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The Effect of Unintended Pregnancy on Maternal Health Care Service Utilisation in South Asia.

Author(s) S. M. Mostafa Kamal1, Che Hashim Hassan2.
Affiliation(s) 1Department of Mathematics, Islamic University, Kushtia-7003, Bangladesh, 2Unit for the Enhancement of Academic Performance, University of Malaya, Kuala Lumpur, Malaysia 3.
Country - ies of focus Bangladesh
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study examines the effect of unintended pregnancy on maternal health care services utilization among women of four South Asian countries using nationally representative survey data conducted between 2005 and 2011. The prevalence of unintended pregnancy ranges from 25% in India to 32% in Bangladesh. Overall, the Indian women sought more skilled services for maternity care than the women of other study countries. The multivariable binary logistic regression yielded that, except for Pakistan, the women with unintended pregnancy were significantly less likely to seek skilled maternal health care services than women who reported that their last child was planned/wanted.
Background Of the estimated annual 210 million pregnancies occurring worldwide, approximately two-fifths are unintended which include mistimed and unwanted pregnancies, out of which 22% end in unsafe and illegal abortions. Unintended pregnancy is a major cause of unsafe abortion. Ninety-five percent of unsafe abortions occur in the developing countries. Worldwide, unsafe abortion accounts for approximately 13% of the total maternal deaths. Millions more suffer long-term life threatening complications caused by unsafe abortion. The pernicious consequences due to unintended pregnancies are well documented. Evidences show that unintended childbearing can cause adverse health outcomes such as depression, anxiety, poor psychological well-being, poor utilization of antenatal care services, low use of supplements, vaccination and nutrition. However, most of these findings are from developed countries. Such evidence is limited in developing countries.
Objectives This study aims to examine the effect of unintended pregnancy on maternal health care service utilization among women of four South Asian countries: Bangladesh, India, Nepal and Pakistan.
Methodology Data used in this study were collected by the most recent and nationally representative Demographic and Health Survey (DHS) conducted in Bangladesh, India, Nepal and Pakistan. The surveys are based on a two-stage stratified sample of households. It accumulated information from married women of reproductive age inclusive of rural and urban areas. The survey obtained various information related to demographic and health issues including fertility, marriage, use of family planning methods, pregnancy intention status, maternal and child health, use of maternal and health care services etc. The surveys collected information of live births that occurred in the five years preceding the survey.Outcome measures.The outcome measures of the study are: (i) skilled antenatal care (ANC) seeking; (ii) adequate ANC (≥4 ANC) visits; (iii) seeking assistance from skilled birth assistants (SBA); and (iv) delivery at facility place. The skilled MHCS has been defined as receiving care from a medically-trained services provider. The facility for childbirth includes a medically equipped health care service centre.Exposure variables.Along with the principal exposure variable ‘unintended pregnancy’, we additionally included socioeconomic and demographic variables which may influence the utilization of MHCS. The list, definitions and measurement of the covariates included for analysis are provided in Table 1.

Statistical analyses.

Both bivariate and multivariable statistical analyses were adopted in this study. Differences of the use of MHCS according to the desirability of pregnancy and other socioeconomic factors were assessed by chi-square (χ2) tests. To assess the net effects of the exposure variables on the outcome measures, four different multivariable binary logistic models were designed for outcome interests. The checking of multi co-linearity results in its non-existence. The results of the logistic regression analyses are presented by odds ratios (ORs) with 95% confidence intervals (CIs). The level of significance was set at 0.10. The statistical analyses were performed by IBM SPSS v21 (SPSS Inc., Chicago, IL, USA).

Results Prevalence of unintended pregnancy.The prevalence of unintended pregnancy was highest in Bangladesh (32%), followed by Pakistan (30%), Nepal (30%) and India (25%). The prevalence of unintended pregnancy differed significantly by place of residence, age at first marriage, maternal age, birth order and wealth index.Prevalence and differentials of MHCS utilisation.A slightly over half of the Bangladeshi women (51.8%) visited at least once for ANC services. The corresponding figures for women in India, Nepal and Pakistan were respectively 76%, 58.3% and 64.8%. The proportion of women who received adequate ANC services was highest in Nepal (50.1%), followed by India (37.3%), Pakistan (28.8%) and Bangladesh (23.9%). Exactly half of the Nepalese women received adequate ANC services. Seeking assistance from SBA was reported to be highest among women of India (46.7%), followed by Pakistan (39.2%), Nepal (36.0%) and Bangladesh (27.7%) respectively. The prevalence of delivery at hospital was highest among Indian women (38.7%), followed by Nepal (45.3%), Pakistan (34.6%) and Bangladesh (24.9%). Pregnancy desireability exhibited a significant difference in the use of four indicators of MHCS. Except in Pakistan, the prevalence of use of MHCS was lowest among those who reported their last child as unwanted.

Results of multivariate regression

The multivariate logistic regression analysis reveals that, when other variables were controlled for, except for Pakistan, the women, experiencing unintended pregnancy were significantly reluctant to seek skilled MHCS than women with wanted pregnancy. For instance, the women of Bangladesh who opined that their last child was unintended, the risk of seeking ANC, SBA and use of facility place for delivery decreased by the factors 0.85 (95% CI=(0.75-0.96), 0.87 (95% CI=0.77-0.99), 0.86 (95% CI=0.76-0.98) respectively as compared to that those with wanted pregnancy. Almost similar results were obtained for India and Nepal. Surprisingly, the Pakistani women experiencing unintended pregnancy were more likely to seek ANC services, but were less likely to go for delivery at hospital than those whose last child was reported as wanted. The other variables that showed to have significant effect on the utilization of MHCS for the study countries are maternal age, age at first marriage, birth order, women’s education, pregnancy termination and wealth index.

Conclusion Overall, the study results provide important insights into the association of unintended pregnancy with four indicators of MHCS utilization. To our knowledge, this study is the first multi-country study of the association of pregnancy intention status and use of maternity care services. All of these outcomes have been previously associated with a variety of factors, including place of residence, education, and standard of living index or wealth quintiles. However, study findings reveal a high prevalence of unintended pregnancy in the study countries which adds another layer of vulnerability over and above these background characteristics on MHCS utilisation. In the study countries, unintended pregnancy is not only a concern from the perspective of fertility, but is also a cause for concern from the point of view of public health, particularly regarding the use of MHCS. Therefore, greater attention is required to curb the high levels of unintended pregnancies in South Asia. Family planning programmes can play a vital role in averting unintended births and in reducing the burden of unintended pregnancy. Improving access to quality contraception may be an important intervention. Awareness should be created as to the long term benefits of using skilled MHCS through information, education and communication (IEC) programmes.

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