The frequency of pregnancy recognition across the gestational spectrum and its consequences in the United States

People recognize they are pregnant at gestational ages ranging from implantation to delivery, yet there is no comprehensive study that identifies the prevalence of pregnancy recognition at different points across this spectrum in the United States. To help clinicians, policymakers, researchers, educators, and public health advocates understand what is known about the spectrum of pregnancy recognition, this commentary integrates key research in three types of literature that have not been brought together before—retrospective studies of people who carried a pregnancy to term, studies of pregnant people presenting for abortion care, and postpartum studies of people who did not recognize their pregnancy until between 20 weeks and delivery. Our commentary also offers a corrective to the psychiatric literature’s inaccurate description of later pregnancy recognition as “pregnancy denial,” which forecloses consideration of the physiological and sociological reasons a pregnancy might be undetected until after 20 weeks. The term “pregnancy recognition” does not have a standard definition, so in this commentary we repeat the meaning used by each article we discuss. For example, in some research “pregnancy recognition” refers to the gestational age at which a person self-reports that they knew they were pregnant, but that research does not specify whether the subject is referring to a personal conclusion based on the first missed period or other pregnancy symptoms, a positive result from a home pregnancy test, or receiving the news (or confirmation of a home test) via urine test or ultrasound from a physician. In addition, some of these studies do not ask respondents whether they are counting weeks from when they believe fertilization occurred, from the first day of their last menstrual period (LMP), or somewhere in between. There is also no standard definition of “late pregnancy recognition,” so we state the meaning each article discussed ascribes to this term as well. Research on “pregnancy recognition” typically treats this phenomenon as an instantaneous, binary process—an informational switch is flipped and an unrecognized pregnancy becomes a recognized pregnancy. However, Peacock and colleagues argue that pregnancy discovery should be understood as a complex process which includes the phases of assessing pregnancy risk, perceiving and correctly interpreting signs and symptoms, and seeking confirmation, and that pregnancy should be acknowledged as a socially constructed phenomenon as well as a biological reality. Similarly, Bell and Fissell suggest that the binary model of pregnant versus not pregnant does not capture many women’s* experiences and propose an alternate model that emphasizes ambiguities in determining or confirming a pregnancy. A liminal state is the period or process when one is betwixt and between different social states. The time between conception and delivery has been analyzed as a transformative liminal experience between being a non-parent and being a parent, because physiological analyses of pregnancy “that only focus on [a woman’s] pregnant body and growing fetus diminish her personhood.” However, the fact one can be physically pregnant without being cognitively pregnant (because there are no test results or detectable markers of pregnancy) raises the possibility that the pregnancy recognition process itself should be considered a liminal state. What type of knowledge should be defined as “pregnancy recognition” is an important consideration for future research. Here we simply note that some people may experience a gap between initial suspicion of pregnancy and full acknowledgement in their recognition process and that this gap is different than the phenomenon of “denial” of pregnancy which we discuss below. Home pregnancy tests were introduced in the United States in 1977 and they became a blockbuster product in 1988 when the first one-step test was introduced. This new technology was revolutionary because it moved the locus of control of pregnancy discovery from the doctor’s office to the home. However, we speculate that the ubiquitous knowledge and use of home pregnancy tests in high-resource settings may create an informational anchor that leads people who have not had a contradictory personal experience to believe that everyone can, does, or should discover their pregnancy early and at home. What is lost in this cultural narrative of early pregnancy detection is the fact that only people who suspect they might be pregnant have a reason to take a home pregnancy test. The question this narrative forecloses is an important one: What happens when people who do not suspect they are pregnant are in fact pregnant? A better understanding of the true spectrum of pregnancy recognition could expand this narrative to be more accurate and inclusive. DOI: 10.1363/psrh.12192