Understanding pregnancy intention and contraceptive decision-making among Native Hawaiians
Awarded 2013
Complex Family Planning Fellowship Research
Reni Soon, MD
University of Hawaii at Manoa

This project had the long-term goal of addressing the unintended pregnancy rate among Native Hawaiians, which is by the best evidence we have, the highest among the major racial groups in Hawaii. Hawaii has the 2nd highest unintended pregnancy rate in the nation. Addressing this health disparity would make strides toward empowering Hawaiians to achieve more of their educational, career and other goals and ultimately improve their lives. To do this, however, one must understand the “problem”, if it even is a problem within the Native Hawaiian community. One must understand how pregnancy is conceptualized, and what an unintended or unplanned pregnancy means to community members. One must understand how pregnancy and childbearing fits in to the lives of Native Hawaiians, and whether planning for a pregnancy is a reality or even a priority. One must understand how decisions regarding pregnancy planning are made. We partnered with a federally qualified community health center that serves a largely Native Hawaiian population to conduct a qualitative study looking at these questions.
For the first phase of our project we conducted ten semi-structured interviews with key informants. The key informants were identified by the Hawaiian community as leaders in education, social work, public health, and reproductive health care. The interview was mainly participant-driven, although a guide was used as a framework with such questions as “Tell me how Hawaiians view pregnancy and having children;” “What are the ideal circumstances into which a baby is born? How important is it if the baby is not born into these circumstances;” “Do you think a lot of Native Hawaiian women have babies when they were not planning on it? If so, why do you think so?”
The interviews were audio-recorded and transcribed verbatim. The research team analyzed the results using content analysis, which is an iterative process among team members to identify themes and relationships. The results were validated with community members and with the key informants, and then were used to inform the development of the focus group and interview guides for the second phase of the project.
In the second phase of the project, we conducted 40 one-on-one interviews with Native Hawaiian women of reproductive age and 8 focus groups with both adult men and women of all ages. The interviews focused on the women’s personal experiences with sex, pregnancy and contraception. The focus groups were segregated by gender and age so that there were two “younger” men’s focus groups, two “older” men’s groups, two “younger” women’s groups, and two “older” women’s groups. The intent of the focus groups was to elicit general attitudes, community expectations, and norms that may affect the attitudes and behaviors of individuals within the community regarding pregnancy and pregnancy planning.
Analysis of the key informant interviews found that there are core Hawaiian values of children and family that strongly affect how Hawaiians view pregnancy, pregnancy planning, and unintended pregnancies. ‘Ohana (families) are large and characterized by tremendous support, which is perceived to lessen the burden of an unintended pregnancy. Pregnancies, whether planned or not, are “blessings”. Participants described the expectation to continue an unplanned pregnancy due to each of these concepts. While Hawaiians hope most children are born under identified ideal circumstances, and therefore ascribe some value to planning pregnancies, these circumstances are not necessary and often do not occur.
Analysis of our focus groups and interviews is not complete, however, many similar sentiments were expressed. It is apparent that unintended or unplanned pregnancies are not perceived in the Hawaiian community the same way they are perceived in the medical/public health communities. To focus on “reducing unintended pregnancies” would not likely impact this community, as it is not seen as a problem. However, planning for pregnancy is a value as many Hawaiians hope community members achieve certain goals before starting childbearing such as graduation from school, financial and relationship stability and they certainly recognize non-ideal times to have children. Programs focused on optimizing pre-conception health or social support may be better received. Family planning initiatives would therefore still be of benefit, however how the cultural values of ‘ohana and children affect attitudes and behaviors around pregnancy and pregnancy planning need to be considered.