Background
Unintended pregnancy is regarded as a serious public health issue both in developed and developing countries, and has received growing research and policy attention during last few decades. According to Population Reference Bureau reports (2009 estimate), each year about 200 million cases of unintended pregnancies occur year worldwide [
1]. Evidence suggests that a quarter of the unintended pregnancies end in unsafe abortions which is one of the leading causes of maternal mortality at the global stage [
1]. In general terms, unintended pregnancy refers to pregnancies that are either mistimed (i.e. occurred at an unplanned or inopportune time), or unwanted (i.e. occurred when parents had no desire for more children) [
2]. Unintended pregnancy has shown to result in a range of adverse physical and psychological health outcomes both for mother and infants [
1,
3] affecting various socio-economic and cultural aspects of community health [
4]. Evidence shows that unplanned/mistimed pregnancies are associated with higher rates of abortion and obstetric complications [
5], poor utilisation of maternal healthcare services (MHS) [
6], and postpartum depression and stress [
7]. Apart from that, unintended pregnancies are associated with significantly increased risk of low birth weight (LBW) and preterm births (PTB) among children [
8] and delayed and/or poor breastfeeding behaviour among mothers [
9]. As a significant contributor to maternal and child morbidity and mortality, in resource poor countries especially the ones characterized by poor sexual and reproductive healthcare infrastructure, unintended pregnancy and abortion pose significant barriers to achieving the maternal and child health related Millennium Development Goals (MDGs) [
10,
11].
With regard to MDG 4 and 5, Bangladesh has made impressive achievements especially in the indicators of family planning and contraceptive use, reduction in fertility rate, and reducing maternal and child mortality. Since 1990, maternal mortality rate (MMR) declined by 66% and infant mortality rate (IMR) by 57% [
12]. During the period between 1975 and 2007, rate of utilisation of any type contraceptives among married women has increased sevenfold (8 to 56%) and that of modern methods has increased almost tenfold (5 to 48%) [
13]. Rate of unintended pregnancy also declined in the country, however, at a slow pace from 33% in 1993 to 29% in 2011 [
14]. Despite these achievements, the prevalence of unmet need for family planning still remains high and have been increasing albeit slowly in recent years. Demographic and Health Survey (DHS) defines unmet need for family planning as a situation of non-use of contraception when women are unwilling to have more children or want to have about two or more years later. According to Bangladesh Demographic and Health Survey (BDHS 2007), unmet need for family planning increased among both urban and rural women in all seven administrative divisions (11% in 2004 to 17% in 2007) [
13]. One longitudinal study conducted on rural women in Bangladesh during 2006 and 2009 found that about a quarter of the women with unmet need for contraception experienced unwanted pregnancy [
15]. These findings reveal that unmet need is a growing concern and can be regarded as a missed opportunity to address unintended pregnancy in the country.
The causes of unintended pregnancy are multifarious, however most commonly attributed to incorrect/non-use and discontinuation of contraceptives, contraceptive failure, unmet need for contraception [
16,
17]. The concept of unmet need for contraception has a central position in the domain of family planning and reproductive health [
15]. Globally, non-use of available contraceptives alone account for 90% of the unwanted pregnancies [
12]. In developed countries, most abortions occur as a result of contraceptive failure and a small proportion are due to nonuse of contraception [
17]. Contraceptive failure accounts for about 50% of all unintended pregnancies in the United States [
18]. High rates of discontinuation and adoption of traditional contraceptive methods are major concerns for family planning programs in Bangladesh [
13]. Addressing the challenges of and unmet need for contraception and unintended pregnancy should be a priority agenda for public health especially in countries like Bangladesh where abortion is not legal. Understanding the socioeconomic determinants of these issues are essential to develop effective strategies for the prevention of unintended pregnancies and provide services to the population in need of service. However, there remains a paucity of research evidence regarding the factors of association with unintended pregnancy in Bangladesh. In this study, we aim to evaluate the prevalence of unintended pregnancy and investigate the association between of unmet need for contraception and unwanted pregnancy. For this purpose, we used data from the latest demographic and health survey which is nationally representative and a reliable source of population health data in the country.
Results
Table
1 shows the basic characteristics (weighted) of the sample population. The mean age of the participants was 25.6 years (SD 6.4) and little less than half were aged below 25 years. More than a quarter of the women were of rural origin. Compared to husbands, women had a higher rate of literacy (80.7 vs 71.5%) and secondary/higher education enrollment rate (50.5 vs 42.5%). About one-fifth of the women had no formal education and half had secondary/higher education qualification. More than two-third of the husbands were engaged in blue collar activities and 27.3% in White collar profession. Well over one-third of the women reported low household wealth status and less than one-fifth of high wealth status. Majority of the women had no employment (89.8%) and were from male-headed households (92%). More than half of the women experienced first child-birth before reaching the age of 18 years. Almost all of the women (95.1) mentioned that single child is the ideal number of children for them. About one-third of the women reported having involvement in personal healthcare decision and little less than one-fifth ever terminating a pregnancy. About two-third of the women mentioned using any contraceptive method and 13.5% reported facing unmet need for contraception. Majority of the women (92.9%) reported making decisions for contraception by husband or jointly with husband and only 7.1% making decisions by themselves alone.
Table 1
Baseline Characteristics of the sample population. BDHS 2011
Age (25.6, SD 6.4) | Age of the participants at the time of the survey | | |
<25 | 3637 | 49.6 |
≥25 | 3701 | 50.4 |
Domicile | Location of residence of households | | |
Urban | 1708 | 23.3 |
Rural | 5630 | 76.7 |
Educational attainment | Total number of years of formal education | | |
Nil | 1414 | 19.3 |
Primary | 2216 | 30.2 |
Secondary/Higher | 3708 | 50.5 |
Educational attainment of husband | Total number of years of formal education | | |
Nil | 2092 | 28.5 |
Primary | 2125 | 29.0 |
Secondary/Higher | 3121 | 42.5 |
Husband’s occupation | Type of employment for income earning | | |
Blue collar | 5336 | 72.7 |
White collar | 2002 | 27.3 |
Wealth status | Availability of household materials | | |
Poor | 3086 | 42.0 |
Middle | 2901 | 39.5 |
Rich | 1351 | 18.4 |
Employment | Working status of respondent at the time of survey | | |
Yes | 750 | 10.2 |
No | 6588 | 89.8 |
Sex of household head | Household head being a male figure | | |
Male | 6754 | 92.0 |
Female | 584 | 8.0 |
Age at first birth | Age at which respondent experienced first childbirth | | |
<18 | 3690 | 50.3 |
≥18 | 3648 | 49.7 |
Ideal number of children | Respondents opinion on the adequate number of children | | |
1 | 6979 | 95.1 |
>1 | 359 | 4.9 |
Has a say in own healthcare decision | Respondent can decide where to go and how much spending on healthcare | | |
Yes | 4395 | 59.9 |
No | 2942 | 40.1 |
Ever had a terminated pregnancy | History of pregnancy termination | | |
Yes | 1338 | 18.2 |
No | 6000 | 81.8 |
Currently using any contraception | Use of contraception of both traditional and modern type at the time of survey | | |
Yes | 4836 | 65.9 |
No | 2502 | 34.1 |
Unmet need for contraception | Fecund women who are not using contraception but want to space/limit pregnancy | | |
Yes | 992 | 13.5 |
No | 6346 | 86.5 |
Decision maker for using contraception | Decision on contraceptive use made by respondent alone or jointly with husband | | |
Respondent | 520 | 7.1 |
Husband /Joint | 6818 | 92.9 |
Results of chi-square tests presented in Table
2 are showing the factors of association with unwanted pregnancy. Cross-tabulation compares the relative percentage of participants reporting unwanted pregnancy against various demographic, socioeconomic and healthcare related factors. The rate of unwanted pregnancy was 29.3%. Results showed that the rate of unwanted pregnancy was higher among participants of rural origin, aging ≥25 years, higher educational status among both husband and wives and reporting poor wealth status. Women from male-headed households and had first childbirth before the age of 18 years were more likely to experience unwanted pregnancy. Women who reported the last pregnancy as desired were more likely have autonomy in own healthcare decision, using any contraception, had no unmet need for contraception, and had decision on contraception made by husband or jointly with husband.
Table 2
Percentage of participants reporting unintended pregnancy across the explanatory variables, BDHS 2011
Age |
< 25 | 40.0 | 53.5 | 111.62 | <0.001 |
≥ 25 | 60.0 | 46.5 |
Domicile |
Urban | 21.6 | 24.0 | 4.74 | 0.031 |
Rural | 78.4 | 76.0 |
Educational attainment |
Nil | 25.2 | 16.8 | 128.13 | <0.001 |
Primary | 34.1 | 28.6 |
Secondary/Higher | 40.8 | 54.6 |
Educational attainment of husband |
Nil | 33.7 | 26.4 | 53.36 | <0.001 |
Primary | 29.6 | 28.7 |
Secondary/Higher | 36.7 | 44.9 |
Husband’s occupation |
Blue collar | 76.3 | 71.2 | 20.22 | <0.001 |
White collar | 23.7 | 28.8 |
Employment |
Yes | 11.0 | 9.9 | 2.17 | 0.15 |
No | 89.0 | 90.1 |
Wealth status |
Poor | 48.9 | 39.2 | 68.90 | <0.001 |
Middle | 36.8 | 40.7 |
Rich | 14.2 | 20.1 |
Sex of household head |
Male | 92.9 | 91.7 | 2.97 | 0.08 |
Female | 7.1 | 8.3 |
Age at first birth |
< 18 | 58.4 | 46.9 | 79.48 | <0.001 |
≥ 18 | 41.6 | 53.1 |
Ideal number of children |
1 | 94.8 | 95.2 | 0.584 | 0.441 |
> 1 | 5.2 | 4.8 |
Has a say in own healthcare decision |
Yes | 61.2 | 59.4 | 1.99 | 0.166 |
No | 38.8 | 40.6 |
Ever had a terminated pregnancy |
Yes | 19.4 | 17.7 | 2.89 | 0.09 |
No | 80.6 | 82.3 |
Currently using any contraception |
Yes | 71.9 | 63.4 | 371.23 | <0.001 |
No | 28.1 | 36.6 |
Unmet need for contraception |
Yes | 98.4 | 81.5 | 48.50 | <0.001 |
No | 1.6 | 18.5 |
Decision maker for using contraception |
Respondent | 9.9 | 5.9 | 35.83 | <0.001 |
Husband /Joint | 90.1 | 94.1 |
Results of multivariate analysis
Table
3 illustrates the factors associated with unwanted pregnancy in Bangladesh. Variables that did not show significant correlation in the chi-square bivariate test were removed from further analysis. Rest of the variables were entered in the regression model firstly singly (Model 1), secondly all at the same time (Model 2). In the univariate analysis (Model 1), compared to women who reported unmet need for contraception had significantly higher odds [OR = 13.13; 95%CI = 9.41–18.31] of experiencing unintended pregnancies compared to those did not report any. Unmet need for contraception appeared to be related with an increased likelihood of experiencing unintended pregnancy [OR = 16.24; 95%CI = 11.34–23.24)] after adjusting for age, type of domicile, educational attainment of respondent, educational attainment of husband, husband’s occupation, wealth status, sex of household head, age at first birth, ever terminating a pregnancy, currently using any contraception, decision maker for using contraception.
Table 3
Results of generalized estimating equations showing the factors associated with unwanted pregnancy in Bangladesh, BDHS 2011
Unmet need for contraception (No) |
Yes | 13.13 (9.41–18.31) | 16.24 (11.34–23.24) |
Acknowledgements
We are sincerely thankful to the DHS Program for providing us the dataset without which this study were not possible. We also acknowledge the supports from many of our colleagues which contributed to the smooth completion of the study.