The minimal sample size was 505 and completed data were available for 494 women. Out of study participants, eight women failed to follow up after the delivery and three questionnaires were incomplete. The response rate was 97.8%.
Proportion of unplanned pregnancy
Majority of pregnancies (n= 346, 70.1%) were planned at the time of conception whereas the proportion of unplanned pregnancies were 17.2 % (n=85) and 12.7% (n=63) were ambivalent.
The mean LMUP score was 8.97 (95% CI 8.62-9.31) with a standard deviation (SD) of 3.914. Median was 11 and the interquartile range (IQR) was 6. Distribution was negatively skewed (-1.135). (Figure 1)
Associated factor profile
The mean age of the study sample was 28.5 years (SD=5.7), 90.6% were Sinhalese and 72.1% were Buddhist. The percentage of married women was 98.4%, mean age at marriage was 23 years and the average monthly income was Sri Lankan rupees 45,000 (1 USD=179.68 LKR in 2016) (56). When considering characteristics of women with unplanned pregnancy, majority (n=79, 92.9%) were married, 51.7% (n=44) married in their teens, 17.5% (n=15) were teenage mothers. Sixty-one percent of women with an unplanned pregnancy and 83% (n=70) of their husbands had been educated up to GCE Ordinary Level, 56.4% (n=48) families had a monthly income less than LKR 40, 000.
Age at marriage (p<0.001, r 0.22) and monthly income (p=0.001, r 0.15) were both significantly and positively correlated to the LMUP score while non-marital relationship (p=0.001), lower educational levels of both parents (p<0.001) were significantly associated with an unplanned pregnancy. Socio-demographic characteristics are summarized in table1.
Table 1-Distribution of socio-demographic characteristics of the study participants
Characteristics
|
Mean (SD)
|
Range
|
P-value
|
rho-value
|
Age at marriage (in years)
|
23(4.5)
|
14-39
|
<0.001 d
|
0.222
|
Maternal age at conception( in years )
|
28.5(5.78)
|
15-48
|
0.331 d
|
-0.44
|
Monthly income (LKR)*
|
45000
|
8000-150,000
|
0.001 d
|
0.154
|
|
|
|
|
|
Characteristics
|
N (%)
|
LMUP score a
|
P value
|
Ethnicity
|
|
|
|
Sinhalese
|
448(90.6)
|
11(5.0)
|
0.107 b
|
Non SinhaleseA
|
46(41.3)
|
10(9.0)
|
|
Religion
|
|
|
|
Buddhist
|
356(72.1)
|
11(5)
|
0.287 b
|
Other ReligionsB
|
138(27.9)
|
11(6.3)
|
|
Marital status
|
|
|
|
Not married
|
8(1.6)
|
2(3.2)
|
* 0.001 b
|
Married
|
486(98.4)
|
11(5)
|
|
Educational level of women
|
|
|
|
Educated up to passing ordinary level
|
172(34.8)
|
10(8.8)
|
<0.001 b
|
Educated up to Grade 12 and above
|
322(65.1)
|
11(2)
|
|
Educational level of spouse
|
|
|
|
Educated up to passing ordinary level
|
292(59.1)
|
10(8)
|
<0.001 b
|
Educated up to Grade 12 and above
|
202(40.8)
|
11(2)
|
|
Employment status of women
|
|
|
|
Unemployed
|
364(73.6)
|
11(6)
|
0.664 b
|
Employed
|
130(26.3)
|
11(3)
|
|
aDataare presented as median [interquartile range].
b Mann–Whitney U tests.
cKruskal–Wallis tests.
d Spearman rank correlation coefficient.
A Tamil, Muslim, and Burger were amalgamated
B Catholic, Islam and Hindu were amalgamated
*1 USD =179.68 LKR in 2016
Family planning characteristics
A larger proportion (76%, n=65) of women with unplanned pregnancies were multiparous, 84.7% (n=72) had never used any family planning method, (of whom 70% (n=51) were using modern methods) and 42.2% (n=35) were not aware of emergency contraceptives. Associated factor profile of women with unplanned pregnancies included, multiparous (p=0.002) women, who never used a family planning method (p<0.001), practicing a modern family planning method (p=0.04) and inadequate knowledge on emergency contraceptives (p=0.037). Distance to the nearest family planning service provision station was significantly negatively correlated to the LMUP score (p=0.03, r-0.09). (Table 2)
Table 2- Family planning characteristics in the study participants
Characteristics
|
Mean (SD)
|
Range
|
p-value
|
rho-value
|
Distance to family planning service (km)
|
2.2(2.0)
|
0.1-20
|
0.033 d
|
-0.096
|
Birth Interval in years (n=241)
|
4.85(3.1)
|
1-17
|
0.484 d
|
0.003
|
Characteristics
|
N (%)
|
LMUP Score a
|
P value
|
Parity (n=494)
|
|
|
|
Primiparity
|
199(40.3)
|
11(2)
|
0.002 b
|
Multiparity
|
295(59.7)
|
11(8)
|
|
Miscarriages
|
|
|
|
No
|
395(79.9)
|
11(6)
|
0.237 b
|
Yes
|
99(20.1)
|
11(2)
|
|
Family planning precise (n=494)
|
|
|
|
Ever used
|
349(70.6)
|
11(7)
|
<0.001 b
|
Never used
|
145(29.3)
|
11(2)
|
|
Most recent practice (n=349)
|
|
|
|
Natural or traditional methods
|
143(40.9)
|
11(5)
|
0.04 b
|
Modern methods
|
206(59.1)
|
10(8.3)
|
|
Modern method used (n=206)
|
|
|
|
Oral contraceptive pills (OCP)
|
102(49.5)
|
|
0.04 c
|
Condoms
|
43(20.8)
|
|
|
Depot medoxy acetic acid (DMPA)
|
29(14.7)
|
|
|
Intrauterine contraceptive devices (IUCD)
|
25(12.1)
|
|
|
Implants
|
7(3.4)
|
|
|
Knowledge on emergency contraceptives
|
|
|
|
Not adequate
|
265(53.6)
|
11(6.5)
|
0.037 b
|
Adequate
|
229(46.4)
|
11(3)
|
|
a Data are presented as median [interquartile range].
b Mann–Whitney U tests.
cKruskal–Wallis tests.
d Spearman rank correlation coefficient
Health of women and antenatal characteristics
Majority of unplanned pregnant women (55.2%, n=47) did not consume peri-conceptional folic acid, 30% (n=26) had visited less than four antenatal clinics and 44% (n=38) had never attended any antenatal classes. The LMUP score significantly and positively correlated to the number of antenatal clinic visits (p<0.001, r 0.30) and the number of antenatal classes attended (p<0.001, r 0.36) while the period of amenorrhea (POA) at booking visit negatively correlated (p<0.001, r-0.24). Delayed folic acid consumption (p<0.001), presence of any medical conditions (p-0.018), maternal anemia (p=0.004), preterm contractions (p=0.042) were significantly associated with an unplanned pregnancy. (Table 3)
Table 3-Health of women and antenatal characteristics of study participants
Characteristics
|
Mean (SD)
|
Range
|
p-value
|
rho-value
|
Pregnancy weight gain (Kg, n=490)
|
9.552(4.9)
|
1-39
|
0.093 d
|
0.076
|
POA at booking visit (weeks, n=490)
|
8.25(4.3)
|
4-36
|
<0.001 d
|
-0.249
|
Number of antenatal clinic visits(n=494)
|
6.4(1.9)
|
0-11
|
<0.001 d
|
0.309
|
Number of antenatal classes(n=494)
|
1.54(1.1)
|
0-4
|
<0.001 d
|
0.369
|
|
N (%)
|
LMUP score a
|
P value
|
Folic acid consumption
|
|
|
|
After confirmation
|
206(56.3)
|
6(9)
|
<0.001 b
|
Peri or at confirmation*
|
288(11.1)
|
12(1)
|
|
Presence of medical conditions
|
|
|
|
Yes
|
245(49.5)
|
11(6)
|
0.018 b
|
No
|
249(50.4)
|
11(5.5)
|
|
Hyperemesis gravidarum
|
|
|
|
Yes
|
21(4.3)
|
10(6.5)
|
P-0.27 b
|
No
|
473(95.7)
|
11(6)
|
|
Gestational diabetes
|
|
|
|
Yes
|
88(17.8)
|
11(3.7)
|
0.69 b
|
No
|
406(82.2)
|
11(6)
|
|
Antepartum hemorrhage
|
|
|
|
Yes
|
26(5.3)
|
10.5(6)
|
0.19 b
|
No
|
468(94.7)
|
11(6)
|
|
Pregnancy-induced hypertension (PIH)
|
|
|
|
Yes
|
41(8.3)
|
11(6)
|
0.67 b
|
No
|
453(91.7)
|
11(6)
|
|
Urinary tract infections
|
|
|
|
Yes
|
7(1.4)
|
10(4)
|
*0.39 b
|
No
|
487(98.6)
|
11(6)
|
|
Anemia
|
|
|
|
Yes
|
39(7.9)
|
10(8)
|
0.004 b
|
No
|
455(92.1)
|
11(5)
|
|
Preterm contractions
|
|
|
|
Yes
|
16
|
10(7.5)
|
0.042 b
|
No
|
478
|
11(6)
|
|
Prolonged rupture of membranes (PROM)
|
|
|
|
Yes
|
13
|
11(1)
|
0.62 b
|
No
|
481
|
11(6)
|
|
Other pregnancy problems/symptoms
|
|
|
|
Yes
|
49
|
10(4.5)
|
|
No
|
445
|
11(6)
|
0.012 b
|
aDataare presented as median [interquartile range].
b Mann–Whitney U tests.
cKruskal –Wallis tests.
d Spearman rank correlation coefficient.
Psychosocial risk during pregnancy
Lower LMUP score was significantly associated with the following psychosocial risk factors during the antenatal period. Women with a current or past history of deliberate self-harm (p=0.009), presence of low mood during pregnancy (p<0.001), women experiencing a stressful life event the during past six months (p<0.001), women who perceived inability to carry out daily functions (p<0.001), inability of care for the baby (p=0.006), families with financial issues (p<0.001)), having a partner with problem drinking (p<0.001), women experiencing GBV (p<0.001), poor relationship satisfaction with partner (p<0.001) and poor relationship with family (p<0.001) were associated with unplanned pregnancies. (Table 4)
Table 4- Psychosocial risk factors of the study participants
Characteristics
|
N (%)
|
LMUP score a
|
P value
|
Past history or current mental health
|
|
|
|
Yes
|
5 (1)
|
11(1.5)
|
*0.85 b
|
No
|
489(99)
|
11(6)
|
|
Past history or current Deliberate Self Harm
|
|
|
|
Yes
|
13(2.6)
|
10(9)
|
0.009 b
|
No
|
481(97.3)
|
11(6)
|
|
History or current use of Psychoactive substance
|
|
|
|
Yes
|
5(1)
|
10(5.5)
|
0.17 b
|
No
|
489(99)
|
11(6)
|
|
Low mood during the past two weeks
|
|
|
|
Yes
|
77(15.6)
|
10(9)
|
<0.001 b
|
No
|
417(84.4)
|
11(3.5)
|
|
Lack of interest in usual pleasurable activities
|
|
|
|
Yes
|
148(29.9)
|
11(2.7)
|
0.094 b
|
No
|
346(70.1)
|
11(6)
|
|
Experience of any stressful life events in the last 6 months
|
|
|
|
Yes
|
37(7.5)
|
5(8)
|
< 0.001 b
|
No
|
457(92.5)
|
11(4)
|
|
Inability to carry out daily functions
|
|
|
|
Yes
|
163(32.9)
|
10(8)
|
<0.001 b
|
No
|
331(67.1)
|
11(4)
|
|
Inability to care for the baby
|
|
|
|
Yes
|
157(31.8)
|
11(5)
|
0.006 b
|
No
|
337(68.2)
|
11(6)
|
|
Financial issues
|
|
|
|
Yes
|
48(9.7)
|
6(9)
|
<0.001 b
|
No
|
446(90.3)
|
11(3.2)
|
|
Physical or psychological handicap children
|
|
|
|
Yes
|
8(1.6)
|
11.5(1.7)
|
0.25 b
|
No
|
486(98.4)
|
11(6)
|
|
Problem drinking partner
|
|
|
|
Yes
|
117(23.7)
|
10(9)
|
<0.001 b
|
No
|
377(76.3)
|
11(3)
|
|
Gender-Based Violence (GBV)
|
|
|
|
Yes
|
13(2.6)
|
2(6)
|
* <0.001 b
|
No
|
481(97.4)
|
11(5)
|
|
Relationship with the husband
|
|
|
|
Poor e
|
43(8.7)
|
6(9)
|
< 0.001 b
|
Good f
|
451(91.3)
|
11(5)
|
|
Relationship within family
|
|
|
|
Poor e
|
55(11.1)
|
10(9)
|
<0.001 b
|
Good f
|
439(88.9)
|
11(5)
|
|
a Data are presented as median [interquartile range].
b Mann–Whitney U tests.
ePoor, very poor answers were amalgamated
fAverage, good, very good answers were amalgamated
Maternal health outcomes
Fifty-four percent (n=46) of unplanned pregnant women had antenatal complications while only 5.8% (n=5) had at least one post-partum complication. The majority of women with unplanned pregnancy 67% (n=57) delivered vaginally and 44.7% (n=38) had more than three days of hospital stay. None of them were associated with a lower LMUP score. (Table 5)
Neonatal outcomes
There were ten multiple pregnancies and the 504 sample of newborns were included in the descriptive statistics. Multiple pregnancy per se has the potential to develop adverse newborn outcomes and therefore 20 newborns of multiple pregnancies were excluded from the analysis of association.
There were 16.4% (n=83) preterm babies, 20.2% (n=102) low birth weight babies and 22% (n=107) had HC less than 2SD for their reference range. There were 88.6% (n=429) babies had initiated breastfeeding within one hour of delivery and only 3.1% (n=15) had been fed with formula milk during their hospital stay. None of the above neonatal parameters were significantly associated with a lower LMUP score. (Table 6)
Table 5-Intra-Partum, Post-Partum Maternal Outcomes
Characteristics
|
N (%)
|
LMUP Score a
|
P value
|
Onset of Labour
|
|
|
|
Spontaneous
|
211(42.7)
|
11(7)
|
0.35 c
|
Induce
|
161
|
11(6)
|
|
Planned caesarian section
|
122
|
11(4.3)
|
|
Fetal distress
|
|
|
|
Yes
|
44(8.9)
|
11(6)
|
0.46 b
|
No
|
450(91.1)
|
11(5.3)
|
|
Mode of delivery
|
|
|
|
Vaginal
|
289(58.5)
|
11(7)
|
0.17 b
|
Caesarian section
|
205(41.5)
|
11(2)
|
|
Presence of post-partum complications
|
|
|
|
Yes
|
41(8.3)
|
11(6)
|
0.86 b
|
No
|
453(91.7)
|
11(6)
|
|
Post-partum hemorrhage
|
|
|
|
Yes
|
10(2.0)
|
9(9.3)
|
* 0.74 b
|
No
|
484(98.0)
|
11(6)
|
|
Post-partum fever
|
|
|
|
Yes
|
12(2.4)
|
11(5.3)
|
* 0.53 b
|
No
|
482(97.6)
|
11(6)
|
|
High Blood pressure
|
|
|
|
Yes
|
10(2.0)
|
10(5.7)
|
* 0.23 b
|
No
|
484(98.0)
|
11(6)
|
|
Intensive care unit (ICU) stay
|
|
|
|
Yes
|
6(1.2)
|
10(6.7)
|
* 0.73 b
|
No
|
488(98.8)
|
11(6)
|
|
Other complications
|
|
|
|
Yes
|
7
|
12(11)
|
0.71 b
|
No
|
487
|
11(6)
|
|
aDataare presented as median [interquartile range].
b Mann–Whitney U tests.
cKruskal–Wallis tests.
Table 6- Neonatal Outcomes
Outcome
|
Mean (SD)
|
Range
|
p- value
|
Rho-value
|
Birth weight (grams, n=484)
|
2880 (572)
|
745-4750
|
0.689 d
|
0.018
|
Maturity (weeks, n=484)
|
38(2.21)
|
25-41
|
0.154 d
|
0.064
|
Head circumference (cm, n=486)
|
32.6(2.1)
|
21-44
|
0.067 d
|
0.068
|
Duration of hospital stay (Days)
|
4.3(4.0)
|
2-65
|
0.752 d
|
0.014
|
|
N (%)
|
LMUP score a
|
P value
|
Apgar 5 min(n=481) *
|
|
|
|
0-3
|
1
|
12(0)
|
|
4-6
|
10(2.3)
|
11.5(1)
|
* P-0.135 c
|
7-10
|
470(97.7)
|
11(6)
|
|
Breastfeeding within 1 hour (n=484)
|
|
|
|
Yes
|
429(88.6)
|
11(6)
|
P-0.145 b
|
No
|
55(11.4)
|
11(2)
|
|
Formula feeding (n=484)
|
|
|
|
Yes
|
15(3.1)
|
11(1)
|
*P-0.152 b
|
No
|
469(96.9)
|
11(6)
|
|
Presence of neonatal complications
|
|
|
|
Yes
|
121(25)
|
11(6)
|
P-0.568 b
|
No
|
363(75)
|
11(6)
|
|
Prematurity (n=484)
|
|
|
|
Yes
|
31(6.4)
|
11(5)
|
P-0.345 b
|
No
|
453(93.5)
|
11(6)
|
|
Jaundice (n=484)
|
|
|
|
Yes
|
22(4.5)
|
11(6.3)
|
P-0.621 b
|
No
|
462(95.4)
|
11(6)
|
|
Sepsis (n=484)
|
|
|
|
Yes
|
9(1.8)
|
10(6.5)
|
* P-0.218 b
|
No
|
475(98.2)
|
11(6)
|
|
Respiratory distress (n=484)
|
|
|
|
Yes
|
36(7.4)
|
11(4.3)
|
P-0.509 b
|
No
|
448(92.5)
|
11(6)
|
|
Meconium aspiration (n=484)
|
|
|
|
Yes
|
11(2.3)
|
10(8)
|
* P-0.16 b
|
No
|
473(97.7)
|
11(6)
|
|
Special care baby unit (SCBU) admission (n=484)
|
|
|
|
Yes
|
70(14.5)
|
11(7)
|
P-0.816 b
|
No
|
414(85.5)
|
11(6)
|
|
Neonatal Resuscitation(n=484)
|
|
|
|
Yes
|
24(4.9)
|
11(1.7)
|
P-0.234 b
|
No
|
460(95.1)
|
11(6)
|
|
aData are presented as median [interquartile range].
b Mann–Whitney U tests.
cKruskal–Wallis tests.
d Spearman rank correlation coefficient.
Psychometric Evaluation of Sinhalese version of LMUP
There were 448 study participants who had completed the Sinhalese version of the LMUP and were included for the evaluation of psychometric properties. The psychometric analysis of the Sinhalese LMUP demonstrated excellent internal consistency, with the Cronbach’s alpha score at 0.936. There were very low levels (maximum 2.4%, n=11) of missing values. Item response option endorsement was <80% and item one has a borderline high endorsement at 80%. All the item-total correlations were above 0.2. Corrected item-total correlations were 0.602 for item 1, 0.907 for item 2, 0.909 for item 3, 0.931 for item 4, 0.931 for item 5, 0.635 for item 6. (Table 7)
The principal component analysis demonstrated that all six items were loaded into one component (Eigenvalues=4.643) and component loading for item 1 was 0.967, item 2 was 0.946, item 3 was 0.946, item 4 was 0.961, item 5 was 0.959, item 6 was 0.723 (Table 8). We also reported the full range of the LMUP scores. (Figure 1)
Table 7- Endorsement and response options for the LMUP scale
Endorsement of the PI items and responses
|
|
LMUP in Sinhalese in Sri Lanka
|
Items
|
Category
|
N
|
%
|
Mean
|
Median
|
SD
|
1.At the time of conception
|
0-always use contraception
|
24
|
5.3
|
1.75
|
2
|
0.543
|
|
1-inconsistant /incorrect use contraception
|
63
|
14.0
|
|
|
|
|
2-not use contraception
|
359
|
80.1
|
|
|
|
|
Missing
|
2
|
0.4
|
|
|
|
2. In terms of becoming a mother
|
0-wrong time
|
68
|
15.1
|
1.58
|
2
|
0.746
|
|
1-ok, but no correct time
|
45
|
10.0
|
|
|
|
|
2-right time
|
329
|
73.4
|
|
|
|
|
Missing
|
6
|
1.3
|
|
|
|
3. Just before became pregnant
|
0-not intend to become pregnant
|
85
|
18.9
|
1.54
|
2
|
0.802
|
|
1-did not have an idea
|
29
|
6.4
|
|
|
|
|
2-intend to become pregnant
|
325
|
72.5
|
|
|
|
|
Missing
|
9
|
2.0
|
|
|
|
4. Just before became pregnant
|
0-not wanted a baby
|
62
|
13.8
|
1.59
|
2
|
0.733
|
|
1-have a mixed feeling of baby
|
49
|
10.9
|
|
|
|
|
2-want a baby
|
326
|
72.7
|
|
|
|
|
Missing
|
11
|
2.4
|
|
|
|
5. Before pregnancy you and your husband
|
0-never discussed on pregnancy
|
60
|
13.3
|
1.59
|
2
|
0.721
|
|
1-discussed on children but no firm agreement
|
58
|
12.9
|
|
|
|
|
2-agreed to pregnancy
|
322
|
71.8
|
|
|
|
|
Missing
|
8
|
1.7
|
|
|
|
6. Health preparations prior to pregnancy
|
0-no action
|
154
|
34.3
|
1.02
|
1
|
0.848
|
|
1-one action
|
124
|
27.6
|
|
|
|
|
2-two or more action
|
163
|
36.3
|
|
|
|
|
Missing
|
7
|
1.0
|
|
|
|
Table 8- Principal component analysis of LMUP
Items
|
Missing data
|
Corrected Item total correlation
|
Cronbach’s alpha
|
Cronbach’s alpha if item deleted
|
Component loadings
|
Sri Lankan Sinhalese
|
|
|
0.936
|
|
Eigenvalues-4.643
|
1 (Contraception)
|
2 (0.4%)
|
.602
|
|
.947
|
.967
|
2 (Timing)
|
6 (1.3%)
|
.907
|
|
.912
|
.946
|
3 (Desire for motherhood)
|
9 (2%)
|
.909
|
|
.911
|
.946
|
4 (Desire of baby)
|
11 (2.4%)
|
.931
|
|
.909
|
.961
|
5 (Partner discussion)
|
8 (1.7%)
|
.931
|
|
.909
|
.959
|
6 (Preparation)
|
7 (1.0%)
|
.635
|
|
.950
|
.723
|