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Global Journal of Health Science; Vol. 10, No. 8; 2018
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education
132
Unplanned Pregnancy and Its Associated Factors
Muslimah Yusof1, Azah Abdul Samad2, Maisarah Omar1 & Noor Ani Ahmad1
1 Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Jalan Bangsar, Kuala
Lumpur, Malaysia
2 Shah Alam Section 7 Health Clinic, Shah Alam, Selangor, Malaysia
Correspondence: Muslimah Yusof, Institute for Public Health, National Institutes of Health, Ministry of Health
Malaysia, Jalan Bangsar, 50590 Kuala Lumpur, Malaysia. E-mail: muslimah_yusof@moh.gov.my
Received: February, 25, 2018 Accepted: June 5, 2018 Online Published: July 25, 2018
doi:10.5539/gjhs.v10n8p132 URL: https://doi.org/10.5539/gjhs.v10n8p132
Abstract
Introduction: Unplanned pregnancy is a major public health concern globally. Numerous studies found various
factors that can predict or determine unplanned pregnancy. However, there were no studies that reported this
problem in Malaysia. The objective of this study is to determine the prevalence of unplanned pregnancy in
Malaysia and the associated factors.
Methods: This nationwide cross-sectional study targeted to women at postpartum period at government primary
health care clinics throughout Malaysia. Structured questionnaire with face-to-face interview was used for data
collection. The factors studied included mothers’ age, husband’s age, ethnicity, religion, marital status, education,
occupation, household income, polygamous marriage, family support, contraception used, and disagreement of
husband on contraception, smoking and alcohol consumption. History of emotional, physical and sexual intimate
partner violence (IPV) were also studied.
Results: A total of 5727 Malaysian postpartum mothers were involved in this survey. The prevalence of unplanned
pregnancy was 42.9% (95% CI: 38.6, 47.4). The multivariate logistic regression revealed that older mothers aged
45-49 years old (aOR: 8.010; 95%CI: 1.909, 33.013) and Muslim mothers (aOR: 2.465; 95%CI: 1.432-4.241)
were significantly associated with unplanned pregnancy. In terms of household income, mothers with less than
RM1000 per month were 1.712 (95% CI: 1.080, 2.713) times more likely to have unplanned pregnancy. The other
significant associated factor was history of emotional intimate partner violence; aOR [1.720 (95% CI: 1.011,
2.925)].
Conclusions: Unplanned pregnancies were observed to be higher among older Muslim women from low income
family. A possibility of unmet need for family planning should be considered and appropriate intervention
strategies planned for these at-risk population.
Keywords: unplanned pregnancy, unwanted pregnancy, prenatal care, contraception, Malaysia
1. Introduction
An unplanned pregnancy is a pregnancy that is reported to have either unwanted (that is, the pregnancy occurred
when no children, or no more children, were desired) or mistimed (that is the pregnancy occurred earlier than
desired) (CDC, 2015; Yunikkerem, Ay, & Piro, 2013; Santelli et al., 2003; Singh, Darroch, Ashford, & Vlassoff,
2009). In contrast, intended pregnancies are when they happened at the ‘right time’ or later than desired (because of
infertility or difficulties in conceiving).
Unplanned pregnancy is a major public health concern in developed and developing countries because of its
adverse health outcomes among women and children. Globally many pregnancies are still unplanned. In the
United States, the proportion of pregnancies that were unplanned increased slightly between 2001 and 2008 (from
48% to 51%), but, by 2011, it decreased to 45% (Finer & Zolna, 2016; Finer & Zolna, 2014).
According to a global report 2008, in all pregnancies 208.2 million, there was 41% unplanned pregnancy. Latin
America/Caribbean showed 58% unplanned pregnancies, North America (48%), Europe (44%) followed by Africa
(39%). Asia showed 37% unplanned pregnancy of all pregnancies 118.8 million (Singh, Sedgh, & Hussain, 2010;
Sedgh, Singh & Hussain, 2014). Finding from the third National survey of sexual attitudes and life styles in Britain
showed 16.2% of pregnancies with known outcome in the past year was unplanned (Wellings, et al., 2013; WHO,
2008).
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Various reasons for unplanned pregnancies have been identified, which include non-use of contraceptive methods
and contraceptive method failure. Non-use of contraceptive methods is one of the important reasons for unplanned
pregnancy, which is mainly due to the high unmet need for contraceptives. Contraceptive method failure
incorporates both users and technological faults (Kost, Singh, Vaughan, Trussell, & Bankole, 2008).
Numerous studies found various factors that can predict or determine unplanned pregnancy. However, there were
no studies that report this problem in Malaysia. Thus, the objective of this study is to determine the prevalence of
unplanned pregnancy in Malaysia and the associated factors.
2. Material and Methods
This is a nationwide clinic-based cross-sectional study of women with infants in the perinatal period (6-16 weeks)
conducted at the Maternal and Child Health Unit at government primary care clinics throughout Malaysia. To
ensure national representativeness, cluster sampling design was employed with health clinics considered as cluster.
Health clinics within states were randomly selected and eligible mothers within the health clinics were considered
as unit of analysis. Detail methodology has been described elsewhere by Ahmad et al. (2018).
The inclusion criteria for this study were mothers who delivered a child within 6 to 16 weeks of recruitment, who
consented to be involved in the study. Only respondents of the legal age of 18 years or above were invited to join
this survey. The exclusion criteria were those under the legal consenting age.
Data was collected using a combination of both face-to-face interview. Responses were captured using tablets with
built-in quality control to minimize errors and was uploaded to the server in the institute after the quality check
done. Data collection was done within the clinic vicinity. Information sheet and consent forms were made available
to every respondent.
2.1 Variable Definition
In this study unplanned pregnancy was defined as responded ‘yes’ to the question “Was your last pregnancy
planned or unplanned?” was used to categorise the pregnancy as planned or unplanned.
Ethnicity was classified based on the major ethnic groups in Malaysia: Malays, Malaysian Chinese, and Malaysian
Indian. Sarawakian and Sabahan are indigenous groups from local Sarawakians and Sabahans and Orang Asal, and
‘Others” was mostly composed of foreigners, immigrants, both legal and illegal, residing in Malaysia. The religion
was based on the main religious in Malaysia, Islam, Buddhism, Hinduism, Christianity, Other religion and No
religion.
The education levels were categorized based on the Malaysian education system. Respondents were considered to
have no formal education/primary education if they had not attended any formal schooling or had only completed
up to 6 years of primary school. Those who had completed 11 years of formal schooling were defined as having
completed secondary education while respondents with diplomas or higher qualifications were considered as
having completed tertiary education. Household income was categories by locally accepted group for household
income, calculated based on the pooled income of family members and categorized into six group.
Family support during confinement was defined as an answer of ‘yes’ to the questions “Did you observe a
confinement period after your last child birth” and “When you need help or have a problem, can you usually count
on family member for support?” Polygamous marriage and contraception use was defined as an answer of ‘yes’ to
the questions “Are you in a polygamous marriage?” and “Do you ever use any methods to avoid pregnancy?”
Intimate partner violence (IPV) was defined as a single or repeated experience of physical and/or sexual violence.
IPV assessed based on the questionnaire used in the WHO Multicounty Study on Women’s Health and Life Events
(WHO, 2005). Physical violence was defined as positive responses to a history of being slapped, pushed, beaten,
kicked, choked or threatened with a weapon, and sexual violence was defined as a positive response for any history
of sexual coercion, sex out of fear or forced to engage in a degrading sexual act. Emotional violence was defined as
a positive response ever having been insulted, publicly humiliated, intimidated or threatened or had a partner who
threatened to hurt the respondent herself or someone she cared about (Ahmad NA, et al., 2018).
2.2 Statistical Analysis
SPSS version 21 was used for data analysis. Descriptive analysis was performed to study the distribution of
unplanned pregnancy in pregnant women in Malaysia. The bivariate analysis was done looking for association
between an independent variable and unplanned pregnancy. Finally, all the variables were included in the
multivariate logistic regression model. The findings were presented as adjusted odd ratio with 95% confident
interval and a p value less than 0.05 was considered significant.
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3. Results
3.1 Socio-Demographic Profile of Sample
A total of 5727 Malaysian postpartum mothers were involved in this survey. Among age groups, the highest
percentage was from those aged 25-29 years old (33.0%), while for the respondents’ husband’s age was from 30-34
years old (32.3%). More than half of them were Malay (63.3%), Islam (74.2%), mothers with secondary education
(60.0%), not working mothers (53.6%). By household income, the highest percentage was from RM5000 and
above group. Only 1.3% of them were not married or had no current partner. The details of socio-demographic
characteristics of the respondents are shown in Table 1.
Table 1. Socio-demographic characteristics of the respondents (n=5727)
Frequency %
Respondent’s age group
18-19 years old 140 2.4
20-24 years old 903 13.9
25-29 years old 1842 33.0
30-34 years old 1749 31.5
35-39 years old 866 15.4
40-44 years old 207 3.6
45-49 years old 20 0.2
Husband’s age
15-19 years old 32 0.5
20-24 years old 368 6.0
25-29 years old 1429 23.9
30-34 years old 1794 32.3
35-39 years old 1098 21.4
40-44 years old 841 10.6
45-49 years old 204 3.4
50 years old and above 108 1.8
Ethnicity
Malay 3889 63.3
Chinese 549 12.8
Indians 262 4.1
Sarawakian 253 5.8
Sabahan 471 9.0
Orang Asal 29 0.6
Others 274 4.3
Religion
Islam 4501 74.2
Buddha 521 12.1
Hindu 237 3.7
Christian 414 8.3
Other religion 9 0.3
No religion 45 1.3
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Education level
No formal/primary education 382 7.2
Secondary education 3300 60.0
Tertiary education 2045 32.8
Occupation
Working 2807 46.4
Not working 2919 53.6
Marital status
Married/have partner 5654 98.7
Not married/no current partner 73 1.3
Household income
Less than RM1000 513 11.2
RM1000-1999 1282 23.1
RM2000-2999 1044 18.2
RM3000-3999 894 14.4
RM4000-4999 532 8.3
RM5000 and above 1462 24.7
Family Support
Yes 5229 90.2
No 464 8.8
No other family member 34 1.0
Polygamous marriage
Yes 76 1.4
No 5560 98.6
Contraception use
Yes 3011 55.3
No 2710 44.7
Disagreement of husband on contraception
Yes 632 11.2
No 5094 88.8
Alcohol drink
Yes 21 0.4
No 5634 98.6
Uncertain 70 1.4
Smoking
Yes 28 0.5
No 5666 99.1
Uncertain 33 0.4
History of Emotional IPV
Yes 5523 3.8
No 198 96.2
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History of Physical IPV
Yes 123 97.5
No 5592 2.5
History of Sexual IPV
Yes 65 98.8
No 5659 1.2
3.2 Prevalence of Unplanned Pregnancy and Associated Factors
The prevalence of unplanned pregnancy was 42.9% (95% CI: 38.6, 47.4). By age group the prevalence was highest
among older mothers aged 45-49 years old at 79.3.4% (95% CI: 53.7, 92.7) while for husband’s age, the highest
prevalence was among youngest husband aged 15-19 years old at 65.5% (95% CI: 37.6, 85.7). By ethnicity,
Sabahan native showed the highest prevalence of 47.4% (95%CI: 36.4, 58.6). Mothers with no formal education or
only primary education were found to be more prevalent to unplanned pregnancy with the prevalence of 47.2% (95%
CI: 40.5, 54.0). According to household income, the highest prevalence was among less than RM1000 group at
49.1% (95% CI: 41.2, 57.1) (Table 2). Unmarried/no current partner mothers were noted to have significantly
higher prevalence at 84.9% (95% CI: 70.9, 92.9) as compared to married mothers (42.4%; 95% CI: 38.0, 46.9).
Mothers in polygamous marriage were found to have higher prevalence at 44.0% (95% CI: 27.8, 61.6) as
compared to monogamous marriage at 42.5% (95% CI: 38.1, 47.0).
Table 2. Prevalence of unplanned pregnancy by socio-demographic characteristics (n=5727)
Variable
Unplanned pregnancy
P value *
Frequency, n % 95% CI
Respondent’s age group <0.001
18-19 years old 76 48.7 33.0, 64.7
20-24 years old 407 44.1 37.4. 51.0
25-29 years old 772 41.3 36.4, 46.3
30-34 years old 667 38.8 34.2, 43.7
35-39 years old 394 47.7 41.4, 54.0
40-44 years old 119 63.4 54.3, 71.7
45-49 years old 16 79.3 53.7, 92.7
Husband’s age 0.006
15-19 years old 21 65.5 37.6, 85.7
20-24 years old 176 47.4 37.0, 58.0
25-29 years old 598 40.3 34.5, 46.2
30-34 years old 709 40.7 36.0, 45.6
35-39 years old 424 38.9 33.2, 44.8
40-44 years old 253 48.5 41.2, 55.8
45-49 years old 117 53.8 43.7, 63.6
50 years old and above 56 56.0 42.4, 68.8
Ethnicity 0.232
Malay 1719 44.9 40.5, 49.5
Chinese 194 36.3 27.2, 47.1
Indian 123 44.4 32.1, 57.5
Sarawakian 95 29.3 14.8, 49.6
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Sabahan 198 47.4 36.4, 58.6
Orang Asal 15 44.2 19.3, 72.4
Others 109 39.9 29.7, 51.0
Religion 0.064
Islam 1987 45.5 41.3, 49.8
Buddha 187 36.5 27.6,46.5
Hindu 113 43.8 29.3, 59.4
Christian 144 30.3 19.1, 44.4
Other religion 4 48.3 13.4, 85.0
No religion 18 33.2 19.2, 51.0
Education level 0.438
No formal/primary education 172 47.2 40.5, 54.0
Secondary education 1445 43.0 38.2, 48.0
Tertiary education 836 41.8 36.4, 47.5
Occupation 0.330
Working 1144 41.5 36.7, 46.5
Not working 1309 44.2 38.9, 49.6
Marital status <0.001
Married/have partner 2396 42.4 38.0, 46.9
Not married/no current partner 57 84.9 70.9, 92.9
* Rao-scott adjusted chi-square statistic. Significance is based on the adjusted F and its degrees of freedom.
3.3 Maternal Factors
Mothers with no contraception use were noted with a higher prevalence of unplanned pregnancy at 45.8% (95% CI:
40.4, 51.3). Alcohol drink and smoking during pregnancy showed significantly higher prevalence of unplanned
pregnancy with the prevalence of 56.3% (95% CI: 26.3, 82.3) and 73.7% (95% CI: 46.2, 90.2) respectively.
3.4 Support System
With regards to family support, mothers with no other family member showed the highest prevalence of unplanned
pregnancy at 65.1% (95%CI; 37.2, 85.5). Alcohol drink and smoking during pregnancy showed significantly
higher prevalence of unplanned pregnancy with the prevalence of 56.3% (95% CI: 26.3, 82.3) and 73.7% (95% CI:
46.2, 90.2) respectively. In term of intimate partner violence, mothers with history of emotional, physical and
sexual prevalence were revealed to have higher prevalence at 61.0% (95% CI: 45.2, 74.8,), 60.5% (95%CI: 41.5,
76.9) and 76.2% (95%CI: 58.3, 88.0) accordingly (Table 3).
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Table 3. Factor associated with unplanned pregnancy (n=5727)
Variables Odd ratio, OR CI (95%)
Adjusted odds ratio, aOR
aOR CI (95%)
Family Support
Yes - -
No 1.299 0.74, 1.733 1.150 0.856, 1.545
No other family
member 2.567 0.847, 7.779 2.867 0.751, 0.944
History of Emotional IPV
Yes 2.142 1.150, 3.987 1.720 1.011, 2.925
No - -
History of Physical IPV
Yes 2.078 0.992, 4.350 1.329 0.728, 2.429
No - -
History of Sexual IPV
Yes 4.318 1.828, 10.199 2.746 0.842, 8.948
No - -
3.5 Predictors of Unplanned Pregnancy
Table 4 shows the multivariate logistic regression revealed that elder mothers aged 45-49 years old (aOR: 8.010;
95%CI: 1.909, 33.013) and Muslim mothers (aOR: 2.465; 95%CI: 1.432-4.241) were significantly associated with
unplanned pregnancy. In term of household income, mothers in the group of less than RM1000 per month were
1.712 (95% CI: 1.080, 2.713) times more likely to have an unplanned pregnancy. The other associated factor was
history of emotional intimate partner violence with AOR of 1.720(95% CI: 1.011, 2.925).
Table 4. Multivariate analysis of the factors associated with unplanned pregnancy (n=5727)
Variables Odd ratio, OR CI (95%)
Adjusted odds ratio, aOR
aOR CI (95%)
Respondent’s age group
18-19 years old 1.352 0.743, 2.458 1.279 0.753, 2.174
20-24 years old 1.121 0.900, 1.397 0.988 0.775, 1.267
25-29 years old R R
30-34 years old 0.903 0.768, 1.061 1.000 0.805, 1.244
35-39 years old 1.296 1.018, 1.648 1.493 1.098, 2.030
40-44 years old 2.466 1.590, 3.822 2.731 1.586, 4.702
45-49 years old 5.453 1.672, 17.786 8.010 1.909, 33.013
Religion
Islam 1.925 1.036, 3.577 2.465 1.432, 4.241
Buddha 1.326 0.701, 2.509 1.310 0.581, 2.953
Hindu 1.794 0.700, 4.599 0.990 0.158, 2.953
Christian R R
Other religion 2.151 0.407, 11.360 2.112 0.560, 7.961
No religion 1.145 0.568, 2.308 1.360 0.483, 3.832
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Household income
Less than RM1000 1.654 1.115, 2.455 1.712 1.080, 2.713
RM1000-1999 1.370 0.993, 1.889 1.497 1.028, 2.179
RM2000-2999 1.377 1.069, 1.773 1.506 1.112, 2.040
RM3000-3999 1.295 0.980, 1.712 1.378 1.042, 1.822
RM4000-4999 1.404 1.021, 1.928 1.430 1.046, 1.957
RM5000 and above R R
Control for husband’s age, ethnicity, education level, occupation, marital status, polygamous marriage, contraception use,
disagreement of husband on contraception, alcohol drink, and smoking.
R=reference.
4. Discussion
There are many factors associated with unplanned pregnancies and studies have reported different determinants
and different predictors on this issue. These factors can be divided into sociodemographic and socioeconomic
which included couple’s age, their socioeconomic status, education, occupational status and residential area. The
associated fertility related factors included mother’s age at the time of marriage, gravidity and parity. Other related
factors included the use of contraceptives, substance abuse and intimate partner violence.
Our findings revealed, 42.9% of the pregnancies were unplanned. The analysis was focused on the last pregnancy
with the intention of minimizing recall bias. The current rate is lower than findings in the United States, a
developed country, 49% of pregnancies were unplanned (CDC, 2015) but consistent with reports from other
studies which reported average prevalence to be 35% ranging from 13% to 82% (Ali, Tikmani, & Qidwai, 2016;
Habte, Teklu, Melese & Magafu, 2013). There is no data on unplanned pregnancies in Malaysia however various
data estimates 25% of unplanned pregnancies in Malaysia (Helen, 2015).
4.1 Maternal Age
Our study showed that the prevalence of unplanned pregnancies was highest among the older mothers aged 45- 49
years old at 79.3%. Studies found that women’s age was the best predictor of pregnancy intention (Ali, Tikmani, &
Qidwai, 2016). In a systematic review study, age was positively related to unplanned pregnancy and more studies
found older women were more likely to experience unplanned pregnancy compared to younger women (Ali,
Tikmani, & Qidwai, 2016). On the contrary, studies from Nigeria, Vietnam and Bangladesh have found that
women usually experienced unplanned pregnancy at extreme childbearing age groups, both the younger and older
age groups (Okonofua, Odimegwu, Ajabor, Daru, & Johnson, 1999; Cu Li, Magnani, Rice, Speizer, & Bertrand,
2004; Rahman, 2012; Kamal & Islam, 2011). Older women were found to prefer natural contraceptive methods
compared to modern contraception which resulted in contraceptive failure. (NIPORT, 2009).
4.2 Education Level
Mothers with no formal education or only received a primary education were found to be more prevalent to an
unplanned pregnancy with the prevalence of 47.2% in this study. Women's education is an important factor in
explaining the fertility and fertility behavior of women. Many studies concluded a significant relationship between
educational level and the likelihood of unplanned pregnancies (Ali, Tikmani, & Qidwai, 2016). Our finding is
consistent with other studies which showed that women with primary or less education were more likely to
experience unplanned pregnancy (Habte, Teklu, Melese & Magafu, 2013; Tebekaw, Aemro, & Teller, 2014; Islam
& Rashid, 2005; Takahashi et al., 2012). As the educational level increases the prevalence of unplanned
pregnancies would decrease. Literate women have more knowledge on their rights and responsibilities to
participate and hence can plan for their own reproductive and sexual health (Habib et al., 2017).
4.3 Socioeconomic Status
A systematic review found women with high economic status were less likely to experience unplanned pregnancy
(Ali, Tikmani, & Qidwai, 2016). Significant relationships were found between economic factors and pregnancy
intention (Okonofua, Odimegwu, Ajabor, Daru, & Johnson, 1999; Adhikari, Soonthorndhada, & Prasartkul, 2009).
Similar to our findings, mothers in the group of less than RM1000 per month were 71% higher have an unplanned
pregnancy. The financial constraint was the most important factor determining the intention of pregnancy.
Generally, women with high economic status were less likely to experience an unplanned pregnancy. These
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findings suggest that women from poor income group were less likely to afford family planning services or less
likely to have access to the family planning services (NIPORT, 2009).
4.4 Socio Cultural, Religion and Women’s Autonomy
In our study Muslim mothers were found to be significantly associated with unplanned pregnancy. This is similar
to a study done in Bangladesh, where Muslim women, as compared to non-Muslim, had a higher incidence of
unplanned pregnancy (30.9% vs. 20.3%) (Cu Li, Magnani, Rice, Speizer, & Bertrand, 2004). Malaysia, being a
Muslim country, the majority (61%) of our population is a Muslim (DOSM, 2010). Our findings could be related to
the Islamic institution who put husbands as the one in charge of the family and any other decision making
pertaining family matters (Omran, 1992).
Social norms also limit women’s freedom to make important decisions as they are dependent on their male partners
for their daily living (Ali, Ali, & Suhail, 2016; Rahman, 2012). In developing countries, men are usually
considered as the main decision maker especially in the male dominant societies. The men will decide on the health
seeking behavior pattern of the family members including the use of contraception. (Ali, Ali, & Suhail, 2016;
Rahman, 2012). Women who have discussed the intention of taking family planning showed less prevalence of
unplanned pregnancy compared to women whose have never discussed it with the husbands (28.4% vs. 31.1%)
(Kamal & Islam, 2011). Findings relate that Muslim women are less likely to use modern methods due to their
traditional beliefs and cultural norms and older women are more reluctant to use modern methods as compared to
their younger counterparts, resulting in higher risk of unplanned pregnancy among the former (NIPORT, 2009).
A report had shown contraceptive prevalence rate in Malaysia for all available method is 55% and for modern
methods is 32%. This is much lower compared to global, 63% and lesser than neighbouring countries, Singapore
55.1% and Thailand 77.5%. (Najimudeen & Sachchithanantham, 2014). Husband’s objection (8% - 12.6%)
contributed for the reasons for not using contraceptive methods. (Najimudeen & Sachchithanantham, 2014).
4.5 Emotional Intimate Violence
The other associated factor that was significant in our study was history of emotional intimate partner violence. In
a study done by Stella Martin et al, similar findings were noted. Emotional intimate partner violence was
associated with unplanned pregnancy aOR=2.5, 95% CI + 1.5 – 4.3) (Martin-de-las-Heras, Velasco, de Dios Luna,
& Martin, 2015).
Strengths and Limitations
The main strength of our study is the large nationally represented data with a robust method. The response rate was
good (85.9%) and various socio-demographic and socio-cultural factors were examined.
Nevertheless, our findings have several limitations. There was no data on the locality of the samples. Accessibility
to health services was not explored. Details of the unintended pregnancy should be probed further as it could be
‘mistimed’ instead of unintended.
Conclusion and Policy Implication
This study examined the prevalence and socioeconomic correlates of unplanned pregnancy among Malaysian
women who attended the government primary health care clinics during the perinatal period. Findings revealed
overall, 42.9% of the most recent pregnancies were unplanned. Significant predictors of unplanned pregnancy
found were elder mothers aged 45–49 years old, Muslim mothers, mothers of lower household income and
mothers with a history of emotional intimate partner violence. Studies should be conducted to find reasons for the
unplanned pregnancies. The relationship between education, health economic status and women’s sexual and
reproductive health practices should be studied. The positive association between unplanned pregnancies among
Muslim women reflects an association with the religious and cultural belief. Therefore, there is a special concern to
see the effect of religion and culture on contraceptive practices. Family planning services are offered free of charge
by government health facilities in Malaysia. Although services are free, contraception usage rates are still low. A
study should be conducted to identify the unmet needs of family planning in Malaysia.
Acknowledgements
We would like to thank the Director General of Health Malaysia for his permission to publish this article. We also
thank the Deputy Director General of Health (Research and Technical Support) for continuous support and
guidance. Our gratitude goes to the Asia Pacific International Research and Education (ASPIRE) Network for their
contribution to the concept of this study and to everyone involved in making this study a success.
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141
Competing Interests Statement
All authors declare no competing interest.
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