Medical Reports & Case Studies

A Review of Unintended Childbirth in Ethiopia: Magnitude and Contributing Factors

^*Correspondence: Gashaw Mehiret, Department of Medicine College of Health Science, Debre Tabor University, Northcentral, Ethiopia, Tel: +251912417863, Email:

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Introduction

Pregnancy intention (a woman's desire at the time of conception) has an impact on the health and wellbeing of the mother, baby, and family at large. Unintended pregnancy has a major social and public health impact in both developing and developed countries. It is one contributing factor for unsafe abortion in most developing countries. It affects women children and societies as a whole [1-3]. The adverse outcomes include a high likelihood of unsafe abortion, late initiation and underutilization of prenatal care, and low birth weight [4,5].

Studies categorized unintended pregnancy into a mistimed and unwanted pregnancy. A mistimed pregnancy is when a woman becomes pregnant earlier than she desires. On the other hand, an unwanted pregnancy is when a woman becomes pregnant when she never intends to ever become pregnant or when she does not want to have any more children [6,7].

Globally about 40% of pregnancies were unintended in 2012. From these 50% were ended with abortion [7]. Although several strategies were developed on the issue, many women in developing countries particularly in sub-Saharan Africa are suffering from unintended pregnancy and unsafe abortion [8]. Unintended pregnancy has become a public concern and is capturing a great deal of attention in Africa because of its high prevalence rate in the continent. In Sub-Saharan Africa, it is estimated that 14 million unintended pregnancies occur every year, with almost half occurring among women aged 15-24 years. This goes together with a low contraceptive prevalence rate in the less developed countries when compared with developed countries [9]. In Ethiopia, according to the EDHS-2016 report, about 23% of the total last pregnancy was unintended (17% and 8% were unwanted and mistimed pregnancies respectively) [10].

As evidence shows several social and psychological factors contribute to unintended pregnancy while abortion, infertility, child, and maternal deaths are negative consequences of unintended pregnancies [4,11]. A study in Pakistan found that women with unintended pregnancies were more likely to not have antenatal care follow-up as compared to women with planned pregnancies [12]. A study in rural India found that mothers reporting unwanted births were 2.3 times more likely to receive inadequate prenatal care. In addition, mistimed/unwanted births had an 83% higher risk of neonatal mortality compared to wanted births [13]. In Ethiopia, unintended pregnancy was mentioned as a cause of low birth weight [14].

Similarly, a recent study in Southeast Nigeria found the age at marriage, level of education, place of residence, and use of contraception were predictors of unintended pregnancy with a 43.8% prevalence of unintended pregnancy in the region [15]. The prevalence of unplanned pregnancy was 71% in South Africa. Younger age, single marital status, high parity, history of abortion. and having five to seven children, age less than 21 years, and single marital status were reported as associated factors for unplanned pregnancy [16].

The magnitude of unintended pregnancy was 30.2% in Sudan in 2014, household size, educational level, parity, and use of modern contraceptive methods were the associated factors for unintended pregnancy in Sudan [17]. Nearly 43% of the pregnancies were unintended of which 25% were mistimed in Malawi. Here the finding showed that the age of the respondent, fertility preference, number of children ever born, wealth status, and region of residence were contributors to unintended pregnancy [18].

Several socio-demographic and reproductive factors were predictors for unintended pregnancy associated with reduced use of prenatal health care services, illicit drug use, intimate partner violence with adverse maternal, mental, and physical health consequences [19].

A Systematic review in Africa identified socio-cultural, environmental, and Economic factors (Peer influence, poverty, religion, early marriage, lack of parental counselling and guidance, non-use of contraceptives, early sexual debut); Individual factors (excessive use of alcohol, substance abuse,). Health service-related factors (cost of contraceptives, inadequate and unskilled health workers, long waiting time and lack of privacy, lack of comprehensive sexuality education, misconceptions about contraceptives, and non-friendly adolescent reproductive services) as influencing factors for adolescent pregnancies in Sub-Saharan Africa [20].

In Guna, unintended pregnancies were high among women aged 15- 19 years (69.4%), unmarried women (45.1%), and non-working women (40.0%). Age, parity, level of education, wealth status, rural residence were associated factors with unintended pregnancies [21]. Similarly, in South Africa two-thirds of the women (64.33%) had unintended pregnancies. Here a significant relationship was found between marital status, unemployed and unintended pregnancy [22].

As evidence shows the trend of teenage pregnancy decreased in East Africa, and slightly increased in Southern Africa between 1992 and 2011 associated with family disruption, female unemployment, and community poverty [23]. Evidence from South Africa showed that levels of unplanned pregnancy were higher in HIV-positive but not on ART. Increased parity and younger age (<24 years) were associated with unplanned pregnancy [24]. As we tried to understand from the literature multiple factors can predict unintended pregnancy. Several studies outlined the factors contributing to unintended pregnancy related to sociodemographic, socioeconomic, sociocultural, fertility, contraceptive, and access-related factors depending on the country's development status. However, in Ethiopia, studies related to unintended pregnancy are so limited, we tried to review the available literature conducted so far in the different corners of the country since this review will provide evidence to policymakers and national health planners on the magnitude and contributing factors for unintended childbirth to design policies and strategies that can help couples to have their desired number of children without facing unnecessary threats to their family health. Furthermore, this review will suggest the need to conduct more strong studies in the future to assess the available cost-effective interventions for reducing unintended childbirth and to improve women’s and children’s health in the country.

Research question

What is the magnitude of unintended pregnancy in Ethiopia?

What are the factors contributing to unintended childbirth in Ethiopia?

Methods and Materials

Search strategy

A review of the literature was conducted by retrieving articles from various databases on factors contributing to unintended childbirth in Ethiopia during March 2019. The electronic databases (PubMed, MEDLINE, and Google Scholar) were searched using keywords or phrases such as ‘Unintended pregnancy’, ‘Unwanted pregnancy’, Mistimed pregnancy ‘factors’ and ‘Ethiopia’. The Boolean logic (AND, OR) search technique was also used.

Data extraction process

The following figure shows the number of articles excluded and included in the final analysis process (Figure 1).

Selection of studies

All epidemiologic studies (descriptive and comparative crosssectional) published between the years from 2008 to 2018 were included in this review. Only published and English language literature were included. Initially, titles and abstracts of the articles were assessed for relevance. Then the full papers of relevant articles were reviewed. Articles without full paper and those published before 2008 were excluded from the review.

Synthesis of study results

The findings from published studies on unintended childbirth were pooled together to develop tables that guided discussion. The results and conclusions of the studies were compared, contrasted, and integrated to arrive at conclusions and recommendations concerning the objectives of this review.

Data quality assurance

To maintain the quality of the data, only those studies which met the inclusion criteria were reviewed. The quality, relevance, and application of the studies were evaluated by experts in the field.

Study participants

A total of 18344 participants were recruited and involved in the 17 included quantitative studies. The least number of participants in a study was 165 women and the largest consisted of 7759 participants.

Result

The magnitude of unintended pregnancy in Ethiopia

Unintended pregnancy (mistimed or unwanted) is high in sub-Saharan Africa including Ethiopia [25]. In Ethiopia, in 2011 about 28.3% were reported to be unintended pregnancy (19.5% and 8.8% were unwanted and mistimed respectively) [26]. The prevalence decrease to 23% (7% unwanted and 8% mistimed) in 2016 [10].

Several studies conducted at Oromiya Region, Bale Zone, Addis Ababa, Hawassa, and East Ethiopia reported that the prevalence of unintended pregnancy was 27.1%, 13.7%, 37.3%, 39.6%, 33.7% respectively. In addition, cross-sectional studies carried out in Arsi Negele and Wolkayit Woredas revealed 41.5% and 26% of unintended pregnancy respectively [27,28]. Out of 713 women surveyed 302 (42.4%) reported unintended births in Damot Gale District, Southern Ethiopia [29]. Prevalence of unintended pregnancy was 35.2% of which the majority of them were miss-timed followed by husbands' influence in North Shewa Ethiopia [30].

In Southwestern Ethiopia, more than one-third (35%) of women reported that their recent pregnancy was unintended [31]. The prevalence of unintended pregnancy was 15.8% in Bihar Dar city, Northwest Ethiopia [32]. More than one-third (36.2%) of women reported unintended pregnancy [33]. The magnitude of unintended pregnancy among female sex workers in Mekelle city was 28.6% [34].

The magnitude of mistimed and unwanted pregnancy

Out of the 413 pregnancies, 112 (27.1%) were unintended of which 90 (21.9%) were mistimed, and 22 (5.2%) were unwanted at Gelemso General Hospital, Oromiya Region [35]. Similarly from a total of 26% unintended pregnancies, 75.9% were mistimed and 24.1% were unwanted pregnancies [28]. Out of 27.9% (578/2072 of unintended childbirths 76.12% were mistimed and 23.87% were unwanted [36].

Factors contributing to unintended pregnancy

Several studies identified different factors contributing to unintended pregnancy in different countries, some of the factors have similarities but some others have differences depending on the socio-cultural and economic deferences of regions [21-23,35].

Socio-demographic factors

Most of the studies in Ethiopia revealed that single, divorced/ widowed marital status as contributing factors for unintended pregnancy [37,38]. Similarly, educational status, occupation, marital status was mentioned as significant factors for unintended pregnancy. The odds of unplanned pregnancy among illiterate were 4.6 times more likely than unintended pregnancy compared diploma and above [38]. Another evidence also showed that the burden of unintended births in Ethiopia falls more significantly on young, unmarried, higher wealth, and ethnic majority women and those with less than secondary education and with large household sizes [39]. A similar study revealed that women with 35 and above age group and single marital status were more likely to have unintended childbirths in Ethiopia [40].

A study revealed that single, divorced/widowed marital status, having more than 2 children, was significantly associated with unintended pregnancy [35]. Similarly, the odds of unintended pregnancy among no spousal communication and own business makers were 4 times more likely than unintended pregnancy compared to their counterparts [41].

Maternal and obstetric factors

A study showed that the burden of unintended births in Ethiopia falls more heavily on high parity [40,42]. A similar study revealed that 35 and above age group, high parity, having a history of abortion, and having health professional visit were factors associated with unintended pregnancy [40]. Unintended pregnancy was associated with having no antenatal visit, poor husband communication about pregnancy, lack of awareness of the concept of unintended pregnancy [43,44]. Age at pregnancy, history of stillbirth, and having more than 2 children were significantly associated factors for unintended pregnancies [37,45,46].

Contraceptive related factors

Several Ethiopian studies relate unintended pregnancy with inappropriate or misuse of contraceptives [38,40,44,47]. The main reasons for facing an unplanned pregnancy were forgetting to take contraceptives, husband preferences, and religious prohibitions [47]. Ever use of family planning, having the autonomy to use contraceptive methods, awareness of contraceptives, and husband communication about pregnancy were determinants of unintended pregnancy [38,40]. Discussing pregnancyrelated issues with husbands, making family planning decisions on their own, and making family planning decisions with their husbands were also mentioned as contributors to unintended births in Ethiopia [38]. Studies also found that having no awareness of contraception and having no spousal communication were found to be significantly associated factors for unintended pregnancy. Women with inadequate awareness of IntraUterine devices were 4 times more likely to have unintended pregnancies as compared to their counterparts [37,48]. The major reasons mentioned for unintended pregnancy were lack of knowledge, disapproval by husband, difficulty to get contraceptive method, and contraceptive failure [49].

Summary of factors contributing to unintended pregnancy

All epidemiologic studies (descriptive and comparative crosssectional) published between the years from 2008 to 2018 were included in this review and the parameter we had used were predictors of unintended pregnancy, sample size and methods, and sample size they were used (Table 1).

Discussion

Several studies reported unintended pregnancy as a global public health problem with significant maternal and child health problems (56- 58). According to Ethiopian Demographic and Health Survey (EDHS,2016) report, the prevalence of unintended childbirth in Ethiopia was 23% [49]. Additionally several epidemiological studies showed 27.1%, 13.7%, 37.3%, 39.6%, 33.7%, 41.5%, 26%, 35%, 42.4%, 35.2%, 15.8%, 36.2% prevalence of unintended pregnancy in different regions of Ethiopia [27-30,35,50- 52,54,55]. The median proportion of unintended pregnancies in Ethiopia was 31.96%. The finding is in line with findings from Sudan (30.2%), Malawi (43%), Guna (40.0%), and Nigeria 43.8% but a higher prevalence of unintended pregnancy was reported in South Africa 71% [16,17,21,60,61]. The variation might be due to the inclusion of only HIV-positive women in South Africa.

Different studies in Africa found several socio-demographic, economic, and cultural factors as predictors for unintended pregnancy [16,17,50,60,61]. Similarly, several studies in Ethiopia identified sociodemographic, maternal, and obstetric as well as contraceptive related factors for unintended births in the country [27-30,35,51,52,54,55]. Single, divorced/widowed marital status, urban residence, having more than 2 children, being formerly married and never married, distance to the nearest health facility were some of the socio-demographic factors mentioned as determinants of unintended childbirth in Ethiopia [27,29,50,53-58]. While maternal factors like age at pregnancy, history of abortion, sex workers, drug users, women with no access/exposure to mass media, women’s education, history of stillbirth, having no awareness of contraception, gravidity>5, 1 parity-2 parity, and partner disagreement on the desired number of children were found to be factors for unintended pregnancy in Ethiopia [30,34,35,54,57,59]. Similar findings were reported in other African countries too [21-24,60].

The majority of studies reported that ever use of contraceptives, disapproval by husband, difficulty to get contraceptive method and method failure, inadequate awareness on contraceptives, unable to discuss pregnancy-related issues with husbands, unable to make family planning decisions on their own, having the autonomy to use contraceptive method and with their husbands were factors associated with unintended pregnancy [27-30,35,51,52,54,55]. Similar findings were found in South Africa, Sudan, and Nigeria [17,24,61].

Women with unintended pregnancies were less likely to receive ANC as compared to their counterparts [12,28,33]. This is in line with a systematic review finding of reduced use of prenatal health care services among women who experienced unintended pregnancy [19]. Similarly in India, mothers reporting unwanted or mistimed births were received inadequate prenatal care and more likely to receive inadequate childhood vaccinations and higher risk of neonatal and infant mortality [13].

Own business makers, family wealth status, and occupational status of women were reported as factors for unintended pregnancy [36,41,53,55]. Similar findings were reported in different African countries, unemployed women, wealth status, and community poverty were more likely to have factors for unintended births. Rich women were less likely to face unintended pregnancy as compared to poor women [21-23].

A study showed that the burden of unintended births in Ethiopia was related to women’s educational status and household size [30,51,53]. Similar findings were reported in sub-Saharan Africa and Nigeria [20,61]. A review in Africa associates unintended pregnancy in teenagers with family disruption, community levels of female unemployment, and community poverty in Southern, East, and West Africa [23]. Similarly, unemployed females, engaged in prostitution and women who are living away from their husbands are at higher risk of unintended pregnancy [32,53].

Strength and limitations of the Study this review include more crosssectional studies, which might not have shown the causal relations between various predictors and unintended pregnancy. Thus, further studies are required to examine the causal association between various determinants and unintended pregnancy. But an extensive review of all the available literature in Ethiopia, exploring all the possible determinants and predictors of unintended pregnancy, and the use of different databases are strengths of the study.

Conclusion

In conclusion, the review found that the magnitude of unintended pregnancy in Ethiopia is relatively high with a median prevalence of 31.96% which suggests the need to put efforts to alleviate the problem through developing an evidence-based intervention. Therefore, increasing women’s empowerment, education, and creating awareness about family planning services, consequences or adverse outcomes of unintended pregnancy to women in particular and community, in general, are important measures to prevent unintended childbirth in Ethiopia.

Abbreviations/acronyms

ANC: Ante-Natal Care

FMOH: Federal Ministry of Health

PNC: Post Natal Care

WHO: World Health Organization

Declarations

The datasets are obtained from the corresponding author through reasonable requests.

Competing Interests

The authors declared that there is no competing interest

Funding

There is no funding received for this particular review.

Authors Contributions

Both authors were involved in the write-up of the proposal, data entry, data analysis, and final manuscript write-up. The final manuscript is read and approved by both authors.