Correlates of mistime pregnancy and unmet need for family planning among women of reproductive age in Sandema, Ghana.

Background: Universally, an estimated 80 million unintended pregnancies comprising both mistimed and unwanted pregnancies are recorded yearly, but only half of women at risk of a mistimed pregnancy use contraceptives. In developing countries, over 100 million females have unmet need and national surveys in Ghana indicate a 29% unmet need rate. Methods: A cross-sectional community based study was used, involving the use of multi-step cluster sampling methods in selecting 300 women of reproductive age. The study was quantitative in nature, using structured interviewer administered questionnaires. Results: More than half (66%) of the women in reproductive age still had unmet need, 71% were currently pregnant and 36% confirmed ever having a mistimed pregnancy. Overall, 53% of the women confirmed never communicating on family planning issues with their partners, a little below half (45%) of the respondents took their own health care decisions and 79% ever received family planning services from a health professional. Factors related to unmet need included mistimed pregnancy, level of education, preferred birth/pregnancy interval, communication between partners and the autonomy to spend self-earnings. Conclusion: Considering that high rates of unmet need results in mistimed pregnancy, improved policies around the influence of unmet need on mistimed pregnancies are needed.

understand fertility and to promote woman's ability to determine when to have children (Adhikari, Soonthorndhada, & Prasartkul, 2009). Globally, an estimated 80 million unintended pregnancies, both mistimed and unwanted, occur each year (Tebekaw, Aemro, & Teller, 2014). Arega and colleagues (2016), defined unintended pregnancy as a mistimed, unplanned or unwanted pregnancy at the time of conception. Each year, in the developing world, only about half of the women at risk of experiencing mistimed pregnancy use a method of contraception (Fotso, Izugbara, Saliku, & Ochako, 2014). This leads to over 100 million female having unmet need in developing countries (Relwani et al., 2015). Unmet need is termed as the discrepancy between a woman's reproductive intentions and her birth control practices (Akanksha, Nandkeshav, Kalpana, Vijay, & Mohan, 2014; Letamo & Navaneetham, 2015). Many women continue to have unmet need for FP as a result of various factors (Wulifan, Brenner, Jahn, & Allegri, 2016). In addition, married women of reproductive age group have unmet need for contraception, inability to use family planning methods to prevent or limit pregnancy despite the interest of practicing it (Mekonnen & Worku, 2011). The situation has existed in the last decade, with contraception prevalence being stagnant and the increase of unmet need occurring (Ayuningtyas, 2016). Previous studies in Pakistan revealed fear of side effects, spousal communication, cultural and social acceptance as the decisive obstacles to decreasing unmet need among women of reproductive age (Hameed, Azmat, Bilgrami, & Ishaqe, 2011).
In Ghana, national surveys observed that a large number of women have an unmet need for family planning, as the acceptor rate for family planning services remains low (Paschal & Matthew, 2015). The Ghana Demographic Health Survey reports thirty percent of currently married women have an unmet need for family planning, with 17 percent having an unmet need for spacing and 13 percent having an unmet need for limiting (GSS et al., 2015). The situation of unmet need is of important concern in Ghana and yet very few studies have been undertaken on the correlates of mistimed pregnancies and unmet need for family planning (Eliason, Baiden, Yankey, & Asare, 2014), and there is a dearth of information on the relationship between unmet need and mistimed pregnancy. The objective of this study was to establish the relationship between unmet need and mistimed pregnancy in Ghana.

Methodology
Study design area, population, and inclusion criteria A cross sectional community based study was conducted targeting women of childbearing age (15 years to 45 years) in Sandema in the Builsa North District of the Upper East Region of Ghana. The study involved only quantitative data collection methods and excluded women who were not within child bearing age. The selection of participants involved a multi-step sampling technique. For the purpose of this study, women with an unmet need for family planning were defined as those who have had a recent delivery, thus presumed to be fecund, and report not wanting any more children at all or wanting to delay the birth of their next child; but not using any method of contraception (Pasha et al., 2015). The data were collected using a pretested and validated questionnaire and analysed using the Statistical Package for Social Sciences (SPSS version 20).

Sampling technique and Sample size determination
A cross-sectional survey was used and the study considered women with child bearing age as the sampling unit. Sandema is the district capital of the Builsa North District and the study used a systematic sampling technique in sampling 314 out of 4,941 houses. The total number of houses in the district (4,941) was divided by the estimated sample size (314) and a random number (3) was generated between 1 and 15 as a starting point. At the household level, simple random sampling was used in selecting respondents. Women were made to select pieces of papers on which "yes" and "no" were written. Any woman who selected yes, was invited and interviewed until the sample size was reached. Sample size was calculated considering the 2015 unmet need rate of the region (26.5%), a confidence interval of 95% and threshold of error at 5%. The sample size for this study was calculated as follows: n = (Z 2 × PQ)/d2, where n represents the desired sample size, Z is the normal standard deviate, whose value at 95.0% confidence level is 1.96, P = current unmet

Outcome measurement
For the purpose of this study, a woman was considered to have an unmet need if she was pregnant or at the post-partum stage but reported that her pregnancy was not wanted at that time or she was fecund but wanted to stop child birth or delay the next pregnancy but was not using any contraceptive methods. Again, respondents were asked if they wanted to be pregnant at the time of conception. If such women considered the pregnancy to have come at the wrong time, then she was considered to have an unmet need. Women who had hysterectomy, or attained menopause or self-reported fecundity were considered to be fecund. The study numerator did not include women who had successfully used natural family planning to prevent or delay pregnancy for the past five years or whose husbands were away for a considerable period but later wanted a child or women who had children less than six months of age.

Data collection
A structured questionnaire was developed and administered to participants. The consent forms and data collection instruments were interpreted to respondents in their preferred local language if they could not understand the English language.
Prior to the data collection, supervisors and data collectors were given three days intensive training on the aim of the study, procedures and data collection techniques. Research assistants were also trained on ensuring participant's confidentiality and handling of non-responses. Once a woman was considered eligible, she was invited orally to participate in the study. All data collectors pretested the questionnaire on 50 respondents who were living in the Navirango central of the same region, which has similar demographic characteristics as Sandema district.

Data analysis
Data was entered into Statistical Package for Social Sciences for analysis and data cleaning was done prior to analysis. The analysis produced descriptive statistics on demographics and other factors that were assessed. Frequency and percentage tables were formed to give a better understanding of the results. Uni-variate logistic regressions were also performed to test associations between various variables, considering a significant p < 0.05.

Results
Background attributes of respondents demographic characteristics indicates that majority of the respondents (37%) were between the ages of 25 and 29 and the least group (ages [30][31][32][33][34] was only 17% of the sampled population. In addition, 32% were senior high school graduates, 14% had completed tertiary education and 16% were uneducated. A little below half (47%) were self-employed, 31% were unemployed and one in every three of them worked at both public and private sectors. Majority of them were Christians (86%), 13% were Muslims, while four respondents (1%) were African Traditional Religious believers. More than half (71%) of the respondents were urban dwellers, while 29% were rural dwellers. More than half (66%) of the women in reproductive age still had unmet need, 71% were currently pregnant and 36% confirmed ever having a mistimed pregnancy (Table 1).  In testing the associations between respondents' characteristics and unmet need, the results indicate that respondents' level of education (p < 0.030), ever having a mistimed pregnancy (p < 0.033) and desired pregnancy/birth interval (p < 0.022) were all statistically significant and related to respondents' unmet need. Aside this, all other background characteristics did not have any statistical relationship with unmet need (Table 3).

Discussion
The study indicates that although women and their partners had positive perception towards family planning (81%), unmet need among women was still high (66%).
Elsewhere in Senegal, Hindin et al., (2015), also found as high as 70% of women with unmet need, as well as Chebet et al., (2015). Reasons such as limited access to family planning services, poor family planning education and counselling, perception about side effects associated with contraceptives could account for this shortfall in translating perception into practice. Meanwhile other regional surveys in Ghana recorded low unmet need, contrary to findings of this study (Eliason et  partners in the current study never approved the use of family planning. This is possible with the reason that traditional, cultural and religious limitations could influence partner decisions on approving family planning. However, this did not determine the unmet need of respondents, contrary to studies in Ethiopia where non-partner approval of contraceptive use still led to reduction in unmet need (Arega et al., 2016). In the current study, reasons such as lack of autonomy in decision making to spend self-earnings, education and interest in birth spacing could determine the unmet need of respondents of this study.
Previous studies have cited working status and place of residence as significant determinants of a woman's unmet need (Begum, Nair, Donta, & Prakasam, 2014), contrary to findings of this study. Considering that work status and place of residence are potential access barriers to family planning services, it is possible for these factors to determine the mistimed pregnancy rate of respondents.
Consequently, the study reported a high unmet need rate with low mistimed pregnancy (9.4%). This is contrary to findings by Kennedy et al., (2013) who reported that more than half of child birth were due to mistimed pregnancies.

Ethical and consent issues
The ethical clearance for this study was granted by the ethical review board of Research Web Africa and University of Ghana review board. Written informed consent was obtained from all participants after the study protocol was explained to them. Voluntary participation of participants was assured and no benefits were given to participants who took part in the study. Both signature and thumbprint acceptance of consent was granted by the Ethics Review Board and participants were invited orally to consent and participate in the study. Face to face interviews were conducted and researchers ensured privacy and confidentiality during interviewing process.