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R E S E A R C H A R T I C L E Open Access
Prevalence and determinants of
unintended pregnancies amongst women
attending antenatal clinics in Pakistan
Muhammad Atif Habib
1,2*
, Camille Raynes-Greenow
3
, Sidrah Nausheen
2
, Sajid Bashir Soofi
2
, Muhammad Sajid
2
,
Zulfiqar A Bhutta
2
and Kirsten I Black
1
Abstract
Background: Unintended pregnancies are a global public health concern and contribute significantly to adverse
maternal and neonatal health, social and economic outcomes and increase the risks of maternal deaths and
neonatal mortality. In countries like Pakistan where data for the unintended pregnancies is scarce, studies are
required to estimate its accurate prevalence and predictors using more specific tools such as the London
Measure of Unplanned Pregnancies (LMUP).
Methods: We conducted a hospital based cross sectional survey in two tertiary care hospitals in Pakistan. We
used a pre tested structured questionnaire to collect the data on socio-demographic characteristics, reproductive
history, awareness and past experience with contraceptives and unintended pregnancies using six item the LMUP. We
used Univariate and multivariate analysis to explore the association between unintended pregnancies and predictor
variables and presented the association as adjusted odds ratios. We also evaluated the psychometric properties of the
Urdu version of the LMUP.
Results: Amongst 3010 pregnant women, 1150 (38.2%) pregnancies were reported as unintended. In the multivariate
analysis age< 20 years (AOR 3.5 1.1-6.5), being illiterate (AOR 1.9 1.1-3.4), living in a rural setting (1.7 1.2-2.3), having a
pregnancy interval of = < 12 months (AOR 1.7 1.4-2.2), having a parity of >2 (AOR 1.4 1.2-1.8), having no knowledge
about contraceptive methods (AOR 3.0 1.7-5.4) and never use of contraceptive methods (AOR 2.3 1.4-5.1) remained
significantly associated with unintended pregnancy. The Urdu version of the LMUP scale was found to be acceptable,
valid and reliable with the Cronbach's alpha of 0.85.
Conclusions: This study explores a high prevalence of unintended pregnancies and important factors especially those
related to family planning. Integrated national family program that provides contraceptive services especially
the modern methods to women during pre-conception and post-partum would be beneficial in averting unintended
pregnancies and their related adverse outcomes in Pakistan
Keywords: Unintended pregnancies, Family planning, Contraceptive methods, London measure of unplanned
pregnancies, Pakistan
* Correspondence: mhab4985@uni.sydney.edu.au;atif.habib@aku.edu
1
Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical
School, University of Sydney, Sydney, NSW 2006, Australia
2
Women and Child Health Division, Aga Khan University, Karachi, Pakistan
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Habib et al. BMC Pregnancy and Childbirth (2017) 17:156
DOI 10.1186/s12884-017-1339-z
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Unintended pregnancies (pregnancies that are mistimed
or unwanted) are a significant public health concern glo-
bally [1]. Of the estimated 210 million pregnancies that
occur throughout the world each year, about 38% are
unintended [2]. Twenty-two percent of global unin-
tended pregnancies end in abortion, many of which take
place with unsafe techniques and/or in unsafe circum-
stances and about 18% end in unplanned births, placing
a substantial burden on health systems [1, 2]. Most of
the unintended pregnancies occur in developing coun-
tries largely due to poor literacy and lack of knowledge
and access to contraceptive methods [3, 4]. In these set-
tings unintended pregnancies contribute significantly to
adverse health, social and economic outcomes [4–8] and
increase the risks of maternal death and neonatal, infant
and child mortality [9].
Pakistan is a developing country where contraceptive
prevalence remains low (35.4%) and the unmet need for
family planning remains high (20.1%) contributing to
high fertility rate (3.8 births/woman) and large numbers
of unintended pregnancies [10, 11]. Annually about 2.25
million abortions are conducted in Pakistan and the
national abortion rate is 50 per 1000 women (15-49 years)
[12]. As abortion remains illegal, many of the proce-
dures are undertaken in unsafe circumstances, leading
to complications and adverse outcomes. Indeed in
2012 over 62,000 women were treated for complica-
tions [13]. Unsafe abortion also contributes to mater-
nal mortality in Pakistan [14–16].
The reported prevalence of unintended pregnancies
in Pakistan is between 16-46% [10–13]. Pakistan
demographic and health surveys (PDHS) of 2006 and
2013 reported the prevalence of unintended pregnan-
cies as 16% and 24% respectively [10, 11]. This
estimate was based only on a single question with a
dichotomous response on mistimed or unwanted
pregnancy at the time of conception. Another study
which estimated the prevalence of unintended preg-
nancies in Pakistan as 46% was based on an indirect
modeling for unintended pregnancies from induced
abortion rates [13]. These measures are not suffi-
cient to accurately measure the burden of unin-
tended pregnancies. However there is a more
accurate, reliable and validated tool. The London
Measure of Unplanned Pregnancies (LMUP) is a six
item scale that has been widely used in both devel-
oped and developing countries [17–30].
Given the adverse impact of unintended pregnancies
on maternal and neonatal morbidity and mortality,
and the lack of available data, our aim was to investi-
gate the prevalence of unintended pregnancy using
the LMUP and examine the socio-demographic pre-
dictors in Pakistan.
Methods
We conducted a hospital based cross sectional survey
between January 2015 and April 2015 to achieve a sam-
ple size of 3000 women. We hypothesized that 40% of
all pregnancies in the antenatal population in our study
setting would be unintended, where the population is
poor and there are high levels of illiteracy, little know-
ledge of contraception and where first pregnancies occur
at a young age [11]. The sample size was estimated using
a prevalence rate of unintended pregnancies of 40%, a
confidence level of 95%, a design effect of 1.5 and a non-
response rate of 10%. The data collection was carried out
in two tertiary care hospitals, one is located in Karachi city
and the other one is located at district Dadu of Pakistan.
Both hospitals have an average attendance of 100 females
per day. Two female research assistants were trained and
employed at both sites for data collection. All pregnant
women attending the antenatal care clinic were eligible
for recruitment.
We developed a participant information sheet, consent
form and an interview administered structured question-
naire. All material was translated into Urdu and then
back translated into English to ensure the accuracy. The
questionnaire was pre tested in an antenatal clinic that
was not a study site. Women were given the participant
information sheet to read, or when they were unable to
read, the study was explained to them in Urdu by the
research assistant.
The questionnaire comprised of three sections; section
one used the standard questions from demographic and
health survey questionnaire to ascertain the characteris-
tics and socio-demographic information of the respond-
ent. Section two contained information about past
reproductive history and family planning and section
three used the Urdu version of pregnancy intention scale
(LMUP) to ascertain unintended pregnancies. In this
section questions were designed such that each response
to the six questions was scored out of two, and
summed to give a final pregnancy intendedness score
between zero and 12. The intention scores were
divided into three groups: zero-three (unplanned),
four-nine (ambivalent) and ten-twelve (planned).
Unintended pregnancy was the main outcome variable.
Women with pregnancy intendedness scores less than
10 (including both ambivalent and unplanned pregnan-
cies) were considered as unintended. The explanatory
variables for analysis were informed by the literature and
their availability in the dataset and are described in
Tables 1 and 2. Variables were grouped into two categor-
ies; socio-demographic factors and women related factors.
In the socio-demographic factors; age, residence, educa-
tion and wealth index were considered. Age at marriage,
gestational age, parity, birth interval, history of previous
miscarriage or abortion, family planning knowledge,
Habib et al. BMC Pregnancy and Childbirth (2017) 17:156 Page 2 of 10
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source of knowledge about family planning and family
planning use were considered in the women related fac-
tors. Age at marriage was used as a proxy for age at
first intercourse which is difficult to ask as it is a cul-
turally sensitive question.
The ethical review committee of Aga Khan University
granted ethical approval (Ref: 3710-Ped-ERC-15). Writ-
ten informed consent was obtained from all participants.
In cases where the woman was illiterate, consent was
documented by a thumbprint on the consent form and
confirmed by a signature from a literate witness. All the
names and personal information regarding the partici-
pants were kept confidential and all identifying informa-
tion was removed from analysis.
The data were analyzed using IBM SPSS version 19
[31]. Initially the scoring of the responses from the data
extracted from LMUP was done and the prevalence of
unintended pregnancy was calculated using data from all
six of the questions in the pregnancy intention instru-
ment. Family planning profile of the participants was
also established and comparison of contraception know-
ledge and use between the data of this study and PDHS
2012 was carried out. Univariate analyses were run
between socio demographic factors and women related
factors. Degree of association was assessed using chi
squared tests. The demographic characteristics with a p-
value <0.25 were then examined using logistic regression
analyses. In multivariate analysis adjusted odds ratios and
95% confidence intervals were calculated to determine the
degree of association between associated factors and preg-
nancy intention.
In order to validate the Urdu version of the scale we
conducted psychometric analysis of the Urdu LMUP.
We assessed the proportion of missing data and consid-
ered item endorsement, with item response option
endorsements of <80% considered to be acceptable
[21–23, 26, 30]. To measure the reliability of scale, we
evaluated the internal consistency by calculating the
Cronbach’s alpha statistic using the standard cut off point
of 0.7 and also looked at the corrected item-total correla-
tions [21–23, 26, 30]. We also did Principal component
analysis to evaluate the internal structure of the LMUP.
The scale would be considered valid if all items load onto
one component with an Eigenvalue larger than one
(i.e. are measuring the same construct) [22, 26, 30].
Results
A total of 3010 women were included in the analysis
with a mean gestational age of 26 weeks at the time of
Table 1 Description of independent variables
Variables Description
Socio demographic factors
Area of residence Urban and rural
Socio economic status
of the household
SES was measured as quintiles of a linear
index derived from household assets and
utilities score, the wealth quintiles were
divided into five (poorest, poorer, middle,
richer, richest)
Women related factors
Age Categorized as <20 years, 20-24 years,
25-29 years and >30 years
Education Years of education completed (illiterate/
years of education)
Age of marriage Categorized as = < 20 years and > 20 years,
used as a proxy for age at first intercourse
Gestational age Recorded in weeks and categorized as <
28 weeks and 28 or more weeks
Parity Defined as the number of previous deliveries
and categorized as = < 2 times and > 2 times
Birth interval Interval from one child's birth date until the
next child's birth date and categorized as
<12 months, 12-24 months and > 24 months
History of abortion
or miscarriage
Any history of previous miscarriage and
abortion and categorized as 1 = Yes and
No = 2
Knowledge about family
planning methods
Ever heard of any family planning method
and categorized as 1 = Yes and No = 2
Use of family planning
methods
Ever used any family planning method and
categorized as 1 = Yes and No = 2
Table 2 London Measure of Unplanned Pregnancies (LMUP)
scale
Question Answer Score
At the time of conception Always use contraception 0
Inconsistently us contraception 1
Not use contraception 2
In terms of becoming
a mother
Wrong time 0
An OK time but not quite right 1
Right time 2
Just before falling pregnant Not intend to become pregnant 0
Did not mind either way 1
Intend to get pregnant 2
Just before falling pregnant Not want a baby 0
Have mixed feeling about having
a baby
1
Want a baby 2
Before falling pregnant had
you and your partner
Never discussed children 0
Discuss children but no firm
agreement
1
Agreed to pregnancy 2
Health actions before falling
pregnant
a
No action 0
1 action 1
2 or more actions 2
a
Health Actions include iron folic acid supplementation, cessation or reduction
in smoking, tobacco/ Pan/ Gutka/
beetle nut chewing and seeking medical advice
Habib et al. BMC Pregnancy and Childbirth (2017) 17:156 Page 3 of 10
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recruitment. Overall, 1150 (38.2%) pregnancies in the
antenatal population were unintended, of which 420
(13.9%) were ambivalent and 730 (24.3%) were
unplanned. The remaining 1860 (61.8%) pregnancies
were considered intended. The socio demographic profile
and women related factors are documented in Table 3.
The majority of women (69.5%) were aged more than
25 years, 51.6% were illiterate and half of the women lived
in a rural area. Among the study population the two low-
est and two highest wealth quintiles accounted for 40.2%
and 40.1% respectively. We found that 55.0% of women
were aged 20 years or younger at the time of their
marriage, 46.1% had a parity of two or more and 53.6%
reported a short birth interval of ≤12 months. Among
study participants 17.4% reported a previous miscarriage
or abortion.
The family planning profile is outlined in Table 4.
Overall 89.9% women had knowledge about at least one
of the contraceptive methods but only 33.4% reported
using them. For modern methods 96.2% of women had
knowledge of the pill, followed by injectables (94.6%),
condoms (88.3%), intrauterine devices (83.5%), implants
(73.5%), female sterilisation (60.9%), and male sterilisa-
tion (15.1%). However use of contraception remained
low with the most commonly used being condoms (19%)
followed by injectables (9.7%), the pill (9.6%), intra uter-
ine device (2.9%), and implants (2.5%). For traditional
methods only 14.5% and 34.5% of women had know-
ledge about the rhythm and withdrawal methods while
13.8% and 46.1% women reported using the rhythm
method and withdrawal method respectively. Knowledge
about emergency contraception was also low as only
25% of women were aware of it and only 23.7% reported
having ever used it. The data regarding source of infor-
mation for family planning revealed that health care pro-
viders (59.9%) are the main source of information
followed by peers (22.2%), husbands (15.0%) and the
media (1.4%). Our family planning data was consistent
with the recent PDHS data and displays a notable
contraceptive knowledge and practice gap (Fig. 1).
Table 5 shows the univariate association between unin-
tended pregnancy and the independent variables. Unin-
tended pregnancy in Pakistani women was significantly
associated with age < 20 years (OR 1.3 1.1-1.7), being
poor (OR 1.8 1.3-2.3), being illiterate (OR 1.4 1.1-1.7),
living in a rural setting (OR 1.5 1.1-1.8), having a preg-
nancy interval of ≤12 months (OR 1.8 1.3-2.9), having a
previous history of miscarriage/abortion (OR 1.8 1.2-2.1),
having parity of> 2 (OR 1.5 1.2-1.8), having no knowledge
of any contraceptive method (OR 1.7 1.5-1.8) and never
use of contraceptive methods (OR 1.2 1.1-3.8).
In the multivariate analysis (Table 6) being poor and
having history of miscarriage/abortion no longer
remained associated with unintended pregnancies but
age < 20 years (AOR 3.5 1.1-6.5), being illiterate (AOR
1.9 1.1-3.4), living in a rural setting (AOR 1.7 1.2-2.3),
having a pregnancy interval of = < 12 months (AOR 1.7
1.4-2.2), having a parity of >2 (AOR 1.4 1.2-1.8), having
no knowledge about contraceptive methods (AOR 3.0
1.7-5.4) and never use of contraceptive methods (AOR
2.3 1.4-5.1) remained significantly associated with unin-
tended pregnancy.
The psychometric analysis of the Urdu LMUP demon-
strated relatively high internal consistency, with the
Table 3 Frequency distribution of sociodemographic and
women related variables
Variable Description N (%)
Pregnancy Intention Unintended (Score <10) 1150 (38.20)
Intended (Score >10) 1860 (61.7)
Area of Residence Rural 1509 (50.1)
Urban 1501 (49.9)
Wealth Index Poorest 599 (19.9)
Second 612 (20.3)
Middle 593 (19.7)
Fourth 604 (20.1)
Richest 602 (20)
Pregnant women age <20 years 135 (4.5)
20-24 Years 783 (26)
25-29 Years 1297 (43.1)
> = 30 Years 795 (26.4)
Pregnant women’s
education
Illiterate 1552 (51.6)
Primary or less
(1-5 years of schooling)
379 (12.6)
Middle(6-8) 159 (5.3)
Matric(9-10) 505 (16.8)
Intermidiate & above (>10) 251 (8.3)
Graduation and above (>12) 164 (5.4)
Pregnant women’s Age
at marriage
≤20 Years 1656 (55)
> 20 Years 1354 (45)
Gestational age <28 weeks 1467 (48.7)
> = 28 weeks 1541 (51.2)
Parity <=2 1161 (53.9)
>2 994 (46.1)
Birth Interval ≤12 months 1200 (53.6)
>12 months 1038 (46.4)
History of Abortion/
Miscarriage
Yes 523 (17.4)
No 2487 (82.6)
Knowledge about Family
Planning
No 306 (10.2)
Yes 2704 (89.8)
Ever Used family planning
methods
No 2004 (66.6)
Yes 1006 (33.4)
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Cronbach’s alpha score at 0.85 and the all item-rest cor-
relations were 0.207 for item 1, 0.483 for item 2, 0.487
for item 3, 0.494 for item 4, 0.467 for item 5 and 0.235
for item 6.
We did not observe any missing data (Table 7). The
LMUP score distribution was non-normal and the
median score was 10 (inter-quartile range 5–11). The
principal component analysis confirmed that all six
items loaded onto one component (Eigenvalue = 3.81)
and the six items component loadings were 0.146 for
item 1, 0.865 for item 2, 0.870 for item 3, 0.902 for item
4, 0.815 for item 5 and 0.331 for item 6. We also report
the full range of the LMUP scores (Fig. 2).
Discussion
In our study the estimated prevalence of unintended
pregnancies in women attending the antenatal care clinic
was 38.2% which is consistent with the estimated global
prevalence [1]. This estimate is higher than previously
reported data of 16% and 24% in PDHS 2006 and 2013
[10, 11] but lower than the 46% reported in the study
conducted by Sathar et al. [12]. These previous studies
used a dichotomous scale whereas we employed the six
item LMUP [17–30, 32]. The prevalence of unintended
pregnancies in our study is higher than the studies from
Iran (33.7%) [21], Kenya (24%) [33], Ethiopia (27.9%)
[34] and Sudan (30.2%) [35] but lower than in Nepal
(41%) [36], Papua New Guinea (49.4%) [20], Tanzania
(45.9%) [37] and Ghana (70%) [38]. The most relevant
comparable data are those from Iran and Papua New
Guniea [20, 21] who also used the LMUP, although in
Papua New Guinea a five item partial LMUP was used
as item 6 was dropped to be locally appropriate.
Our study showed that the likelihood of unintended
pregnancies is significantly associated with age less than
20 years. This is consistent with the Papua New
Guinean, Kenyan and Tanzanian data [20, 33, 37] and
makes sense given that younger women have higher fer-
tility, higher frequency of sexual intercourse, lower know-
ledge of contraceptive methods and higher rates of
Table 4 Family planning knowledge, use and source of information
Knowledge n (%) Ever used n (%) Health care providers n (%) Media n (%) Husband n (%) Peers n (%) Others n (%)
Any family planning
method
2706 (89.9) 904 (33.4) 1621 (59.9) 39 (1.44) 406 (15.0) 602 (22.2) 36 (1.3)
Condoms 2658 (88.3) 505 (19.0) 1555 (58.5) 40 (1.5) 827 (31.1) 226 (8.5) 11 (0.4)
Pill 2896 (96.2) 278 (9.6) 1955 (67.5) 130 (4.5) 46 (1.6) 733 (25.3) 32 (1.1)
IUD 2513 (83.5) 73 (2.9) 1819 (72.4) 30 (1.2) 25 (1.0) 608 (24.2) 30 (1.2)
Injectable 2847 (94.6) 276 (9.7) 1987 (69.8) 80 (2.8) 31 (1.1) 715 (25.1) 34 (1.2)
Implants 2212 (73.5) 55 (2.5) 1712 (77.4) 13 (0.6) 20 (0.9) 453 (20.5) 13 (0.6)
Female sterilization 1833 (60.9) 04 (0.2) 1510 (82.4) 16 (0.9) 31 (1.7) 236 (12.9) 38 (2.1)
Male Sterilization 455 (15.1) 02 (0.4) 271 (59.6) 05 (1.1) 40 (8.7) 129 (28.4) 10 (2.2)
Emergency Contraception 753 (25.0) 178 (23.7) 386 (51.2) 05 (0.6) 93 (12.3) 267 (35.5) 03 (0.4)
Rhythm 436 (14.5) 60 (13.8) 199 (45.7) 04 (0.9) 125 (28.6) 102 (23.3) 07 (1.5)
Withdrawal 1038 (34.5) 478 (46.1) 158 (15.2) 03 (0.3) 654 (63.0) 195 (18.8) 28 (2.7)
Fig 1 Comparison of contraception knowledge and use between survey for prevalence and determinants of unintended pregnancies among
women attending antenatal clinics in Pakistan and PDHS 2012. **PIS~Pregnancy Intension Survey (Present study),**PDHS~Pakistan Demographic
and Health Survey
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contraceptive failure relative to older women [33, 37, 39,
40].Likewisewomenwhowereilliterateweremorelikely
to have an unintended pregnancy [20, 35, 36] which is con-
sistent with evidence documenting that literate women
have a better understanding of their rights and responsibil-
ities and have more freedom, control and participation in
decisions around contraception use and family planning
[41–44].
In our study parity was significantly associated with
unintended pregnancies. Women who had a parity of
greater than two were more likely to have an unintended
pregnancy. This finding is comparable to studies con-
ducted in other developing countries [20, 34, 35, 38, 45].
Similar to parity, short birth intervals of less than
12 months were also found to be significantly associated
with unintended pregnancies in our study as has been
noted elsewhere [20, 46, 47].
Consistent with the available literature [20, 33–38],
our study found that unintended pregnancy is strongly
associated with a lack of awareness of contraceptive
methods. As contraceptive awareness has been found to
be directly related to its’use [48–50] it is essential to im-
plement initiatives to improve community knowledge
about contraceptive methods. Our study also found that
women who had never used contraception had twice
at risk of having an unintended pregnancy compared
to current users, as is consistent with the literature
[20, 33–38, 51]. Furthermore, ever use of modern
methods(includingcondoms,pills,IUDs,injectables,
implants, male and female sterilization and emergency
contraception) was very low and use of traditional
methods high (Table 4).
This use of modern methods is alarmingly low, par-
ticularly the long acting reversible contraceptives
(LARC) such as intrauterine devices (IUDs) and im-
plants, possibly due to fear of infertility and side effects
[52, 53]. Our data is consistent with the recent PDHS
which estimated the unmet need to be 20.1% [11, 54]
which is well below that of neighboring countries like
India, Nepal and Bangladesh [55–57]. It is evident that
National family planning programs are failing to reach
many women in need of contraception [52, 58]. Studies
Table 5 Unadjusted association between unintended
pregnancy and predictor variables, Pakistan 2015
Variable Unintended
pregnancy n (%)
OR pvalue
Area of Residence
Rural 670 (58.3) 1.5 (1.1-1.8) <0.001
Urban 480 (41.7) Ref
Wealth Index
Poorest 266 (23.1) 1.8 (1.3-2.3) <0.001
Second 259 (22.5) 1.7 (1.2-2.1) <0.001
Middle 244 (21.2) 1.6 (1.1-2.0) <0.001
Fourth 199 (17.3) 1.1 (0.9-1.4) 0.311
Richest 182 (15.8) Ref
Pregnant women age
<20 years 41 (3.6) 1.3 (1.1-1.7) <0.001
20-24 Years 205 (17.8) 0.4 (0.3-0.5) <0.001
25-29 Years 519 (45.1) 0.7 (0.6-0.8) <0.001
> = 30 Years 385 (33.5) Ref
Pregnant women’s
education
Illiterate 552 (48) 1.4 (1.1 -1.7) 0.011
Primary or less
(1-5 years of schooling)
153 (13.3) 1.1 (0.7-1.5) 0.769
Middle (6-8) 62 (5.4) 1.0 (0.6-1.6) 0.995
Matric (9-10) 216 (18.8) 1.2 (0.8-1.7) 0.398
Intermidiate & above (>10) 103 (9) 1.1 (0.7-1.6) 0.683
Graduation and above (>12) 64 (5.6) Ref
Pregnant women’s
Age at marriage
≤20 Years 648 (56.3) 1.1 (0.9-1.3) 0.248
> 20 Years 502 (43.7) Ref
Gestational age
<28 weeks 534 (46.4) 1.2 (0.6-1.4) 0.071
> = 28 weeks 616 (53.6) Ref
Parity
>2 528 (51.4) 1.5 (1.2-1.8) <0.001
<=2 500 (48.6) Ref
Birth Interval
≤12 months 521 (50.2) 1.8 (1.3-2.9) 0.003
>12 months 516 (49.8) Ref
History of Abortion/
Miscarriage
Yes 259 (22.5) 1.8 (1.2-2.1) <0.001
No 891 (77.5) ref
Table 5 Unadjusted association between unintended
pregnancy and predictor variables, Pakistan 2015 (Continued)
Knowledge about
Family Planning
No 95 (8.3) 1.7 (1.5-1.9) 0.007
Yes 1055 (91.7) ref
Ever Used family
planning methods
No 657 (57.1) 1.2 (1.1-3.8) <0.001
Yes 493 (42.9) ref
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from Pakistan have demonstrated that lack of spousal
communication, religious beliefs, concerns about infertil-
ity and side effects and supply side factors such as poor
access, lack of counseling and insufficient availability of
modern methods are the major hurdles to the acc-
eptance of modern contraceptive methods [59–61].
Antenatal and postnatal counseling programs in other
countries have demonstrated they can improve contra-
ceptive prevalence [62–65]. Similar initiatives could eas-
ily be integrated into the Pakistan lady health workers
(LHW) program (which has a workforce of more than
100,000 LHWs) [66]. Of course increased availability of
modern methods of contraception would need to
accompany any such educational program.
After adjusting for other factors women living in rural
areas exhibited increased odds of an unintended pregnancy
compared to their urban counterparts, a finding consistent
with previous studies in similar settings [37, 67, 68], this is
likely to be associated with the higher prevalence of pov-
erty, illiteracy, poor contraceptive knowledge and little ac-
cess to modern contraceptive methods and services in rural
areas. Additionally rural women may not have autonomy
Table 6 Adjusted association between unintended pregnancies
and of predictor variables, Pakistan 2015
Variable Unintended
pregnancy n (%)
AOR pvalue
Area of Residence
Rural 670 (58.3) 1.7 (1.2-2.3) <0.001
Urban 480 (41.7) ref
Wealth Index
Poorest 266 (23.1) 1.4 (0.9-2.2) 0.063
Second 259 (22.5) 1.7 (0.9-1.8) 0.068
Middle 244 (21.2) 1.6 (0.8-1.8) 0.087
Fourth 199 (17.3) 1.1 (0.8-1.4) 0.311
Richest 182 (15.8) ref
Pregnant women age
<20 years 41 (3.6) 3.5 (1.1-6.5) 0.022
20-24 Years 205 (17.8) 1.0 (0.7-1.4) 0.937
25-29 Years 519 (45.1) 1.1 (0.9-1.4) 0.345
> = 30 Years 385 (33.5) ref
Pregnant women’s
education
Illiterate 552 (48) 1.9 (1.1-3.4) 0.025
Primary or less
(1-5 years of schooling)
153 (13.3) 1.8 (1.0-3.1) 0.053
Middle (6-8) 62 (5.4) 1.8 (0.9-3.5) 0.100
Matric (9-10) 216 (18.8) 1.9 (1.1-3.2) 0.022
Intermidiate & above (>10) 103 (9) 1.5 (0.8-2.6) 0.195
Graduation and above (>12) 64 (5.6) ref
Parity
>2 528 (51.4) 1.4 (1.2-1.8) <0.001
<=2 500 (48.6) ref
Birth Interval
≤12 months 521 (50.2) 1.7 (1.4-2.2) <0.001
>12 months 516 (49.8) ref
History of Abortion/
Miscarriage
Yes 259 (22.5) 1.1 (0.7-1.8) 0.080
No 891 (77.5) ref
Knowledge about
Family Planning
No 95 (8.3) 3.0 (1.7-5.4) <0.001
Yes 1055 (91.7) ref
Ever Used family
planning methods
No 657 (57.1) 2.3 (1.4-5.1) <0.001
Yes 493 (42.9) ref
Table 7 Endorsement and response options for the LMUP scale
Endorsement of the PI items
and response option
LMUP
Pakistan
Items Category n %
At the time of conception 0. Always use
contraception
642 21.3
1. Inconsistently use
contraception
219 7.3
2. Not use contraception 2149 71.4
In terms of becoming a
mother
0. Wrong time 629 20.9
1. An OK time but not
quite right
145 4.8
2. Right time 2236 74.3
Just before falling pregnant 0. Not intend to become
pregnant
734 24.4
1. Did not mind either
way
198 6.6
2. Intend to get pregnant 2078 69.0
Just before falling pregnant 0. Not want a baby 729 24.2
1. Have mixed feelings
about having a baby
110 3.7
2. Want a baby 2171 72.1
Before falling pregnant had
you and your husband
0. Never discussed
children
601 20.0
1. Discussed children but
no firm agreement
274 9.1
2. Agreed to pregnancy 2135 70.9
Health actions before falling
pregnant
0. No Action 1001 33.3
1. Action 1267 42.1
2 or more Actions 742 24.7
Total 3010 100.0
Habib et al. BMC Pregnancy and Childbirth (2017) 17:156 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
in decision making and may have little or no say in
family planning decisions [68, 69].
Our results indicate that the Urdu LMUP in Pakistan
performed very well, with demonstrated reliability and
validity in terms of acceptability, targeting, internal
consistency and structural validity. The validation results
are comparable (Table 7) with the similar validation
studies for LMUP conducted in Iran, Malawi, India,
United States and Brazil [21–23, 26, 30].
The use of a validated pregnancy intention scale
(LMUP) to estimate unintended pregnancies was the
main strength of our study, but there are some limita-
tions. Firstly there is a possibility of recall bias due to
retrospective nature of the questionnaire. Secondly the
cross-sectional design does not allow causal inferences
and lastly the results may not be generalizable to the
whole country since the study was conducted only in
two tertiary care hospitals. And finally is the lack of a
test-retest analysis in the psychometric data for the
stability of the scores.
Although efforts are being made by both private and
public institutions, access to modern methods remains a
challenge in Pakistan. Similarly the provision of safe
abortion services remained a neglected area due to its
illegal status and stigmatization [70]. Recent estimates
suggest that about 25,000 unintended pregnancies and
their related abortions and unplanned births could be
averted over a 5-year period only by changing 4% of
current oral contraceptive users in Pakistan to LARC
[71]. Community midwives and lady health visitors are
well placed to provide LARC services [52] that will allow
women the possibility of birth spacing and family
limiting [72]. As many women in Pakistan do not have
the freedom to decide about family planning it is essen-
tial that men are also engaged in education programs
which have been found to effectively improve attitudes
and behaviors, a decrease in the fertility and an increase
in the contraceptive use [73].
Conclusion
The high prevalence of unintended pregnancies resulting
in induced abortions and unplanned births in Pakistan
highlight the urgent need for a concerted effort through
a private and public partnership to improve the know-
ledge and access to modern contraceptive methods and
safe abortion services. An integrated national family pro-
gram that provides contraceptive services to women dur-
ing pre-conception and post-partum would be beneficial
in averting unintended pregnancies and their related
adverse outcomes in Pakistan.
Abbreviations
IUD: Intra uterine device; LARC: Long acting reversible contraceptives;
LHW: Lady health worker; LMUP: London measure of unplanned
pregnancies; PDHS: Pakistan demographic and health survey
Acknowledgements
This manuscript is a part of MAH’s thesis to fulfill the requirement for a PhD
at the University of Sydney. We are grateful to the Women and Child Health
Division, Aga Khan University for providing the opportunity and resources for
conducting the survey. We are also thankful to the University of Sydney for
funding MAH's PhD scholarship (IPRS/APA) and CRG's funding through an
NHMRC career development fellowship. We would like acknowledge the
efforts of Mr. Mushtaq Mirani, Mr. Qamar Junejo, Mr. Abid Hussain, Miss
Zarnigar and Miss Nasima for their efforts and hard work in the survey. We
would also like to thank all the participants who took part in the study.
Fig 2 Distribution of Pregnancy intention score
Habib et al. BMC Pregnancy and Childbirth (2017) 17:156 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Funding
The study was funded by Swiss Red Cross, Switzerland.
Availability of data and material
The datasets used and analyzed during the current study is available from
the corresponding author on reasonable request.
Authors’contributions
MAH, KB, CRG conceived design and idea of the survey. MAH, SBS and SN
were involved in data collection. CRG, KB and ZAB provided advice on data
analysis. MAH and SM conducted the data analysis. MAH prepared the
manuscript. CRG, KB, SN, SBS and ZAB reviewed the manuscript. All authors
seen the final draft and approved the manuscript.
Competing interests
The authors declare that they have no competing interest.
Consent for publication
Not applicable.
Ethics approval and consent to participate
This study was conducted under approval by institutional review boards at
the Aga Khan University, Karachi, Pakistan. Written consent was taken from
all participants.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical
School, University of Sydney, Sydney, NSW 2006, Australia.
2
Women and
Child Health Division, Aga Khan University, Karachi, Pakistan.
3
Sydney School
of Public Health, University of Sydney, Sydney, NSW 2006, Australia.
Received: 29 February 2016 Accepted: 22 May 2017
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