“If I know I am on the pill and I get pregnant, it’s an act of God”: women’s views on fatalism, agency and pregnancy

Abstract

Objectives

Fatalism is the idea that outside forces have control over events. Pregnancy and pregnancy prevention play a prominent role in many women’s lives, and we sought to understand if and how fatalism informed their thinking about these issues.

Study design

We conducted in-depth interviews with 52 unmarried women between the ages of 18 and 30. We used NVivo to analyze the transcripts. The current analysis focuses on the ways that women discussed fatalism and pregnancy both in response to a direct question and as it came up spontaneously.

Results

The majority of respondents expressed a mix of fatalistic and non-fatalistic views about pregnancy. Many related that “fate,” “destiny” and/or God play a role in pregnancy, but most also asserted that pregnancy risk could be substantially reduced, most commonly by using contraception. Fatalism sometimes served a positive function, for example as a mechanism to deal with an unintended pregnancy. Having a fatalistic outlook did not preclude contraceptive use. Rather, some women using highly effective methods related that if they were to become pregnant, they would interpret it as a sign that the pregnancy was “meant to happen.” Finally some women related that there was no guarantee a woman could get pregnant when she wanted to, suggesting that some degree of fatalism may be inevitable when it comes to pregnancy.

Conclusions

Fatalism and agency should not be viewed as opposing outlooks when it comes to pregnancy and pregnancy prevention; having fatalistic views about pregnancy does not preclude contraceptive use.

Implications

Given that women do not have total control over attainment of a wanted pregnancy or even prevention of pregnancy, some amount of fatalism about fertility is a logical and pragmatic response. Both research and clinical practice need to recognize that fatalism and contraceptive use are often not in conflict.

1. Introduction

Fatalism is the belief that life events are predetermined or controlled by outside forces such as God or fate [1,2]. Many programs and policies aimed at improving health outcomes encourage individuals to engage in healthy behaviors and change unhealthy ones — to act with agency — and it is typically assumed that a fatalistic outlook is a barrier to positive, agentic behaviors [2]. Pregnancy planning and pregnancy prevention might be particularly vulnerable to fatalistic thinking. While a public health perspective posits that pregnancies should be planned and intended, approximately half of US pregnancies are unintended [3,4,5]. It is possible that fatalism, or the extent to which individuals perceive themselves to have control over when a pregnancy occurs, influences their willingness to make a conscious decision to become pregnant as well as their ability or desire to prevent it from happening.

Several qualitative studies suggest a range of ways that fatalism can influence individuals’ views of pregnancy. When Woodsong et al. [6] asked low-income women about pregnancy and pregnancy planning, many of the respondents expressed a fatalistic outlook when they related that childbearing was an important part of the plan that God had for each individual. Some indicated that it was not possible or appropriate for pregnancy to be planned, as God has the ultimate power to cause pregnancy. At the same time, most interviewees “saw no conflict between God’s will and decisions to use contraception” [6] (p. 68)] and, as some explained, God could put contraception in an individual’s path. Similar ideas about fatalism and pregnancy emerged in interviews with low-income women living in suburban Washington [7]. The overwhelming majority of interviewees indicated that women have control over pregnancy and pregnancy prevention. Like the individuals interviewed by Woodsong et al. [6], many indicated that God determined when a pregnancy would occur; however women in the study also identified more secular forces such as fate, and some discussed both as playing a role in pregnancy. Some interviewees thought pregnancy planning was valuable, if not idealistic, while others indicated that pregnancy could not or should not be planned [7]. Finally, when Borrero asked focus groups of low-income African American women to talk about their contraceptive decision-making processes, many expressed a belief that pregnancy was not completely preventable and that contraception was a way to slow down a process ultimately controlled by God or fate [8]. While these studies were investigating pregnancy planning and prevention, none of them systemically examined contraceptive use among respondents as it related to fatalistic outlooks.

At least one study has examined pregnancy and fatalism from an alternative perspective: When women (and couples) make a conscious decision to become pregnant, they may not be able to do so. Bell and Hetterly [1] examined fatalism among 58 women dealing with infertility. They found that both high and low income women invoked fatalism as a way to avoid individual blame and maintain a sense of optimism, though higher income women tended to adopt this strategy only after they had explored all the medical options. While religiosity is often conflated with fatalism, the interviewees also used it in an agentic fashion. Religious practices provided both the strength to deal with infertility and an active strategy for providing hope, for example through prayer. The authors conclude that when researchers view agency and fatalism as binary outlooks, they overlook the benefits of fatalism.

This study addresses the issues of fatalism and pregnancy based on in-depth interviews with unmarried women. We found that most interviewees expressed both fatalistic and non-fatalistic outlooks, and we expand on this duality by assessing situations where women discussed both outlooks in the same thought, as well as by identifying distinct themes related to both fatalistic and agentic outlooks. Additionally, we examine associations between fatalism and consistency of contraceptive use.

2. Methods

Data for the analysis come from 52 semi-structured in-depth interviews with women selected to best match the sociodemographic profiles of women at greatest risk of unintended pregnancy: unmarried women aged 20–30 who had a household income less than 300% of the federal poverty level. Respondents were recruited from a large Northeastern city and a smaller Midwestern city through both a professional recruiting company and on Craigslist. Verbal and written consent was provided by all participants, and they received $100 cash as compensation. All interviews were conducted in November 2013 and lasted between 45 and 120 min. The interview guide and study protocols were approved by the Guttmacher Institute’s Institutional Review Board. Interviews were conducted by two of the authors (Frohwirth and Blades) as well as a graduate assistant.

The semi-structured interview solicited information about women’s attitudes and experiences around pregnancy and parenting, and collected detailed information about contraceptive use patterns over the previous 12 months. The issue of fatalism emerged from the data and served as an ex post facto analysis. The interview guide only contained one item directly related to fatalism; all respondents were asked whether they believed “that there’s a specific time that [you are] meant to get pregnant” and whether “destiny [has] anything to do it.” However, many women brought up issues related to fatalism over the course of the interview, and this information was analyzed as well.

We followed Agar’s [9] qualitative strategy of reading each woman’s interview in its entirety to understand each respondent’s comprehensive narrative. An inductive and deductive coding structure was also developed using NVivo, wherein all data related to respondents’ fatalistic beliefs was highlighted for further analysis. Three coders (the authors) initially analyzed the same interviews to assess intercoder reliability, yielding an agreement of 83–100%. We then analyzed data to summarize emerging themes and concepts and to explore patterns of similarities and differences across interviews. Key relevant topics that emerged were summarized via textured description and illustrated using direct quotes from participants [10].

We also examined patterns between fatalistic attitudes and consistency of contraceptive use over the last 12 months. Respondents classified as ‘always consistent’ reported use of a contraceptive method at every sexual encounter. These included women who switched methods but reported no gap in coverage and those who used a backup method when they failed to use their primary method correctly. ‘Mostly consistent’ users reported method use over the past year that left them unprotected from pregnancy on only a few occasions, for example, one or two instances of inconsistent use of a primary method that was not backed up by a secondary method. ‘Inconsistent’ users reported many incidents of unprotected sex. These included behavior such as forgoing methods entirely, multiple unsuccessful attempts at withdrawal, condoms removed before ejaculation and skipping pills on multiple occasions.

3. Findings

About half of the 52 respondents were aged 20–25, and the rest were aged 26–30. Twenty-one respondents were Latina (seven were interviewed in Spanish), 18 were Black and 13 were white. Fifteen had children. Most respondents had never been married (n=30) but 20 were cohabitating. Only a minority of women expressed solely fatalistic (n=9) or solely non-fatalistic (n=5) beliefs about pregnancy; the majority of respondents (n=38) related a mix of both.

3.1. Variations in fatalistic beliefs

Almost all of the women expressed some degree of fatalism about pregnancy and contraception, and we identified five broad themes. Most commonly (n=37), women referenced non-specific forces that exerted control over their lives. For example, 18 women referenced “fate” and “destiny:”

“There’s always a plan, in everyone’s life, of how it’s supposed to be, and I feel that I got — I had my two children at the young age and they’re — it’s — it was destiny.”

—Elena, mixed beliefs.

A similar number of women (n=22) used some variation of the phrase “meant to happen” when describing pregnancy timing. This usage indicated respondents’ belief that the timing of pregnancies in people’s lives is predetermined by an outside force:

I: Is there anything that’s appealing about the idea of getting pregnant right now?

R: I mean, sometimes I think about it, and I’d just be like, you know if it happens, it’s maybe because it’s a sign that it’s meant to happen.

— Tamara, mixed beliefs.

Women also referenced God as controlling whether or not they became pregnant (n=22). Whereas “fate” and “destiny” were often neutral or non-specific, the role of God could sometimes be benevolent or punishing.

A related theme did not name any controlling power or force, but nonetheless articulated the idea that pregnancy cannot be planned (n=11). In some instances, women referenced their own experiences with unintended pregnancies or unsuccessful attempts to get pregnant. Even without a prior pregnancy experience, some indicated that pregnancy is something that “just happens” in people’s lives:

“[…] it just always happens so, that’s kind of what I feel like. However, I do have a co-worker, who, she’s married... and she planned her kid. Like, she’s like, I want to get pregnant at this time, and she was, ended up being pregnant, I’m like, wow! I don’t know, I felt like that was amazing because, you just, — that never happens.”

— Sonya, only fatalistic.

Less common themes related to fatalism included the belief that contraception does not work and the idea that some women’s unconscious or subconscious desires to have, or not to have, children have an effect on whether or not they actually become pregnant.

3.2. Agency, control and non-fatalistic beliefs

Among the 42 women who expressed non-fatalistic outlooks, we identified three distinct themes. Most commonly (n=25), women indicated that pregnancy can be prevented, and most directly or indirectly referenced contraception:

“So, I mean if you’re deathly afraid [of becoming pregnant], then you make sure that you’re doing what you need to do whether — whatever, there’s so many different types of prevention. You know, there are so many ways to prevent it.”

— Michele, mixed beliefs.

Respondents acknowledged contraceptive fallibility, but maintained that fertility can still be controlled by using contraception consistently and correctly, by using more than one method or by avoiding sexual contact. The second subtheme, expressed by 10 women, was control. These interviewees explicitly referenced their ability to control their behavior, their ability to get pregnant or the outcome of the pregnancy.

“I just think it should happen when someone is ready for it, I think it’s something that you have complete control over so why not choose, you know.”

Cora, only agentic.

In discussing ways that they were able to control their fertility, some women (n=11) referenced science or biology. These respondents related that pregnancy occurs via well understood mechanisms, and, therefore, women and couples have agency over planning and preventing pregnancy.

3.3. Explicit tension between fatalism and agency

A majority of interviewees (n=38/52) expressed both fatalistic and non-fatalistic views at different points in their interviews. Nearly half of the women (n=24) expressed both fatalism and control over fertility within the same sentence or thought.

I: Do you feel like destiny has anything to do with that [when you will become pregnant]?

R: No, I do. I am a big believer of fate, and what’s meant to be. I’ve actually thought about that quite some — a lot of times, you know, people can’t get pregnant or when it’s —are they ready, when does God think they’re ready. […].

I: Do you feel like when it is kind of that time — do you feel like there’s anything you can do to prevent a pregnancy sort of when it is your time?

R: Well, of course, I can use birth control or contraceptives, and probably wouldn’t get pregnant.

— Monica, mixed beliefs.

Some women clearly articulated how contraceptives needed to be used to avoid pregnancy, but still allowed that fate played a role. Inconsistent contraceptive use and contraceptive failures were often perceived as a gray area, where destiny could coexist with control.

“I mean, I play a big part in whether or not I get pregnant, in the sense that it’s my choice whether or not to have sex with this person, it’s my choice whether or not to protect myself by wearing a condom, it’s my — you know, so it’s, like, my choice whether I want to go through with it or not, and the ending outcome — I mean, I don’t have control over whether or not I get pregnant of course. But I have control over what steps I take. Am I taking my — you know, am I taking my pill regularly? [...] So, there might, God might know. God knows, I don’t know. I don’t know when I’m meant to have a baby but there are certain steps that I can take to prevent me necessarily having a baby right now.”

— Claire, mixed beliefs.

The above quote shows how agentic beliefs can be nested within fatalistic ones. This respondent related that she has the ability to exert some control over her reproductive outcomes by using contraception, but, ultimately God has control over whether she actually gets pregnant.

In another example of the interplay between fatalism and agency, contraceptive failure was sometimes interpreted as a sign that the timing of pregnancy is predestined:

“…it’s like, if I know I am on the pill and I get pregnant, it’s an act of God, and I’m meant to be pregnant.”

— Nikki, mixed beliefs.

Another way in which some respondents expressed tensions between fate and agency was in their views of fertility as opaque and mysterious. In contrast to the non-fatalistic view of fertility discussed above, some women felt that the invisible process of becoming pregnant was a site of the tension between what they could and could not control:

“So, I feel like [pregnancy is] one of those things where it’s, like, half of your control and half up to like the air and the wind and the stars align a certain way, you know […] So it’s like pregnancy is [a] really funny thing, it’s really funny. It’s definitely a miracle and I’ve watched a documentary, it’s actually very hard to get pregnant, it’s actually very —because there is so much things against you.”

— Beth, mixed beliefs.

3.4. Fatalism, agency and contraceptive use

Most of the women we interviewed had been protected from pregnancy for all or most of the last 12 months (Table 1). Half had always used contraception during all periods of sexual activity, and an additional 15 women were mostly consistent, for example only having unprotected sex on a few occasions over the last 12 months; 11 were inconsistent users. Only one respondent indicated a desire to become pregnant during the year (not shown).

Table 1.

Interviewees’ type of fatalistic belief by consistency of contraceptive use.

Type of fatalistic belief	Consistency of contraceptive use
	Always consistent	Mostly consistent	Inconsistent	Total
Only fatalistic	2	3	4	9
Only non-fatalistic	4	0	1	5
Mixed	20	12	6	38
Total	26	15	11	52

Patterns between fatalism and pregnancy protection levels were not always straightforward. Women who expressed only fatalistic beliefs (n=7) fell into all three contraceptive consistency categories, including two who were consistent users. Four of the five women who only expressed non-fatalistic views always used methods consistently, but one was an inconsistent user. Among women who were mixed in their outlooks, half were always consistent users, 13 were mostly consistent and seven were inconsistent. In short, the patterns do not reveal a straightforward pattern wherein fatalism is associated with less consistent use, and sometimes the associations are counterintuitive.

4. Discussion

In line with prior qualitative research [7,8,6], many women held complex views about fatalism and pregnancy, with most expressing both fatalistic and non-fatalistic outlooks. We identified several themes in women’s discussions of fatalism. Most commonly, women referred to non-specific forces such as fate and destiny or used terminology such as “it’s meant to happen.” A substantial minority of women also referenced God.

As reported in previous research [7,6], some of participants indicated that pregnancy cannot be planned. However these women did not seem to think it was inappropriate or unnatural to plan a pregnancy. Rather, they suggested that the nature of people’s lives and romantic relationships and the unpredictability of fertility made it difficult to plan a pregnancy.

Women expressed non-fatalistic outlooks only slightly less frequently than fatalistic ones, and here, too, we identified several themes. Unprompted, and sometimes in response to questions about the role of fate, a majority of women related that the risk of pregnancy can be substantially reduced, and identified contraception as the best way to achieve this goal. Women also expressed non-fatalistic views when discussing the biological mechanisms of pregnancy and their ability to control their fertility.

Examples where women expressed both fatalistic and non-fatalistic views in the same thought or exchange provide insights into the ways outlooks often considered to be in opposition can sometimes be complementary. For example, some contraceptive users related that if they became pregnant despite these preventive strategies, they would interpret it as a sign that the pregnancy was meant to happen. Adopting Bell and Hetterly’s framework [1], where agency and fatalism are not regarded as binary outlooks, fatalism can be seen as positive or agentic and corresponds with research suggesting that fatalism can allow some women to make the best of an undesired pregnancy [11]. Contraceptive failure, theoretical and real, was portrayed in a neutral or even positive light as opposed to a product of personal failure.

Research has demonstrated that fatalism plays a role in how women deal with infertility [1], and we suggest that some degree of fatalism informs how women think about their fertility even in the absence of fertility problems. Some of the women we interviewed made reference to the fact that, even when contraception is not used, there is no guarantee that an individual woman will become pregnant. Childbearing is an organizing feature of many women’s lives [12]. Given that women are not expected to have complete control over their ability to get pregnant it is, perhaps, unrealistic to expect them to believe that they have complete control over preventing pregnancy.

We did not find any straightforward patterns between fatalistic outlooks and contraceptive use. It is often assumed that fatalism discourages women from using contraception even if they do not want to become pregnant. By contrast, we found that some women who expressed only fatalistic views towards pregnancy used contraception quite consistently, and most women who reported mixed views were also quite consistent in their use.

Our study has several limitations. Our sample was limited to unmarried young adult women with low or modest incomes living in two metropolitan areas of the United States. Fatalism was not the focus of the study. If we had included a series of questions about fatalism, we might have uncovered even more complex patterns and themes. Finally, our measure of contraceptive consistency was less precise than those used on quantitative surveys.

In sum, when issues of fatalism arise during discussions with patients, nonjudgmental reactions by health care professionals might encourage patients to speak openly regarding their concerns about contraception and their own fertility. Given that women do not have total control over attainment of a wanted pregnancy or even prevention of pregnancy, some amount of fatalism about fertility and one’s ability to control it is a logical and pragmatic response. At a minimum, providers should be aware that many women hold complex views about pregnancy and pregnancy prevention, and they should not assume that expressing a fatalistic outlook means that a particular woman is not, or will not be, a consistent contraceptive user.