Unintended pregnancies can negatively affect financial, health, educational, and social outcomes. Reproductive justice is a health equity imperative that entails the right to have or not have children, and to parent children with autonomy and personal agency.¹ Fully supporting patients who have unintended pregnancies is increasingly urgent, especially for those with marginalized identities. A previously published American Family Physician (AFP) article describes evidence-based management of unintended pregnancies for family physicians.² We aim to highlight the implications for health equity.

Racial and ethnic minorities; patients who are immigrants, economically disadvantaged, disabled, or gender diverse; and those in rural communities have limited access to family planning and contraceptive counseling. This, along with a legacy of white supremacy, settler colonialism, and economic exploitation, contributes to higher rates of unintended pregnancies.^3–7 In the United States, there has been a long history of reproductive coercion in Black, Indigenous, and Hispanic communities, ranging from forced sterilization to unethical birth control experiments.^6,8 Additionally, racially marginalized populations encounter greater interpersonal and systemic discrimination, which may lead to reduced engagement with and trust in the health care system.⁹ Black, Hispanic, and lower-income women have been steered toward particular contraceptive methods and have experienced coercive contraceptive counseling practices.¹⁰ Even well-intentioned efforts to reduce unintended pregnancies through multiple inquiries about contraceptive use and directing patients to long-acting contraceptives can create disrespectful interactions and reduce autonomy in family planning.

Although unintended pregnancies can have harmful consequences for patients, not all unintended pregnancies are unwanted or undesired. Considering whether to continue an unintended pregnancy requires a complex calculus that includes the policy environment (eg, protections, supports, and benefits for birthing people and families) and potential effects on physical, mental, and emotional health for pregnant patients and their families. Black, Indigenous, lower-income, and rural-residing people are at an increased risk for maternal morbidity and mortality, and the declining access to high-quality and culturally centered care further exacerbates these risks.⁶ Compared with intended pregnancy, unintended pregnancy leads to a higher risk of perinatal depression, interpersonal violence, and infant low birth weight and almost doubles the risk for preterm delivery.^11,12 Preterm birth is a leading cause of infant mortality, and infant mortality rates are higher for Black and Indigenous populations, people of color, and rural residents in the United States.¹³

Beyond health, there are potential impacts on financial stability, employment, and career trajectory because pregnancies (intended and unintended) in the United States are often accompanied by financial stress.^14,15 Adoption is an option; however, it results in family separation, which is a traumatic historical and contemporary reality that disproportionately affects Black, Indigenous, and immigrant people in the United States.¹⁶

For those who cannot or choose not to carry an unintended pregnancy to term, access to abortion care is an essential aspect of health equity and racial and economic justice.⁶ Recent estimates suggest that a nationwide abortion ban would increase maternal mortality by 21% overall and by 33% in Black patients.¹⁷ The effects of restricting abortion access would likely extend beyond maternal mortality. In a landmark analysis of outcomes among pregnant people who sought an abortion, those denied abortion access were less likely to have an aspirational life plan, and those who had an aspirational life plan were less likely to achieve it.¹⁸

Through clinical care and influencing policies in the health care system, primary care clinicians can reduce the inequitable impacts of unintended pregnancies. The first step is to implement patient-centered contraceptive counseling using a reproductive justice lens, including focusing on the patient’s sexual and reproductive health goals and using shared decision-making based on their values, lived experiences, and preferences, as described in the previous AFP article.^2,19 Additionally, by learning about and reckoning with the legacy of medical racism, clinicians can take steps to mitigate its effects on care, such as reevaluating tools that inappropriately reduce access to vaginal birth after cesarean delivery.²⁰ In administrative and leadership roles, clinicians can advocate for health care policies and payment systems that ensure access to high-quality, evidence-based, patient-centered care for all people, including the full range of reproductive care.²

Family physicians have a role beyond clinical care for patients with unintended pregnancies. Advocating for expanding the social safety net to reduce the negative financial and social impacts of pregnancy and parenting (eg, affordable childcare; paid parental and family medical leave; a living wage; safe, affordable housing; access to affordable, nutritious food) sets the foundation for health equity and reproductive justice.