Underestimation of pregnancy risk among women in Viet Nam

RESEARCH ARTICLE Open Access
Underestimation of pregnancy risk among
women in Vietnam
g
s o
,
of
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birth outcomes [2], increased levels of pregnancy-related tended pregnancies occur [1, 4], and where the health
n who desire
Londeree et al. BMC Women's Health (2020) 20:159 
https://doi.org/10.1186/s12905-020-01013-6appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonsto prevent pregnancy is critical.
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
Health, Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, USA
Full list of author information is available at the end of the articlebarriers to contraception use among wome* Correspondence: gallo.86@osu.edu1Division of Epidemiology, The Ohio State University, College of Publicmorbidity and mortality [3, 4], as well as mental health infrastructure is often ill-equipped to handle the conse-
quences of unintended pregnancy, understanding theilies. Consequences of these pregnancies include poorand 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
bivariable and multivariable logistic regression models to identify correlates 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 or
rural 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 or
other behaviors and beliefs relating to contraceptive use.
Conclusions: Findings reinforce the need to address inaccurate perceptions of pregnancy risk among women at
risk of experiencing an unintended pregnancy.
Keywords: Contraception, Health knowledge, attitudes, practice, Pregnancy, unplanned, Risk assessment, Vietnam
Background
Of pregnancies occurring 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-
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-pregnancy risk among reproductive-age, sexually-active women in Hanoi, Vietnam who did not desire pregnancyJessica Londeree1, Nghia Nguyen2, Linh H. Nguyen2, Dun
Abstract
Background: Addressing women’s inaccurate perception
contraceptive uptake and adherence. Few studies, though
underestimation of pregnancy risk among women at risk
Methods: We assessed the association between demogralicence and your intended use is not permitte
permission directly from the copyright holder
The Creative Commons Public Domain Dedica
data made available in this article, unless otheH. Tran3 and Maria F. Gallo1*
f their risk of pregnancy is crucial to improve
have evaluated the factors associated with
unintended pregnancy.
hic and behavioral characteristics and underestimatingd by statutory regulation or exceeds the permitted use, you will need to obtain
. To view a copy of this licence, visit 
tion waiver ( applies to the
rwise stated in a credit line to the data.
Londeree et al. BMC Women's Health (2020) 20:159 Page 2 of 7According 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
behavior and adherence. Indeed, underestimation of
pregnancy  ... 7) 156 (94.0) 66 (93.0)
Non-Kinh 15 (6.3) 10 (6.0) 5 (7.0)
Monthly household income
≥ 15,000,000 Vietnamese dong 170 (71.7) 117 (70.5) 53 (74.6)
< 15,000,000 Vietnamese dong 44 (18.6) 30 (18.1) 14 (19.7)
Missing 23 (9.7) 19 (11.4) 4 (5.6)
Current male condom use
Yes 165 (69.6) 117 (70.5) 48 (67.6)
No 72 (30.4) 49 (29.5) 23 (32.4)
Current traditional contraception useb
Yes 147 (62.0) 100 (60.2) 47 (66.2)
No 90 (38.0) 66 (39.8) 24 (33.8)
Frequency of sexual intercourse
At least once per week 187 (78.9) 131 (78.9) 56 (78.9)
Less than once per week 41 (17.3) 31 (18.7) 10 (14.1)
Missing 9 (3.8) 4 (2.4) 5 (7.0)
Health provider discussed contraception
Yes 126 (53.2) 83 (50.0) 43 (60.6)
No 110 (46.4) 82 (49.4) 28 (39.4)
Missing 1 (0.4) 1 (0.6) 0 (0)
Pregnancy ambivalence
Ambivalent 49 (20.7) 16 (9.6) 33 (46.5)
Not-ambivalent 187 (78.9) 150 (90.4) 37 (52.1)
Londeree et al. BMC Women's Health (2020) 20:159 Page 4 of 7
t r
-ac
Londeree et al. BMC Women's Health (2020) 20:159 Page 5 of 7past month) and not currently using highly-effective
contraception. Women having less frequent sex (includ-
ing those who experience forced sex) or those using a
highly-effective contraceptive method can face the risk
unintended pregnancy. However, we focused our study
on assessing correlates of reported unintended preg-
nancy risk among women who are most susceptible to
unintended pregnancy, and thus should be the target of
public health interventions. As perceived susceptibility
to a health outcome is a key determinant of behavior
change, the high prevalence of pregnancy risk underesti-
mation in our sample reinforces the need for interven-
tions to address inaccurate perceptions of pregnancy
risk, especially among women who are older and who
live in non-urban settings. Future studies should assess
the effect of interventions shown to improve reproduct-
ive and contraceptive knowledge, such as entertainment
education (e.g., radio drama) [19], tailored oral education
[20], or other health promotion materials (e.g., posters,
brochures) [21, 22], on correcting inaccurate perceptions
of pregnancy risk in this setting.
Our study also reinforces the need for a more nuanced
categorization of contraceptive need. At present, contra-
ceptive use is commonly categorized into ‘met’ and ‘un-
met’ need, based on fecundity, sexual activity and
current contraceptive use. Incorporating perception of
contraceptive need into the categorization of contracep-
tive use could further elucidate why some women fail to
use effective contraceptive methods, despite their avail-
ability. One such strategy of categorization, known as
the Tékponon Jikuagou approach, splits contraceptive
use into five categories: real met need (current users of a
Table 1 Demographic and behavioral characteristics of women a
pregnancy risk (N = 237) (Continued)
Overall
n (%)
Missing 1 (0.4)
aWomen were classified as at risk of unintended pregnancy if they were sexually
using a highly-effective contraceptive method
bTraditional contraception included use of rhythm and withdrawalmodern method), perceived met need (current users of a
traditional method), real no need, perceived no need
(those with a physiological need for family planning who
perceive no need), and perceived unmet need (those
who realize they have a need but do not use a method)
[14]. The use of this categorization could better inform
targeted behavioral interventions to prevent unintended
pregnancy.
We note that our results should not be generalized to
users of highly-effective contraception as such general-
izations could be subject to selection bias. Our findings
concerning pregnancy ambivalence illustrate thispotential source of bias; the women in our sample who
were not ambiguous about avoiding pregnancy were
more likely to underestimate the probability they would
become pregnant. Initially, this finding may seem un-
usual as one may expect that those who are most adam-
ant about avoiding pregnancy would be more aware of
their pregnancy risk. However, we may also expect that
most women who choose not to use contraceptives, des-
pite having great desire to avoid pregnancy, would be-
lieve it is improbable they could naturally conceive. In
short, by selecting on non-use of highly-effective contra-
ception, we observe an association between pregnancy
ambiguity and risk underestimation that may otherwise
not be observed in a sample of all women of reproduct-
ive age. Indeed, in a study of contraceptive users and
non-users in the United States, Rahman et al. found that
women who were ambivalent about pregnancy were
more likely to have accurate perceptions of their risk of
pregnancy [17], in contrast to our own findings.
Regarding the association between pregnancy risk
underestimation and age, we acknowledge that the abil-
ity to become pregnant naturally declines with increas-
ing age. Women’s fecundity begins to gradually lessen at
age 32, before dropping rapidly at the age of 37 with the
onset of perimenopausal menstrual irregularity [23].
Thus, though all women in this sample were of repro-
ductive age, the low perceived pregnancy likelihood
among older women could be based – in part – on bio-
logic reality. Nonetheless, if reproductive age women are
sexually active and not using highly-effective contracep-
tion, the risk of unintended pregnancy persists. There-
fore, the belief that pregnancy is very unlikely remains
isk of unintended pregnancya in Hanoi, Vietnam by perceived
Perceived pregnancy risk
Underestimated (n = 166) Not underestimated (n = 71)
n (%) n (%)
0 (0) 1 (1.4)
tive, of reproductive-age, did not desire to become pregnant and were notan underestimation of pregnancy likelihood, especially
for women under the age of 37 years. Additionally, we
observed that the level of pregnancy risk underestima-
tion was similar in older age groups: women ages 32–37
years had nearly identical odds of pregnancy risk under-
estimation relative to women ages 38–45 years. These
findings further suggest that women’s perception of their
ability to become pregnant does not fully align with the
natural decline in fecundity with age.
Our study population was relatively homogenous;
most participants in our sample were married, of the
Kinh ethnicity and resided in an urban setting. This
Table 2 Bivariable and multivariable analyses of correlates of pregnancy risk underestimation among women at risk of unintended
pregnancy a in Hanoi, Vietnam (N = 237)
OR (95% CI) aORb (95% CI)
Age in years
21–31 Ref – Ref –
32–36 3.20 (1.58–6.48) c 2.21 (0.95–5.16)
37–45 2.82 (1.42–5.60) c 1.95 (0.86–4.45)
Residence
Town or rural area 4.02 (1.17–13.78) c 3.91 (0.96–13.78)
City Ref – Ref –
Highest level of education completed
Upper secondary or less 1.56 (0.81–3.03) c 1.37 (0.61–3.08)
Higher Ref – Ref –
Marital status
Married 1.61 (0.55–4.71) – –
Other Ref – – –
Ever been pregnant
Yes 8.33 (0.85–81.66) c 5.76 (0.50–65.83)
No Ref – Ref –
Ethnicity
Kinh 1.18 (0.39–3.59) – –
Non-Kinh Ref – – –
Monthly household income
≥ 15,000,000 Vietnamese dong 0.97 (0.48–1.98) – –
< 15,000,000 Vietnamese dong Ref – – –
Current male condom use
Yes 1.14 (0.63–2.08) – –
No Ref – – –
Current traditional contraception used
Yes 0.77 (0.43–1.38) – –
No Ref – – –
Frequency of sexual intercourse
At least once per week 0.75 (0.35–1.64) – –
Less than once per week Ref – – –
Health provider discussed contraception
Yes 0.65 (0.37–1.16) c 0.71 (0.35–1.43)
No Ref – Ref –
Pregnancy ambivalence
Ambivalent 0.12 (0.06–0.24) c 0.11 (0.05–0.25)
Not-ambivalent Ref – Ref –
OR Odds Ratio, CI Confidence Interval, aOR Adjusted Odds Ratio
a Women were classified as at risk of unintended pregnancy if they were sexually-active, of reproductive-age, did not desire to become pregnant and were not
using a highly-effective contraceptive method
b Adjusted for all variables in column
c P-value < 0.25 and thus was included in the initial full model for the multivariable analysis
d Traditional contraception included use of rhythm and withdrawal
Londeree et al. BMC Women's Health (2020) 20:159 Page 6 of 7
Londeree et al. BMC Women's Health (2020) 20:159 Page 7 of 7homogeneity limits the generalizeability of our findings
to similar population groups. Additionally, our conveni-
ence sampling strategy furthers limits the generalizability
of our findings, as women seeking care from a single fa-
cility in Hanoi may not be representative of all
reproductive-age women in the region. Despite these
limitations, our study is the first to quantitatively assess
correlates of inaccurate pregnancy risk estimation in a
non-Western context.
Conclusions
As women in middle and low-income countries experi-
ence disproportionate rates of unintended pregnancy [1],
it is crucial to assess potential modifiable factors contrib-
uting to poor contraceptive use in these regions. In the
present study of women at risk of unintended pregnancy
in Hanoi, Vietnam, most women underestimated their
risk of pregnancy. These findings highlight the need for
interventions to address women’s misconceptions of
their pregnancy risk.
Abbreviations
aOR: adjusted odds ratio; CI: Confidence interval; OR: Odds ratio
Acknowledgements
Not applicable.
Authors’ contributions
NN and MG developed the study protocol. LHN and DHT led the data
collection. JL conducted the analysis and drafted the manuscript. All authors
were involved in revising the manuscript and approved the final manuscript.
Funding
This work was supported by the Bill & Melinda Gates Foundation
[OPP1171894] and the National Center for Advancing Translational Sciences
[UL1TR001070]. The content is solely the responsibility of the authors and
does not necessarily represent the official views of the Bill & Melinda Gates
Foundation, the National Center for Advancing Translational Sciences, or the
National Institutes of Health.
Availability of data and materials
The study dataset is available from the corresponding author following
institutional approvals.
Ethics approval and consent to participate
Institutional review boards at The Ohio State University and the Hanoi
School of Public Health approved the study, and women provided written
consent before enrolling.
Consent for publication
Not applicable.
Competing interests
The authors have no competing interests.
Author details
1Division of Epidemiology, The Ohio State University, College of Public
Health, Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, USA.
2Department of Obstetrics and Gynecology, Vinmec International Hospital,
458 Minh Khai, Hanoi, Vietnam. 3Department of Research and Training, Hanoi
Obstetrics and Gynecology Hospital, La Thanh Street, Hanoi, Vietnam.Received: 11 June 2019 Accepted: 6 July 2020
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