Abstract

The study aims to estimate the proportion of puerperae with an unplanned pregnancy, evaluate trends and identify factors associated with its occurrence in Rio Grande-RS, Brazil. Trained interviewers applied a single, standardized questionnaire to all puerperae residing in the municipality in 2007, 2010, 2013, 2016 and 2019. The chi-square test compared proportions and the Poisson regression with robust variance adjustment in the multivariate analysis. The prevalence ratio (PR) was the effect measure employed. The study includes 12,415 puerperae (98% of the total). The unplanned pregnancy rate was 63.3% (95%CI: 62.5%-64.1%). After adjusting, the highest PR for not planning pregnancy were observed among younger, black women, living without a partner, with more significant household agglomeration, lower schooling, and household income, multiparous and smokers. The rate of unplanned pregnancy is high and stable, with a higher propensity among women those with the highest risk of unfavorable events during pregnancy and childbirth. Reaching these women in high schools, companies, services and health professionals, in addition to the mass media, can be strategies to prevent unplanned pregnancy.

Key words:
Unplanned pregnancy; Unwanted pregnancy; Risk factors; Reproductive health; Fertile period

Introduction

Approximately 85 million of the 213 million pregnancies that occurred in 2012, the most recent estimate available, were unplanned¹1 Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann 2014; 45(3):301-314.. This type of pregnancy is associated with late initiation of appointments, inadequate prenatal care, and adverse outcomes such as low birth weight, prematurity, need for induced labor, and longer hospitalization time²2 Dibaba Y, Fantahun M, Hindin MJ. The effects of pregnancy intention on the use of antenatal care services: systematic review and meta-analysis. Reprod Health 2013; 10:50.

3 Shah PS, Balkhair T, Ohlsson A, Beyene J, Scott F, Frick C. Intention to become pregnant and low birth weight and preterm birth: a systematic review. Matern Child Health J 2011; 15(2):205-216.

4 Ticona DM, Huanco D, Ticona-Rendón MB. Impact of unplanned pregnancy on neonatal outcomes: findings of new high-risk newborns in Peru. Int Health 2024; 16(1):52-60.^-55 Carlander A, Hultstrand JN, Reuterwall I, Jonsson M, Tydén T, Kullinger M. Unplanned pregnancy and the association with maternal health and pregnancy outcomes: A Swedish cohort study. PLoS One 2023; 18(5):e0286052.. Furthermore, these women are generally younger, single or without a partner, of low socioeconomic status, and very often victims of intimate partner violence⁶6 Goossens J, Van Den Branden Y, Van der Sluys L, Delbaere I, Van Hecke A, Verhaeghe S, Beeckman D. The prevalence of unplanned pregnancy ending in birth, associated factors, and health outcomes. Hum Reprod 2016; 31(12):2821-2833.^,77 Lukasse M, Laanpere M, Karro H, Kristjansdottir H, Schroll AM, Van Parys AS, Wangel AM, Schei B; Bidens study group. Pregnancy intendedness and the association with physical, sexual and emotional abuse: a European multi-country cross-sectional study. BMC Pregnancy Childbirth 2015; 15:120.. For these reasons, not planning a pregnancy is a global public health issue⁸8 Khan MN, Harris ML, Shifti DM, Laar AS, Loxton D. Effects of unintended pregnancy on maternal healthcare services utilization in low-and lower-middle-income countries: Systematic review and meta-analysis. Int J Public Health 2019; 64(5):743-754..

Approximately 55% of births are unplanned in Brazil, representing about 1.4 million births/year⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118.. Among Brazilian women, besides the factors already mentioned, also identified as significantly associated with this outcome are Brown, Yellow, and Black people, household crowding, unemployment, multiparity, alcohol consumption, and tobacco use⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118.

10 Moreira LR, Ewerling F, Santos IS, Wehrmeister FC, Matijasevich A, Barros AJD, Menezes AMB, Gonçalves H, Murray J, Domingues MR, Silveira MF. Trends and inequalities in unplanned pregnancy in three population-based birth cohorts in Pelotas, Brazil. Int J Public Health 2020; 65(9):1635-1645.

11 Prietsch SO, González-Chica DA, Cesar JA, Mendoza-Sassi RA. Gravidez não planejada no extremo Sul do Brasil: prevalência e fatores associados. Cad Saude Publica 2011; 27(10):1906-1916.^-1212 Nilson TV, Amato AA, Resende CN, Primo WQSP, Nomura RMY, Costa ML, Opperman ML, Brock M, Trapani Junior A, Damasio LCVDC, Reis N, Borges V, Araújo AC, Ruano R, Zaconeta ACM. Unplanned pregnancy in Brazil: national study in eight university hospitals. Rev Saude Publica 2023; 57:35.. The most recent of these studies dates from 2020 and included only one hospital in eight Brazilian capitals¹²12 Nilson TV, Amato AA, Resende CN, Primo WQSP, Nomura RMY, Costa ML, Opperman ML, Brock M, Trapani Junior A, Damasio LCVDC, Reis N, Borges V, Araújo AC, Ruano R, Zaconeta ACM. Unplanned pregnancy in Brazil: national study in eight university hospitals. Rev Saude Publica 2023; 57:35.. The only one to consider trends was conducted in Pelotas-RS, finding an unplanned pregnancy rate of 62.7% in 1993, 65.9% in 2004, and 52.2% in 2015¹¹11 Prietsch SO, González-Chica DA, Cesar JA, Mendoza-Sassi RA. Gravidez não planejada no extremo Sul do Brasil: prevalência e fatores associados. Cad Saude Publica 2011; 27(10):1906-1916.. Since then, no other study evaluating trends in Brazil has been published on this topic.

The Rio Grande Perinatal Studies, conducted every three years since 2007, collected a range of information from the six months before pregnancy to the immediate postpartum period. Among this information is one addressing pregnancy planning. Five census surveys were conducted over 13 years¹²12 Nilson TV, Amato AA, Resende CN, Primo WQSP, Nomura RMY, Costa ML, Opperman ML, Brock M, Trapani Junior A, Damasio LCVDC, Reis N, Borges V, Araújo AC, Ruano R, Zaconeta ACM. Unplanned pregnancy in Brazil: national study in eight university hospitals. Rev Saude Publica 2023; 57:35..

This article aims to measure prevalence, assess trends, and identify factors associated with unplanned pregnancy in a medium-sized municipality in the Extreme South of Brazil from 2007 to 2019.

Methods

The present study was conducted in Rio Grande-RS, Brazil, from 2007 to 2019. This municipality is located on the south coastline, about 300 km from Porto Alegre and 250 km from the border with Uruguay. Its population increased from 195 thousand to 212 thousand during this period. Its economy is based on trade and agribusiness, mainly rice production and extensive livestock, fertilizer industries, and fishing and port activities.

The public health network has changed little over these 13 years, with 36 PHC units, four specialty centers, and two general hospitals, one with mixed care and the other exclusively dedicated to the Unified Health System (SUS). The Human Development Index (HDI) reached 0.744, while infant mortality increased from 9.3 to 11/1000 births¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). Rio Grande. Panorama [Internet]. 2010 [acessado 2022 mar 10]. Disponível em: https://cidades.ibge.gov.br/brasil/rs/rio-grande/panorama.
https://cidades.ibge.gov.br/brasil/rs/ri... .

The data presented in this article are nested in the Rio Grande Perinatal Studies, surveys conducted in 2007, 2010, 2013, 2016, and 2019 to monitor the care offered during pregnancy and childbirth in the municipality. The inclusion criteria were having had a child between January 1 and December 31 in those years and having reached at least 20 weeks of gestational age or 500 g of birth weight.

The design is cross-sectional, and the respondents were approached only once, within 48 hours after delivery while still in the hospital. Moreover, it is a census study because it includes all puerperae living in urban and rural areas¹⁴14 Silva IS. Cancer epidemiology: principles and methods. Lyon: World Health Organization & International Agency for Research on Cancer; 1999..

Data were collected through a single, standardized, pre-coded questionnaire divided into blocks, which sought information from pregnancy planning to the immediate postpartum period. Most of the questions and variables originated from blocks D, E, and F for this study. These blocks investigated reproductive health (number of pregnancies, abortions, children born alive or dead, age at first pregnancy, and first delivery), maternal lifestyle and behavior (tobacco use and alcohol/coffee/mate consumption, and physical activity), and maternal demographic and household sociodemographic characteristics (number of residents in the household, degree of kinship, age, schooling, occupation, and individual income in the month immediately preceding the interview). Further details on the methodology used in these surveys can be obtained in a specific publication¹⁵15 Cesar JA, Mendoza-Sassi RA, Marmitt LP. Evolução da assistência à gestação e ao parto no extremo sul do Brasil. Rev Saude Publica 2021; 55:50..

The questionnaires were applied by four interviewers trained for 40 hours, who underwent a pilot study in the month immediately before the beginning of data collection. Daily, they visited the maternity ward and all the wards of each hospital in search of births whose mothers resided in Rio Grande. When meeting a puerperae, the interviewer explained that the study invited her to participate. She signed two copies of the Informed Consent Form (ICF) if accepted. One copy was delivered to the mother, while the other was filed at the Faculty of Medicine of the Federal University of Rio Grande (FURG) project headquarters. The interview was started only after this step.

The 2007, 2010, and 2013 surveys were based on physical questionnaires, in which the interviewers coded and revised the closed-ended questions at the end of each working day. The following day, the questionnaires were delivered to the project headquarters, where they were revised and entered twice by different professionals and in the reverse order of the first. Entries were compared at each block of 100 questionnaires and, if necessary, corrected. All these steps were performed using the free software Epi Data¹⁶16 Lauritsen JM, editor. EpiData Data Entry, Data Management and basic Statistical Analysis System. Odense [Internet]. Denmark: EpiData Association; 2000-2008 [cited 2022 mar 10]. Available from: http://www.epidata.dk. and Epi Info¹⁷17 Dean AG, Arner T, Sunki G, Friedman R, Lantinga M, Sangam S, et al. Epi InfoTM, a database and statistics program for public health professionals. Atlanta: CDC; 2011..

In the 2016 and 2019 surveys, data were entered simultaneously with the interview using tablets and the REDCap (Research Electronic Data Capture) application¹⁸18 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42(2):377-381.. At the end of each day, these questionnaires were downloaded to the FURG server and revised.

The outcome of this study was defined based on the negative response to the following question: “Did you plan to have this child, or did you accidentally become pregnant?”. All puerperae who answered “not having planned” or “having become pregnant unintentionally” were considered unplanned pregnancies, thus constituting the outcome of this study.

The initial analysis consisted of listing the frequency of the variables of interest. Then, a bivariate analysis was performed to verify the distribution of the outcome concerning different exposures, which was evaluated using Pearson’s chi-square test. Subsequently, multivariable analysis was performed using Poisson Regression with robust variance adjustment¹⁹19 Kirkwood BR, Sterne JAC. Essentials of medical statistics. 2ª ed. London: Blackwell Science Ltd; 2003.^,2020 Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21.. This last stage obeyed a previously defined hierarchical model with the independent variables allocated in three levels: distal (demographic and socioeconomic), intermediate (reproductive and pregnancy care), and proximal (behavioral and lifestyle). The variables located at a hierarchically higher level than the variable in question were considered potential confounders vis-à-vis the outcome, in this case, not planning the pregnancy (Chart 1). The p-value associated with the outcome should be ≤0.20²¹21 Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997; 26(1):224-227. to be maintained in the model in the adjusted analysis. The effect measure was the prevalence ratio for a 95% confidence interval (95%CI). Wald tests for heterogeneity and linear trends were used for ordinal exposures¹⁹19 Kirkwood BR, Sterne JAC. Essentials of medical statistics. 2ª ed. London: Blackwell Science Ltd; 2003.. All these analyses were performed using the statistical package Stata 11.0²²22 StataCorp. Stata Statistical Software: release 11.2. College Station: StataCorp LP; 2011..

Approximately 10% of the interviews were partially repeated within 15 days after the initial interview to evaluate the agreement of the answers provided by the mothers shortly after birth. The Kappa index of agreement ranged from 0.61 to 0.99, with most values ranging from 0.72 to 0.91, a satisfactory level²³23 Gordis L. Epidemioloy. 4ª ed. Philadelphia: Elsevier Saunders; 2009..

FURG’s Health Research Ethics Committee (CEPAS) approved all research protocols under the following numbers: 2007 (Opinion No. 05369/2006); 2010 (Opinion No. 06258/2009); 2013 (Opinion No. 02623/2012); 2016 (Opinion No. 0030-2015) and 2019 (Opinion No. 278/2018).

Results

A total of 12,663 puerperae were identified in the five surveys conducted in Rio Grande. We successfully interviewed 12,415 of them, representing a 98% response rate.

Table 1 shows the proportional distribution of mothers who did not plan the pregnancy according to the main variables studied. We observed an increase in the proportion of this condition among younger mothers (≤19 years old), less educated (≤8 study years), and belonging to the first and second quartile of household income. Furthermore, we identified a growing proportion between those with a higher number of residents in the household, higher parity, and smokers. The penultimate column on the right of this same table shows the variation between the extremes (2007 and 2019). The highest percentage elevation for non-planning occurred among mothers living in households with up to two occupants, reaching 23.2%. In contrast, the smallest decline occurred among those with 12 or more schooling years, reaching 8.1%. The last column shows the linear trend test. Only one of the categories of variables included in this table (age 20-29 years) was not statistically significant (p_tend=0.163). The overall prevalence of unplanned pregnancy in the period was 63.3% (95%CI: 62.5%-64.1%).

Table 2 shows that only the “unemployed partner” and “previous abortions” variables lost statistical significance after controlling for confounders among all the variables in the Chart 1. All other variables had an independent effect on the outcome. Thus, puerperae aged 11-19, Black, who lived with a partner, with up to eight schooling years, and belonging to the worst quartile of income showed a higher PR of not having family planning than those aged 30 years or more, White, living with a partner, with 12+ schooling years, and belonging to the best income quartile, respectively. Mothers who did not engage in paid work during pregnancy, had two or more children, and smoked before or during pregnancy showed a higher PR than the others for not planning the pregnancy. Finally, the greater the number of residents in the household, the greater the PR for non-planning with a clear dose-response effect.

Discussion

Practically two out of three Rio Grande women did not plan the pregnancy, and this rate was high at the end of the period, especially among those at greater risk for unfavorable events during pregnancy and childbirth. The adjusted analysis showed that younger puerperae, Black, living without a partner, with more significant household crowding, lower schooling and household income, higher parity, and smokers had the highest PR for not planning the pregnancy.

The mean prevalence of 63.3% of non-planning observed in these surveys is similar to that observed in the baseline of the 1993 Pelotas cohort (62.7%), slightly lower than in 2004 (65.9%), but higher than the 2015 rate (52.2%)¹⁰10 Moreira LR, Ewerling F, Santos IS, Wehrmeister FC, Matijasevich A, Barros AJD, Menezes AMB, Gonçalves H, Murray J, Domingues MR, Silveira MF. Trends and inequalities in unplanned pregnancy in three population-based birth cohorts in Pelotas, Brazil. Int J Public Health 2020; 65(9):1635-1645.. In São Luís, Maranhão, this prevalence reached 68.1% in 2010²⁴24 Costa ACM, Oliveira BLCA, Alves MTSS. Prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast. Rev Bras Saude Materno Infantil 2021; 21(2):461-471., while it was 53.8% in Ribeirão Preto, São Paulo²⁵25 Vieira CS, Braga GC, Lugarinho PTC, Stifani BM, Bettiol H, Barbieri MA, Cardoso VC, Cavalli RC. Sociodemographic factors and prenatal care behaviors associated with unplanned pregnancy in a Brazilian birth cohort study. Int J Gynecol Obstetr 2020; 151(2):237-243.. In Brazil, a hospital-based study conducted between 2011-12 found a prevalence of non-pregnancy planning of 55.4%⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118., while a survey conducted in 2020 in eight university hospitals identified 67.5%¹²12 Nilson TV, Amato AA, Resende CN, Primo WQSP, Nomura RMY, Costa ML, Opperman ML, Brock M, Trapani Junior A, Damasio LCVDC, Reis N, Borges V, Araújo AC, Ruano R, Zaconeta ACM. Unplanned pregnancy in Brazil: national study in eight university hospitals. Rev Saude Publica 2023; 57:35.. This high level in different locations indicates that this problem requires actions at different levels of public service management. Besides the health sector, education should also be included since most of them are still in high school.

The younger the age, the greater the proportion of parturients who did not plan the pregnancy in Rio Grande. This pattern was also identified in other studies. It can be attributed to a lack of knowledge about effective pregnancy prevention methods, immaturity, difficulty accessing safe contraceptive methods, concern about the side effects of their use, carelessness, or disinterest⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118.

10 Moreira LR, Ewerling F, Santos IS, Wehrmeister FC, Matijasevich A, Barros AJD, Menezes AMB, Gonçalves H, Murray J, Domingues MR, Silveira MF. Trends and inequalities in unplanned pregnancy in three population-based birth cohorts in Pelotas, Brazil. Int J Public Health 2020; 65(9):1635-1645.

11 Prietsch SO, González-Chica DA, Cesar JA, Mendoza-Sassi RA. Gravidez não planejada no extremo Sul do Brasil: prevalência e fatores associados. Cad Saude Publica 2011; 27(10):1906-1916.^-1212 Nilson TV, Amato AA, Resende CN, Primo WQSP, Nomura RMY, Costa ML, Opperman ML, Brock M, Trapani Junior A, Damasio LCVDC, Reis N, Borges V, Araújo AC, Ruano R, Zaconeta ACM. Unplanned pregnancy in Brazil: national study in eight university hospitals. Rev Saude Publica 2023; 57:35.^,1515 Cesar JA, Mendoza-Sassi RA, Marmitt LP. Evolução da assistência à gestação e ao parto no extremo sul do Brasil. Rev Saude Publica 2021; 55:50.^,2424 Costa ACM, Oliveira BLCA, Alves MTSS. Prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast. Rev Bras Saude Materno Infantil 2021; 21(2):461-471.

25 Vieira CS, Braga GC, Lugarinho PTC, Stifani BM, Bettiol H, Barbieri MA, Cardoso VC, Cavalli RC. Sociodemographic factors and prenatal care behaviors associated with unplanned pregnancy in a Brazilian birth cohort study. Int J Gynecol Obstetr 2020; 151(2):237-243.

26 Fundo das Nações Unidas para a População (UNFPA). Relatório sobre a Situação da População Mundial 2022. Vendo o invisível: Em defesa da ação na negligenciada crise da gravidez não intencional [Internet]. UNFPA Brasil; 2022 [acessado 2023 jan 15]. Disponível em: https://brazil.unfpa.org/pt-br/publications/situacao-da-populacao-mundial-2022.
https://brazil.unfpa.org/pt-br/publicati... ^-2727 Ameyaw EK, Budu E, Sambah F, Baatiema L, Appiah F, Seidu AA, Ahinkorah BO. Prevalence and determinants of unintended pregnancy in sub-Saharan Africa: A multi-country analysis of demographic and health surveys. PloS One 2019; 14(8):e0220970..

Black mothers also showed a higher PR for not planning the pregnancy, confirming a similar finding in other studies⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118.^,1515 Cesar JA, Mendoza-Sassi RA, Marmitt LP. Evolução da assistência à gestação e ao parto no extremo sul do Brasil. Rev Saude Publica 2021; 55:50.^,2424 Costa ACM, Oliveira BLCA, Alves MTSS. Prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast. Rev Bras Saude Materno Infantil 2021; 21(2):461-471.^,2828 Pacheco VC, Silva JC, Mariussi AP, Lima MR, Silva TR. As influências da raça/cor nos desfechos obstétricos e neonatais desfavoráveis. Saude Debate 2018; 42(116):125-137.^,2929 Victora CG, Matijasevich A, Silveira MF, Santos IS, Barros AJD, Barros FC. Socio-economic and ethnic group inequities in antenatal care quality in the public and private sector in Brazil. Health Policy Plan 2010; 25(4):253-261.. Besides the factors already mentioned, Black mothers struggle more in accessing health services that are often insufficient and have inadequate quality²⁸28 Pacheco VC, Silva JC, Mariussi AP, Lima MR, Silva TR. As influências da raça/cor nos desfechos obstétricos e neonatais desfavoráveis. Saude Debate 2018; 42(116):125-137.

29 Victora CG, Matijasevich A, Silveira MF, Santos IS, Barros AJD, Barros FC. Socio-economic and ethnic group inequities in antenatal care quality in the public and private sector in Brazil. Health Policy Plan 2010; 25(4):253-261.

30 Macinko J, Mullachery P, Proietti FA, Lima-Costa MF. Who experiences discrimination in Brazil? Evidence from a large metropolitan region. Int J Equity Health 2012; 11:80.^-3131 Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, Bastos FI, Almeida C, Bahia L, Travassos C, Reichenheim M. The Lancet Brazil Series Working Group. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782):2042-2053.. This situation indicates structural discrimination; it is part of the Brazilian social organization, has multiple determinants, is not recent, and is not easily perceived by clients. However, it will require efforts from civil society and, above all, the Federal Government through policies and programs²⁸28 Pacheco VC, Silva JC, Mariussi AP, Lima MR, Silva TR. As influências da raça/cor nos desfechos obstétricos e neonatais desfavoráveis. Saude Debate 2018; 42(116):125-137.^,3030 Macinko J, Mullachery P, Proietti FA, Lima-Costa MF. Who experiences discrimination in Brazil? Evidence from a large metropolitan region. Int J Equity Health 2012; 11:80.^,3131 Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, Bastos FI, Almeida C, Bahia L, Travassos C, Reichenheim M. The Lancet Brazil Series Working Group. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782):2042-2053..

The lower the level of education and the worse the income, the greater the PR for not planning the pregnancy. No single factor has as many benefits to maternal and child health as schooling²⁶26 Fundo das Nações Unidas para a População (UNFPA). Relatório sobre a Situação da População Mundial 2022. Vendo o invisível: Em defesa da ação na negligenciada crise da gravidez não intencional [Internet]. UNFPA Brasil; 2022 [acessado 2023 jan 15]. Disponível em: https://brazil.unfpa.org/pt-br/publications/situacao-da-populacao-mundial-2022.
https://brazil.unfpa.org/pt-br/publicati... . By improving schooling, women gain access to essential information to care for their health and their children’s, acquire argumentative skills, become better aware of their rights, and start to participate more effectively in social life, including holding positions in the labor market⁴4 Ticona DM, Huanco D, Ticona-Rendón MB. Impact of unplanned pregnancy on neonatal outcomes: findings of new high-risk newborns in Peru. Int Health 2024; 16(1):52-60.^,2727 Ameyaw EK, Budu E, Sambah F, Baatiema L, Appiah F, Seidu AA, Ahinkorah BO. Prevalence and determinants of unintended pregnancy in sub-Saharan Africa: A multi-country analysis of demographic and health surveys. PloS One 2019; 14(8):e0220970.. By doing so, they increase household income, improve purchasing power, and their living conditions and their family’s. These advances undoubtedly contribute to better planning of their lives, which includes choosing the most appropriate moment to become a mother²⁷27 Ameyaw EK, Budu E, Sambah F, Baatiema L, Appiah F, Seidu AA, Ahinkorah BO. Prevalence and determinants of unintended pregnancy in sub-Saharan Africa: A multi-country analysis of demographic and health surveys. PloS One 2019; 14(8):e0220970.^,3131 Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, Bastos FI, Almeida C, Bahia L, Travassos C, Reichenheim M. The Lancet Brazil Series Working Group. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782):2042-2053., which helps explain the higher PR observed for not planning a pregnancy among those with the lowest socioeconomic status compared to the others.

Not having a partner was a risk factor for unplanned pregnancy. Unstable relationships, even with the same partner, hinder the continued use of contraceptive methods, which increases exposure to pregnancy⁵5 Carlander A, Hultstrand JN, Reuterwall I, Jonsson M, Tydén T, Kullinger M. Unplanned pregnancy and the association with maternal health and pregnancy outcomes: A Swedish cohort study. PLoS One 2023; 18(5):e0286052.^,2424 Costa ACM, Oliveira BLCA, Alves MTSS. Prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast. Rev Bras Saude Materno Infantil 2021; 21(2):461-471.. In Ribeirão Preto, São Paulo, the odds ratio for not planning a pregnancy among women without a partner was 7.56 (95%CI: 5.98-9.56) times higher than the others²⁵25 Vieira CS, Braga GC, Lugarinho PTC, Stifani BM, Bettiol H, Barbieri MA, Cardoso VC, Cavalli RC. Sociodemographic factors and prenatal care behaviors associated with unplanned pregnancy in a Brazilian birth cohort study. Int J Gynecol Obstetr 2020; 151(2):237-243.. In Rio Grande perinatal surveys, the presence of a partner positively affected and had an independent effect on different outcomes¹¹11 Prietsch SO, González-Chica DA, Cesar JA, Mendoza-Sassi RA. Gravidez não planejada no extremo Sul do Brasil: prevalência e fatores associados. Cad Saude Publica 2011; 27(10):1906-1916.^,1515 Cesar JA, Mendoza-Sassi RA, Marmitt LP. Evolução da assistência à gestação e ao parto no extremo sul do Brasil. Rev Saude Publica 2021; 55:50.. This analysis reinforces the importance of a partner, often the biological father, as a protective factor for mother and child health.

The possibility of not planning the pregnancy also increases with a higher number of residents in the household. The dose-response effect was evident, even more so than the values observed for other variables, such as household income and maternal education. In environments with many people, as they are responsible for most household chores, women often neglect their health care²⁷27 Ameyaw EK, Budu E, Sambah F, Baatiema L, Appiah F, Seidu AA, Ahinkorah BO. Prevalence and determinants of unintended pregnancy in sub-Saharan Africa: A multi-country analysis of demographic and health surveys. PloS One 2019; 14(8):e0220970.. This situation may lead to the irregular use of contraceptive methods, especially when used daily, such as oral contraceptives, which are widely adopted²³23 Gordis L. Epidemioloy. 4ª ed. Philadelphia: Elsevier Saunders; 2009.. The incorrect use of contraceptives can result in pregnancy prevention failures, leading to unplanned pregnancies⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118.^,1111 Prietsch SO, González-Chica DA, Cesar JA, Mendoza-Sassi RA. Gravidez não planejada no extremo Sul do Brasil: prevalência e fatores associados. Cad Saude Publica 2011; 27(10):1906-1916.^,2424 Costa ACM, Oliveira BLCA, Alves MTSS. Prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast. Rev Bras Saude Materno Infantil 2021; 21(2):461-471.

25 Vieira CS, Braga GC, Lugarinho PTC, Stifani BM, Bettiol H, Barbieri MA, Cardoso VC, Cavalli RC. Sociodemographic factors and prenatal care behaviors associated with unplanned pregnancy in a Brazilian birth cohort study. Int J Gynecol Obstetr 2020; 151(2):237-243.^-2626 Fundo das Nações Unidas para a População (UNFPA). Relatório sobre a Situação da População Mundial 2022. Vendo o invisível: Em defesa da ação na negligenciada crise da gravidez não intencional [Internet]. UNFPA Brasil; 2022 [acessado 2023 jan 15]. Disponível em: https://brazil.unfpa.org/pt-br/publications/situacao-da-populacao-mundial-2022.
https://brazil.unfpa.org/pt-br/publicati... .

Smoking was an independent risk factor for not planning pregnancy. The Birth in Brazil Study also identified an odds ratio of 1.23 (95%CI: 1.06-1.43) for not planning a pregnancy among puerperal smokers⁹9 Theme-Filha MM, Baldisserotto ML, Fraga AC, Ayers S, Gama SG, Leal MD. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012. Reprod Health 2016; 13(Supl. 3):118.. Few studies have shown this association. Considering that it is widely known that smoking is harmful to the health of both the mother and the fetus and even so some women continue to smoke, the lack of family planning may indicate a lack of concern for their health. It would be interesting to evaluate this finding in other studies. In any case, in Rio Grande, tobacco use appeared as an independent determinant of unplanned pregnancy, and this needs to be considered by health teams.

When interpreting these results, we should consider that data were collected over 13 years, during which essential changes occurred in the local economic setting, from full employment driven by the shipbuilding activity of oil platforms to high unemployment rates after shipyards’ decommission. These factors certainly impacted the results presented, at least until 2013. However, these changes do not change the direction or eliminate the results found. It is essential to highlight that this work has the shortest interval between data collection ever carried out in Brazil. It included all puerperae in a medium-sized municipality with a response rate of at least 96% in the five surveys, a rare finding in Brazil.

This study showed a high prevalence of unplanned pregnancies, especially among those at greater risk of adverse events during pregnancy and childbirth. We observed an evident overload among the most vulnerable, further increasing this group’s morbimortality risk. It would be appropriate to reach these women through sensitization campaigns and the availability of safe, reversible contraceptive methods, with adequate guidance from public health services to prevent unplanned pregnancies, which would bring countless benefits to mother and child health in Rio Grande.

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