Quantitative research has produced ample evidence that ambivalence about pregnancy hampers effective contraceptive use and that fertility intentions vary over time and across partners. However, these studies have not explained the sexual, social and emotional dynamics that lead to ambivalence. In this issue of Perspectives on Sexual and Reproductive Health (see article), Jenny Higgins and colleagues use information collected in a series of in-depth interviews to explore how people feel about the prospect of a pregnancy with a given partner or at a given time; how these feelings help them meet their sexual, social and emotional needs; and the implications for contraceptive use.
Three themes emerged from the interviews with 36 men and women of diverse backgrounds. For some people, even if they do not intend or wish to have a baby, the prospect of pregnancy can enhance arousal during sexual encounters. For others, it suggests the promise of a closer relationship with their partner. Still others view it as a means for gaining emotional or material security. Study participants also acknowledged that their pursuit of pleasure sometimes led them to disregard the risk of pregnancy—or in the authors' words, they sometimes "had more immediately salient goals than averting pregnancy."
The authors recognize that understanding and addressing pregnancy ambivalence will go only so far toward improving contraceptive use and lowering the incidence of unintended pregnancy. However, they argue that developing a greater understanding of pregnancy risk-taking is essential to helping programs respond to people's reproductive goals.
Also in This Issue
• The pill is distinguished both by its popularity in the United States and, among highly effective reversible methods, by the high frequency with which women stop using it. One possible risk factor for early discontinuation, Debra Kalmuss and colleagues report (see article), is women's prior experiences with the method—specifically, their reason for discontinuing use. In a clinic-based study, side effects during previous use were more strongly linked to women's dissatisfaction with the method and discontinuation soon after they resumed use than were logistical or fertility-related reasons for quitting in the past. The authors point out that women's experiences with the pill are "relevant for large numbers of pill starters and … relatively easy to ask women about."
• Peer-led sexual health education interventions have been widely implemented, but a literature review by Caron Kim and Caroline Free finds little evidence that this approach is effective (see article). Of 13 studies that met the basic inclusion criteria—an appropriate comparison group, both baseline and postintervention data, and reporting of all outcomes—only three met an additional 10 quality criteria, and two met nine criteria. Most interventions produced improvements in knowledge, attitudes and intentions, but few yielded changes in behavior. Whereas one study reported a reduced risk of chlamydial infection, another found no effect on STD incidence. One study found that young women (but not young men) who received peer-led education were less likely than nonrecipients to have ever had sex. No effects on condom use were reported.
• Do negative associations between early sexual debut and teenagers' educational achievement persist beyond adolescence? In analyses of data from the National Longitudinal Study of Adolescent Health (see article), Aubrey L. Spriggs and Carolyn Tucker Halpern find that the proportion of respondents who had begun postsecondary schooling by young adulthood was lower among those who began having sex at an early or typical age than among those who started late. However, multivariate findings suggest that the differences were due largely to characteristics and experiences that predated sexual initiation. Thus, the researchers comment, efforts aimed at postponing young people's sexual debut are not sufficient to protect educational attainment. Rather, "targeting mediators of the sexual debut–education relationship seems a more realistic and appropriate response."
• A good policy does good only if it is implemented well. At four Title X–supported clinics in Pennsylvania, most staff interviewed about advance provision of emergency contraception favored the idea. However, as Paul Whittaker and coauthors report (see article), many did not know that their agency has a policy of offering the method in advance to all women who have no medical contraindications to using it, are not sterilized and are not using long-term methods. Many of those interviewed routinely offer emergency contraception services to eligible women, but use their own criteria to assess eligibility. Staff also indicated that time constraints and cumbersome clinic procedures deter them from offering emergency contraception to women in advance of need. The authors suggest that staff education and organizational changes to streamline procedures could facilitate routine provision.
• In a longitudinal study of clinic patients at risk of unintended pregnancy (see article), Ellen K. Wilson and Helen P. Koo find that "a consideration of the characteristics of women's relationships with their sexual partners may provide insight into [their] contraceptive use." Some findings were in line with the authors' expectations—for example, women who reported good communication with their partner had an elevated likelihood of saying that they used condoms. But other results were surprising, such as the finding that women in relatively established relationships were more likely than those in less established relationships to rely on withdrawal. Wilson and Koo speculate as to the reasons for the differences they found and stress the need for providers to take into account the context of women's relationships when offering contraceptive services.
-—The Editors