Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study

Introduction

During 2015–2019, there were at least 121.0 million unintended pregnancies each year¹. Unintended pregnancy is untimely, unplanned, unwanted at conception, or pregnancy which occurs earlier than desired². The definition of unintended pregnancies has complex considerations. The condition influenced the terms by how they (a person or the partner) feel about the pregnancy itself, or generally, their reproductive plans. Unintended pregnancy occurs when a woman wishes to become pregnant at a future date but not at the time she became pregnant, or pregnancy occurs when the woman does not want to become pregnant at the time or at any time in the future³. Unintended pregnancy can result from not using contraception or using contraception inadequately during sex. Despite having no desire to become pregnant, women with low perceived susceptibility were more likely not to have used contraception at the previous sex⁴.

Unintended pregnancy has the risk of causing various disorders to women and their babies. Women who experience unintended pregnancy are at risk of experiencing decreased physical function, general health, vitality, and social function. The mental health of women who experienced an unintended pregnancy was 9.19 times more likely to decline than women with a desired pregnancy. Women with unintended pregnancies are at risk of developing poor mental health in the future, depression, and parenting stress^5–7. Besides, other threats that can occur are increased body weight during inadequate pregnancy, the increased risk of giving birth by Sectio Caesarea, the duration of breastfeeding is shorter, and children born from unintended pregnancy at the age of under five have a low developmental score^8,9. Various conditions that arise from unintended pregnancy can threaten a woman's health during pregnancy and childbirth and affect the infant's birth development.

The government should take measures to reduce unintended pregnancy. However, the reality is that unintended pregnancy in Indonesia is still relatively high. For example, the proportion of unintended pregnancy among women of childbearing age in Indonesia was 15.4% in 2012¹⁰ and increased to 16.3% in 2020¹¹.

Most unintended pregnancies occur in women with the intention of not wanting any more children¹¹. Women with high parity and experiencing pregnancy complications are more likely to experience unintended pregnancy¹². Meanwhile, the majority of unintended pregnancies in Indonesia occurred in married women. As many as 3.26% of unintended pregnancies occurred in women who were never married or had no partners (widows)¹². Moreover, a study conducted by Rohmah et al. reported that pregnancy among teenagers in Indonesia was 5.7% in women who were not married or had no partners¹³. Although the proportion of unintended pregnancies among unmarried women in Indonesia is small, the problems they cause are more complex than those of married women.

Pregnancy in unmarried women is much more likely to happen accidentally and have adverse effects¹⁴. In a qualitative study in the Nagari Sungayang community, one of Indonesia's western regions, an unmarried woman's pregnancy is considered an act that religion prohibits. The situation contradicts the traditional values and culture of the local community¹⁵. On the other hand, in Indonesia, where most of the population is Muslim; they believe that a child born due to pregnancy outside or before a legal marriage is considered a child born out of adultery¹⁶. Therefore pregnancy for an unmarried woman is regarded as a disgrace. Some people try to cover up this disgrace by getting married even though their age is not sufficient. As a result, underage marriages occur, causing depression, anxiety, fear, and stress¹⁷.

The main burden of unintended pregnancy for single or divorced/widowed women is physical changes during pregnancy. The added responsibility is gaining a negative status from society. The unfavorable position of this society is even more dominant for unmarried women. Some of the burdens of unmarried mothers due to pregnancy outside of marriage include the financial responsibility of child care, conflict, no support from family, negative labels from others, and past regrets¹⁸. Women who are unable to bear the burden of unintended pregnancy often decide to have an abortion. During 2010–2014, 59% of unintended pregnancies in developed countries and 55% of unintended pregnancies in developing countries ended with abortion¹⁹. During 2015–2019 the proportion of unintended pregnancies that ended with abortion increased¹. Thus, women bear a double burden, and if they were making inappropriate decisions about unintended pregnancy, it would create more complex problems. These problems include medical complications due to unhealthy abortion, post-traumatic stress, the legal burden of an abortion, socioeconomic issues, childbirth in adolescence, and more susceptibility to divorce if women carried out marriage after pregnancy¹⁹.

Unintended pregnancy in unmarried women is one of the most difficult challenges faced by the health system. A previous study reported the case of an unmarried woman who became pregnant twice out of wedlock and had not received antenatal care (ANC) services, either in the public or private health sector. We should note that unmarried women who experience unintended pregnancy tend to hide their pregnancies and not carry out pregnancy care¹⁰. Unmarried women are less innovative in finding information related to pregnancy¹⁴. Considering the huge impact caused by unintended pregnancy on unmarried women, it is necessary to evaluate the implementation of ANC. This evaluation aims to ensure that unmarried women receive adequate services during pregnancy and obtain good delivery outcomes. Based on the background narration, the study aims to analyze the effect of unintended pregnancy on ANC visits performance among unmarried women in Indonesia.

Methods

Results

The result shows the proportion of unmarried women who have experienced an unintended pregnancy in the last five years in Indonesia is 26.0%. This study presents the distribution map of the percentage of unintended pregnancy among unmarried women by the province in Indonesia in Figure 1. The figure shows a trend towards a higher distribution of unintended pregnancy rates in Indonesia's central region.

Figure 1. Distribution map of the percentage of unintended pregnancy among unmarried women by the province in Indonesia in 2017.

Based on the type of residence, unmarried women living in rural areas drove both ANC visits categories. Meanwhile, unmarried women in the 20–24 age group dominated the ANC visits category < four times based on the age group. Moreover, unmarried women aged 25–29 populated the ANC category for ≥ four visits.

Table 1 shows that the marital status of unmarried women with the divorced/widowed category occupied the two types of ANC visits. However, according to education level and employment status, unmarried women with secondary education and employment dominate the two categories of ANC visits.

Based on wealth status, the most deficient unmarried women occupied both categories of ANC visits. However, according to health insurance ownership, uninsured unmarried women dominate the ANC visits < four times. Meanwhile, in various ANC visits ≥ four times, the two types of health insurance ownership have an equal frequency.

Table 2 shows the results of binary logistic regression of ANC visit performance among unmarried women in Indonesia. This final stage analysis uses “ANC visits < four times” as a reference.

Table 2 shows that unmarried women who experienced an unintended pregnancy were 0.588 times less likely than those who did not experience an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). Thus, this analysis indicates that unmarried women who have an unintended pregnancy in Indonesia are less likely to complete ANC visits.

Apart from unintended pregnancy, the study found all the independent variables as a significant determinant of ANC visit performance. Based on the type of residence, unmarried women living in rural areas are 1.406 times more likely than unmarried women living in urban areas to make ANC visits ≥ four times (AOR 1.406; 95% CI 1.405-1.407). These results indicate that living in rural areas is a protective factor for unmarried women to complete ANC visits.

Table 2 also indicates that the age group is a determinant of the ANC visits performance. For example, unmarried women in the 20–24 age group were 1.276 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 1.276; 95% CI 1.274-1.277). Meanwhile, unmarried women in the 35–39 age group were 2.414 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 2.414; 95% CI 2.411-2.417). Moreover, unmarried women in the 45–49 age group are 35.009 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 35.009; 95% CI 34.849-35.170).

According to marital status, unmarried women never in union are 1.513 times more likely than unmarried women who are divorced/widowed to have ANC visits ≥ four times (AOR 1.513; 95% CI 1.511-1.516). Thus, unmarried women who have experienced marriage in Indonesia are less likely to have complete ANC visits.

The analysis also found that women in all education levels were more likely than those with no education to make ≥ four ANC visits. Unmarried women with primary education were 4.404 times more likely than unmarried women to have ANC visits ≥ four times (AOR 4.404; 95% CI 4.396-4.412). Unmarried women with secondary education are 4.875 times more likely to make ANC visits ≥ four times (AOR 4.875; 95% CI 4.867-4.883). Besides, unmarried women with higher education are 2.504 times more likely than unmarried women to make ANC visits ≥ four times (AOR 2.504; 95% CI 2.499-2.509).

Based on employment status, employed unmarried women have a probability of 1.305 times than unemployed unmarried women to make ANC visits ≥ four times (AOR 1.305; 95% CI 1.304-1.306). This information shows that employment is a protective factor for unmarried women in Indonesia to complete ANC visits.

The binary logistic regression results found that all wealth status categories were more likely than the poorest to complete ANC visits. Unmarried women with the more deficient category's wealth status are 2.073 times more likely than the most deficient unmarried women to make ANC visits ≥ four times (AOR 2.073; 95% CI 2.072-2.075). Unmarried women with a wealth status in the middle category are 3.010 more likely to make ANC visits ≥ four times (AOR 3.010; 95% CI 3.008-3.013). Unmarried women with wealth status in the more affluent category were 2.313 times more likely than the poorest unmarried women to make ANC visits ≥ four times (AOR 2.313; 95% CI 2.311-2.315). Moreover, the richest unmarried women have 3,950 times the probability of making ANC visits ≥ four times than the most deficient unmarried women (AOR 3.950; 95% CI 3.946-3.955).

Finally, according to health insurance ownership, insured unmarried women have a probability of 1.219 times more likely than uninsured unmarried women to make ANC visits ≥ four times (AOR 1.219; 95% CI 1.218-1.220). This analysis indicates that insured is a protective factor for unmarried women in Indonesia to complete ANC visits.

Discussion

The analysis found that unmarried women who had an unintended pregnancy in Indonesia were less likely to complete ANC visits. Less than optimal prenatal care in women with an unintended pregnancy is common in many countries on various continents, such as Africa, Asia, the USA, and Europe²⁴. Several previous studies in the USA, Iran, Kenya, and Ethiopia also revealed a strong association between pregnancy unwantedness and the frequency and timing of ANC visits^25–29.

Many factors can explain the finding, including socio-cultural and psychological factors. Marriage in Indonesia symbolizes a religious, social order while experiencing pregnancy in an unmarried woman will carry social stigma^30,31. The health value of people who share extramarital incubation, which the community sees as a disgrace, is considered less important than social values. By conducting ANC visits, the surrounding community will be aware of extramarital pregnancies, a massive social threat. The women even felt stigma until the fetus in the womb grew into a child and had a severe psychological impact³¹.

Social stigma and psychological burden for unmarried women who experience pregnancy do not only occur in Indonesia. In many communities in some developing countries, unmarried woman pregnancies tend to be associated with poverty and low education³². For example, a study in Sri Lanka found that women who became pregnant outside of wedlock realized that they had violated social norms, so they tended to blame themselves; some even attempted suicide³³.

This study indicates that living in rural areas is a protective factor for unmarried women to complete ANC visits. The situation means that unmarried women living in rural areas have better ANC visits than unmarried women in cities. Rural regions in Indonesia are characterized by high community awareness and togetherness compared to urban areas. Social relations in rural communities are heightened and tend to last longer³⁴, thus building a good interaction pattern who cares about each other in the neighborhood. Bullying and negative social sanctions are not common in rural areas due to the politeness culture, which is still firmly attached³⁵. Thus, we felt this condition reduces the psychological burden of a woman who experiences an unwanted pregnancy.

Contrary to rural areas, urban areas have more modern culture, and politeness in the interaction pattern is lower. As a result, there is a fear among women who experience unwanted pregnancies of receiving bullies from their environment^36,37. This phenomenon makes women with unintended pregnancies in urban areas reluctant to have regular pregnancy checks.

The study also found age group as a determinant of the ANC visits performance. Although previous research has found variations in knowledge about pregnancy health, the older the mother is during pregnancy, more aware they are of their health risk^38,39. The situation influences the decision-making of pregnant women whether to use ANC according to standards or not. The study results can explain why the ANC of four visits is significant in the 45–49 year age group. The results align with a lesson in Thailand that found that pregnant women over 35 years old had the highest score in promoting completed ANC visits⁴⁰.

Several other studies widely revealed the low utilization of ANC in the age group of 15–19 years old^41,42. The incidence of unwanted pregnancy at an early age is generally experienced by those who are still students. The younger the gestational age, the higher the social burden borne by the family. Adolescents who experience unintended pregnancies tend to be in a terrible condition, feel sad, depressed, and not receive support from their parents⁴³. The situation is their barrier to utilizing ANC according to standards.

Unmarried women who have experienced marriage in Indonesia are less likely to have complete ANC visits. The status of widowed or divorced in several regions in Indonesia is stigmatized, especially for those who became divorced³⁰. This stigmatization will undoubtedly worsen for widows or divorced women who experience pregnancy because the “naughty woman” label will be attached³¹. The socio-psychological burden faced by widows or divorced women who experience unwanted pregnancies is much heavier than the other women's. The situation was what became an obstacle for the widow or divorced women to carry out ANC checks regularly. Many previous studies have found that widows or divorced women are more likely to experience unsafe sex because doing it without contraception¹².

Meanwhile, the study results found that all education levels led a better chance of making ANC visits ≥ four times than no education. These results indicate that the higher a person's education, the higher her understanding of pregnancy risk^44,45. Even though pregnant women still feel the social burden, higher education can better control the situation. Educated pregnant women can choose healthier behavior due to sufficient background knowledge⁴⁶. Several other studies have shown a direct influence between education and health behavior in pregnant women^46,47. Finally, several previous studies often found education a strong determinant of better health sector performance^48–51.

On the other side, the results of the analysis indicate that the employment is a protective factor for unmarried women in Indonesia to complete ANC visits. Society saw working women as more independent women. Some jobs also require specific educational levels. Thus, working women generally have a more educated social environment than women who do not work⁵². There is a growing trend of women joining the workforce, and more and more women are working in the formal sector. The condition is in line with the increasing education level of women⁵³. The higher a person's education level, the more modern their mindset tends to be, accepting changes more efficiently, and being more resilient. Previous research has shown that working women's self-image is higher than that of unemployed women⁵⁴. Women with a better self-image can better control their behavior, including being more independent in making decisions about their health. These conditions make employment a protective factor for unmarried women who experience unintended pregnancies.

Moreover, results of the binary logistic regression test found that women in all the above poorest wealth status categories are more likely than the poorest to complete ANC visits. This study's products align with previous research that found that wealth significantly affects the fair use of antenatal care⁵⁵. Previous studies have also confirmed inequality in receiving health services between the rich and the poor⁵⁶.

Finally, the analysis found that insurance ownership is a protective factor for unmarried women in Indonesia to complete ANC visits. However, spending to pay for health services remains a consideration in utilizing health services. Health insurance participants no longer need to think about paying for the health services they receive. Meanwhile, people who do not have health insurance still have to pay a fee every time they attend health services. The condition is a barrier to health services for people who do not have insurance⁵⁷. Even though Indonesia's primary health services can be obtained free of charge for ANC services, not all people access the Puskesmas (public health centers)⁵⁸. In Indonesia, many people use private practicing midwives to receive ANC services, namely 40.5%, because private practicing midwives are more affordable⁵⁹. Of course, people who do not have health insurance have to pay a fee to receive ANC services from private midwives. It becomes natural if people do not have insurance, the ANC utilization rate is lower than those with insurance.

Conclusions

Based on the analysis results, the study concluded that women who experienced an unintended pregnancy in Indonesia had a lower probability of having complete ANC visits. Apart from unintended pregnancy, the study also found seven independent variables to determine ANC visit performance. The seven variables are residence, age group, marital status, education level, employment, wealth status, and health insurance ownership.