The Role of Pregnancy Intendedness in Shaping Contraceptive Practices and Family Planning Experiences: Evidence from Sub-Saharan Africa

Graduation Year

2024

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Public Health

Major Professor

Russell S. Kirby, Ph.D.

Committee Member

Ellen M. Daley, Ph.D.

Committee Member

Rachel B. Rapkin, M.D., Ph.D.

Committee Member

Jason L. Salemi, Ph.D.

Keywords

Behavior, Contraception, Multilevel Modeling, Postpartum, Unintended Pregnancy

Abstract

Background: Despite the associated adverse health and economic implications associated with unintended pregnancy, there remains a paucity of literature examining the effect of unintended pregnancy on postpartum contraceptive and reproductive behavior in many parts of Sub-Saharan Africa (SSA), including Nigeria.

Aims: The overall aim of this doctoral dissertation was twofold. First, to quantitatively examine whether and to what extent the intendedness of a woman’s most recent pregnancy is linked to subsequent contraceptive behaviors and family planning experiences. Secondly, to disentangle the influence of compositional and contextual level factors on these study outcomes. In the first paper, I investigated the extent to which pregnancy intendedness was associated with women’s stages of behavior change for contraceptive use as well as the effectiveness level of the contraceptive method choice. In the second paper, I examined the extent to which recent pregnancy intendedness was associated with the likelihood of experiencing missed opportunities (MOs) for postpartum family planning (FP) counseling. In the third paper, I aimed to identify compositional and contextual factors associated with covert contraceptive use among women who reported a previous history of either mistimed or unwanted pregnancy.

Methods: This dissertation research was completed using data from nationally representative population based cross-sectional surveys conducted in Nigeria by the Performance Monitoring for Accountability 2020 (PMA2020) project between 2016-2018. The study sample comprised nonpregnant women of reproductive age (15-49 years). Descriptive statistics were used to characterize the study samples and multilevel logistic (binary and multinomial) regression analyses were performed to quantify the magnitude of the association between pregnancy intendedness (classified as intended, mistimed, unwanted) and stages of behavior change for contraceptive use (pre-contemplation, contemplation, action), effectiveness level of contraceptive method (no method, less effective method, moderately effective method, most effective method), and postpartum FP counseling, as well as to investigate the effect of compositional and contextual- level influences on covert contraceptive use. The effect measures of association between pregnancy intention and each outcome in this dissertation research were computed as adjusted odds ratios (aOR) and 95% confidence intervals.

Results: In manuscript I, I found that approximately one in three women reported a recent unintended pregnancy with 23.1% reporting a mistimed pregnancy and 6.1% of women reporting an unwanted pregnancy. Approximately two-thirds (65.7%) of women reporting either a mistimed or unwanted pregnancy were not using a method of contraception. Further, I observed that having a recent mistimed vs intended pregnancy was associated with higher odds of being in the contemplation stage (aOR = 1.59, 95% CI = 1.13-2.22) and in the action stage (aOR = 2.17, 95% CI = 1.52-3.11). Having a recent unwanted vs intended pregnancy was also associated with being at the action stage (aOR = 1.85, 95% CI = 1.18-2.91). A recent mistimed vs intended pregnancy was associated with a significantly higher odds of using moderately effective (aOR = 1.47, 95% CI = 1.02-2.12) and most effective (aOR = 2.45, 95% CI = 1.41-4.20) contraceptive methods while a recent unwanted vs intended pregnancy was associated with higher odds of using most effective methods (aOR = 6.19, 95% CI = 2.04-18.83). In manuscript II, nearly 60% of women who were within 24 months postpartum (N = 6479), experienced MOs for postpartum FP counseling while 45% of those who visited a health facility visit in the past 12 months (N = 4194) experienced MOs for postpartum FP counseling. After adjusting for compositional and contextual level covariates (i.e., in the best fitting models), I did not observe an association between having a mistimed pregnancy and MO for postpartum FP counseling. Similarly, no association was observed between having an unwanted pregnancy and MOs (Ps > 0.05). In manuscript III, I found that approximately 62% of women with a previous unintended pregnancy – mistimed or unwanted – were not using contraceptives. Among those using a contraceptive method, approximately 12% were using them covertly (as opposed to overtly). At the individual-level, having less than secondary level of education (aOR = 5.88, 95% CI = 1.20-28.72) and not married or cohabiting (aOR = 11.29, 95% CI = 2.93-43.56) were associated with increased odds of using a contraceptive method covertly. I did not observe a significant difference in covert contraceptive use between women who had mistimed pregnancy relative to those who had an unwanted pregnancy (mistimed: aOR = 3.1, 95% CI = 0.9-11.1). At the community-level, living in a communities with average poverty levels (aOR = 6.18, 95% CI = 1.18-32.55) and exposure to FP mass media (aOR = 6.84, 95% CI = 1.62-29.11) were associated with higher odds of covert contraceptive use. Measures of variation showed a non-ignorable variability in covert contraceptive use across communities.

Conclusions: Despite the negative consequences associated with unintended pregnancy, I found most women do not use a method of contraception following an unintended pregnancy. However, experiencing a recent mistimed or unwanted pregnancy may impact women’s cognitive appraisal of the likelihood and risks associated with experiencing another unintended pregnancy, motivating them to adopt strategies to prevent a repeat unintended pregnancy. However, I also found that provider-client communication regarding family planning may be occurring less often, with providers not consistently addressing women’s prior pregnancy intendedness, which is crucial for delivering high-quality, client-centered family planning services. Additionally, some women whose last pregnancy was mistimed or unwanted may opt to use contraception without informing their partner/spouse.

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