Introduction

Approximately half of all pregnancies, totalling 121 million or 331,000 per day on average each year globally, are unintended (1). Though the unintended pregnancies have declined globally, this rate remains considerably high in developing countries (2). In India, data from the first three rounds of National Family Health Surveys (NFHS) conducted during 1992-93, 1998-99, and 2005-06, respectively, indicate that approximately one-fourth of the women reported their pregnancies as unwanted (3,4). However, the subsequent fourth and the fifth round of the NFHS conducted in 2015-16 and 2019-21 showed only one percent decline in this proportion (5,6). The fifth round of the NFHS conducted in (2019-21) estimates that eight percent women stated that their pregnancy was unwanted and exhibited nine percent unmet need for contraception (6). This reveals that women who want to stop childbearing are still not using contraceptives, resulting in an unwanted birth. The idea of unwanted pregnancy had been of great importance for demographers to depict fertility behaviour and estimate the levels of unmet need for contraception and family planning. Preventing an unwanted pregnancy was an integral part of achieving the Millennium Developmental Goal and is still an indispensable part of the Sustainable Development Goal.

India, being the most populous country in the world, faces unique challenges in reproductive health and family planning. During the 1950s, policymakers realized that with India's limited resources, the country's growing population could dampen its economic growth. Over the years, India has taken various measures to tackle population growth and family planning issues. In the London Submit 2012, India committed to spending $3 billion by 2020 for family planning programs, to improve the access, choice and quality of family planning services and to increase modern contraceptive usage from 53.1% to 54.3% and to ensure that the three-fourths of the demand for modern contraceptives is fulfilled by 2020 (7).

Unwanted births in India represent a crucial concern within the realm of reproductive health and family planning (8,9). These pregnancies can negatively impact the quality of life of the mother and the child (10). Pregnancy can be unintended for various social and economic reasons, for example, no desire to have an additional child at the moment, unavailability of financial resources to bear the expenses of another child, lack of access to contraception (8,11). Unwanted pregnancies result mainly from the ambivalent fertility desires of women or their spouses during their fertility course. These ambivalent women may change their fertility desires attributed to various reasons, like the desire to have more sons (12,13) and the loss of a child (14,15). Studies reflect that various factors contribute to unwanted pregnancies in India, such as the place of residence, religion and ethnicity of household, age of mother, age at marriage, duration of the marriage, age at first cohabitation, education of mother and father (16–18) contraceptive use (16,19), and husband's decision on fertility (14,20–22).

Many studies on unwanted birth indicate an under-estimation of the unwanted birth using a cross-sectional study design where women may consider their unwanted pregnancy as wanted post-delivery or at the time of raising the child (23–26). Various studies have adopted different methodologies to measure unwanted pregnancies using the cross-sectional study design. John Bongaarts (1990) was the first to measure the wanted pregnancy using information on the desire for more children (24). A study based on India by Kulkarni and Choe (1998) proposed an actual and wanted parity progression ratio to measure wanted pregnancy (27). Pregnancies have also been measured as wanted or unwanted based on the women's self-reporting of their pregnancy status as wanted or unwanted (28). A recent study based on cross-sectional data estimated unwanted pregnancies based on ideal and actual living children (29).

Estimation of unwanted births based on cross-sectional data has its own limitations. On the other hand, the panel study design provides a unique opportunity to calculate the exact measure of unwanted births in India, and its main risk factors. The use of the panel data set can help determine the changing reproductive intentions and attitudes. The availability of panel data on sexual preferences provides a unique opportunity to bring about a different perspective on fertility choices and behaviour. Furthermore, panel studies offer the best way to determine whether ambivalent women behave according to their intentions (13).

Studies on unwanted pregnancies using cross-sectional data have concentrated mainly on two questions - desired and the ideal number of children (24,29), which may change over time. Using a panel study design can result in the accurate prevalence of unwanted births in India. Using a panel study like the Indian Human Development Survey (IHDS) to estimate unwanted pregnancy holds significant importance for policy makers and planners because it provides a more precise estimate than that obtained through cross-sectional data with potential bias. Against this background, this study endeavours to estimate the prevalence of unwanted pregnancy and its determinants utilizing the first two rounds of the IHDS data conducted during 2004-05 and 2011-12.

Data source

The present study uses the two rounds of the IHDS data, IHDS I and II, conducted during 2004-05 and 2011-12, respectively. In IHDS I, the total sample consisted of 215,754 individuals across 41,554 urban and rural households covering all states and union territories of India, except Andaman, Nicobar and Lakshadweep islands. The IHDS II survey interviewed 42,152 households and covered 204,568 individuals from 1420 villages and 1042 urban blocks of India; around 83% were re-interviewed consisting of 204,569 individuals across 42,152 urban and rural households and 25,479 eligible women covering all states and union territories of India, except for Andaman, Nicobar and Lakshadweep islands. A total of 2134 new households were added in IHDS-II, and thus they did not have a counterpart in IHDS-I. The 6911 households from IHDS-I did not have an counterpart in IHDS-II since they were lost due to follow-up. Therefore only 22,962 married and fertile women in the IHDS-I (2004-05) survey were selected for the analysis. For the present study, only the status of the child as being wanted or unwanted is considered, and the pregnancies or births that were mistimed were not included.

Outcome variables

The principal interest of the study was to check an unwanted pregnancy between the surveys. The eligible women's responses to the desire to continue childbearing in IHDS-1 (2004-05) was utilized. Women's willingness to continue childbearing was obtained by asking, "Do you want more children (in addition to the child you are now carrying?". The response categories were: "No", "No sterilized (Husband)", "Not fertile anymore", "Yes", and "Unsure". For analysis purposes, the categories were recorded as: 'wants more' (want another child) and 'no more' (those who don't want any more children). Women who considered themselves infecund in IHDS-I were not included in the analysis. The dependent variable was dichotomous with "0" occurrence of no live birth in between the surveys of those who stated “No” desire for another child in IHDS-I and "1" occurrence of at least one live birth in between the survey of those who stated “No” desire for another child in IHDS-I."

Independent variables

The study incorporated a range of independent variables at the community, household, and individual levels, encompassing the mothers and children. The community-level variables was the place of residence (rural/urban). The household-level variables included wealth index (poorest, poorer, middle, richer, richest) a proxy for the socio-economic status of the household, religion (Hindu, Muslim, Others), and caste (Scheduled Caste (SC), Scheduled Tribe (ST), Other backward class (OBC), Others). The caste of the women is categorized based on the frequency distribution and also according to the DHS–India (2015-16) categorization of caste (5). Individual-level variables included women’s age in completed years (less than 20, 20-24, 25-29, 30-39, 40 and above), woman's education (no education, primary education, secondary education, higher education), duration of marriage (0-4, 5-9, 10-14, more than 15 years), current contraceptive use (not using, using), husband desire for more children (doesn't want, want); total number of living son (no son, one son, two sons and 2+ son); ideal number of children in relation to actual living children (ideal=actual living children, ideal>actual living children, Ideal <actual).

Statistical measures

For this study, the data from the women's files from the two rounds of the IHDS survey was merged to construct a panel dataset. Subsequently, pooled binary logistic regression analysis was conducted to determine the predictors of unwanted pregnancies among currently-married women. The adjusted odds ratio (AOR) and the 95% confidence interval (CI) were calculated. Additionally, descriptive and univariate analyses was also conducted on the panel data to investigate the socio-economic and demographic variables linked to unwanted pregnancies among women in India. All statistical analyses were performed using Stata version 14.

Conceptual framework

The conceptual framework expands upon prior knowledge to elucidate the connection between unwanted pregnancies and the socio-demographic and life cycle factors that underlie them. During IHDS-I, a group of women expressed their intention of not having any more children; however, some of them did indeed give birth in the inter-survey period between IHDS-I and IHDS-II. This suggests that a range of community, household, and individual factors might have influenced the women who experienced live births during the inter-survey period. These factors could potentially contribute to the occurrence of unwanted pregnancies. Figure 1 provides a representation of the conceptual framework.

Results

To provide a different perspective on the significance of responses regarding the desire to continue childbearing, the reproductive behaviour of currently married women in IHDS-I (2004-05) and their willingness to continue childbearing was analyzed. Table 1 reveals that in IHDS-I, out of the total number of women surveyed, 39% did not desire to continue childbearing, 21% desired to continue childbearing, while 40% had either been sterilized or had become infecund.

Among the 9,007 women who did not wish for more children, 26% experienced an unwanted birth between the two survey periods (Table 2).

To measure the extent of unwanted births among currently married women who did not want any more children in IHDS-I (2004-05), we presented the percentage distribution of women who had experienced unwanted births during the inter-survey period, categorized according to the background characteristics (Table 3).

The associations between unwanted births and the independent variables were tested using chi-square tests at 5% significance level. Out of total unwanted births, a little over four-fifths of unwanted births were from rural areas, and only 16% were from urban areas. Religion and caste had a crucial role in determining women's fertility behaviour. Among all religious groups, four-fifths of the unwanted births were among Hindus, followed by Muslims. There was not much difference between the unwanted births reported by the women from SC/ST (34%) and OBC (38%). Around one-fifth of the women from Other caste group reported unwanted birth. Older women and those in long-term marriages exhibited more consistent behaviour compared to younger and recently married women, who had a higher incidence of unwanted births between the two survey periods. The use of contraception among those who experienced unwanted births was approximately 19%, while non-users accounted for around 65%, indicating the unmet need for contraception. Husband’s desire had a significant association with in determining subsequent fertility.

Multivariable model result

The binary logistic regression model was carried on after adjusting for all covariates to examine the factors affecting unwanted pregnancies. The results of the multivariable logistic regression model are presented in Table 4, showing the AOR of unwanted births with a 95% CI.

After controlling for the background factors, it was found that Muslim women had significantly higher odds (AOR = 2.81, 95% CI = 1.73–4.59) of experiencing unwanted births. Women belonging to the SC/ST caste were more likely to experience unwanted births than women belonging to Others caste groups (AOR = 1.41, 95% CI = 1.13-1.77). Women aged 40 years and above were less likely to report unwanted births (AOR = 0.02, 95% CI = 0.01-0.03) relative to younger women (less 20 years). Women's educational level also showed a significant association with unwanted births. Women with primary education were less likely to experience unwanted births (AOR = 0.66, 95% CI = 0.53-0.81) compared to the women with no formal education. The duration of marriage also significantly affected unwanted births. Women married for more than 15 years had lower odds of experiencing unwanted births (AOR = 0.27, 95% CI = 0.07-0.96) compared to women married for 0-4 years. Contraceptive use was another significant determinant of unwanted pregnancies, with modern contraceptive users 79% less likely to report unwanted births (AOR = 0.21, 95% CI = 0.18-0.24) compared to non-users of contraceptives.

In a patriarchal social setup, women's decisions are often influenced by their spouse's desires, especially regarding fertility choices. After controlling for other factors, it was found that if a woman's husband desired for more children, then women had 5.80 times higher odds of experiencing unwanted births (95% CI = 4.72-7.11) compared to women whose husbands did not want additional children. Son preference is prevalent in India, especially among couples with no sons. To achieve their desired number of children, couples may continue childbearing practices until they have the desired number of sons. The results reflect that women with at least one son were 50% less likely to experience unwanted pregnancies (AOR = 0.52, 95% CI = 0.43-0.63) compared to women with no sons. Additionally, achieving the desired fertility was a significant predictor of unwanted pregnancies. Women whose desired number of children exceeded their actual living children had 4.63 times higher odds of experiencing undesired pregnancies (95% CI = 3.94-5.46) than women whose ideal number of children matched their actual number of children.

Discussion

The study focuses on the unwanted pregnancy that has emerged as one of the global public health concerns. The study addresses the ambivalent fertility intentions among currently married women in India using the IHDS panel data conducted during 2004-05 and 2011-12. The study hypothesizes that a woman has experienced unwanted pregnancy if she stated no desire for an additional child in IHDS-I and has experienced a live birth between the two survey periods that is IHDS-1(2004-05) and IHDS-II (2011-12). The results showed that among the women who wanted to cease childbearing in IHDS-I, 74% were successful in averting an unwanted birth in the follow-up period. Nevertheless, 26% women among those who had no desire for an additional child in IHDS-I reported an unwanted birth between the two survey periods.

In the multivariable regression analysis, ambivalent fertility intention was an independent predictor of birth avoidance. The regression results indicated that Muslim women were more uncertain about their fertility intentions and were significantly more likely to experience unwanted births between the survey periods. Previous studies have also found a significant relationship between Muslim women and unwanted pregnancies (16,30–33). Among Muslims, the act of abortion is considered to be "haram", which means crime; this might be a possible reason for the unwanted pregnancies among them (34–37). Moreover, the knowledge and use of contraception among Muslim women from the poorest households was found to be lower compared to their Hindu counterparts (5). According to the fourth round of the NFHS, the unmet need for spacing was also highest among Muslims compared to other religions in India (5). Thus, the policies should focus on Muslim women as unwanted pregnancy among them is comparatively higher than women belonging to other religions.

Women residing in rural areas were found to experience more unwanted births than urban women. On similar lines, a study conducted using the Demographic health surveys data set of sub-Saharan African countries concluded that rural women were more likely to experience an unwanted birth than women residing in urban areas (38). On the contrary to this, a study conducted in India stated that urban women were more ambivalent about their fertility intentions than rural women (16), as the ideal family size is relatively smaller in the urban setting than in the rural area which results in more inconsistency in the fertility outcomes among the urban women. A study on Bangladesh also found higher unintended pregnancies among the women residing in urban areas relative to rural areas (39). Education also increases the odds of more consistent fertility outcomes among women. The logistic analysis results suggested that more educated women were less likely to experience an unwanted than uneducated women. A cross-sectional study conducted in India also showed that as the education level of the women increases, the odds of pregnancy be unwanted decreases (16).

Most rural women are not well educated, which prevents them from properly using contraceptive methods (40,41), which in turn results in higher levels of unwanted pregnancies among them.The odds of unwanted pregnancy decrease with the increase in the household's economic condition, which suggests that a woman belonging to a higher wealth quintile had a higher purchasing power to avail the family planning services than the women belonging to lower wealth quintiles (42–44). Also, a study conducted in India and the United States on a similar line showed that women from higher wealth quintile are less likely to report unwanted pregnancies than women from lower wealth quintile households (42,44). Moreover, a study conducted in 10 countries concluded that women from poor households were less likely to receive family planning services than women from higher wealth quintile households (45).

Women who have uncertainty in their fertility intention pose a significant challenge to family planning programs. It is expected that women who do not desire additional children should use contraceptives to limit their family size. However, the study findings show that these women were not using contraceptives in IHDS-I (2004-05). A study conducted in an Indian setting also concluded that the women using contraceptives were 36% less likely to conceive an unwanted pregnancy than the non-users of contraceptives (19). Fertility decisions are often situational and depend on the current circumstances, which can be modified in the given time. Still, the results from the present study, in a way, hint towards the role of patriarchy and desire for the son, which changes the course of fertility intention and results in an unwanted pregnancy.

The multivariable regression analysis also indicates that the woman's decision on desired fertility is influenced by her husband's choices. The husband's desire for another child showed a significant positive relationship with the woman's subsequent fertility, which indicates that a woman's reproductive behaviour is very much influenced by her spouse's desire for an additional child. Previous studies also showed that the husband plays a crucial role in altering the fertility intentions of the woman (14,20–22). Also, son preference cannot be ignored in a patriarchal set-up like India. The study also showed that having no son was essential in deviating from the previous fertility intentions. The deviations in the fertility intentions could be influenced by the society, in-laws, or driven by the husband's intention to have more sons. The husband’s preference for the sex of a child has a high impact on the fertility levels of a country (46).

Previous studies in India indicated that women tend to stop their childbearing as they reach the desired number of sons than a daughter (47,48). The present study used a panel study design for the analysis. As the objective of the study was to only measure the unwanted pregnancy, so we haven't captured the changes in fertility intentions from IHDS-I to IHDS-II was not captured. Also, since the data is quantitative and at the two-time points, we cannot capture the in-between survey factors, leading to unwanted pregnancy. So, we have used the covariates at the time period 1 and found their association with the unwanted bearing among the currently married women in India, which is generally used in many studies (32,49–51).

Conclusion

Unwanted pregnancies in India are a pressing issue that merits comprehensive exploration, and this study, utilizing panel data, contributes valuable insights into this complex phenomenon. The use of panel data is essential in providing more robust and less biased results compared to cross-sectional studies, as it allows us to track changes and dynamics over time (52). This research aligns with existing studies that have noted discrepancies between retrospective and prospective surveys in estimating the prevalence of unwanted pregnancies (53,54). These findings underscore the importance of methodological rigour when investigating sensitive issues like unwanted pregnancies and offer a more accurate foundation upon which to base policy decisions and family planning programs. The implications of our findings are significant for the design of future family planning programs in India. Despite the government's long-standing efforts to provide a range of contraceptive options since the 1950s, the persistence of a substantial number of unwanted pregnancies in India remains a formidable challenge. Our study highlights a high unmet need for contraception in the country, emphasizing the urgency of addressing this issue. Moreover, our research underscores the need for holistic approaches to combat unwanted pregnancies. This includes educational initiatives aimed at altering societal perceptions of gender and promoting the value of the girl child. While commendable initiatives like "Beti Bachao Beti Padhao Yojna" have been launched, our findings suggest room for further improvements. These programs should not merely target girls but should also engage with parents, communities, and households to remove deeply ingrained gender biases. Furthermore, counseling and education for couples should be prioritized in India's family planning strategy. In a context where husbands play a pivotal role in fertility decisions, it is imperative to include them in discussions around family planning. By engaging both women and men in conversations about contraception, family size, and reproductive health, we can promote more informed and empowered choices, ultimately reducing the incidence of unwanted pregnancies.

Abbreviations

NFHS National Family Health Survey

SC Scheduled Caste

ST Scheduled Tribe

OBC Other Backward Class

AOR Adjusted Odds ratio

DHS Demographic and Health Surveys

IHDS Indian Human Development Survey

CI Confidence Interval

WHO World Health Organization

Funding

The authors did not receive support from any organization for the submitted work.

Data availability

The present study is based on a large dataset that is publicly available on the India Human Development Survey (IHDS) conducted by the National Council of Applied Economic Research (NCAER) in India. The data is accessible from https://www.icpsr.umich.edu/web/DSDR/series/507

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval statement

This study requires no ethics approval for the authors as the analysis used only de-identified existing unit record data from the Indian Human Development Survey. We confirm that all methods were performed in accordance with the relevant guidelines and regulations.

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