## Robert A Hahn and Marcia Inborn

Print publication date: 2009

Print ISBN-13: 9780195374643

Published to Oxford Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780195374643.001.0001

# Understanding Pregnancy in a Population of Inner-City Women in New Orleans—Results of Qualitative Research

Chapter:
(p.114) 4 Understanding Pregnancy in a Population of Inner-City Women in New Orleans—Results of Qualitative Research
Source:
Anthropology and Public Health
Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780195374643.003.0005

# Abstract and Keywords

Unintended pregnancy is defined as a pregnancy that is mistimed or unwanted, and this classification has been widely used in survey research. This chapter explores the utility of these constructs for women in New Orleans, LA. It examines sexual debut and history, contraceptive knowledge and use, abortion, pregnancy history, partner relations, and service use among seventy-seven women (seventy-three of whom were African-American) using a qualitative methodology. It provides insight into the cultural and social context in which these events and decisions take place, and explores the multiple dimensions that shape women's sexual behaviors and their desires for pregnancy. Many structural and individual factors affect women's preferences and ability to postpone a pregnancy or to use contraception.

# Introduction

Unintended pregnancies are defined as births that are either unwanted or mistimed or those that end in abortion (Brown and Eisenberg 1995 ; Finer and Henshaw 2006 ). Almost half (49%) of the pregnancies in the United States in 2001 were unintended and almost half of unintended pregnancies ended in abortion (Finer and Henshaw 2006 ). Longitudinal studies of women in Europe who had their abortion requests denied have found severe negative effects on the children’s long-term psychosocial development including effects on schooling, social adjustment, alcohol and drug abuse, criminal activity, and employment (Kubicka et al. 1995 ; Myhrman, Olsen, Rantakallio, and Laara 1995 ). Where abortion is illegal and unsafe, unintended pregnancy is a major contributor to maternal morbidity and mortality (Bernstein and Rosenfield 1998 ; Daulaire, Leidl, Mackin, Murpy, and Stark 2002 ). Although the unfavorable consequences of unintended pregnancy are well delineated, unintended pregnancy itself is less well defined.

Clearly a serious health problem, unintended pregnancy is a difficult problem to address as well. The apparent ambivalence seen in reports of women asked whether a pregnancy was intended, such as in statements that they did not want to get pregnant but were either not using contraception or using it (p.115) irregularly, calls into question the idea that intendedness can be routinely and easily inferred from survey research. Correspondingly, it is not possible to simply assume that either intentionality or future intentions directly affect decisions to use contraception. The problem is that many factors, structural and individual, affect women’s preferences and ability to postpone a pregnancy or to use contraception effectively.

Unintended pregnancy, although an apparently commonsense notion, has spawned considerable debate about its meaning and measurement. In demography, the term is used to describe the sum of pregnancies that were either mistimed (a pregnancy that was wanted but not at that time) or unwanted (a pregnancy that was not desired at any time) or a pregnancy resulting in abortion. In discussions about unintended pregnancy, simplistic notions about the relationship between intention and behavior have been questioned by demographers, anthropologists, and health-care providers (see Barrett and Wellings 2002 ; Luker 1975 ; Moos, Petersen, Meadows, Melvin, and Spitz 1997 ; Santelli et al. 2003 ; Trussell et al 1999 ; Ward 1990 ).

The relationship between measures of intention to perform a behavior and performing the behavior is rarely straightforward. An example is the relationship between intending to use a condom and self-report or use of condoms. Although many studies report a correlation between intention to use a condom and condom use, both report of intention to use and use are moderated by many individual and community factors (Jemmott, Jemmott, and Villarruel 2002 ; Jemmott and Jemmott 1990 ) and the correlation may be low (Molla, Astrøm, and Brehane 2007 ). To account for this, behavior change specialists have sought to build theory that sets intent and use within a broader framework of structural and individual characteristics such as availability and cost, community and peer standards, gender power and roles, and social psychological constructs such as self-efficacy (Hornik 1991 ).

Theories of behavior have not been involved in discussions of pregnancy intendedness; instead the notion of intention is seen as a practical measurement tool in family planning. For example, rates of unintended pregnancies have been used to demonstrate an unmet need for family planning services. But as the following discussion makes clear, changing demographics and community norms about sex, marriage, and contraception, as well as improvements in social research demand that the intendedness of pregnancy be reexamined from a more comprehensive multidimensional and structural perspective, that is, an anthropological perspective.

One difficulty with exploring the notion of intendedness in pregnancy is that it overlaps contested domains of gender: female individual and legal autonomy, female sexuality, female adolescence, gender power, religion, and ethnicity. These domains freight the discussion with topics and issues that need to be considered beyond any simple operational definition of (p.116) “intendedness.” As noted above, diverse group of academics and health-care providers have already questioned its utility and its meaningfulness to women (see Barrett and Wellings 2002 ; Luker 1975 ; Moos et al. 1997 ; Santelli et al. 2003 ; Trussell, Vaughan, and Stanford 1999 ; Ward 1990 ). A comprehensive exploration demands a comprehensive approach, combining qualitative and quantitative methods.

It is not unreasonable that a single measure, a small number of measures, or even a series of algorithms for measuring pregnancy intendedness should fail to reflect complex circumstances and desires. Understanding the meaning of intendedness was the primary motivation behind this ethnographic study. The areas we explored included life and career expectations, perceptions and experiences with sex, values associated with childbearing and motherhood, perception of family and local community support for early childbearing, adult and juvenile identities, relationships with partners, experiences with contraception, and attitudes toward abortion. We explore these areas as only an ethnographic study can in a sample of inner-city, low-income, predominantly African American women attending public clinics in New Orleans, Louisiana.

Our respondents present a complex story to support their pregnancy decisions: idealized expectations set against poverty and poor career opportunities; gaming with the chance of conception in the heat of the moment; community notions of sex and sexuality and the inevitability of early intercourse; the high prevalence of teen pregnancy and acquiescence to teens getting pregnant after the fact; the volatility of relationships and marriage; imperfect contraceptive practice and knowledge; and the rejection of abortion as an alternative to contraception. These concerns combine to explain the difference between general intentions—perhaps formed in retrospect—reported in surveys and the intentionality of pregnancy at the time of conception.

Studying unintended pregnancy in New Orleans provides key insights for other poor urban environments, given its sociodemographic composition and fertility patterns. It needs to be noted that although the study reported here was conducted before Hurricanes Katrina and Rita devastated the city and the surrounding coast, we use the present tense to describe New Orleans. About 28% of individuals in New Orleans live in poverty (Census 2000 ), compared with about 17% in all of Louisiana (Proctor Dalaker 2003 ) and 12.4% in the United States as a whole (Census 2000 ). In Louisiana, poverty is strongly associated with reported levels of unintended pregnancy. Overall, slightly more than half of live births to all women in Louisiana are reported as unintended (Louisiana Department of Health and Hospitals 2000 ). Moreover, among births to women who used Medicaid to pay for health care before and during pregnancy, almost 70% are reported as unintended, as compared with 31% among births to women who reported other sources of payment (Louisiana (p.117) Department of Health and Hospitals 2000 ). Nationally, reported unintended pregnancy increases with the poverty level of the population. For example, of the births to women with household incomes of less than 100% of the federal poverty level, almost 45% were reported as unintended, compared with 21% of the births to women with household incomes greater than or equal to 200% of the federal poverty level (Henshaw 1998 ).

Teen births also contribute to elevated unintended pregnancy rates in New Orleans. Over 17% of births in New Orleans were to women aged between 15 and 19 years in 2001 (Louisiana Department of Health and Hospitals 2003 ). This percentage is higher than the national average; about 13% of births in the United States are to teens (AGI 1999 ). Furthermore, over 77% of live births that occur to women under 20 in Louisiana are reported as unintended (Louisiana Department of Health and Hospitals 2000 ). This estimate is also high in comparison to the national average. According to the latest estimates at the national level, about 66% of live births to women 15 to 19 years of age are unintended (Henshaw 1998 ). These data suggest that poor and young women in New Orleans are at higher risk of unintended pregnancy, in comparison to the general U.S. population.

This research attempts to provide a more in-depth look at adolescent and unintended pregnancy in a high-risk population and explores the meanings of pregnancy planning and intendedness within this context. We believe that a qualitative study like this, in a context such as New Orleans, can contribute to the national discussion on unintended pregnancy, particularly since, as noted above, the overwhelming majority of adolescent pregnancies are reported as unintended (Henshaw 1998 ) and adolescent pregnancies contribute to high rates of unintended childbearing in the United States.

# Designing the Study

This chapter reports on The Determinants of Unintended Pregnancy Risk in New Orleans study. The study, funded by the U.S. Centers for Disease Control and Prevention (CDC), had qualitative and quantitative components. The overall goals of this study were to (1) determine what pregnancy planning means in the study community, (2) examine the perceived consequences of unintended pregnancy in this community, (3) assess factors that differentiate women with intended pregnancies from women with unintended pregnancies, (4) determine factors that differentiate effective from less effective contraceptive users, and (5) develop better measures for the multiple dimensions of pregnancy intention that may be useful in research and surveillance. Two sites were used: a public prenatal clinic and a public family planning clinic. In the prenatal clinic, we interviewed currently pregnant women attending their first prenatal (p.118) screening appointment. In the family planning clinic, we interviewed new and continuing users of family planning. This chapter reports the results of the qualitative phase of the study, specifically to inform goals 1 and 2.

## The Field Guide

Many research guides were developed by senior members of a research team and then modified during field testing. We set out to have a collaborative design process with all members of the research team from the beginning. Although this was more time consuming, it gave members of the team an opportunity to work together before data collection started and positions in the project solidified. The time was used to explore and articulate the goals for the study and share knowledge of the subject and expectations for the research. The research team—Ilene Speizer, director of the quantitative study, Carl Kendall, director of this study, John Santelli, CDC project officer, and field-workers Aimee Afable-Munsuz, Alexis Avery, and Norine Schmidt—collectively developed the field (interview) guide that was used for the qualitative phase of the study. The field-workers had substantial prior experience working with the target population on family planning issues.

First, the team talked about their experiences working on these research projects and their general opinions about adolescent knowledge and attitudes toward sex, contraception, and pregnancy among adolescents in New Orleans. Then we reviewed the proposal and available questionnaires from the quantitative study. The demographer on the team, Ilene Speizer, reviewed the findings from the NTFS, the national survey conducted about women’s fertility behavior. Following this, the team collectively identified factors that they felt influenced adolescent sexual behavior. We call these domains or themes. These domains served to organize the research guide. The domains and content area were derived both from the published literature and from personal experience with the target population. For example, we identified a domain of contraception that we called family planning (that was how the population referred to contraception). The team then identified a range of topics within the domains, and specified information to be collected about each topic. For example, within the family planning domain we wanted to know which methods were familiar to the young women, which ones were used, how they were used, and the drawbacks and benefits associated with each method. We wanted to know this both from the personal experience of these women and from a community perspective. At this stage the team did not worry about the length of the interview; what was important was participation in the process.

Next, the team focused on designing the questionnaire. Since we were collecting a mix of responses to closed and open-ended questions, and since (p.119) we were using three interviewers, we selected a rapid assessment design for the questionnaire. Rapid assessment procedures in anthropology began with Scrimshaw and Hurtado’s early efforts to involve health workers in conducting qualitative research on local understanding of health and illness (Scrimshaw and Hurtado 1987 ) and have become a very common approach for qualitative data collection in many fields. They mix open-ended questions that are suggested to the respondents with suggestions for probes and follow-ups, with a few close-ended questions. The interviewer is not required to read the question as written, but to focus on the underlying concepts and issues. This is facilitated by the participation of the interviewers in the development of the study and the guide. Items did not need to be presented in the order they occur in the guide, but the order was suggested. This kind of research instrument is called a semi-structured guide.

During the development of the guide, some of the discussion focused on what respondents would and would not feel comfortable talking about in the clinic setting and under the limited conditions of rapport established in single interviews. Here, we suggested that the interviewers depersonalize questions and ask about others—such as friends or community members. We also asked respondents to comment on hypothetical scenarios that we presented. The guide was repeatedly tested in the field for salience, ability to engender discussion, and duration. The final guide contained 115 open- and close-ended items. Open-ended items predominated and the instrument included free lists and responses to extended hypothetical scenarios. Free lists are a spontaneous listing of a response to a question. The only legal probe is “what else?” An example would be “list all the forms of birth control you know.” The scenarios detailed the travails of two teenagers in love, and choices when they started having sex and when they got pregnant. Respondents could provide their own conclusions for the short scenarios, or select from options and justify their choices. Among the close-ended items were dates and timing of pregnancies, and tables documenting contraceptive use.

The guide was developed to elicit women’s perceptions of community standards as well as their own expectations and experiences. The guide was long, but a culling of questions took place after saturation was reached on items. Saturation refers to the point when questions elicit no new information. For example, after sufficient information on community standards was elicited and no new information was being obtained, the sections assessing these standards were eliminated from subsequent interviews. This procedure is disconcerting for quantitative researchers, since it generates “missing information” for some informants, and questions by themselves may provoke ways of responding to other questions. We certainly wanted to avoid the latter effect, and the kind of “missing information” was of the general community knowledge sort. It is easy to test that the information already collected is generally (p.120) shared by the population by asking questions such as “Is it true that people around here think that …” in subsequent interviews.

The guide consisted of eleven sections: two of them collected basic demographic information, four elicited information on community standards, and the remaining five included a scenario, and questions about individual behavior as described in the following text. The sections on community standards covered general attitudes toward childbearing and contraceptive use, perspectives on pregnancy planning and contraceptive practices of the women’s friends and acquaintances, and attitudes toward sexual practices and the different motivations of boys and girls for sex (data were relatively uniform across respondents, became quickly repetitive and these sections were dropped from later interviews). The seventh section used a scenario approach to elicit respondent attitudes about abortion, marriage, sex, and adolescent childbearing. In the scenarios, Tanya, a 16-year-old high school girl, must make decisions about an unintended pregnancy with her 21-year-old boyfriend, James.

Sections eight through eleven dealt with the respondents’ own history of experiences and relationships. First, we gathered information about the age, residence, education, and occupation of current boyfriends, fiancés, and husbands, along with information about their partners’ goals and interactions with the interviewees. Specifically, we explored communication and power dynamics between the women and their partners. Second, we assessed women’s contraceptive history and asked a series of questions about pregnancy and childbearing and the impact of these pregnancies on relationships and plans for the future from a woman’s point of view. We did not interview their male partners for several reasons. It would have been very difficult to arrange logistically, but more importantly, we felt that our respondents would be more open and frank if their partners were not involved. Third, women were asked about their personal sexual histories, including the age at which they had sex for the first time, and their concerns about sexually transmitted diseases (STDs). Finally, women were asked about their experience with reproductive health services.

No names or patient numbers were collected, but because adolescents were included in the sampled population, the interviews were not treated as exempt from institutional ethical review procedures. The complete field guide and the consent procedures were approved by the institutional review boards (IRB) of the Tulane University Health Sciences Center, CDC, and the collaborating clinics. The interviews were conducted between February and August of 2001. No reimbursement was provided for participating in the study.

## Fieldworkers

As mentioned above, three female fieldworkers with masters of public health degrees and experience conducting qualitative research in inner-city New (p.121) Orleans communities were selected for the study. All the interviewers were non–African American; two were White and one was Asian. All were in their late 20s and early 30s. We selected the interviewers based on their skill and experience, as well as dedication to the topic. One fieldworker was the graduate assistant on the overall project, and would use the data for her dissertation. A second fieldworker was also a doctoral student at the time of the study.

Although taping and transcribing field notes are rapidly becoming standard for many qualitative inquiries, we decided not to do this. Taping and transcribing interviews would permit detailed content and linguistic analyses and provide a check of the performance of our interviewers. However, the clinics where the interviews were conducted were noisy, which would have required the informant to hold an intrusive and conspicuous tape recorder or microphone to the respondents’ faces. In addition, we felt that tape recorders would be viewed with suspicion. Further, recording and transcription adds substantial time and costs to the process. Given the instrument, confidence in the interviewers, the relatively large number of interviews, and the expectation that much of the content of each interview would be either short answer or redundant, we opted not to record the interviews. We taped a small number of interviews (approximately six, two for each interviewer) for interview quality control, but for all interviews, the fieldworkers transcribed responses in notebooks as the interview was being conducted. Later that day, they retyped and expanded those notes into electronic field notes using the research guide as a template. The field notes were reviewed for content and completeness by project staff and returned to the interviewers for revision when appropriate. During the first few days of the study, we attempted to provide daily feedback. This close supervision, especially during the first dozen or so interviews, is critical to the success of rapid assessment procedures or other qualitative data collection methods that use interviewers. Final versions were collated into the project database. Normally, an interviewer completed two interviews each day. The three field-workers transcribed verbatim as well as paraphrased responses, a method that guarantees both content relevance and the alertness of the interviewer.

Each week, fieldworkers met with the rest of the research team and were asked to provide summaries, including composite results, unusual cases, and to ask any questions that they had about the interviews. These meetings also provided a forum for the discussion of problems and challenges encountered during the interviews. At these meetings, interviewers would indicate if they thought that a particular informant was open and forthcoming. For the most part, the interviewers felt that their interviews and interaction with the women went well. They noticed that the women talked candidly about sex, and appeared quite eager to talk about topics that they admitted they might not discuss freely with friends or family. These findings were fairly consistent across informants and inspired confidence in the veracity of the reported (p.122) histories. After all the data had been collected, the interviewers participated in summarizing, analyzing, writing reports, and preparing this chapter.

## Recruiting Clients

At the prenatal clinic, fieldworkers recruited clients at their first prenatal screening appointment to avoid interviewing the same women twice. Most of the screening patients were in the early stages of pregnancy, although some were pregnant for 6 months or longer. In the family planning clinic, fieldworkers kept a list of women who had been interviewed to avoid duplication. This log was maintained separately from the interviews themselves, and was destroyed after the completion of data collection to preserve confidentiality. In both clinics, women 3 or 4 places back on the appointment calendar were recruited because they had the best chance of completing the interview that took between 45 minutes and 1 hour without interruption. Women were not selected by age, race, marital status, and childbearing status, but fieldworkers occasionally looked for women in certain age ranges to compensate for under-representation in the total sample. No inclusion or exclusion criteria were used to screen prenatal or family planning clients into the sample. The interviews took place in private, non-examination rooms of the clinics.

## Data Management and Analysis

A project database was created to archive interviews. The weekly summary meetings provided a forum to discuss themes relating to the research domains in the original research guide and to identify new, emerging themes. Quantifiable responses from the few close-ended questions in the guide were coded and summarized with SPSS®. The interviews were entered into MS Word® and indexed and searched with dtSearch® 5.25. User thesauri, a list of related terms were developed and potential relationships among terms explored. For example, condoms might be recorded in the notes as condom, rubber(s), or protection. A user thesaurus would search for all four terms at once with a single entry {condoms}. The final dimensions analyzed in this chapter were chosen based on findings that emerged from research meetings where we discussed results of interviews and preliminary analyses of terms and themes in the data. In the regular weekly meetings, we asked the field-workers to summarize each question in the guide across all their interviews, highlighting anything new that might have emerged that week. In these meetings, various terms or themes would emerge. After discussion, we would decide to pursue some of these themes in subsequent interviews. We also developed a spreadsheet for the interviews to track sociodemographic characteristics of the sample and responses to both closed and some open-ended questions. This (p.123) allowed us to check how frequently certain responses were found, and to informally explore associations. Thus, we had two kinds of data: impressionistic accounts of the way respondents answered our questions and how those accounts knitted together, and a database with “quasi-statistical” information about frequencies of responses and correlations. Neither source of information was treated as definitive by itself. Both the terms explored and the conclusions drawn were based on independent agreement among the entire research team including co-investigators, fieldworkers, and the project coordinator. Of course, some findings emerged as versions of this chapter were written. These findings were illustrated with quotes from the interviews. These quotes were selected because they either characterized the main positions shared by women in the sample, or they effectively linked apparently divergent positions.

# Findings

Seventy-seven interviews were completed, 37 in the prenatal clinic and 40 in the family planning clinic. The age of respondents ranged from 14 to 38 years. Half of the women were 19 years of age or younger, with the average at 21 years. Seventy-three women were African American, 3 were Hispanic, and 1 was White. Fifty-three were Baptist, 7 Catholic, 5 “other,” and 12 reported no religion or did not respond to this question. We measured degree of religiosity by asking the women whether they felt themselves to be “not,” “somewhat,” “very,” or “extremely” religious. A little over half said they were “somewhat religious,” 15 said “not religious,” and 12 described themselves as “very” religious. Only one woman answered she was “extremely” religious.

About a quarter of the sample were attending high school, and 17 women were attending or had completed college. Twenty-nine were not attending college but had completed high school. Ten women had dropped out of high school.

Among women aged 20 and above, 14 were unemployed and 23 were employed. Exactly half of the 22 women between 18 and 19 years were employed, as were 5 of the 11 between 16 and 17 years, but none of the 3 between 14 and 15 years were employed. Most of the employed women worked in the retail, restaurant, and tourism sectors or in administrative support positions.

Nine of the women reported they were not currently in a relationship. Forty-nine reported having boyfriends, nine were engaged, and nine were married. Some of the women with boyfriends reported that they were planning to marry in the near future but did not consider themselves “engaged.”

Age at first sex ranged from 12 to 22 years, with a median of 16. Among those who had ever given birth, age at first birth ranged from 13 to 28 years, with the median at 21 (mean 18.5) years. Of the 64 women who reported at least one pregnancy, 37 reported using a contraceptive method at the time (p.124) of conception. Of the 97 first or last pregnancies with detailed information, 45 took place while the woman reported using a contraceptive method. The frequency of contraceptive use at the time of pregnancy corresponds closely to the frequency of reported use in the year before the pregnancy in the quantitative data generated in the survey component of the study (see Speizer et al. 2004 for details of the quantitative data).

The classification of pregnancies as intended, mistimed, or unwanted was a difficult task. Our examination reveals the relevance of the multiple domains we identified, as illustrated in the account of this 26-year old single mother (family planning client):

When I got pregnant when I was 17, I had an abortion. I wanted to graduate high school and go off to college. I found out I was pregnant 2 weeks before graduation. That was messed up. I wanted to get an abortion, was too young to have a child, could have gone to college even with a baby but it would have been too hard. The second time I got pregnant when I was 24 and felt like I was old enough to have that baby. I was in school and didn’t think it would change things too much. I was in a bad relationship with that baby’s father so I knew I would have to have it by myself but I wanted her. Even though I didn’t plan on getting pregnant I wanted her once I did. It was different than the first time. I wasn’t using birth control and so I knew it was possible I would get pregnant, that’s why I was taking pregnancy tests every month. With me, I didn’t plan on getting pregnant and did, but it was because I wasn’t using birth control so I knew it was possible and it happened, so I didn’t really plan it but I didn’t really prevent it either.

The interview demonstrates how important contextual issues are for decision making about fertility. Timing and the difference between her expectation of ideal age for pregnancy and her actual age seem critical reasons for her initial abortion. With respect to her second pregnancy, a bad relationship with her boyfriend and being in college seemed plausible reasons for this woman to avoid pregnancy, but she did not use birth control. Although she did not plan to become pregnant, once she did, that became the reason to want the pregnancy, reversing our expectations of the sequence of planning. A conventional approach to determining whether this woman was experiencing unintended pregnancies would classify the second pregnancy as unintended. Yet, the account provides evidence to support the opposite conclusion as well. The woman in question, as did many others in the study, seemed to take risks with pregnancy that she manifestly—if somewhat ambivalently—claims to be avoiding, a phenomenon that perplexes many researchers in this field. Clearly, a complex web of motivations underlies her decision. The present study addresses only part of this paradox by providing insight into the cultural and social context in which key events and decisions take place. The following sections (p.125) will explore the multiple conceptual domains that shape women’s sexual risk-taking behavior and desires for pregnancy in the study population.

## Sex

Initiation of sexual intercourse, generally during adolescence, places a young woman at immediate risk of pregnancy, but motivation to initiate sex is often unrelated to a desire to have children. Our respondents are clear about what constitutes sex. Sex is penile–vaginal sex and it occurs soon after girls start dating. Dating means spending time alone with a partner. Sex often begins within the year after a girl starts dating, and a third of the sample population reported getting pregnant in the first year after they first had sex. Because dating starts at around age 14, this pattern contributes enormously to teen pregnancy. The women often treated sex as unavoidable and seemed unconcerned about the possible pregnancy and STD risks they were taking when engaging in sex. Although some women reported having discussed sex with their boyfriends before it happened, having sex was generally described as something expected and rather uneventful. The following passage illustrates this perspective:

(18-year-old, family planning client, 1 child)

I had first sex at 13, had sex for a year before I got pregnant. I didn’t use birth control. I didn’t worry about pregnancy or STDs. I did it just to do it, don’t even know why. Like, my cousin and him [first sex partner] was best friends, and my cousin was telling me that he [the friend] wanted to just do it, so I just did it.

Our respondents had a difficult time explaining why they had sex at an early age and often blamed it on the boys. One respondent remarked:

(17-year-old, family planning client, no children)

It feels good, they like it, they’re freaky, if you are young and the boy keeps bucking his head against you then you might do it for him, it’s like drugs, once you start you keep doing it, you have a weak mind, you should be thinking of other things. Don’t know really why girls do, don’t get it, I don’t even really like kissing.

Many responded with “don’t know” when asked why girls have sex. Others gave “disinterested” reasons: “[Reasons to have sex] just to do something, to feel important, just because other girls did it already.”

Informants were also asked to give reasons why boys have sex. According to some, sex for boys is a “need” or “urge.” According to many, boys are obsessed with how reports of their sexual activity boost their reputation. They reported that boys have sex to impress their friends or “be macho,” and to feel like men. Yet, sexual curiosity, feeling accepted among peers, and occasionally being in love were sentiments reported to be shared by both girls and boys. Further, (p.126) the ways in which sex asserts adulthood was a common theme, as illustrated in the following accounts:

(23-year-old, family planning client, 2 children)

Some boys think having sex makes them a man, some boys think having babies make them a man. They just trying to be big like that.

(22-year-old, prenatal client, on third pregnancy)

Make them [girls] feel grown, they want babies, most when they start having sex that young it’s because their fathers weren’t in the picture, or didn’t give them enough attention, so they need attention from another man.

Eventually women developed a justification for sex. Sex for these young women was reported to fill an emotional void. Sex can secure the attentions and affections of boys, and ultimately can bring a child, described by most women as one of the only reciprocated loves in a woman’s life. All in all, the picture these young women paint of sex and sexuality is an emotionally logical and coherent one. It legitimizes intercourse, rather than alternative forms of sex, and justifies it for its potential outcome as a life-giving event rather than as a self-indulgent act. The link between sex for reproduction—a sexuality that publicly denies or even condemns pleasure—and the idea that any pregnancy intention is real, but not straightforward, bespeaks an ambiguity that characterizes intentions.

(25-year-old, prenatal client, no children)

It just happens—it’s one of those things that happen. It’s gonna happen.

You want one of your own—after you take care of other kids soon you want one too. You can trick a guy and have one—girls do this cause they think the guys will stick around for them, some guys do and some don’t. Girls think it’s worth the try.

Thus, early sexual play and first sex exposes young women to the risk of an unintended pregnancy, especially because contraception is often not used.

## Childbearing and Motherhood

Respondents were asked at several points in the interview about their perceptions of childbearing and motherhood. A theme that emerged was that the women’s ideal childbearing goals seemed incongruent with their lived reality, in which early childbearing was a key feature. In fact, women in our study reported two different responses when confronted with an early pregnancy: an ideal one in which teen pregnancy was frowned upon, and an alternate one in which teen pregnancy was accepted and eventually supported by families and friends, one that sometimes brought greater intimacy and communication with family.

### The Ideal Reproductive Life Course.

When asked about the “best” or “ideal” time to have a baby, many responded that it was preferable to wait until after (p.127) school was finished and a steady job was found and the woman felt prepared to raise a child or was more or less “established”:

(18-year-old, family planning client, no children)

(Ideal time to have child) I think 24 or 25. I want to finish school. I want to have more to offer to my child when I have one. I’m here today worrying about my pregnancy test, so it’s funny to tell you this. But I do want to wait until I get established before I have children. I think you should stop when you are 30. After that you are old to be having kids. I don’t want to be 35 having a little baby, when your child is a teenager you’ll be too old to enjoy it. I think I want my baby before 30. If I don’t have one by then maybe I’ll change my mind.

Another common theme that emerged from the discussion was that a woman is not ready to have a baby if she lacks responsibility or cannot take care of herself. An interesting observation here is that this negative was not age related. Older women and younger women were considered equally able or unable to fulfill these criteria.

(18-year-old, family planning client, no children)

If you’re not ready for the responsibility, can’t take care of yourself, no job, if you got no goals as far as school, people that like to go out a lot can’t take care of a baby and do that at the same time.

(23-year-old, family planning client, 2 children)

You should be financially stable, emotionally stable, able to take care of the kids, finish high school. It isn’t really about age.

Reasons not to have a baby included schooling and valuing yourself:

(17-year-old, family planning client)

So you can finish school, education is important and you should concentrate on school. So you put yourself first, the boy should not be, he should be last and you should be concentrating on yourself. If you are too young; if you are in school you need to worry about the new LEAP test (Louisiana Educational Assessment Program, a standardized educational achievement test) so that you can graduate. You can’t do that if you are caring for a baby; your boyfriend is not serious about having kids.

Although many women consistently reported ideal expectations about pregnancy, they often found themselves living a different life. This situation was a source of anxiety for many young women, like this 20-year-old mother (family planning client) of a 4-month-old son, who reflected on how she was unable to live up to her father’s expectations:

My dad, he’s a minister and it took him some time [to accept the pregnancy]. He found out when he saw my navel popping out, I was 7 months pregnant. I was (p.128) scared to tell him. He was disappointed. My older sister got pregnant at 16. I was his baby. He didn’t think I would get pregnant without being married. Even though I was in school and older, it still was hard for him. I was a good girl to him, his little girl. Then they treated me differently. I made the choice to be an adult. I was not the baby any more. They wanted me to move out and get a job and take care of myself like an adult. It was stressful.

These initial feelings of surprise and confusion expressed by the women and their families were later tempered with the unconditional support of family and friends, as discussed in the next section. As these women lived out their own reproductive careers, they described their own norms and values as an alternative to the ideal.

### An Alternative Reproductive Life Course.

Many young women—after espousing the ideal life course—also described an alternative one. The goal of this alternative life course is to complete fertility at a very early age. According to one young woman, desiring to complete fertility in the early 20s seemed to be pretty common among her peers:

(17-year-old, family planning client, no children)

They want to have their family soon, not worried about much after graduating high school. Some act like they want to go to college but they don’t really want to, if they had a baby they’d be fine. Most of my friends do want to finish [high] school first. They think they should have all their babies by the time they are 22. Get it all done with. The school I go to has about 1100 kids and lots of the girls are pregnant. In the graduating class maybe there is 200 boys and 100 girls and maybe 30 of those girls are pregnant. Some in my class are already working on their second child. Now they talk about finishing school but it is so hard for them to really do it, how would they have the time?

In fact, many younger respondents spoke about the benefits that having a baby at a young age could bring. They revealed that a baby was an opportunity to have someone to love, to receive love back, and to receive attention either from a boyfriend, other friends, or parents. Many of the younger respondents stated that pregnancy was a way to restore a young woman’s self-confidence. This young prenatal client reflects some of these issues in the following quote:

(15-year-old prenatal client pregnant with second child, first pregnancy at 13 years of age)

They really give me a lot with these babies, I got a lot of new attention when before they really didn’t. They are making sure I’m ok, buying lots of things, didn’t buy me anything the whole time [prior to first pregnancy].

Older women were more likely to mention starting a family and settling down as reasons for having a baby (ideal expectations). Still, they also articulated (p.129) feelings similar to their younger counterparts, even hostility toward their parents. A 29-year-old pregnant woman listed the following reasons for having a baby: “Makes you feel important, to get attention, to get at your parents.”

Furthermore, although women acknowledged potential obstacles in the future, there was a general sense of acceptance of an unplanned pregnancy by them and their community and little apprehension about the long-term impact. Surprisingly, many women reported that their first pregnancy had little or no effect on their dreams or goals. Of those who admitted their goals would have to be put on hold, many did not seem too disappointed about the unexpected turn of events. In fact, some women perceived an early pregnancy as something that brought meaning into their lives, indicating that it made them more motivated and more diligent about achieving their goals:

(20-year-old family planning client talking about her four-month old first child)

My life is more meaningful now. I’m not trying to get the guy anymore, wasting my time. Now I’m trying to get through my classes. I’m more focused. I’ve got to support my baby.

To summarize, although women report an ideal time to have children, they also accept an alternative life course that permits variation in the timing of these events. Whether this acceptance is because of alternative or changing ideals or reflects acceptance of the reality of mistimed or unwanted pregnancies can be further enlightened by examining factors that affect women’s motivation and control over pregnancy timing including relationships, contraception, and abortion.

## Marriage and Partner Relationships

First pregnancy had a special meaning in women’s romantic lives. Many young respondents believed their first pregnancy affected their relationship with their boyfriend in a positive way. They felt that the pregnancy made them grow closer. When asked how their first pregnancies affected their relationships, two young women responded:

(21-year-old prenatal client pregnant for first time)

It brought us closer together. It’s like we got a bond now.

(17-year-old prenatal client pregnant for first time): Well, he [is] closer now. He just be doing different things. Every time he comes over, he touches my stomach. He rubs my stomach and asks me if I feel alright.

These positive sentiments were not always long lived. As the demands of motherhood became more real and more taxing, so did the demands on the relationship, often ending it. In fact, most women no longer had a relationship (p.130) with the father of their first baby. Many women in the sample reported a general sense of scepticism about men, relationships, and marriage.

Unstable relationships characterized many of these women’s lives, and many had to face a reality that foreshadowed life as a single mother. Generally, the women were determined to raise their children without the support of the men in their lives, as articulated by this 26-year-old single mother of a 2-year-old girl (family planning client, who had an abortion at 17):

I didn’t think he would care so little for the baby. I thought it would be ok with him but even if he left I wanted to have that baby. My girl could care less about him now. Most girls are daddy’s girls and love their father, but my girl could care less about him.

Furthermore, many women, despite their age, did not foresee marriage at all. Just as the goal of “being established” before getting pregnant was somewhat “idealistic,” so was the goal of being married. In some cases, marriage was even viewed as undesirable because it changed relationships in a negative way. Ironically, for advocates of marriage, it was perceived as burdensome and signaled an even greater commitment than parenthood, as this young woman explains:

(15-year-old prenatal client, currently pregnant with second child from a father different than that of the first child)

Yeah, it’s serious. We’re having this baby together. I ain’t marrying him. I’m not ready for that, wait until I get older. I’m not worried about being married. My momma isn’t married, she’s staying with my brother’s daddy. Getting married isn’t important really, as long as you are together. If you have a baby then that’s one thing. You don’t need the papers. Being married is different, it changes your life. (More than having a baby with someone?) Yeah, it’s different, it’s another person, adult in your life. Boyfriends get all unruly and then they can go, not when you’re married.

Many of the women we interviewed recognized that the father would not necessarily be in the picture for the long term, even if the pregnancy was being used to “keep” the man. Women knew and accepted that pregnancy is associated with the risk of being a single parent.

## Contraception

All respondents had experience using birth control. A common scenario in this community is illustrated with the following comment:

(20-year-old, family planning client, 1 child)

I was using condoms only when I first started having sex and then decided to get pills my freshman year of college. I took them for a year and a half. They were giving me (p.131) headaches and making me have worse cramps but that’s not why I stopped taking them, just didn’t like taking them. I was using condoms after that and now after my baby I’m on Depo. It has made me bleed a lot, but that’s been my only side effect. I can’t tell if it’s making me gain weight because I just had my baby.

Misconceptions about use and effects of methods seemed to drive method switching. When women switch methods they may be more vulnerable to pregnancy. Many women switched because the effectiveness of methods was suspect. They were also uncertain about the plausibility of planning a pregnancy:

(38-year-old, family planning client, mother of 3 children)

You know, I was using pills when I got pregnant with my last 2 children and I still got pregnant, so I don’t know. Sometimes I wonder if God’s got plans for me that I don’t know about. With my last pregnancy I wanted to get my tubes tied and something happened with my delivery and they couldn’t do it then. Must be something with me, keep having these kids at this time in my life. I was not planning to but it happened anyway. I think we can do what we can do but sometimes things just happen to us that we aren’t planning.

In these cases, the women’s uncertainty about contraception was related to (1) misinformation about hormonal methods and experience with a wide range of side effects; (2) poor experience with condoms; and (3) the fact that there was very little discussion about contraception between the women and their partners. We cannot rule out difficulties with the quality of care these women received or poor patient–provider communication. We elaborate briefly on the first three areas.

### Hormonal Methods: Side Effects, Misperceptions, Misinformation, Limited Access.

“The pill” and “the shot” (Depo-Provera) were the methods most commonly used, yet women reported a range of serious side effects with these two methods. Irregular bleeding, weight gain, nausea, leg pain, varicose veins, and mood swings were reported by women on the pill. Prolonged or breakthrough bleeding, headaches, and weight gain/loss were reported by women on the shot. Additionally, fatigue, migraine headaches, calcium depletion, and links to cancer were side effects that women reported to be associated with the shot. According to several women, the side effects often became so unbearable they had no choice but to discontinue the method they were using. These respondents both got pregnant almost as soon as they stopped contracepting.

(26-year-old, family planning client, 1 child)

I went on pills after my abortion until I was 21. I went on Depo after that for a couple of years but then started having side effects. I was bloating and had enlarged breasts and then having break-through bleeding. I thought I was pregnant so didn’t get my next shot. I kept asking the nurses here why I was all of (p.132) a sudden getting these side effects and all they could say were they were side effects and it was ok but that wasn’t good enough so I stopped the shots.

Similar to side effects, which concerned many women, misperceptions and misinformation about contraception served as potential barriers to effective method use. Women who had used or were using the pill or the shot often reported missing pills, failing to return to the clinic for a new pill prescription, or failing to return to the clinic for their trimonthly injection, both because of their imperfect knowledge of the mechanism of action of these birth control methods and because of financial difficulties:

(23-year-old, family planning client, children)

I got on the pill at 15, before I was sexually active. It was a birthday present from my Aunt and Grandmother. I was seeing a boy and they brought me for pills. Then I got big on the pills so I stopped them. I was using condoms on and off and got pregnant at 18. After my son was born I got on Depo, it was good, no side effects, I liked it. I lost my Medicaid and couldn’t afford to get the shot at my doctors, it was $60 a visit and$20 a shot. So I got off it. They told me there that I wouldn’t get pregnant for a year after stopping, but 6 months later I got pregnant.

Women had many misperceptions about contraception, including the injection’s duration of effectiveness, as mentioned earlier. Other concerns included the risk of infertility and cancer from hormonal contraception and misinformation on how to take pills correctly. Women reported that they needed to “rest” their body from birth control, particularly hormonal methods. We could not discover the source of this information, although a few women mentioned learning about this from their family planning providers. Side effects of hormonal methods and misperceptions about method use led women to cycle these methods on and off, resulting in periods of pregnancy risk, unless condoms were used in the interim. The next section discusses condom use and perceptions among the women interviewed.

### Condoms.

Almost all women reported having used condoms, often called protection. When used, they were often employed temporarily or as a default method during the transition between two hormonal methods. Respondents generally had little faith in the effectiveness of condoms. Many reported having condoms pop or fail, although some admitted it was the condom slipping off and not tearing or ripping that was responsible for pregnancy. Seven women even contended that men poke holes in condoms on purpose so they can get the woman pregnant. According to one family planning client:

(19-year-old, 1 child)

I used condoms when I was having sex at first. I would bring ‘em. I didn’t want him to use his ‘cause who knows what kind they were, if they were old or something. We used condoms but one popped and I got pregnant. (How did it pop?) (p.133) It just did, after we were done it was popped. I check ‘em too. I make sure there ain’t no holes in ‘em. So I got pregnant. (Did that only happen once, that the condom popped?) Yeah. After my son [was born] I went on Depo in the hospital and that’s what I use still.

Another common reason mentioned for not using condoms consistently was that the women did not always have them around. Also, women reported that requesting a partner to use a condom can undermine the trust in the relationship. When describing the first time she had sex, one woman expressed her reluctance to insist on using condoms because she feared that it would jeopardize her relationship with her first boyfriend:

(20-year-old, family planning client, no children)

(When did you first have sex?) My senior year when I was 18. His name was Harry. We went to 2 different schools but we were in this program where we went to Delgado [a community college] in the morning. He was the first person I was talking to in the 9th grade, my first boyfriend or relationship. We always talked about it [having sex] because he always brought the subject up. I was scared. He didn’t use a condom. I asked him but he talked about, “Oh I trust you and you should trust me.”

Men are presented in these interviews as playing an intentional role in contraception often through sabotage or manipulation. This situation is exacerbated by the general lack of discussion about contraception between women and their partners.

### Discussing Contraception with Partners.

Women usually took it upon themselves to initiate a contraceptive method, because they reported that men generally responded apathetically when the topic was introduced. Even though women were cognizant of the potential risks to which they were exposed, they were reluctant to confront their partners about condom use (even if they suspected STDs) or other contraceptive methods, often leading to an unanticipated pregnancy.

(20-year-old, prenatal client, children)

After my first son I went on Depo and then on pills. It was my decision. We don’t talk about it much. He knows I wouldn’t sleep around and I think he doesn’t. I should know better because he goes away. If he brings back something (STD) I would just die but I just don’t do anything about it.

(26-year-old, family planning client, child)

We use condoms, not every time but most of the time. He don’t really worry about it at all, I’m the one who’s here getting the shot. I decide on it. He would use nothing if it was up to him. He doesn’t really like condoms. He doesn’t like to use them.

Women were using contraception based on their own initiative to avoid an unintended pregnancy. In more challenging situations, however, such as (p.134) having sex with someone for the first time or when the partner disapproves of birth control, many women seem more willing to risk pregnancy than to confront their partners.

## Abortion

To generate an understanding of unintended adolescent pregnancy and abortion, the questionnaire included several hypothetical scenarios describing a 16-year-old high school student named Tanya and her 21-year-old boyfriend James. In response to a scenario in which Tanya gets pregnant accidentally, there seemed to be a strong sentiment that the right thing to do was to keep and raise the baby even if the boyfriend was not willing to assume the role of father or if it interfered with Tanya’s career plans. Respondents generally assumed that Tanya’s family would help out, that she could “get the boy on child support,” get a job herself, or get help from the government, and that things would work out one way or another.

In addition, some respondents seemed to suggest that Tanya’s decision to keep the baby signaled greater self-confidence, responsibility, and maturity, a possible indication of her passage into adulthood. In contrast, when respondents raised the issue of abortion spontaneously, they portrayed it as less admirable because it allowed young women to duck the inevitable responsibility of motherhood.

Of the 72 women who responded to the scenario questions, 47 were opposed to abortion for any reason. Women commonly referred to abortion as “killing the baby.” Many of them expressed feelings about abortion similar to those expressed by this 15-year-old prenatal client, pregnant for the first time:

SCENARIO: Tanya and James talked about it (the unintended pregnancy). James is really worried about making enough money to support Tanya and the baby. Tanya wants to have an abortion. What should she do?

R: She shouldn’t have the abortion, her mama didn’t kill her, why should she kill the child? He’ll make some money, and save it.

Twenty-five of the 77 women felt that abortion was an acceptable option. A 22-year-old pregnant mother of three (on her fourth pregnancy) expressed the following:

R: If she wants it (the abortion), she should have it no matter what he say. Because sooner or later he’s gonna be gone.

Women’s personal experience with abortion coincided with these attitudes. Abortion was used rarely in this sample. Six women had a total of seven abortions in this group. The perceived immorality of abortion, combined with the (p.135) women’s perceptions of and experience with contraception, restricted the women’s choices as articulated by this young woman:

(18-year-old prenatal client, 5-month-old child)

All the ones that take the shot, none of them get pregnant. But most of the ones who take the pill got pregnant. I knew that condoms break. I should have expected it (pregnancy) to happen. I don’t mind having children. I want children, I love babies. I was the only child. It’s not like I tried to get pregnant. But I feel if it does happen, I would accept, I would never get an abortion.

Ambivalence toward contraception, rejection of abortion, and acceptance of pregnancy created a different spectrum of choices than might be thought for these women, one which excluded pregnancy termination and treated pregnancy as the inevitable consequence of sexual intercourse, no matter the woman’s intent.

# Discussion

It is important to emphasize, as Luker ( 1999 ) does, that the discourse of “unintended pregnancy” today refers to a different set of issues than when it was introduced in the past. As discussed earlier, a study on unintended pregnancy conducted in the 1960s might have interviewed mothers in their 30s or 40s with large families to explore unwanted pregnancies at the end of their childbearing period. But the bulk of unintended pregnancies today are early (mistimed) pregnancies (Brown and Eisenberg 1995 ). Certainly different factors are involved in the intentionality of pregnancy measured at these two separate times. Our findings generally characterize women’s preferences at the beginning of their reproductive careers, as opposed to women’s or couples’ views of how long to extend childbearing.

To plan a pregnancy, a woman would have to feel in control of many of the factors—both personal and structural—we outlined earlier. This study suggests that in the lives of the women we studied, having control over these factors is not a realistic expectation. In these circumstances women’s report of the intendedness of pregnancy often seems more like a rationalization after discovering that they are pregnant rather than the outcome of a deliberate choice. The notion that planning pregnancy is irrelevant for certain women is not a new one. Moos et al. ( 1997 ), who conducted focus groups with 18 African American and White women in North Carolina, suggest that the concept of planning a pregnancy might not be salient in lower-income groups. However, Barrett and Wellings ( 2002 ), who conducted in-depth interviews among different ethnic groups in London, England, provide a cross-cultural perspective among a more diverse audience. Of the 47 women interviewed, 18 were not born in (p.136) the United Kingdom and the pool represented great ethnic diversity. Their data suggest that the act of deliberately planning a pregnancy is foreign to many women, despite their socioeconomic status and/or ethnic origin. In their study a “planned” pregnancy had to meet four criteria: intending to become pregnant, stopping contraception, partner agreement, and reaching the right time in terms of lifestyle/life stage. They conclude that women tend not to use terms like “planned” and “intended” spontaneously, and that there is variation in women’s understanding of these terms. They also leave open for discussion the findings that the “adoption of planning behavior some of the time suggest that pregnancy planning is an available choice” and that “not planning may have particular advantages in certain contexts and needs further investigation” (Barrett and Wellings 2002 :555).

Our study sheds light on the applicability of the concept of “planning” or “intending” pregnancy. The study illustrates that the elements we explore in our domains—knowledge, access, and support for use of contraception, the value of pregnancy timing, and supportive relationships with partners—that might make planning pregnancy relevant are either absent, under transformation, or not perceived as under women’s own control.

When discussing their first sex and first pregnancies, many of the women in our study described inadequate preparation for sex and contraception. Contraception as understood in this community has unpredictable consequences and is loaded with economic, physical, and psychological costs. Hormonal methods are perceived to take a physical toll on women’s bodies, and continued use is easily disrupted by missed appointments and/or the inability to make payments. The effectiveness of the methods themselves is suspect, knowledge and use of them is inadequate, and reported condom failure is high. Women’s partners are often able to manipulate or sabotage the use or nonuse of contraception.

These factors—side effects, negative knowledge and attitudes, and lack of partner support—that make contraception difficult to adhere to are reported by women in other studies (Miller 1986 ; Sable and Libbus 1998 ). Further, reports of condom breakage and/or slippage are consistent with findings of several clinic-based studies, although the magnitude varies according to the population studied (Crosby, Sanders, Yarber, Graham 2003 ; Macaluso et al. 1999 ; Spruyt et al. 1998 ). According to the most recent of these studies, which sampled both men and women in a university setting, reports of condom slippage/breakage reached 28% among those who had reported they used a condom in the last 3 months (Crosby et al. 2003 ). Within this climate of family planning uncertainty, choosing to keep a pregnancy may be seen as a feasible and responsible action, while controlling conception may not. The family planning choice appears to be between abortion and pregnancy, not between pregnancy and nonpregnancy, and abortion is not an option for many women in this sample.

(p.137) Additional family and community factors influence pregnancy. For example, the negative consequences of early pregnancy seem less relevant to this population of women. Educational and career opportunities are often lacking; fathers of the babies are often not present; and marriage is viewed as a burden to women and sometimes an even greater commitment than motherhood itself. Zabin ( 1999 :2) makes a similar point when she refers to the “weakness of couples’ timing intentions” in the context of unstable relationships. She argues that women who expect to marry in the future may place more value on avoiding pregnancy with a casual partner than women in similar relationships who do not foresee marriage at all. As suggested by several studies (Miller 1986 ; Schoen, Astone, Kim, and Nathanson 1999 ; Stevens-Simon, Beach, and Klerman 2001 ; Zabin, Astone, and Emerson 1993 ), effective planning or behaviors necessary to avoid conception occur only when there exist strong motivations and a supportive environment to remain nonpregnant. Our study finds that the women in our sample express these motivations, but they also describe conditions that might make pregnancy, or even an unplanned pregnancy, an option valued in this community.

Our study also suggests that the desire to assert adulthood, develop both natal and conjugal family stability, and attain greater intimacy with partners are possibly more powerful motivations for pregnancy than idealized scripts for career and marriage are for postponing pregnancy. These findings are consistent with the earlier literature on adolescent childbearing in poor African American communities (Anderson 1994 ; Burton 1990 ; Geronimus 2003, 1991, 1996 ). Much of this literature suggests that the idealized and conventional female life course that is promoted in higher-income groups—one that prescribes the sequence of educational achievement, career fulfillment, and then family formation—needs to be reconsidered. Anderson’s ( 1994 ) ethnographic work in inner-city Philadelphia suggests that as urban poverty persists, the conventionalized family constituted by love, marriage, and career loses its meaning. In this context, early pregnancy is a consequence of young women’s search to fulfill normal developmental and emotional goals, such as the search for identity and love (Anderson 1994 ). Burton’s ( 1990 ) work in a poor suburban Northeastern community also characterizes an accelerated family timetable, which she ascribes to perceptions of early mortality and the low probability of marriage, and gives rise to early childbearing.

In line with our critique of the concept of pregnancy planning, Geronimus ( 1996, 2003 ) urges public health policy analysts and researchers to reconsider how they have come to understand and frame the public health issue of early childbearing in poor African American contexts. She reminds us that fertility norms are culturally and socially defined, and demonstrates this notion with empirical evidence of differential age-at-first-birth distributions in several US contexts (Geronimus 2003 ). She argues that in the case of poor, urban, African (p.138) American populations, an early fertility timing norm is a collective strategy in response to poverty and the rapid deterioration of poor women’s health (Geronimus 2001, 2003 ). She claims that “poor women may attempt to fulfill their multiple roles and obligations in a sequence that fits the realities of different social circumstance and health-risk profile than those familiar to many researchers and policy analysts” (Geronimus 1991 :466). From this perspective, it is reasonable to conclude that the material, gender, and other socioeconomic realities of the women in our study give rise to a world in which planning pregnancy, in the traditional sense, or from the majority’s perspective, loses its force. This reality shapes, and to some extent, makes uncertain, the elements—sexual experience, contraception, timing of motherhood, relationships with partners—of women’s lives that make pregnancy planning salient.

Given that this study reports on a small sample of 77 women recruited purposively from publicly funded reproductive health clinics in New Orleans, we cannot make substantiated claims for the generalizeability of the findings presented here. However, as discussed, many of the themes that emerged in this study are consistent with the unintended pregnancy literature and with the literature on adolescent childbearing in poor African-American communities. While these findings may not be strictly generalizeable beyond our sample, to the extent that poverty and socioeconomic disadvantage shape personal motivations and the traditional institutions that make pregnancy planning salient, the themes presented here are relevant to other populations (see Anderson 1994 ).

# Conclusion

The portrait of young men and women faced with poverty and reduced schooling and/or job opportunities, in an environment of unstable and impermanent relationships and early sexuality is certainly not unique to the women in this study, New Orleans, or even the United States. To the extent that this chapter contributes to understanding the interplay of reduced opportunities, sexuality and fertility, and community and individual response, it contributes to more universal concerns.

As we have presented in this chapter, women’s decision making about sexual risk taking and childbearing is multifaceted. Our respondents present complex stories to support their childbearing decisions:

• idealized expectations set against poverty and poor career opportunities;

• gaming with the chance of conception in the heat of the moment;

• conventional notions of sexuality and the inevitability of early intercourse;

• a community with a high prevalence of teen pregnancy and acquiescence to it after the fact;

• the volatility of relationships and marriage;

• (p.139)
• imperfect contraceptive practice and knowledge; and

• the rejection of abortion as an alternative to contraception.

These concerns combine to explain the difference between general intentions—perhaps formed in retrospect—reported in surveys and the intentionality of pregnancy at the time of conception.

Returning to the theme that began this chapter, the simple statistical indicator of unintended pregnancy itself is a poor proxy for the rich social, cultural, and health information that surrounds this concept. While perhaps useful for advocacy, it provides little insight for developing health programs, or understanding the complex web of social determinants that define health and ill health and create healthy outcomes. As public health moves to understand how social and economic conditions produce health and illness and to redress health disparities as a primary role, the unpacking of popular indicators, and the detailing of the multidimensional web of social, cultural, political, and economic determinants of health will continue to be an important role for medical anthropology.

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