Unintended Pregnancy and Associated Factors among Pregnant Women Attending Antenatal Care Unit in Public Health Facilities of Dire Dawa City, Eastern Ethiopia, 2021

Background Unintended pregnancy refers to a pregnancy that is either mistimed or unwanted. Unintended pregnancy has been a troubling public health and reproductive health issue, which imposes appreciable adverse consequences on the mother, child, and the public in general. Globally 121 million unplanned pregnancies occurred from 2015 to 2019. A significant proportion (61%) of these pregnancies ended in abortions each year. In Ethiopia, the challenges of unintended pregnancy and its related complications still exist because of the high rate of unmet need for contraceptives. In addition, no research has been conducted on unintended pregnancy among pregnant women in Dire Dawa city administration. Objective To determine the prevalence of unintended pregnancy and associated factors among pregnant women attending antenatal care public health facilities in Dire Dawa in 2021. Methods A facility-based cross-sectional study was conducted. After being chosen randomly, 382 pregnant women were interviewed at 9 urban public health facilities. A pretested questionnaire was used to collect data, entered into Epi Info 7, and exported into SPSS version 25 for analysis. The variables, which were significant at P ≤ 0.25 in bivariate analysis, were included in multivariable analysis. Statistical significance was declared at a P value <0.05 and a 95% CI. Results In this study, the prevalence of unintended pregnancy was 23.8% at 95% CI (19.8–28.3). The following factors were associated with unintended pregnancy: single women (AOR = 10.93, 95% CI 3.65–32.74), low family income (2000 ETB) (AOR = 4.01, 95% CI 1.73–9.28), parity 3 (AOR = 10.3, 95% CI 4.07–25.84), no history of family planning use (AOR = 5.91, 95% CI 2.46–14.21), and husband decision-making role on reproductive health (AOR = 2.956, 95% CI 1.048–8.340). Conclusion and Recommendations. The prevalence of unintended pregnancy was relatively high in this study. Efforts should be made to scale up women's decision-making power on family planning services and give support to empower women economically. There is the need to promote family planning services to minimize unintended pregnancy and to decrease parity and family size.


Introduction
Unintended pregnancy refers to a pregnancy that is either mistimed or unwanted.Unintended pregnancy has been a troubling public health and reproductive health issue, which imposes appreciable adverse consequences on the mother, child, and the public in general.Globally 121 million unplanned pregnancies occurred from 2015 to 2019.A signifcant proportion (61%) of these pregnancies ended in abortions each year.Although there has been a decline in unintended pregnancy around the globe, it has been unequal between high-income countries, compared with middle and low-income countries, where 66 unintended pregnancies per 1,000 women and 93 per 100 women, respectively [1][2][3][4].
An analysis of data from a study conducted in developing countries has indicated that the magnitude of unintended pregnancy in those countries varies from 13% to 82%.Te results of sub-Saharan multicountry analysis of demographic and health surveys showed that the unintended pregnancy prevalence rate was 29%, ranging from 10.8% in Nigeria to 54.5% in Namibia.In sub-Saharan Africa, unintended pregnancy is still a challenge and remains high due to limited access to reproductive health care.Across sub-Saharan Africa, 35%-65% of pregnancies among human immunodefciency virus-positive women were unplanned, whereas in Cape Town, South Africa, 46% were reported as unintended pregnancies [5][6][7].
Unintended pregnancy has serious consequences for women everywhere.Unplanned pregnancy often forces women to confront difcult issues, including abortion, relinquishing a child to adoption, or the raising of a child without the necessary fnancial, physical, and emotional support.Health consequences include the inherent risks of pregnancy, which may be complicated by other medical problems, and the risks of multiparity.Hemorrhage, infection, and hypertensive disorders, all play a major role in maternal mortality throughout the developing world.Each unintended pregnancy may put women at risk for signifcant morbidity and mortality due to poverty, malnutrition, lack of health care, and inadequately trained health care providers [5][6][7][8].
According to Ethiopia's Mini Demographic and Health Survey 2019, only 41% women use any modern contraceptive method.Te recent reports show that the magnitude of unintended pregnancy ranges from 33.3% to 34.8%.Despite the burden of abortion being high in Ethiopia, the unmet need for family planning in the country is still a major reproductive health problem [9,10].
Te induced abortion rate was higher in Dire Dawa and other urban cities as a result of unintended pregnancies [8].In addition, no information or research has been conducted on unintended pregnancy in the study area (Dire Dawa city administration).For this reason, understanding the prevalence of unintended pregnancy should be pointed out according to the local context, and in addition, identifying factors associated with unintended pregnancy among pregnant women may contribute to the designing of prevention strategies and reproductive health service utilization.Terefore, this study intends to assess the prevalence of unintended pregnancy among pregnant women attending antenatal care units in urban public health facilities in Dire Dawa city.

Subject of Study and Eligibility
Requirements.All pregnant women who were attending ANC units in nine urban public health facilities in Dire Dawa city were the source of the population for the study.Pregnant women who were attending ANC service during the study time period were included in the study.

Sample Size and Sampling
Procedure.Te sample size was calculated using a single population proportion based on a prevalence of 41.54% reported in Arsi Negele [2].Ten there is the 95% confdence interval (CI z/2 � 1.96) and the 5% margin of error (d).Te fnal sample size was 373 with a 10% nonresponse rate and it became 410.However, the total number of pregnant women attending the health care unit was less than 10,000, and we used a correction formula to come up with the fnal sample size.True sample � (sample size X population)/(sample size + population-1) � (2,259,920)/(5921) � 382.
Dire Dawa city has eight public PHCUs and two hospitals.Of the nine health facilities (8 PHCUs and 1 hospital) that were included in the study, one hospital was excluded because it was the COVID-19 treatment center.Te sample size was proportionally allocated to the selected health institutions.Ten, the study participants were selected by using a simple random sampling technique, as shown in Figure 1.

Proportionate allocation
where nj is sample size of the jth health facility, n � n1 + n2 + n3 is the total sample size, Nj is population size of the jth health facility, and N � N1 + N2 + N3 is the total population size.

Data Collection Tools and Procedures.
A face-to-face interview was conducted using a structured questionnaire that was adopted from the related studies [12,13].Te survey questions were under consideration in terms of sequence, cultural sensitivity, and appropriateness.It had three sections.Te frst section had 10 items and focused on sociodemographic and economic history; the second section consisted of 12 items and was used to assess sexual and reproductive history; and the third section had 10 items, which were used to measure family planning and reproductive health service needs.Nine data collectors (facilitators) and two supervisors were assigned.Te interaction was conducted between one interviewer and the interviewee.Te room and the environment were made conducive to maintain their privacy and social distance (2-meter distance) between the study participants and the interviewer in order to prevent COVID-19.Wearing of a face mask, clean gloves, and use of hand sanitizer was ensured.

Dependent Variable
(1) Unintended pregnancy Training was also given for data collectors and supervisors.Moreover, the flled questionnaires were checked at the feld level, frst by the data collectors themselves and then by their respective supervisors on a daily basis.At the entry level, the data were checked carefully for invalid codes, duplicated entries, and missing value of records with due emphasis on the expected quality of data.Te internal consistency of questionnaire was measured by Cronbach's alpha, and it was reported to be 0.92, which is above the recommended value of Cronbach's alpha, which is 0.70.
2.9.Data Process Management and Analysis.Data were coded and checked for completeness and consistency.Te data were entered into Epi Info 7 and exported to SPSS software version 25 for further analysis.Descriptive and summary statistics were analyzed.Bivariate analysis was used to test the association between the independent variables and the outcome variable.All explanatory variables that were associated with the outcome variables in bivariate analysis were included in multivariate logistic regression to determine the independent predictor of unintended pregnancy.Te variables, which were signifcant at P ≤ 0.25 in bivariate analysis, were included in multivariable analysis.Te direction and strength of statistical association were measured by an odds ratio with a 95% CI.Te statistical signifcance level was set at P value � 0.05.Finally, the results Obstetrics and Gynecology International were presented in tables and fgures, which were followed by an interpretation of the fndings.

Ethical Approval and Consent
Ethical clearance was received from Dire Dawa University College of Medicine and Health Science Research and Ethics Review Committee (RERC).A support letter was written to Dire Dawa health bureau to obtain permission, and communication has been established with the head of the health facilities after presenting letters of support.Informed consent was obtained in writing from every participant prior to the start of this research activity, and to ensure confdentiality, participant names were not used during data collection.Tis anonymity was explained clearly to all participants.

Results
A total of 382 currently pregnant women were interviewed, and the response rate was 100%.Te majority of respondents, i.e., 372 (97.4%) were residents, and nearly onethird, i.e., 125 (32.7%) of the study participants were between the ages of 25 and 29.Te mean age of study participants was 25.79 (SD ± 5.32).Concerning marital status, 347 (90.8%) were married and 26 (6.8%) were not married.Of all, 151 (39.5%) women had no formal education and 98 (25.7%) had primary education.More than half, 213 (56.5%) of the respondents were housewives.Of the majority of respondents, 206 (53.9%) reported a medium level of monthly family income (2,000 to 4,999 ETB) and 120 (31.4%) reported a high level of family income.Te mean monthly income of the respondents was 4,063 ETB, as shown in Table 1.

Obstetrics History of Study Participants.
Tree-fourths of the respondents, i.e., 285 (74.6%) had a history of pregnancy, and 176 (46.1%) of the respondents were pregnant for the frst time at the age of 15-19 years.Women were asked about the number of pregnancies, 88.8% of the study participants accounted for 1-3 pregnancies and 11.8% of them had 4 or more pregnancies.222 (58.1%) of study participants have 1-3 children, 118 (30.9%) have no children, and 42 (11%) have more than 3 living children.Regarding the current pregnancy status, 91 (23.8%) of the pregnancies were unintended, of which 55 (14.4%) were mistimed and 36 (9.4%) were unwanted types of pregnancies, as shown in Figure 2.
Te remaining 291 (76.2) were intended pregnancies.Te most common reasons why they experienced an unintended pregnancy were no use of family planning method 37 (40.7%) and method failure 32 (35.1%).Tree hundred thirty-seven (88.2%) had no previous unintended pregnancies but 45 (11.8%) had a previous history of unintended pregnancies.Regarding abortion, 87 (22.8%) of respondents experienced abortion one to two times.Of these, 54 (62%) had experienced spontaneous abortion but 27 (31%) had induced and 6 (7%) had both types of abortion, as shown in Table 2.

Sexual Reproductive Health Service History of Study
Participants.Tree hundred twenty-four (84.8%) participants responded that they had heard about family planning methods.Health institutions and friends were the main sources of information for family planning, which accounted for 218 (67.3%) and 103 (31.8%), respectively.Nearly one-third of the participants, 135 (41.7%), knew about all methods, while 113 (34.9%) knew only about injectable methods and 45 (13.9%) knew about implants of study participants, and 351 (91.9%) had a history of family planning use.From those who have a history of family planning, the most mentioned method that was reported to be used was injectable (42.7%).Most of the participants, 324 (84.8%), had received information about ANC and PNC as shown in Table 3.

Factors Associated with Unintended Pregnancy among
Pregnant Women Attending ANC.In bivariate analysis, marital status, family income, number of pregnancies, number of alive children, decision maker on RH, history of family planning use, and reason not to use family planning were identifed to be signifcantly associated with unintended pregnancy.At multivariate analysis, only marital status, family income, number of living children, decision maker on RH, and history of family planning use remained signifcantly associated with unintended pregnancy.Marital status was shown to be signifcantly associated with unintended pregnancy.When compared to married women, single women were about 10.93 times more likely to have an unintended pregnancy (AOR 10.938, 95% CI 3.653-32.749).
In addition, those pregnant women who have a low monthly family income were 4 times more likely to report their current pregnancy as unintended as those women who have a high monthly family income (AOR � 4.017, 95% CI 1.738-9.284).
Unintended pregnancy was ten times more likely (AOR 10.263, 95% CI 4.075-25.849)among pregnant women with four or more alive children than among those with one or two children.
Te husband's decision role on the reproductive health of those pregnant women was higher by 2.96 times (AOR 2.956, 95% CI 1.048-8.034)than those women who decided by themselves.
Women who have never used family planning are nearly 5.9 times more likely (AOR 5.915% CI 2.461-14.217) to report an unintended pregnancy as compared to women who have used family planning, as shown in Table 4.

Discussion
Te fndings of this study show that 23.8% at 95% CI (19.8-28.3) of study subjects have an unintended pregnancy.Of these unintended pregnancies, 55 (14.4%) of them were mistimed and 36 (9.54%) of them were unwanted.Tis fnding was comparable with that of the previous studies conducted at Gondar 20.6% [15], Mizan Tepi 22.3% [16], Debre Birhan 23.5% [17], Saesie Tsaeda Emba 24.9% [18], and Addis Zemen 26.1% [19].However, it was higher than 4 Obstetrics and Gynecology International that of the study conducted at Belesa 13.7% [20], Egypt 15.9% [21], and Iran 19.8% [22].Te diference may be due to the sample size and study design.Te sample size for study conducted in Belesa and Egypt were 619 and 827, respectively, which is larger than our study.In addition to that, both the previous studies were community-based studies.But it was also lower than the study conducted in Michew 29.7% [23], Hadiya Zone 36.2% [14], Hawassa 33.7% [24], and Jimma 36.5% [25].Tose variations may be attributed to the diference in the sociodemographic characteristics; some of them were based on community-based studies, time variation, and sample size.In addition to this, the diference may be due to cultural diferences, especially with the other mentioned African countries.
Te study also revealed that women who are not married (single) were 10.9 times more likely to report having an unintended pregnancy (AOR 10.938 95% CI 3.653-32.749)than married women.Similar studies conducted in Arsi Negele [2], Gelemso [12], Gondar [15], Michew [23], and Dilla University [26] showed that single women were more likely than married women to have had an unintended pregnancy in the frst place.It could be that single women might have unplanned sexual activity for reasons other than child bearing that leads them to unintended pregnancies.In terms of income, pregnant women with a low monthly family income were four times more likely than those with a high monthly family income to have an unintended pregnancy (AOR 4.017, 95% CI. (1.738-9.284)).Tis study had nearly similar fndings to studies conducted in Pakistan [27], Malawi [28], Iran [23], and Egypt [21].Other studies reported that there is no association between income and unintended pregnancy, which could be because of the different study settings or diferences in measurement of the socioeconomic variables like Saesi Tsaedaemba, Woreda, Eastern Zone of Tigray [18], and Arba Minch [14].It was also noted that the number of alive children was a predictor of unintended pregnancy in this study.Pregnant women with a parity of three or above were 10 times more likely to experience an unintended pregnancy than pregnant women with a parity of one or two (AOR 10.263) (95% CI 4.075-25.849).Te fnding was in line with that of the studies conducted in Gelemso [12], Addis Zemen [19], and Bako Tibe district [1].In relation to the association of contraceptive use and unintended pregnancy, women who have never used family planning are nearly 6 times more likely (AOR 5.86, 95% CI 2.440-13.865) to have an unintended pregnancy as compared to women who have used family planning.Tis fnding was comparable with the fndings in Arisi Negele [2], Addis Ababa [29], and Hawasa [24].Furthermore, in this study, unintended pregnancy was  [30], Tepi general hospital [16], Arba Minch [31], and Bako Tibe district [1].

Conclusions
Approximately one-fourth of the study participants reported that their pregnancy was unintended.Unintended pregnancy was signifcantly associated with marital status, family income, number of alive children, family planning method use, and decision-making role on reproductive health among study subjects at Dire Dawa city urban health facilities.No use of contraceptives, method failure, and partner refusal were among the main reasons mentioned by study participants for unintended pregnancy.Tis implies that less efort is being made to provide family planning counseling to women and their partners, particularly single women and multipara women.

Recommendations
To come up with a solution in order to minimize the problem of unintended pregnancy and the reasons mentioned by the study subjects, the following recommendations are forwarded.

To Ethiopian Federal Ministry of Health. Te Ministry of
Health should enhance family planning access and promote women's empowerment.Health facilities should design programs to train the community to bring sustainable behavioral changes in reproductive health and promote husband and wife communication about FP.Health professionals, voluntary aid associations, and policy makers should design diferent policies that help women to restrict family sizes (i.e., family planning policy) and give support to empower women economically.
7.2.To Dire Dawa Health Bureau.Programs should be designed in order to ensure good behavioral change on family planning methods among women of reproductive age groups and their partners.More energy should be focused on the dissemination of information on proper, consistent, and efective utilization of contraceptives, partner participation, and role since method failure and partner refusal can lead to unintended pregnancy.

To Health Professionals.
Health professionals should give due attention to the improvement in the provision of efective reproductive health counseling and quality of care.
7.3.1.Researcher.Further administration-wide studies should be conducted to show a comprehensive picture of unintended pregnancy and its associated factors.

Table 1 :
Sociodemographic characteristics of pregnant women attending ANC unit at urban public health facilities of Dire Dawa city, 2021.
Figure 2: Status of current pregnancy among pregnant women attending ANC unit at urban public health facilities of Dire Dawa administration, 2021.

Table 2 :
Obstetrics history of pregnant women attending ANC unit at urban public health facilities of Dire Dawa city, 2021.

Table 3 :
Sexual reproductive health service history of pregnant women attending ANC unit at urban public health facilities of Dire Dawa city, 2021.

Table 4 :
Bivariate and multivariate logistic regression analyses of factors associated with unintended pregnancy of pregnant women attending ANC unit at urban public health facilities of Dire Dawa city, 2021.