This study improves on previous findings that focus only on ambivalence related to pregnancy intention or to decision making, and explores women's mixed, fluctuating, or unresolved feelings and attitudes about pregnancy before many participants had completed pregnancy decision making. Acknowledging and exploring sources of ambivalence regarding pregnancy may help health providers and policymakers to comprehensively support women with respect to both their experiences and reproductive goals.

Background and aims COVID‐19 forced healthcare systems to implement telehealth programs, facilitated in Massachusetts by a policy requiring insurers to reimburse for telehealth visits. Prior studies suggest that telehealth is effective for obstetric care, but little is known about its implementation in response to policy changes in underserved communities. We utilized the RE‐AIM framework to evaluate telehealth implementation in a large academic urban obstetric practice that serves a medically underserved population. Methods RE‐AIM elements were assessed through retrospective review of electronic health record (EHR) data for all obstetric encounters between March 19 and August 31, 2020 and review of clinic implementation processes. Data extracted included demographics, number and type (in‐person or telehealth) of prenatal visits, prenatal diagnoses, delivery outcomes, and number and type of postpartum visits. Data were analyzed using descriptive statistics. Results A total of 558 patients (60.6% Hispanic; 13.2% primary language Spanish) had 1788 prenatal visits, of which 698 (39.0%) were telehealth visits. A total of 209 patients had 230 postpartum visits, of which 101 (48.3%) were telehealth visits. The Reach of the intervention increased from 0% of patients at baseline to 69% in August. Effectiveness measures were limited but suggested potential for earlier diagnosis of some prenatal conditions. Adoption was high, with all 30 providers using telehealth, and the telehealth was found to likely be feasible and acceptable based on uptake. Increases in the percentage of telehealth visits over time and continuation post‐lockdown suggested maintenance was potentially achievable. Conclusions The COVID‐19 pandemic has changed traditional approaches to healthcare delivery. We demonstrate that the use of the RE‐AIM framework can be effective in facilitating implementation of telephone visits in a large academic urban obstetric practice after state‐level policy change. This may be of particular importance in settings serving patients at higher risk for maternal morbidity and poor birth outcomes.

We demonstrate increased odds of unplanned or poorly timed pregnancy among women with preconception binge drinking, marijuana use, and opioid use; however, no association is observed with other substances after multivariable adjustment, including tobacco. Further research to evaluate high-level preconception substance use and substance disorders with pregnancy planning and timing is warranted. Focused efforts optimizing preconception health behaviors and reducing risk of unplanned or poorly timed pregnancy are needed.