Commentary Family Planning

Should Preventing Unintended Pregnancy Be Family Planning’s Holy Grail?

Christine Dehlendorf

Our history is marred by examples of contraceptive coercion. Family planning programs and research can counter that history by changing how we define our goals and success.

Earlier this month marked the 53rd anniversary of the U.S. Supreme Court’s history-making decision Griswold v. Connecticut, which struck down laws banning contraceptive use among married couples on June 7, 1965.

While it was a turning point for contraceptive access, the Griswold decision was clearly a product of its time, failing to address the existence of sex outside of marriage (it would be another seven years before the court struck down contraceptive bans altogether in Eisenstadt v. Baird). Anniversaries like Griswold‘s remind us what underlying values—like, that only married people should have sex—have shaped the history of contraception in the United States.

One deeply entrenched and unjust value has been about whose reproduction is acceptable to society and whose is not.

To this day, the public receives strong messages that childbearing is a good idea for white, straight, and, as in the case of Griswold, married people with means. Meanwhile, those who don’t fit these categories—namely the poor, Black and brown people, and those who are unmarried—have often been the targets of misguided efforts to control their reproduction, including through the promotion of contraception. As a family planning researcher, I see evidence of this thinking in how we measure our work’s success.

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My research program, the Program in Woman-Centered Contraception at the University of California, San Francisco, seeks to advance family planning efforts that prioritize patients’ preferences and values and to work toward health equity in family planning. For equity to be achieved, we believe that health-care researchers, providers, advocates, and members of the public need to understand how inequality has been at the root of contraceptive promotion and distribution in this country.

What we as researchers, providers, and advocates define as success in our policies, programs, and messaging, and how we measure that, reflects our values. If we are not careful, these measures of success can perpetuate the troubling history in this country of what anthropologist Shellee Colen defined as “stratified reproduction”: the unequal ability of people of different races, ethnicities, and socioeconomic classes to give birth to and raise children in a healthy environment.

For example, the field of family planning has taken for granted that preventing unintended pregnancy is the ultimate goal at both an individual and population level. However, as research with women increasingly shows, whether or not a pregnancy is “unintended” does not dictate how someone will feel about that particular pregnancy. For some people, an unexpected pregnancy is a disaster; for others, it’s a “happy accident.”

Despite this, there have been countless efforts in U.S. history to prevent “unintended pregnancy”—particularly among marginalized groups whose reproduction has been devalued. For example, after FDA approval of the contraceptive implant Norplant in 1990, legislatures in thirteen states proposed laws to incentivize or require welfare recipients to start on Norplant. The injectable contraception Depo-Provera has been disproportionately marketed to Black women. And some judges today have offered inmates reduced sentences if they agree to be sterilized or use contraception. In these cases, it seems family planning program leaders and policymakers have prioritized population control over the autonomy of women and families.

The choices that family planning researchers, providers, and advocates make in our work can perpetuate the narrative of stratified reproduction—or shift it. As we fight to protect contraceptive access, we must ensure that our narrative becomes more inclusive, more just, and more aligned with the experiences and values of women themselves. By asking questions in our work about what women really want, and then reflecting those values in our programmatic decisions and measures of success, we can elevate patient-centeredness over population control.

If concepts like “intention” and “planning” do not fit neatly into everyone’s experiences of pregnancy and parenthood, why is measurement of unintended pregnancy the gold standard of success in family planning programming and policies? Without a doubt, countless individuals have benefited from avoiding unintended pregnancy thanks to contraception, because that is what they wanted for themselves. However, by focusing our efforts on preventing unintended pregnancy, we make assumptions about individuals’ experiences, preferences, and desires about their reproduction.

We can end up valuing the reduction of pregnancy in the marginalized groups who receive care through our programs and initiatives, instead of honoring their reproductive autonomy—defined as the ability and fundamental right of individuals to make and act on their own decisions about sex and reproduction.

Further, the ubiquitous use of unintended pregnancy as a measure of success has an insidious side effect: perpetuating abortion stigma. If we assume all unintended pregnancies are a negative outcome, the implication is that abortion is also a negative outcome. In reality, women have a huge range of emotions and responses regarding abortion and its place in their lives. If a woman uses abortion, regardless of how many times, to achieve her reproductive goals and is satisfied with the experience, then by any patient-oriented measure, the outcome is a success.

Besides unintended pregnancy, several other widely used measures of success—including use of IUDs or other highly effective methods—paint over individual experiences and autonomy. Many people love their IUD, and that is great. However, for many people, the IUD is not the right choice for them. Maybe they don’t want to use a method that is inside their uterus. Or they don’t want to use a method that lasts for years, or they don’t want a method that they need a provider to remove for them. All of those are valid reasons for not choosing an IUD. We should not mark it as a “failure” of our efforts to improve contraceptive access if a patient does not choose this method. Instead of unintended pregnancy and proliferation of IUDs, let’s find new measures of success.

Let’s measure success by people’s ability to access the services they need and by their positive experiences with those services. My team is currently testing a measure of whether patients feel their needs were met during a contraceptive counseling visit. New performance measures such as these can help us shift our focus to these areas.

Let’s measure success by reproductive quality of life. Are patients having the pregnancies they want and not having the pregnancies they don’t want? Are they able to raise their children in safe, sustainable environments, as is the goal of reproductive justice? It is possible to measure the well-being of individuals and roll them up to the group level without losing the nuance of individual people’s experiences. If we are talking about populations, let’s talk about how healthy and happy our population is with their reproductive lives, instead of focusing on outcomes that impose an outdated narrative on everyone.

All people have the fundamental right to have children or not. Our family planning programs, and our measures of success, should elevate that undeniable truth instead of repeating our problematic history.

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