International Journal of Gynecology and Obstetrics 128 (2015) 228–231
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Unintended pregnancy and associated risk factors among young pregnant women Intira Sriprasert a, Somsak Chaovisitsaree a, Narisa Sribanditmongkhol a, Nuchanart Sunthornlimsiri a, Chumnan Kietpeerakool b,⁎ a b
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
a r t i c l e
i n f o
Article history: Received 27 May 2014 Received in revised form 29 August 2014 Accepted 7 October 2014 Keywords: Contraception Risk factors Unintended pregnancy Young women
a b s t r a c t Objective: To assess pregnancy intention and the associated risks among young pregnant women. Methods: In a descriptive study, pregnant women aged 15–24 years were recruited at a prenatal clinic in Chiang Mai University Hospital, Thailand, between March 1, 2012, and February 28, 2013. Participants were interviewed by trained interviewers using a standardized questionnaire to elicit information about baseline characteristics, pregnancy intention, and contraception practice. Results: Overall, 250 participants were recruited (mean age 20.7 ± 2.4 years), and 163 (65.2%) declared that the pregnancy was unintended. The odds of the pregnancy being unintended were increased in students (P = 0.006), women aged 20 years or younger (P = 0.024), and women whose partner was a similar age (P = 0.026). A higher percentage of women with unintended pregnancy than with intended pregnancy reported having no time to use contraception, a perceived difficulty of regular contraceptive use, fear of parents finding out about sexual activity, and embarrassment about using contraception. Conclusion: Pregnancy among young pregnant women in Thailand was often unintended. Educational status, age, and age difference between the couple were independently associated with unintended pregnancy. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The identification and prevention of unintended pregnancies continues to receive attention. A report evaluating data gathered from nationally representative and small-scale surveys in 80 countries [1] observed that approximately 41% of pregnancies were unintended in 2008. In Asia, the prevalence of unintended pregnancy is thought to vary from 33% to 48% [1]. A substantial number of unintended pregnancies are terminated, and the procedure is unsafe in many cases [2–4]. Unintended pregnancies ending in a live birth are associated with a significantly heightened risk of poor newborn, child, and maternal health [1,5,6]. Understanding whether a pregnancy was intended can be helpful when identifying women who might need a lot of prenatal support [3,5,7]. Whether intended or not, there is ample evidence regarding the negative impact of pregnancy in young women on maternal and child health. Young maternal age is associated with a significantly increased risk of maternal anemia, poor prenatal care compliance, preterm delivery, low birth weight, newborn admission to the intensive care unit, and postpartum complications [6,8–13]. Many pregnancies occurring in ⁎ Corresponding author at: Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand. Tel.: + 66 43 363030; fax: +66 43 348359. E-mail address: [email protected] (C. Kietpeerakool).
young women are unintended [2,3], which further increases the risk of problems. Therefore, the number of unintended pregnancies among young women and the associated risks are important topics of inquiry. However, before interventions can be designed and tested, it is necessary to identify specific sociodemographic risk factors associated with unintended pregnancy. Accordingly, the aim of the present study was to assess pregnancy intention and the associated risks among young pregnant women in Thailand. 2. Materials and methods The present descriptive study was prospectively conducted among pregnant women aged 15–24 years who attended a prenatal clinic at the Chiang Mai University Hospital, Chiang Mai, Thailand, between March 1, 2012, and February 28, 2013. The study was approved by the Research Ethics Committee of the Faculty of Medicine, Chiang Mai University. Informed consent was obtained from all participants. Participants were interviewed by trained interviewers who used a standardized questionnaire to elicit information on baseline characteristics, pregnancy intention, and previous contraception practice. A pregnancy was deemed to be unintended when it was reported to have been either unwanted or mistimed (wanted but at a later time). Beliefs and barriers to contraception were evaluated with an 11-item questionnaire that was adapted from a qualitative study exploring reasons for low contraceptive use among young individuals through focus
http://dx.doi.org/10.1016/j.ijgo.2014.09.004 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
I. Sriprasert et al. / International Journal of Gynecology and Obstetrics 128 (2015) 228–231
which, if any, were independently associated with unintended pregnancy. No correction was made for multiple testing.
Table 1 Characteristics of the participants.a Characteristics
Values (n = 250)
Women’s characteristics Mean age, y Primigravida Educational attainment No formal education Primary education Secondary education Bachelor degree In graduate schoolb History of induced abortion in previous pregnancy Contraception methods used at time of conception None Oral contraceptive pill Condom Depot medroxyprogesterone acetate Emergency contraceptive pill Intrauterine device Partner’s characteristicsc Mean age, y Age group, y ≤20 21–30 N30 Joint characteristicsc Woman 1–4 y older than partner About the same age Women 1–8 y younger than partner Woman ≥9 y younger than partner a b c
229
3. Results 20.7 ± 2.4 168 (67.2) 19 (7.9) 18 (7.2) 159 (63.6) 21 (8.4) 33 (13.2) 19 (7.6) 89 (35.6) 118 (47.2) 21 (8.4) 13 (5.2) 8 (3.2) 1 (0.4) 24.5 ± 5.0 60 (25.1) 151 (63.2) 28 (11.7) 21 (8.8) 48 (20.1) 132 (55.2) 38 (15.9)
Values are given as number (percentage) or mean ± SD. Currently studying for Bachelor degree. Calculated for 239 participants with available data.
group discussions [14]. The items covered five main categories: misconceptions and fears; gender power relations; sociocultural expectations and contradictions; short-term planning dilemma; and health system barriers [14]. Participants were asked to rate each item as “agree/yes,” “disagree/no,” or “do not know.” Statistical analysis was done via SPSS version 17.0 (SPSS Inc, Chicago, IL, USA) and STATA version 10 (StataCorp, College Station, TX, USA). Data are summarized as mean ± SD or number (percentage). Univariate analysis was carried out to identify variables potentially associated with unintended pregnancy, including age, gravidity, education level, and age difference between the couple. These variables were then included (if P b 0.20) in a stepwise logistic regression analysis to determine
During the study period, 250 participants were recruited. The mean age of the participants was 20.7 ± 2.4 years, and most were younger than their partners (Table 1). Some were currently students (Table 1). Approximately one-third of the participants had not been using contraception at the time of conception (Table 1). Among the women who had been using contraception, the most common method was the oral contraceptive pill (Table 1). Despite their attendance at a prenatal clinic, 163 (65.2%; 95% confidence interval [CI] 58.9%–71.1%) participants reported that they had not intended to become pregnant. Table 2 shows the characteristics associated with unintended pregnancy. Four dichotomous variables were assessed via a stepwise logistic regression analysis to evaluate their independent impact on the risk of unintended pregnancy. Three variables were independently associated with increased risk of unintended pregnancy: status of education (being a student vs completed education), participant’s age (≤20 y vs N20 y), and age difference between the woman and her partner (small vs large). Participants who were students were at the highest risk of unintended pregnancy (odds ratio [OR] 8.02; 95% CI 1.84–34.91). Younger participants had almost twice the risk of unintended pregnancy as compared with older participants (Table 2). Pregnant women whose age was slightly different from that of their partner were more likely to have an unintended pregnancy than were those who were much younger than their partner (OR 2.30; 95% CI 1.11–4.79). Overall, the major obstacles to contraceptive use were fears related to adverse effects (Table 3). Approximately half of all the participants worried about the adverse effects of contraceptives for either herself or the fetus in case of pregnancy. The proportion of women who reported major concerns about the safety of contraceptives was similar between those who intended to become pregnant and those who did not (Table 3). However, the proportion who reported that they did not have time to use contraception was higher among women with an unintended pregnancy than among those who had planned their pregnancy (Table 3). Compared with women with an intended pregnancy, a higher percentage of participants with unintended pregnancy reported a perceived difficulty of regular contraceptive use, fear of contraceptives being discovered by parents, that they were embarrassed to use contraceptives, and no effective contraceptive service (Table 3). Barriers related to partners and social and religious issues were not reported by many participants (Table 3).
Table 2 Predictors for unintended pregnancy.a Variables
Currently in graduate school Yes No Participant age, y ≤20 N20 Extent of age difference, y Lowb Highc Gravidity 1 ≥2
Total no. of women
No. (%) with unintended pregnancy
Univariate analysis P value
Multivariate analysis Adjusted OR (95% CI)
P value
30 209
28 (93.3) 127 (60.8)
b0.001
8.02 (1.84–34.91)
0.006
110 129
79 (71.8) 76 (58.9)
0.030
1.94 (1.09–3.43)
0.024
201 38
137 (68.2) 18 (47.4)
0.017
2.30 (1.11–4.79)
0.026
155 84
109 (70.3) 46 (54.8)
0.091
1.26 (0.69–2.28)
0.440
Abbreviations: OR, odds ratio; CI, confidence interval. a Includes 239 women who provided data on partner’s age. b Included 21 women 1–4 y older than partner, 48 women about the same age, and 132 women 1–8 y younger than partner. c Woman at least 9 y younger than partner.
230
I. Sriprasert et al. / International Journal of Gynecology and Obstetrics 128 (2015) 228–231
Table 3 Beliefs and barriers to contraceptive use.a Beliefs and barriers to contraception
Harm to herself Harm to fetus in case of pregnancy Socially inappropriate to use Religion opposes use Embarrassing to use Fear of being seen by parents Perceived difficulty in regular use Intercourse in a hurry; no time to use Men disapprove of use Lack of awareness of partner Lack of effective service a
Characteristics of the participants All participants (n = 250)
Intended pregnancy (n = 87)
Unintended pregnancy (n = 163)
134 (53.6) 136 (54.4) 5 (2.0) 4 (1.6) 7 (2.8) 24 (9.6) 32 (12.8) 58 (23.2) 12 (4.8) 11 (4.4) 23 (9.2)
46 (52.9) 51 (58.6) 3 (3.4) 2 (2.3) 0 7 (8.0) 9 (10.3) 8 (9.2) 3 (3.4) 3 (3.4) 6 (6.9)
88 (54.0) 85 (52.1) 2 (1.2) 2 (1.2) 7 (4.3) 17 (10.4) 23 (14.1) 50 (30.7) 9 (5.5) 8 (4.9) 17 (10.4)
Values are given as number (percentage).
4. Discussion In the present study, the frequency of unintended pregnancy and the associated risk factors have been systematically evaluated. The frequency of unintended pregnancy was high (65.2%). Significant independent variables correlated with unintended pregnancy were educational status, age, and age difference between the couple. The present findings underscore that a group of young pregnant women requires comprehensive support. Educational attainment has previously been identified as one of the key sociodemographic risk factors for unintended pregnancy among young women [15,16]. Kuroki et al. [15] reported that, compared with women who continued education after high school, women who did and did not complete high school were 3.2-fold and 2.6-fold more likely to have an unintended pregnancy, respectively. Similarly, Calvert et al. [16] observed that young women with a primary education level in Tanzania were three times more likely to declare their pregnancy to be unplanned than were more highly educated women. A notable finding in the present study was the high rate of pregnancy among participants in graduate school (13.2%). Getting pregnant during graduate school can interrupt the education program and even result in school dropout [17]. Unsurprisingly, almost all the pregnancies among young women in graduate school were unintended, and pregnancy among this group of women was eight times more likely to be unintended than among those who had completed their education. Several studies have investigated whether age is associated with unintended pregnancy, with inconsistent results [15,16,18]. Increasing age was noted to be directly associated with unintended pregnancy among young women in Tanzania [16], whereas the likelihood of unintended pregnancy fell as age rose in Ethiopia [18] and the USA [15], as in the present study. Kuroki et al. [15] noted that, as compared with women older than 24 years, women younger than 20 years and those aged 20–24 years in the USA had, respectively, a 3.5-fold and 3.3-fold higher risk of unintended pregnancy. In Ethiopia, the rate of unintended pregnancy was shown to be lower among women aged 20–24 years than among those aged 15–19 years (22.8% vs 27.1%, respectively) [18]. In the present study, women aged 20 years or younger had an approximately twofold higher risk of unintended pregnancy as compared with older women. Darroch et al. [19] noted that, among pregnant women younger than 18 years, those with a partner who was at least 6 years older were less likely to have an unintended pregnancy than were those with a partner of similar age. The substantial effect of age difference between the couple on intention of pregnancy was reaffirmed by the present findings, which showed that the likelihood of unintended pregnancy decreased as the age difference between sexual partners increased. Approximately 70% of young pregnant women who were with partners who were younger or no more than 8 years older than them declared the current
pregnancy as unintentional, as compared with 47% of those whose partner was at least 9 years older. Because an older partner is more likely to be employed and in a better position to care for a family, a lower rate of unintended pregnancy among young women with much older partners would be anticipated. The present findings have practical implications for the design of intervention and policy for effective contraception for young women. Half the participants worried about the adverse effects of contraceptives. This major misconception was apparent in both women who intended to become pregnant and those who did not, indicating a substantial deficit in baseline knowledge of contraception among young pregnant women in Thailand, irrespective of pregnancy intention. Furthermore, a substantial number of young women used contraceptive methods that have fairly high failure rates during typical use (e.g. oral contraceptive pills or condoms), and experienced problems related to contraceptive compliance (i.e. little time or a perceived difficulty of regular contraceptive use). These findings highlight the importance of both correcting misinformation about the safety of modern contraceptive methods and promoting the use of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, among young women. LARC is safe and requires no user compliance once inserted, thereby eliminating inconsistent and incorrect use. Importantly, the effectiveness of LARC is much higher than that of shortacting contraceptives and does not vary by age, so frequency of unintended pregnancy would reduce [20]. The present study has some limitations. First, the participants were recruited during attendance at a prenatal clinic, and thus pregnancies ending in abortion were not taken into account. As a result, the true prevalence of unintended pregnancy is probably higher than is reported here. Second, it was not possible to determine whether unintended pregnancies were unwanted or mistimed. Despite these limitations, the present study makes an important scientific contribution because there has been limited information regarding risk factors for unintended pregnancy among young women, particularly in Asia—an area with a high rate of unintended pregnancy [1]. In conclusion, the rate of unintended pregnancy among young pregnant women in Thailand is high. Educational status, age, and age difference between the couple were independently associated with unintended pregnancy in the present study. As compared with women with intended pregnancy, a higher proportion of women with unintended pregnancy reported having no time to use contraception, a perceived difficulty of regular contraceptive use, fear of parents finding out about sexual activity, and embarrassment about contraceptive use. Conflict of interest The authors have no conflicts of interest. References [1] Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plan 2010;41(4):241–50. [2] Areemit R, Thinkhamrop J, Kosuwon P, Kiatchoosakun P, Sutra S, Thepsuthammarat K. Adolescent pregnancy: Thailand’s national agenda. J Med Assoc Thail 2012; 95(Suppl. 7):S134–42. [3] Rosengard C, Phipps MG, Adler NE, Ellen JM. Adolescent pregnancy intentions and pregnancy outcomes: a longitudinal examination. J Adolesc Health 2004;35(6): 453–61. [4] Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet 2006;368(9550):1908–19. [5] Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plan Perspect 1998;30(5):223–30. [6] Fraser AM, Brockert JE, Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995;332(17):1113–7. [7] Hellerstedt WL, Pirie PL, Lando HA, Curry SJ, McBride CM, Grothaus LC, et al. Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. Am J Public Health 1998;88(4):663–6. [8] Watcharaseranee N, Pinchantra P, Piyaman S. The incidence and complications of teenage pregnancy at Chonburi Hospital. J Med Assoc Thail 2006;89(Suppl. 4): S118–23.
I. Sriprasert et al. / International Journal of Gynecology and Obstetrics 128 (2015) 228–231 [9] de Vienne CM, Creveuil C, Dreyfus M. Does young maternal age increase the risk of adverse obstetric, fetal and neonatal outcomes: a cohort study. Eur J Obstet Gynecol Reprod Biol 2009;147(2):151–6. [10] Thaithae S, Thato R. Obstetric and perinatal outcomes of teenage pregnancies in Thailand. J Pediatr Adolesc Gynecol 2011;24(6):342–6. [11] Aviram A, Raban O, Melamed N, Hadar E, Wiznitzer A, Yogev Y. The association between young maternal age and pregnancy outcome. J Matern Fetal Neonatal Med 2013;26(15):1554–8. [12] Chantrapanichkul P, Chawanpaiboon S. Adverse pregnancy outcomes in cases involving extremely young maternal age. Int J Gynecol Obstet 2013;120(2):160–4. [13] Olsson CA, Horwill E, Moore E, Eisenberg ME, Venn A, O’Loughlin C, et al. Social and emotional adjustment following early pregnancy in young Australian women: a comparison of those who terminate, miscarry, or complete pregnancy. J Adolesc Health 2014;54(6):698–703. [14] Nalwadda G, Mirembe F, Byamugisha J, Faxelid E. Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives. BMC Public Health 2010;10:530.
231
[15] Kuroki LM, Allsworth JE, Redding CA, Blume JD, Peipert JF. Is a previous unplanned pregnancy a risk factor for a subsequent unplanned pregnancy? Am J Obstet Gynecol 2008;199(5):517.e1–7. [16] Calvert C, Baisley K, Doyle AM, Maganja K, Changalucha J, Watson-Jones D, et al. Risk factors for unplanned pregnancy among young women in Tanzania. J Fam Plan Reprod Health Care 2013;39(4):e2. [17] Uzun AK, Orhon FS, Baskan S, Ulukol B. A comparison between adolescent mothers and adult mothers in terms of maternal and infant outcomes at follow-ups. J Matern Fetal Neonatal Med 2013;26(5):454–8. [18] Habte D, Teklu S, Melese T, Magafu MG. Correlates of unintended pregnancy in Ethiopia: results from a national survey. PLoS One 2013;8(12):e82987. [19] Darroch JE, Landry DJ, Oslak S. Age differences between sexual partners in the United States. Fam Plan Perspect 1999;31(4):160–7. [20] Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366(21):1998–2007.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Unintended pregnancy and associated risk factors among young pregnant women Intira Sriprasert a, Somsak Chaovisitsaree a, Narisa Sribanditmongkhol a, Nuchanart Sunthornlimsiri a, Chumnan Kietpeerakool b,⁎ a b
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
a r t i c l e
i n f o
Article history: Received 27 May 2014 Received in revised form 29 August 2014 Accepted 7 October 2014 Keywords: Contraception Risk factors Unintended pregnancy Young women
a b s t r a c t Objective: To assess pregnancy intention and the associated risks among young pregnant women. Methods: In a descriptive study, pregnant women aged 15–24 years were recruited at a prenatal clinic in Chiang Mai University Hospital, Thailand, between March 1, 2012, and February 28, 2013. Participants were interviewed by trained interviewers using a standardized questionnaire to elicit information about baseline characteristics, pregnancy intention, and contraception practice. Results: Overall, 250 participants were recruited (mean age 20.7 ± 2.4 years), and 163 (65.2%) declared that the pregnancy was unintended. The odds of the pregnancy being unintended were increased in students (P = 0.006), women aged 20 years or younger (P = 0.024), and women whose partner was a similar age (P = 0.026). A higher percentage of women with unintended pregnancy than with intended pregnancy reported having no time to use contraception, a perceived difficulty of regular contraceptive use, fear of parents finding out about sexual activity, and embarrassment about using contraception. Conclusion: Pregnancy among young pregnant women in Thailand was often unintended. Educational status, age, and age difference between the couple were independently associated with unintended pregnancy. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The identification and prevention of unintended pregnancies continues to receive attention. A report evaluating data gathered from nationally representative and small-scale surveys in 80 countries [1] observed that approximately 41% of pregnancies were unintended in 2008. In Asia, the prevalence of unintended pregnancy is thought to vary from 33% to 48% [1]. A substantial number of unintended pregnancies are terminated, and the procedure is unsafe in many cases [2–4]. Unintended pregnancies ending in a live birth are associated with a significantly heightened risk of poor newborn, child, and maternal health [1,5,6]. Understanding whether a pregnancy was intended can be helpful when identifying women who might need a lot of prenatal support [3,5,7]. Whether intended or not, there is ample evidence regarding the negative impact of pregnancy in young women on maternal and child health. Young maternal age is associated with a significantly increased risk of maternal anemia, poor prenatal care compliance, preterm delivery, low birth weight, newborn admission to the intensive care unit, and postpartum complications [6,8–13]. Many pregnancies occurring in ⁎ Corresponding author at: Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand. Tel.: + 66 43 363030; fax: +66 43 348359. E-mail address: [email protected] (C. Kietpeerakool).
young women are unintended [2,3], which further increases the risk of problems. Therefore, the number of unintended pregnancies among young women and the associated risks are important topics of inquiry. However, before interventions can be designed and tested, it is necessary to identify specific sociodemographic risk factors associated with unintended pregnancy. Accordingly, the aim of the present study was to assess pregnancy intention and the associated risks among young pregnant women in Thailand. 2. Materials and methods The present descriptive study was prospectively conducted among pregnant women aged 15–24 years who attended a prenatal clinic at the Chiang Mai University Hospital, Chiang Mai, Thailand, between March 1, 2012, and February 28, 2013. The study was approved by the Research Ethics Committee of the Faculty of Medicine, Chiang Mai University. Informed consent was obtained from all participants. Participants were interviewed by trained interviewers who used a standardized questionnaire to elicit information on baseline characteristics, pregnancy intention, and previous contraception practice. A pregnancy was deemed to be unintended when it was reported to have been either unwanted or mistimed (wanted but at a later time). Beliefs and barriers to contraception were evaluated with an 11-item questionnaire that was adapted from a qualitative study exploring reasons for low contraceptive use among young individuals through focus
http://dx.doi.org/10.1016/j.ijgo.2014.09.004 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
I. Sriprasert et al. / International Journal of Gynecology and Obstetrics 128 (2015) 228–231
which, if any, were independently associated with unintended pregnancy. No correction was made for multiple testing.
Table 1 Characteristics of the participants.a Characteristics
Values (n = 250)
Women’s characteristics Mean age, y Primigravida Educational attainment No formal education Primary education Secondary education Bachelor degree In graduate schoolb History of induced abortion in previous pregnancy Contraception methods used at time of conception None Oral contraceptive pill Condom Depot medroxyprogesterone acetate Emergency contraceptive pill Intrauterine device Partner’s characteristicsc Mean age, y Age group, y ≤20 21–30 N30 Joint characteristicsc Woman 1–4 y older than partner About the same age Women 1–8 y younger than partner Woman ≥9 y younger than partner a b c
229
3. Results 20.7 ± 2.4 168 (67.2) 19 (7.9) 18 (7.2) 159 (63.6) 21 (8.4) 33 (13.2) 19 (7.6) 89 (35.6) 118 (47.2) 21 (8.4) 13 (5.2) 8 (3.2) 1 (0.4) 24.5 ± 5.0 60 (25.1) 151 (63.2) 28 (11.7) 21 (8.8) 48 (20.1) 132 (55.2) 38 (15.9)
Values are given as number (percentage) or mean ± SD. Currently studying for Bachelor degree. Calculated for 239 participants with available data.
group discussions [14]. The items covered five main categories: misconceptions and fears; gender power relations; sociocultural expectations and contradictions; short-term planning dilemma; and health system barriers [14]. Participants were asked to rate each item as “agree/yes,” “disagree/no,” or “do not know.” Statistical analysis was done via SPSS version 17.0 (SPSS Inc, Chicago, IL, USA) and STATA version 10 (StataCorp, College Station, TX, USA). Data are summarized as mean ± SD or number (percentage). Univariate analysis was carried out to identify variables potentially associated with unintended pregnancy, including age, gravidity, education level, and age difference between the couple. These variables were then included (if P b 0.20) in a stepwise logistic regression analysis to determine
During the study period, 250 participants were recruited. The mean age of the participants was 20.7 ± 2.4 years, and most were younger than their partners (Table 1). Some were currently students (Table 1). Approximately one-third of the participants had not been using contraception at the time of conception (Table 1). Among the women who had been using contraception, the most common method was the oral contraceptive pill (Table 1). Despite their attendance at a prenatal clinic, 163 (65.2%; 95% confidence interval [CI] 58.9%–71.1%) participants reported that they had not intended to become pregnant. Table 2 shows the characteristics associated with unintended pregnancy. Four dichotomous variables were assessed via a stepwise logistic regression analysis to evaluate their independent impact on the risk of unintended pregnancy. Three variables were independently associated with increased risk of unintended pregnancy: status of education (being a student vs completed education), participant’s age (≤20 y vs N20 y), and age difference between the woman and her partner (small vs large). Participants who were students were at the highest risk of unintended pregnancy (odds ratio [OR] 8.02; 95% CI 1.84–34.91). Younger participants had almost twice the risk of unintended pregnancy as compared with older participants (Table 2). Pregnant women whose age was slightly different from that of their partner were more likely to have an unintended pregnancy than were those who were much younger than their partner (OR 2.30; 95% CI 1.11–4.79). Overall, the major obstacles to contraceptive use were fears related to adverse effects (Table 3). Approximately half of all the participants worried about the adverse effects of contraceptives for either herself or the fetus in case of pregnancy. The proportion of women who reported major concerns about the safety of contraceptives was similar between those who intended to become pregnant and those who did not (Table 3). However, the proportion who reported that they did not have time to use contraception was higher among women with an unintended pregnancy than among those who had planned their pregnancy (Table 3). Compared with women with an intended pregnancy, a higher percentage of participants with unintended pregnancy reported a perceived difficulty of regular contraceptive use, fear of contraceptives being discovered by parents, that they were embarrassed to use contraceptives, and no effective contraceptive service (Table 3). Barriers related to partners and social and religious issues were not reported by many participants (Table 3).
Table 2 Predictors for unintended pregnancy.a Variables
Currently in graduate school Yes No Participant age, y ≤20 N20 Extent of age difference, y Lowb Highc Gravidity 1 ≥2
Total no. of women
No. (%) with unintended pregnancy
Univariate analysis P value
Multivariate analysis Adjusted OR (95% CI)
P value
30 209
28 (93.3) 127 (60.8)
b0.001
8.02 (1.84–34.91)
0.006
110 129
79 (71.8) 76 (58.9)
0.030
1.94 (1.09–3.43)
0.024
201 38
137 (68.2) 18 (47.4)
0.017
2.30 (1.11–4.79)
0.026
155 84
109 (70.3) 46 (54.8)
0.091
1.26 (0.69–2.28)
0.440
Abbreviations: OR, odds ratio; CI, confidence interval. a Includes 239 women who provided data on partner’s age. b Included 21 women 1–4 y older than partner, 48 women about the same age, and 132 women 1–8 y younger than partner. c Woman at least 9 y younger than partner.
230
I. Sriprasert et al. / International Journal of Gynecology and Obstetrics 128 (2015) 228–231
Table 3 Beliefs and barriers to contraceptive use.a Beliefs and barriers to contraception
Harm to herself Harm to fetus in case of pregnancy Socially inappropriate to use Religion opposes use Embarrassing to use Fear of being seen by parents Perceived difficulty in regular use Intercourse in a hurry; no time to use Men disapprove of use Lack of awareness of partner Lack of effective service a
Characteristics of the participants All participants (n = 250)
Intended pregnancy (n = 87)
Unintended pregnancy (n = 163)
134 (53.6) 136 (54.4) 5 (2.0) 4 (1.6) 7 (2.8) 24 (9.6) 32 (12.8) 58 (23.2) 12 (4.8) 11 (4.4) 23 (9.2)
46 (52.9) 51 (58.6) 3 (3.4) 2 (2.3) 0 7 (8.0) 9 (10.3) 8 (9.2) 3 (3.4) 3 (3.4) 6 (6.9)
88 (54.0) 85 (52.1) 2 (1.2) 2 (1.2) 7 (4.3) 17 (10.4) 23 (14.1) 50 (30.7) 9 (5.5) 8 (4.9) 17 (10.4)
Values are given as number (percentage).
4. Discussion In the present study, the frequency of unintended pregnancy and the associated risk factors have been systematically evaluated. The frequency of unintended pregnancy was high (65.2%). Significant independent variables correlated with unintended pregnancy were educational status, age, and age difference between the couple. The present findings underscore that a group of young pregnant women requires comprehensive support. Educational attainment has previously been identified as one of the key sociodemographic risk factors for unintended pregnancy among young women [15,16]. Kuroki et al. [15] reported that, compared with women who continued education after high school, women who did and did not complete high school were 3.2-fold and 2.6-fold more likely to have an unintended pregnancy, respectively. Similarly, Calvert et al. [16] observed that young women with a primary education level in Tanzania were three times more likely to declare their pregnancy to be unplanned than were more highly educated women. A notable finding in the present study was the high rate of pregnancy among participants in graduate school (13.2%). Getting pregnant during graduate school can interrupt the education program and even result in school dropout [17]. Unsurprisingly, almost all the pregnancies among young women in graduate school were unintended, and pregnancy among this group of women was eight times more likely to be unintended than among those who had completed their education. Several studies have investigated whether age is associated with unintended pregnancy, with inconsistent results [15,16,18]. Increasing age was noted to be directly associated with unintended pregnancy among young women in Tanzania [16], whereas the likelihood of unintended pregnancy fell as age rose in Ethiopia [18] and the USA [15], as in the present study. Kuroki et al. [15] noted that, as compared with women older than 24 years, women younger than 20 years and those aged 20–24 years in the USA had, respectively, a 3.5-fold and 3.3-fold higher risk of unintended pregnancy. In Ethiopia, the rate of unintended pregnancy was shown to be lower among women aged 20–24 years than among those aged 15–19 years (22.8% vs 27.1%, respectively) [18]. In the present study, women aged 20 years or younger had an approximately twofold higher risk of unintended pregnancy as compared with older women. Darroch et al. [19] noted that, among pregnant women younger than 18 years, those with a partner who was at least 6 years older were less likely to have an unintended pregnancy than were those with a partner of similar age. The substantial effect of age difference between the couple on intention of pregnancy was reaffirmed by the present findings, which showed that the likelihood of unintended pregnancy decreased as the age difference between sexual partners increased. Approximately 70% of young pregnant women who were with partners who were younger or no more than 8 years older than them declared the current
pregnancy as unintentional, as compared with 47% of those whose partner was at least 9 years older. Because an older partner is more likely to be employed and in a better position to care for a family, a lower rate of unintended pregnancy among young women with much older partners would be anticipated. The present findings have practical implications for the design of intervention and policy for effective contraception for young women. Half the participants worried about the adverse effects of contraceptives. This major misconception was apparent in both women who intended to become pregnant and those who did not, indicating a substantial deficit in baseline knowledge of contraception among young pregnant women in Thailand, irrespective of pregnancy intention. Furthermore, a substantial number of young women used contraceptive methods that have fairly high failure rates during typical use (e.g. oral contraceptive pills or condoms), and experienced problems related to contraceptive compliance (i.e. little time or a perceived difficulty of regular contraceptive use). These findings highlight the importance of both correcting misinformation about the safety of modern contraceptive methods and promoting the use of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, among young women. LARC is safe and requires no user compliance once inserted, thereby eliminating inconsistent and incorrect use. Importantly, the effectiveness of LARC is much higher than that of shortacting contraceptives and does not vary by age, so frequency of unintended pregnancy would reduce [20]. The present study has some limitations. First, the participants were recruited during attendance at a prenatal clinic, and thus pregnancies ending in abortion were not taken into account. As a result, the true prevalence of unintended pregnancy is probably higher than is reported here. Second, it was not possible to determine whether unintended pregnancies were unwanted or mistimed. Despite these limitations, the present study makes an important scientific contribution because there has been limited information regarding risk factors for unintended pregnancy among young women, particularly in Asia—an area with a high rate of unintended pregnancy [1]. In conclusion, the rate of unintended pregnancy among young pregnant women in Thailand is high. Educational status, age, and age difference between the couple were independently associated with unintended pregnancy in the present study. As compared with women with intended pregnancy, a higher proportion of women with unintended pregnancy reported having no time to use contraception, a perceived difficulty of regular contraceptive use, fear of parents finding out about sexual activity, and embarrassment about contraceptive use. Conflict of interest The authors have no conflicts of interest. References [1] Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plan 2010;41(4):241–50. [2] Areemit R, Thinkhamrop J, Kosuwon P, Kiatchoosakun P, Sutra S, Thepsuthammarat K. Adolescent pregnancy: Thailand’s national agenda. J Med Assoc Thail 2012; 95(Suppl. 7):S134–42. [3] Rosengard C, Phipps MG, Adler NE, Ellen JM. Adolescent pregnancy intentions and pregnancy outcomes: a longitudinal examination. J Adolesc Health 2004;35(6): 453–61. [4] Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet 2006;368(9550):1908–19. [5] Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plan Perspect 1998;30(5):223–30. [6] Fraser AM, Brockert JE, Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995;332(17):1113–7. [7] Hellerstedt WL, Pirie PL, Lando HA, Curry SJ, McBride CM, Grothaus LC, et al. Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. Am J Public Health 1998;88(4):663–6. [8] Watcharaseranee N, Pinchantra P, Piyaman S. The incidence and complications of teenage pregnancy at Chonburi Hospital. J Med Assoc Thail 2006;89(Suppl. 4): S118–23.
I. Sriprasert et al. / International Journal of Gynecology and Obstetrics 128 (2015) 228–231 [9] de Vienne CM, Creveuil C, Dreyfus M. Does young maternal age increase the risk of adverse obstetric, fetal and neonatal outcomes: a cohort study. Eur J Obstet Gynecol Reprod Biol 2009;147(2):151–6. [10] Thaithae S, Thato R. Obstetric and perinatal outcomes of teenage pregnancies in Thailand. J Pediatr Adolesc Gynecol 2011;24(6):342–6. [11] Aviram A, Raban O, Melamed N, Hadar E, Wiznitzer A, Yogev Y. The association between young maternal age and pregnancy outcome. J Matern Fetal Neonatal Med 2013;26(15):1554–8. [12] Chantrapanichkul P, Chawanpaiboon S. Adverse pregnancy outcomes in cases involving extremely young maternal age. Int J Gynecol Obstet 2013;120(2):160–4. [13] Olsson CA, Horwill E, Moore E, Eisenberg ME, Venn A, O’Loughlin C, et al. Social and emotional adjustment following early pregnancy in young Australian women: a comparison of those who terminate, miscarry, or complete pregnancy. J Adolesc Health 2014;54(6):698–703. [14] Nalwadda G, Mirembe F, Byamugisha J, Faxelid E. Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives. BMC Public Health 2010;10:530.
231
[15] Kuroki LM, Allsworth JE, Redding CA, Blume JD, Peipert JF. Is a previous unplanned pregnancy a risk factor for a subsequent unplanned pregnancy? Am J Obstet Gynecol 2008;199(5):517.e1–7. [16] Calvert C, Baisley K, Doyle AM, Maganja K, Changalucha J, Watson-Jones D, et al. Risk factors for unplanned pregnancy among young women in Tanzania. J Fam Plan Reprod Health Care 2013;39(4):e2. [17] Uzun AK, Orhon FS, Baskan S, Ulukol B. A comparison between adolescent mothers and adult mothers in terms of maternal and infant outcomes at follow-ups. J Matern Fetal Neonatal Med 2013;26(5):454–8. [18] Habte D, Teklu S, Melese T, Magafu MG. Correlates of unintended pregnancy in Ethiopia: results from a national survey. PLoS One 2013;8(12):e82987. [19] Darroch JE, Landry DJ, Oslak S. Age differences between sexual partners in the United States. Fam Plan Perspect 1999;31(4):160–7. [20] Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366(21):1998–2007.
