Continuation of Unintended Pregnancy

Abstract

Background:

Forty-four percent of all pregnancies worldwide are unintended. Induced abortion has drawn a lot of attention from clinicians and policy makers, and the care for women requesting it has been covered in many publications. However, abortion challenges the values of many women, is associated with negative emotions, and has its own medical complications. Women have the right to discuss their unintended pregnancy with a clinician and receive elaborate information about other options to deal with it. Continuing an unintended pregnancy, and receiving the necessary care and support for it, is also a reproductive right of women. However, the provision of medical information and support required for the continuation of an unintended pregnancy has hardly been approached in the medical literature.

Objective:

This review presents a clinical approach to unintentionally pregnant patients and describes the information and support that can be offered for the continuation of the unintended pregnancy.

Discussion:

Clinicians should approach patients with an unintended pregnancy with a sympathetic tone in order to provide the most support and present the most complete options. A complete clinical history can help frame the problem and identify concerns related to the pregnancy. Any underlying medical or obstetric problems can be discussed. A social history, that includes the personal support from the patient’s partner, parents, and siblings, can be taken. Doctors should also be alert of possible cases of violence from the partner or child abuse in adolescent patients. Finally, the clinician can provide the first information regarding the social care available and refer the patients for further support. For women who continue an unintended pregnancy, clinicians should start antenatal care immediately.

Conclusion:

Unintentionally pregnant women deserve a supportive and complete response from their clinicians, who should inform about, and sometimes activate, all the resources available for the continuation of unintended pregnancy.

Summary

Forty-four percent of all pregnancies worldwide are unintended. Induced abortion has drawn a lot of attention and the care for women requesting it has been covered in many publications. However, abortion challenges the values of many women, is associated with negative emotions, and has its own medical complications. Women have the right to discuss their unintended pregnancy with a clinician and receive elaborate information about other options to deal with it. Continuing an unintended pregnancy, and receiving the necessary care and support for it, is also a reproductive right of women. However, the provision of medical information and support required for the continuation of an unintended pregnancy has hardly been approached in the medical literature. This review presents a clinical approach to unintentionally pregnant patients and describes the information and support that can be offered for the continuation of the unintended pregnancy. Clinicians should approach patients with an unintended pregnancy with a sympathetic tone. A complete clinical history can help frame the problem and identify concerns related to the pregnancy. Any underlying medical or obstetric problems can be discussed. A social history, that includes the personal support from the patient's partner, parents, and siblings, can be taken. Doctors should also be alert of possible cases of violence from the partner or child abuse in adolescent patients. Finally, the clinician can provide the first information regarding the social care available and refer the patients for further support. For women who continue an unintended pregnancy, clinicians should start antenatal care immediately.

Background

Unintended pregnancies include those that are unwanted, unplanned, or mistimed (Moss 2015). It has been estimated that 44 percent of all pregnancies worldwide are unintended, around 56 percent of them end up in abortion, approximately 32 percent in birth, and 12 percent in miscarriage (Bearak et al. 2018; The Lancet 2018; Sedgh, Singh, and Hussain 2014). Evidence also suggests that in the last three decades, the proportion of unintended pregnancies ending in abortion has increased in developing regions but decreased in developed areas of the world (Bearak et al. 2018). These women are in a difficult situation and deserve their primary care provider to offer comprehensive support in an open-minded, positive, and detailed way. These patients require information, and sometimes activation, of all the resources available for the continuation of unintended pregnancy.

Many women report both negative and positive feelings about getting pregnant unintentionally (Arteaga, Caton, and Gomez 2019; Askelson et al. 2015; Tanner et al. 2013). Studies also indicate that some women, who hold negative views toward having become pregnant unintentionally but have the child, after the delivery express a positive opinion on the pregnancy (Williams et al. 2001; Joyce, Kaestner, and Korenman 2000; Sedgh, Singh, and Hussain 2014).

A substantial proportion of women have not decided whether or not they want to continue their unintended pregnancy when they first visit their primary care provider (Moss 2015). Induced abortion is legal in most countries, with regional variations of the law in places like Australia, the United States, or the UK (Centre for Reproductive Rights 2018). Abortion has been given a great deal of attention by clinicians and policy makers, and the legal framework, together with the medical, psychological, and social care, for women requesting it has been covered in many publications (National Health and Medical Research Council 2013; The American College of Obstetricians and Gynaecologists 2014; Royal College of Obstetricians and Gynaecologists 2011). However, induced abortion challenges the social, cultural, and ethical values of many women and those around them and some of the physicians who care for them (Moss 2015). It is also associated with negative emotions, including feelings of grief, regret, guilt, or emptiness (Lie, Robson, and May 2008). Finally, induced abortion is associated with an increased risk of some medical problems including obstetric hemorrhages and infections, alcohol or drugs misuse, and suicidal behavior (The Royal College of Obstetricians and Gynaecologists 2011; Fergusson, Horwood, and Boden 2013).

Women have the right to discuss their unintended pregnancy with their primary care provider and receive detailed, complete, and accurate information about other options to deal with pregnancy (Moss 2015).

Continuing an unintended pregnancy, and receiving the necessary care and support for it, is a reproductive right of women, and the role of primary care clinicians is essential to make sure that this right can be exercised. Evidence shows that women who receive more support are more likely to continue their pregnancy (Lie, Robson, and May 2008; González 2013). Despite all this, the provision of medical information and support required for the continuation of unintended pregnancy has hardly been approached in the medical literature and tends to be poor and unstructured in primary care settings. Unintentionally pregnant women are in a vulnerable situation and deserve an open-minded, supportive, and positive response from primary care clinicians, who should inform about, and sometimes leverage, all the resources available for the continuation of unintended pregnancy.

In this review, we present a clinical approach to unintentionally pregnant patients and describe the information and support that can be offered in primary care for the continuation of an unintended pregnancy.

Framing the Problem

An empathic clinical relationship is ideal for this sort of discussion. Clinicians must appreciate that unintended pregnancy increases women’s vulnerability and causes stress and anxiety (Moss 2015). If the patient is ambiguous about the pregnancy, it may help to continue a clinical interview, as in routine pregnancy care (Moss 2015). This can be clarifying for the patient, who may find in the conversation with the clinician reassurance and support for her uncertainties. The doctor or nurse may ideally communicate in a supportive way, making sure that all their concerns are addressed. The patient’s capability for abstract and future thinking needs to be assessed, especially in the case of adolescents (Hornberger 2017). The clinicians may also need to deal with some difficulties in communication due to the patient’s educational level, which can also be associated with unintended pregnancy, or address poor language skills, particularly in the case of migrant women who may not be native speakers of the local language (Wellings et al. 2013).

Although women don’t expect the doctor to give moral advice, the spiritual and cultural practices of patients have to be acknowledged (Hornberger 2017). Noting how the patient relates to the fetus can help at this point, the language used to describe it may reflect the closeness that the woman feels toward the life growing in her body (Lie, Robson, and May 2008).

A complete reproductive and clinical history helps frame the problem, identifies the medical concerns related to the pregnancy, and also builds an empathic relationship with the patient. As with patients whose pregnancy was planned, the pregnancy should be confirmed and gestational age estimated (Moss, Snyder, and Lu 2015). Any possible complications of the pregnancy should also be recorded. Taking a reproductive history would also help to define the clinical background of the patient. Finally, the clinical history would include details on medical problems, such as hypertension, diabetes, or mental illness, as well as medication, alcohol, or recreational drugs taken by the patient.

The risk of continuation of pregnancy to the mother’s health is the most frequently cited reason to have an abortion, that is, 97 percent of cases in the UK (The Royal College of Obstetricians and Gynaecologists 2011). It should be noted that maternal health has improved in recent decades, with maternal mortality falling by approximately 44 percent over the past twenty-five years worldwide, affecting now less the twenty women per 100,000 live births in most high- and middle-income countries (World Health Organization 2015). The risks of all underlying medical problems or any obstetric complications can be discussed with the patient at this point. Clinicians may also want to make patients aware that many medical problems, including diabetes, asthma, thyroid disorders, and depression, can be managed successfully during pregnancy, using conventional or alternative treatments (National Institute of Health and Care and Excellence 2017; Australian Government Department of Health 2018; Zolotor and Carlough 2014).

Social History

A social history, including marital or partner status, employment, financial stability, and presence of any other social problems, for example, housing, legal, or migration issues, is useful. It has been reported that unintended pregnancy is associated with drug use and with lower socioeconomic level (Wellings et al. 2013; Iseyemi et al. 2017). In most countries, whether or not to continue a pregnancy is the woman’s choice only, with the father of the child having no right to affect the decision (Center for Reproductive Rights 2018). However, women who are supported by a partner are more likely to accept and continue their unintended pregnancy and have lower levels of psychological distress after birth (Lie, Robson, and May 2008; Barton et al. 2017; Gomez et al. 2018). This source of support can be explored by simply asking, “Is your partner aware of the pregnancy?” “What does he think about it?” “What is your relationship with him?” or “Do you have any other children in common or separately?”

The support from other people, such as the patient’s parents, siblings, or friends, can also be important (Moss, Snyder, and Lu 2015). Asking questions around who knows about the pregnancy and whom the patient is going to tell can help to identify these supportive figures and suggest their involvement (Moss 2015). In our experience, the pressure of unintended pregnancy can lead women to make an ineffective use of their own family or social network. Adolescent patients may find it difficult to tell their families about the pregnancy and underestimate the support they can offer (Rentschler 2003; Lloyd 2004). However, the clinician can help to relieve this pressure and unlock the communication with close and supportive relatives and friends by openly discussing the potential support that the patient may have from them.

In patients who report a lack of personal support, doctors should also be alert of possible coercion that could lead the woman toward an unwanted abortion (Moss 2015; Broen et al. 2005). Two systematic reviews have reported associations of intimate partner violence with requests for abortion, especially repeated abortion, and with higher risk of preterm birth and low birth weight (Hall et al. 2014; Hill et al. 2016). Therefore, questions about exposure to violence from partner should also be standard (Moss 2015; The Royal College of Obstetricians and Gynaecologists 2011). While the evidence on the effectiveness of interventions to reduce violence from the partner during the pregnancy is still inconclusive, it is likely that interventions conducted by multidisciplinary teams, involving the social services and justice institutions, initiated by the clinician at this point, might result in violence being interrupted, a reduction in abortion requests, and better birth outcomes (Jahanfar, Howard, and Medley 2014).

Clinicians must be alert to the possibility of child abuse in adolescent patients, especially when they refuse to involve their parents or when they are accompanied by a controlling adult who wishes to remain particularly close to the patient. Laws regulating clinical care of underage patients, the minor’s and their parents’ rights and responsibilities, vary between and within countries. However, it is widely accepted that doctors and nurses have to acknowledge the opinions of underage patients when planning their clinical management (General Medical Council 2007; American Academy of Pediatrics 1995). The ethical obligations of beneficence may require that clinicians provide medical care for underage women with unintended pregnancy, sometimes without parental knowledge (General Medical Council 2007; Torralba i Rosello 2001). In some cases, the parental intervention may be negative or unnecessary, such as for underage women abused by their parents, emancipated, or considered legally mature (General Medical Council 2007). Clinicians have to be familiar with the laws that apply in their area of practice and locale. In any case, adolescents should be asked very carefully about their parents, who can be a strong source of support (Moss 2015).

The age of consent and the legal age at which an individual is considered mature enough to consent to sex varies between, and sometimes within, countries. Therefore, a girl who is pregnant and under the age of consent has suffered a statutory rape, even if both partners are younger than the age of consent in some jurisdictions. In this case, the appropriate authorities must be informed (Ageofconsent.net 2018).

Many women with unintended pregnancies express concerns on social issues around pregnancy and childcare (Askelson et al. 2015). The role of the partner, the relationship, the rights, and the obligations that he has toward the education of the child can be discussed, acknowledging the local regulations, with which clinicians may need to be familiar.

The doctor or nurse can also provide the first information on the social care available in the area and refer the patients to the social services for further support (Moss, Snyder, and Lu 2015). In many countries, employment of pregnant women and maternity pay have legal protection, there is financial support for people with children, and both education and health care receive public funding (GOV.UK n.d.; Department of Human Services of the Australian Government 2018; USA.GOV 2018). For women who feel unable to look after a child, family and friends care (kinship care), private or public-assistance fostering, or adoption can be an option. However, all policies around childcare are complex and require assessment beyond primary care clinics.

Follow-up and Antenatal Care

Some patients may prefer to address their unintended pregnancy in a single appointment of average duration, requiring that the clinician moves quickly through these complex topics. Other patients may prefer to be seen over more than one appointment. The latter would help to build rapport, allow time for patient reflection, and for the clinician to arrange resources to meet her needs between visits. Written, objective, evidence-guided information on the medical and social support available for the continuation of unintended pregnancy can also be provided.

Three systematic reviews have reported that unintended pregnancy is associated with late initiation and inadequate use of antenatal care services, preterm birth, low birth weight, and higher risk of perinatal depression (Dibaba, Fantahun, and Hindin 2013; Shah et al. 2011; Abajobir et al. 2016). These results may be affected by methodological limitations and confounders such as women’s socioeconomic status or previous health issues. However, this evidence seems enough to recommend that for women who continue an unintended pregnancy, clinicians start antenatal care immediately and are proactive in the follow-up, to prevent adverse maternal and perinatal outcomes (The Royal College of Obstetricians and Gynaecologists 2011; National Health and Medical Research Council 2013; Dibaba, Fantahun, and Hindin 2013).

Future Research

To improve the care for women to continue an unintended pregnancy, further clinical, social, and legal research and development is needed. More studies of good quality on the long-term clinical and social outcomes, experiences, and needs of women who continue unintended pregnancies are required. This should help to develop effective interventions to support unintentionally pregnant women in a variety circumstances. The male partners of unintentionally pregnant women are frequently cited in the literature mostly as negative characters, related to abuse, irresponsibility, and abandonment. Studies on the views of partners would improve the understanding of women’s social network and could be used to understand the support they need. Similarly, the role of parents and siblings of women with unintended pregnancy, that may constitute a substantial source of support, requires further research. The liberalization of abortion laws should not stop medical research to make the continuation of medically or socially complicated pregnancy safer.

The continuation of unintended pregnancy of underage women, those who have been raped, illegal migrants, or those exposed to violence needs specific research. Studies on all these topics, based on developing countries, are specially required as this part of the world has the highest incidence of unintended pregnancies and its management, given the social circumstances, can be very different from the one in developed areas (Bearak et al. 2018). This article addresses an international audience. However, future reviews should ideally be written locally, acknowledging each country or area, cultural values, social resources, and regulations.

Biographical Notes

Luis Ayerbe is a family physician. He qualified in Madrid (Spain) in 1998 and finished his primary care training in 2003. Since 2004, he has been practicing in the UK. He combines clinical work with research and teaching. He has worked in King’s College London and Queen Mary University of London and has recently started in a new position in the University of Cambridge.

María Pérez-Piñar is a family physician. She qualified in 1998 in Madrid (Spain) and finished her primary care training in 2002. Since 2007, she has been practicing medicine in the UK, and she has participated in a number of research projects.

Cristina López del Burgo is a family physician. She qualified in 1998 in Pamplona (Spain) and finished her primary care training in 2002. She has worked since then in the University of Navarre combining teaching and research activity.

Eduardo Burgueño is a family physician. He qualified in Valladolid (Spain) in 1997 and finished his primary care training in 2001. In 2008, he moved to the Democratic Republic of Congo, where he has been combining medical practice with research and teaching activity in the University of Mwene-Ditu, where he is the dean.