Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.spe2 São Paulo Dec. 2011
Pregnancy planning: prevalence and associated aspects*
Planificación del embarazo: prevalencia y aspectos asociados
Ana Luiza Vilela BorgesI; Fernanda Bigio CavalhieriII; Luiza Akiko Komura HogaIII; Elizabeth FujimoriIV; Luís Ricardo BarbosaV
IRN. Ph.D. Professor of the Collective Health
Nursing Department, School of Nursing, University of São Paulo. São Paulo, SP,
IIRN, Marília City Adminsitration. Marília, SP, Brazil
IIIRN. Associate Professor, Maternal-Child and Psychiatric Nursing Department, School of Nursing, University of São Paulo. São Paulo, SP, Brazil
IVRN. Associate Professor, Collective Health Nursing Department, School of Nursing, University of São Paulo. São Paulo, SP, Brazil
VMathematician, School of Nursing, University of São Paulo. São Paulo, SP, Brazil
The aims were to know the prevalence of and associated aspects to the planned pregnancy. Using the Brazilian version of the London Measure of Unplanned Pregnancy, we classified the pregnancy of 126 women who had a positive urine pregnancy test in primary health centers in the city of Marília, São Paulo. The prevalence of planned pregnancy was 33.3% [25.2%-42.3%]. We found that age, partners age, living with a partner, having a previous pregnancy and a previous abortion or miscarriage were positively associated to the planning of the pregnancy. We conclude that planning a pregnancy is not frequent yet and is mainly determined by personal and relational contexts of a woman's life as well as by their reproductive history and not simply by contraception use or schooling, as it has been traditionally considered.
Descriptors: Contraception; Pregnancy; Sexual and reproductive health
Se objetivó estimar la prevalencia de embarazo planificado y analizar los aspectos asociados a él. El embarazo planificado fue evaluado por London Measure of Unplanned Pregnancy, versión brasileña. Fueron estudiadas 126 mujeres que se presentaron en unidades básicas de salud de Marília, São Paulo, para confirmación de gravidez, con resultado positivo. La prevalencia de embarazo planificado fue 33,3% [25,2%-42,3%]. Los aspectos asociados positivamente al embarazo planificado fueron: edad, edad del compañero, cohabitación con el compañero, haber estado embarazada anteriormente y haber experimentado un aborto anterior. El planeamiento del embarazo aún no es un evento frecuente y está determinado, sobre todo, por el contexto personal y afectivo de las mujeres, así como por su trayectoria reproductiva; y no simplemente por el uso de métodos anticonceptivos o nivel de escolaridad, como tradicionalmente se ha pensado.
Descriptores: Anticoncepción; Embarazo; Salud sexual y reproductiva
More than a decade has passed since the sexual and reproductive rights have been defined at a global level, with full support from the Brazilian government, but several gaps still exist surround the consolidation of these rights in our society. Undoubtedly, the issues regarding reproductive planning appear as important challenges, mainly because there is a rather long course to pursue between what is recommended in the promotion of care and sexual and reproductive health and what is actually experienced by Brazilian women in a reproductive age.
Although experiencing an undesired or unplanned pregnancy is a situation present in the life of Brazilian women, even with the increased amount of information and improved accessibility to contraceptive methods, the single national source of information about pregnancy planning is the National Demographics and Health Survey (Pesquisa Nacional de Demografia e Saúde - PNDS), that uses the Demographic Health Survey(1) questionnaire, conducted in 79 developing countries. In its standard instrument, it performs an indirect assessment of the planning of the current pregnancy or one that occurred up to five years before the interview through one single question: In the pregnancy (OF NAME), did you want a child at that time, did you want to wait longer or not have any more children?(1).
The PNDS survey, performed in 2006, found that only 54% of the births that occurred in the five-year period before the study were actually wanted, even considering the high prevalence of the use of modern birth control methods in the country(1).
At a first view, it appears that intentionality, the desire or planning of a pregnancy are synonymous(2). Actually, the desire and intention to become pregnant are elements that comprise the planning of a pregnancy(3-4), mainly because the desire is considered a feeling that does not necessarily conduct to an action, and, therefore, the intention is closely related to the personal context, such as the support from the partner and their position at work, which can trigger one or more initiatives to become pregnant(3). Planning, on the other hand, concerns the behavioral domain, because it includes adopting measures centered on conception(3) and can only exist as long as there is the desire and/or the intention, regardless of the intensity(4-5).
Knowing and measuring the unplanned pregnancy is essential to assign a new direction to the actions aimed at sexual and reproductive in the primary health care setting. This is justified because it is known that women who face an unplanned pregnancy are more prone to consuming less folic acid than the recommended amount, both before and after the pregnancy, smoking during pregnancy, reporting postpartum depression, starting prenatal care after the first trimester, terminate the pregnancy, among other problems(3,5-6). Therefore, the objective of this study was to estimate the prevalence of planned pregnancies and analyze its associated aspects.
This cross-sectional study was performed with 126 women subjects aged between 18 and 42 years, users of Family Health Strategy units in the city of Marília, São Paulo state. These women were selected between January and June 2010 when they sought the health service to confirm they were pregnant. After taking the immunological test, which verifies the human chorionic gonadotropin in the urine to diagnose the pregnancy, women with positive tests were invited to participate in the study. The exclusion criteria were their not knowing how to read or write, because the questionnaire was self-administered, and being younger than 18 years of age, due to the need to obtain the guardians' authorization for the adolescent to participate.
To classify the pregnancy planning, the Portuguese version of the London Measure of Unplanned Pregnancy (LMUP)(7-8) was used. The LMUP is a short and self-administered instrument, consisting of six items that comprise one single domain: the pregnancy planning. The items refer to the use of contraceptive methods in the month the pregnancy occurred; on the time when the pregnancy occurred; the intention to become pregnant; the desire to become pregnant; a previous talk with the partner about having children; and, finally, the measures taken to prepare for a pregnancy.
It is a valid measure and practicable for any type of pregnancy, regardless of its outcome, either birth or miscarriage/abortion. The score it obtained by adding the points, which range between 0 and 2 for each item (the respondents should not be allowed to see the item's scores), with a total maximum of 12 points. The criterion indicated by the authors of the instrument is that the higher the score, the greater the indication that it refers to a planned pregnancy. Therefore, they suggest the segmentation of the points into at least three groups (unplanned pregnancy); 4-9 points (ambivalent regarding the pregnancy planning); and 10-12 points (planned pregnancy).
This way, all women whose scores were equal to or greater than 10 points were classified as having planned their pregnancy. The women also filled in an instrument about their sociodemographic characteristics and reproductive history.
The data were processed with the Statistical Package for the Social Sciences (SPSS) 19.0, and described through total and relative frequency, mean, standard deviation, minimum and maximum. The categorical variables were compared using the chi-square test for the difference of proportions and the continuous quantitative variables were compared using the Mann-Whitney non-parametric test.
The study project was approved by the Research Ethics Committee at the University of São Paulo School of Nursing (process number 858/2009). Approval from the Municipal Health Department was obtained to apply the instrument among the women users of primary health care services.
The 126 women with a positive pregnancy test, who agreed to answer the questionnaire were, in average, 24.6 years old (sd = 6.2) and 10.5 years of education (sd = 2.4). Most of them lived with a partner (72.2%) and were unemployed (67.4%). For half of them, that was their first pregnancy (51.6%). All other sociodemographic and reproductive characteristics are listed in Table 1.
Table 2 shows that 65.1% of the women were not using any contraceptive method. For 47.6% of the women, the pregnancy occurred at a wrong or not quite the right time in their lives, and 34.9% did not intend to get pregnant. A considerable part of the sample revealed they did not want a child at that time (19.0%). It is observed that only a little more than half the women had talked with their partner and agreed about having children (50.8%).
The prevalence of planned pregnancy was 33.3% [25.2%-42.3%]. The aspects associated with pregnancy planning were having a steady partner, not being the first pregnancy and have experienced a miscarriage/abortion. The mean current age and partner's age were statistically different between the women who planned their pregnancy and those who did not. These data are described on Tables 3 and 4.
The sociodemographic and reproductive profile of the women involved young women to women of 42 year of age with previous pregnancy, some were single and others lived with their partner. This diversity of types of affective relationships and reproductive history becomes relevant with the intention is to measure the pregnancy planning, because there is a positive relationship between age and number of children and the undesirability of the pregnancy(1).
It is noted that there is an inconsistent or lack of use of contraception in the month before the pregnancy was identified. Although a study(9) has shown, by comparing the 1996 and 2006 PNDS survey data, that using the pill, condom, and other so-called modern methods, such as tubal ligation and vasectomy, has increased substantially in Brazil, it should not be disregarded that contraception is founded on subjectivity and not on rationality(10). In other words, the use of methods is not necessarily continuous and consistent, thus generating situations of contraceptive vulnerability. Furthermore, because not using contraception does not always mean that the women or couples are planning or wanting a pregnancy; therefore, it cannot be the only indicator of pregnancy planning(11).
Regarding the time when the pregnancy occurred, half the women reported that it was the right time and only one small part stated it was the wrong time. The women consider the life contexts in which they are with the purpose of tying to postpone the pregnancy to a time when the personal and/or professional circumstances are favorable for a child to arrive(12).
In this study, less than half of the women reported they intended to become pregnant. Another study(4) found that the women did not use the terms planned and intentional spontaneously. Most of all, the women had referred to their intention of becoming pregnant, but not necessarily had they planned the pregnancy, which confirms that intention is only an initial step of planning.
The proportion of undesirability found in this study was the same as the 19.0% observed in the PNDS survey (2008) related to the current pregnancy(1). It is noted that, although the concepts of unplanned and unwanted pregnancy are used as synonyms, here they appeared with different magnitudes. The proportion of unplanned pregnancies was nearly eight percentage points smaller than the proportion of undesirability. In fact, the pregnancy planning is a complex concept that considers not only elements concerning the desire and intention, but also personal contexts and circumstances, besides the contraceptive behavior per se. Therefore, it appears that measuring only desirability would overestimate pregnancy planning.
One third of the women were classified as having planned the pregnancy. Undoubtedly, from the point of view of one's sexual and reproductive health, efforts should be made so that all pregnancies can be planned. However, studies have warned that the occurrence of unplanned, unwanted, or unintentional pregnancies has not reduced over time, even considering the increase in women's education and the changes in social, affective and work relationships, besides the improvement of contraceptive technologies and the increase in accessibility to contraceptive methods(13-14).
A study performed in the United States, with the purpose to analyze the data um of the National Survey of Family Growth and the study regarding the tendencies of increase in unplanned pregnancy rates, found that between 1995 and 2002 there was an increase in the proportion of births of an unplanned pregnancy. In women younger than 25 years of age, the unplanned pregnancy rate increased from 10.4% in 1995 to 18.6% in 2002, and the number of undesired births per 1,000 women of ages between 15-24 years increased from 25 to 48(15). According to the Pregnancy Risk Assessment Monitoring (PRAMS) performed by the Center for Disease Control and Prevention, in 2006, the undesired pregnancy rate increased from 33.4% to 59.5% in 24 U.S. states(14).
The aspects that appear as statistically different between the group of women who planned the pregnancy and those who did not indicate that women who plan their pregnancy may be more experienced, from the reproductive point of view, and not only women with a high education level or those who are employed. It cannot be denied that the women's work situation interferes in the pregnancy planning, precisely because it is part of the personal circumstances of her life, although the present study did not find any statistically significant difference regarding the employment situation between women who did or did not plan their pregnancy.
In this study, older women, who has a stable relationship with partner who was also older, and had already experienced a pregnancy or miscarriage/abortion were those who most planned their pregnancy. These women, somehow, were able to gather the necessary tools to experience a pregnancy exactly at the time they wanted, intentionally and with the support from their partner. Therefore, it appears that younger women, without a steady partner and in the beginning of their sexual life(16), and those who have never been pregnant are the most vulnerable to experience an unplanned pregnancy. To provide the necessary conditions for women to plan their pregnancy, besides the simple act of offering contraceptive methods is a challenges for health care professionals, particularly because the use of contraceptive methods does not always correspond to the expressed intentions(11). We agree that fecundity cannot, in fact, be totally controlled, and that the act of becoming pregnant cannot be seen as a rational activity based only of planning and foreseeing, as this may be true for some couples but not for all of them.
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Received: 10/30/2011 * Study awarded a prize in the Poster Session, 2º Simpósio
Internacional de Políticas e Práticas em Saúde Coletiva na Perspectiva da
Enfermagem SINPESC, University of São Paulo School of Nursing, São Paulo,
9-11 October 2011.
* Study awarded a prize in the Poster Session, 2º Simpósio Internacional de Políticas e Práticas em Saúde Coletiva na Perspectiva da Enfermagem SINPESC, University of São Paulo School of Nursing, São Paulo, 9-11 October 2011.