In a nationally representative sample of Rwanda women of reproductive age, we found that exposure to high-risk fertility behaviors was positively associated with an unintended pregnancy. This association was independent of potential confounders that include marital status, education, employment status, place of residence, and household wealth index. Our results contribute to the emerging data on negative health outcomes of exposure to high-risk fertility behavior particularly in low and middle income countries like Rwanda [10, 11, 13], suggesting that high-risk fertility behavior exposure is a risk factor for unintended pregnancies. Given the cross-sectional design of the current study, we cannot confirm a causal relationship between high-risk fertility behavior and unintended pregnancies.
The current study indicated that nearly half of reported unintended pregnancy was observed in women who are not in a relationship. The findings were congruent with reports from previous studies conducted in eastern Africa which revealed a significant association between unintended pregnancy and marital status [17, 18]. An analysis of the Kenya Demographic and Health Survey (KDHS) 2014 indicated that the probability of married women of getting unintended pregnancy was 28% lower compared to those who were single [19], whereas in Tanzania unmarried women were 2.24 times more likely than married women to have experienced unintended pregnancy and 4.63 times more likely than married women to have had an unwanted pregnancy [18]. Similarly, in Malawi, single women were more likely than women in the union to report that their pregnancy had been unwanted (25% vs. 20%) (20). A common belief is that unmarried women are more likely to have sexual intercourse for reasons other than having children. Unmarried women may also have difficulties related to access to contraceptives because of shame associated with procuring contraceptives [7].
In the current study, we did not find significant differences in the prevalence rates of unintended pregnancy by employment status which is contrary to other previous studies which revealed that most unintended pregnancies were among unemployed women [21, 22]. Furthermore, previous research has also found a significant association between mother’s education level, wealth index, and place of residence, and pregnancy intention [23, 24]. However, in the current study, we did not find an association between these variables and pregnancy intention. Our findings suggest that socioeconomic factors may play a limited role in explaining unintended pregnancies in Rwanda. Educating women about pregnancy risks and contraceptive counseling may be more relevant to reduce unintended pregnancies among Rwandan women.
In this study, women who engaged in either single high–risk fertility behavior (52.4%) or multiple high–risk fertility behaviors (57.3%) had unintended pregnancies, which corroborates the reports from other studies conducted in sub-Saharan Africa [20, 23]. A study from Malawi revealed that age, the ideal number of children, and the age at first marriage significantly influenced the intention to get pregnant. The probability of having current pregnancy as unintended was higher when the age of women was higher [20]; while another study conducted in Tanzania indicated unintended pregnancy was most likely to occur in younger aged women who might have limited knowledge and skills for pregnancy control [18]. Additionally, women who had 3 or more children were more likely to experience unintended pregnancy than those with 2 or fewer children [7, 20, 22]. For women who have attained the desired number of children, lack of counseling, and provision of postpartum contraceptives contributes to unintended pregnancies [7].
Other studies have also reported an association between exposure to high-risk fertility behaviors and unintended pregnancies [18, 25, 26]. Findings from these studies were consistent with the results of the current study, although these studies assessed each risk factor separately. This suggests, in part, that mother’s age, birth intervals, and parity contribute in one way or another to pregnancy intention. A mother’s age has previously been linked to unintended pregnancies [18, 25]. Other studies have identified birth interval as an important predictor of unwanted pregnancies [27, 28]. Another study in Botswana has found an association between parity and unintended pregnancies [4].
This study must be considered with limitations in mind. First, the study was cross-sectional which precludes causal interpretation. Second, the sensitive nature of the question related to pregnancy intention, social desirability, and recall bias may have introduced measurement error and therefore misclassification bias. Third, not all predictors of unintended pregnancies that were captured in the 2014-15 RDHS. The current study’s primary strength is the large, representative sample size of Rwandan women of reproductive age. The availability of several variables in the 2014-15 RDHS also allowed us to adjust for potential confounders further strengthening the study. Efforts by the DHS program to collect high-quality data ensures the reliability and accuracy of findings.