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On-line version ISSN 1982-0194
Acta paul. enferm. vol.25 no.3 São Paulo 2012
Association between unplanned pregnancy and the socioeconomic context of women in the area of family health*
Edméia de Almeida Cardoso CoelhoI; Maria Lindiane de Souza AndradeII; Laís Vilanova Tavares VitorianoII; Jussilene de Jesus SouzaIII; Diorlene Oliveira da SilvaIV; Maria Enoy Neves GusmãoV; Enilda Rosendo do NascimentoVI; Mariza Silva AlmeidaVI
IDoctor of Nursing Practice. Associate Professor of the School of Nursing, Federal University of Bahia - UFBA - Salvador (BA), Brazil
IINursing Students. Federal University of Bahia - UFBA - Salvador (BA), Brazil. PIBIC/CNPq Scholarship
IIIMaster's degree in Nursing. Graduate Program in Nursing, Federal University of Bahia - UFBA - Salvador (BA), Brazil
IVMaster's degree in Collective Health. Statistics from the School of Nursing, Federal University of Bahia - UFBA - Salvador (BA), Brazil
VPhD degree in Collective Health. Adjunct Professor of the School of Nursing, Federal University of Bahia - UFBA - Salvador (BA), Brazil
VIDoctor of Nursing Practice. Associate Professor of the School of Nursing, Federal University of Bahia - UFBA - Salvador (BA), Brazil
VIIDoctor of Nursing Practice. Adjunct Professor of the School of Nursing, Federal University of Bahia - UFBA - Salvador (BA), Brazil
OBJECTIVE: To estimate the prevalence of unplanned pregnancy and verify its association with sociodemographic factors in women enrolled in the FHS - Family Health Strategy, in suburban sanitary Salvador - BA.
METHODS: A quantitative, exploratory, cross-sectional study, with a sample of 191 pregnant women, stratified by health units. The pregnancy was categorized into planned and unplanned, and sociodemographic characteristics constituted the independent variables. The magnitude of the associations was obtained by the ratio of prevalence and confidence intervals (95%), estimated by Poisson regression, with the level of statistical significance, 5% (p < 0.05).
RESULTS: The prevalence of unplanned pregnancy was 66.5%; age, marital status, occupational situation, and income exhibited statistically significant proportional differences with regard to type of pregnancy. There was a positive association between age, marital status and occupation with unplanned pregnancy.
CONCLUSIONS: The results reaffirm the association between unplanned pregnancy and socioeconomic conditions, and the ESF appears to have been effective in ensuring the reproductive rights of women.
Keywords: Pregnancy, unplanned; Socioeconomic factors; Family health program; Family planning (Public health); Community health nursing
Since the establishment of the Program of Integral Assistance to Women's Health in 1984, the state recognizes the right of women to dissociate sexual activity from procreation. Actions toward the implementation of contraception were instituted in the Brazilian public health system. However, the difficulties in exercising their sexual and reproductive rights have exposed women to a series of situations that compromise their health, among them, the consequences of an unplanned pregnancy. From the perspective of reproductive rights, the choice of falling pregnant is a rational decision and is the result of exercising reproductive autonomy and freedom. Therefore, unplanned pregnancy is considered as the result of a process in which there was no conscious decision by the woman or couple for it to occur (1).
For women in unfavorable socioeconomic conditions, and who do not know their rights concerning reproduction, contraception presents a problem. Thus, unplanned pregnancy occurs due to the lack of information and poor access to and inappropriate use of contraceptive methods, discontinuity in the supply of contraceptive by the service, limited offer in the variety of methods, and the adverse side effects that lead to abandoning the use of contraceptives and limitation of their effectiveness (2).
Added to all these issues, there are relationship problems, ambivalent desire, and lack of sexual education, especially in cases of teenage pregnancy (3). Unplanned pregnancy is not restricted to conscious factors, as there is association between conscious and unconscious reasons for its occurrence (4), but although these motivations are valued, it is important to consider that access to information and contraceptive methods open avenues for women to have control over their fertility and allow them to make choices according to their desires.
In Brazil, the outcome of a large number of unplanned pregnancies is abortion, which is an important factor in maternal morbidity and mortality and it is the main single cause of maternal mortality in Salvador (5). Abortion-related deaths occur mainly among young and poor women who have more difficult access to health services due to social and economic issues.
With regard to the responsibilities of the public health system in guaranteeing the exercise of sexual and reproductive rights of women, the FHS - Family Health Strategy - plays an important role. Considering the change in the assistential model of health care, the FHS proposes to incorporate collective health promotion actions and disease prevention by gradually replacing individualized, high cost and low impact curative attendance (6).
However, studies conducted in the public health system, including areas within the scope of the FHS, have shown that the variety of contraceptive methods is limited, supply is irregular and removed from women's other, with contradictions between the proposals of public health policies and the practice developed in the FHS (7, 8). Research has also shown that mulatto and Afro-Brazilian women, of low education level and low family income, are more prone to unintended pregnancy because they have restricted information about and access to contraceptives and little power to negotiate condom use with their partners (9, 10).
Therefore, in the context in which pregnancy is included, there is an intersection of factors of a biological, social, and subjective order that enables this to occur. Material conditions are of singular importance because, although they are not the determinants in the choice of motherhood, they define its characteristics and possibilities (11). Considering that the development of female autonomy is influenced by multiple factors, emphasis is placed on the importance of socioeconomic conditions such as those that define access to information and means to enable decision-making.
In the FHS, as part of their day-to-day routine, professionals come into contact with women who frequently experience unplanned pregnancies and live in conflict when it occurs. In view of the foregoing discussion, the aim of this study was to estimate the prevalence of unplanned pregnancies among women within the area of FHS coverage and to verify the association between unplanned pregnancy and sociodemographic and economic factors.
An exploratory and quantitative cross-sectional study was conducted with the use of survey data from the research "The occurrence of unplanned pregnancy within the areas of FHS coverage in Salvador - BA", which was undertaken in ten Family Health Units (FHU) in the Sanitary District of "Subúrbio Ferroviário" (railroad suburb) of Salvador, BA, from March to September 2010.
"Subúrbio Ferroviário" (railroad suburb) is a region in the city of Salvador with a population of 324,931 inhabitants. Among the 12 existent sanitary districts in Salvador, the "Subúrbio Ferroviário" area was identified as the largest area covered by the FHP, as it has a series of complex health problems and social risk factors (12).
The units were selected in accordance with the following criteria: to be in operation with activities in reproductive planning for over one year; provide safety guarantees for the activity of the interviewers; and guaranteed access due questions of a geographical nature. The following Family Health units (FHU) were included in the study: Alto de Coutos, Alto do Cruzeiro, Beira Mangue, Fazenda Coutos II, Fazenda Coutos III, Ilha Amarela, Itacaranha, Rio Sena, São Tomé de Paripe, Sérgio Arouca-Paripe.
A random sample of 263 women was estimated, which was stratified by the Family Health Units. The sample was based on the total number of women in childbearing age registered at FHU (N = 31,018) and the prevalence of unplanned pregnancies obtained in the National Demographic and Health Research (13) of 45.8% taking into consideration a sampling error of 6% (d = 0.06) and level of confidence of 95% (α = 0.05). The age group between 10 and 14 years was also included in the calculation since pregnancy is a reality in this age group.
Data was collected by means of an interview form containing structured and semi-structured questions applied to the pregnant women selected to be part of the sample and who agreed to participate in the study. The questions with single or multiple answers contained information with categories of responses stimulated by the researcher as regards sociodemographic and economic aspects, sexual and reproductive experiences, and care received from health services.
The instrument was validated in a pilot test from which nine pregnant women undergoing prenatal follow-up at the FHU of Vista Alegre were drawn. The number of women interviewed corresponded to 20% of the total of women scheduled during the month in which the pilot test was applied. This information did not form part of the study sample. Contact was established with the management of the FHU and nurses before the pilot test, and the visits to the service were scheduled according to the attendance schedule of the pregnant women. This occurred immediately after the project was approved by the Research Ethics Committee of the Nursing School of the Federal University of Bahia.
The interviews with pregnant women were held at the unit at the time of attendance for prenatal care or on the day and time set by the women during the research period. The nurses provided support so that the interview could be held in an individual attendance room providing the women with an environment that would assure her privacy.
Quality control of collected data was performed by the researcher responsible for the project, who supervised the interviewers in the field and reviewed all the instruments after they were returned from the field.
The dependent variable of the research was un planned pregnancy, defined by the combination of the following question: Do you consider that your pregnancy was: planned; unplanned, did you want to wait longer; unplanned, you did not want to have more children; unwanted, did not want to become a mother; unwanted, did not want to have more children; was not sure if had been planned; other reasons. The category unwanted pregnancy was aggregated to that of unplanned pregnancy. The following sociodemographic and economic variables were used: age, marital status, race/self-declared color, religion practiced, last grade of schooling completed, occupational status, and total family income. The occupational situation was categorized into the four following levels: 1: remunerated activity (domestic help, workers in the informal trade which includes street vendors, seafood vendors, the Bahian acarajé; in the service sector including manicure, seamstress, working in a restaurant); 2. housewives; 3. students; and 4. unemployed.
Exploratory analyses were performed in order to characterize the study population and verify the association between the characteristics of interest through the use of descriptive measurements (means, medians and standard deviations), bivariate frequency distributions, and measures of association. The differences between the ratios were verified using Pearson's Chi-square and Fisher's Exact tests at a level of statistical significance of 5%. To estimate the magnitude of the associations, prevalence of unplanned pregnancy was used as a measurement of frequency and RP and the 95% confidence intervals were used as a measure of association, based on the estimation of the relative incidence of Poisson regression with robust variance (14). In all the analyses, a level of statistical significance of 5% was adopted (p < 0.05). The database was generated using Microsoft Access version 2002 and the STATA Software v.8.0 was used for statistical analysis of the results.
The study was approved by the Research Ethics Committee in Nursing Protocol No 44/2009, 22/03/2009. All the participants signed the Term of Free and Informed Consent (TFIC) assuring them anonymity, confidentiality of information, the right to withdraw from the study without detriment, and permission of access to the researchers and to the results of the study. The adolescents signed the TFIC and a Free and Informed Term of Consent was signed by their guardians authorizing their participation in the study.
The population sample consisted of 191 pregnant women, which corresponded to an response rate of 72.6% of the total (n=263). Of these, 66.5% declared that they experienced an unplanned pregnancy. Due to nonattendance of appointments made by the nurses and/or not being at home for the home visits of the interviewers, 72 (27.4%) women were excluded from the study.
In the population under study, there was a predominance of women with a mean age of about 24 years (SD = 5.9 years), mulatto (62.9%) or Afro-Brazilian (30.6%), Protestant (41.6 %) or Catholic (35.3%) religion, married/cohabiting (67.0%). The last grade of school completed ranged equally between incomplete primary school (34%) and complete high school education (31%) with a predominance of family income of up to 1 MW (44%) or between 1 and 3 MW (44%), as regards occupational situation, there were housewives (49.7%) and those involved in remunerated activity (30.4%) (data not shown).
The data in Table 1 shows the statistically significant proportional differences between the type of pregnancy and the respondent's age (p = 0.012). Among those who were younger than 20, those who had not planned the pregnancy (30.7%) were outstanding, two times higher than those with planned pregnancy (14.1%); and among those who were 20 and older, the highest percentage was for planned pregnancies (85.9%).
It was found that the groups did not differ with regard to race and type of pregnancy (p value = 0.256), but there was a predominance of mulattoes for both types of pregnancy and there was a gradient between white and other groups (6.3 %), Afro-Brazilian (27%) and mulatto (66.7%) for unplanned pregnancy. The group of white women was noted as representing the lowest ratio for both types of pregnancies, and mulattos showed the highest ratio of those who did not plan (66.7%) and between those who had planned pregnancy (55%).
With regard to religion, an equal percentage distribution was found among the various categories for both types of pregnancy (value of p = 0.978).
For marital situation, statistically significant proportional differences were found between the type of pregnancy (value of p = 0.000). Married/stable partnerships were found more frequently between those who did not plan the pregnancy (56.4%) was well as between those who had planned it (89.1%). No single women without a fixed partner declared to be experiencing a planned pregnancy. Among the single women with a fixed partner, a majority were among those who had not planned the pregnancy (37.3%).
The relationship between the last grade of schooling completed and the type of pregnancy showed no statistically significant proportional differences (p = 0.353), but higher rates of unplanned pregnancy were found among the less educated women.
With respect to the occupational category, statistically significant proportional differences were found among the groups (value of p = 0.035). The majority of those who had not planned the pregnancy were housewives (48.8%), although Housewives were also more frequent among those who planned their pregnancy (51.6%), as they represented the largest group in total number of women interviewed (49.7%). Women who were engaged in remunerated activity were the most frequently found (39.0%) among those who had planned their pregnancy . Among the students, a highest percentage was found among those who did not plan their pregnancy (17.3%), and this was 4 times higher when compared with those who had planned their pregnancy (4.7%).
An inverse relationship was found between family income, unplanned pregnancy, and statistically significant proportional differences among the groups (value of p = 0.011). Among those who did not plan pregnancy, a high percentage of women with a family income below one minimum salary were found; and planned pregnancy was higher among those with a family income between one and three minimum wages (59%).
The data in Table 2 assessed the magnitude of the associations found between types of pregnancy and sociodemographic factors. There was association between the respondent's age and occurrence of unplanned pregnancy. Among those who became pregnant at the age of <20 years, the chance of unplanned pregnancy occurring was 1.3 times higher (95% CI 1.05 to 1.53) when compared with those older than 20.
When evaluating the association between marital status and unplanned pregnancy, it was observed that single women had more chance of falling pregnant without planning when compared with married/women in stable partnerships. Single women with a fixed partner were 1.5 times more likely to fall pregnant (95% CI 1.211.78), and single women without a fixed partner were 1.7 times more likely to fall pregnant (95% CI 1.49 - 2.02).
It was found that students had 1.4 times chance (95% CI 1.06 to 1.92) of falling pregnant without planning when compared with those who were engaged in remunerated activity, and this association was statistically significant.
According to the National Demographic and Health Survey (PNDS), of the births in the first 5 years of the present decade, 45.8% were not planned to occur at that time. Women with less education, Afro-Brazilian and residents in less favored regions of the country had greater difficulty in planning pregnancy. Thus, reproductive intentions occur differently among women as they are subject to the influence of socioeconomic conditions (13).
In the present research, a prevalence of 66.5% of pregnancy reported as unplanned was found, and it must be emphasized that the study was conducted in an area whose population in conditions of great economic social vulnerability, differing from the PNDS data that include women from all social strata. The pregnant women who participated in this study were relatively young, predominantly Afro-Brazilian with low income and education.
In the present study, significant associations between age and the occurrence of pregnancy were found, and teenage girls were exposed to greater chances of unplanned pregnancy, however, it was found that this event occurs in women throughout their reproductive cycle. There was a greater frequency of adolescent pregnancy among youngsters with less education and lower income, which may be explained by the difficulties of access to contraceptive methods, information on sexuality and reproduction, situations this population group are subject to in Brazil (15). In addition, adolescence is a phase with a propensity to challenges and new discoveries, when an imaginary belief prevails that everything can happen to others, but not to them (16).
The predominance of Afro-Brazilians in the study was an indicator of more unfavorable socioeconomic levels and corroborates the estimates of IBGE - Brazilian Institute of Geography and Statistics, determining greater limitation in reproductive health care, which compromises freedom of choice. Although race/color showed no association with unplanned pregnancy, greater prevalence of pregnancy was found in women in this population group. Most Afro-Brazilian women have a lower socioeconomic level, less access to good quality health services and they are more prone to risks of becoming ill and dying (17).
In a previous study in the same geographical area as that of the present study, it was found that among the 376 women in childbearing age 61.7% were found to be married or in a stable partnership (18). This reality was reaffirmed in the present study, because this was the marital situation of the majority of women who experienced pregnancy. Association between the occurrence of unplanned pregnancy and marital status was found both for the single women with a fixed partner and those without a fixed partner.
Unplanned pregnancy is also influenced by differences in age, work and income, duration of relationship, whether or not they have had children and/or previous miscarriages, whether they are in partnerships or single, if there are casual partners, which either does or does not interfere with the ability of women and men to protect themselves during sexual relations (19). One has to consider that the ambivalence resulting from the development of identity that naturalizes the social function of motherhood accompanies women, and in view of the difficulties of access to information and means of regulating fertility, there is a trend towards allowing pregnancy to occur (20).
It is difficult for women to gain autonomy and reproductive freedom, considering the low education of the participants in the study. The highest level of unplanned pregnancy occurred in those who had studied up to the 5th grade of elementary school or had incomplete elementary schooling. But 30.7% of those with unplanned pregnancies were adolescents, assuming that they were the largest part of the group in this category of schooling, which is in agreement with the results shown in the literature.
In a research conducted in the same geographical area, it was found that of the 376 women, 54% had elementary schooling or incomplete high school education; 37.9% had completed high school education, 7% completed primary schooling or had incomplete primary schooling, and only 0.8% had entered into higher education (18).
In general, those with least schooling were the ones with the worst conditions in terms of inclusion in the work market (12). In 2001, according to the Inter-Union Department of Statistics and Socioeconomic Studies (DIEESE), women represented 41.9% of the economically active population of Brazil, and those who worked outside their home were domestic helpers or worked in the areas of education, health, textiles and clothing manufacture (21).
The long working hours to which they are exposed and the distance from health services contribute to reduced access to information and to the means that would enable them to prevent unwanted pregnancies. As regards occupation among the participants in this study, the results converged with those discussed in the literature, and it was found that the highest percentage of women (49.7%) developed activities, such as being housewives and providers of child and family care (13).
With regard to the association found between occupation and unplanned pregnancy, it was found that students had more chances of becoming pregnant without prior planning, when compared with other occupations, probably because they are included in the group of adolescents that have specificities related to this phase. However, in the present study, the occurrence of unplanned pregnancy was more prevalent among housewives and therefore, among those who are financially dependent on their partners or family members, a factor that makes it difficult to achieve autonomy and freedom of choice.
The reality revealed by the women in this study is convergent with that found in the literature as regards the importance of socioeconomic conditions in the occurrence of unplanned pregnancy. It may be argued that this event is, in part, a result of adverse conditions in this field, since conditions of low income, low degree of schooling, domestic work at home outside of it, and low personal and family income predominate, and these lead to dependence on the partner, which makes it difficult for women to have control of their bodies, a basic condition for reproductive freedom and autonomy.
The socioeconomic conditions presented by the women in this study do not justify the difficulties of access to information and contraceptive methods, but this reality has previously been shown in many studies, and seems to repeat itself within the areas of FHS coverage, in view of the high percentage of unplanned pregnancies. The occurrence of pregnancy is something that brings with it the intersection of multiple factors, including those related to the development of female identity towards motherhood, but the difficult socioeconomic conditions combined with the dependence on the partner, confirmed in this study dueto low income or lack of it, place these women in a situation of inequality in comparison with those who have more social opportunities, which favors reproductive citizenship.
Further studies are needed to broaden knowledge in this field, by investigating other aspects that are involved in the occurrence of unplanned pregnancies. Redirecting public policies toward women requires improvement in living conditions with regard to education, better opportunities in the work market, a worthy income, in addition to full and equal health care, without race, gender, age or any other type of discrimination. It behooves the FHS professionals to implement and/ or redirect actions that favor reproductive choices in order to make the self-determination of women feasible.
The authors thank CNPq for financing the study (No. 57/2008), FHP professional teams, especially managers, nurses and community health workers for supporting the study and facilitating the access to the women. We also thank the women who participated in the study for making this research possible.
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Corresponding Author: Received article 10/06/2011 and accepted 07/09/2011 * Study based on the research "The occurrence of unplanned pregnancies within the areas of the Family Health Program coverage in Salvador - BA - Brazil.
Edméia de Almeida Cardoso Coelho
Av. Orlando Gomes - 1558 - Casa 14 E - Piatã
41650-010 Salvador - BA
Supported by CNPQ from 2009 to 2010.
Received article 10/06/2011 and accepted 07/09/2011
* Study based on the research "The occurrence of unplanned pregnancies within the areas of the Family Health Program coverage in Salvador - BA - Brazil.