Non-use of contraception is associated with about 900,000 unintended births in the United States each year. Why do women choose not to use a contraceptive? Surprisingly, the potential for side effects, a key focus in many providers’ educational messages, was a concern for only 10% of women enrolled in the National Survey of Family Growth who were asked about their nonuse of contraception that led to their unintended pregnancy.[1] More commonly, women mistakenly thought they couldn’t get pregnant, with 41% giving that response. In general, women who think that sex won’t lead to pregnancy either believe that they are not in the fertile phase of their menstrual cycle or they think, mistakenly, that they are infertile. About 24% reported that they hadn’t expected to be having sex. This set of women was more likely to be unmarried and not cohabiting (42%) than were women who were married (12%) or cohabiting (16%).

About 1 in 5 women “didn’t really mind getting pregnant.” That’s called ambivalence, and it turns out that our understanding of what exactly ambivalence means is ambiguous. Ambivalence is more nuanced and multi-faceted than surveys and research have implied. A recent study of 576 single women ages 18-29 who were sexually active in the previous 12 months examined the permutations of ambivalence so clinicians can better identify strategies for serving those women who are “on the fence” when it comes to having a baby.[2] According to the researchers, ambivalence can take different forms, with a blend of dimensions that are both cognitive (whether one “should” or “should not” do something) or affective (how one “feels” about something). As pertains to family planning behaviors, a woman cognitively considers whether avoiding pregnancy, say with contraceptive use, is either important or unimportant to her. She additionally will affectively feel either upset or pleased were she to find herself pregnant at this point in time.

There are women who cognitively think it is important to avoid a pregnancy—in other words, they “should” take measures to prevent pregnancy, even if they may be pleased if they have an unintended pregnancy. However, no matter how pleased they might feel about getting unexpectedly pregnant, these women generally use contraception. These women would be classified as having positive ambivalence. In fact, these women were just as likely to use consistent and effective contraception as were women who were not ambivalent at all—you know, the ones who think it important to avoid pregnancy because they would be upset about a pregnancy. Using effective contraception consistently requires substantial planning, a cognitively-driven behavior, write the researchers, not spur-of-the-moment decisions.

In contrast, other women say it isn’t important to avoid a pregnancy yet, if pregnant, they would be unhappy about it. These women—with negative ambivalence—are substantially less likely to use effective contraception, whether consistently or at all. Relatively few women expressed negative ambivalence, only about 3%. Yet it is this 3% of women who pose the greatest family planning challenge. They don’t want a baby and would be unhappy with a pregnancy, but they are not taking action to prevent pregnancy. This negative ambivalence is most common among women who are neither working nor in school. Men, analyzed in another arm of the study, were four times more likely to fall into the negative ambivalence category.

The researchers also analyzed women who reported no ambivalence, finding that these women acted in ways that supported their attitudes. Least likely to use contraception are women who think it unimportant to avoid getting pregnant but who would be pleased to be so. And most likely to use contraception are those women who think it important to avoid a pregnancy because they would be upset about it.

Most of the women (77%) in the survey reported that every pregnancy is a “blessing,” even the pregnancies over which the women may be upset…even the women with negative ambivalence. Those who felt that every pregnancy is a blessing expressed the greatest conflicted feelings if they thought it important to avoid a pregnancy because they are not in a position to have one because, for example, their finances or relationships were not secure. Among the women surveyed, 37% women with incomes three or more times the poverty level said they “didn’t mind getting pregnant” compared to 16% living at poverty levels. Just over half of college graduates said the same, compared to the 18-19% at lower educational levels. Married women were less likely to mind (29%) compared with single women (7%). Least likely to think every pregnancy is a blessing were women who would be upset over pregnancy and so thought it important to avoid pregnancy.

Another recent study explored the concept of unintended pregnancy and consequently babies as a “gift.” The researchers conducted indepth qualitative interviews with 28 women who did not desire a pregnancy but were at risk for one. Nearly all women had positive feelings toward babies themselves, even if they were to have a baby when they didn’t really want one. Their negative feelings arose from considering the experiences associated with having a baby, such as changing diapers and dealing with crying, and about effects a baby would have on their lives such as losing freedom and facing increased financial needs.[3] The researchers suggested that messages need to address both the positive and the negative emotions women may have about unintended pregnancy.

—Deborah Kowal, MA, PA, managing editor and co-author of Contraceptive Technology

[1] Mosher W, Jones J, Abma J. Nonuse of contraception among women at risk of unintended pregnancy in the United States. Contraception 2015; 92:170-6.

[2] Yoo SH, Guzzo KB, Hayford Sr. understanding the complexity of ambivalence toward pregnancy: does it predict inconsistent use of contraception. Biodemo Soc Biol 2014:60:49-66.

[3] Askelson NM, Losch ME, Thomas LJ, Reynolds JC. “Baby? Baby not?”: Exploring women’s narratives about ambivalence towards an unintended pregnancy. Women & Health 2015;55:842-58.