Exploring pregnancy intention and contraceptive counseling preferences in women undergoing spontaneous abortion
Abortion, Contraception
Awarded 2016
Complex Family Planning Fellowship Research
Rachel Flink-Bochacki, MD
University of Pittsburgh

Background:  Over one million spontaneous abortions, or miscarriages, occur in the United States every year.  Despite knowing that almost half of pregnancies overall are unintended, there has been little previous research into the pregnancy intentions, future family planning goals, and contraceptive counseling preferences of women experiencing miscarriage. 
1. Find the overall prevalence of unintended and unwanted pregnancy among those ending in miscarriage, and describe the patient-level characteristics associated with these findings, using nationally-representative data from the National Survey of Family Growth (NSFG).
2. Explore the pregnancy intentions, emotional reactions, health care needs, future family planning goals, and preferences for family planning counseling among women experiencing miscarriage, using qualitative interviews.
NSFG Analysis:  We performed a secondary data analysis of the 2011-2013 NSFG, identifying 1,351 pregnancies ending in miscarriage, representing nearly 16 million miscarriages nationwide.  We found that 44.5% of pregnancies ending in miscarriage were unintended, with 15.3% of the total specifically unwanted.  Both unintended and unwanted pregnancies were more common among younger women, those who weren’t married, and those who already had multiple children.  This analysis provides a needed baseline awareness of differing pregnancy intentions among women experiencing miscarriage, drawing attention to the diverse family planning needs of women experiencing pregnancy loss.
Qualitative Study:  We enrolled and interviewed 26 women who experienced miscarriages in the previous year, and asked about their preconception intentions, feelings about pregnancy and miscarriage, future family planning goals, and thoughts about family planning counseling after miscarriage.  Interview transcripts were analyzed by two coders, and we used an iterative and collaborative approach to understand common themes and overarching theory.  We found that initial pregnancy intentions were not predictive of emotional reactions to miscarriage, and that family planning goals after miscarriage were often not consistent with initial pregnancy intentions.  Women were generally receptive to family planning counseling at the time of miscarriage care, though many did not immediately feel ready to consider their future reproductive plans and preferred to defer discussion until follow-up.  This analysis illustrates that emotional responses and future reproductive plans following pregnancy loss are complex and diverse, and it challenges the relevance of initial pregnancy intentions to understanding future family planning care needs.
Implications:  Providers should be aware that while nearly half of pregnancies ending in miscarriage are unintended, initial pregnancy intentions do not predict emotional reactions, future pregnancy plans, or feelings about family planning counseling after miscarriage.  Instead of asking about pregnancy intention as a proxy for understanding care needs, providers should be open-minded and specifically ask women about their feelings and goals, to optimize provision of timely and appropriate care.