Brenda Colley Gilbert

The measurement and meaning of unintended pregnancy.

Unintended pregnancy combines two aspects of fertility: unwanted and mistimed pregnancies. The personal partnership social and political realities of these two aspects are different and the use of separate categories may better reflect the way women think about a pregnancy. A better understanding of the multiple dimensions of unintended pregnancy also may lead to a better understanding of the consequences of these pregnancies. Likewise better knowledge of the extent of mistiming and perhaps the strength of intentions may be important in understanding health impact. Effective programs to prevent unintended pregnancy must use terms that are familiar to women and must build upon cultural understanding of the problem to be prevented. Research should focus on the meaning of pregnancy intentions to women and the processes women and their partners use in making fertility decisions. It should prospectively address the impact of pregnancy intentions on contraceptive use. Both qualitative and quantitative research have contributed to our understanding of fertility decisionmaking; both will be essential to the creation of more effective prevention programs. (excerpt)

Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the Pregnancy Risk Assessment Monitoring System 1996-1997.

Objective: This study examines whether unintended pregnancy is associated with physical abuse of women occurring around the time of pregnancy, independent of other factors. Methods: In 1996–1997, state-specific population-based data were obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 39,348 women in 14 states who had delivered a live-born infant within the previous 2–6 months. The study questionnaire asked about maternal behaviors and characteristics around the time of pregnancy. Results: Women who had mistimed or unwanted pregnancies reported significantly higher levels of abuse at any time during the 12 months before conception or during pregnancy (12.6% and 15.3%, respectively) compared with those with intended pregnancies (5.3%). Higher rates of abuse were reported by women who were younger, Black, unmarried, less educated, on Medicaid, living in crowded conditions, entering prenatal care late, or smoking during the third trimester. Overall, women with unintended pregnancies had 2.5 times the risk of experiencing physical abuse compared with those whose pregnancies were intended. This association was modified by maternal characteristics; the association was strongest among women who were older, more educated, White, married, not on Medicaid, not living in crowded conditions, receiving first trimester prenatal care, or nonsmoking during the third trimester. Conclusions: Women with unintended pregnancies are at increased risk of physical abuse around the time of pregnancy compared with women whose pregnancies are intended. Prenatal care can provide an important point of contact where women can be screened for violence and referred to services that can assist them.

Physical Abuse Around the Time of Pregnancy: An Examination of Prevalence and Risk Factors in 16 States

Objectives: From self-reports we describe and compare the levels and patterns of physical abuse before and during pregnancy while also describing the demographic and pregnancy-related characteristics of physically abused women, the stressful experiences of abused women prior to delivery, and the relationship of the abused woman to the perpetrator(s). Methods: We used population-based estimates from the Pregnancy Risk Assessment Monitoring System (1996–98) to calculate a multiyear 16-state prevalence with 95% confidence intervals (CIs) and unadjusted risk ratios for demographic, pregnancy-related, and stressful experiences variables. Results: We found the prevalence of abuse across the 16 states to be 7.2% (95% CI, 6.9-7.6) during the 12 months before pregnancy, 5.3% (95% CI, 5.0–5.6) during pregnancy, and 8.7% (95% CI, 8.3–9.1) around the time of pregnancy (abuse before or during pregnancy). The prevalence of physical abuse during pregnancy across the 16 states was consistently lower than that before pregnancy. For time periods both before and during pregnancy, higher prevalence was found for women who were young, not White, unmarried, had less than 12 years of education, received Medicaid benefits, or had unintended pregnancies, and for women with stressful experiences during pregnancy, particularly being involved in a fight or increased arguing with a husband or partner. For each of these risk groups, the prevalence was lower during pregnancy than before. Abuse was ongoing before pregnancy for three quarters of the women experiencing abuse by a husband or partner during pregnancy. Conclusions: Women are not necessarily at greater risk of physical abuse when they are pregnant than before pregnancy. Both the preconception period and the period during pregnancy are periods of risk, which suggests that prevention activities are appropriate during routine health care visits before pregnancy as well as during family planning and prenatal care.

The Pregnancy Risk Assessment Monitoring System (PRAMS): Current Methods and Evaluation of 2001 Response Rates

Objectives. Our objectives were to describe the methodology of the Pregnancy Risk Assessment Monitoring System (PRAMS), examine recent response rates, determine characteristics associated with response, and track response patterns over time. Methods. PRAMS is a mixed-mode surveillance system, using mail and telephone surveys. Rates for response, contact, cooperation, and refusal were computed for 2001. Logistic regression was used to examine the relationship between maternal and infant characteristics and the likelihood of response. Response patterns from 1996 to 2001 were compared for nine states. Results. The median response rate for the 23 states in 2001 was 76% (range: 49% to 84%). Cooperation rates ranged from 86% to 97% (median 91%); contact rates ranged from 58% to 93% (median 82%). Response rates were higher for women who were older, white, married, had more education, were first-time mothers, received early prenatal care, and had a normal birthweight infant. Education level was the most consistent predictor of response, followed by marital status and maternal race. From 1996 to 2001, response to the initial mailing decreased in all states compared, but the decrease was offset by increases in mail follow-up and telephone response rates. Overall response rates remained unchanged. Conclusions. The PRAMS mail/telephone methodology is an effective means of reaching most recent mothers in the 23 states examined, but some population subgroups are more difficult to reach than others. Through more intensive follow-up efforts, PRAMS states have been able to maintain high response rates over time despite decreases in response to the initial mailing.

Differences Between Mistimed and Unwanted Pregnancies Among Women Who Have Live Births

CONTEXT Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes. METHODS Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and womens behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks. RESULTS The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed. CONCLUSION Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.

The Pregnancy Risk Assessment Monitoring System (PRAMS): methods and 1996 response rates from 11 states.

Objectives: To determine if the Pregnancy Risk Assessment Monitoring System (PRAMS) is a unique and valuable MCH data source and an effective mechanism for states to collect MCH data, and to assess if recent changes in it have improved efficiency and flexibility. Methods: Each component of the PRAMS methodology is described: sampling and stratification, data collection, questionnaire, and data management and weighting. To assess effectiveness, we calculated response rates, contact rates, cooperation rates, refusal rates, and questionnaire completion rates. Logistic regression was used to examine the relationship between maternal and infant characteristics and the likelihood of response. Four criteria were defined to measure improvement in PRAMS functioning. Results: Overall response rates for the 11 states in 1996 ranged from 66% to 80%. Cooperation rates were high (85–99%), with contact rates somewhat lower (73–87%). Response rates were higher for women who were older, White, married, had more education, were first-time mothers, and had a normal-birthweight infant. In all states, parity and education were the most consistent predictors of response, followed by marital status and race. Between 1988–1990 and 1996–1999, the number of states and areas participating in PRAMS increased from 6 to 23, response rates improved, and the time for a state to start data collection and to obtain a weighted dataset both decreased. Conclusions: PRAMS is a unique and valuable MCH data source. The mail/telephone methodology used in PRAMS is an effective means of reaching most women who have recently given birth in the 11 states examined; however, some population subgroups are not reached as well as others. The system has become more efficient and flexible over time and more states now participate.

Socioeconomic and racial/ethnic disparities in unintended pregnancy among postpartum women in California.

Objective: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. Methods: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. Results: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. Conclusions: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women.

Adolescent dual use of condoms and hormonal contraception: trends and correlates 1991-2001.

Background Use of condoms with hormonal contraceptive methods (dual use) is recommended for adolescents at increased risk for sexually transmitted infections and pregnancy. Goal The goal was to measure the extent of dual use among adolescents, to estimate trends in dual use 1991–2001, to assess factors associated with dual use in 2001, and to develop information useful for prevention programs. Study Design We used 6 Youth Risk Behavior Surveys of 9th–12th graders conducted 1991–2001. Each survey was an independent, nationally representative sample. Sample sizes ranged from 10,904 to 16,262, and overall response rates ranged from 60–70%. We estimated trends in dual use for the 1991–2001 period using linear logistic regression models of dual use on year of survey controlling statistically for grade, sex, and race/ethnic group, and evaluated correlates of dual use with chi-squared analysis. Results Dual use increased significantly throughout 1991–2001, from 3.2% (95% confidence interval, ± 0.7%) in 1991 to 7.2% (± 0.8%) in 2001. During this period, condom use increased and pill use did not. In 2001, 32% (± 2.6%) of all users of hormonal methods (pill or injection) also used condoms. Students in a number of categories had higher rates of dual use: those who were white (8.9% ± 1.2%), 12th graders (9.2% ± 1.5%), and those aged 17 and older (8.8% ± 1.3%). Greater dual use was not associated with increased sexual or drug use risk behaviors. Conclusion Dual use has increased but remains low, especially among those most at risk.

Investing time in health: do socioeconomically disadvantaged patients spend more or less extra time on diabetes self‐care?

BACKGROUND Research on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time. OBJECTIVE To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes. DATA Eleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001. METHODS Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics. RESULTS Proportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day. DISCUSSION Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

Pregnancy Intention: How PRAMS Data Can Inform Programs and Policy

Background: In most states, the Pregnancy Risk Assessment Monitoring System (PRAMS) is the only source for state-specific, population-based data on the prevalence of unintended pregnancy among women having a live birth. These data can be used in a variety of ways to inform state policies and programs aimed at the prevention of unintended pregnancy. Objectives: This paper highlights the programmatic and policy development activities undertaken by three states in relation to unintended pregnancy as well as the role that PRAMS data played in those efforts. Results: Georgia, Oklahoma, and Washington have used PRAMS data to gain support for program initiatives directed at unintended pregnancy, to promote policies aimed at either monitoring or reducing unintended pregnancy, and to acquire additional funds for related programs, such as family planning.