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Unexpected pregnancies and unintended consequences

31 Mar 2022

  • UNFPA report highlights the need for better family planning and reproductive health awareness
By Sumudu Chamara In Sri Lanka, about 360,000 women become pregnant every year, and one out of every three of these pregnancies are estimated to be unintended pregnancies. This is in a context where the Demographic and Health Survey of 2016 has estimated the unmet need for family planning to be at 7.3%, a figure the United Nations Population Fund (UNFPA) said may have been further augmented due to the Covid-19 pandemic. More information about the state of unintended pregnancies in the world was discussed in a recently released study report titled “Seeing the Unseen: The Case for Action in the Neglected Crisis of Unintended Pregnancy”, which was conducted by the UNFPA which compared Sri Lanka’s situation with global figures.  Adding that the report shows how easily the most fundamental rights of women and girls are pushed to the backburner in times of crises, the UNFPA said in a press release issued this week that this situation calls on decision makers and health systems to prioritise the prevention of unintended pregnancies by improving the accessibility, acceptability, and quality of sexual and reproductive healthcare services and information. Sri Lanka’s situation The report had published the latest (2022) statistics with regard to Sri Lanka’s demographics indicators. Among other data, it said that the total fertility rate per female was 2.1%. While male life expectancy at birth had been recorded as 74 years, female life expectancy was 81 years. With regard to unplanned birth and abortion rates, and the proportion of unintended pregnancies that ended in unplanned births, abortions, or miscarriages in the 2015–2019 period in terms of the Gender Inequality Index (GII), the latter an index for the measurement of gender disparity, the report said that Sri Lanka is among the countries or territories with a GII greater than 0.35 (rate per 1,000). In that list, Sri Lanka had been ranked at the 11th place.  Of other countries in the South Asian region, the Maldives had been ranked in the fifth place under the same classification. However, other countries in the region with a GII greater than 0.35, namely Bhutan, Nepal, India, Bangladesh, and Pakistan, were below Sri Lanka. No country from the region had been listed as a country or territory with a GII greater than 0.35. The report also analysed the progress towards sexual and reproductive health that comes under the International Conference on Population and Development (ICPD) goals (targets agreed on by 179 countries in 1994 at the ICPD regarding universal education, the reduction of infant and child mortality, the reduction of maternal mortality, and access to reproductive and sexual health services including family planning). The results showed that in the 2014-2020 period, the percentage of births attended by skilled health personnel was 100%. In addition, regarding the contraceptive prevalence rate among females in the 15-49 years age group in 2022, the report showed that 45% of all such females had used some sort of method, while 67% were married or in a union. With regard to the prevalence of modern contraceptives, the report said that 37% of all females had used such methods, while 55% of them were married or in a union.  Regarding the unmet need for family planning among females in the 15-49 years age group in 2022, the report said that 5% of all females and 7% of married females and females in partnerships, fall under this category. Moreover, the data also showed that in Sri Lanka, the proportion of the demand satisfied with modern methods among all females in the 15-49 years age group was 74%. Regarding the availability of laws and regulations that guarantee access to sexual and reproductive healthcare, information, and education in 2022, the UNFPA report ranked Sri Lanka’s situation as 86%. What is more, analysing progress towards ICPD goals with a focus on gender, rights, and human capital, the report ranked Sri Lanka at the third place. Statistics showed that unintended pregnancies per 1,000 females in the 15-49 years age group in the 2015-2019 period was 39, and that child marriage by the age of 18 years in the 2005-2020 period was 10%. With regard to the total net enrolment rate in the 2010-2020 period, the report said that in primary education, secondary education, and in upper-secondary education, it was 99%, 100%, and 84%, respectively. However, data about the prevalence of genital mutilation among females aged 15-49 years, and decision making on sexual and reproductive health and reproductive rights, were unavailable. Global situation The UNFPA further pointed out that public health emergencies like the Covid-19 pandemic have given rise to an increase in unintended pregnancies, as access to sexual and reproductive health services are disrupted. According to the UNFPA, nearly half of all pregnancies, totalling around 121 million each year, throughout the world, are unintended. The UNFPA pointed out key facts from the 2022 State of World Population (SoWP) report.  It added that every year, almost half of all pregnancies in the world are recorded as unintended, and that between 2015 and 2019, there were roughly 121 million unintended pregnancies globally each year.  It also noted that globally, an estimated 257 million females who want to avoid pregnancy are not using safe, modern methods of contraception, and that in 47 countries, about 40% of sexually active females are not using any contraceptive methods to avoid pregnancy.  In addition, it pointed out that nearly a quarter of all females are not able to say no to sex. In this regard, it further said that contraceptive use is 53% lower among females who have experienced intimate partner violence, and that according to studies, rape-related pregnancies are equally or more likely to occur than pregnancies from consensual sex. Over 60% of the unintended pregnancies, and almost 30% of all pregnancies, end in abortion, according to the SoWP 2022. It was also highlighted that 45% of all abortions performed globally are unsafe, and that unsafe abortions hospitalise about seven million females a year globally and cause 5-13% of all maternal deaths, which is one of the leading causes of maternal death, and in developing countries, unsafe abortions cost an estimated $ 553 million per year in treatment costs alone. As per the SoWP 2022, in humanitarian emergencies, such as the ongoing war in Ukraine, many females lose access to contraception and/or experience sexual violence. It noted that some studies have shown that over 20% of female refugees and girls will face sexual violence, an estimated 4.8 million unintended pregnancies will occur in Afghanistan by 2025 as a result of health system disruptions and gender inequality, and that in the first 12 months of the Covid-19 pandemic, the estimated disruption in contraceptive supplies and services lasted an average of 3.6 months, leading to as many as 1.4 million unintended pregnancies. Costs of unintended pregnancies Discussing the impacts of unintended pregnancies, the report noted: “The most obvious consequences are the direct outcomes of the pregnancies themselves, which are births, abortions, or miscarriages. It may be tempting therefore to measure the impacts by weighing two possible scenarios: one in which a female invests her time and resources in a baby versus one in which she invests in herself. But that is a false dichotomy. A female who obtains an abortion may do so in order to invest limited resources in the children she already has. A female denied the agency to choose pregnancy may also lack the means to invest in either herself or the baby. And a female with ample economic resources may incur other costs, such as continued exposure to a violent partner.” It underscored that rather than investigating the outcomes of unintended pregnancies, first, attention must be paid to the exercise or denial of choice that begins before pregnancy. “The opportunity costs cannot all be calculated. But there are also concrete and quantifiable ways in which researchers have sought to understand some of the costs: costs to the health system for pregnancies that are unwanted whether they come to term or not; costs in terms of female’s economic and educational contributions and opportunities; and the potential for complex risks to the mental and physical health of both mothers and babies. There are also risks among those who choose to abort their pregnancies, particularly in places with restrictive abortion laws, where females resort to unsafe abortions, often experiencing avoidable maternal morbidity and even mortality,” the report read. Discussing the consequences of unintended pregnancies that cannot be easily proved or disproved, it pointed out certain theories such as those that say that higher rates of unintended births could lead to higher crime rates or to increased household stress, and stigma endured by unmarried females that can have lifelong, even multi-generational, consequences. It raised concerns about consequences often being borne by adolescents and younger persons who experience an unintended pregnancy, which may include girls having to drop out of school and difficulties pertaining to resuming school after a pregnancy. With regard to how unintended pregnancies open the door to human rights violations, it was noted: “With the exception of pregnancies resulting from sexual violence and the various forms of reproductive coercion, most unintended pregnancies are not the direct result of human rights violations. But these pregnancies can lead to consequences that make females including girls vulnerable to human rights violations. Among the acknowledged negative effects, unintended pregnancy is associated with delayed prenatal care and thus potentially worse health outcomes for the pregnant female and, if she continues the pregnancy, with preterm birth. Pregnancy, unintended or not, can lead to being forced to leave school or discrimination in employment. This discrimination in turn can compound the already fragile socio economic circumstances that may underlie the unintended pregnancy in the first place. In extreme cases, out of wedlock pregnancies may result in criminal penalties or death sentences, extrajudicial deaths such as so called ‘honour killings’ or suicide.”  Moreover, the UNFPA report said that a recent meta analysis covering 30 studies and more than 65,000 participants found that females who had become pregnant unintentionally were at a significantly higher risk of developing postpartum depression than females who had become pregnant by choice, and that this correlation has shown up in numerous studies in different countries and regions of the world. Adding that females who seek out but are not able to obtain an abortion may be particularly at risk, the report noted that a 2011 cohort study in Brazil, which looked at depression among 1,057 females, had found a higher incidence of postnatal depression among females who had attempted, unsuccessfully, to abort their pregnancies, relative to a comparison group of females who had not attempted an abortion.  Quoting the World Health Organisation (WHO) recommendations for family planning, the report said that self-administered injectable contraception should be made available as an additional approach to delivering injectable contraception for individuals of reproductive age, that over-the-counter oral contraceptive pills should be made available without a prescription for individuals using oral contraceptive pills, and that over-the-counter emergency contraceptive pills should be made available without a prescription to individuals who wish to use emergency contraception. Sri Lanka’s situation regarding unintended pregnancies, one out of every three pregnancies being unintended ones, is alarming, especially in a context where unintended pregnancies is a matter that has been discussed for a long time. Even though legal reforms, large-scale health sector infrastructure developments, and other projects require a substantial amount of monetary resources, there are simpler and effective steps, such as improving sex education and taking policy-level decisions regarding the matter, that the authorities can pay attention to.


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