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PATIENT STORY

As a longtime pregnancy care provider, I found it difficult to choose a single story as representative of pregnancy and birth. Most of the stories are meaningful because of the context of the relationship with the woman and the family—a few are tragic and yet filled with grace and the amazing strength displayed by even the very young. Some are truly epic tales, and all are learning opportunities. Pregnancy experiences are filled with consternation at the myriad of changes, discomforts, and worries. They are filled with laughter as women's bodies alter in amazing ways; we waddle, unconsciously rest plates on our bellies, and lose sight of our feet (Figure 4-1). Our partners and/or supportive others alternate between reassurance and befuddlement. And then a child appears, miraculously from a space that seems far too small to accommodate, and (regardless of the outcome) a new journey begins.

FIGURE 4-1

Dr. Mindy A. Smith and her husband, Gary, touching bellies during Mindy's pregnancy with Jenny.

EPIDEMIOLOGY

  • Planned pregnancy—Approximately 85% of sexually active women not using a contraceptive method will become pregnant over the course of a year.

  • Unplanned pregnancy—The unintended pregnancy rate in the United States is around 50 pregnancies annually per 1000 women.1 A single act of intercourse at a random time in the menstrual cycle carries a 4% to 6% risk of pregnancy; risk increases to around 30% if intercourse occurs from 5 days prior to and within 24 hours after ovulation.2,3

    • Unintended pregnancy (defined as a mistimed pregnancy or one not desired at the time of conception) can result from lack of use of a contraceptive or contraceptive failure.

    • Unintended pregnancy occurs among women of all ages, socioeconomic status, and marital status. Although unintended pregnancies are often associated with teens, 41% of pregnancies among women 35 to 39 years of age and 51% of those among women older than 40 years are unintended.4

    • Some unintended pregnancies end in abortion. A total of 664,435 legally induced abortions occurred in the United States in 2013 (12.5 per 1000 women aged 15 to 44 years; 200 abortions per 1000 live births).5 During 2004 to 2013, the percentage of abortions in adolescents ages 15–19 years decreased by 31%; rates in other age groups also decreased, with the exception of women over age 40 years, where rates remained stable.5

    • Of all abortions for which gestational age was reported, 66% were performed at ≤8 weeks' gestation.5

  • While maternal mortality has declined dramatically compared to the 1900s, recent data show an increase in the pregnancy-related mortality ratio (17.8 deaths per 100,000 live births in 2009 compared to 7.2 deaths in 1987).6 The maternal mortality rate in 2013–2014 in 27 states and the District of Columbia rose significantly from 20.6 maternal deaths per 100,000 live births ...

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