Underestimation of pregnancy risk among women in Vietnam
RESEARCH ARTICLE Open Access
Underestimation of pregnancy risk among
women in Vietnam
Jessica Londeree1, Nghia Nguyen2, Linh H. Nguyen2, Dung H. Tran3 and Maria F. Gallo1*
Abstract
Background: Addressing women’s inaccurate perceptions of their risk of pregnancy is crucial to improve
contraceptive uptake and adherence. Few studies, though, have evaluated the factors associated with
underestimation of pregnancy risk among women at risk of unintended pregnancy.
Methods: We assessed the association between demographic and behavioral characteristics and underestimating
pregnancy risk among reproductive-age, sexually-active women in Hanoi, Vietnam who did not desire pregnancy
and yet were not using highly-effective contraception (N = 237). We dichotomized women into those who
underestimated pregnancy likelihood (i.e., ‘very unlikely’ they would become pregnant in the next year), and those
who did not underestimate pregnancy likelihood (i.e., ‘somewhat unlikely,’ ‘somewhat likely’ or ‘very likely’). We used
ivariable and multivariable logistic regression models to identify co
elates of underestimating pregnancy risk.
Results: Overall, 67.9% (n = 166) of women underestimated their pregnancy risk. In bivariable analysis,
underestimation of pregnancy risk was greater among women who were older (> 30 years), who lived in a town o
ural area, and who reported that it was “very important” or “important” to them to not become pregnant in the
next year. In multivariable analysis, importance of avoiding pregnancy was the sole factor that remained statistically
significantly associated with underestimating pregnancy risk (odds ratio [OR]: 0.11; 95% confidence interval [CI],
0.05–0.25). In contrast, pregnancy risk underestimation did appear to vary by marital status, ethnicity, education o
other behaviors and beliefs relating to contraceptive use.
Conclusions: Findings reinforce the need to address inaccurate perceptions of pregnancy risk among women at
isk of experiencing an unintended pregnancy.
Keywords: Contraception, Health knowledge, attitudes, practice, Pregnancy, unplanned, Risk assessment, Vietnam
Background
Of pregnancies occu
ing worldwide from 2000 to 2014,
an estimated 44% of were unintended [1]. Unintended
pregnancies, defined as pregnancies that are unwanted
or mistimed at the time of conception, pose a substantial
social and economic burden for women and their fam-
ilies. Consequences of these pregnancies include poo
irth outcomes [2], increased levels of pregnancy-related
mo
idity and mortality [3, 4], as well as mental health
concerns and lost educational opportunities among chil-
dren [5, 6]. Despite these consequences, a large gap re-
mains between the availability of contraceptive methods
and their use. An estimated 80% of the 85 million
women annually who have an unintended pregnancy are
not using contraception at the time of conception [4]. In
lower and middle-income countries, where most unin-
tended pregnancies occur [1, 4], and where the health
infrastructure is often ill-equipped to handle the conse-
quences of unintended pregnancy, understanding the
a
iers to contraception use among women who desire
to prevent pregnancy is critical.
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* Co
espondence: XXXXXXXXXX
1Division of Epidemiology, The Ohio State University, College of Public
Health, Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, USA
Full list of author information is available at the end of the article
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According to the health belief model, appropriate per-
ception of susceptibility to a given health outcome is a
key determinant of health behavior and behavior change
[7, 8]. A woman’s cognizance of her risk of unintended
pregnancy then may play a crucial role in contraceptive
ehavior and adherence. Indeed, underestimation of
pregnancy risk has been found to lead to unmet contra-
ceptive need [9, 10] and, subsequently, unintended preg-
nancy [11, 12].
Several studies across a range of settings have revealed
a significant discrepancy between perceived and actual
pregnancy risk. In a study among reproductive-age
women in France, Moreau and Bohet found that, among
women who reported inconsistent use of contraception
or unprotected intercourse in the last 4 weeks, 63% did
not think they could become pregnant unintentionally
[13]. Sinai et al. observed that, among women in Mali
and Benin, 33.7% of women at risk of pregnancy (i.e.,
women who were fecund and sexually active) believed
that they could not become pregnant [14]. In anothe
study of women attending reproductive healthcare
clinics in the United States, Biggs et al. found that 27%
of women planning to use no method or a low-efficacy
contraceptive method (i.e., natural family planning, with-
drawal, diaphragm, or sponge) underestimated their risk
of pregnancy from engaging in 1 year of unprotected
intercourse [15].
Although addressing inaccurate perceptions of preg-
nancy risk may be central to preventing unintended
pregnancy, few studies to date have evaluated the factors
associated with underestimation of pregnancy risk
among women at risk. Assessing these factors could help
identify target populations for interventions to address
the gap between perceived and actual pregnancy risk
and, accordingly, the gap between the existence of effect-
ive contraception and its use. The aim of the present
study was then to assess the prevalence and co
elates of
underestimation of pregnancy risk among sexually- ac-
tive women in Hanoi, Vietnam, who were not using a
highly-effective method of contraception and yet did not
desire pregnancy.
Methods
We analyzed data from cross-sectional, convenience
study of women in Hanoi, Vietnam. The parent study’s
primary objective was to assess a method of measuring
eliefs concerning contraception safety and naturalness,
and these findings will be reported elsewhere. The par-
ent study enrolled 500 adult women of reproductive age
(18–45 years) attending the obstetrics-gynecology de-
partment of a large public hospital for routine care o
accompanying someone at the facility during Novembe
2017 to September 2018. To participate in the study,
women had to have at least a minimal level of literacy,
eport being comfortable using a computer, be sexually
active (defined as ≥1 penile-vaginal act in past month),
not be pregnant or
eastfeeding, and not want a preg-
nancy within the next 12 months. Written consent was
provided by participants before enrollment, and the re-
search was approved by institutional review boards at
The Ohio State University and the Hanoi School of
Public Health.
We administered a questionnaire on demographics
and contraception-related beliefs and behaviors. As part
of this questionnaire, we asked participants to report the
likelihood (“very unlikely, somewhat unlikely, somewhat
likely and very likely”) they would become pregnant in
the next year. For the present study, we restricted ou
analysis to women who were not cu
ently using a highly
effective method of contraception, specifically either a
tier 1 (i.e., implant, intrauterine device, tubal ligation o
vasectomy) or a tier 2 method (i.e., injectable contracep-
tion, lactational ameno
hea, oral contraception, patch
or vaginal ring) [16]. Thus, we excluded 261 women
who were using a tier 1 or 2 method and 2 women who
were missing data on perceived likelihood of pregnancy
over the next year (Fig. 1).
Based on responses regarding the perceived likelihood
of pregnancy, we dichotomized women into those who
underestimated pregnancy likelihood (i.e., women who
eported it was ‘very unlikely’ they would become preg-
nant in the next year), and those who did not underesti-
mate pregnancy likelihood (i.e., women who reported it
was ‘somewhat unlikely,’ ‘somewhat likely,’ or ‘very
likely’ they would become pregnant in the next year).
Based on the literature, we selected the following demo-
graphic characteristics to evaluate as potential co
elates
of pregnancy likelihood underestimation [13, 15, 17]: age
(categorized into 21–31 years, 32–36 years, and 37–45
years); residence (city vs. town or rural area); marital
status (ma
ied vs. other); ethnicity (Kinh vs. other); edu-
cation (secondary or lower vs. higher); and monthly
household income (< 15 million Vietnamese dong
[equivalent to ~ 650 U.S. dollars] vs. higher). We also
assessed the following contraception-related beliefs and
ehaviors: cu
ent use of male condoms (yes vs. no),
cu
ent use of traditional contraceptive methods (i.e.,
hythm, withdrawal; yes vs. no), ever been pregnant (yes
vs. no), experience ever discussing contraceptive
methods with health provider (yes vs. no), and ambiguity
towards becoming pregnant (ambiguous vs. not-
ambiguous). In response to the question “How import-
ant is it to you to not become pregnant in the next
year?” women who reported it was ‘very important’ o
‘important’ were categorized as not-ambiguous toward
ecoming pregnant, while those who reported it was
‘neutral’ or ‘not important’ were categorized as ambigu-
ous towards becoming pregnant.
Londeree et al. BMC Women's Health XXXXXXXXXX:159 Page 2 of 7
In separate bivariable logistic regression models, we
assessed the relationship between potential co
elates
and pregnancy risk underestimation. We then ran a mul-
tivariable logistic regression model fitted with all co
e-
lates that were associated with the outcome in the
ivariable analysis using a p-value of < 0.25 [18]. We
used SAS 9.4 (SAS, Cary, NC) for all analyses.
Results
The analysis is based on 237 women who were suscep-
tible to unintended pregnancy (i.e., sexually-active,
eproductive-age women who were not using a tier 1 o
2 method of contraception and did not wish to become
pregnant in the next year). Most participants resided in
a city (88.2%), had attended education beyond upper sec-
ondary school (73.0%), were ma
ied (93.7%), were eth-
nically Kinh (93.7%), and reported a household income
of > 15 million Vietnamese dong (71.7%) (Table 1). The
median age of participants was 34.1 years (standard devi-
ation, 5.3; range, 21–45 years). Participants reported the
following methods of contraception (based on a hier-
archical categorization, in which those reporting mul-
tiple methods only had their first response in the
following ordered list included): male condom (n =