The effects of pregnancy intention on the use of antenatal care services: systematic review and meta-analysis

Maternal health care is important for better maternal, Perinatal and infant health outcomes. High maternal and neonatal mortality rates are associated with inadequate and poor-quality maternal health care, including antenatal care, skilled attendance at birth and postnatal care. Hence, achieving the MDG goal on maternal health requires providing high-quality pregnancy and delivery care, improving sexual and reproductive health care and universal access to all its aspects [1‐3]. Indeed, the benefits of healthcare seeking are tremendous particularly in settings where public health resources are limited. Antenatal care is recognized as a key maternal service in improving a wide range of health outcomes for women and children. It provides an opportunity to provide interventions for improving maternal nutrition, to encourage skilled attendance at birth and use of facilities for emergency obstetric care [1, 4]. Delayed entry into antenatal care may result in missed opportunities to diagnose pregnancy induced hypertension, gestational diabetes, or sexually transmitted infections.

However, use of these maternal health services is limited, especially in developing countries with high maternal and child mortality. Several individual, household and community level factors have been assessed for the underutilization of maternal health services [5‐9]. Among individual factors, studies have considered the role of pregnancy intention in the use of antenatal care. Though, the effects of unintended child bearing remain debated, the committee on unintended pregnancy at the Institute of Medicine concluded that “the consequences of unintended pregnancy are serious, imposing appreciable burdens on children, women, men, and families” [10, 11]. Accordingly, a number of studies have assessed the relationship between antenatal care and pregnancy intention finding that women with unintended pregnancies initiate antenatal care late and make inadequate antenatal care visits [12‐16]. But, inconsistent findings have been reported in other studies concerning the association between pregnancy intention and antenatal care utilization [17‐20]. In particular, the two studies from developing countries (by Marston and Cleland, and Gage) used DHS data of different countries and found an inconsistent association between pregnancy intention and antenatal care. Given the inconsistent findings, and the fact that under-utilization of modern health services are major reasons for poor health in many developing countries of the world, the objective of this study is to systematically review and meta-analyse studies on the association between pregnancy intention and antenatal care.

This study reviewed the evidence on the association between pregnancy intention and antenatal health care, specifically on timely initiation of antenatal care and receipt of adequate antenatal care. Thirty-two observational studies were included into the analysis, selected based on a series of inclusion criteria. We found that there is an increased odds of delayed antenatal care and inadequate antenatal care use among women with unintended pregnancies as compared to women with intended pregnancies. Subgroup analysis done for developing and developed countries also showed a significant association.

However, there were heterogeneities among studies included in the analysis. This was specifically true for analysis on delayed initiation of antenatal care. Although the majority of the studies were cross-sectional studies, there were few cohort/longitudinal studies. Hence, measurement of exposure varied between the studies, although it did not affect the result significantly as shown by the sub-group analysis. They also varied in sample size, but we included studies that controlled for confounders to obtain directly comparable estimates. Even then, the confounders controlled for vary from one study to another. This makes interpretation difficult. Moreover, the bulk of studies on this subject came from the United States, and may not be representative of all developed countries. Publication bias was checked using funnel plot and the result showed that there is no publication bias.

The strength of the systematic review includes; inclusion of studies with adjusted estimates, an extensive literature search, large total sample size of the studied population, a focused research question, and robust effect size and their confidence intervals. There are also some limitations of the study. First, there were few unpublished studies included and majorities were publications on peer reviewed journals and those available online. This is because access to unpublished research reports is difficult. Majority of the studies included are cross-sectional and thus lacks strength to make plausible conclusions. These cross-sectional studies measured exposure sometime after birth and as a result recall bias and ex-post rationalization affect exposure measurement. Previous studies have shown that maternal response to questions of pregnancy intention will vary based on the time lag between the actual pregnancy and the timing of assessment [24‐26].

This analysis was restricted to the effects of pregnancy intention on maternal health-care seeking behavior, as measured by timely initiation of ANC and receipt of adequate ANC .This does not mean pregnancy intention is the only factor affecting prenatal care. Several individual, household and community level factors influence the outcomes, and this needs to be kept in mind in interpreting these findings. For instance, among individual level factors, maternal education is consistently and significantly associated with use of antenatal care services. Household socio-economic status, women’s employment, urban residence and parity were among the individual and household level factors associated with the use of antenatal care services in different studies [27‐29]. Moreover, community and heath care factors such as women’s autonomy, accessibility, affordability and quality of health services are among the factors reported by different studies as important factors in the utilization of antenatal care services [5, 6, 30, 31].

The systematic review demonstrated that women’s pregnancy intention influences antenatal care utilization. Sub-group analysis also showed that there are increased odds of delayed and inadequate antenatal care use among women with unintended pregnancies in both developing and developed countries. This has important policy implications, particularly for developing countries with high maternal mortality. Information on the importance of planning and healthy timing of pregnancies should be provided for women of reproductive ages through all appropriate channels. Moreover, maternal health care providers should provide appropriate counseling for women with unintended pregnancies to encourage them to complete the recommended package of antenatal care services.