Unintended Pregnancy in Rural Communities

Research Article

J Fam Med. 2020; 7(8): 1228.

Unintended Pregnancy in Rural Communities

Van Arnam M1, Englert C2*, Mestad R3 and Germain L4

1Department of Obstetrics and Gynecology, Abington-Jefferson Health, USA

2Department of Medicine, Upstate Medical University, USA

3Department of Obstetrics and Gynecology, Upstate Medical University, USA

4Department of Public Health and Preventive Medicine, Upstate Medical University, USA

*Corresponding author: Englert C, Department of Medicine, Upstate Medical University, USA

Received: October 05, 2020; Accepted: November 17, 2020; Published: November 24, 2020


Background: Unintended pregnancy accounted for 45% of all pregnancies in the US in 2011. This is more prevalent than many other developed countries and has been studied in women with varying ages, races, income levels, and education; however little research has been dedicated to unintended pregnancy in rural populations.

Objective: To identify whether there is an association between unintended pregnancy and geographical location in New York State. Intent of pregnancy based on maternal age and education was also analyzed.

Methods: A retrospective cohort study using the Statewide Perinatal Database System (SPDS) to extrapolate maternal demographics including education level, age, and pregnancy intention for pregnancies between 2004 to 2015. RUCA codes delineated Rural, Suburban, or Urban residence. We analyzed the data using relative risk as a measure of association between geographical location and pregnancy intent. A confidence interval of 95% with a p <0.05 was considered significant.

Results: SPDS Data from 210,999 pregnancies between 2004 to 2015 were analyzed. Rural women had similar percentages of unintended pregnancy (34.5% vs 35.8%). Rural women were not at increased risk of unintended pregnancy based on geographical location. The risk for unintended pregnancy decreased as maternal age increased. There was an increased risk for unintended pregnancy with lower maternal education, illustrating an inverse relationship similar to maternal age.

Conclusion: Rural-Urban variation in health care is well documented, although rural women have similar percentages of unintended pregnancy. More attention is necessary to ensure sufficient distribution of family planning resources.

Keywords: Unintended Pregnancy; Geographical Residence


RUCA: Rural-Urban Commuting Area Codes; SPDS: Statewide Perinatal Database System


The incidence of unintended pregnancy is an important measure of reproductive health within a population. It measures the extent of autonomy women harness to decide freely when and if to have children. The aim to reduce unplanned pregnancy is multi-faceted. Women with unintended pregnancy have higher rates of suicide, depression, poor nutrition during gestation, unstable family relationships, risk of miscarriage, low birth weight infants, and delayed onset of prenatal care [1]. According to data obtained from the National Survey of Family Growth and the National Center for Health Statistics, 45% of all pregnancies were classified as unintended in the United States in the year 2011. Although this is an improvement from the 51% of unintended pregnancies in 2005, the United States unintended pregnancy rate is higher than that of other developed countries and there remains significant room to improve the nation’s reproductive health [2].

Multiple studies have been conducted to investigate variation in unintended pregnancy rates among women of different ages, races, income levels, and education levels. In 2010, the overall pregnancy rate was 57.4 pregnancies per 1000 women aged 15 to 19. Women aged 18 to 19 accounted for 69% of all teen pregnancies [3]. Previous studies have also shown that women with the least amount of education attained have the highest rates of unintended pregnancy [4]. In 2011, women without a high school degree had the highest unintended pregnancy among those of any education level (73 per 1,000), with rates declining further with each level of education attained). Poor and low-income women have an unintended pregnancy rate approximately five times the rate for women in the highest income bracket [4,5].

Most of these studies have been conducted in urban populations; there are few studies investigating unintended pregnancy rates among women in rural populations. Rural America accounts for 22.8% of women in the United States aged 18 years and older [6]. It has been shown that rural-urban variation exists in U.S family planning services, with geographical disparities permeating throughout [7]. Lack of access to family planning information such as with sex education courses, public library resources, internet access, etc. remains a serious barrier to obtaining contraceptive knowledge. Lack of education, financial stability, and ability to acquire health insurance all disproportionately affect rural women [7]. Only 46% of the agencies providing publicly funded family planning services reported that their clinic sites are located in mostly rural locations, the majority of which are health departments and Federally Qualified Health Centers [8]. This study was designed to compare pregnancy intention among urban, suburban, and rural populations. Our secondary aim was to identify trends between intent of pregnancy based on maternal age, maternal education, and a combination of those variables with geographical region of residence. This study is intended to be the first step in determining what unique barriers, if any, rural women face in terms of establishing successful family planning. In identifying any potential barriers, interventions may be developed to provide women in rural communities with better education and access to comprehensive family planning resources.


This is a retrospective cohort study conducted using the New York Statewide Perinatal Database System (SPDS), which was developed as a New York State Department of Health Initiative, existing in every hospital where maternal/newborn services are offered (Section 400.22-Statewide Perinatal Data System). It is a registry that collects clinically relevant data surrounding maternal and neonatal demographics to give hospitals and public health agencies information for quality improvement and improved public health efforts. Our sample used de-identified pregnancy data collected from the Perinatal Database from the years 2004 to 2015. De-identified pregnancy data collected included location of residence, pregnancy intention, maternal age, and maternal education level. The primary independent variable of interest is geographical location of residence based upon Rural-Urban Commuting Area Codes (RUCA). RUCA codes classify U.S census tracts using measures of population density, urbanization, and daily commuting. RUCA codes were used to delineate urban, suburban, or rural area of residence. Our dependent variable of interest is pregnancy intention, classified as either intended or unintended. The SPDS classifies pregnancy intention into “sooner, later, then, or not then or future.” We define intended pregnancy as desiring a pregnancy sooner or now. We defined unintended pregnancy as desiring a pregnancy, but at a later time or not wanting a pregnancy now or in the future.

The 2004 to 2015 pregnancy data was aggregated into geographical residence (rural, suburban, or urban) and pregnancy intent (unintended or intended). We used relative risk as a measure of association between geographical location and pregnancy intent. The Relative Risk (RR) is used to determine whether geographical location is a risk factor for unintended pregnancy. We combined suburban + urban pregnancy data, denoted as “non-rural” to use as the comparison group against the rural pregnancy data. A Confidence Interval (CI) of 95% is used to estimate the precision of the OR with a P value <0.05 used to determine likely statistical significance. Intent of pregnancy based on maternal age and maternal education, was also analyzed.

This study was approved by State University of New York Upstate Medical University Institutional Review Board.


De-identified pregnancy data from 210,999 pregnancies between the years 2004 to 2015 was included. Rural women accounted for 24,578 of the total pregnancies (11.6%) with 16,095 intended pregnancies and 8,483 unintended pregnancies. Urban women accounted for 127,319 of the total pregnancies (60.3%) with 82,346 intended pregnancies and 44,973 unintended pregnancies. Suburban women accounted for 59,102 of the total pregnancies (28.1%) with 37,372 intended pregnancies and 21730 unintended pregnancies.

Similar percentages of unintended pregnancy between rural women (34.5) and non-rural (suburban + urban) women (35.8) were found (Table 1). Rural women did not have increased risk of unintended pregnancy compared to non-rural women (Risk Ratio [RR]:0.96;95% CI 0.95 to 0.98; P<0.00001) (Table 1).