Understanding the Gap Between Fertility Intentions and Outcomes

The ability of women to safely and effectively control their fertility is a critical health and human rights issue. Family planning provides a range of health, social, and economic benefits for women and their families, yet more than 200 million women worldwide who wish to delay or limit their childbearing are not using any method of contraception. The global health community has recently seen renewed interest in promoting family planning use worldwide. This increased focus on family planning raises questions about how best to deliver reproductive health services to the women who need them, which requires a clearer understanding of how women make decisions about their fertility and how such decisions are carried out.This dissertation explores the reasons why women's stated fertility intentions do not always align with their fertility behaviors or outcomes. The first paper explores the concept of unmet need for family planning by using both quantitative and qualitative methods to better understand why women who want to prevent a pregnancy choose not to use contraception in Luanda Province, Angola. The second paper considers the social context in which women make decisions about their pregnancies in a post-abortion care context in Zanzibar, Tanzania. The third paper examines how women's experiences in early childhood shape their risk of unintended pregnancy later in life in the United States.These dissertation papers provide three distinct examples of how researchers' and policy makers' perceptions of women's reproductive decision-making may fail to recognize or address crucial determinants of fertility intentions, behaviors, and outcomes. In particular, they highlight the importance of considering women's fertility decisions within the context of their full reproductive lives, and point to the need for further research to better understand how such decisions shift over the course of women's lives. Policies and programs that can accommodate how these decisions are formed and changed over time are necessary for ensuring that all women have the right to make decisions about their reproduction and to enact these decisions in safe and effective ways