Unintended Pregnancy Among Antenatal Women at A Tertiary Maternity Hospital in Sierra Leone: Prevalence and Associated Factors

doi:10.21203/rs.3.rs-5271547/v1

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Unintended Pregnancy Among Antenatal Women at A Tertiary Maternity Hospital in Sierra Leone: Prevalence and Associated Factors

https://doi.org/10.21203/rs.3.rs-5271547/v1

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Background

Unintended pregnancy remains a significant public health challenge in sub-Saharan Africa, with far-reaching consequences for maternal and child health. This study aimed to investigate the prevalence and associated factors of unintended pregnancy among antenatal women at a tertiary maternity hospital in Sierra Leone.

Methods

A cross-sectional study was conducted among 1,005 pregnant women attending their first antenatal visit at Princess Christian Maternity Hospital, Freetown, from March to June 2024. Participants were selected using systematic sampling. Data were collected through a semi-structured questionnaire and analyzed using descriptive statistics and multivariable logistic regression.

Results

The prevalence of unintended pregnancy was 31.8% (95% CI: 29.0-34.7%), with 30.0% mistimed and 1.8% unwanted. Factors independently associated with unintended pregnancy included age below 20 years (aOR: 3.57, 95% CI: 2.30-5.55, p<0.001), non-married status (aOR: 3.73, 95% CI: 2.60-5.36, p<0.001), and unemployment or student status (aOR: 1.74, 95% CI: 1.25-2.42, p=0.001). Women who communicated with their partner about pregnancy (aOR: 0.10, 95% CI: 0.07-0.16, p<0.001) and whose pregnancy was desired by their partner (aOR: 0.05, 95% CI: 0.03-0.09, p<0.001) had significantly lower odds of unintended pregnancy.

Conclusion

The high prevalence of unintended pregnancy, particularly among younger, unmarried, and economically vulnerable women, underscores the urgent need for targeted interventions. Enhancing partner communication and male involvement in family planning could significantly reduce unintended pregnancies. These findings could inform the development of comprehensive reproductive health strategies in Sierra Leone and similar settings.

Sexual & Reproductive Medicine

Unintended Pregnancy

Sierra Leone

Antenatal Care

Family Planning

Unintended pregnancies, encompassing both mistimed and unwanted pregnancies, present a significant challenge to global public health with far-reaching consequences for both maternal and child health.(1,2). Between 2010 and 2014, approximately 44% of pregnancies worldwide were unintended. In developed countries, this figure fell by 30% compared to the 1990-1994 period, whereas in low income countries, it decreased by 16%.(3) It is estimated that the average rate of unintended pregnancy in sub-Saharan Africa (SSA) is approximately 33.9%, which includes 22.1% of mistimed pregnancies and 11.2% of unwanted pregnancies.(4)

The 2019 Sierra Leone Demographic and Health Survey (SLDHS) indicated an unintended pregnancy rate of 17%, comprising 14% mistimed pregnancies and 3% unwanted pregnancies.(5) This figure emphasizes the ongoing challenge of unintended pregnancy in Sierra Leone, a country with an alarmingly high global maternal mortality rate partly attributed to inadequate preconception care.(5) The 2013 and 2019 SLDHS reported the prevalence of induced abortions in Sierra Leone as 9%,(5) underscoring the urgent need for improved family planning and reproductive health services.

Unintended pregnancy can result in a multitude of unfavorable outcomes, such as premature birth, maternal anxiety and depression, lack of family support, financial challenges, and attempted abortions.(6) In Sierra Leone, women frequently resort to abortion in cases of unintended pregnancy to avoid societal stigma associated with extramarital pregnancies, dropping out of school, and perceived difficulties in child rearing.(7) Despite the high risks associated with unsafe abortions, they are often viewed as a more favorable option to avoid shame and social consequences.(8)

Modern contraceptive methods, which involve products or medical procedures that prevent pregnancy during sexual intercourse, are critical in preventing unintended pregnancy.(9) These methods are rooted in sound reproductive biology, have precise protocols for correct usage, and have demonstrated efficacy through well-designed studies.(10) However, the prevalence of modern contraceptive use in Africa remains low, at approximately 26%.(11)

Although there was a slight increase in modern contraceptive use from 20% in 2013 to 24% in 2019, the level of contraceptive coverage remained insufficient in Sierra Leone.(12)

The World Health Organization (WHO) has reported that approximately two-thirds of unintended pregnancies in low-income countries are caused by a lack or limited access to contraceptive methods.(13) . This staggering statistic highlights the pressing need for increased access to and utilization of modern contraceptive methods in these countries. Studies conducted in various African countries have identified a range of factors that contribute to unintended pregnancy, including age, parity, marital status, educational level, communication between partners regarding family planning, and contraceptive awareness.(4,11,14–17)

The 2019 SLDHS provided invaluable data on the prevalence of unintended pregnancies. However, there is a lack of research on the specific factors associated with this issue. This dearth of evidence hinders evidence-based policymaking and implementation of targeted interventions aimed at enhancing sexual and reproductive health outcomes in Sierra Leone. In this study, we investigated the prevalence, associated factors, and implications of unintended pregnancy among women who attended antenatal clinics at a tertiary referral hospital for maternity care in Sierra Leone.

Study Design and Setting

We conducted a cross-sectional, questionnaire-based study at the Princess Christian Maternity Hospital (PCMH) in Freetown, Sierra Leone. PCMH is a public government-owned facility, that serves as the country's national referral maternity hospital, and is affiliated with the University of Sierra Leone Teaching Hospitals Complex. This setting provides access to a diverse population of pregnant women.

Participants and sampling

Inclusion and exclusion criteria

Eligible participants were women of childbearing age attending their first antenatal clinic visit at PCMH. We excluded women who were too ill to participate or had diagnosed psychiatric disorders or learning disabilities that could impair their ability to provide informed consent or accurate responses.

Sampling strategy

We employed a systematic sampling method to recruit participants from March 19 to June 30, 2024. Using the antenatal clinic registration book as a sampling frame, we calculated a sampling interval (K) by dividing the estimated monthly first-visit attendees (approximately 900) by our predetermined sample size. This resulted in the selection of every third eligible woman after triage.

Sample size

We initially calculated the sample size using the single population proportion formula:

n = [Z^2 × P(1-P)] / d^2

Where:

n = sample size
P = expected prevalence of unintended pregnancy (29.9%, based on Ojuok et al., 2022)(18)
Z = 1.96 (95% confidence level)
d = 0.05 (5% precision)

This yielded an initial sample size of 322. We then adjusted for a finite population correction:

nf = n / [1 + (n/N)]

Where N = 2000 (estimated target population size), resulting in a final calculated sample size of 277.

However, we ultimately collected data from 1,005 participants, which significantly exceeded our initial calculations. This larger sample size was intentionally pursued to enhance the study's statistical power, allowing for more precise estimates, improved generalizability, and a more robust analysis of less common factors associated with unintended pregnancy.

Data collection

Trained research assistants administered a semi-structured questionnaire to participants in a dedicated space within the antenatal clinic, to ensure privacy during the interview. The questionnaire was developed based on review of previous similar studies(19–21) and expert consultations, and contextualized for relevance. The tool covered socio-demographic characteristics, obstetric and medical history, contraceptive knowledge and use, pregnancy intention and related factors, partner relationship dynamics, and socioeconomic status indicators. To ensure data quality, we conducted pilot testing of the questionnaire and provided comprehensive training to the research team on interview techniques and ethical considerations.

Statistical analysis

Descriptive analysis was performed, and the mean and standard deviation for normally distributed continuous variables and median and interquartile range for non-normally distributed variables were reported. Student’s t-test or Mann–Whitney U test was used to analyze normally and non-normally distributed continuous variables, respectively. Chi-square analysis or Fisher’s exact test was used to analyze categorical variables as appropriate. Multivariable regression models were used to identify associations between unintended pregnancy and epidemiological factors, as well as variables regarding contraceptive use and relationship with the partner. Variables were selected for inclusion based on theoretical relevance and bivariate analysis results (p < 0.2). We reported adjusted odds ratios (aOR) with 95% confidence intervals (CI) and considered p-values < 0.05 as statistically significant. We performed statistical analyses using SPSS version 27 (IBM Corp, Armonk, NY, USA).

Ethical considerations

This study received approval from the Sierra Leone Ethics and Scientific Review Committee (SLESRC No: 005/03/2024). We obtained written informed consent from all participants prior to their involvement. Participants were assured of confidentiality, anonymity, and their right to withdraw at any time without consequences. We implemented strict data protection measures, including de-identification of personal information and secure data storage.

Sociodemographic characteristics of participants (n=1,005)

Table 1 presents the sociodemographic characteristics of 1,005 pregnant women who attended the antenatal clinic at Princess Christian Maternity Hospital (PCMH) during the study period. The majority of participants (88.8%) were 20 years of age or older. The mean (standard deviation) age was 25.7 (5.37) years. Islam was the predominant faith, with 77.6% of participants identifying as Muslim. Most women (79.1%) were multiparous, having given birth at least once before, while 20.9% were nulliparous. Nearly half (48.2%) of the respondents were self-employed, 20.1% were housewives, and 26.4% were either unemployed or students. The distribution was diverse, with 57.4% having completed secondary education, 17.4% reaching the tertiary level, and 20.6% reporting no formal education. The majority (73.0%) were married, while 18.0% were single. A substantial proportion (71.0%) of respondents reported previous use of modern contraceptives, whereas 29.0% had never used them.

Regarding pregnancy intention, 320 participants (31.8%) reported unintended pregnancies. Of these, 302 (30.0%) were classified as mistimed, and 18 (1.8%) as unwanted. The remaining 685 participants (68.2%) reported their pregnancies as intended.

Sociodemographic characteristics were strongly associated with unintended pregnancy. As shown in Table 2, women under 20 years of age had a significantly higher prevalence of unintended pregnancy compared to older women (61.1% vs. 28.1%, p<0.001). Nulliparous women also reported higher rates of unintended pregnancy than multiparous women (39.1% vs. 29.6-30.3%, p=0.012). Marital status was strongly associated with pregnancy intention, with never-married women reporting the highest prevalence of unintended pregnancies (59.7%), followed by divorced/separated/widowed women (50.0%), while married women had the lowest prevalence (24.3%) (p<0.001).

Sociodemographic characteristics independently associated with unintended pregnancy

Multivariate analysis revealed that maternal age below 20 years (aOR: 3.57, 95% CI: 2.30-5.55, p<0.001), non-married status (aOR: 3.73, 95% CI: 2.60-5.36, p<0.001), and being unemployed or a student (aOR: 1.74, 95% CI: 1.25-2.42, p=0.001) were independently associated with unintended pregnancy (Table 3).

Table 4 highlights partner-related factors. Women who communicated with their partner about pregnancy were significantly less likely to report an unintended pregnancy (aOR: 0.10, 95% CI: 0.07-0.16, p<0.001). Similarly, women whose pregnancy was desired by their partner had lower odds of unintended pregnancy (aOR: 0.05, 95% CI: 0.03-0.09, p<0.001). Also, women who reported to be victim of sexual violence were more likely to report unintended pregnancy, although this association was not statistically significant.

In this cross-sectional study conducted from March 19 to June 30, 2024, we examined the prevalence and associated factors of unintended pregnancy at the Primary Referral Maternity Hospital in Freetown, Sierra Leone. We observed a prevalence of 31.8% for unintended pregnancies, with 30.0% classified as mistimed and 1.8% as unwanted. Factors independently associated with unintended pregnancy included age below 20 years, non-married status, and unemployment or student status. Women who communicated with their partner about pregnancy and whose pregnancy was desired by their partner had significantly lower odds of unintended pregnancy.

The 31.8% prevalence of unintended pregnancies in our study is higher than the 17% reported in the 2019 SLDHS.(5) This discrepancy underscores the complex nature of unintended pregnancies and highlights the importance of considering contextual factors in prevalence assessments. While the prevalence reported from the SLDHS was a nationally representative value, the higher figure from our study was institutionally derived and suggests there may be more variability, at the sub-nationally levels in Sierra Leone, with the burden and nature of unintended pregnancy. We found that 30.0% of pregnancies were mistimed and 1.8% were unwanted, differing from the SLDHS figures of 14% and 3%, respectively.(5)

Notwithstanding, the prevalence observed in our study aligns with reports from SSA, which have shown considerable variability. Comparable rates were found in North Ethiopia (26%), Ghana (29.8%), and Southeast Ethiopia (37.2%).(21–23) In contrast, substantially lower prevalences were reported in Abuja Teaching Hospital, Nigeria (16%), and Gondar Town, Ethiopia (20.6%).(15,20) Conversely, higher rates were observed in the 2014 Ghana Demographic and Health Survey (DHS)(40%) and across three Tanzanian districts (45.9%).(21,24) These variations highlight the importance of considering regional and methodological differences when interpreting prevalence data across different studies and geographical contexts.

Several factors may contribute to the higher prevalence of unintended pregnancies observed in our study. The setting PCMH, as the main obstetric referral center in Sierra Leone, likely receives a significant proportion of high-risk pregnancies, including those among teenagers. Additionally, as a public hospital, PCMH probably serves a population with lower socioeconomic status, who may be at higher risk for unintended pregnancies, while individuals with higher socioeconomic status might be more likely to choose private hospitals.

We identified several sociodemographic factors significantly associated with unintended pregnancy in Sierra Leone. The most prominent factors include age under 20 years, unemployment or student status, nulliparity, and never having been married. Our results align with several studies conducted in similar settings across Africa. For instance, a survey among women in Nairobi slums reported comparable associations between unintended pregnancy and factors such as age, parity, and marital status.(19) The higher proportion of unintended pregnancies among women under 20 years in our study is consistent with trends observed in the 2014 Ghana DHS(21) and a population-based survey in Gambia.(16)

The association between unmarried status and higher odds of unintended pregnancy in our study corroborates findings from various other research efforts.(25,26) Another study in Gambia found that unmarried women were 11.38 fold more likely to experience an unintended pregnancy compared to married women.(16) Our finding regarding the association between nulliparity and unintended pregnancy contrasts with some studies from Ghana that reported higher odds of unintended pregnancy with increasing parity.(14,21) This discrepancy highlights the importance of considering local contexts when interpreting such associations.

Several factors may underlie the observed associations. Younger women and adolescent girls in Sierra Leone, often still in secondary school and dependent, may be more vulnerable to unintended pregnancies, owing to a combination of factors. These include a higher likelihood of engaging in unprotected sexual activities, possibly driven by peer pressure or material motivations,(27) and reliance on potentially uninformed sources (parents, peers, media) for information about sexual maturation and reproductive health. The higher prevalence among unmarried women may be influenced by societal norms in Sierra Leone, where access to reproductive health services such as contraception is reduced for single women compared to married women. This societal pressure could even lead to a reluctance to seek family planning advice.

The association between nulliparity and unintended pregnancy in our context may be explained by the fact that nulliparous women tend to be younger, still in school, and unemployed, potentially rendering them less prepared for pregnancy. Limited knowledge of sexual and reproductive health among nulliparous participants may also contribute to this observation.

The strong protective effect of partner communication and partner desire for pregnancy on unintended pregnancy rates highlights the critical role of male involvement in reproductive health decisions. This finding aligns with growing evidence from other low- and middle-income countries emphasizing the importance of engaging men in family planning efforts.(14,17) Studies have identified factors such as awareness of traditional family planning methods, inter-partner communication, and women's limited autonomy as associated with unintended pregnancies.(14,17,28) Additionally, reproductive coercion, intimate partner violence, and exposure to partner violence have been linked to an increased risk of unintended pregnancies.(28,29) In our study, we reported a higher frequency of sexual abuse among women who reported unintended pregnancy, although not significant. In our opinion, considering the disruptive implications for women’s health and autonomy, as well as potential consequences if the violence is perpetrated during pregnancy, this finding is alarming and deserves additional investigation.(2,30)

Our findings have significant clinical and policy implications for addressing unintended pregnancies in Sierra Leone. Clinically, there is an urgent need for targeted interventions, particularly for young, unmarried, and economically disadvantaged women. Healthcare providers should offer age-appropriate sexual and reproductive health education, tailored counseling, and improved access to family planning services. These efforts should be complemented by strategies to engage men in reproductive health decisions and promote partner communication regarding family planning.

From a policy perspective, addressing socioeconomic factors associated with unintended pregnancies is crucial. This includes implementing economic empowerment programs and educational support initiatives, particularly for adolescents and young adults. Policies should also focus on strengthening contraceptive services and improving accessibility and quality. By adopting a comprehensive approach that addresses both clinical and socioeconomic factors, Sierra Leone can reduce unintended pregnancies and improve the overall reproductive health outcomes.

Limitations

This study has some limitations. The cross-sectional design limits our ability to establish causal relationships between the identified factors and unintended pregnancies. Additionally, the single-center nature of our study may limit the generalizability of our findings to other settings in Sierra Leone. Future research should consider multi-center studies and longitudinal designs to better understand the dynamics of unintended pregnancies over time and across different healthcare settings.

This study reveals a 31.8% prevalence of unintended pregnancies at a tertiary referral hospital in Freetown, Sierra Leone. Factors independently associated with unintended pregnancy include young age, unmarried status, unemployment or student status, and nulliparity. The protective effect of partner communication and desire for pregnancy underscores the importance of male involvement in reproductive health decisions.

These findings highlight the complex interplay between sociodemographic, economic, and relational factors that influence unintended pregnancies. A multifaceted approach is necessary that incorporates age-appropriate sexual education, improved access to family planning services, economic empowerment programs, and initiatives promoting partner communication.

aOR: Adjusted odds ratio; DHS: Demographic Health Survey; PCMH: Princess Christian Maternity Hospital; SLDHS: Sierra Leone Demographic Health Survey; SLESRC: Sierra Leone Ethics and Scientific Review Committee; SSA: sub-Saharan Africa; WHO: World Health Organization.

Ethics approval and consent to participate

Consent for publication

Not applicable

Availability of data and materials

Data can be obtained upon request from the corresponding author, Dr. Alieu Kanu ([email protected]). All the authors fully comprehend the importance of disseminating individual-level data. Our objective is to ensure that the data generated from our research are gathered, organized, managed, and shared in a manner that optimizes their usefulness.

Competing interest

The authors declare that they have no competing interest.

Funding

This study did not obtain any grants from funding entities in the public, commercial, or non-profit domains.

Authors` contributions

AK and AKB were responsible for the conceptualization of the study. AK, AKB, MO, SK, ME, and MBJ were responsible for the design and implementation of the study. AK, AKB, IPJ, FYT, SK, and FJ were responsible for obtaining consent and collecting the data. ES and MO conducted the data analysis, and AK, MO, and MBJ wrote the results. AK and MBJ wrote the other sections of the manuscript. All authors critically reviewed and approved the final manuscript.

Acknowledgements

We extend our heartfelt gratitude to the management of Princess Christian Maternity Hospital for enabling us to conduct this study at their facility. We also acknowledge the department head and staff of the hospital who provided invaluable support in various ways during this research. We express our sincere appreciation to the pregnant participants, who graciously cooperated during the interviews.

Authors` information

AK, AKB: Medical Doctor and early career researchers, University of Sierra Leone Teaching Hospitals Complex: Princess Christian Maternity Hospital, Freetown, Sierra Leone; MO: Board-certified Obstetrician and Gynecologist at the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy, and former Technical Advisor at the University of Sierra Leone Teaching Hospitals Complex on behalf of Doctors with Africa CUAMM; IPJ, FYT, FJ: Medical Students, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; SK: Registrar, University of Sierra Leone Teaching Hospitals Complex: Princess Christian Maternity Hospital, Freetown, Sierra Leone; ME: Consultant Obstetrician and Gynecologist, University of Sierra Leone Teaching Hospitals Complex: Princess Christian Maternity Hospital, Freetown, Sierra Leone; ES: Full Professor of Obstetrics and Gynecology at the University of Milan and Head of Infertility Unit, Obstetric and Gynecological Emergency Room and Sexual and Domestic Violence Aid at the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; MBJ: Research Fellow, McMaster University, Hamilton ON, Canada

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Tables 1 to 4 are available in the Supplementary Files section

The authors declare no competing interests.

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Unintended Pregnancy Among Antenatal Women at A Tertiary Maternity Hospital in Sierra Leone: Prevalence and Associated Factors

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Introduction

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