Abstract
BackgroundIt is unclear whether unintended pregnancies are associated with adverse outcomes. Data are predominantly from high-income countries and have methodological limitations, calling the findings into question. This research was designed to overcome these limitations and assess the relationships between pregnancy intention and miscarriage, stillbirth, low birthweight, neonatal death and postnatal depression in a low-income country.MethodsThe pregnancy intention of 4,244 pregnant women in Mchinji District, Malawi, was measured using the validated Chichewa version of the London Measure of Unplanned Pregnancy (LMUP). Women were re-interviewed postnatally to assess pregnancy outcome. Postnatal depression was assessed using the WHO’s Self-Reporting Questionnaire. Multivariable regressions were conducted, with the choice of confounders informed by a pre-existing conceptual epidemiological hierarchy.ResultsPlanned pregnancies are associated with a reduced risk of any (adjusted RR 0.90 [95%CI 0.86, 0.95]) or high symptoms of depression (adjusted RR 0.76 [95%CI 0.63, 0.91]) compared to unplanned pregnancies in rural Malawi. There was no relationship between pregnancy intention and the composite measure of miscarriage, stillbirth, low birthweight and neonatal death. There was some evidence that greater pregnancy intention was associated with reduced adjusted risk of stillbirth (0·93 [95%CI 0·87, 1·00]).ConclusionOur study is the first to use a psychometrically valid measure of pregnancy intention, and to do so antenatally. As pregnancy intention increases, the risk of postnatal depression and, possibly, stillbirth decreases. This suggests a new, clinical use for the LMUP; identifying women antenatally who are at risk of these adverse pregnancy outcomes.
Highlights
Unintended pregnancies may pose an increased risk to both mother and baby but the evidence on this is inconclusive [1], largely due to the methodological problems faced in the investigation of relationships between pregnancy intention and maternal and child outcomes
We investigated transformations, including box-cox for the Self-Reporting Questionnaire (SRQ) score and fractional polynomials for the antenatal London Measure of Unplanned Pregnancy (LMUP) score, but the distribution of the resulting residuals still violated the assumptions of linear regression so that this method was not used
Having grouped the antenatal LMUP score into the recognised categories of unplanned, ambivalent and planned, we can see from our analyses that there is a suggestion of a doseresponse relationship between the level of pregnancy intention and the risk of any symptoms of postnatal depression in both the uni- and multi-variate models (Tables 2 and 3)
Summary
Unintended pregnancies may pose an increased risk to both mother and baby but the evidence on this is inconclusive [1], largely due to the methodological problems faced in the investigation of relationships between pregnancy intention and maternal and child outcomes. Most estimates of the levels of unintended pregnancy in low-income countries are derived from surveys such as the Demographic and Health Survey (DHS) This asks ‘At the time you became pregnant did you want to become pregnant did you want to wait until later, or did you want to have no (more) children at all?’. The ensuing conceptual framework guided the development of items which were piloted, fieldtested and psychometrically evaluated to finalise the content of the LMUP This groundwork and measure development methodology mean that the LMUP should be a more accurate and valid way of measuring pregnancy intentions. This research was designed to overcome these limitations and assess the relationships between pregnancy intention and miscarriage, stillbirth, low birthweight, neonatal death and postnatal depression in a low-income country.
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