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Published in final edited form as: Womens Health Issues. 2018 Aug 22;28(5):408–414. doi: 10.1016/j.whi.2018.07.001

It’s not planned, but is it okay? The acceptability of unplanned pregnancy among young people

Anu Manchikanti Gomez a,*, Stephanie Arteaga a, Natalie Ingraham b, Jennet Arcara a, Elodia Villaseñor a
PMCID: PMC6202114  NIHMSID: NIHMS990009  PMID: 30143419

Abstract

Background:

It is well-established that current measures of pregnancy intentions fail to capture the complexity of couples’ lived experiences and decisions regarding reproductive decision-making. Despite limitations, these measures guide programs, policy, and clinical practice. Here, we describe pregnancy acceptability, which captures whether individuals anticipate considering an unexpected pregnancy welcomed, manageable, or okay.

Methods:

Individual qualitative interviews were conducted with 50 young (ages 18–24) women and their male partners (n=100) to elucidate prospective pregnancy desires and perspectives on pregnancy planning. Using a thematic approach, we analyzed data from a subsample (n=88) of participants who did not currently desire a pregnancy.

Results:

Despite lack of pregnancy desire, 37 participants indicated that a pregnancy would be acceptable. Several themes emerged as reasons for pregnancy acceptability, including feeling prepared for children, relational stability, having knowledge of what it takes to parent, and taking a “whatever happens” approach toward pregnancy planning. Notably, a number of reasons for pregnancy acceptability were also described as reasons for lack of acceptability. For example, while many parents in the sample found pregnancy acceptable owing to their knowledge of the time and resources that raising children required, other parents found pregnancy unacceptable for this same reason.

Conclusions:

Acceptability captures nuances of prospective views on pregnancy and what it means for young people’s lives that current intentions language and framing often neglects. Additionally, acceptability may be a construct that resonates with the perspectives and lives of young people for whom the notion of active pregnancy planning is not salient.

Introduction

Despite recent declines in unintended pregnancy rates in the US, 45% of all pregnancies are still classified as unintended (Finer & Zolna, 2016). The traditional measurement of unintended pregnancy dichotomously and retrospectively classifies pregnancies as intended or not, based on whether the pregnancy was wanted at the time of pregnancy or not at all (Santelli et al., 2003). A growing body of literature suggests that binary classifications of pregnancies as unintended or intended may misclassify women’s intentions and neglect the complexity of pregnancy planning (Borrero et al., 2015; Miller, 2011; Mumford, Sapra, King, Louis, & Buck Louis, 2016; Santelli et al., 2003). Some women have unclear, ambivalent, or indifferent pregnancy intentions, while others clearly do not plan to become pregnant but may welcome an unexpected pregnancy (Borrero et al., 2015; Miller, 2011; Santelli et al., 2003). The conceptualization and measurement of “intention” in unintended pregnancy indicators is often imprecise: for example, unintended pregnancy measures are frequently based on pregnancy wantedness, the timing of pregnancy, and contraceptive use, with no reference to the terms “intention” or “intended.” For example, the questions utilized for the National Survey of Family Growth’s (NSFG) measure of unintended pregnancy never directly ask women if a pregnancy was intended (Mumford et al., 2016). Moreover, there is often a gap between feelings, behavior, and intention, as they are qualitatively different constructs (Bachrach & Morgan, 2013; Jones, 2017; Sable & Libbus, 2000; Santelli, Speizer, Avery, & Kendall, 2006; Zabin, 1999). One analysis of the NSFG used an alternative construction that classified pregnancies as intended when women were not using or stopped using contraception because they wanted to become pregnant, and when women who did not want future pregnancies also reported not minding become pregnant; this alternative measurement approach yielded a prevalence of unintended pregnancy six percentage points lower than the conventional approach (Mumford et al., 2016). Moreover, traditional measures of unintended pregnancy may over-represent low-income women, women of color, and young women, for whom pregnancy planning may be less likely to be a salient or realistic concept (Borrero et al., 2015; Edin & Kefalas, 2005; Jones, Frohwirth, & Blades, 2016; Kendall et al., 2005; Moos, Petersen, Meadows, Melvin, & Spitz, 1997; Zabin, 1999). These problems in conceptualization and operationalization blur the clinical and public health relevance of data on unintended pregnancy, as well as the scope of unintended pregnancy. Nevertheless, reducing unintended pregnancy has been a longstanding public health imperative in the United States, evidenced most recently by its inclusion in the Healthy People 2020 goals (U.S. Department of Health and Human Services, 2010).

Researchers have explored the context of pregnancies that do not explicitly fall into the intended and unintended categories. Some have characterized pregnancy intentions as on a spectrum rather than a binary (Higgins, Popkin, & Santelli, 2012; Schwarz, Lohr, Gold, & Gerbert, 2007; Zabin, 1999). Others have focused on pregnancy ambivalence, which captures conflicting feelings and desires towards pregnancy, though two studies found that women who would typically be categorized as ambivalent because of “incongruent” answers about desire for and happiness about pregnancy were clear about their desires toward pregnancy (Aiken, Dillaway, & Mevs-Korff, 2015; Gómez, Freihart, Arteaga, & Villaseñor, 2017). More recently, scholars have proposed the construct of pregnancy acceptability in response to the chasm between data on pregnancy intentions and women’s lived experiences, including their emotional, financial, relational, and social contexts (Aiken, Borrero, Callegari, & Dehlendorf, 2016; Borrero et al., 2015). The concept of pregnancy acceptability emerged to encompass more complexity towards perceptions of pregnancy than typically allowed for by conventional approaches. For example, some women make postconception decisions about whether a pregnancy is acceptable, regardless of preconception desire; others may not view an unintended pregnancy as a negative event (Aiken et al., 2016; Borrero et al., 2015). In particular, Aiken and colleagues (2016) argue that rather than preemptively labeling pregnancies as unwanted or occurring too soon, equally important is whether women would classify a pregnancy as acceptable or not after it occurs. Indeed, in a qualitative study of low-income African American and white women in Pittsburgh, participants described making postconception assessments of the acceptability, the timing, their preparedness, and their feelings about pregnancy (Borrero et al., 2015). This may have implications for future health outcomes, as maternal and child health outcomes have been shown to differ based on the specifics of timing, wantedness, and feelings about the pregnancy (D’Angelo, Colley Gilbert, Rochat, Santelli, & Herold, 2004; Pulley, Klerman, Tang, & Baker, 2002; Shah et al., 2011).

To date, no work has prospectively examined pregnancy acceptability, which, stemming from prior work on acceptability and our data, we conceptualize as the perception that a pregnancy would be considered welcomed, okay, and/or manageable regardless of whether it is currently wanted or planned (Aiken et al., 2016; Borrero et al., 2015). The present analysis responds to a gap in the literature by describing the ways that pregnancy acceptability is conceptualized in a qualitative study of young women and their male partners.

Methods

We analyzed qualitative data from the Young Couples Study, a mixed methods study that sought to inform the development of new measures of pregnancy intentions. Couples were recruited via Facebook and Craigslist, as well as flyers posted at various community organizations, health clinics, community college, and universities in the San Francisco Bay Area. Interested participants filled out online screening surveys and, if eligible, provided contact information for study staff. To be eligible for the study, the female partner had to select Latina or Hispanic, Black or African-American, Asian, or White as a racial/ethnic identity; be between the ages of 18 and 24; not be pregnant or actively trying to become pregnant; and be able to identify a primary male partner age 18 or older with whom she was sexually active and had been in a relationship with for at least two months. We used a purposive sampling approach, ensuring racial and ethnic diversity in the sample, as well as inclusion of parents and young people who were not students. Trained interviewers conducted separate, simultaneous, in-depth qualitative interviews with 50 young women and their male partners (n=100) in 2015–16. Interviews were conducted in person and averaged 77 minutes in length. Prior to the interviews, participants completed brief surveys to assess demographic characteristics, contraception history, and pregnancy intentions. Upon completing the interview, each partner received an incentive of $30. Using a semi-structured interview guide, we explored participants’ relationship histories, pregnancy and contraceptive experiences, and current and future pregnancy intentions. Pregnancy intentions were elicited by asking participants to describe if they would like to become pregnant in the future, if they had talked to their partner about pregnancy, when the ideal time to become pregnant would be, and if their pregnancy plans factored into their contraceptive decision-making. Lastly, participants were asked how they would feel if they unexpectedly found out they were pregnant today, which evoked the construct of pregnancy acceptability. Participants were not explicitly asked how they would resolve a pregnancy, though many spontaneously described this in their interviews. The Committee for Protection of Human Subjects at the University of California, Berkeley approved the study protocol.

Interviews were digitally recorded and transcribed verbatim. To inform measure development, we qualitatively analyzed participants’ descriptions of their current pregnancy intentions and desires. During the measure development process, we observed that many participants described how an unexpected pregnancy would be acceptable even if they did not currently desire a pregnancy. These initial observations informed our full coding and analysis process for this paper.

To guide our analysis, we used the “Sort and Sift, Think and Shift” method, in which we initially created extensive analytic memos of each transcript to capture important emergent themes (Maietta, 2006). These analytic memos informed the iterative development of a codebook, which was finalized after all memos were completed and reviewed by team members. We then performed the first cycle of coding utilizing a “lumping” approach, in which larger excerpts of text were coded to capture the overall topics and ideas identified during the memo writing process (Saldana, 2016). Transcripts were coded using Dedoose, a web-based software. For this analysis, we focused on codes regarding individual and partner desires for pregnancy and acceptability of an unexpected pregnancy.

After completion of initial coding, two members of the research team independently performed a second cycle of coding to classify half of the participants according to both pregnancy desire and acceptability. Participant classifications were compared until coding agreement was reached (85% original matching codes before convergence). Pregnancy desire referenced the extent to which participants wanted or did not want to become pregnant. Participants were classified as having some degree of acceptability if they used expressions like “okay,” “acceptable,” “not life ending,” and “wouldn’t mind” when discussing how they would feel if they were unexpectedly pregnant today, even if they also discussed not wanting or actively planning a pregnancy. This reflects prior conceptualizations of pregnancy acceptability as distinct from pregnancy planning status (Aiken et al., 2016; Borrero et al., 2015). Acceptability classifications occurred independently of pregnancy desire or how a participant hypothesized they would resolve an unexpected pregnancy; for example, owing to their feelings about abortion, a few participants who would find a pregnancy unacceptable expected to parent. While participants described multiple considerations when discussing how they would feel if pregnant today, no participants felt that a pregnancy would be both acceptable and unacceptable. As we sought to understand how the concept of pregnancy acceptability shed light on perceptions of unintended pregnancies, participants who currently desired a pregnancy and would find a pregnancy acceptable (n=7, including those who were trying to become pregnant1) and participants who desired a pregnancy and would find it unacceptable (n=1) were excluded from this analysis. Additionally, we excluded four more participants whose pregnancy desire and/or acceptability was unclear from their interviews. Thus, the final analysis included 88 participants. In the results, we describe pregnancy acceptability among our sample, followed by four major themes that described influences on pregnancy acceptability or lack thereof.

Results

The average participant age was 22.4 years (SD = 2.8) (Table 1). Participants were racially diverse owing to the purposive sampling approach. Most participants (n=63) had been in a relationship with their partner for at least a year, and 34 were parents. For more than half of the subsample (n=51), a pregnancy was currently neither desired nor acceptable, while 37 participants would find a pregnancy acceptable despite not desiring a pregnancy.

Table 1:

Demographic characteristics of study participants

Characteristic Total subsample (n=88) Pregnancy not acceptable (n=51) Pregnancy acceptable (n=37)
Mean age (SD), years 22.4 (2.7) 21.9 (2.5) 23.0 (2.9)
n (%) n (%) n (%)
Gender
 Female 46 (52.3) 27 (52.9) 19 (51.4)
 Male 42 (47.7) 24 (47.1) 18 (48.7)
Race/ethnicity1
 Latino 45 (51.1) 24 (47.1) 21 (56.8)
 Black 16 (18.2) 6 (11.8) 10 (27.0)
 Asian/Pacific Islander 16 (18.2) 13 (25.5) 3 (8.1)
 Native American 3 (3.4) --- 3 (8.1)
 White 32 (36.4) 15 (29.4) 17 (46.0)
 Two or more races 20 (22.7) 8 (15.7) 12 (32.4)
Educational attainment
 Less than high school 3 (3.4) 3 (5.9) ---
 High school 14 (15.9) 9 (17.7) 5 (13.5)
 Vocational or technical school, associate’s degree 6 (6.8) 3 (5.9) 3 (8.1)
 Some college 41 (46.6) 20 (39.2) 21 (56.8)
 College degree 24 (27.3) 16 (31.4) 8 (21.6)
Currently a student 50 (56.8) 29 (56.9) 21 (56.8)
Parent 34 (38.6) 10 (19.6) 24 (64.9)
In a relationship for more than one year 63 (71.6) 34 (66.7) 29 (78.4)
Married or cohabiting 25 (28.4) 7 (13.7) 18 (48.7)
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(1)

Note:Participants could report identifying with multiple racial and ethnic groups, thus the sum of all categories exceeds 100%.

Participants described pregnancy acceptability and lack thereof in many ways, depending on how they felt an unexpected pregnancy would impact their lives. Feelings of acceptability were commonly expressed through phrases such as “it would be okay” or “it wouldn’t be the end of the world.” Notably, while 37 participants described some level of acceptability of pregnancy, there was diversity within the group with regards to how acceptability manifested and the degree to which a pregnancy would be acceptable. Assessments of acceptability were often made independent of or despite one’s lack of desire for pregnancy.

“I mean, I don’t want her to get pregnant right now, but if she did I’d be okay with it because I like children and I want kids…Like I want kids in my life, you know, in the future, but I don’t want to have them right this second. So it’s like if she was to get pregnant, I’d be okay with it, but I really hope she don’t.”

−23-year-old Black man

Like these participants, others in our sample considered many factors, including finances, desire for children, and relationship quality when deciding whether a pregnancy would be acceptable. Notably, more parents and couples who were living together or had been together for over a year would find a pregnancy acceptable than participants who were not parents, were not living together, or had a shorter relationship length. Conversely, those who were currently full-time students or who reported shorter (<1 year) or more casual relationships (not living together or married) more often described an unexpected pregnancy as being unacceptable. We did not find that pregnancy acceptability differed by overall desire to become pregnant in the future or by desired pregnancy timing.

In the following sections, we present the major themes influencing acceptability (and lack thereof) of an unexpected pregnancy. Results are not presented by race/ethnicity, as few differences were noted among the different groups.

Perceived “readiness”: Meeting milestones

Several participants (n=15) described feeling ready for children, making a pregnancy acceptable. They described readiness in terms of both age and structural factors such as financial security or employment status. With regards to age-related preparedness, transitions from adolescence to young adulthood coincided with reaching specific milestones, such as graduating from high school or college, and signified that participants were “old enough” for children. For example, one participant described feeling relief at having moved past the perceived enormous negative social consequences of teen childbearing and how her new stage of life influenced how she would feel about an unexpected pregnancy.

“I feel like I’ve reached a stage where if I did happen to get pregnant, it wouldn’t be like a whole life-ending situation. If I got pregnant in high school, I probably would have been completely devastated and been like, ‘Oh my God! My life is over!’”

−21-year-old mixed race woman

For this participant, the acceptability of an unexpected pregnancy was largely based on her age, and the decreased social stigma placed on those who choose to parent later in life compared to teen parents.

Other participants described “readiness” in terms of stability in other domains, such as employment or income. Again, while “now” was not an ideal time for a pregnancy—many participants mentioned wanting to own a home or increase their incomes before having children—some participants would find a pregnancy acceptable under their current structural conditions.

“I think that we are comfortable enough in our finances and, you know, our careers to be able to do that. I mean, it’s not something that we look forward to at the moment because my husband wants to get out of the military and whatnot.”

−23-year-old White woman

Participants who would find a pregnancy unacceptable owing to a lack of readiness (n=40) described not yet meeting these key life milestones. This was especially true for couples where one or both partners were still in college.

“But also, I don’t feel like we’re ready to have another child right now. So even though (partner) would like to have another kid, as much as we would like to, so she could have a brother or a little sister, I just, I feel like the best thing to do would just be to wait until we finish with our school, and we actually have our careers going.”

−22-year-old mixed race man

The experience of parenting while in school influenced this participant’s feelings toward unintended pregnancy in two important ways: his lack of financial preparedness before having a child, as well as the struggles of juggling school and parenting, made a pregnancy unacceptable for his life until he had graduated from college and started his career. Likewise, other participants who would not find a pregnancy acceptable expected to postpone pregnancy until after they finished their schooling.

A number of participants (n=13) mentioned wanting to be “financially independent” before having their first child or additional children, pointing to lack of income as undergirding their feelings of being unprepared. These participants often still lived with their parents, were currently in school and dependent on financial aid, or had low-wage jobs. One participant described how the financial burden of becoming a parent and her “poverty-level” wages made a pregnancy unacceptable for her life at this time.

“So I’m basically living like paycheck to paycheck, so I have to budget really well. And if I had a kid, like that would be kind of impossible.”

−24-year-old Asian woman

Other participants also cited the lack of income to support a child as the main reason they would find a pregnancy at this time unacceptable. Many of these participants had clear notions of the type of jobs and income level they would need before they would consider accepting and continuing a pregnancy. Some future milestones, such as home ownership, felt out-of-reach for most participants in the increasingly expensive San Francisco Bay Area, so they focused on pursuing educational and career goals before or in lieu of having (more) children.

Relational stability and dynamics

Being in a stable and happy relationship inspired confidence that participants could successfully co-parent with their partner, even if they personally felt unprepared for a pregnancy for other reasons (n=10). Some saw a child as the ultimate symbol of love, making a pregnancy more acceptable in their eyes. More men than women noted partner-related reasons underlying acceptability.

“Because it would be with her, so I wouldn’t feel dreaded that I got some person pregnant that I really don’t want having my child or being the mother of my child or even think that I would spend my life with this person. So as far as her having my child, that’s a hundred percent acceptable, but in my current situation in life, I’m not ready for a child.”

−29-year-old mixed race man

Financial issues were the primary reason this participant wanted to postpone pregnancy. However, his love for his partner and perception they could co-parent well would lead him to find a pregnancy acceptable.

Conversely, a few participants would find a pregnancy unacceptable owing to relational dynamics, such as uncertainty about the longevity or stability of their relationship, or low relationship quality. For participants in less serious relationships, lack of pregnancy acceptability was connected to the lack of longevity of the partnership; some participants expressed that since they could not see themselves marrying their partner, they certainly did not want to have children with them. Low relationship quality and instability made it too stressful and unstable for some in more long-term relationships to consider a pregnancy acceptable with their current partner.

Knowledge of what it takes to parent

The knowledge of what it takes to parent, acquired from parenting experience, working with children, or spending time with family members’ children, led some participants (n=14) to feel that they “could handle” a(nother) child. Unlike readiness to parent, participants in this category cited having the knowledge or skills to parent as their reason for pregnancy acceptability, despite their age or home or financial situation. For some women in particular, this included positive experiences with previous pregnancies.

“Because I’ve done it before so like I already know what it’s going to be like. And I kinda like, I guess I can rearrange my plans to fit the next baby, so I wouldn’t mind.”

−23-year-old Latina woman

“I think because I know what that experience is like with (partner) to have a baby together and like have moments of being excited and being happy, like this is a little person.”

−22-year-old White woman

For these women, a pregnancy would be acceptable, in part, because they have an understanding of “what it takes” to parent and raise children, including the day-to-day time, tasks, and money involved, as well as the expected benefits of parenting. This acceptability was often despite the additional financial limitations that a(nother) child would bring into their lives.

Conversely, five participants considered their current parenting knowledge a factor in the unacceptability of pregnancy. Four of these participants connected their knowledge of the intense challenges of parenting and the financial limitations they faced as reasons why a pregnancy would be unacceptable, while the fifth acknowledged she was not emotionally or physically prepared for another pregnancy. For example, one participant described how her financial situation and feelings about abortion were major incentives for her to avoid pregnancy at this time, as another child would be unacceptable for her.

“… I would either force myself to get an abortion or force myself into having another kid. So I’d rather just prevent it all because I wouldn’t get an abortion. But I can’t have another kid, and I know that I can’t have another kid. I can’t afford it.”

−23-year-old mixed race woman

While all the parents in the sample acknowledged the challenges of parenting, participants for whom pregnancy was currently unacceptable saw adding another child as a challenge they were not ready or willing to take on in addition to their current parenting responsibilities.

“Whatever happens, happens”: (lack of) agency over pregnancy

Among some participants who would find an unexpected pregnancy acceptable, a salient factor was fatalism—that is, the belief pregnancies are largely out of one’s control. These participants (n=12) felt that pregnancies “happen for a reason” and would therefore find an unexpected pregnancy acceptable, despite less than ideal timing. Participants who employed the “whatever happens” approach to pregnancy fell into a few groups: those who felt a general lack of control in their lives, had strong religious beliefs, or had medical conditions that made fertility feel out of their control.

For some participants, unforeseen life events, including loss of loved ones, previous unintended pregnancies, or sudden loss of housing or a job, led to a general feeling of lack of control over their lives. Accordingly, these individuals described growing accustomed to adapting to life events when they happen, regardless of whether it is the “right” time or not.

“It’s like it might not have been the right time for me, what I thought was not the right time for me, but if I got pregnant, that’s basically like, it’s just how things go. It’s just like, well, everything happens for a reason.”

−21-year-old Latina woman

While this participant was not sure if she wanted to have more children, her past experience of getting pregnant while using contraception influenced how much control she expected to have over her fertility, as well as her belief that “everything happens for a reason.” If she were to get pregnant, she indicated that she would gladly accept the pregnancy and parent another child.

Under this theme, religious participants viewed an unexpected pregnancy as something controlled or gifted to them by God and, consequently, something that must be incorporated into their lives.

“Well, like we’re Christian, so we believe in God. And if God decides like they’re gonna have a baby, there’s nothing really that can stop it.”

−24-year-old Asian man

These participants viewed an unexpected pregnancy as “meant to be” and generally would not consider abortion as an option, also owing to their religious beliefs.

For a minority of female participants and one male participant, feelings of lack of control over pregnancy were grounded in perceptions of infertility. The expectation that becoming pregnant would be difficult often meant that these participants would welcome a pregnancy, even if it was not desired at the time. For example, one participant explained how her contraception choices have been impacted by polycystic ovarian syndrome, which can decrease fertility (Norman, Dewailly, Legro, & Hickey, 2007):

“I was a lot less quick to use it [contraception]. Because I felt like, if this is my chance, I don’t want to trap it in a condom. You know, like if this is going to be it, that this is like that magic number, you know, like whatever, it takes 50 sex times to get a baby.”

−23-year-old White woman

This participant reflected the experiences of a few female participants who portrayed how they would accept a pregnancy or even the risk of a pregnancy, through their avoidance of contraception; they felt that pregnancy was out of reach owing to their expected fertility challenges. Pregnancy acceptability in this case is explained as welcoming “whatever” happens despite timing because they felt this might be their only chance to become pregnant.

Discussion

Among 88 young women and men who did not currently desire a pregnancy, we find a broad range of expectations about and perspectives on unexpected pregnancy. Despite their current lack of desire for pregnancy, two-fifths of this subsample would find an unexpected pregnancy acceptable. Importantly, participants who did not desire pregnancy would find a pregnancy unacceptable for a host of reasons—sometimes for the same reasons that others cited when describing the acceptability of pregnancy. Salient influences included perceived readiness based on meeting milestones for adulthood, relationship quality, desire for children, knowledge of parenting realities, and fatalism. The nuances of pregnancy perceptions revealed in this analysis are largely missed by current approaches to measuring unintended pregnancy and reinforce previous calls for more holistic and precise measurement in this area (Aiken et al., 2016; Callegari, Aiken, Dehlendorf, Cason, & Borrero, 2017; Klerman, 2000; Mumford et al., 2016; Santelli et al., 2003).

Pregnancy acceptability may be a construct that resonates with young people for whom the notion of active pregnancy planning is not salient. This is particularly true in emerging adulthood, when barriers to pregnancy preparedness and the stigma of young parenthood may make it less likely that an individual will consider a pregnancy intended—even if a pregnancy would be seen as positive or welcomed, or deemed wanted after it occurs. Traditional constructs of pregnancy planning are liable to completely bypass these perspectives; thus, programs and clinical practices that rely on these constructs risk neglecting the needs of individuals who hold them. Similarly, our ability to affect the externalities influencing pregnancy acceptability vary: While relationship quality, intimate knowledge of what it takes to parent, and fatalism are individual and experiential, and will always vary in a population, structural realities (e.g., access to employment, education, or capital) can be more clearly targeted by public policy. Thus, we find the “readiness” theme in our results ripe for further research, highlighting the need for policies supporting young people as they enter adulthood and contemplate pregnancy and parenting.

The context of current fertility trends and structural realities influencing decision-making about fertility among young people in the U.S. may play an outsize role in our results related to perceived readiness for parenting. For the first time, women in their early 30s have a higher birth rate than women in their 20s (Hamilton, Martin, Osterman, Driscoll, & Rossen, 2017). While these fertility trends are undoubtedly influenced by improved access to contraception, the Great Recession particularly depressed fertility in women just starting their childbearing years (Schneider, 2015). In the presence of increased structural constraints and economic uncertainty, traditional milestones of young adulthood may occur later, or not at all: difficulty obtaining and maintaining employment during economic downturns may result in the postponement of marriage, boomeranging back to parents’ homes, and delays in home purchasing, among other economic realities and difficulties (Schneider, 2015). In our study, a number of participants expressly mentioned housing (unaffordability, having to live with parents or roommates, substandard housing quality) as a reason for unacceptability of pregnancy. However, while the impact of structural concerns on pregnancy acceptability may be stronger among our study participants owing to the high cost of housing of the San Francisco Bay Area, the overall themes do reflect the broader reality of young adults’ inability to realize the larger economic conditions to enable childbearing seen in research addressing recent economic and fertility trends (Schneider, 2015). This reality may give way to a disconnect between pregnancy desires and what young people can realistically “intend” or “plan for,” and underscores our findings on acceptability, as current economic contexts may make it difficult to actualize these desires.

This study is among the first to examine prospective pregnancy acceptability and is particularly unique in its inclusion of young couples. Strengths include the large sample of racially and ethnically diverse young people, and an analytic approach yielding insights regarding pregnancy expectations outside the traditional constructs. Notably, considering pregnancy desire and acceptability together allowed us to more clearly understand participants’ contraceptive needs, as several participants voiced different levels of pregnancy desire and acceptability, which was sometimes reflected in their (lack of) use of contraception. Limitations include geographic focus, as the study only included participants in Northern California. While the results of this study are not generalizable owing to qualitative study design, they do offer unique insights into decision-making for young adults around pregnancy planning and prevention.

Implications for Practice and Policy

In November 2016, the National Quality Forum endorsed measures to monitor the quality of family planning care (Office of Population Affairs & U.S. Department of Health and Human Services, 2017). Two of these measures include as their denominator the population of women at risk of unintended pregnancy, defined as “those who have ever had sex, are fecund and neither pregnant nor seeking pregnancy” (Gavin, Frederiksen, Robbins, Pazol, & Moskosky, 2017; Office of Population Affairs & U.S. Department of Health and Human Services, 2017). By this definition, all women in our subsample were “at risk of unintended pregnancy,” yet the range of pregnancy desires and acceptability in their narratives makes clear that this group is far from monolithic. Some may feel they cannot or are not allowed to verbalize their true desires, owing to societal norms around appropriate childbearing age, reaching normative milestones of adulthood, fertility difficulties, or for other reasons. Contraceptive needs likely vary based on these contexts—individuals may not actually be in need of contraception, may be looking for shorter-term methods, or may be disinclined to regularly use contraception. Thus, use of data on unintended pregnancy to measure quality in family planning care or for informing public health goals such as Healthy People 2020 is precarious, given that these data rely on subjective classifications of pregnancy (U.S. Department of Health and Human Services, 2010). When women are not “trying” to become pregnant, public health programs and healthcare providers may assume that clients are in need of contraception, neglecting that some might find an unexpected pregnancy acceptable or desirable, and may only or additionally need preconception care. In order to more effectively provide services to all young people, research and practice should work from a holistic, multidimensional understanding of pregnancy perspectives. Adding a focus on constructs such as acceptability that capture perceptions of unexpected pregnancy with more gradation than the dichotomous intended/unintended framework—and doing so with the language that young people use to describe their lived experiences—will provide a more complex perspective on individuals’ intentions and can better highlight their family planning needs and the barriers to achieving them.

Acknowledgements

Research reported in this publication was supported by the Berkeley Population Center and the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Award Numbers R00HD070874, R24HD073964). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors extend their thanks to Research Staff Miguel Alcala, Bridget Freihart, Elizabeth Gonzales, Marlene Meza, Kylie Mulvaney, Josué Meléndez Rodriguez, and Bill Stewart for their work interviewing participants and supporting data analysis. The authors gratefully acknowledge Krystale Littlejohn, Zakiya Luna, and LaKisha Simmons for providing feedback on this manuscript. Anu Manchikanti Gomez had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Biographies

Anu Manchikanti Gomez, PhD, MSc is Assistant Professor and Director of the Sexual Health and Reproductive Equity (SHARE) Program in the School of Social Welfare at the University of California, Berkeley. A health equity researcher, her scholarship advances the understanding and promotion of sexual and reproductive health equity throughout the life course, emphasizing social, relational and structural determinants of health among racial, ethnic and sexual minorities and youth in the US.

Stephanie Arteaga, MPH, is a Research Associate with the SHARE Program at the University of California, Berkeley. Her research interests are health disparities in sexual and reproductive health, especially among young Latina women.

Natalie Ingraham, PhD, MPH, is Assistant Professor of Sociology at California State University, East Bay and was formerly a Research Associate with the SHARE program at the University of California, Berkeley. Her research focuses on intersections of body size, gender, sexuality, and health from a sociological perspective.

Jennet Arcara, MPH, MPP is a Research Associate with the SHARE Program at the University of California, Berkeley and a PhD candidate at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. Her research focuses on the roles of gender, autonomy, and power in reproductive health in domestic and international contexts.

Elodia Villaseñor, MPH, was formerly Project Director with the SHARE Program at the University of California, Berkeley. Her research focuses on sexual and reproductive health equity and investigating the strength, knowledge, and power of youth and advocates.

Footnotes

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Notably, individuals who indicated they were trying to become pregnant at the time of screening were ineligible for the study; though they were eligible for the study based on their response to screening questions, a few participants indicated they were currently trying to become pregnant during their interviews.

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