The purpose of the study was to examine reproductive life planning practices among Title X family planning health care providers and clinical staff. Reproductive life planning is a program priority for Title X clinics, those that receive federal money for providing family planning services to low-income women and men. The goal of reproductive life planning is to decrease unwanted and unintended pregnancies and improve preconception health care however; this practice has not been described. First, a conceptual analysis was conducted to create a definition of reproductive life planning that was consistent with the literature. Reproductive life planning is a process that is centered on reproductive and other life goals and is personalized, collaborative, fluid, and focused on health-promotion. Second, a mixed methods design was used to examine reproductive life planning practices and qualitative interviews were conducted to explore barriers and facilitators to implementing reproductive life planning practices. Data were obtained from health care providers and clinical staff employed at Title X clinics in Illinois, Iowa, Minnesota, Missouri, Nebraska, and North Dakota. A total of 148 clinicians completed a web-based survey which was analyzed to describe which types of patients, the topics covered, and the frequency with which reproductive life planning was discussed during an office visit. Surveys were then examined to identify 20 providers to conduct qualitative interviews with to further explore reproductive life planning practices. The qualitative interviews were also performed to explore the barriers and facilitators clinicians face to practicing reproductive life planning. The results of the web-based questionnaire were examined mainly with medians and frequencies to examine reproductive life planning practices. Qualitative interviews were coded using a content analysis approach to two aims; one to examine how reproductive life planning was using during clinic visits and two, to identify the barriers and facilitators clinicians face when discussing reproductive life planning with patients. Findings from the survey and the interviews suggest that most clinicians are discussing pregnancy intentions with their patients. However, from the interviews, three types of scope of reproductive life planning emerged; those clinicians who screened their patients’ pregnancy intentions, those who planted the seed in the patient’s mind, and those who explored the context of a patient’s life and their goals to contextualize how pregnancy and childbearing would fit into their lives in order to clarify pregnancy intention and move toward the corresponding health behaviors. It is argued that the third group of providers is using reproductive life planning as intended by experts. Finally, barriers to RLP discussions were examined as well as approached providers used to overcome the barriers. In conclusion, many clinicians are practicing reproductive life planning as intended, however many are not. Improved training and protocols are needed to ensure clinicians are providing their patients with the best reproductive life planning discussions. Additionally, systemic structures, like access to quality family planning services, need to be improved to aid clinicians in helping their patient plan their families.

Background: Rapid repeat pregnancy (RRP), a pregnancy occurring less than 24 months from a prior birth, and unintended pregnancy-related induced abortions can be prevented with family planning. However, few studies have adequately addressed the role of male partners in reproductive decision-making. Objectives: The goal of this research is to understand the interrelationships between couple pregnancy intention, intimate partner violence (IPV), reproductive health and behaviors. Specifically, this project aims to: (1) examine the extent to which couple pregnancy intentions are associated with RRP and (2) induced abortions among women in the U.S., and (3) examine the extent to which IPV around the time of pregnancy is associated with postpartum birth control use by race/ethnicity and receipt of prenatal contraceptive counseling among U.S. women with live births. Methods: This project uses data from the 2006-2010 National Survey on Family Growth (NSFG), and the 2004-2008 national Pregnancy Risk Assessment Monitoring System (PRAMS). RRP and induced abortion of first pregnancy were self-reported in the NSFG. Couple pregnancy intentions were categorized as: both intended (M+P+), both unintended (M-P-), maternal intended and paternal unintended (M+P-), maternal unintended and paternal intended (M-P+). Multiple logistic regression analysis was used to assess the relationships between couple pregnancy intentions and RRP and induced abortion. Data on IPV and postpartum contraceptive use came from PRAMS. Stratified analyses were conducted to assess differences in the association by race/ethnicity and receipt of prenatal contraceptive counseling. Results: Compared to couples where pregnancy was intended by both, those with discordant pregnancy intentions and both unintended pregnancy had greater odds of induced abortion. The odds of RRP was higher for M-P+ couples and lower for M+P- couples. Abused women were significantly less likely to report postpartum contraceptive use. This was particularly true for Hispanic women who reported no prenatal birth control counseling and all other racial/ethnic groups who received birth control counseling. Conclusion: Health providers may need to consider the interpersonal dynamics of couple-based decision-making and behaviors to prevent RRP and induced abortions due to unintended pregnancy. Providers should discuss contraceptive options that are not partner-dependent within the context of abusive relationships.

Globally, in low and middle-income countries 4 out of every 10 pregnancies is reported to be unintended. Having an unintended pregnancy increases the risk of maternal and infant morbidity and mortality, preterm birth, low birth weight, and decreases rates of breast-feeding. The United States (U.S.) consistently has some of the highest rates of preterm birth, infant and maternal mortality of all high-income countries and 45% of all pregnancies in the U.S. are reported to be unintended. The etiology of these outcomes and their relationship to pregnancy intention are complex and multifactorial, but we know this disproportionately effects women living in poverty both in the U.S. and globally. When couples have the knowledge, access, and power to decide when and whether to become pregnant they are more likely to seek preconception care, thus increasing the likelihood of planned pregnancies leading to improved maternal and child health outcomes. Primary prevention strategies to improve maternal/child health outcomes in the U.S. include sexual and reproductive health considerations such as increasing access to birth control. Globally, strategies include expanding access, as well as focusing on the empowerment of women and improving gender social norms. Focusing on community level norms and individual empowerment can lead to greater reproductive autonomy, which in turn leads to an increase in the uptake of birth control and family planning. This broader consideration of multiple levels of power or autonomy is often lacking in approaches taken in the U.S. More information is needed about the social context and determinants of pregnancy intention in our communities, particularly of women living in poverty. The purposes of this dissertation were to 1) to describe reproductive autonomy and family planning challenges in a population of marginalized Ecuadorian women; 2) develop a conceptual framework of reproductive autonomy from the global literature; 3) to validate a shortened form of an interpersonal violence scale used in a study of low-income pregnant women in Kentucky; and finally 4) to investigate the association between pregnancy intention and individual, interpersonal and community factors of impoverished women living in Kentucky. The qualitative study of women in Ecuador identified barriers and facilitators to family planning in a low-resource community. The major themes that emerged were that women’s autonomy was limited by men, shame was ‘keeping women quiet’, systems failed women, and as women aged they were able to build resilience in spite of these challenges. Many reported reproductive coercion, gender-based violence, and regret. Those who could leave unsupportive partners and found social support were more effective at planning their pregnancies. Evidence supports these themes are relatively common in the global literature, particularly of women living in poverty. The comprehensive review of these findings was used to develop a conceptual framework of reproductive autonomy. The Socio-Ecological Model was used to organize the data based on individual, interpersonal or community level determinants of pregnancy intention and reproductive autonomy. This new conceptual model, called the Power and Reproductive Autonomy (PARA) model, was used as a guide to analyze multiple levels of data in a secondary analysis of pregnant women living in poverty in Kentucky. Prior to this secondary analysis study, a measure used in the parent study needed to be validated. A short form of the Women’s Experience with Battering (WEB) scale was found to be psychometrically valid to measure of the impact of intimate partner violence for this population. Findings from the secondary analysis included high rates of unintended pregnancy (66%), and women with unintended pregnancy were more likely to report exposure to interpersonal violence, poor social support, and anxiety at the bivariate level. At the community (county) level those with an unintended pregnancy were more likely to live in counties with fewer social associations, and in rural communities. None of the access, gender equity, income inequality, or violence variables were correlated to pregnancy intention. In the final multilevel model, controlling for demographic variables, only being unmarried and answering the question in English were significant predictors of unintended pregnancy. The rate of social associations in a county was marginally significant with pregnancy intention, in that the presence of social associations appeared to decrease the likelihood of unintended pregnancy. Operationalizing the PARA framework to examine predictors of unintended pregnancy in Kentucky proved to not yield expected results; county level variables related to access, gender equity, and violence were not found to be significantly correlated. Women answering the question in Spanish had significantly higher rates of planned pregnancy, which is a new finding. Having opportunities for social engagement also seemed to be a protective factor in preventing unintended pregnancies. Limitations of cross-sectional data also make it a challenge to capture cumulative life stressors which could contribute to poor reproductive autonomy. Future studies may yield a greater understanding of the social context of pregnancy intention if more interpersonal data related specifically to reproductive autonomy are in the model, such as reproductive coercion, relationship power, communication, and contraceptive decision making. Additionally, further examination of structures or systems that provide economic opportunities in the community is a promising area of reproductive autonomy and pregnancy intention research.