalence about avoiding conception may undermine the sincerity of women’s intentions and their desires for highly-effective contraception. At the same time, unintended pregnancies that are greeted with happiness may have different implications for maternal and child health outcomes compared to pregnancies that are greeted with unhappiness. Identifying which unintended pregnancies are most likely to result in adverse outcomes is a target for future research.

INTRODUCTION

Unintended pregnancy is a major and persistent population health issue in the United States. Almost half of the 6.7 million pregnancies occurring each year are estimated to be unintended, and this figure has remained virtually unchanged in the past decade (Finer & Zolna, 2014). Unintended pregnancy is associated with a host of adverse maternal and neonatal outcomes including delayed initiation of prenatal care, higher rates of maternal smoking and alcohol use, lower rates of breastfeeding, and premature birth (Dott et al., 2010), (Dye et al., 1997), (Gipson et al., 2008), (Mohllajee et al., 2007), (Orr et al., 2000). The demographic gradients associated with unintended pregnancy imply that these adverse consequences disproportionately affect the least advantaged members of the U.S. population, including women living in fragile socioeconomic circumstances and women of racial and ethnic minority groups (Finer & Henshaw, 2006), (Finer & Zolna, 2014).

A potential barrier to preventing unintended pregnancies and their associated adverse health outcomes is that women’s pregnancy intentions are not straightforward to measure and interpret. While the international Demographic and Health Surveys (DHS) and the National Survey of Family Growth (NSFG) and Pregnancy Risk Assessment Monitoring System (PRAMS) in the United States measure rates of unintended pregnancy based upon timing (i.e. did the pregnancy occur at the right time, too soon, or was it never intended to happen at any time?), there has been much debate about the ability of discrete timing-based measures to capture the nuances of women’s attitudes towards pregnancy (Santelli et al., 2003), (Santelli et al., 2009), (Barrett et al., 2004). Indeed, evidence from the United Kingdom has highlighted the wide range of meanings women may attach to terms such as “planned,” “unplanned,” “intended,” “unintended,” “wanted,” and “unwanted” (Barrett & Wellings, 2002).

In the United States, studies mainly employing data from the NSFG have considered how intentions based upon timing compare with feelings about pregnancy (i.e. was the pregnancy greeted with happiness or unhappiness?). Intriguingly, women’s answers to these questions often appear to be inconsistent or incongruent. In particular, women frequently profess happiness about pregnancies they also classify as unintended (Trussell et al., 1999). Although these constructs are measured retrospectively in the NSFG and thus such incongruence might easily be attributed to recall bias (i.e. the evolution of feelings after pregnancy has occurred or once a baby is born) (Rosenzweig & Wolpin, 1993), the same phenomenon has been demonstrated even when questions about intentions and feelings are asked prospectively, before pregnancy has occurred (Aiken & Potter 2013).

Despite the prevalence of this apparent paradox––in particular for Latinas, among whom happiness about unintended pregnancies appears to be more common when compared to non-Hispanic whites (Chandra et al., 2005) (Hartnett, 2012)––the question of how to interpret incongruence in pregnancy intentions and feelings is unresolved. In the current literature, a number of related yet distinct possibilities have emerged. Pregnancy desires may not be fully established, or there may be equivocal feelings about avoiding pregnancy, including motivational ambivalence and psychological complexity in pregnancy desires and attitudes towards risk (Miller et al., 2012), (Kavanaugh & Schwarz, 2009), (Higgins et al., 2008). Yet it is also possible that feeling happy at the prospect of a pregnancy while wanting no more children are not mutually exclusive (Sable & Libbus, 2000), (Aiken & Potter 2013), (Yoo et al., 2014). For these women, mixed feelings about pregnancy may represent distinct concepts i.e. they may be earnestly trying to avoid conception yet still view pregnancy or childbearing as a joyous event.

Differentiating between these possibilities and understanding their underpinnings is important for accurately interpreting women’s reports of their pregnancy desires, ensuring access to desired methods of contraception, and targeting preventative strategies to those pregnancies that are most likely to result in adverse maternal and child health outcomes. In light of this importance, the objective of this study is to explore pregnancy intentions and feelings about pregnancy from women’s own perspectives with a view towards shedding further light upon the paradox of incongruence. Through in-depth interviews with women who want no more children, we assess women’s pregnancy intentions, including contraceptive use and desires, and investigate the factors underlying their feelings about a future pregnancy. By including both Latina and non-Hispanic white women, and women with both public and private health insurance, we also examine similarities and differences in feelings and intentions across sociodemographic groups.

METHODS

Between September 2013 and February 2014, we conducted in-depth interviews with 27 women who wanted no more children in the future (n=23) or for at least four years (n=4). Participants were selected from the Postpartum Contraception Study (PPC), a longitudinal survey of 403 women who were recruited immediately following delivery from St. David’s Hospital in Austin, Texas, and followed up at regular intervals over 24 months. Further details regarding the PPC study can be found in Potter et al. 2014 (Potter et al., 2014). At each follow-up, the survey assessed contraceptive use, desires, and prospective pregnancy intentions and feelings about pregnancy (asked for the first time at the 6 month follow-up). Women were selected for in-depth interview just after the 12-month follow-up survey had been completed. Only women who wanted no more children ever or for at least four years, whose feelings at the prospect of a pregnancy were happy or unhappy (not don’t know, since this category likely represents a different type of ambivalence involving incompletely established desires), and whose intentions and feelings were consistent across the 6, 9 and 12-month interviews were eligible for participation. Six of the women selected for interview had already become unintentionally pregnant again.

The major comparison of interest was between women with incongruent intentions and feelings (i.e. women who wanted no more children ever or for at least four years, but professed happiness at the prospect of a pregnancy in the next few months) and women with congruent intentions and feelings (i.e. women who wanted no more children ever or for at least four years, and professed unhappiness at the prospect of a pregnancy in the next few months). To allow comparison of the factors influencing feelings about pregnancy between Latina and white women, participants within the incongruent and congruent groups were further selected on the basis of ethnicity (Latina vs. non-Hispanic white), and language spoken (English vs. Spanish). To account for differences in ability to implement childbearing plans through access to contraception and to allow comparison across socioeconomic strata, participants were also selected on the basis of insurance status at the time of delivery (public vs. private). By the time of the interviews, most of those women who had been covered by public insurance (mainly Medicaid or Emergency Medicaid) at the time of delivery had lost all insurance coverage.

Potential participants were contacted by telephone and asked if they would be willing to be interviewed. All of the women contacted agreed to take part in the study and all gave their informed consent to be interviewed. Human Subjects approval for the study was granted by the Institutional Review Board at the University of Texas at Austin.

The sample matrix of interview participants is shown in Table 1. Seventeen women with incongruent intentions and feelings and ten women with congruent intentions and feelings were selected and interviewed. Among incongruent women, 13 were Latina (7 of which were Spanish-speaking), and 4 were white. Thirteen had public insurance, and 4 had private insurance. Among congruent women, 6 were Latina (of which 3 were Spanish-speaking), and 4 were white. Six had public insurance, and 4 had private insurance.

TABLE 1.

In-Depth Interview Participant Sample Matrix

	Incongruent Intentions and Feelings	Congruent Intentions and Feelings
Latina + Public Insurance	11†	4*
White + Public Insurance	2	2
Latina + Private Insurance	2**	2**
White + Private Insurance	2	2
Total	17	10

^†6 Spanish-speaking, 5 English-speaking

^*2 Spanish-speaking, 2 English-speaking

^**1 Spanish-speaking, 1 English-speaking

The interview sample was also diverse in terms of age, parity, relationship status, and level of educational attainment, and the distribution of these characteristics was similar between the incongruent and congruent groups (Table 2).

TABLE 2.

Characteristics of In-Depth Interview Participants

	Incongruent Intentions and Feelings (n=17)	Congruent Intentions and Feelings (n=10)
Age (years)	29.5 (19–40)	29.5 (22–38)
Parity	3 (1–7)	3 (1–5)
Relationship Status
Married	12	5
Cohabiting	4	4
Single	1	1
Level of Education
Less than High School	4	3
High School	7	3
Greater than High School	6	4

Figures are means and ranges (in parentheses) or frequencies.

Interviews lasted between 45 and 90 minutes, were conducted in either English or Spanish, and took place in person in participants’ homes. Participants were offered $30 as a token of appreciation for their time. The interviewing process was semi-structured, ensuring that key topics such as the influences underlying participants’ intentions and feelings were explored, while allowing sufficient flexibility for other interesting avenues to be spontaneously pursued. Pregnant participants were asked about both their prospective feelings and intentions on the basis of their answers to the survey questions and how they felt about the pregnancy at the time of the in-depth interview, and none reported any change in their intentions or feelings.

Two members of the research team (the lead author and one of two research assistants) were present at each interview and convened immediately afterwards to discuss the case and write detailed field notes. All interviews were audio recorded and transcribed verbatim in the language of the interview. Interviews in Spanish were then translated into English by a native Spanish-speaker who had extensive prior experience discussing pregnancy and contraception with Spanish-speaking women. Throughout the data-collection phase, the research team met regularly to discuss emerging themes, iteratively develop the transcript coding guide, and monitor thematic saturation. Using the resulting coding guide, we conducted content and thematic analyses of each interview according to the principles of grounded theory (Strauss & Corbin, 1990). Atlas.ti 7.0 software was used to assist with the coding and management of transcripts and notes. To protect confidentiality, all women were assigned pseudonyms.

RESULTS

Over the course of six months, we talked to 27 women living in apartment buildings in the inner city, 5000 square-foot houses in the leafy suburbs, and trailer parks in the far outskirts of town. Each woman who so generously gave her time to talk to us painted a self-portrait, expressing her childbearing intentions and feelings about pregnancy in all their various shades and textures. While it is impossible to do complete justice to such richness in the space of a manuscript, we focus here on six overarching themes that emerged from women’s narratives. The first two relate to women’s answers to questions about intentions, and the latter four relate to women’s answers to questions about feelings: 1) the strength and sincerity of pregnancy intentions; 2) the financial implications of another child; 3) perceived emotional stress associated with another pregnancy; 4) belief in fate or God’s plan should a pregnancy arise; 5) social norms and expectations dictating feelings about pregnancy; and 6) practical vs. emotional perspectives on another pregnancy. Throughout discussion of these themes, we emphasize similarities and differences between women with congruent and incongruent feelings and intentions and between Latina and non-Hispanic white women. Themes four and five apply only to incongruent women.

1. Strength and Sincerity of Future Pregnancy Intentions

Regardless of feelings about a future pregnancy, future childbearing intentions were clear, strong, and earnest. None of the women to whom we talked expressed ambivalent or conflicted desires to avoid pregnancy. Indeed for many women, their ideal number of children had been long surpassed and they were adamant about preventing another pregnancy. Moreover, motivation to realize intentions was expressed through an almost universal desire to use highly effective contraceptive methods (intrauterine devices, implants, or sterilization), and women frequently described their frustrations arising from unsuccessful attempts to obtain these methods. Marissa, a 34-year old U.S.-born Latina mother of five, expressed happiness at the idea of a pregnancy but told us of her difficulties implementing her intentions when relying on Medicaid: “I don’t want no more kids. I just want to get my life in order and want to relax and enjoy me and not have to worry about, you know, taking care of the baby. I had my oldest daughter when I was very, very young, and then my three youngest are only three years apart, and now I want to be able to just get up and do things, not, oh I have to find a sitter, so can’t do this or that… I just don’t want to do it. I really don’t. I’m supposed to be having a tubal in a couple of weeks. I’ve signed that paper (meaning for informed consent, which must be given at least 30 days before the procedure) five or six times, but something always comes up, like my Medicaid isn’t good no more, so I’m going to try this one more time. I just don’t want to deal with kids no more.”

Delfina, a 40-year old publicly-insured Latina mother of seven who was born near Guadalajara, Mexico but moved to the U.S. when she married her third husband 12 years ago, also expressed happiness about the idea of a pregnancy in the next few months, but told us: “I definitely don’t want to have any more…it’s very important for me not to get pregnant right now because I need to work so that the children can have a better life. I’m using the injection to keep from getting pregnant because for an IUD you have to pay $300 to get it, and the injection is much cheaper. Really, I would like my husband to use birth control but he doesn’t want to. He doesn’t want to use condoms and I’ve tried talking to him about vasectomy but it turns into a fight.”

The experiences of these two women are illustrative of those expressed by almost all of the women to whom we talked and demonstrate emphatically the sincerity behind their answers to the Yes/No childbearing intentions question asked in the wider survey from which the in-depth interview sample was derived. Additionally, sincerity of the desire to have no more children was consistent across ethnic group, country of birth, and level of socioeconomic disadvantage.

2. The Financial Implications of Another Child

The predominant reason women described for wanting no more children was the financial difficulty another baby would precipitate. Kaitlyn, a white 26-year old mother of three with public insurance, expressed unhappiness at the idea of a pregnancy. When explaining her intentions she said: “Five is a lot of people to provide for financially. We’re not planning no more babies in the future. All the stuff you don’t think of like baby Tylenol and thermometers that don’t work and all that stuff really, really adds up. Formula, if you don’t have WIC, formula’s going to run you $300 a month. We barely, barely make it work. Barely. I just do not see how we would do it with another one.”

The same concerns about affording and caring for another baby in financially fragile circumstances applied equally to women with incongruent intentions and feelings. Ana, a 26-year old married mother of three with public insurance was born in Michoacán, Mexico and moved to the U.S. five years ago. In her answers to the survey questions, she had expressed happiness at the idea of a pregnancy in the next few months. By the time we met up with her for the interview, she was pregnant again with her fourth child. She described to us the circumstances of her pregnancy and the reasons why she wanted no more children: “I was so frustrated. I thought no, I cannot be pregnant again. I just could not believe it…we were using withdrawal and I wanted to use the one that goes here (gestures to her upper arm where the implant is placed) but the cost was three sixty. I was going to try to pay in installments, but then I got pregnant…When it happened, we did not have a place to live. We were living with other people in their house. I did not want to get pregnant. I wasn’t planning on getting pregnant. We had a lot of financial problems and you feel the pressure, the stress when children are little and they need so much care. It’s a big responsibility.”

In addition to being applicable to both white and Latina women, financial considerations were not the concern solely of women living in economically disadvantaged circumstances. Both middle-class congruent and incongruent women also frequently cited money as the most important reason for wanting no more children, albeit in terms of lifestyle compromise rather than dire financial straits. Jennifer, a 36-year old white mother of two with private insurance would greet the idea of a pregnancy with happiness, yet when describing her reasons for wanting no more children told us: “Adding another would be kind of a game-changer. It would be crazy. We moved to this house because we didn’t have enough room in our other one….we would need a bigger car because we wouldn’t be able to fit three car seats and two adults into what we have now. And then, we’d like to retire someday. It would put me off returning to work so that would be another couple of years that I would be home and more pressure on my husband. He’s the one breadwinner right now. He’s told me if we had another baby he would cry.”

3. Perceived Emotional Stress Associated with Another Pregnancy

For women with congruent intentions and feelings, unhappiness about a future pregnancy was frequently based upon not only the same financial issues cited as reasons for wanting no more children but also the perceived psychological and emotional stress another pregnancy would cause. A key idea among these women was that of going over a threshold or “tipping point” where another child would have a very negative impact on their lives. Marisol, a 34-year old U.S.-born Latina mother of five with private insurance described the reasons why she would feel unhappy about another pregnancy: “I have a big family, five girls. My ideal family size was three…I ended up with five. It’s overwhelming to have five kids and a full-time job and to try to get everything else in. Five is more than enough…. It’s very important to me not to get pregnant right now. I would be devastated. My plate is so full and if I add any other side to it, I wouldn’t be able to function for my kids. I also want to go back to school, and I was going to start in August, but I pushed that back because school requires more time that would be away from my kids. My family is very important to me, and I really do look forward to seeing them in the afternoon and spending that time, but I think I would be very overwhelmed. I would be shut down, just shut down. I wouldn’t want to deal with it. I’m at my max”.

By contrast, none of the women with incongruent intentions and feelings to whom we talked linked negative emotional stress with their feelings about another pregnancy, even when another child would clearly be an economic burden. Rather, they tended to focus on children as a “blessing’, and talk about “rising to the occasion” using the resources available or about another baby being “just another kid”. Marissa, the 34-year old U.S.-born Latina mother of five whom we earlier learnt was hoping to get a sterilization through Medicaid to avoid having any more children told us: “I’d be a little shocked, but happy. I wouldn’t be mad. I wouldn’t be mad at all about it. I’d be happy….I’m pregnant, I’m gonna have a baby, and that’s, I mean, to me it’s a blessing….it’s joyous, it’s bringing life into this world and no matter what the situation is or whatever, you’re going to have to take care for and take care of. There would really be no big change: just another baby. I don’t work or go to school or anything right now that I got to take care of my 18-month old, so it’s be the same, just what I’m doing now, I’d just be busier because I’d have a toddler and an infant.”

Vanessa, a 34 year-old Latina mother of four who was born in El Salvador and came to live in the United States six years ago wanted to get sterilized at the time of her last delivery but did not qualify for Medicaid. She and her husband ended up using condoms, and by the time of the interview, she was already pregnant again. She described how, despite serious financial stress, feelings of love and joy prevailed: “There have been times when we’ve had a lot of debts, moments when the debts have been very high and we didn’t even have money for food. We are a big family and we have so many bills to pay each month. I am definitely not asking for another child, but if he comes, I am not going to be upset. You have this love for your children, you created them, and they are here, and it is a life, so somehow you know what to do. You rise to the occasion and don’t stop to think about all the bad things.”

This difference between congruent and incongruent women in the perception of how much a pregnancy would negatively affect their lives was applicable to both Latina and white women and to both publicly and privately insured women in our sample.

4. Belief in Fate or God’s Plan Should a Pregnancy Arise

Although virtually all of the women with whom we talked desired a highly effective method of contraception to help implement their childbearing intentions, women who would nonetheless feel happy at the prospect of a pregnancy frequently talked about viewing an unintended pregnancy in a positive light through either a belief in God’s plan or in the power of fate. Lucia, a 28 year-old mother of three with public insurance who was born in rural Mexico and moved to the U.S. eleven years ago had wanted to use an IUD after giving birth to her fourth child but changed her mind after her husband told her it was abortifacient. Although she is still trying hard to avoid pregnancy by getting her husband to consistently use condoms, she explained: “God gave women this gift of motherhood. The gift of creating life inside your body. This is very important to me. And if I got pregnant I would say, ‘I believe strongly in God’, so I would think ‘if God is sending me a baby, even without me planning for it, it is because I can handle it, I can take care of it.’”

Whereas belief in God’s will was more commonly expressed among Latina women, white women tended instead to talk about fate or things being “meant to be”. Sandra, a white 39 year-old mother of two, with private insurance provides an illustration: “I’m one of those people that thinks everything happens for a reason. If I didn’t have the IUD, and I found out I was pregnant, I would just think it was what was supposed to happen.”

Such thinking about fate or God’s will was common to incongruent women across socioeconomic strata. None of the congruent women to whom we talked invoked either concept when explaining their feelings about a future pregnancy.

5. Social Norms and Expectations Dictating Feelings about Pregnancy

While the women with incongruent intentions and feelings discussed so far described truly positive feelings about a future pregnancy despite wanting to prevent it, others were in fact unhappy at the idea of a pregnancy but felt unable to admit it openly. Despite having professed happiness in response to the survey questions about feelings about a future pregnancy, these women revealed during the interview that their actual feelings would very different. This disjunction, which was almost exclusively expressed by Latina women and in particular those who were born outside of the U.S., was explained as a response to the social expectation that having children would automatically be viewed as a joyful and thankful event. These women often described growing up, getting married, and becoming a mother as a strict set of social norms that had been instilled in them as children and young adults and the idea of suggesting that children would be an unwelcome emotional burden was seen as unacceptable.

Delfina, the 40-year old Latina mother of seven whose difficulties obtaining the IUD were described earlier, answered in the survey that she would be happy about another pregnancy. But at her interview she told us: “Maybe I would feel depressed because it is not in my plans, but I would have to process it and accept it. I would not call it a burden because we are talking about babies, and I would not like to call it that, because it’s a human being, it’s a life, it’s my child. What I mean is, I can’t call anybody a burden because we are all human beings. So I have to accept the way things are, and not call it a burden.”

Commonly, the admission of unhappiness or frustration at the prospect of a pregnancy augured shame and guilt. Martina, a 31-year old cohabiting Latina mother of five who had no insurance at the time of her delivery, who was born in Guanajuato, Mexico and moved to the U.S. 15 years ago, explained to us that although she admitted feeling unhappy about a pregnancy to us behind closed doors, she would not feel comfortable saying the same thing to friends or acquaintances in her community: “For me, the feeling would be total frustration. But with the last one I would complain about being pregnant because I didn’t want more children and people still hold it against me… But I am desperate at the moment. I really don’t want to have more children, and I tell God: please no more.”

6. Practical vs. Emotional Perspectives on Another Pregnancy

Although both congruent and incongruent women talked about their existing children as a source of happiness, women who would feel unhappy when contemplating a future pregnancy tended to take a pragmatic approach to questions about feelings, focusing on money, time, and emotional reserve. For incongruent women, on the other hand, deep emotions were at the forefront when answering questions regarding feelings about a future pregnancy. For incongruent women, the idea of not only their own children but of children in general was seen as joyous. Despite wanting no more children, often due to the practical realities of providing for another baby, such warm feelings appeared to override any reservations––the important exception being those women described above who expressed happiness because they felt an obligation to do so.

Violeta, a 24 year-old Latina mother of three who was born in San Luis Potosi, Mexico, wanted no more children for at least seven years. She had wanted to use the implant after her last delivery but had no insurance to cover it. By the time we met for the interview, she was pregnant again, but despite her current difficult financial circumstances, she told us: “At the moment, everything is a challenge. My husband is not working enough hours. You see, he works outside and if it rains he can’t work, so it affects us a lot, because we can barely make the rent, and by the time we buy groceries we don’t have much left. We barely make it…. When I found out [I was pregnant] I was anxious, but I was also happy because a baby is a baby. It’s a blessing and so you are happy for it. It wasn’t planned, but we are all happy about it. You’re always happy because a child is always a blessing…at least for me, you think that children are the most beautiful thing in the world and it makes you happy.”

Such feelings were not exclusive to women in any particular ethnic or socioeconomic group. Despite living in very different socioeconomic circumstances, Jennifer, the 36-year old white mother of two who earlier described the extra burdens another baby would place on her and her husband, echoed Violeta’s thoughts: “I think I would be excited…I would love to have another baby. Babies are cute and cuddly and when you hold them… if you would have known me five years ago you would have thought there’s no way she’s having kids. But now that I have them and they’re so wonderful and we’re just having a really good time with them that I think ‘oh it would be so nice to have another baby’, but you forget how hard it is, and the reality would set in, and I think ‘oh my gosh it would be so hard’…it’s definitely my heart and not my head, the emotional side of me that’s like ‘oh we got another squishy baby’, but then my logic side is like ‘I really shouldn’t, this is good now, we have a good life.”

In short, as Jennifer so eloquently put it, although both groups of women expressed similar reasons for wanting no more children, incongruent women tended to respond to questions regarding feelings about pregnancy with warm emotions, whereas congruent women tended to answer with more practical considerations in mind.

DISCUSSION

Women with incongruent intentions and feelings told us in their own words that it is indeed possible to feel happy at the prospect of a pregnancy while simultaneously trying to prevent conception. Although these women lacked the ability to obtain highly effective methods of contraception, their childbearing intentions and their desires to use such methods were clear. Moreover, the reasons women cited for wanting no more children were virtually identical between those who would feel positively and those who would feel negatively about another pregnancy. These reasons were predominantly related to the financial challenges another baby would bring.

The feelings expressed by incongruent women at the idea of another pregnancy did not detract from their strong intentions. Rather, happiness was an equally sincere but distinct component of these women’s attitudes towards pregnancy, often the product of deep and heartfelt feelings about children, the perception that another child would bring joy rather than disruption, and the view that even an unintended pregnancy would be a blessing or a gift. The major exception to the sincerity of professed happiness was that expressed predominantly by foreign-born Latina women, who felt that social pressures left them with no option but to convey happiness about a pregnancy in spite of truly negative feelings

Women’s descriptions of their happiness at the prospect of an unintended pregnancy point towards several attractive explanations for the paradox of incongruence in intentions and feelings. The first is that although none of the women to whom we talked wanted or intended another pregnancy, they were able to envisage their ability to cope with one should it arise. In stark contrast to women who would feel unhappiness about an unintended pregnancy, women who professed happiness appeared to perceive that the associated burden of emotional or psychosocial stress would be low. One of the main points of difference between these two groups of women was the perceived opportunity cost of another baby weighed against other competing personal commitments or aspirations. For incongruent women, being a mom was often cited as the current main goal, whereas for congruent women, commitment to a job or a plan to go back to school was likely to be seriously derailed by another pregnancy. These results reflect previous observations on the influence of attitudes towards childbearing on competing behaviors and emphasize the importance of social psychological context in examining fertility intentions (Barber, 2001). Highly influential work examining the reasons why unmarried women living in fragile socioeconomic situations have children before ensuring economic and marital stability suggests that their decisions can be understood as a product of their perceived opportunities and their view of motherhood as an attainable goal (Edin, 2005). Although our analysis does not speak to why women choose to have children in the first place, we suggest that some of these same factors might also apply to feelings about a future unintended pregnancy.

A second possible explanation, also related to perceived ability to cope with an unintended pregnancy, is that belief in fate or God’s plan can be used to rationalize the idea of an unintended pregnancy and cast it in a more positive light. Prior research has suggested that some women may be happy about a pregnancy because they are fatalistic about conception or because they do not find the concept of planning a pregnancy to be meaningful (Jaccard et al., 2003), (Zabin, 1999). While this kind of reasoning was not expressed by women in our study––all of whom were convinced that use of a highly effective method would enable them to prevent pregnancy and ultimately believed that they were in control of whether or not they got pregnant––fate or the will of God was often evoked as a mechanism for coping with the idea of an unintended pregnancy. This ability to rise to the occasion suggests that for some women, happiness may be partly a reflection of making the best of an unanticipated situation.

A third explanation is that in better economic circumstances, women with incongruent intentions and feelings might actually choose to have more children. Previous qualitative work has demonstrated that for some women concrete childbearing plans are often different from their “ideal world” attitude to a pregnancy (Fischer et al., 1999). For many of the incongruent women in our study, the perceived personal utility and fulfillment derived from children was high. Children were viewed as a blessing and a source of happiness even though the economic reality of another child would constitute a substantial burden. Recent research among adolescent populations has suggested that attitudes towards pregnancy are strongly linked to the view of motherhood as one’s main source of personal satisfaction or achievement (Fedorowicz et al., 2014), a concept that may also be applicable here.

Interestingly, examples of these three explanations for why women express happiness about pregnancies that would be unintended were found across ethnic and socioeconomic groups in our sample. While we cannot say on the basis of a small qualitative study whether these types of happiness might be more common among Latina women (and thus explain why incongruence has previously been demonstrated to be more prevalent among Latinas), we certainly found views about children as a blessing and a joyous life event to be especially prominent among the Latina women to whom we talked. This finding is consistent with previous literature on Latina women’s attitudes towards pregnancy, and in particular LeVine’s ethnographic study of women living in rural Mexico, which found that women often expressed a desire for more children than they were able to afford (LeVine, 1993). Studies have also pointed to differences in attitudes towards motherhood among Mexican women living in Mexico, Mexican women living in the United States, and U.S.-born Mexican-American women, with women with the closest ties to Mexico having the most positive attitudes (Guendelman et al., 2001). The Latina women in our study also more commonly invoked God’s plan rather than fate as a way of coping with a pregnancy should it occur, reflecting previous work on the influence of religion in Latina attitudes towards pregnancy (Hayford & Morgan, 2008). It has also been documented that Latina women face increased challenges to obtaining more effective methods of contraception due to both a higher likelihood of lacking health insurance (Montez et al., 2009) and difficulty navigating the health system and gaining knowledge about contraceptive methods due to language barriers (Dehlendorf et al., 2010), both of which may increase the need to formulate strong coping mechanisms for unintended pregnancies.

Critically, due to a reluctance to express negative feelings about pregnancy and childbearing, happiness declared in response to survey questions may not be an accurate reflection of some Latina women’s true feelings. For these women, professed happiness was about fulfilling a sense of obligation or duty reinforced by family, friends, community and sometimes also male partners, and it is possible that the higher levels of incongruence found among Latina women on the basis of survey data may be an artifact of this phenomenon. Our findings underscore the potential relevance of Latina women’s social and cultural origins on their beliefs about motherhood and feelings about future pregnancies, and more investigation of how to distinguish between true and obligated happiness on the basis of survey questions is clearly warranted.

Previous studies examining pregnancy intentions and feelings have concluded that incongruence may be a reflection of ambivalence about avoiding conception, a representation of equivocal or evolving intentions and desires, or a product of two distinct constructs. The key message from our findings is that women who want no more children but profess happiness at the prospect of a pregnancy should not automatically be assumed to lack clear motivation to avoid conception. For some women, this assumption would not only misrepresent their childbearing intentions but also contradict their sincere desire to use a highly effective method of contraception. There have been several recent developments of validated scales designed to prospectively measure attitudes towards pregnancy and efforts to plan pregnancy (Morin et al., 2003), (Paterno & Han, 2014). In light of our conclusions, future research focused on the prospective measurement of pregnancy desires should further explore the dimensions of happiness separately from constructs used to measure intention.

The main strength of this study is the richness of detail afforded by the qualitative approach. Despite the relatively small number of women interviewed, we are confident of having achieved or at least closely approached thematic saturation. We were also able to achieve representation of Latina and non-Hispanic white women from a variety of different backgrounds. An important limitation of the study is that women were recruited from only one city in Texas, where recent state policy surrounding family planning has restricted public funding for contraception and likely inhibited participants’ ability to access contraception and avoid pregnancy. The analysis is also focused on women who are parous and, in some cases, have had many children. For these reasons, generalizability of the findings to other populations and settings is not guaranteed. Additionally, we did not have the opportunity to interview women’s partners, the influence of whom is likely to be significant (Miller et al., 2010) and is a target of our future research.

Understanding that women with incongruent intentions and feelings may have a strong desire to avoid pregnancy is likely to be important for ensuring adequate access to contraception. Very few of the women in this study were able to access their desired method of contraception, mostly because their insurance coverage had run out before contraceptive counseling and a plan for method placement or prescription had been made postpartum. Through discussion of pregnancy desires, providers could assist women in aligning their childbearing intentions with their contraceptive choices and help them to obtain their desired methods.

The evidence that women may earnestly feel happy or able to cope with pregnancies they truly do not intend suggests a promising path for future investigation into the health impacts of unintended pregnancy. Attitudes towards unintended pregnancies appear to wary widely, and thus rather than focusing on the health outcomes of intended versus unintended pregnancies, it may be more fruitful to turn our attention to determining which unintended pregnancies are most likely to be predictive of adverse health and psychosocial consequences. Perhaps, even when unintended pregnancies occur in non-optimal financial circumstances, the desire and ability among incongruent women to “rise to the occasion” with time, energy, and love could contribute to positive health outcomes.

Research Highlights.

• Happiness about pregnancy may coexist with sincere intent to avoid conception

• Intent to avoid conception is influenced by perceived negative economic consequence

• Happiness aligns with the perception of low psychosocial and emotional stress

• For some women, happiness is an response resulting from sociocultural obligation

• True happiness about unintended pregnancy may have implications for health outcomes