Director’s Note: This week, we feature research [1] summarized by Dr. Sidney Harrison, who completed the FACTS elective while in medical school. Although preconception counseling is strongly encouraged in primary care settings, reproductive life planning is often omitted from these conversations. The study by Wang et al [1]examined the efficacy of a single screening question to assess pregnancy intention, and its association with pregnancy incidence rates among female nurses. The research was published in JAMA Network Open in 2023. To learn more about the reproductive life plan and many other topics in women’s health, browse our online, self-paced CME course!

Introduction

The World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG) advocate for including preconception counseling in the primary care assessment. Despite this, evidence shows pregnancy intention is not commonly discussed with women of reproductive age, leading to gaps in reproductive healthcare. Several barriers may contribute to these gaps. Research reveals low utilization of folic acid supplements prior to conception and a high number of unintended pregnancies. Social bias may influence reporting of pregnancy intentions, and current screening methods may not adequately capture the nuances of pregnancy intention.

“Evidence shows pregnancy intention is not commonly discussed with women of reproductive age, leading to gaps in reproductive healthcare.”

The One Key Question initiative proposes a simple screening query: “Would you like to become pregnant in the next year?” While this concise approach may open a door to more frequent preconception counseling in primary care, its effectiveness remains unexplored. This study by Wang et al aims to investigate the correlation between such screening questions and pregnancy probabilities over the course of a year, and the variability of pregnancy intentions among women over time.

Methodology

Participants in this study were selected from the Nurses’ Health Study 3 (NHS3). The NHS3 is an ongoing online cohort that includes female and male registered nurses or nursing students born after January 1, 1965. As of April 2022, the study had recruited 48,919 women. Every 6 months, follow-up questionnaires were collected to update participants’ lifestyle, reproductive, and medical information. Additional surveys were sent every 3 months to those actively attempting to conceive. To account for potential questionnaire return delays and early pregnancy detection challenges, participants were monitored for 18 months to identify pregnancies occurring within 12 months after completing the initial survey. Inclusion criteria stipulated returning at least one follow-up questionnaire within 18 months. The study officially concluded on April 1, 2022 with 48,700 participants. Upon exclusion of certain groups based on pregnancy status, age, menopause, surgical procedures, and incomplete data, 18,376 women were included in the final analysis.

A sequence of questions monitored pregnancy intentions and status. The participants were first questioned about current pregnancy status. Women who were not pregnant were asked whether they were actively attempting to conceive or considering pregnancy within the coming year. Subsequent questions addressed the duration of attempts and contraceptive usage for those actively trying. These inquiries were part of both baseline and follow-up surveys. Examination of the duration of pregnancy attempts among those actively trying aligned with expected patterns.

Results

The research included 18,376 premenopausal, nonpregnant women primarily from the U.S. with an average age of 32.4 years. Initial findings showed 5.5% of them were actively seeking pregnancy, 13.3% were considering it, and 81.2% were neither seeking nor considering pregnancy. Among those asked about contraception, most women who were actively seeking pregnancy were not using it. Around one-third of these women had been attempting pregnancy for over a year. They tended to be married, without children, and more religious.

Over 12 months, 1,314 pregnancies occurred, and women who were actively seeking pregnancy had a higher likelihood of becoming pregnant. Their crude cumulative pregnancy probability was 38.8%, significantly surpassing those contemplating (27.6%) and not contemplating (1.7%). After demographic adjustments, women actively seeking pregnancy were 23 times more likely to conceive, while contemplators were 13 times more likely compared to non-contemplators. Time-to-pregnancy varied, with median durations of 3.3, 6.7, and 7.8 months, respectively. Associations between initial intention and pregnancy within 12 months varied by age, partnership status, race/ethnicity, and parity. Notably, intention strongly affected the likelihood of pregnancy, especially among older women, non-Hispanic Whites, single individuals, and nulliparous women.

“Women actively seeking pregnancy were 23 times more likely to conceive, while contemplators were 13 times more likely compared to non-contemplators. Time-to-pregnancy varied, with median durations of 3.3, 6.7, and 7.8 months, respectively.”

Cumulative pregnancy risks were higher for those under 35 years, excluding those with infertility history or prolonged attempts. Findings were consistent even when COVID-19 data were omitted. A significant portion of women changed their pregnancy intention during follow-up, particularly those initially considering pregnancy. Changes were more common among women aged 25 to 34, married, without children, and with higher education levels. The frequency of intention changes was similar when only the main follow-up questionnaires were considered.

Discussion

The study by Wang et al of more than 18,000 nonpregnant women of reproductive age discovered a connection between pregnancy intention and subsequent pregnancies within a year. Women who were actively seeking pregnancy exhibited a significantly higher likelihood of conception (38.8%) compared to those contemplating (27.6%) or neither trying nor contemplating (1.7%). Among participants who reported their intention multiple times, approximately half of those initially contemplating pregnancy altered their intention within a year. Regular screening for pregnancy intention could inform clinical interventions like contraceptive/family planning discussions or preconception care such as recommending folic acid supplementation.

“Among participants who reported their intention multiple times, approximately half of those initially contemplating pregnancy altered their intention within a year.”

This research also shed light on the probability of pregnancy over 12 months and the time-to-pregnancy based on varying pregnancy intentions. These findings echoed previous research on fertility behavior, emphasizing the changing nature of pregnancy intentions over time. Pregnancy intention showed a weaker correlation with pregnancy within a year among specific demographic groups, highlighting the need for tailored approaches in reproductive healthcare. Additionally, the study estimated a 12-month infertility prevalence of 33.7% among women who were actively trying, indicating a higher rate than previously reported in the U.S. This underscores the importance of a comprehensive approach when evaluating infertility prevalence.

The strengths of this research lie in its large prospective design with frequent follow-up intervals, enabling thorough tracking of pregnancy intention and status. The use of a single easy-to-implement question enhances its clinical applicability. The study emphasizes the importance of recognizing the fluidity of pregnancy intention in research contexts. It also considers the social and demographic factors influencing unintended pregnancy.

“The study emphasizes the importance of recognizing the fluidity of pregnancy intention in research contexts … (and) the need for primary care physicians to assess their patients’ intentions regarding conception.”

Limitations include the homogeneity of the participant pool, comprising mainly non-Hispanic White nurses, potentially limiting generalizability. The lack of data on the partner’s pregnancy intention and incomplete information on contraceptive use at baseline pose additional constraints, warranting further investigation in diverse populations. Future studies should focus on determining the reproducibility of these findings in more diverse populations.

This article emphasizes the need for primary care physicians to assess their patients’ intentions regarding conception. Without this vital information, many patients lack the necessary preconception knowledge and planning essential for a healthy pregnancy.

Editor’s Note: For a deeper dive into reproductive life planning, read Dr. Kaitlyn Eckert’s summary of research titled, The Reproductive Life Plan: A Practical Tool for Family Planning Counseling. It was published in the FACTS blog in 2023.