Fertility control? Middle-aged Australian women's retrospective reports of their pregnancies
Dr Edith Weisberg, Sydney Centre for Reproductive Health Research, Family Planning New South Wales, 328-336 Liverpool Road, Ashfield, NSW 2131. Fax: (02) 9716 5134; e-mail: firstname.lastname@example.org
Objective: To assess middle-aged Australian women's retrospective reports of how intended and wanted were their pregnancies, and the degree of happiness associated with these pregnancies.
Methods: A self-administered questionnaire was sent to 1000 participants in the Mid-Age cohort of the Australian Longitudinal Study on Women's Health.
Results: Responses from 811 women (81%) showed that, although 32% of first pregnancies were unplanned and 29% were unwanted, most women recall being happy with their pregnancies and termination rates were very low. The second pregnancy was the most planned and wanted and associated with the highest levels of happiness.
Conclusions: While the majority of middle-aged women report having been happy to be pregnant, and the majority of pregnancies are described retrospectively as planned and wanted, a significant proportion of pregnancies are unwanted, unplanned or resulting from unintended contraceptive failure.
Implications: The data support the continuing need for widely available, affordable and sensitive fertility control services.
The ability to control fertility is fundamental to women's personal and economic self-determination. It is widely believed that modern contraceptive options mean that fertility is completely controllable, but evidence suggests that as many as half of all pregnancies are not planned.1 However, not all unintended pregnancies are unwanted and the relationships between pregnancy intention, the pregnancy being wanted or unwanted and levels of happiness are explored in this report.
The Australian Longitudinal Study on Women's Health (ALSWH) established in 1996 has a large randomised data base of women aged between 45 and 50 when the database was established who are now post-menopausal.2 One thousand women from this Mid-age cohort (ALSWH), all of whom reported having experienced at least one pregnancy, were randomly selected and invited to participate in a survey of their reproductive histories. The women were aged 52 to 57 when surveyed in 2003, and were thus able to report on their entire reproductive lives. This cohort of women was among the first to have reasonably easy access to contraception, including the oral contraceptive pill. While contraception has changed extensively over their reproductive lifespan, the extent to which these women recall contraception as effective and their recollections of the extent to which their pregnancies were planned and wanted sheds light on issues surrounding the decision-making of later generations of women regarding pregnancy and motherhood.
The questionnaire based on questions used in the National Family Health Survey3 and the PRAMS Surveillance of Family Planning Practices and Pregnancy Intention in the US4 was developed by members of the Research Committee of Family Planning NSW, the staff of ALSWH, and members of the NHMRC Clinical Trials Unit in 2004. It was piloted with 30 middle-age members of the Pilot Cohort of the ALSWH.
Women were asked for information about timing of each pregnancy — whether it was ‘too soon’, ‘the right time’ or later than they wanted. Pregnancies were classified as unplanned/unintended if the woman stated that the pregnancy occurred too soon. Women were also asked whether they wanted a pregnancy at the time or wanted a pregnancy at some time in the future and whether they were using some form of contraception at the time they became pregnant. Feelings of happiness and unhappiness with the pregnancy were also elicited. A five-point scale was dichotomised, with ‘very unhappy’ and ‘unhappy’ contrasted with ‘didn't mind’, ‘happy’ and ‘very happy’.
One thousand mid-age participants were sent a letter of invitation, a consent form and a questionnaire. After three weeks they were sent a reminder, and those who had not responded within another three weeks received a telephone reminder. Completed questionnaires were received from 812 women giving a response rate of 81%. One woman reported never having been pregnant, despite having reported pregnancy in earlier surveys, leaving 811 questionnaires for analysis.
The women participating in the survey were born between 1947 and 1950. Three-quarters were Australian born, a third living in urban, 58% in rural and 8% in remote areas, the majority in NSW, Victoria or Queensland but all states were proportionately represented. Thirty per cent had reached intermediate or school certificate level,19% leaving or higher school certificate, 13% were university graduates and 17% had no formal qualifications. The remainder had either completed an apprenticeship or held a training certificate or diploma.
Number of pregnancies reported varied from 1 to 11, with a median of 3. Because of small numbers, recall of pregnancies beyond the fifth is not reported here. Sample size varies as a result of some missing data.
Of 808 women who recalled their feelings at the time of their first pregnancy, 581 (71.9%) were ‘happy’, 174 (21.5%) were ‘unhappy’, 51 (6.3%) ‘didn't mind’ and two could not remember. Table 1 shows the number of women, for the first pregnancy, who recall the pregnancy as ‘unplanned’, ‘unwanted at that time’, and ‘unwanted ever’, those who recalled it as having resulted from contraceptive failure, and those whose pregnancy ended in termination. While, in general, those who recalled being unhappy were also those who recalled the pregnancy as unwanted and unplanned, and were by far the most likely to have a termination, some women who were happy about the pregnancy did not recall it as planned or wanted. It is notable that 31% of first pregnancies are recalled as unplanned, and 11% as resulting from contraceptive failure. Table 2 summarises women's recall of their first five pregnancies. The second pregnancy was the most likely to be intended and wanted while the fourth and fifth were least likely to be intended or wanted.
Table 1. Recalled happiness with first pregnancy and other characteristics of that pregnancy.
|Unwanted at time||165||94.8||26||51.0||36||6.2||227||28.2|
Table 2. Recalled characteristics of pregnancies one through five.
|Unhappy||174 (22%)||57 (7.8%)||59 (12.6%)||40 (16.3%)||14 (15.1%)|
|Happy||581 (73.4%)||646 (88.1%)||393 (83.6%)||186 (75.9%)||67 (72.0%)|
|Unplanned||253 (31.9%)||113 (15.4%)||74 (15.7%)||41 (16.7%)||23 (24.7%)|
|Unwanted at time||229 (28.9%)||92 (12.6%)||87 (18.5%)||52 (21.2%)||24 (25.8%)|
|Unwanted ever||75 (9.5%)||28 (3.8%)||47 (10%)||41 (16.7%)||18 (19.4%)|
|Contraceptive failure||90 (11.4%)||107 (14.6%)||100 (18.9%)||57(23.3%)||41 (16.3%)|
|Terminated||41 (5.2%)||23 (3.1%)||21 (4.5%)||17 (6.9%)||10 (10.8%)|
This is a retrospective study of a middle-aged group of women reflecting on their reproductive histories and their feelings on finding themselves pregnant. The response rate at 81% compares favourably with other comparable studies.5,6
Overall, most women recall being happy with their pregnancies. Although 32% of first pregnancies were unplanned and 29% were unwanted at the time, termination rates were very low. It is notable that unintended pregnancies are not always recalled as unwanted, nor are they necessarily associated with recalled unhappiness. The second pregnancy was the one which was associated with the highest level of happiness, planning and being wanted.
Previous studies7,8 have indicated that unintended pregnancies are not necessarily unwanted and that a planned pregnancy may become unwanted depending on individual circumstances.
There are limitations to a retrospective design. The most obvious is that recall of feelings and intentions from several decades earlier is likely to be affected by subsequent and current events, including feelings towards the child, marital history, and other life events. Feelings for an existing child may be very different to the feelings experienced on discovering a pregnancy, and recollection of events decades ago may be tempered by life events and experiences since then. Williams et al., for example, found that women's self reports of whether a pregnancy was wanted or intended became more positive between their original retrospective ratings and a telephone interview two years later.9 It is likely that the actual experience at the time might have been less positive than the retrospective reports made in middle age by the women in our survey.
While the majority of middle-aged women report having been happy to find themselves pregnant, and the majority of pregnancies are described retrospectively as both planned and wanted, a significant proportion of pregnancies is described as unwanted, unplanned, or resulting from unintended contraceptive failure. The data support the continuing need for widely available, affordable information and services relating to fertility control.