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Background: Women in sub-Saharan Africa (SSA) have a higher risk of unintended pregnancies that are more likely to be terminated, most of which are unsafe with associated complications. Unmet need for contraception is highest in SSA and exceeds the global average. This study investigates the association between unmet/met need for contraception and pregnancy termination SSA. Methods: We used pooled data from Demographic and Health Surveys conducted from January 2010 to December 2018 in 32 countries in SSA. Our study involved 265,505 women with diverse contraception needs and with complete data on all variables of interest. Multilevel logistic regression at 95% CI was used to investigate the association between individual and community level factors and pregnancy termination. Results: We found an overall pregnancy termination rate of 16.27% ranging from 9.13% in Namibia to 38.68% in Gabon. Intriguingly, women with a met need for contraception were more likely to terminate a pregnancy [aOR = 1.11; 95% CI 1.07–1.96] than women with unmet needs. Women with secondary education were more likely to terminate a pregnancy as compared to those without education [aOR = 1.23; 95% CI 1.19–1.27]. With regards to age, we observed that every additional age increases the likelihood of terminating a pregnancy. At the contextual level, the women with female household heads were less likely to terminate a pregnancy [aOR = 0.95; 95% CI 0.92–0.97]. The least socio-economically disadvantaged women were less likely to terminate a pregnancy compared to the moderately and most socio-economically disadvantaged women. Conclusions: Our study contributes towards the discussion on unmet/met need for contraception and pregnancy termination across SSA. Women with met need for contraception have higher odds of terminating a pregnancy. The underlying cause of this we argued could be poor adherence to the protocols of contraceptives or the reluctance of women to utilise contraceptives after experiencing a failure. Governments of SSA and non-governmental organisations need to take pragmatic steps to increase met needs for contraception and also utilise mass media to encourage women to adhere to the prescription of contraceptives in order to reduce the incidence of unplanned pregnancies and unsafe abortions.
This study used the most recent DHS data from 32 countries in SSA that were conducted between January 2010 and December 2018. Specifically, data was extracted from the women’s files of the DHS data sets of the countries. The DHS are national surveys carried out every five years in over 90 low- and middle- income countries globally [19]. The DHS concentrates on non-communicable diseases, maternal and child health issues, physical activity, sexually transmitted infections, fertility, health insurance, tobacco use, and alcohol consumption. The surveys mainly provide data to monitor the demographic and health profiles of the respective countries [19]. The sample for the present study consisted of women with unmet/met need for contraceptives (aged 15–49) and had complete cases on all variables of interest (N = 265,505). The DHS program granted us access to the dataset after the evaluation of our concept note. The datasets are freely available to the public at www.measuredhs.com. The outcome variable of this study was ever terminated a pregnancy. This was derived from the question “have you ever had a pregnancy terminated?”. It was coded as 0 = “No” and 1 = “Yes”. Undeniably, due to the measurement approach, this variable may include some spontaneous abortion cases. However, the range of induced abortion found in this study (9.13%–38.68%) and the average (16.27%) are comparable to the prevalence reported from some of the countries included in this study such as Burkina Faso (12%) [20], Nigeria (23%) [21], Ghana (24%–25%) [15, 22] and Ethiopia (33.6%) [23]. This shows that the majority of the reported prevalence in this study are induced abortions and as such findings and recommendations from the study may be instructive to governments of sub-Saharan Africa. The main explanatory variable was unmet/met need for contraception and thirteen other explanatory variables were considered as well. All these variables were grouped into individual and contextual level variables based on the hierarchical nature of the dataset. The variables were selected based on their availability in the dataset, practical significance and theoretical relevance for unmet/met need for contraception and pregnancy termination in previous studies [15, 24, 25]. Unmet/met need for contraception was accompanied by these responses: never had sex, unmet need for spacing, unmet need for limiting, no unmet need, not married and no sex in the last 30 days, and infecund and menopausal. Women who had never had sex, and infecund/menopausal women were excluded from the analysis because they were not exposed to the contraceptive need measurement [15, 25]. We then generated a binary measure of contraception needs by coding the rest of the responses into ‘unmet need’ (unmet need for spacing and unmet need for limiting) = 0 and ‘met need’ (no unmet need, using for spacing and using for limiting) = 1 [25]. The other explanatory variables were age, wealth status, education, marital status, and parity. Age was recorded as 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, and 45–49. Wealth status was categorized into poorest, poorer, middle, richer, and richest. Education was classified into four categories: no education, primary education, secondary education, and higher education. Three variables were considered at the contextual level, namely place of residence, socio-economic disadvantage, and sex of head of household. The socio-economic disadvantage variable was generated from the education and occupation variables and captured as tertile 1(least disadvantaged), tertile 2 (moderate disadvantaged), and tertile 3 (most disadvantaged). The sex of the household head was captured as male and female. We employed both descriptive and inferential analytical approaches. First, we computed the proportion of women who had ever terminated a pregnancy (see Table Table1).1). Following the hierarchical nature of the data set, the Multilevel Logistic Regression Model (MLRM) was employed. This comprises fixed effects, and random effects [26]. The fixed effects/measures of associations of the model were gauged with binary logistic regression which resulted in odds ratios (ORs) and adjusted odds ratios (aORs) (see Table Table2).2). The random-effects/ measures of variations, on the other hand, were assessed with Intra-Cluster Correlation (ICC) [27] (see Table Table2).2). All the analyses were carried out using STATA version 13.0. Background characteristics and proportion ever terminated pregnancy Multilevel binary logistic regression results on the predictors of pregnancy termination among women with unmet/met need for contraception in sub-Saharan Africa χ2 = 158.11 p = 0.0000 χ2 = 196.68 p = 0.0000 χ2 = 157.85 p = 0.0000 χ2 = 200.96 p = 0.0000 *p < 0.05 **p < 0.01 *** p < 0.001 We assessed the fitness of all the models with the Likelihood Ratio (LR) test. The presence of multicollinearity between the independent variables was checked before fitting the models. The variance inflation factor (VIF) test revealed the absence of high multicollinearity between the variables (Mean VIF = 2.98).
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