These systematic deviations offer a window into drivers of health behavior and potential points of intervention. My dissertation applies decision-making constructs from behavioral economics to reproductive health outcomes. Specifically, I examine the trade offs between risk and reward and between now and later. These preferences are fundamental characteristics of decision-making. Risk tolerance and temporal discounting have been demonstrated to be drivers of financial behavior, and these same concepts have now been extended to the study of health behavior. Sexual behavior and pregnancy decision-making are an understudied and, as I demonstrate, particularly relevant area for exploration. National and international public health priorities include reduction of unintended pregnancy. Defined as pregnancies that are mistimed or unwanted, unintended pregnancies comprised 45% of all pregnancies to women aged 15-44 in the United States in 2011. Half of those pregnancies ended in abortion. Reproductive health literature reports inconsistencies between intention and behavior regarding contraceptive use and pregnancy. Nonuse or inconsistent use of contraception is common among women at risk of unintended pregnancy, meaning those sexually active with a stated desire not to get pregnant. Misperception of pregnancy risk may also result in reduced contraceptive use and subsequent unintended pregnancy, regardless of knowledge of available methods. In my second chapter, I conduct a systematic scoping review of the literature on temporal and risk preferences,cannabis grow supplier and sexual and reproductive health behavior. Temporal discounting is the rate at which people devalue delayed rewards in comparison to more temporally present rewards.

Higher discount rates indicate less willingness to exchange current consumption for future consumption. Individual decision-making is also shaped by perception of risk. Prospect theory describes decision-making in the context of risk. Risk preferences are generally measured as willingness to take gambles with income. People willing to take fewer gambles are generally deemed risk averse and those more willing to take gambles risk tolerant. I examine the consistency of findings from 20 studies identified to meet my inclusion criteria. Mapping the literature can identify common themes and gaps in current knowledge. While the majority of studies concern sexual risk behavior, I draw comparisons to outcomes of unintended pregnancy and contraceptive use. Finally, I make recommendations for future avenues of research based on the existing literature. I expand the empirical research on economic preferences and reproductive behavior in my third chapter, which examines risk preferences and sexual and contraceptive behavior in the 1997 cohort of the National Longitudinal Survey of Youth . I test the hypothesis that the propensity to take risk manifests not only in the financial decisions commonly studied by decision theorists, but also in less-well studied choices that affect reproductive health. I investigate the association of risk tolerance with several proximate determinants of unintended pregnancy, including high-risk sexual behavior, contraceptive non-use, inconsistent contraceptive use, and the effectiveness of contraceptive method type. In addition to risk preferences and discounting, uncertainty affects reproductive decision making and behavior. Variation in economic context may influence contraceptive and sexual behavior, thereby altering risk of unintended pregnancy and decision-making once a pregnancy has occurred. My fourth chapter examines how the recent Great Recession and economic uncertainty affect unintended pregnancy and pregnancy decision-making. I use the National Survey of Family Growth , a nationally representative sample of reproductive aged women. Understanding how the economy affects pregnancy intention and decision-making brings insight to the discussion of decision-making and reproductive outcomes as well economic drivers of fertility.

The goal of this dissertation is to improve understanding of behavioral drivers of reproductive health. The incorporation of concepts from behavioral economics into reproductive health frameworks may improve our predictions of distributions of disease and also generate hypotheses of pathways between social environment and health [1]. It may be especially useful for behaviors that offer benefits, or “rewards”, in the present that offset future negative consequences, or “costs”, to health later. The chapters show that economic preferences and measures of uncertainty have implications for our understanding of mechanisms underlying choices that drive reproductive health. This is an important step towards predicting who will be at highest risk of adverse outcomes and potentially develop models for intervention. Although sexually transmitted infections and unintended pregnancy have long been major public health concerns worldwide, unprotected sex and ineffective contraceptive use persist. Much literature shows that decisions affecting sexual behavior and fertility result from a complex process that involves norms, resources, knowledge, power, and individual tolerance for risk and propensity to make impulsive choices. The fact that unhealthy behaviors persist despite knowledge of risk has perplexed public health practitioners and led them to consider whether insights might be gleaned from behavioral economics – a field committed to explaining why humans act in ways inconsistent with rational self interest. Economists have theorized that individual behavior results from a desire to maximize utility, which varies based on individual preferences. These preferences, elaborated by behavioral economics, include the trade offs between risk and reward and between now and later, and are fundamental characteristics of decision-making. Risk and temporal preferences have been demonstrated to be drivers of financial behavior, and these same concepts have now been extended to the study of health behavior.

Sexual and reproductive behaviors are particularly relevant to study in the context of behavioral economics because the results of risky sex have delayed and uncertain consequences to health, in the form of pregnancy or STI acquisition, and so risk and temporal preferences are particularly salient. This review summarizes the scope of the literature relating temporal and risk preferences to sexual and reproductive behavior, to determine if discounting or risk tolerance are reliable correlates of choice relating to sex, pregnancy and STI risk. I first describe background literature on sexual and reproductive health that is relevant to the application of temporal discounting and risk tolerance. Next, I briefly define temporal discounting and risk preferences and discuss relevant literature in other health domains. This background motivates the systematic scoping review of the literature on temporal discounting or risk tolerance and sexual and reproductive outcomes, which follows. Nearly half of pregnancies to women aged 15-44 in the United States are unintended. These unintended pregnancies are associated with negative outcomes for mothers and children, including delayed prenatal care, maternal depression,cannabis drainage system lower quality of maternal-child relationship, and higher rates of preterm birth. Unintended pregnancies, like many public health problems, concentrate among low income women and women from minority racial/ethnic groups . Young age, low education, previous pregnancies, non-married status, and urbanicity explain much but not all of the concentration of unintended pregnancy among poor and minority women in developed contexts. The consequences of unintended pregnancy are more severe in the developing world, and lead to excess maternal mortality, morbidity from births, and unsafe abortions. Research reports inconsistencies in behavior and intention regarding contraceptive use and pregnancy. Nonuse or inconsistent use of contraception is common among sexually active women with a stated desire to avoid pregnant. Lack of information about method availability, especially long acting methods, appears more common among women reporting unintended pregnancy. Contraceptive use is influenced by a variety of system level factors, such as access and cost, as well as individual decision-making. Research on attitudes toward contraceptives has, moreover, reported that fear of side effects or differences between desired and available method features also affect use. Misperception of risk may also result in reduced contraceptive use and subsequent unintended pregnancy regardless of knowledge of available methods. A study of family planning patients found, for example, that nearly 46% of women who engaged in unprotected intercourse in the past 3 months underestimated the risk of conception and that underestimation predicted unprotected sex.

Similarly, a study of women seeking abortion services found that the majority of women thought themselves to have an inaccurate risk of pregnancy prior to conception. A California study following young women who initiated a new method of contraception and who reported not wanting to be pregnant within a year found high rates of discontinuation over the year. Similarly in the field of sexual risk behavior, risk reduction strategies including condom distribution, increasing HIV/AIDS risk perception, and education have proven successful strategies at reducing some but not all sexual risk behavior. A strong body of literature shows that sexual decision-making is often spontaneous and unplanned, especially in the context of alcohol or substance use. The intuitive connection between individual decision-making and unintended pregnancy and STI risk behavior has lead reproductive health researchers to explore the field of behavioral economics. In a white paper, the Behavioral Economics in Reproductive Health Initiative noted the opportunity to apply behavioral economics to global reproductive health concerns. They describe the importance of trade-offs between today versus tomorrow and of beliefs about probability in individual calculation of pregnancy or STI risk in reproductive decision-making. These notions apply to earlier cited literature showing that people misestimate the risks of pregnancy and STIs and make impulsive decisions relating to sex.Given the importance and persistence of sexual risk behavior and the gap between contraceptive use and intention, behavioral economics concepts would seem particularly useful for research concerned with reproductive health. Temporal discounting is the rate at which people devalue delayed rewards in comparison to more temporally present rewards . Higher discount rates indicate less willingness to exchange current consumption for future consumption. Delay discounting is typically assessed with hypothetical questions about different monetary amounts in the present or in the future. Most people would choose a higher amount of money over a lower amount if both were offered at the same time. However as the higher amount is delayed, individuals may switch to preferring the lower but sooner amount to the higher but later amount. The amount and delay at which the switch occurs is called the indifference point and can used to calculate individual discount rates. Those with very high discount rates discount the future value of a reward steeply as the delay increases and, therefore, show a present bias. Those with lower discount rates seem to value the future more similarly to the present. The preference for smaller pleasures in the present to larger benefits in the future can explain certain behaviors like smoking again one day after you quit. Probability discounting is similar to delay discounting, except that it measures a person’s sensitivity to uncertainty rather than delay of rewards. While delay discounting assesses the trade off between an immediate and delayed reward, probability discounting assesses the trade off between a certain and probabilistic reward. In discounting tasks, if both larger and smaller rewards are certain, most people would prefer a larger amount. However as the probability of the larger amount decreases, there is a shift to the smaller, certain amount. Similar to delay discounting, the point at which a person switches from a larger less probable rewards to a smaller certain reward is considered the indifference point of probability discounting. Probability discounting is closely tied to the concept of risk tolerance, as it is a measure of the degree of monetary risk someone is willing to assume. Behavioral economists have posited that discount function is nonlinear over time and instead fits a hyperbolic shape, meaning that there is attenuation in the rate of devaluation with increasing delays. Hyperbolic discounting reflects inconsistencies between long term goals and short-term rewards, and explains “impulsive” decisions as the value is discounted more steeply with shorter delays. Present biased individuals make far sighted plans when rewards are distant but often reverse their choices in favor of short term rewards as the decision-point is reached. Literature linking temporal discounting to health behavior has emerged. Researchers have proposed that temporal discounting relates to unhealthy behavior and explains inconsistencies between exhibited behavior and stated intention. Health behaviors, including sexual risk behavior, often involve the present/future trade offs that are central to the concept of discounting. Unhealthy behaviors also typically have a delayed effect on health, such that one might not immediately experience loss of health or functioning. Indeed, the immediate rewards of the behavior often are so strong that they overpower the risk of future negative outcomes . This has led researchers to propose that unhealthy choices may be related to an individual’s temporal discount rate, or the degree to which they value present rewards versus future outcomes.