Unintended Pregnancy and Its Prevention

The USDHHS counts unintended pregnancy among major public health problems (Healthy People, 2010). Almost half of pregnancies in the United States are unintended, with 42% of them ending in abortion (Finer & Henshaw 2006). Women with unintended pregnancies are disproportionately young, low-income group, single, and non-white, primarily African American (Finer & Henshaw 2006). Unintended pregnancy has biological, psychological, economic, and social consequences (Brown & Eisenberg 1995). Compared with women with planned pregnancies, those with unintended pregnancies initiate prenatal care later (Kost, Landry, & Darroch 1998), have higher rates of behavioral risk factors during pregnancy (Berkowitz & Papiernik 1993; Brown & Eisenberg 1995; Poole & Hawkins 1999), and report higher rates of partner physical abuse (Gazmararian et al., 1995).

In 1970 the U.S. Congress enacted the Title X program as part of the 1970 Public Health Service Act. It is the sole federal program providing family planning and reproductive health care, funding around 4,600 clinics, preventing an estimated 1.3 million unintended pregnancies each year. Since 1995, an average of five million women each year obtained contraceptive services from these clinics. Nearly two-thirds of the clients have incomes below 100% of poverty level; 89% have incomes below 200% of poverty level. Congress has not increased Title X funding since 1981 (Office of Population Affairs [OPA], 2001).

Preconception Care

Preconception care (Moos, 2002; Moos & Cefalo 1987) is a set of interventions to identify and modify biomedical, behavioral, and social risks to a women's health or pregnancy outcome. Preconception care counsels about unhealthy behaviors screens for and treats communicable diseases and endocrine conditions (that is, diabetes and hypothyroidism) and dispenses nutrients such as folic acid. Its goal is to increase awareness and address potential risks to women's health and pregnancy outcomes before a pregnancy is known (Johnson et al., 2006).

Pregnancy and Women's Health

Maternal mortality rate (MMR) had decreased markedly during the 19th century, but without much progress being made since mid-1980s. A Massachusetts study identified inadequate prenatal care as a prominent risk factor for MMR and declared that one-third to one-half of all maternal deaths were preventable (Sachs et al., 1992).

Profound racial disparities exist for all four indicators in Table 1. This remains true even when controlling for mothers' income and educational levels (Mustillo et al., 2004; Schoendorf, Hogue, Kleinman, & Rowley 1992). Other social risk factors for IMR include education and marital status. IMR decreases

with increasing maternal education and unmarried mothers are at higher risk for poor pregnancy outcomes (Mathews & MacDorman, 2006). Marital status is a marker for social, emotional, and financial support that independently impact these outcomes. Young maternal age, low education, and other negative social indicators are risk factors for LBW and IMR (Hamilton et al., 2007; Hillemeier, Weisman, Chase, & Dyer 2007; Mathews & MacDorman).

Sexually Transmitted Infections

STIs increase women's morbidity, threaten fertility, and directly cause poor birth outcomes. Chlamydia has the highest infection rate of reportable STIs in the United States (Centers for disease control and prevention [CDC], 2006), is asymptomatic for many, and if untreated, can result in pelvic inflammatory disease and infertility (Gray-Swain & Peipert 2006). Gonorrhea symptoms and health effects are similar (CDC, n.d.-a; Zar, 2005). Gonorrhea, chlamydia, herpes simplex virus (HSV) infection, and bacterial vaginosis can impact birth outcomes (CDC, n.d.-b).

Infection with human immunodeficiency virus (HIV) can be transmitted to the baby during pregnancy, labor, delivery, or breastfeeding (perinatal transmission). In the United States, HIV testing and drug therapy has reduced the perinatal transmission rate to 2% or less (CDC, 2004). Only 142 cases of HIV or AIDS were diagnosed among babies exposed perinatally in the United States in 2005 (CDC, 2007). It is important to note that this low perinatal HIV transmission rate does not reflect women's reality in the developing world where HIV prevalence rates among pregnant women are between 25 and 45% (Reithinger, Megazzini, Durako, Harris, & Vermund 2007).

Almost 90% of pregnant women with active hepatitis B infection transmit it to their babies. Untreated infection results in chronic infection rates and resultant liver disease (March of Dimes, 2007). All U.S. babies are immunized at birth for hepatitis B infection; two additional doses are required during infancy to assure protection.

Substance Use, Tobacco, and Alcohol

Concurrent abuse of substances is frequent, complicating research on any substance's impact on birth outcome. Furthermore, many pregnant abusers are economically disadvantaged, a risk factor for unfavorable perinatal outcomes (Bolnick & Rayburn 2003).

Social workers can use the professional five intervention roles—teacher, broker, clinician, mediator, and advocate—in working with substance using women (Sun, 2004). Women-centered substance abuse programs address specific needs such as HIV or STI risk reduction, child care, reproductive health services, and parenting classes (Marsh, D'Aunno, & Smith 2000). Treatment strategies include empowering “recovering” women with reproductive health knowledge and decision-making skills (Jessup & Brindis 2005). Absence of woman-centered or pregnancy-specific services deters pregnant and parenting women from seeking treatment. Few treatment programs have special services for pregnant women (Brady et al., 2001).

More than 200 women have been prosecuted for fetal abuse for having abused substances during pregnancy (Marcellus, 2004). Treating substance use by pregnant women as criminal also deters women from seeking prenatal care and substance abuse treatment; social workers are obliged to serve as extensions of the legal system (Finkelstein, 1994; Paltrow, Cohen, & Carey 2000).

Violence against Women

Research since mid-1980s reports that intimate partner violence (IPV) is associated with increased mortality, injury and disability, poor general health, chronic pain, substance abuse, reproductive disorders, and poorer pregnancy outcomes (Plichta, 2004). Pregnant women are more vulnerable to violence; homicide leads the causes of death for pregnant and recently pregnant women (Shadigian & Bauer 2005).

Since the mid-1980s, then U.S. Surgeon General C. Everett Koop and others recommended routine screening for IPV during pregnancy (ACOG, 2006, 2007; USDHHS, 1986). However, screening rates and practices are far from optimal and enhanced violence prevention training for all practitioners working with women (Shadigian & Bauer 2005). Screening protocols must include an adequate referral network, and social workers are in a leadership position to advocate for services in the form of counseling, shelters, and legal assistance.

Nutrition and Exercise

Insufficient physical activity significantly contributes to women's morbidity and mortality. Ensuring sufficient physical activity in daily life is strongly related to social support and self-efficacy (Smith, Cheung, Bauman, Zehle, & McLean 2005). Less than half of pregnant women are physically active, increasing their risk for mood problems and pre-eclampsia (Poudevigne & O'Connor, 2006; Saftlas, Logsden-Sackett, Wang, Woolson, & Bracken 2004).

Obesity during pregnancy increases risk of maternal, fetal, and neonatal complications, diabetes, pre-eclampsia, caesarian section, and birth defects (Siega-Riz & Laraira 2006). Women entering pregnancy at higher weights are more likely to retain their increased gestational weight with subsequent pregnancies; women who retain their pregnancy weight increase risks of complications in future pregnancies, including gestational diabetes (Bainbridge, 2006). Clinicians discourage obese women from attempting weight loss during pregnancy (Yu, Teoh, & Robinson 2006).

Poverty and Racism

Women head more than half of poor families, and women and children constitute the fastest growing segments of poverty dwelling people (DeNavas-Walt, Proctor, & Lee 2006). Poverty is associated with inadequate health care and nutrition, excess stress and limited alternatives (Krieger, 2001). Problems persist for low-income women's accessing reproductive health services beyond the postpartum period. Some states are experimenting with Medicaid waivers for well-women's health that would provide primary health care services, including contraception and cancer screening (Gold, 2003).

Social determinants of health such as poverty and racism impact reproductive health outcomes (Krieger, 2001; Krieger, Rowley, Herman, Avery, & Phillips 1993; Institute of Medicine, 2003). Lu and Halfon (2003) posit that optimal reproductive outcomes result from health influences throughout life. Mustillo et al. (2004) found that women's self-reported experiences with racial discrimination were associated with PTB and LBW and concluded that this discrimination may contribute to the racial disparities in birth outcomes.

Roles and Implications for Social Work

Social workers work in the reproductive health arena at the micro level by providing social support, counseling, education, and financial assistance to women and their families. Social workers must also help communities and society through social work practice at the macro level to support policies that emphasize prevention, increase access to the broad spectrum of reproductive health services, and lessen social determinants of health, such as poverty and racism. Social workers can advocate for policies and programs that reduce reproductive health risk factors, such as programs for smoking cessation, substance abuse prevention and treatment, violence prevention, nutrition and fitness, and poverty alleviation. We can advocate for access to reproductive health care for poor women beyond prenatal care and delivery by supporting Medicaid waivers for family planning and other reproductive health care in the preconceptional, postpartum, and interpartum periods. Finally, we must staunchly support efforts to reduce unintended pregnancy by supporting a woman's right to control her fertility, expanding access to these services for low-income women. As suggested by Miller, Piccinino, and Tsui (2005, p. 109), “nothing in the history of this country suggests that the family planning needs of the population are likely to be met without the strongest possible advocacy.”