Geographic Access to Working Family Planning Centers and Unintended Pregnancies among Married Women: A Community Based Nested Case Control Study

Background: Unintended pregnancies pose substantial risk to mothers and children. In Pakistan, unintended pregnancies account for 46% of all pregnancies. Lack of geographic access to open and well-supplied family planning (FP) centers may be related to the occurrence of such pregnancies, particularly in rural areas. Objective: The objective of this analysis is to determine if geographic access to family planning centers in the Thatta district of Pakistan is related to unintended pregnancy rates among married women. Methods: We conducted a community-based, nested case-control study of 800 pregnant women identified from the database of an active surveillance system, which registers and follows all pregnant women in the catchment area of Thatta district. Women were enrolled during the first trimester; those that reported their pregnancy to be unintended were selected as cases (n = 200), and those whose pregnancies were intended served as controls (n = 600). We defined geographic access as including both the distance of a family planning center from the woman’s home, and availability of personal transportation. Logistic regression was used for analysis. Results: In the multivariate model, neither distance [OR = 1.0; 95% CI (0.95 - 1.05)] nor availability of transportation [OR = 1.14; 95% CI (0.78 - 1.67)] were significantly associated with unintended pregnancy. In fact, women with unintended pregnancies were more likely to be aware of family planning [OR = 2.21; 95% CI (1.23 - 3.97)] and more likely to have been using a contraceptive method before conceiving their index pregnancy [OR = 3.59; 95% CI (1.83 - 7.06)]. Other factors related to unintended pregnancy were older maternal age [OR = 1.13; 95% CI (1.08 - 1.17)], having already had at least one son [OR = 3.13; 95% CI (1.93 - 5.07)]; spousal opposition to contraceptive use, [OR = 3.24; 95% CI (1.89 - 5.56)] and low spousal education level [OR = 1.85; 95% CI (1.08 - 3.18)] as compared to women with intended pregnancy. Conclusion: Lack of geographic access to FP centers is not a risk factor for unintended pregnancy in women from the Thatta district. However, in this population, unintended pregnancies are more common among older women, women having at least one son, and those who have a spouse who does not approve of contraceptive use, and is less educated. Of note, women who reported unintended pregnancy did have knowledge about FP and were more often using contraceptives before they conceived.