Commentary: Midwife Points to Missing Link in Halting Unintended Pregnancies

July 2012E. Angel James

In the United States, studies have shown that almost half of all pregnancies are unintended. When those pregnancies continue to birth, negative health, economic and social outcomes for mothers, infants and society tend to follow.

Yet reversing this trend has proven to be extremely difficult. Despite pockets of improvement, such as the decline in pregnancy rates among California adolescents, national rates of unintended pregnancy have remained intractable for over 30 years, since the Office of the Surgeon General first recognized the problem in the 1979 Healthy People report [1,2].

Perhaps that’s why the US Department of Health and Human Services has chosen to accept the Institute of Medicine’s recommendations that contraceptives and contraceptive counseling be covered for women without cost sharing by all new health insurance policies and state exchanges under the Patient Protection and Affordable Care Act (PPACA, or ACA for short). This makes the ACA – recently upheld by the Supreme Court – the first federal law to offer interventions for unintended pregnancy that go beyond health education.

Huge Step Forward May Not Be Enough

E. Angel James It is a huge step forward in a landmark piece of legislation. Yet those of us who work in this field know that simply increasing access is not likely to be enough to decrease the rate of unintended pregnancies nationwide.

The reasons are complex, but they almost certainly include the negative ways fertile women are perceived and portrayed among policymakers and throughout society. A more thorough understanding of the effect these perceptions have is particularly important today. No one should think that the ACA’s provision for increasing access to contraception will somehow solve the problem of unintended pregnancies.

Those most at risk of experiencing an unintended pregnancy in the US are young, poor and minority women [3]. Decisionmakers tend to view these women as having little power and thus little influence over policy decisions. That lack of power or value is consistently reinforced in a variety of ways – from Rush Limbaugh’s recent comments about college women who use contraceptives and Michigan legislators’ rejection of debate that referenced female anatomy to the iconic connotation of the “welfare queen” and the ongoing controversy regarding sexual education.

This dynamic almost certainly means that in the policy realm access to contraception will continue to come under attack. One need only consider the recent controversy over religious exemptions for women who work for or receive health care from religious institutions to know that one provision in one law will not alone counter images and ideas that have cultural roots that extend decades – some would say centuries.

Perhaps more importantly, women’s perception of themselves, especially the self-perception of the most vulnerable women – their education and acculturation tells them repeatedly they have little power and little value – makes it much less likely they will take advantage of this expanded access, should it survive the political attacks. Turning back the forces that constantly reinforce that perception is a much steeper challenge than fighting a legislative battle.

Yet until we address the underlying social context in which unintended pregnancy occurs, the monumental step of reframing unintended pregnancy as an issue of access, however admirable, is unlikely to be enough. There is much more work to be done.

E. Angel James is a predoctoral student in the UCSF School of Nursing Department of Family Health Care Nursing. She is the 2012 recipient of the 13th Annual Ann Klobas Outstanding Health Policy Paper Award from the Department of Social and Behavioral Sciences at UCSF School of Nursing and a recipient of the National Institute of General Medical Sciences Initiative for Maximizing Student Development fellowship. Her research interests include unintended pregnancy and the nursing role in unintended pregnancy prevention and abortion care. She has many years of experience as a nurse in women’s health, in both hospital and clinic settings, including working as a certified nurse-midwife and nurse practitioner for Planned Parenthood of the Pacific Southwest and her current volunteer work as a clinician at the Women’s Community Clinic in San Francisco. She received her BSN and MS from the University of Illinois at Chicago.


1. Boonstra HD. Winning campaign: California’s concerted effort to reduce its teen pregnancy rate. Guttmacher Policy Review. 2010;13(2):18-24.

2. Office of the Surgeon General & Office of the Assistant Secretary for Health. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Washington, DC: United States Public Health Department; 1979.

3. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-85.