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Unintended Pregnancy Resolution Among Parous Women in Twelve Low- and Middle-Income Countries

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Unintended Pregnancy Resolution Among Parous Women in Twelve Low- and Middle-Income Countries Journal of Biosocial Science (2021), page 1 of 27 doi:10.1017/S0021932021000225 RESEARCH ARTICLE Unintended pregnancy resolution among parous women in twelve low- and middle-income countries Heini Väisänen1,2* and Ewa Batyra3 1Institut national d’études démographiques (INED), France, 2Department of Social Statistics and Demography, University of Southampton, UK and 3Population Studies Center, University of Pennsylvania, USA *Corresponding author. Email: [email protected] (Received 25 November 2020; revised 8 April 2021; accepted 8 April 2021) Abstract Around 40% of pregnancies worldwide are unintended and a half of those are terminated. Yet, few inter- national comparisons of unintended pregnancy resolution (choosing birth or abortion) exist. This study analysed how parous women’s pregnancy intentions and abortion decisions are associated with their reproductive histories and country contexts using twelve Demographic and Health Surveys representing four context groups: post-Soviet/communist and Asian countries with liberal abortion legislation, and Asian and Latin American countries with restrictive abortion legislation. Similarities were found across contexts: preference to have children of both sexes, space births, stop childbearing after reaching desired family size and an increased likelihood of unintended pregnancy when using less-effective contraceptive methods versus none. Contextual factors most clearly associated with reports of unintended pregnancy resolution were type of abortion legislation and living in post-Soviet/communist contexts. Women’s pro- pensity to report abortions and unintended pregnancy varied by context and the decision-making pro- cesses for pregnancy versus fertility management were different. Keywords: Unintended pregnancy; Induced abortion; LMICs Introduction In 2008, around half of pregnancies were unintended in the ‘less developed’ regions of the world, declining to around 40% in 2012. About a half of these pregnancies ended in an induced abortion (hereafter: abortion); 38% in a live birth; and 13% in a miscarriage (Sedgh et al., 2014). Even though this means many women make the choice between continuing or aborting unintended pregnancies each year, the likelihood of choosing an abortion over an unintended birth, and its interdependence with both individual-level characteristics and country contexts, have not been researched before. Existing studies provide evidence from single countries in Europe (Sihvo et al., 2003; Font-Ribera et al., 2007; Rossier et al., 2007; Levels et al., 2010) or North America (Gomez- Scott & Cooney, 2014) leaving low- and middle-income countries (LMICs) understudied. For LMICs, there are a few international comparisons of the determinants of unintended preg- nancy (Hubacher et al., 2008), birth (Adetunji, 1998) or abortion (Bankole et al., 1998, 1999; Chae et al., 2017a), but they treat these events separately rather than examining the process leading to unintended birth or abortion in a single study. Research that examined both abortions and unin- tended births (Pallitto et al., 2013) or abortions and unintended pregnancies (Bankole et al., 2014) focused only on one specific determinant of these outcomes (intimate partner violence and HIV status, respectively), and used data encompassing only selected regions of the countries. There is a © The Author(s) 2021. Published by Cambridge University Press. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.76, on 27 Sep 2021 at 03:36:02, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0021932021000225 2 Heini Väisänen and Ewa Batyra lack of nationally representative studies documenting the process of unintended pregnancy reso- lution (i.e. experiencing an unintended pregnancy and subsequently choosing an abortion or birth) examining these events across LMICs. This study aimed to fill this gap in the literature by analysing Demographic and Health Surveys (DHSs) for twelve LMICs. Following Rossier et al. (2007)andCoastet al. (2018), this study approached unintended pregnancy resolution as a process (see Conceptual Framework section). It examined how the likelihood of experiencing an unintended pregnancy rather than an intended pregnancy, and subsequently choosing an abortion or birth, are associated with individual and contextual factors. The focus was on individual reproductive histories: family composition (number and sex of existing children), fertility desires (the difference between the ‘ideal’ and actual family size), contraceptive use before pregnancy and interval since last birth. It also explored how context is associated with unintended pregnancy resolution. A cross-country comparative approach was taken and thus countries were divided into four context groups based on the legal status of abortion and cultural context (see Cultural-Legal Context section): (1) Post-Soviet/communist and (2) Asian countries with liberal abortion legislation, and (3) Asian and (4) Latin American countries with restrictive abortion legislation. Twelve DHSs that had calendar data on the timing and planning status of births, timing of abortions and contraceptive use available were included. Due to the very low number of unintended pregnancies reported among nulliparous women in these data (see Methods) and due to one of the key explanatory variables being time since last birth, the analyses focused on parous women. The study provides new information on unintended preg- nancy resolution, and tells policymakers which groups of women might be more likely to experience an unintended birth or abortion. Unintended pregnancy resolution: current evidence Previous studies on unintended pregnancy resolution have mostly focused on high-income coun- tries (HICs) and on individual-level socio-demographic characteristics. Reproductive histories in HICs have been associated with unintended pregnancy resolution. In the Netherlands, women who had fewer than two children were more likely to experience an unintended pregnancy than those with more children, but parity was not associated with subsequently choosing an abortion (Levels et al., 2010). In France, women in their mid-20s to mid-30s often reported wanting to stop childbearing as the motivation for abortion (Sihvo et al., 2003). In some LMICs, such as Zambia and Nigeria, the likelihood of unintended pregnancy increased with parity, whereas those who had no children were much more likely to abort an unintended pregnancy than parous women (Bankole et al., 2014). Many studies either did not include parity in their analyses or did not compare results between different parities (Font-Ribera et al., 2007; Rossier et al., 2007; Gomez-Scott & Cooney, 2014). Socioeconomic position’s association with unintended pregnancy resolution has been stud- ied in HICs. In Barcelona, Spain, young women with low education were more likely to choose an abortion rather than unintended birth than those aged 25 years or more with more edu- cation (Font-Ribera et al., 2007). In France, young women often chose abortion due to being a student, whereas older women often did so due to their work situation (Sihvo et al., 2003). In the United States, adolescent women with strong educational aspirations were more likely to terminate an unintended pregnancy than those without (Gomez-Scott & Cooney 2014). Relationship status is linked to the likelihood of unintended pregnancy and subsequent deci- sions to terminate or continue the pregnancy. For instance, French women without a cohabiting partner were less likely to experience an unintended pregnancy, but more likely to subsequently abort one than those with partners (Rossier et al., 2007). Unstable partnerships and being single have also been cited as important reasons for abortion in France and Barcelona (Sihvo et al., 2003; Font-Ribera et al., 2007). For LMICs, a multi-country study (fifteen urban/rural sites) showed that intimate partner violence increased the odds of unintended birth and abortion among pregnant women Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.76, on 27 Sep 2021 at 03:36:02, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0021932021000225 Journal of Biosocial Science 3 (Pallitto et al., 2013). A complex relationship between women’s HIV status and experiencing an unintended pregnancy, and subsequently choosing an abortion, was found in three provinces in Nigeria and four states in Zambia (Bankole et al., 2014). To the best of the authors’ knowledge, no study in LMICs has examined in a comprehensive manner the process of unintended pregnancy resolution and its socio-demographic determinants more broadly. These previous results, albeit very limited, for the most part including both parous and nullip- arous women unlike this study, and mostly focused on HICs, were used to identify potentially important individual-level explanatory variables. The focus here is on how the previously under- studied aspects of reproductive histories and contraceptive use are associated with unintended pregnancy resolution among parous women. Role of family composition and contraceptive use in unintended pregnancy,
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