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Underestimation of pregnancy risk among women in Vietnam RESEARCH ARTICLE Open Access Underestimation of pregnancy risk among women in Vietnam Jessica Londeree1, Nghia Nguyen2, Linh H. Nguyen2, Dung H. Tran3 and Maria F. Gallo1* Abstract Background: Addressing women’s inaccurate perceptions of their risk of pregnancy is crucial to improve contraceptive uptake and adherence. Few studies, though, have evaluated the factors associated with underestimation of pregnancy risk among women at risk of unintended pregnancy. Methods: We assessed the association between demographic and behavioral characteristics and underestimating pregnancy risk among reproductive-age, sexually-active women in Hanoi, Vietnam who did not desire pregnancy and yet were not using highly-effective contraception (N = 237). We dichotomized women into those who underestimated pregnancy likelihood (i.e., ‘very unlikely’ they would become pregnant in the next year), and those who did not underestimate pregnancy likelihood (i.e., ‘somewhat unlikely,’ ‘somewhat likely’ or ‘very likely’). We used bivariable and multivariable logistic regression models to identify correlates of underestimating pregnancy risk. Results: Overall, 67.9% (n = 166) of women underestimated their pregnancy risk. In bivariable analysis, underestimation of pregnancy risk was greater among women who were older (> 30 years), who lived in a town or rural area, and who reported that it was “very important” or “important” to them to not become pregnant in the next year. In multivariable analysis, importance of avoiding pregnancy was the sole factor that remained statistically significantly associated with underestimating pregnancy risk (odds ratio [OR]: 0.11; 95% confidence interval [CI], 0.05–0.25). In contrast, pregnancy risk underestimation did appear to vary by marital status, ethnicity, education or other behaviors and beliefs relating to contraceptive use. Conclusions: Findings reinforce the need to address inaccurate perceptions of pregnancy risk among women at risk of experiencing an unintended pregnancy. Keywords: Contraception, Health knowledge, attitudes, practice, Pregnancy, unplanned, Risk assessment, Vietnam Background Of pregnancies occurring worldwide from 2000 to 2014, an estimated 44% of were unintended [1]. Unintended pregnancies, defined as pregnancies that are unwanted or mistimed at the time of conception, pose a substantial social and economic burden for women and their fam- ilies. Consequences of these pregnancies include poor birth outcomes [2], increased levels of pregnancy-related morbidity and mortality [3, 4], as well as mental health concerns and lost educational opportunities among chil- dren [5, 6]. Despite these consequences, a large gap re- mains between the availability of contraceptive methods and their use. An estimated 80% of the 85 million women annually who have an unintended pregnancy are not using contraception at the time of conception [4]. In lower and middle-income countries, where most unin- tended pregnancies occur [1, 4], and where the health infrastructure is often ill-equipped to handle the conse- quences of unintended pregnancy, understanding the barriers to contraception use among women who desire to prevent pregnancy is critical. © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. * Correspondence:
[email protected] 1Division of Epidemiology, The Ohio State University, College of Public Health, Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, USA Full list of author information is available at the end of the article Londeree et al. BMC Women's Health (2020) 20:159 https://doi.org/10.1186/s12905-020-01013-6 http://crossmark.crossref.org/dialog/?doi=10.1186/s12905-020-01013-6&domain=pdf http://orcid.org/0000-0001-8004-0544 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ mailto:
[email protected] According to the health belief model, appropriate per- ception of susceptibility to a given health outcome is a key determinant of health behavior and behavior change [7, 8]. A woman’s cognizance of her risk of unintended pregnancy then may play a crucial role in contraceptive behavior and adherence. Indeed, underestimation of pregnancy risk has been found to lead to unmet contra- ceptive need [9, 10] and, subsequently, unintended preg- nancy [11, 12]. Several studies across a range of settings have revealed a significant discrepancy between perceived and actual pregnancy risk. In a study among reproductive-age women in France, Moreau and Bohet found that, among women who reported inconsistent use of contraception or unprotected intercourse in the last 4 weeks, 63% did not think they could become pregnant unintentionally [13]. Sinai et al. observed that, among women in Mali and Benin, 33.7% of women at risk of pregnancy (i.e., women who were fecund and sexually active) believed that they could not become pregnant [14]. In another study of women attending reproductive healthcare clinics in the United States, Biggs et al. found that 27% of women planning to use no method or a low-efficacy contraceptive method (i.e., natural family planning, with- drawal, diaphragm, or sponge) underestimated their risk of pregnancy from engaging in 1 year of unprotected intercourse [15]. Although addressing inaccurate perceptions of preg- nancy risk may be central to preventing unintended pregnancy, few studies to date have evaluated the factors associated with underestimation of pregnancy risk among women at risk. Assessing these factors could help identify target populations for interventions to address the gap between perceived and actual pregnancy risk and, accordingly, the gap between the existence of effect- ive contraception and its use. The aim of the present study was then to assess the prevalence and correlates of underestimation of pregnancy risk among sexually- ac- tive women in Hanoi, Vietnam, who were not using a highly-effective method of contraception and yet did not desire pregnancy. Methods We analyzed data from cross-sectional, convenience study of women in Hanoi, Vietnam. The parent study’s primary objective was to assess a method of measuring beliefs concerning contraception safety and naturalness, and these findings will be reported elsewhere. The par- ent study enrolled 500 adult women of reproductive age (18–45 years) attending the obstetrics-gynecology de- partment of a large public hospital for routine care or accompanying someone at the facility during November 2017 to September 2018. To participate in the study, women had to have at least a minimal level of literacy, report being comfortable using a computer, be sexually active (defined as ≥1 penile-vaginal act in past month), not be pregnant or breastfeeding, and not want a preg- nancy within the next 12 months. Written consent was provided by participants before enrollment, and the re- search was approved by institutional review boards at The Ohio State University and the Hanoi School of Public Health. We administered a questionnaire on demographics and contraception-related beliefs and behaviors. As part of this questionnaire, we asked participants to report the likelihood (“very unlikely, somewhat unlikely, somewhat likely and very likely”) they would become pregnant in the next year. For the present study, we restricted our analysis to women who were not currently using a highly effective method of contraception, specifically either a tier 1 (i.e., implant, intrauterine device, tubal ligation or vasectomy) or a tier 2 method (i.e., injectable contracep- tion, lactational amenorrhea, oral contraception, patch or vaginal ring) [16]. Thus, we excluded 261 women who were using a tier 1 or 2 method and 2 women who were missing data on perceived likelihood of pregnancy over the next year (Fig. 1). Based on responses regarding the perceived likelihood of pregnancy, we dichotomized women into those who underestimated pregnancy likelihood (i.e., women who reported it was ‘very unlikely’ they would become preg- nant in the next year), and those who did not underesti- mate pregnancy likelihood (i.e., women who reported it was ‘somewhat unlikely,’ ‘somewhat likely,’ or ‘very likely’ they would become pregnant in the next year). Based on the literature, we selected the following demo- graphic characteristics to evaluate as potential correlates of pregnancy likelihood underestimation [13, 15, 17]: age (categorized into 21–31 years, 32–36 years, and 37–45 years); residence (city vs. town or rural area); marital status (married vs. other); ethnicity (Kinh vs. other); edu- cation (secondary or lower vs. higher); and monthly household income (< 15="" million="" vietnamese="" dong="" [equivalent="" to="" ~="" 650="" u.s.="" dollars]="" vs.="" higher).="" we="" also="" assessed="" the="" following="" contraception-related="" beliefs="" and="" behaviors:="" current="" use="" of="" male="" condoms="" (yes="" vs.="" no),="" current="" use="" of="" traditional="" contraceptive="" methods="" (i.e.,="" rhythm,="" withdrawal;="" yes="" vs.="" no),="" ever="" been="" pregnant="" (yes="" vs.="" no),="" experience="" ever="" discussing="" contraceptive="" methods="" with="" health="" provider="" (yes="" vs.="" no),="" and="" ambiguity="" towards="" becoming="" pregnant="" (ambiguous="" vs.="" not-="" ambiguous).="" in="" response="" to="" the="" question="" “how="" import-="" ant="" is="" it="" to="" you="" to="" not="" become="" pregnant="" in="" the="" next="" year?”="" women="" who="" reported="" it="" was="" ‘very="" important’="" or="" ‘important’="" were="" categorized="" as="" not-ambiguous="" toward="" becoming="" pregnant,="" while="" those="" who="" reported="" it="" was="" ‘neutral’="" or="" ‘not="" important’="" were="" categorized="" as="" ambigu-="" ous="" towards="" becoming="" pregnant.="" londeree="" et="" al.="" bmc="" women's="" health="" (2020)="" 20:159="" page="" 2="" of="" 7="" in="" separate="" bivariable="" logistic="" regression="" models,="" we="" assessed="" the="" relationship="" between="" potential="" correlates="" and="" pregnancy="" risk="" underestimation.="" we="" then="" ran="" a="" mul-="" tivariable="" logistic="" regression="" model="" fitted="" with="" all="" corre-="" lates="" that="" were="" associated="" with="" the="" outcome="" in="" the="" bivariable="" analysis="" using="" a="" p-value="" of="">< 0.25="" [18].="" we="" used="" sas="" 9.4="" (sas,="" cary,="" nc)="" for="" all="" analyses.="" results="" the="" analysis="" is="" based="" on="" 237="" women="" who="" were="" suscep-="" tible="" to="" unintended="" pregnancy="" (i.e.,="" sexually-active,="" reproductive-age="" women="" who="" were="" not="" using="" a="" tier="" 1="" or="" 2="" method="" of="" contraception="" and="" did="" not="" wish="" to="" become="" pregnant="" in="" the="" next="" year).="" most="" participants="" resided="" in="" a="" city="" (88.2%),="" had="" attended="" education="" beyond="" upper="" sec-="" ondary="" school="" (73.0%),="" were="" married="" (93.7%),="" were="" eth-="" nically="" kinh="" (93.7%),="" and="" reported="" a="" household="" income="" of=""> 15 million Vietnamese dong (71.7%) (Table 1). The median age of participants was 34.1 years (standard devi- ation, 5.3; range, 21–45 years). Participants reported the following methods of contraception (based on a hier- archical categorization, in which those reporting mul- tiple methods only had their first response in the following ordered list included): male condom (n =