1. "No Judging Eyes": Youth Experiences of Effective (and Ineffective) Pregnancy Options Counseling


      Adolescents and young adults (AYA) aged 15-19 in the United States have the highest rates of unintended pregnancy compared to other ages, putting them in need of adequate pregnancy options counseling. Despite this need, available pregnancy options counseling training modalities have not been informed by AYA perspectives. This study explored AYA experiences and recommendations to facilitate the development of stakeholder-informed implementation of pregnancy options counseling for AYA.


      We conducted semi-structured phone interviews with a purposive sample (including those who chose parenting, adoption, and abortion) of United States-based key informants aged 18-35 years who self-reported experiencing a pregnancy under 20 years old. We recruited participants through clinics, adoption-related organizations, Facebook, Craigslist, and a university-based research registry. We recorded and transcribed all interviews, then conducted content analysis informed by the Consolidated Framework for Implementation Research. After generating the initial codebook, we added and refined codes and identified key themes during coding meetings through an iterative process including coding reconciliation. Two independent coders identified facilitators and barriers to effective pregnancy options counseling through inductive and deductive analysis utilizing Dedoose (9.0.17).


      The sample included 52 participants, including 20 experiences of parenting, 18 of abortion, 17 of adoption, and 4 of miscarriage. Ages at time of adolescent pregnancy ranged from 13-19 years, with 8 pregnancies at age 15 and younger, 15 at ages 16-17, and 36 at ages 18-19. Fifty-one participants identified as female and 1 as non-binary. 14 identified as LGBTQ and the rest as heterosexual. 9 identified as African American or Black, 5 as biracial, 3 as Asian, 7 as Hispanic, 26 as Caucasian, and 2 as other. Participants named the following facilitators to effective options counseling for AYA: 1) positive provider communication skills (compassion/kindness, respect, attention to nonverbal cues, validation), 2) comprehensive content of provider discussion (discussing all options, asking the adolescent about feelings, choice, life plans, and available supports), 3) provision of materials (brochures, videos), and 4) intentional connection to resources/next steps (parenting class, support group, counselor/therapist, prenatal care, abortion provider, adoption agency). Barriers to effective options counseling included: 1) lack of counseling on all options and/or coercive/directive counseling, 2) poor communication skills (judgmental stance, too much/not enough information) 3) lack of available resources (such as provider time/knowledge and financial assistance), and 4) confidentiality concerns. We identified no differences in these perspectives across pregnancy outcomes. Participants who expressed having already decided on their desired pregnancy outcome prior to options counseling noted they still wanted unbiased counseling around all options.


      Despite differences in timing, location, and other demographics, AYA who experienced a pregnancy in adolescence described suboptimal pregnancy options counseling when it was performed at all. Preserving confidentiality and ensuring developmentally-appropriate, respectful communication should be considered the basic minimum standards for pregnancy options counseling, but these are often not met. Understanding AYA perspectives on options counseling can inform the formulation of AYA-centered pregnancy options counseling training platforms for providers to effectively implement this essential practice.

      Sources of Support

      Society for Family Planning. NIH T32GM008425.