Levels, trends and predictors of unintended pregnancy among adolescents and young women aged 15-14 in India: An analysis from NFHS-4 and 5 Survey

doi:10.21203/rs.3.rs-2367138/v1

Background

Unintended pregnancy is an important reproductive health issue among women. Little is known about the prevalence of unintended pregnancy and its associated factors among Indian adolescents and young women in India. The present study aims to determine the prevalence of unintended pregnancy, its association with sociodemographic and behavioural characteristics and identify the important determinants among female adolescents and young women aged 15–24 in India from NFHS-4 to 5.

Methods

Data from the fourth and fifth rounds of the National Family Health Survey conducted in 2015-16 and 2019–2021 are used for the analysis. Ever-married adolescents and young women of age 15–24 who have given at least one birth in the last 5 years were taken into the analysis with a finalized sample of 62,079 women in NFHS-4 and 53,635 women in NFHS-5. Univariate and bivariate analysis was used to examine the association of unintended pregnancy with the explanatory variables. Further, a binary logistic regression analysis was employed to identify the predictors of unintended pregnancy among adolescents and young women aged 15–24 from NFHS-4 to 5.

Results

The results revealed that at least seven per cent of the pregnancies during both surveys (NFHS-4 & 5) were unintended in India. The trend shows a slight increase (7.29–7.52%) in unintended pregnancy among adolescents and young women aged 15–24 from NFHS-4 to NFHS-5. Covariates like age, religion, education, region, birth in last five years, the ideal number of children, knowledge of the ovulatory cycle, heard about family planning, interaction with family planning worker, age at birth and unmet need put forth a strong influence upon unintended pregnancy in India. In contrast, factors like wealth index, media exposure, body mass index and caste were not significant predictors of unintended pregnancy in India.

Conclusions

The present study discloses that unintended pregnancy among adolescents and young women is a significant obstacle to achieving commendable reproductive health in India. The study reports important findings which can be beneficial for the policymakers and health care providers to formulate target-based programmes to reduce unintended pregnancy among the young population in India.

unintended

pregnancy

adolescents

young

NFHS

survey

India

Unintended pregnancy is an important reproductive health issue among women. It represents a major public health challenge in middle and low-income countries, affecting a woman and her family on physical, economic and social facets (1). Increased maternal and infant mortality and abortions result from unintended pregnancy among women (2). Unintended pregnancy refers to a pregnancy which occurs earlier than the desired time (mistimed) or occurs when the individuals desire no more children (unwanted) (3). Women of the reproductive age group (15–49 years) bear the risk of unintended pregnancy throughout their life (4). These unintended pregnancies have social, cultural, physical, and health repercussions for the mother and the fetus (5).

From 2010-14, an estimated 44% of pregnancies among women were unintended. However, the rate of unintended pregnancy declined tremendously by 30% in the developed world, from 64 per 1000 women aged 15–44 in 1990-94 to 45 in 2010-14. On the other hand, the unintended pregnancy rate fell by 16% from 77 per 1000 women to 65 among women aged 15–44. In developed regions, the decline in unintended pregnancy coincided with a declining abortion rate. In contrast, in developing countries, the decline in unintended pregnancy corresponded with a declining unintended birth rate. In the developed nations, 59% of unintended pregnancies ended in abortion from 2010 to 2014, compared to 55% in developing nations (6). As per the nationwide demographic and health survey data from six south Asian countries, including Bangladesh, Pakistan, Nepal, Afghanistan, Maldives and India, 19% of the pregnancies were reported as unintended, the highest in Bangladesh (28.4%) to lowest in India (11.9%) (7). In India, the latest National Family Health Survey round (NFHS-5, 2019–2021) revealed that the prevalence of unintended pregnancies remains more or less the same.

A substantial amount of research on unintended pregnancy among women has revealed that socioeconomic factors like younger age (15–19 years), poor economic background, being illiterate, and rural place of residence are important predictors of unintended pregnancies (8, 9). Women who do not use contraception and face domestic violence also influenced unintended pregnancy among women (10). Moreover, the husband's desire for more children was associated with a high risk of unintended pregnancy, while highly empowered women were associated with a low level of unwanted pregnancy (11).

Despite having the lowest prevalence of unintended pregnancy in the South Asian region, more than 10 per cent of women reporting their pregnancy as unintended stands as a significant problem in achieving the desired level of reproductive health in India. The main focus of earlier studies has always been on women of reproductive age group. Little is known about the prevalence of unintended pregnancy and its associated factors among Indian adolescents and young women in India. To the best of our knowledge, no studies have investigated the phenomenon of unintended pregnancy among young and vulnerable women. Targeted interventions are only possible when substantial studies focus on peculiar groups or targets. Therefore, the aims of the present study were to (i) determine the prevalence of unintended pregnancy among female adolescents and young women aged 15–24 in India; (ii) examine the association between sociodemographic and behavioural characteristics and unintended pregnancy and (iii) identify the important determinants of unintended pregnancy among female adolescents and young women in India.

The data used in the present study has been taken from the fourth and fifth rounds of the National Family Health Survey (NFHS) conducted in 2015-16 and 2019-21 respectively. NFHS is a large-scale nationally representative cross-sectional survey of Indian households that collects data on population, health, nutrition and other domains. All five NFHS surveys have been conducted under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India. MoHFW designated the International Institute for Population Sciences (IIPS), Mumbai, as the nodal agency for all the rounds of NFHS. Based on a two-stage stratified sampling technique, NFHS adopts a uniform sample design, which is representative at the national, state/union territory, and district levels in each survey round. A total of 664,972 households were selected for the sample, out of which 636,699 were successfully interviewed with a response rate of 98 per cent (12). The present study's analysis is limited to married women (including married, widowed, divorced and separated women) of age 15–24 who have given at least one birth in the last 5 years. The final sample size after applying the inclusion criteria for NFHS-4 and NFHS-5 was 62,079 and 53,635, respectively.

Dependent Variable

The outcome variable of the present study was pregnancy intention. Women reported whether their most recent birth was wanted at the time (planned birth), at a later time (mistimed birth), or not at all (unwanted birth) (12). At the time of the survey, women were asked the question: “At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want any (more) children at all?”. The women responded with either of the three options, i.e., Then’, ‘Later’ and ‘Not at all’. The women responded as ‘Then’ classified as wanted, ‘Later’ as mistimed and ‘Not at all’ as unwanted pregnancy (13). For analysis, mistimed and unwanted pregnancies have been clubbed to form a dependent variable unintended pregnancy (categorized as intended and unintended).

Explanatory Variables

A set of categorical variables was considered for the present study's analysis. The selection of these explanatory variables was based on several studies in the past and were categorized as socioeconomic, demographic and behavioral characteristics. The socioeconomic variables included age (categorized as 15–19 and 20–24), place of residence (categorized as urban and rural), caste (categorized as Scheduled caste, Scheduled Tribe, Other Backward Castes and others), religion (categorized as Hindu, Muslims and Others), education (categorized as No education, primary, secondary and higher education), wealth quantile (categorized as poorest, poorer, middle, richer and richest), regions (categorized as north, central, east, northeast, west and south), media exposure (categorized as No and Yes). The demographic characteristics included birth in the last 5 years (one and 2 and above), ideal number of children (categorized as 0–1, 2 and 3 and above), age at birth (categorized as less than 18 and 18 and above) and body mass index (categorized as not normal and normal). Behavioural characteristics included knowledge of the ovulatory cycle (categorized as No and Yes), heard about family planning categorized as No and Yes), interaction with a health worker about any methods of family planning (categorized as No and Yes), and unmet need (categorized as No and Yes).

Statistical analysis

The study starts with descriptive analysis by giving the profile distribution of the study participants. Bivariate analysis was used to inspect the association between unintended pregnancy and the explanatory variables in the study. The Chi-square tests identified the significance of the association. A binary logistic regression was applied in order to examine the effect of sociodemographic and behavioural factors on unintended pregnancy. All the statistical analyses were performed in STATA (version 15). The logistic regression results were presented as adjusted odds ratios (AOR) along with a 95% confidence interval. The high-risk predictors were identified on the basis of a p-value (p < 0.05).

Profile distribution of adolescents and young women

Tables 1 and 2 present the results of the univariate distribution of the study's explanatory variables and dependent variables in NFHS-4 and 5. Most of the respondents were aged 20–24 in both survey rounds. The majority of the respondents belonged to the OBC category and belonged to the Hindu religion in both NFHS-4 and 5. 75 per cent of the respondents resided in rural areas, and more than 50 per cent had secondary education in both survey periods. Most respondents belonged to the poorest and poorer wealth quantile during the survey periods. Region-wise, most respondents belonged to the eastern region of India in NFHS-4, whereas most in NFHS-5 belonged to the Western region of India. Media exposure among adolescents decreased from 78.12% in NFHS-4 to 72.34% in NFHS-5. More than 65% of adolescents and young women had given at least one birth in the last 5 years. A significant proportion of respondents reported two children as an ideal number of children one should have in both survey periods. Knowledge of the ovulatory cycle among adolescents and young women increased from 80.19% in NFHS-4 to 87.93% in NFHS-5. 60 per cent of the respondents have heard about family planning in NFHS-4, which scarcely increased to 61.01 in NFHS-5. Interaction with a health worker about family planning methods decreased significantly from 68% in NFHS-4 to 53% in NFHS-5. Unintended pregnancy showed a negligible decline from NFHS-4 (7.29) to NFHS-5 (7.52). Most respondents were above age 18 when they gave birth at both survey periods. Most of the respondents reported normal body mass index during both survey periods. Lastly, unmet need among adolescents and young women decreased drastically from 26.72% in NFHS-4 to 1.76% per cent in NFHS-5

Table 1

Percentage distribution of sociodemographic and behavioural characteristics of adolescents and young women aged 15–24, India, NFHS-4
Predictors	Frequency	Per cent
Age
15–19	6,085	9.80
20–24	55,997	90.2
Caste
SC	13,806	23.13
ST	7,012	11.75
OBC	26,689	44.71
Others	12,187	20.42
Religion
Hindu	49,640	79.96
Muslim	9,846	15.86
Others	2,596	4.18
Residence
Urban	15,494	24.96
Rural	46,588	75.04
Education
No	11,995	19.32
Primary	8,938	14.40
Secondary	36,137	58.21
Higher	5,011	8.070
Wealth Quantile
Poorest	13,478	21.71
Poorer	15,293	24.63
Middle	14,295	23.03
Richer	12,022	19.36
Richest	6,994	11.27
Regions
North	7,437	11.98
Central	14,328	23.08
East	17,679	28.48
North East	2,328	3.75
West	8,388	13.51
South	11,922	19.20
Media Exposure
No	13,584	21.88
Yes	48,498	78.12
Birth in last 5 years
One	41,657	67.1
2 and above	20,425	32.9
Ideal number of children
0–1	5,085	8.19
2	45,359	73.06
3 and above	11,639	18.75
Knowledge of the ovulatory cycle
No	12,299	19.81
yes	49,783	80.19
Heard about Family Planning
No	24,426	39.34
yes	37,656	60.66
Told by a health worker about any methods of family planning
No	28,987	68.03
Yes	13,620	31.97
Intention of last pregnancy
Intended	57,556	92.71
Unintended	4,523	7.29
Age at birth
Less than 18	12,485	20.11
18 and above	49,597	79.89
Body Mass Index
Not Normal	23,948	39.08
Normal	37,334	60.92
Unmet Need
Yes	16,587	26.72
No	45,493	73.28
Total	62,082

Table 2

Percentage distribution of sociodemographic and behavioural characteristics of adolescents and young women aged 15–24, India, NFHS-5
Predictors	Frequency	Per cent
Age
15–19	5,164	9.63
20–24	48,473	90.37
Caste
SC	13,005	25.62
ST	5,805	11.43
OBC	22,930	45.16
Others	9,032	17.79
Religion
Hindu	43,212	80.56
Muslim	8,627	16.08
Others	1,798	3.35
Residence
Urban	11,733	21.87
Rural	41,904	78.13
Education
No	7,362	13.72
Primary	5,786	10.79
Secondary	34,715	64.72
Higher	5,774	10.76
Wealth Quantile
Poorest	13,427	25.03
Poorer	13,239	24.68
Middle	11,712	21.84
Richer	9,668	18.03
Richest	5,591	10.42
Regions
North	5,352	9.98
Central	8,899	16.6
East	367	0.69
North East	9,489	17.7
West	21,389	39.9
South	8,114	15.14
Media Exposure
No	14,835	27.66
Yes	38,802	72.34
Birth in last 5 years
one	37,000	68.98
2 and above	16,637	31.02
Ideal number of children
0–1	4,016	7.49
2	40,556	75.61
3 and above	9,065	16.9
Knowledge of ovulatory cycle
No	6,473	12.07
yes	47,164	87.93
Heard about Family Planning
No	20,913	38.99
yes	32,724	61.01
Told by a health worker about any methods of family planning
No	14,278	52.15
Yes	13,100	47.85
Intention of last pregnancy
Intended	49,603	92.48
Unintended	4,032	7.52
Age at birth
Less than 18	10,346	19.29
18 and above	43,291	80.71
Body Mass Index
Not Normal	19,322	36.98
Normal	32,922	63.02
Unmet Need
Yes	946	1.76
No	52691	98.24
Total	53,637

Insert Tables 1 and 2 here

Figure 1 presents the trend of unintended pregnancy among adolescents and women aged 15–24 during NFHS-4 and NFHS-5. It shows an increase in the percentage of unintended pregnancy in ages 15–19 and 20–24 from NFHS-4 to NFHS-5. Overall, unintended pregnancy among 15–24 aged women increased from 7.29 to 7.52 per cent. Similarly, Fig. 2 shows the trend of wanted, mistimed and unwanted pregnancy among adolescents and young women in India during the two survey periods. The level of wanted pregnancy barely increased from NFHS-4 to NFHS-5, mistimed pregnancy slightly increased from 5.47 to 5.74, whereas unwanted pregnancy decreased a little from 1.81% in NFHS-4 to 1.45% in NFHS-5.

Insert Figs. 1 and 2 here

Association of sociodemographic and behavioural characteristics and Unintended Pregnancy

Tables 3 and 4 shows the per cent distribution of unintended pregnancy and sociodemographic and behavioural characteristic of adolescent and young women aged 15–24 in India in NFHS-4 and 5. It shows the association of background characteristics with unintended pregnancy in India. Factors like age, caste, religion, education, region, birth in last 5 years, ideal number of children, knowledge of ovulatory cycle, heard about family planning, interaction with family planning worker, age at birth and unmet need were significantly associated with unintended pregnancy. It was found that unintended pregnancy decreased as the age increased during both survey periods. Caste-wise, unintended pregnancy was highest among Other and SC women in both periods. Religion-wise, unintended pregnancy was higher among respondents of Other religions, followed by Hindu religion in both NFHS-4 and 5. In both surveys, women of urban residence account for a higher level of unintended pregnancy (7.84% & 7.22%). The results reveal that education and unintended pregnancy were positively associated. Unintended pregnancy increases as the education level increases among the respondents at both survey periods. Region-wise, there was a higher prevalence of unintended pregnancy in the Central region (8.98%) and North-east (8.16%) in NFHS-4.

On the other hand, a higher prevalence of unintended pregnancy in NFHS-5 was observed in the Western (8.51%) and central regions (8.39%). In both survey periods, women exposed to media showed a higher but insignificant association with unintended pregnancy. Unintended pregnancy was higher among those who had two and above births in the last 5 years in both NFHS-4 and 5 (11.67% & 11.96%). Women who reported their ideal number of children as zero to one had higher unintended pregnancies at both rounds of the survey. Women who knew about the ovulatory cycle and heard about family planning showed a significantly lower prevalence of unintended pregnancy throughout the survey periods. Women whom a health worker told about methods of family planning showed a lower prevalence of unintended pregnancy in both NFHS-4 (6.36%) and NFHS-5 (6.75%). Lastly, women with unmet need showed a higher prevalence of unintended pregnancy in both survey periods (13.44% & 17.86%).

Table 3

Prevalence of unintended pregnancy by sociodemographic and behavioural characteristics of adolescents and young women aged 15–24, India, NFHS-4
Predictors	Per cent	p-value
Age		0.004
15–19	8.36
20–24	7.32
Caste		0.000
SC	7.75
ST	6.78
OBC	7.14
Others	8.21
Religion		0.001
Hindu	7.26
Muslim	7.47
Others	8.67
Residence		0.036
Urban	7.84
Rural	7.30
Education		0.000
No	6.49
Primary	7.37
Secondary	7.62
Higher	8.52
Wealth Quantile		0.190
Poorest	7.23
Poorer	7.54
Middle	7.79
Richer	7.05
Richest	7.34
Regions		0.000
North	7.27
Central	8.98
East	7.86
North East	8.16
West	4.78
South	3.78
Media Exposure		0.349
No	7.24
Yes	7.47
Birth in last 5 years		0.000
One	5.32
2 and above	11.67
Ideal number of children		0.000
0–1	11.03
2	7.08
3 and above	7.26
Knowledge of the ovulatory cycle		0.000
No	8.50
yes	7.15
Heard about Family Planning		0.001
No	7.85
yes	7.11
Told by a health worker about any methods of family planning		0.001
No	7.26
Yes	6.36
Age at birth		0.000
Less than 18	8.97
18 and above	7.05
Body Mass Index		0.639
Not Normal	7.45
Normal	7.35
Unmet Need		0.000
Yes	13.44
No	5.08

Table 4

Prevalence of unintended pregnancy by sociodemographic and behavioural characteristics of adolescents and young women aged 15–24, India, NFHS-5
Predictors	Percent	p-value
Age		0.001
15–19	8.38
20–24	7.07
Caste		0.000
SC	7.76
ST	6.25
OBC	6.99
Others	8.46
Religion		0.000
Hindu	7.20
Muslim	6.40
Others	8.34
Residence		0.893
Urban	7.22
Rural	7.18
Education		0.002
No	6.57
Primary	6.36
Secondary	7.46
Higher	7.31
Wealth Quantile		0.615
Poorest	7.36
Poorer	7.32
Middle	7.12
Richer	7.01
Richest	6.79
Regions		0.000
North	6.88
Central	8.39
East	8.03
North East	5.95
West	8.51
South	5.78
Media Exposure		0.181
No	6.96
Yes	7.29
Birth in last 5 years		0.000
One	5.06
2 and above	11.96
Ideal number of children		0.000
0–1	9.39
2	7.1
3 and above	6.74
Knowledge of ovulatory cycle
No	9.22
yes	6.93
Heard about Family Planning		0.000
No	7.87
yes	6.75
Told by a health worker about any methods of family planning		0.000
No	7.69
Yes	5.86
Age at birth		0.000
Less than 18	8.91
18 and above	6.81
Body Mass Index		0.084
Not Normal	7.48
Normal	7.07
Unmet Need		0.000
Yes	17.86
No	7.01

Insert Tables 3 and 4 here

Factors Affecting Unintended Pregnancy among adolescents and young women

The correlates and predictors of unintended pregnancy among adolescents and young women are presented in Tables 5 and 6. Age-group of women is significantly associated with unintended pregnancy. The women in the age-group 20–24 years are at 16% and 35% lower risk of having unintended pregnancy than those in the age-group 15–19. The women of 'ST castes are 22% less likely to have an unintended pregnancy than the scheduled castes in NFHS-4, whereas caste does not have a significant relationship with unintended pregnancy in NFHS-4. The women of 'Other' religion are nearly 37% and 68% significantly more likely to have an unintended pregnancy than those of the Hindu religion in both NFHS-4 and 5. Women residing in rural residence were less significantly likely to have unintended pregnancy in both NFHS-4 [AOR: 0.87, CI: 0.80–0.95] and 5 [AOR: 0.98, CI: 0.83–1.13]. Education seemed to be positively associated with unintended pregnancy. With the increasing level of education among women, a remarkable increase in unintended pregnancy was observed. Women having higher education are 52% and 35% more likely to have unintended pregnancies in both rounds of the survey. Wealth was not significantly associated with unintended pregnancy. In NFHS-4, women from Central and Southern regions were 33% significantly more likely and 53% less likely to have unintended pregnancy, respectively. On the other hand, in NFHS-5, women from the western region were more likely to have unintended pregnancies [AOR: 1.59, CI: 1.34–1.88]. The likelihood of experiencing unintended pregnancy increases by nearly 2.40 and 2.71 times if the women had given birth to two or more children in the last 5 years in NFHS-4 and 5 both. Women reporting 3 and above children as the ideal number were 52% and 68% less likely to have an unintended pregnancy than those reporting one child as the ideal number. Women who knew about the ovulatory cycle showed a lower likelihood of unintended pregnancy in NFHS-4 [AOR: 0.83, CI: 0.75–0.90] and NFHS-5 [AOR: 0.75, CI: 0.65–0.85]. Women whom a health worker told about methods of family planning showed significantly 11% and 15% lower likelihood of unintended pregnancy than their counterparts in NFHS-4 and 5. Unmet need was significantly associated with unintended pregnancy. The women with no unmet need were 83% and 70% less likely to have an unintended pregnancy than those with unmet need in NFHS-4 and 5, respectively.

Table 5

Binary Logistic Regression of factors associated with unintended pregnancies among adolescents and young women aged 15–24 in India, NFHS-4
Predictors	Adjusted Odds Ratio	P > z	[95% Conf. Interval]
Age
15–19	1
20–24	0.84	0.001	0.760	0.932
Caste
SC	1
ST	0.78	0.000	0.699	0.869
OBC	0.91	0.031	0.838	0.991
Others	1.05	0.354	0.948	1.162
Religion
Hindu	1
Muslim	1.01	0.000	0.929	1.121
Others	1.37	0.000	1.207	1.552
Residence
Urban	1
Rural	0.87	0.001	0.806	0.950
Education
No education	1
Primary	1.12	0.052	0.999	1.245
Secondary	1.27	0.000	1.162	1.394
Higher	1.52	0.000	1.321	1.754
Wealth
Poorest	1
Poorer	1.02	0.000	0.928	1.121
Middle	1.07	0.224	0.961	1.186
Richer	0.93	0.231	0.821	1.049
Richest	0.86	0.039	0.740	0.992
Regions
North	1
Central	1.33	0.000	1.205	1.458
East	1.10	0.078	0.990	1.219
North East	1.05	0.484	0.919	1.196
West	0.62	0.000	0.533	0.726
South	0.47	0.000	0.407	0.550
Media
No	1
Yes	1.02	0.691	0.934	1.109
Birth in last 5 years
1	1
2+	2.40	0.000	2.219	2.591
Ideal number of children
1	1
2	0.57	0.000	0.506	0.652
3 and above	0.48	0.000	0.421	0.556
Knowledge of ovulatory cycle
No	1
Yes	0.83	0.000	0.756	0.900
Heard about family planning
No	1
Yes	0.94	0.136	0.872	1.019
Told by a health worker about methods of family planning
No	1
Yes	0.89	0.006	0.817	0.967
Unmet need
Yes	1
No	0.17	0.000	0.158	0.191
Body Mass Index
Not Normal	1
Normal	1.02	0.665	0.937	1.107
Age at birth
Less than 18	1
18 and above	0.92	0.132	0.826	1.025

Table 6

Binary Logistic Regression of factors associated with unintended pregnancies among adolescents and young women aged 15–24 in India, NFHS-5
Predictors	Adjusted Odds Ratio	P > z	[95% Conf. Interval]
Age
15–19	1
20–24	0.65	0.000	0.559	0.760
Caste
SC	1
ST	0.86	0.077	0.725	1.016
OBC	0.93	0.295	0.821	1.061
Others	1.08	0.366	0.913	1.280
Religion
Hindu	1
Muslim	0.83	0.034	0.694	0.986
Others	1.68	0.000	1.393	2.019
Residence
Urban	1
Rural	0.98	0.747	0.837	1.137
Education
No education	1
Primary	0.98	0.846	0.803	1.197
Secondary	1.29	0.001	1.105	1.498
Higher	1.35	0.008	1.083	1.695
wealth
Poorest	1
Poorer	0.97	0.638	0.844	1.110
Middle	1.00	0.960	0.853	1.163
Richer	0.96	0.686	0.804	1.154
Richest	0.85	0.175	0.665	1.077
Regions
North	1
Central	1.05	0.719	0.800	1.382
East	1.12	0.498	0.810	1.545
North East	0.93	0.440	0.767	1.122
West	1.59	0.000	1.341	1.886
South	0.95	0.575	0.788	1.141
Media
No	1
Yes	1.19	0.008	1.047	1.349
Birth in last 5 years
1	1
2+	2.71	0.000	2.442	3.008
Ideal number of children
1	1
2	0.59	0.000	0.499	0.699
3 and above	0.42	0.000	0.348	0.514
Knowledge of ovulatory cycle
No	1
Yes	0.75	0.000	0.652	0.854
Heard about family planning
No	1
Yes	0.85	0.003	0.757	0.945
Told by a health worker about methods of family planning
No	1
Yes	0.78	0.000	0.704	0.863
Unmet need
Yes	1
No	0.30	0.000	0.245	0.358
Body Mass Index
Not Normal	1
Normal	0.91	0.077	0.820	1.010
Age at birth
Less than 18	1
18 and above	0.86	0.028	0.748	0.984

Insert Tables 5 and 6 here

Unintended pregnancy among adolescents and young women appears to be a significant public health concern. It hampers a woman's physical, social and emotional well-being and has deleterious outcomes for her family and children. The present study examines the levels, patterns and determinants of unintended pregnancy among women aged 15–24 in India using the data from two periods, i.e., NFHS- 4 and NFHS-5. The prevalence of unintended pregnancy can be minimized by scrutinizing the risk factors among this vulnerable and young age group of women, which can lead to the development of more focused and target-oriented interventions.

The results revealed that at least seven per cent of the pregnancies during both surveys were unintended in India. The trend shows a slight increase (7.29–7.52%) in unintended pregnancy among adolescents and young women aged 15–24 from NFHS-4 to NFHS-5. Despite the initiatives launched by the government of India, such as Rashtriya Kishor Swasthya Karyakram (RKSK) launched in 2014, no significant decline has been observed in unintended and teenage pregnancy among adolescents and young women. In this initiative, Adolescent Friendly Health Clinics were made to educate the community about preventive and curative reproductive health services. According to a recent article, poor implementation of RKSK, along with pandemic-induced problems like loss of livelihood, lack of information among adolescents, and worsening mental health conditions, have made the situation more troublesome (14). Factors like age, religion, education, region, birth in last five years, the ideal number of children, knowledge of the ovulatory cycle, heard about family planning, interaction with family planning worker, age at birth and unmet need were significantly associated with unintended pregnancy. In contrast, factors like wealth index media exposure, body mass index and caste were not significant predictors of unintended pregnancy in India.

Adolescents of the younger age group (15–19) were likelier to have unintended pregnancies than the older age groups. This finding goes in tune with previous studies, which also stated that younger women are more susceptible to unintended pregnancy (13, 15). Religion has been an established predictor of unintended pregnancy in the past. Studies hold the view that unintended pregnancy is more common among Muslim women than Hindu women (16, 17). A plausible explanation can be seen through differences in principles among women along the lines of religion (18). On the contrary, the present study reveals that women from other religions (Christian/ Sikh/ Buddhist) were more likely to experience unintended pregnancy than their Hindu counterparts. It showed less likelihood of unintended pregnancy among Muslim women as well. Some studies align with this finding that Muslims are less likely to experience unintended childbearing than Christians and Hindus (13). The wealth index showed no statistically significant association with unintended pregnancy, similar to a study based in Pakistan (19).

Education of women, which is an important factor in determining the fertility behaviour of women, showed no significant effect on unintended pregnancy in the present study. In fact, with the increasing level of education among women, a remarkable increase in unintended pregnancy was observed. Few studies in conducted in Bangladesh, Nepal and Japan have aligned results with our study (20–22). Place of residence played an important role in defining unintended pregnancy in India. Women from urban areas were more prone to experience unintended pregnancy. These findings go in tune with another previous study which revealed that living in rural areas decreases the probability of having an unintended pregnancy compared with living in urban areas. It also stated that contraceptive services in urban areas might be hampered due to heavy rural-to-urban migration (23). Another plausible reason could be that the incidences of unintended pregnancy are underreported by women in rural areas (20).

Regional variation played a significant role in unintended pregnancy among adolescents and young women in India. Women from the Central and Western regions were more likely to experience unintended pregnancy, whereas Southern regions showed the lowest preponderance of unintended pregnancy. The regional variation in India's demographic and health outcomes is influenced by a composite set of social, economic, cultural and political factors, hence the variation in unintended pregnancy (24). These significant differences in pregnancy intention by region depict a need for targeted and improved family planning services in India's Central and Western regions (20). The unmet need among women is a major contributing factor to unintended pregnancy. Prior research also suggests that women with unmet needs are at times higher risk of experiencing unintended pregnancy than those who met their contraception needs (25).

Knowledge of the ovulatory cycle and family planning methods were major determinants of unintended pregnancy among women. This finding suggests that inadequate awareness and education towards reproductive health and family planning matters can put a woman at risk of unintended pregnancy (26). Likewise, women whom a health worker told about family planning methods showed a significantly lower likelihood of unintended pregnancy than their counterparts. With the introduction of female community health workers, called the Accredited Social Health Activists (ASHAs) at the village level under the National Rural Health Mission (NRHM), in 2005, barriers between women and health workers have been reduced. They are well positioned to play a vital role in guiding women about unwanted pregnancies and safe abortion services, educating them about family planning methods and reproductive health in general (27). Lastly, higher parity was associated with a higher risk of unintended pregnancy. Women who have given birth to two or more children in the last 5 years in were showed more likelihood of unintended pregnancy among adolescents and young women (17, 28).

The present study, through its findings, states that unintended pregnancy among adolescents and young women is a significant obstacle to achieving commendable reproductive health in India. The study reports important findings which can be beneficial for the policymakers and health care providers to formulate target-based programmes to reduce unintended pregnancy among the young population in India. It is imperative to tackle this problem among the young population so that their social and reproductive life is not affected throughout their life course. Unintended pregnancy is significantly linked to health hazards like abortion, infant and maternal mortality and even mental health problems among women. Thus, it becomes significant to formulate unique interventions by considering all the factors identified in this study. Efforts should be made to create awareness about family planning and other reproductive health topics among adolescents. Adolescents' interaction with family planning workers should be improved to reduce adverse health outcomes among this young and vulnerable section of the population in India.

NFHS

National Family Health Survey

MoHFW

Ministry of Health and Family Welfare

IIPS

International Institute for Population Sciences

SC

Scheduled Caste

ST

Scheduled Tribe

OBC

Other Backward Caste

AOR

Adjusted Odds Ratio

CI

Confidence Interval

RKSK

Rashtriya Kishor Swasthya Karyakram

ASHA

Accredited Social Health Activist

NRHM

National Rural Health Mission

Ethics approval and consent to participate: The study is based on a secondary dataset; hence, no ethical approval from any institutional board was required. The Institutional Review Board of the International Institute for Population Sciences approved the study and its data collection. It also ensured the confidentiality of the participants was conserved, and informed consent was sought from the respondents during the survey.

Consent for publication: Not applicable

Availability of data and materials: The data set used in the present study is available in public domain on the official website of DHS https://dhsprogram.com/ and IIPS https://iipsindia.ac.in/content/data-request. However, in order to utilize the datasets, one has to place a request for the same and after getting the access, the datasets can be downloaded easily from the website. In special cases, the datasets can be made available from the corresponding author on reasonable request too.

Competing interests: The authors declare no conflict of interest.

Funding: There was no funding received for this study by any organisation or individual whatsoever.

Authors' contributions: H.S. did all the analysis and wrote the main manuscript text. H.S prepared all the tables and figures. S.K.S. guided and supervised the entire process. Both the authors reviewed the final version of the manuscript.

Acknowledgements: Not applicable

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No competing interests reported.

Levels, trends and predictors of unintended pregnancy among adolescents and young women aged 15-14 in India: An analysis from NFHS-4 and 5 Survey

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Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background And Rationale

Data And Methods

Dependent Variable

Explanatory Variables

Statistical analysis

Results

Profile distribution of adolescents and young women

Association of sociodemographic and behavioural characteristics and Unintended Pregnancy

Factors Affecting Unintended Pregnancy among adolescents and young women

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1