The results of this study suggest that Brazil has a high prevalence of unintended pregnancy, which affects more than 50 % of all pregnancies carried to parturition. Similar prevalence is reported in national and international literature, indicating that less than half of women report having the intention to become pregnant at that time [2, 6]. According to estimates based on data from the United Nations Population Division for 2012, approximately 40 % of pregnancies worldwide, or 85 million pregnancies, were unintended. The region with the highest percentage of pregnancies that were unintended was the Latin America and the Caribbean region (56 %), whereas the lowest percentage unintended were found in Africa (35 %) [4]. As mentioned in the introduction, the last nationwide study of pregnancy intendedness in Brazil was carried out in 2006 and showed that 53.9 % of women who had a child in the last 5 years did not plan the pregnancy [14]. More recent research among postpartum women living in a southern city of the country found that 65 % did not plan their pregnancies [18].
In terms of associated factors, unintended pregnancy in this sample was predominantly more likely with younger age, brown and yellow skin color, lower schooling level, not having a partner, not having a paid job, alcohol abuse and tobacco use. The effect of sociodemographic and individual variables is consistent with literature on intention of pregnancy at conception and showed the high degree of social vulnerability of these women [19, 20]. Prietsch and colleagues [18], investigating the factors associated with unplanned pregnancy in a sample of women in Southern Brazil, found statistically significant association between having an unplanned pregnancy and having black and brown skin color, being a teenager, being single, having a low income, being a smoker and having multiparity.
Worldwide, women of childbearing age, regardless of skin color and socioeconomic status, are at risk for experiencing unintended pregnancies, but the extent of that risk is widely variable, with disadvantaged groups of women being the most affected. The health disparities seen in unintended pregnancies must be a main target for social and health policies to reduce inequalities in health [21, 22].
Unintended pregnancy has been linked to many factors, including high risk of unhealthy behaviors. If a woman has an unintended pregnancy, she may be unprepared for it and thus may be less aware of changing her habits, such as improving nutrition or quitting smoking, compared with women with intended pregnancies. These factors may result in less favorable outcomes [1, 23].
Despite being consistent with others studies, the protective effect for unplanned pregnancy found among women aged 35 years and over may reflect recent changes in the fertility behaviour of the Brazilian population. Data from the Brazilian Ministry of Health show that, in the last few years, fertility has been delayed. From 2000 to 2010, the fertility rate among women aged 15 − 19 and 20 − 24 years decreased from 18.8 % to 17.7 % and from 29.3 % to 27.0 %, respectively. Although the latter group still account for the largest portion of fertility in Brazil, the age distribution of fertility was more dispersed in 2010 than in 2000, with increased participation of those over 30 years old [24].
In addition to all of these factors, previous maternal complications and preterm birth revealed strong and significant associations with unintended pregnancy, even after adjusting for sociodemographic and individual risk factors. This relationship with birth outcome was also found by a prospective observational study of 400 postpartum women enrolled at a university medical centre in the United States. In this study, women with a history of prior preterm birth also had a higher chance of unintended pregnancy [12]. A possible explanation is that adverse birth outcomes can trigger anxiety, depression and posttraumatic stress syndrome, all of which are associated with unintended pregnancy [25, 26]. Insufficient contraceptive use might also be related to the risk of unintended pregnancy among depressed women, as those with elevated depression and stress were more likely to be at risk for inconsistent contraceptive use [27]. Another possible explanation is that prematurity is a major risk factor for infant mortality and health complications in newborns, and mothers with previous preterm birth may not feel confident in facing a new pregnancy.
The protective effect of neonatal death related to unwanted and mistimed pregnancy may be explained by different mechanism. Many researchers agree that the intention and decision to have another pregnancy after an adverse outcome such as neonatal death is rife with ambivalent feelings, although 50 %–60 % of mothers wish to become pregnant immediately after this loss [28–30]. Some authors call this decision ‘replacement child syndrome’, characterized by a subsequent pregnancy and birth to substitute for a previous child who has died [31]. Furthermore, there is the belief that a new pregnancy would allow bereaved parents overcome the previous death [29, 32].
In this study, adverse experience in the previous pregnancy was a risk factor for unwanted pregnancy. It is important to understand, beyond the medical approach, the psychological aspects involved in the desire for a new pregnancy and to recognize the contextual factors that impede or facilitate women in their ability to change their behaviour and to choose the moment to be pregnant, as well as the best method to prevent pregnancy.
Family planning in Brazil is an aspect of primary care through the Family Health Strategy [33], but shortcomings remain in terms of access and quality of care. The contraceptive needs of part of the population, particularly women with lower socioeconomic status and education levels and ethnic minorities, are not met, contributing to high rates of unplanned pregnancy in these groups [34]. The low coverage and quality of family planning is caused by several factors. Most professionals working in family planning cite overhead tasks, numbers of appointments incompatible with the available human resources, lack of support material and appropriate physical space for consultations, insufficient training of professionals and outdated information [35]. Conversely, women have often referred to shortages or inadequate information about suitable and available contraceptive methods [36].
The implementation of periodic counselling and guarantee of access to contraceptive methods for all women, especially those at risk for unintended pregnancy, must be a target of an effective family planning policy. Additionally, it is worthwhile to understand the social and cultural context in which unintended pregnancy occurs to avoid to focusing only on individual factors. It is important to integrate social determinants into the causal framework and to create interventions that meet the needs of women and families, especially the most vulnerable. Understanding the persistence of high rates of unplanned pregnancy worldwide, despite the availability of various contraceptive methods, is an important issue for future researches [37].
However before drawing conclusions it is important to consider the strengths and limitations of the current study. The strengths of this study are that it is based on a large, nationwide sample of women and is representative of all births in Brazil in the year it was conducted. It can thus provide reliable and comparable information about unintended pregnancy prevalence and risk factors in Brazil.
There are some limitations. First, the question on pregnancy intention was measured shortly after birth, whereas unwanted pregnancies are more likely to be terminated earlier with induced abortion. Therefore, the prevalence of unintended pregnancy may be underestimated. Second, womens’ intention to become pregnant is a complex process, and knowledge of pregnancy evokes many emotions ranging from worry and fear to happiness and excitement. These emotions may vary during pregnancy and change following the birth, which may have had an impact on women’s responses. Third, in this study the women were not asked about the use of contraceptive methods. We believe this information is important for a better understanding of the factors associated with unplanned pregnancy. However the lack of this variable does not invalidate the other findings of the study. We suggest that future studies examine this relationship.