Introduction

High rates of rapid repeat pregnancy (RRP), or pregnancy occurring <24 months from a prior birth, continue to be a serious public health problem in the United States. Despite the availability of effective contraception, nearly a third of all births in the United States are not spaced in accordance to the recommended guidelines. Women experiencing RRP have an increased risk for poor perinatal outcomes including preterm birth, small for gestational age, low-birthweight infants, and neonatal death. Risk factors for RRP include unmarried status, younger age, lower income or educational attainment, multiple prior births, and prior adverse obstetrical outcomes. Women in abusive relationships are also disproportionately affected by RRP.

The majority of RRP are unintended pregnancies. Nearly half of all pregnancies in the United States are unintended, of which 29% are mistimed (occurring earlier than desired) and 19% are unwanted. Of unintended pregnancies, 43% end in induced abortion. The direct health costs of unintended pregnancies amount to nearly $5 billion annually, causing unnecessary burden on poor families and the health care system. The increase in unintended pregnancy rate over the last few years, currently 52 women per 1000, is cause for concern given the adverse impacts on maternal and infant health outcomes and behaviors. Examples of these include premature birth, postpartum depression, substance use during pregnancy, delayed prenatal care, and poor contraceptive practices.

Repeat unintended pregnancy and poor birth spacing are mainly due to inconsistent use of contraceptive methods and lack of family planning. More than half of women with unintended pregnancies do not use contraceptive methods around the time of conception. Disparities in unintended pregnancy rate persist particularly among certain subpopulations including women who are young, less educated, of low income, cohabiting, serving in the military, or of racial and ethnic minority groups. Non-Hispanic black and Hispanic women have higher prevalence of unintended births than non-Hispanic white women and more than twice the rate of unintended pregnancies than any other racial or ethnic group.

Central to the issue of RRP and unintended pregnancy is the role of male partners and their desire for conception. The bulk of research exploring predictors of RRP in the United States has focused on adolescent or minority populations. Boardman et al assessed risk factors for unintended and intended RRP among adolescents using data from the 2002 National Survey of Family Growth (NSFG). Having a partner intend the repeat pregnancy was associated with decreased likelihood of an adolescent unintended RRP. However, the study did not adjust estimates for important covariates that might influence RRP, such as paternal characteristics. Another study reported on correlates of RRP using a nationally representative data set of women in the United States. After adjusting for maternal age at first birth and conception of second or higher-order births (index pregnancy), women who reported an unintended index pregnancy were more likely to experience RRP. However, paternal pregnancy intention was not considered in the analysis. The evidence for the influence of partners’ intention on RRP is therefore not yet clear and merits further attention.

Very few studies have explored the role of partner pregnancy desires and their contribution to the reproductive decision-making process. RRP has been typically described among adolescent females without considering the male perspective or the impact of concordance or discordance in couples’ pregnancy intentions. The current study addressed these gaps in knowledge by examining the impact of discordant pregnancy intentions among couples on RRP. This study will examine the association between couple pregnancy intentions and RRP among women in the United States.

Materials and Methods

Data come from the 2006 through 2010 NSFG, which collects information on families, relationships, fertility, and health behaviors from a nationally representative sample of noninstitutionalized, English- or Spanish-speaking individuals residing in the United States. Teenagers and racial/ethnic minorities were oversampled to ensure an adequate sampling of non-Hispanic blacks, Hispanic adults, and those aged 15-19 years. Further details of the methodology are described elsewhere. Multiparous women with history of at least 2 completed pregnancies prior to the interview were included in the current study (n = 5479). To ensure that cohabiting partner characteristics could reasonably be used as proxy for paternal characteristics, the sample was restricted to women who cohabited with 1 husband or partner at the time of second pregnancy conception. Women who did not report cohabitation at the time of their second pregnancy (n = 542) and those who lived with multiple partners or husbands (n = 1275) were excluded. Respondents who did not provide information regarding the exposure and outcome of interest were also excluded (n = 199). The final sample size for analysis consisted of 3463 women. This study was approved as exempt by the Virginia Commonwealth University Institutional Review Board.

RRP, the outcome of interest, was defined as pregnancy onset within 24 months of a previous pregnancy outcome. Women who experienced a second pregnancy (herein referred to as the index pregnancy) within 24 months of their first pregnancy resolution were categorized as experiencing RRP. In contrast, women who experienced an index pregnancy ≥24 months from the first pregnancy resolution were categorized as not experiencing RRP. The first pregnancy could have ended with a live birth, elective abortion, miscarriage, stillbirth, or ectopic pregnancy. Dates of events such as first pregnancy outcome and second pregnancy conception were recorded in month and year and converted to century-months, which are convenient for computing the intervals between dates because subtraction yields intervals in months. Interpregnancy intervals were calculated as the time elapsed in months between the completion date of the first pregnancy and the conception date of the index pregnancy.

Couple pregnancy intentions for index pregnancies were based on questions regarding the wantedness of pregnancy prior to conception. Consistent with the literature, intended pregnancy was defined as a pregnancy that occurred to those who wanted a child at the time of the index pregnancy, wanted it sooner, or were indifferent. Unintended pregnancy was defined as one that was mistimed (eg, desire to get pregnant later in the future but not at conception) or unwanted (eg, no desire to get pregnant at the time of conception or in the future). Female respondents were also asked similar questions about their partner’s pregnancy desires prior to the index pregnancy. Even if retrospective reporting could lead to biased estimates of health outcomes related to unintended births, the direction of such bias is unclear. Scant literature has explored the reliability of women’s report of paternal pregnancy intention. Nonetheless, extant studies have found women’s assessments of paternal pregnancy intentions to be reliable and consistent with their partners’ self-reports. For instance, Morgan found that wives reported husbands’ intentions accurately and concluded couple intentions could be estimated with information gathered from the mother. It has also been argued that random measurement error due to self-reports and proxy reports of intention may be more important to consider than systematic error stemming from proxy reports about spouse’s intentions. Thus, paternal pregnancy intentions were categorized similar to maternal pregnancy intention categories and 4 dyadic types were created: both intended (M+P+); maternal intended and paternal unintended (M+P–); maternal unintended and paternal intended (M–P+); and both unintended (M–P–). Concordant pregnancy intentions where both couples desired the index pregnancy were treated as the referent group since this group may be more likely to plan for the pregnancy and least likely to experience RRP.

Potential covariates that could modify or confound the relationship between couple pregnancy intentions and RRP were considered. Individual maternal characteristics included race/ethnicity, maternal age at interview, highest completed year of school or degree received, and income relative to poverty level. Childhood psychosocial and demographic factors included intact family until age 18 years, raised religion, age of mother-figure at first child birth, and nativity or being born outside the United States. Sexual development and behavior variables consisted of menarche, age of first sexual encounter, and effectiveness of contraceptive method at first sex (most effective; somewhat effective; least effective; not effective). Most effective contraceptive methods include those that result in <10 pregnancies per 100 women per year (ie, vasectomy, sterilization, intrauterine device, implants, shots, pill, ring, patch, and emergency contraception). Somewhat effective methods are those that have a pregnancy rate of 15-24 per 100 women per year (ie, diaphragm, male/female condoms, withdrawals, sponge, cervical cap). Least effective methods result in 25 pregnancies per 100 women per year (ie, spermicide [foam, jelly, cream, suppository], fertility awareness methods such as rhythm or safe period). Having no form of contraceptive use is not effective against pregnancy. First pregnancy factors included maternal age at delivery, marital status when first pregnancy ended, and poor pregnancy outcome such as stillbirth, miscarriage, or ectopic pregnancy. Factors specific to the index or second pregnancy included any contraceptive method used in the interval between the end of the first and index pregnancy, maternal age at conception, and marital status when the index pregnancy began.

Cohabiting partner characteristics at the time of the index pregnancy included the age of partner or husband and years of cohabitation. The NSFG did not directly inquire about paternal characteristics for each pregnancy, however, it did ask about the start and end dates of cohabitation with current and former husbands and partners, and dates of marriages. Dates of marriages were considered as the start of cohabitation for women who reported no premarital cohabitation with former husbands. Based on this information, cohabiting partner characteristics at the time of the index pregnancy served as proxy for paternal characteristics as long as the conception date occurred within the cohabiting time frame.

All analyses were conducted using software (SAS, Version 9.4; SAS Institute Inc, Cary, NC) to account for the multistage, complex sampling design. Descriptive statistics including unweighted frequencies and weighted percentages were generated to assess the distribution of characteristics by RRP and couple pregnancy intent. Using SAS Proc Survey procedures and appropriate analysis weights, separate logistic regression models provided crude odds ratios (COR), adjusted odds ratios (AOR), and 95% confidence intervals (CI) to determine if couple pregnancy intentions were associated with RRP. Effect modification by race/ethnicity ( P = .118) and interval birth control use ( P = .775) were assessed using interaction terms but were not found to be statistically significant; therefore, these were assessed as potential confounding factors. An iterative process of modeling was used where variables considered as potential confounders were maintained in parsimonious regression models if their presence resulted in a ≥10% change in the odds ratios for the association between couple pregnancy intentions and RRP.

Materials and Methods

Data come from the 2006 through 2010 NSFG, which collects information on families, relationships, fertility, and health behaviors from a nationally representative sample of noninstitutionalized, English- or Spanish-speaking individuals residing in the United States. Teenagers and racial/ethnic minorities were oversampled to ensure an adequate sampling of non-Hispanic blacks, Hispanic adults, and those aged 15-19 years. Further details of the methodology are described elsewhere. Multiparous women with history of at least 2 completed pregnancies prior to the interview were included in the current study (n = 5479). To ensure that cohabiting partner characteristics could reasonably be used as proxy for paternal characteristics, the sample was restricted to women who cohabited with 1 husband or partner at the time of second pregnancy conception. Women who did not report cohabitation at the time of their second pregnancy (n = 542) and those who lived with multiple partners or husbands (n = 1275) were excluded. Respondents who did not provide information regarding the exposure and outcome of interest were also excluded (n = 199). The final sample size for analysis consisted of 3463 women. This study was approved as exempt by the Virginia Commonwealth University Institutional Review Board.

RRP, the outcome of interest, was defined as pregnancy onset within 24 months of a previous pregnancy outcome. Women who experienced a second pregnancy (herein referred to as the index pregnancy) within 24 months of their first pregnancy resolution were categorized as experiencing RRP. In contrast, women who experienced an index pregnancy ≥24 months from the first pregnancy resolution were categorized as not experiencing RRP. The first pregnancy could have ended with a live birth, elective abortion, miscarriage, stillbirth, or ectopic pregnancy. Dates of events such as first pregnancy outcome and second pregnancy conception were recorded in month and year and converted to century-months, which are convenient for computing the intervals between dates because subtraction yields intervals in months. Interpregnancy intervals were calculated as the time elapsed in months between the completion date of the first pregnancy and the conception date of the index pregnancy.

Couple pregnancy intentions for index pregnancies were based on questions regarding the wantedness of pregnancy prior to conception. Consistent with the literature, intended pregnancy was defined as a pregnancy that occurred to those who wanted a child at the time of the index pregnancy, wanted it sooner, or were indifferent. Unintended pregnancy was defined as one that was mistimed (eg, desire to get pregnant later in the future but not at conception) or unwanted (eg, no desire to get pregnant at the time of conception or in the future). Female respondents were also asked similar questions about their partner’s pregnancy desires prior to the index pregnancy. Even if retrospective reporting could lead to biased estimates of health outcomes related to unintended births, the direction of such bias is unclear. Scant literature has explored the reliability of women’s report of paternal pregnancy intention. Nonetheless, extant studies have found women’s assessments of paternal pregnancy intentions to be reliable and consistent with their partners’ self-reports. For instance, Morgan found that wives reported husbands’ intentions accurately and concluded couple intentions could be estimated with information gathered from the mother. It has also been argued that random measurement error due to self-reports and proxy reports of intention may be more important to consider than systematic error stemming from proxy reports about spouse’s intentions. Thus, paternal pregnancy intentions were categorized similar to maternal pregnancy intention categories and 4 dyadic types were created: both intended (M+P+); maternal intended and paternal unintended (M+P–); maternal unintended and paternal intended (M–P+); and both unintended (M–P–). Concordant pregnancy intentions where both couples desired the index pregnancy were treated as the referent group since this group may be more likely to plan for the pregnancy and least likely to experience RRP.

Potential covariates that could modify or confound the relationship between couple pregnancy intentions and RRP were considered. Individual maternal characteristics included race/ethnicity, maternal age at interview, highest completed year of school or degree received, and income relative to poverty level. Childhood psychosocial and demographic factors included intact family until age 18 years, raised religion, age of mother-figure at first child birth, and nativity or being born outside the United States. Sexual development and behavior variables consisted of menarche, age of first sexual encounter, and effectiveness of contraceptive method at first sex (most effective; somewhat effective; least effective; not effective). Most effective contraceptive methods include those that result in <10 pregnancies per 100 women per year (ie, vasectomy, sterilization, intrauterine device, implants, shots, pill, ring, patch, and emergency contraception). Somewhat effective methods are those that have a pregnancy rate of 15-24 per 100 women per year (ie, diaphragm, male/female condoms, withdrawals, sponge, cervical cap). Least effective methods result in 25 pregnancies per 100 women per year (ie, spermicide [foam, jelly, cream, suppository], fertility awareness methods such as rhythm or safe period). Having no form of contraceptive use is not effective against pregnancy. First pregnancy factors included maternal age at delivery, marital status when first pregnancy ended, and poor pregnancy outcome such as stillbirth, miscarriage, or ectopic pregnancy. Factors specific to the index or second pregnancy included any contraceptive method used in the interval between the end of the first and index pregnancy, maternal age at conception, and marital status when the index pregnancy began.

Cohabiting partner characteristics at the time of the index pregnancy included the age of partner or husband and years of cohabitation. The NSFG did not directly inquire about paternal characteristics for each pregnancy, however, it did ask about the start and end dates of cohabitation with current and former husbands and partners, and dates of marriages. Dates of marriages were considered as the start of cohabitation for women who reported no premarital cohabitation with former husbands. Based on this information, cohabiting partner characteristics at the time of the index pregnancy served as proxy for paternal characteristics as long as the conception date occurred within the cohabiting time frame.

All analyses were conducted using software (SAS, Version 9.4; SAS Institute Inc, Cary, NC) to account for the multistage, complex sampling design. Descriptive statistics including unweighted frequencies and weighted percentages were generated to assess the distribution of characteristics by RRP and couple pregnancy intent. Using SAS Proc Survey procedures and appropriate analysis weights, separate logistic regression models provided crude odds ratios (COR), adjusted odds ratios (AOR), and 95% confidence intervals (CI) to determine if couple pregnancy intentions were associated with RRP. Effect modification by race/ethnicity ( P = .118) and interval birth control use ( P = .775) were assessed using interaction terms but were not found to be statistically significant; therefore, these were assessed as potential confounding factors. An iterative process of modeling was used where variables considered as potential confounders were maintained in parsimonious regression models if their presence resulted in a ≥10% change in the odds ratios for the association between couple pregnancy intentions and RRP.

Results

Table 1 shows the weighted distribution of characteristics by couple pregnancy intentions. Among couples with concordant pregnancy intendedness (M+P+), more of the women were highly educated (61.1%), of higher income (41.0%), aged 30-44 years at conception for index pregnancy (30.9%), and married at first and second pregnancy (63.8% and 78.1%, respectively) compared to other pregnancy intention dyad groups. Couples with discordant pregnancy intentions (ie, M+P–, M–P+) and mutual pregnancy unintendedness (M–P–) had greater percentage of women who were racial/ethnic minorities, less than high school educated, of low income, aged ≤14 years at first sexual encounter, aged ≤19 years at first and second pregnancy, and not married at first and second pregnancy compared to couples with mutually intended index pregnancy ( Table 1 ). Among the dyadic groups, the average mean ± SE number of months between the first and second pregnancies was: 38.0 ± 1.27 (M+P+), 26.3 ± 1.66 (M–P–), 40.1 ± 2.17 (M+P–), and 24.4 ± 1.56 (M–P+), P = .0021 (not shown in Tables 1-4 ).

Table 1

Weighted distribution of characteristics by couple pregnancy intention dyads

	M+P+ unweighted, n = 1915	M–P– unweighted, n = 917	M+P– unweighted, n = 232	M–P+ unweighted, n = 399
	Weighted column %
Maternal characteristics
Race/ethnicity a
Non-Hispanic white	63.6	55.3	51.9	42.5
Non-Hispanic black	8.2	17.7	14.4	25.2
Hispanic	19.2	19.4	25.6	24.2
Non-Hispanic other race	9.0	7.6	8.1	8.1
Age at interview, y a
≤19	0.2	2.5	0.9	2.4
20–24	3.3	11.9	8.6	13.2
25–29	13.7	20.2	21.4	20.9
30–34	20.1	19.7	27.7	20.5
35–39	32.3	20.1	23.0	21.2
40–44	30.4	25.6	18.4	21.7
Education a
Less than high school	15.2	22.3	26.0	27.0
High school	23.6	30.5	39.1	31.1
Greater than high school	61.1	47.3	34.9	41.9
Income to poverty level a
<150%	27.9	39.0	48.0	46.8
150–299%	31.2	37.1	30.1	31.8
≥300%	41.0	23.9	21.9	21.4
Childhood psychosocial and demographic factors
Intact family until age 18 y a
No	30.6	45.9	45.9	50.6
Raised religion
Catholicism	37.1	34.0	39.7	35.3
Protestantism	42.6	51.5	46.9	50.4
Other	12.1	6.9	5.9	7.4
None	8.2	7.6	7.6	6.9
Age of mother-figure at first birth, y a
<18	16.9	25.0	23.4	20.2
≥18	83.1	75.0	76.6	79.8
Born outside United States a
No	78.9	84.9	81.7	79.2
Sexual development and behavior
Age of menarche, y
<12	20.3	27.5	22.3	27.2
12	25.9	27.0	30.1	24.5
13	27.1	26.1	21.8	23.2
14	14.6	10.2	14.0	12.5
≥15	12.0	9.2	11.7	12.5
Age at first sexual encounter, y a
<15	11.6	24.1	22.1	21.2
15–17	41.9	44.5	44.6	49.4
≥18	46.5	31.4	33.3	29.4
Effectiveness of contraception at first sexual encounter a
Most effective	22.0	19.0	16.7	15.9
Somewhat effective	45.2	42.7	40.7	41.5
Least effective	0.9	0.4	0.02	1.2
Not effective	31.9	37.8	42.6	41.4
First pregnancy factors
Maternal age at delivery, y a
≤19	24.7	48.9	47.4	54.9
20–29	61.6	46.9	50.1	38.3
30–44	13.7	4.2	2.5	6.8
Marital status when pregnancy ended a
Not married	36.2	65.0	72.1	66.7
Married	63.8	35.0	27.9	33.3
Poor pregnancy outcome
Yes	15.1	10.3	18.0	11.7
Interval contraceptive use a
No	87.4	80.4	80.4	84.4
Second pregnancy factors
Maternal age at conception, y a
≤19	7.3	30.3	17.3	32.7
20–29	61.9	59.1	65.8	57.5
30–44	30.9	10.6	16.9	9.8
Marital status when pregnancy began a
Not married	21.9	59.4	65.7	63.2
Married	78.1	40.6	34.3	36.8
Years of cohabitation, y a
≤7	19.4	39.4	38.9	48.2
8–11	23.1	18.5	14.4	16.7
12–16	27.8	18.5	24.6	14.8
≥17	29.8	23.5	22.1	20.4

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