Prevalence of unintended pregnancy and associated factors among married women in west Belessa Woreda, Northwest Ethiopia, 2016

Unintended pregnancies are a major public health problem that can have adverse physical, mental, social, and economic outcomes. In this study, we observed the burden of unintended pregnancy among married women via a community-based survey of pregnant women. Eight rural kebeles and one urban kebele were included. The list of married pregnant women from each kebele was used as a sampling frame.

Participants were selected randomly and asked about their socio-demographic, reproductive and environmental characteristics. Additionally, the classification of their current pregnancy as intended or unintended was assessed and further questions were recorded among women who reported their current pregnancy to be unintended.

The total sample size was 619 participants. However, only 592 participants responded to the questionnaire. Out of the respondents, 523 were living in rural kebeles and 378 of the participants were unable to read and write. The mean age of the respondents was 28.4 years (±7.03). Out of the 592 women, 81 had unintended pregnancies and out of 81 women who had unintended pregnancies, 60 were mistimed and 21 were unwanted.

Regarding the determinants of unintended pregnancies, older age, history of stillbirth, and not discussing pregnancy with husbands were factors which can increase the likelihood of unintended pregnancies. Meanwhile, making a family planning decision alone and discussing family planning with their husbands had a negative correlation and thus a protective effect in developing unintended pregnancies.

Unintended pregnancy is a major global concern due to its association with adverse physical, mental, social and economic outcomes. It is not just a problem of young, poor women or minorities; it affects all segments of the community and contributes greatly to maternal and infant mortality [1]. Out of the 210 million annual pregnancies worldwide, about 79 million are unintended and out of this, 50% end in abortion [2].

Globally, the maternal mortality ratio (MMR) was 216 maternal deaths per 100,000 live births in 2015. Developing countries account for approximately 99% of the global maternal deaths in 2015, with sub-Saharan Africa alone accounting for roughly 66% [3]. The 2016 Ethiopian Demographic and Health Survey (EDHS) report showed the MMR in Ethiopia was 412 per 100,000 live births [4].

Between 20 and 40% of all births that occur in developing countries are unwanted, posing a hardship for families and jeopardizing the health of millions of women and children [3]. Women who experience an unintended pregnancy are less likely to have prenatal, perinatal and postnatal care [5].

Unintended pregnancies can result from a lack of contraceptive use, contraceptive failure and incorrect use of contraceptives [5]. Multiple studies have also shown other variables that influence the likelihood of unintended pregnancies including sociodemographic and economic conditions [6‐12] as well as reproductive and environmental factors [6, 7, 9, 11‐13].

An institution based study conducted in Felege Hiwot hospital in Ethiopia’s Amhara Region showed a prevalence of unintended pregnancies at 29.5% [9] and another study conducted in Arba Minch, southern Ethiopia, showed a prevalence of unintended pregnancies of 19.4% [14]. Most of the studies conducted in Ethiopia regarding unintended pregnancies are institution based and community-based information on unintended pregnancies among married women is limited. Therefore, this study aimed to assess the status of unintended pregnancies among married pregnant women in the general population. This study may inform policymakers in addressing the burden of unintended pregnancies and related complications among married women.

This study aimed to measure the magnitude of unintended pregnancies and associated factors. According to this study’s finding, the prevalence of unintended pregnancy was 13.7%. This result is lower than studies done in Southern Ethiopia (Arba Minch) [14], the Amhara region (Felege Hiwot Hospital [9], and Western Ethiopia (Ganji) [10]. The majority of this study’s participants consisted of rural women who traditionally bear many children [19]. Moreover, the participants of this study are married women who, as evidenced by other studies done in Ethiopia, are less likely to have unintended pregnancies [20, 21]. In addition, the Ethiopian government is striving to address maternal health problems and there have been improvements in access and utilization of reproductive health care services over time [4, 19, 22]. When we compare this result with the study done in Ganji, the health service coverage in Ganji was 52% [10] while the health service coverage for this study was 85%. Therefore, the growing availability of family planning services in the study communities could explain the lower rate of unintended pregnancies.

In this study, a history of stillbirth was significantly associated with unintended pregnancy. When a woman had a history of stillbirth, she might fear its re-occurrence and have less desire to become pregnant again [17, 23]. Unintended pregnancy was also higher among married pregnant women in the age group of 40–44 years. This finding is consistent with a study conducted in Ganji woreda [10]. Women above the age of forty are less likely to desire further pregnancies since they likely have the ideal number of children that they want. Moreover, complications related to pregnancy are very common in this age group which may further deter them from desiring pregnancy [18, 24]. Additionally, this group of women are older and less literate and may have less knowledge about the importance and accessibility of reproductive health services [25]. Spousal support among this group may also be limited. Relationships in this age group are more likely to be unstable and women may perceive themselves as having a low risk of conceiving contraceptives [26]. Also, they are more likely to have past experiences of unwanted contraceptive side effects that may deter their use of contraceptives [26, 27]. This combination of characteristics may make these women less likely to use family planning methods correctly [28] and more likely to practice unsafe sex. In addition, some diseases associated with previous pregnancies may influence their interest in becoming pregnant.

The role of partners has a significant effect on a woman’s intention to become pregnant. Women who did not have open communication about their pregnancy with their husbands had higher odds of having an unintended pregnancy than women who did communicate. When women have open communication about their pregnancy before and after conception, they get the support of their partners and have a higher likelihood of planning a pregnancy. In the absence of communication with their husbands, rural women, who spend most of their time at home, may not have adequate information about family planning which may result in unintended pregnancies. Moreover, women might not have the autonomy to decide about their fertility [29].

There appears to be a protective effect from unintended pregnancies when both husband and wife discuss and agree on their family planning goals as well as when a wife makes family planning decisions independently. Unintended pregnancy increases when the husband is the sole decision-maker in the family planning. This result is consistent with a study conducted in Senegal [11]. When women are empowered to be decision-makers and/or have the support of their husband in making family planning decision, they have improved knowledge and access to reproductive health care services [30, 31]. Therefore, joint decision making and/or sole female decision making decreases the occurrence of unintended pregnancies and allows families to lead more stable lives.

Although this study was strengthened by being community-based, the addition of qualitative measures would enrich the data. In addition, social desirability bias could lead women to report that their pregnancy was intended even though it was not, leading to an underestimate of the burden of unintended pregnancies. The other limitation of this study is that only married pregnant women were included. Whereas the majority of the unintended pregnancies result from illegitimate sexual intercourse, which is most common among sexually active teenagers and unmarried women. Lastly, the preference of some women not to disclose their unintended pregnancy might underestimate its burden.

Our results showed a low rate of unintended pregnancies among married women in the study areas at 13.7%. Age, history of adverse pregnancy outcomes and involvement of partners in reproductive health issues were associated with unintended pregnancies. Women who are in the late reproductive ages need close follow up and support in family planning. Furthermore, psychological support for women who have a history of adverse outcomes of pregnancy such as a history of stillbirth would also be an important group to connect to services to decrease the burden. Moreover, empowering women and increasing partner involvement in reproductive health may decrease unwanted pregnancies and its downstream consequences. Therefore, reproductive health programs that focus on building confidence and autonomy of women in planning their pregnancy may have a high impact on reducing unintended pregnancy.