Abigail Aiken trained in clinical medicine at the University of Cambridge, before completing an MPH at Harvard School of Public Health, a PhD in public policy at the University of Texas at Austin, and a post-doc at the Office of Population Research at Princeton. She is now assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin. Aiken is a new associate editor of BMJ SRH.
Kate Womersley, BMJ SRH’s social media editor, caught up with Aiken to hear about the current political challenges to the field, Aiken’s upbringing in Northern Ireland and her vision for research in sexual and reproductive health that speaks to the public.
I was struck by one of your recent papers that questions the difference between an ‘unintended’ pregnancy and an ‘undesired’ pregnancy. I was hoping you could talk more about that.
That paper was motivated by a qualitative study we did here in Texas examining a persistent difficulty that you see in the quantitative data on pregnancy intentions. Even though a woman might classify a pregnancy as ‘unintended’, she still might say that she is very happy about it. This sounds likes an incongruent or discordant situation – why would you be happy about a pregnancy you didn’t intend? But what we found by talking to women in a series of in-depth interviews is that for many people, pregnancy intentions are not a dichotomy between ‘intended’ and ‘unintended’. They are not first and foremost a timing-based concept. People don’t often think “Now is exactly the right time for me so I’m going to plan out conception.” Some would say there is never a good time for them. Really what women identified as most important, and what they based their feelings on was much more about the life impacts: am I in a place right now where I can feel good about this? Does the idea of a child make me feel happy? So even though someone might not have specifically planned or intended a pregnancy, and in that sense they would classify it as “unintended”, it might still be greeted with happiness, and therefore still be “desired”.
One major reason why that distinction between “unintended” and “undesired” is important is that people have been trying for a long time to look at the relationship between unintended pregnancy and negative health outcomes. That evidence has been very mixed – either inconclusive or weak. Our hypothesis is that part of that the lack of a strong association may be because there is conflation between those pregnancies that weren’t planned and weren’t quite intended or expected but actually turned out to be a really positive, life-affirming experience, with those that were truly a seriously negative life event for somebody.
If deep interviews give us better insight into the distinction between planning pregnancy and a woman’s feelings about pregnancy, how do you think such research could shape policy to better serve women?
A lot of public health policy is focused on reducing unintended pregnancy – both in the U.S. and the U.K. This is despite the fact that there isn’t actually strong evidence that unintended pregnancy (as it is currently measured) leads to adverse health outcomes. That approach puts a strong focus on pregnancy planning and the idea that everyone needs to plan exactly when to get pregnant and be in the ‘right life circumstances’ for a child.
In real life, though, we know that for many women, planning a pregnancy is not an idea that resonates or simply isn’t realistic in the context of their lives. As we develop these new measures and try to focus less on translating timing-based intentions to strict plans, and more on trying to help women prevent those pregnancies that they really don’t want, this would allow a reproductive-rights and reproductive justice orientated approach.
We want people to be able to have the families and lives they desire, and really, it’s for them to decide what’s best in terms of their reproductive goals. We can facilitate fulfillment of those goals through policies that recognize the plurality of individual desires and circumstances.
Do researchers choose questions that are easy to ask rather than perhaps asking the right question to start with?
I think so. What we really need to find, which we have been unsuccessful with so far but hope to be successful with in the future – is a measure that picks up the spectrum of feelings and attitudes people have with respect to a potential pregnancy, yet is simple enough to be asked in the context of a large survey or a 15-minute consultation. The biggest challenge is how to take the complex, interesting information from in-depth interviews, and operationalize it into a question that can be asked easily and quickly.
What have you learned from running this research – about designing and leading such projects?
The first important thing is to think carefully about why you are doing qualitative work. There are generally two reasons: One is that you find a really interesting pattern or quirk in your quantitative data, and you want to be able to say why this is so. For example, we know from large data sets that some people are happy about pregnancies they didn’t intend, but the number we have in front of us – the proportion of people who said that – can’t tell us why they said it.
The second reason is that you might be looking at an area that’s completely new. We want to know how women in the US are accessing abortion online, but we don’t yet know anything about that. We have no large-scale quantitative data to tell us about it. So we may start with a qualitative project to try and figure out what the landscape looks like, what’s even going on before we start trying to design a survey or another method for getting at the question on a large scale.
In terms of how you do it, I think it’s really important to have a research team that’s well educated in the issue you’re studying and the contexts of peoples’ lives. If researchers can meet participants in person, that’s even better as you can see where people live and what life is like for them. To have really good interviewers who are comfortable exploring very personal issues – who can put people at ease, and empathize even if they have never been through the experience themselves – is one of the most important elements of qualitative research.
Did you get a sense from these interviews that women didn’t have opportunities to talk about these feelings with healthcare professionals?
That’s sometimes the case. Women at the end interviews would say, “Gosh, it was so nice just to be able to talk about that, or to know that someone cared what I thought or had to say about that.” But I have an hour or more to sit and listen in an interview, whereas doctors and other professionals don’t have that luxury. If you’re talking to someone about contraceptive options, you want to talk about their pregnancy intentions and attitudes to pregnancy all in a couple of minutes. One of the things I’ve been working on with some clinicians is to develop key questions to use in these conversation to overcome the limitations of a clinical encounter.
Could you share some of the ways you might ask those questions?
A lot of the conversations about contraception start of with, “Do you plan to have children at any time in the future and, if so, how many and when? And what method of contraception are you going to use to make sure you don’t get pregnant before you plan to?” It’s introduced as a strict planning paradigm. The assumption is, every pregnancy must be planned.
The reality, however, is that a lot of women don’t plan. It’s just not meaningful for them. In their lives, they’ve never known any woman who’s planned a pregnancy, and it’s not something they may feel empowered to do. Beginning a conversation with, “Right, when do you want to get pregnant, and what are you going to do in the meantime to ensure you don’t?” isn’t really resonating with them.
Instead, we’ve thought about beginning a conversation with, “Do you think you would like to have (more) children some day?” Just something open like that, to avoid putting pressure on them to get their ducks in a row. It sounds very obvious but I think as clinicians we are trained to optimize a patient’s health, and even if we go about it in a rigid way, we’re always looking for a good outcome. It’s important to realize that so much of what you get from the encounter with the patient happens when you allow them to see you’re interested in hearing what they have to say, that you’re open to their view of the world. “What do you think about having children in the future?” is a lot easier to answer than “When are you having children and what are you doing in the meantime to prevent it?”
Some people feel stigmatized and embarrassed to say, “I’m not in a ‘good’ place where it’s perfect for me to have a kid right now, but I might want one anyway.” Just because someone doesn’t tell you that, doesn’t mean they’re not going to think it. It’s really important to take an open-minded approach.
We’ve been talking about women who do actually get to see a health professional. Your work on contraception and access in Texas shows that with budget cuts for reproductive care (you were looking at women postpartum) the numbers of women receiving LARC is decreasing. Does it look like the situation in Texas at last might be changing for the better?
We have two competing goals in Texas. On the one hand the national ‘Healthy People 2020’ goal is to reduce unintended pregnancy, the prevalence of which is even higher in Texas than the national average. On the other hand, the goal of some legislators is to restrict women’s access to contraception as much as possible. The two things clearly conflict.
The main problem people have in accessing LARC methods is the very high upfront costs. When the family planning budget was cut by two thirds in Texas in 2011, many clinics that wanted to be able to serve the same number of women had to cut LARC methods or severely reduce what they could offer. LARCs are the most expensive method of contraception for providers in clinics to buy, as well as for women to access up front. Since then, there has definitely been a public conversations and a groundswell of advocacy. Clinicians became involved too, saying that we have to be able to offer people the most effective contraceptive methods. Not everyone is going to want them, but we have to realize it’s not acceptable for these options not to be available due to cost. As a result, some public funding for family planning that was cut was reinstated in the 2013 legislative budget. However, the damage had already been done. The reinstated money did not necessarily go back to the clinics serving the population that needs them most.
Texas is still lagging behind many other states when it comes to contraceptive access. The way the legislature goes about providing family planning services is flawed because any provider who offers abortions is still excluded from receiving state funds. The legislature are still trying to make sure that people are diverted away from Planned Parenthood, even if the person wouldn’t be going there for anything other than contraception, a Pap smear or an STI test.
Even though there is lots of support for access to IUDs and implants, women have to be able to get to providers nearby, which are accessible and acceptable to them. Many women have been going to Planned Parenthood for years as their trusted provider in their local area. There is a real disconnect when legislators say “Yes, we do want these women to have access to LARC methods, but we don’t want to them have access via their regular provider.” We still have a lot of work to do try to figure out how to get around that problem.
What role do you think clinicians have in advocating for their patients?
A huge role. Clinicians have a key part to play in ensuring their patients have access to the full range of contraceptive options. Evidence from Texas indicates that some clinicians still have their own opinions about what kind of methods women should use, or they’re a bit behind on the evidence. For example, some clinicians are late getting on board with the recommendations from ACOG that it’s absolutely fine to give IUDs to nulliparous women. It used to be thought you could only give an IUD to women who have had children, because the cervix of a nulliparous women would make placement too painful and difficult. The best evidence shows this isn’t the case. By being up-to-date and listening to patients’ needs and preferences, providers in Texas and the whole of the USA really can do a lot for the patients they serve by helping to remove barriers to contraceptive access.
What is on the horizon for your research in 2018?
The most exciting thing coming up is a project we’ve been working on to extend work on the safety and effectiveness of medical abortion in Ireland and Northern Ireland through Women on Web regarding how successful these abortions are and what the complication rates looks like. What the first study wasn’t able to speak to, though, is what exactly the experience of this process is like for women.
We are coming to the end of a comparative study that looks at Irish and Northern Irish women who have travelled, and women who have used pills online. We really wanted to get to the heart of how a woman makes that decision – is it all about the resources she has? Or might there be other reasons people prefer one method rather than the other? Also, what are the unmet needs people have as they go through either process?
This research is coming at an opportune time, because as we look forward to 2018 and the referendum that the Irish people have been promised on the Eighth Amendment––which guarantees fetuses equal rights to pregnant women in Ireland––we really need peer-reviewed scientific evidence that illuminates what the decision-making process and experience is like for women. We are trying to finish in time to inform the conversation before the referendum.
We are hoping the research will do two things. Firstly, that those in the Irish parliament making these decisions will take it into consideration when they lay out the terms of the referendum. And second, we hope it will inform the public conversation.
It’s clear you work hard to make your research relevant to the scientific community, as well as distilling information to the media and suggesting tweetable messages. Do you have advice to other researchers about how to do this well?
It is so important to do that. The discipline of public policy has impressed that upon me. The incentives in academia can be quite perverse. We are expected to publish – “publish or perish” is what they say, and sometimes it’s tempting to get stuck in that race to get publications out. But if you’re working on issues that are relevant to current policy conversations, you might be faced with a decision about whether your results could inform a public conversation that’s happening right now. Are you going to wait for the publishing process in an academic journal, or will you go ahead and release those results because you know they could have an impact on the real world? I think that’s one thing academic publishing could really help with: understanding that the work academics do is useful in the policy world and public conversation. It would be great to have ways through journals to expedite research which has power to inform policy-making to make sure it gets out there in time.
My advice for others would be that when you have evidence and expertise in an area, sharing that knowledge beyond your scholarly colleagues and to look beyond the ivory tower of the academic field is so important. If you’re able to communicate your research, to testify to a legislature or write an op-ed, don’t be afraid to. It really is one of the most rewarding things you can do as a scholar.