Why do we care about unintended pregnancies? Rates of unintended pregnancy “indicate the extent to which women and couples can determine freely whether and when they have children,” as stated by Finer and Zolna. There is some evidence that women and girls who have unintended pregnancies have a higher likelihood of other risk factors, such as smoking during pregnancy, and to have worse birth outcomes, such as prematurity. Preventing unintended pregnancy is one of the Healthy People 2020 goals. As pointed out in this post by Dr. Rebekah Rollston, while the rates of unintended pregnancy have declined in the US over the past several years, they are still much higher than in other similar-income countries, with cost barriers being one of the likely culprits.
Interestingly, the measurement of the unintendedness of pregnancy has not received the same scrutiny as the actual rates in the literature. The common definition and the one used by Healthy People 2020 is that these are pregnancies reported as “mistimed” or “unwanted.” Crucially, questions about pregnancy intentions are most often asked of women retrospectively, as in the National Survey of Family Growth. In some cases, answers of “unsure” have also been categorized as unintended. Intended births are generally those reported as wanted now or sooner. While this approach to measurement is concise, it may obscure important information.
As described by Rocca and colleagues in their recent Medical Care article, this kind of binary measure assumes that women have clear preferences for pregnancy and childbearing and that the memory of these preferences does not change after the pregnancy has occurred. But women may have conflicting feelings about pregnancy that cannot be captured in such a simplistic way. Measuring pregnancy intention using more detailed measures is likely to provide better information that can be used to improve practice and to develop new programs and policies with the goal of helping women freely determine their fertility.
The Desired to Avoid Pregnancy (DAP) Scale is the first prospective measure of pregnancy preference to be developed and evaluated using rigorous psychometric methods. Rocca and colleagues drafted 60 items based on existing research, evaluated comprehension through 25 cognitive interviews, and administered items in a survey with 594 nonpregnant women in 7 US states. Final item selection was based on item response theory and the instrument was evaluated using standard methods. Overall, the authors found that the measure had good internal validity.
Importantly, the authors report that the scale did not have differential item functioning based on participant characteristics–meaning that the scale might be useful across diverse populations. The final DAP scale includes 14 items that cover 3 conceptual domains: cognitive preference, affective feelings, and practical consequences.
Without understanding women’s motivations, we cannot provide effective and supportive healthcare. Given the breadth of the items, the DAP scale looks like a useful tool for capturing a range of pregnancy and childbearing preferences, and could be helpful in clearly identifying women who would benefit from contraceptive care. This measure of pregnancy preferences is a great contribution to research on unintended pregnancies.
Jordyn Gunville