Prevalence and Associated Factors of Unintended Pregnancy Among Pregnant Women Attending Antenatal Care Unit at Jimma University Medical Center: A Cross Sectional Study

year there are around 210 million pregnancies world-wide, out of these pregnancies, 44% of pregnancies are unintended and around 59% pregnancies ABSTRACT Background: Unintended pregnancy is an important public health problem in both developing and developed countries, because of its association with adverse social and health outcomes for mothers, babies, and family as a whole. Unintended pregnancies impose serious health problems to mothers and their infants by causing an unnecessarily high risk of pregnancy-related complications and self-induced abortions. Hence, this study aimed to determine the prevalence of unplanned pregnancy and assess associated factors among pregnant women attending antenatal care at Jimma University Medical Center.In this study a facility-based cross-sectional study design was conducted on pregnant women following antenatal care at Jimma University Medical Center from July 25 to August 20, 2019. A convenience sampling technique was used, and sample size was calculated as 194. The Prevalence of unintended pregnancy was 32.5% among the study sample; the majority of the unintended pregnancies were miss-timed followed by husband influence. The significant association (95% CI, p<0.05) was seen between unintended pregnancy and residence, education, and the use of modern contraceptive methods. The prevalence of unintended pregnancy was high in the study area; and programs improving educational status of the partner and knowledge of modern contraceptive methods is demanded.

ended by abortion. Most of these unintended pregnancies (65 pregnancies per 1000 women) happen in developing countries like Ethiopia [9,10]. Different studies done in Ethiopia indicate that the prevalence of unintended pregnancy is 37.8%, 36.9%, 33.3%, 36.5% and 32.9% in Addis Ababa [11], Dilla [12], Harar [13], Wellega [14], Debre Markos [15] respectively. There are multiple reasons for unplanned pregnancy, normally non-use of contraception, failure of contraception, unreliable method of contraception, failure of contraception, or rape [16]. Lack of knowledge on sexual and reproductive health is one important that contributed to unplanned pregnancy especially in teenage girls who are commonly left out in the national contraceptive program [17].
Unintended pregnancy is high among women who have lower/ no educational level, single women, women who have low income, women who have multiple sexual partners, unemployed women, women who didn't use family planning, multiparous mothers, young women, women who traveled long time to reach health facility, women who have more children, multi-gravida women, women who are not visited by health professionals, women who discussed with their husband and women who desire fewer children [11][12][13][14][15][16].Although several international declarations were passed on the problem, many in sub-Saharan Africa are suffering from unwanted pregnancy. In most African countries, abortion remains both unauthorized and unsafe, and the leading cause of maternal death accounted for a global average of 1.3% of pregnancy-related fatalities [17].This study aimed to assess the prevalence and factors associated with unintended pregnancy among pregnant women attending the antenatal care unit of Jimma university medical centre from July 25 to August 20, 2019.

Study Area and Period
This study was conducted among pregnant women who were attending the antenatal clinic at Jimma University Medical center (JUMC) from July 25 to August 20, 2019. JUMC is one of the teaching hospitals in Ethiopia, located 345 km southwest to Addis Ababa.

Study Design
An institutional-based cross-sectional study was employed.

Source Population
All pregnant women who attended ANC follow up at JUMC.

Study Population
All pregnant women who attended ANC follow up at JUMC during the study period.

Inclusion Criteria and Exclusion Criteria
Inclusion Criteria: Pregnant women who visited the ANC unit during the data collection period and who fulfilled the inclusion criteria were included.
Exclusion criteria: Pregnant women who had a hearing, speech problem, and critically ill were excluded from the study.

Sample Size and Sampling Technique
The sample size was determined based on the single population proportion formula, with an assumption that 29% of pregnant women are having unplanned pregnancy in the area [18]. With 5% margin of error (d) and confidence level of 95% (z α/2 = 1.96).
However, because, the total pregnant women attending the health care system were less than 10,000 and we used a correction formula to come up with the final sample size. A convenient sampling technique was used because the pregnant women attending the ANC unite in the area were quite limited and it was almost less than 500. Hence, Sample size is determined by using the following  Where ni-The initial sample size required P-National prevalence of unplanned pregnancies among woman in reproductive age =29% (17) d-The margin of sampling error tolerated Mostly5% zα/2-is 95% of confidence interval Since our source population is less than 10,000, which are 500 we use the correction formula as follows.

Data collection Method and Instrument
The data was collected by face to face interviews using a structured questionnaire and pre-tested questionnaire.

Data Quality Control
The questionnaire was prepared in English for the first time and translated to the local language by a person who does not have any involvement in the study as well as to the discipline. After the translation has over, all necessary modifications were taken place.
The data collectors were medical interns and midwifery, both of them were working at the ANC unit in JUMC. • Residence

Data Processing and Analysis
The collected data were first checked for completeness, entered, and analyzed by using Statistical Package for Social Science, SPSS (Version 21), chi-square test was used for a test of association between dependent and independent variables and presented in tables and figures.

Socio-Demographic Characteristics of the Respondents
From total study participants of 194 women interviewed 62.9% were Oromo in Ethnicity. From the total study participants 59.2% were 20-24 years age group at their first marriage and 93.3% were married in their marital status, 32% attend secondary education and about 44.8% were housewife in occupation and about 55.7% have income below poverty line (Table 1).

Knowledge and Practice of the study participants on Modern Contraceptives
The majority of the study participants 99% were aware of modern contraceptives. Their numbers for each source of information included: (66.5%) for health institutions, (32.5%) for mass media. About 53.1% knew more than one method of contraceptive. 53.1% knew at least one advantage of modern contraceptive methods and 45.9% knew more than one advantage.
68.6% of study participants had previously used modern contraceptive while 31.4% had never used any methods of modern contraceptives. Pills were the most frequently used method with 51.5% followed by Injectable for 38.6% (Table 2). Out of the total respondents 61(31.4%) have never used modern contraceptives, for most of them the reason not to use was fear of side effects (24.6%) which is followed by religious view(21.3%) (Figure 1). Figure 1: reasons for not using modern contraceptives among study participants.

Distribution of Respondents by Status of their Current Pregnancy
Out of the total participants 63(32.5%) respondents claimed their current pregnancy was unintended. Twenty eight (44.4%) claimed that the reason for their unintended pregnancy was that because it was miss timed that is they require the pregnancy in the future, which was followed by husband influence 13(20.6%) ( Figure 2).

Perception on Average Number of Children by Study Participants
As the number of times a woman become pregnant increases, tendency to experience unintended pregnancy increases. Most of the respondents 71(36.6%) perceived that 3 children in life are enough while only 2(1.0%) wish to have a single child. Those who claimed their current pregnancy was unplanned only 1(1.6%) wanted to have five and above children while those with planned current pregnancy17 (13.0%) of them wish to have (Table 3).

Factors associated with Unplanned Pregnancy Status
The chi-square analysis indicated that income status among study participants (P-value=0.2209), and religion (p-value=0.3629) were found not to be significant of association with unintended pregnancy; whereas residence (p-value=0.00001) modern contraceptive use (p-value=0.0175), Educational status (p-value=0.0130) were found to be significant of association with unintended pregnancy.

Discussion
The prevalence of unintended pregnancy in this study was 32.5% which is consistent with similar studies conducted in Harar [13], Debre Markos [15] 33.3%, and 32.9% respectively and higher than a study done in Kersa(27.9%) [19] and Gelemseo General Hospital (27.1%) [20].The difference might be due to the difference in the source population, sample size where the present study focused only on pregnant women attending ANC at the health institution. However, the finding of this study is lower than studies done in Addis Ababa (37.8%) [11], Dilla (36.9%) [12], Wellega (36.5%) [14]. This difference may be due to different reasons like study design difference in in sample size, socio-cultural difference, time variation, demographic differences between the current study and the previous studies. For instance, a study done in Wellega is a community-based study design which assessed all pregnant women including who had no antenatal visit. So, the difference between the current study and previous Wellega study may be study design difference. In addition to this, the difference may be due to cultural and religious difference. Globally the prevalence of unintended pregnancy is 38% [21]. which is larger than the finding in this study. In Sub-Saharan Africa (SSA) 39% of pregnancies are unintended, ranges from 30% in Western Africa to 59% in Southern Africa in 2014 [22].
The current study showed that residence is significantly associated with an unintended pregnancy (p=0.00001), these findings were in line with a study in Khartoum state Sudan [23] Wollega [14].This is because women who live in rural areas have less contraceptive usage and husband influence is more common in women who reside in rural areas than that of urban. Study in Pakistan also showed that the women who had at least one son were almost three times more likely to report their recent pregnancies unintended compared to those who did not have a son [24]. Also, in a study done in Vietnam, increased number of live sons was positively associated with unintended pregnancy [25].
This implies that, culturally, male child preference is common in these countries, particularly in rural areas. The women who had a live male child may have been interested in preventing pregnancy for the sake of spacing or may no longer desire fertility, but with limited contraceptive use, they may experience an unintended pregnancy. In addition, urban women are almost three times more likely than rural women to receive ANC from a skilled provider.The study also has revealed that short-acting contraceptives (Injectable Depo Provera and oral contraceptive pills) were highly used by the respondents.
Further, literature supported the findings of this study, where these short-acting contraceptives possess potential problems with compliance and convenience such as missing the doses resulting in higher unintended pregnancy rates. pregnancy was associated with There is a direct relationship between a woman's education level and whether she is likely to receive ANC from a skilled provider.

Conclusion
This finding concluded that the prevalence of unintended pregnancy is relatively high in the study area. Educational status, residence, and religion were the most important predictor variables of unintended pregnancy. The social-cultural and economic positions of women in society as well as an influence by her husband were also contributed to unintended pregnancy Reducing the prevalence of unintended pregnancy especially in the rural area is recommended.

Limitations
As this is a cross-sectional study, the associations observed may not be causal enough and since this study is institution based, it may suffer from lack of generalizability.

Ethical Consideration
Before the data collection letter of permission was taken from Jimma University, Institute of Health to JUMC and Ethical clearance was obtained from Jimma University Institutional Review Board.
The objective of the study was explained to the study participants, privacy maintenance and confidentiality was ensured. Furthermore, the study participants' involvement in the study was based on their willingness.