Unwanted pregnancy in Indonesia: prevalence and decision making

Women who have an unwanted pregnancy may decide to terminate that pregnancy and will experience social and, potentially, psychological changes that can affect their future (Frederico et al, 2018). Pregnancy at a young age increases the likelihood of a woman not finishing school, and teenagers who become pregnant must consider how to communicate with their parents, as they may encounter family disharmony or even a partner's demand for an abortion (Frederico et al, 2018). Women with an unwanted pregnancy may feel depressed, afraid, confused or embarrassed, and may be prone to emotional turmoil (Biaggi et al, 2016). They may also be pressured by their family, peers or environment and experience physical and psychological changes as a result of the pregnancy (Bledsoe et al, 2017; Rosnani et al, 2022). These factors may put pressure on women with an unwanted pregnancy to make a decision quickly, without considering the potential consequences, and can result in women having an abortion without indication or medical assistance (Kantorová, 2020).

Globally, approximately 21 million women aged 15–19 years old become pregnant every year; 49% of these pregnancies are unwanted, and more than half end in abortion (World Health Organization, 2019). In Asia, as many as 8.3 million women aged 15–19 years old become pregnant each year, 43% of which are unwanted and 28% of which end in abortion (Darroch et al, 2016).

Women aged 15–24 years old in developing countries are more vulnerable to unwanted pregnancy and unsafe abortions (41%) (Shah and Åhman, 2012). In Indonesia, the age-specific fertility rate for women aged 15–19 years and 20–24 years is 40.1 and 109.7 per 1000 women respectively (Statistics Indonesia, 2016). A survey of Indonesian women aged 15–24 years old found that 1% of women and 6% of men had premarital sex, and 1% of women experienced an unwanted pregnancy, with 60% of them choosing to abort (Statistics Indonesia et al, 2008).

Women may need to make complex decisions to manage an unwanted pregnancy. Making the decision to abort or continue a pregnancy should include assessing the associated risks, as well as their ability to care for a child and the required preparation, before a decision is made (Moeliono, 2017). It may be difficult for teenagers to decide whether to continue an unwanted pregnancy; various factors have been shown to influence their decision-making at different levels (Alhassan et al, 2016). At the individual level, these factors include their perception of their ability to be a mother, the choice to continue their education, depression, financial problems and the potential burden of shame associated with a teenage pregnancy (Frederico et al, 2018; Zia et al, 2021). At the interpersonal level, these include support, parental attitudes, male participation, stigma, family expectations, norms, traditions, assumptions of others regarding religion and school achievement, parental child communication, taboo discussions on sex, partner readiness, finances and the desire to have children (Loi et al, 2018; Bain et al, 2020). Research specific to Indonesia has shown that the factors influencing decision making in women with an unwanted pregnancy include parental intervention (Mulyanti, 2017), family roles, birth intervals, number of children, economic circumstances, medical issues and the dominant role of the husband (Sopiatun, 2011).

Young women with an unwanted pregnancy may make a decision without considering the potential consequences, and should be given support for their decision-making. This assistance can include non-judgmental counselling, including on the legal options, and referral to appropriate services (Hornberger, 2017). In addition, adolescents should be targeted by family planning services, because they greatly contribute to fertility rates, new pregnancy outcomes and the use of contraception (Suryani et al, 2015). In Indonesia, within the family and community, unwanted pregnancies are viewed negatively (Mulyanti, 2017). The issue has become stigmatised in society, where women with an unwanted pregnancy outside of marriage are seen as women who have engaged in ‘bad’ behaviour (Smith et al, 2016; Makleff et al, 2019).

The decision to become pregnant should be a joint decision between a couple. If a husband is not ready to accept a pregnancy, there is a risk of coercion or violence (Ajayi and Ezegbe, 2020). If both partners are educated and financially stable, they may be more able to make an informed decision about a pregnancy (Smith et al, 2016). Counselling is effective in providing support to those with an unwanted pregnancy, if the counsellor can encourage a woman to freely share her thoughts; counsellors should be mindful of a woman's values, culture and other associated factors in these circumstances (Mulawarman and Munawaroh, 2016). Common associated factors include social class, age, ethnicity and gender (McLeod, 2006; Mafula and Satrio Pambudi, 2022).

It is important to provide support for women with an unwanted pregnancy, to help them make a decision on whether to continue with the pregnancy. This support can be provided through counselling appropriate to individual characteristics and circumstances. The present study examined factors associated with decision making for women aged 15–24 years with an unwanted pregnancy. Previous studies have revealed factors that should be considered when providing counselling to adolescents and adolescents' preferences regarding family planning (McLeod, 2006; Suryani et al, 2015; Mulawarman and Munawaroh, 2016; Mulyanti, 2017), but no factors related to decision making for unwanted pregnancies in adolescents have been established.

Methods

Study design

This cross-sectional study used secondary data from the Indonesian demographic and health survey, which is part of Inner City Fund International. Access to the dataset was requested through their website and approved (no. 156783). Written informed consent for each individual was taken during the survey's data collection procedure.

Sample size

The survey was conducted in December 2017. The IDIR71FL dataset (Indonesian Individual Recode phase 7) was used to obtain complete data on women aged 15–49 years, with a survey population of 49 627. The data were weighted based on the number of provinces in Indonesia, to obtain an average number of participants for each region. Two-stage stratified cluster sampling was used by the survey when collecting data, by selecting clusters from each stratum and a list of families from the selected clusters. The families to be interviewed were then selected, which included women aged 15–24 years old. In total, there were 9218 women, and any records with missing data were not used.

Variables

This study's independent variables were region, age, education, wealth index, residence, occupational status, whether the participant had ever visited a health facility, sex of household head, contraceptive methods, intention to use contraceptives, planning a new pregnancy, desire for more children and physical partner violence. Education was categorised as high, secondary, primary or no education (Kebudayaan, 2003). The wealth quintiles were richest, richer, middle, poorer and poorest (Croft et al, 2018; The Demographic and Health Survey (DHS) Program, 2018), based on principal component analysis (Vyas and Kumaranayake, 2006). Place of residence was categorised into rural and urban (Badan Pusat Statistik, 2010). Employment status was determined based on whether the participant was currently working (yes or no) (The DHS Program, 2017). For planning a new pregnancy, the categories were have another, undecided and no more. The desire to have more children was categorised as within 2 years, after 2 years, unsure on timing, undecided and no more (The DHS Program, 2017). Physical partner violence was categorised into beating if refuse to have sex with partner, beating if argue with partner and beating if go out without telling partner (The DHS Program, 2017).

The dependent variable was the decision on how to manage an unwanted pregnancy. Unwanted pregnancy was defined as unplanned or unwanted, such as a pregnancy that occurs when no children or no more children are desired (Santelli et al, 2003). The decision was categorised as either the decision for continuation (the participant intended to have the baby and either raise it themselves or make other arrangements) or termination (the respondent intended to have an abortion) (Brauer et al, 2019).

Data analysis

Data analysis was aided by STATA version 16.1 software. Univariate analysis was used to present the description of each variable to be studied in both independent and dependent variables. Chi-squared tests were conducted to analyse the determinants of the decision made. Variables were submitted for the final multivariable model if the P value at chi-square analysis was <0.25 (Bursac et al, 2008; Rachmawati et al, 2022).

Multivariate analysis using binary logistic regression was used to determine the independent variables that had the greatest influence on the dependent variable. Continuation was used as a reference. The strength of the relationship between the independent and dependent variables was tested using odds ratios with 95% confidence intervals. The significant variables with P<0.05 and 95% confidence interval were considered determinants of the decision to terminate an unwanted pregnancy. To account for clustering effects and sampling weight resulting from the multistage cluster random sampling used to obtain data for the national survey, this study used STATA's ‘svy’ survey commands.

Ethical considerations

The authors received approval to access and download the survey data. The survey itself was approved by the institutional review board of Inner-City Fund International: ICF IRB no. FWA00000845. The project complies with all requirements of 45 CFR 46: protection of human subjects. Informed consent was obtained from all participants. For participants under 16 years old, informed consent was obtained from their parents. Information on the ethical review for the survey is available on the website: https://dhsprogram.com/Methodology/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm.

Results

The participants' demographic data are shown in Table 1. Most participants chose to continue with their pregnancy (81.2%). The greatest proportion of respondents was from Java (33.4%). The majority were between 15 and 19 years old (74.9%), had secondary education (68.8%) and were from middle to upper wealth levels (64.8%). Most lived in urban areas (61.5%), did not work (65.5%) and did not visit health facilities (74.5%). The head of almost all households was a man (83.2%). Most respondents did not use contraception (99.8%) at the time of data collection but intended to (81.2%), and were planning another pregnancy (93.5%) although most were unsure of the timing they wanted for future pregnancies (55.5%). A quarter of respondents experienced physical partner violence (25.5%). Most violence originated from a participant going out without telling their partner (21.2%).

Bivariate analysis found that region, age, education, wealth index, residence, visits to a health facility, planning a future pregnancy and physical partner violence were correlated with the decision to terminate an unwanted pregnancy (Table 2). These variables were subjected to multivariate analysis.

Table 3 shows the results of the multivariate analysis. Participants in Sulawesi were more likely to terminate (adjusted odds ratio: 1.237, P=0.012), compared to those from other islands. Those with primary education (adjusted odds ratio: 1.719, P<0.001), a greater wealth index (adjusted odds ratio: 0.688, P<0.001), who lived in rural areas (adjusted odds ratio: 1.165, P=0.015) or who experienced physical partner violence (adjusted odds ratio: 1.576, P<0.001) were more likely to decide to terminate their unwanted pregnancy. Those who were undecided on whether or not they wanted another pregnancy in future were less likely to terminate (adjusted odds ratio: 0.613, P=0.005) than those who knew whether they did or did not want to become pregnant again.

Discussion

This study analysed data from the Indonesian demographic and health survey of 2017 in order to assess factors related to the decision to terminate an unwanted pregnancy among women aged between 15 and 24 years old. Residence, education, wealth and experiencing physical partner violence were factors related to deciding to terminate.

Women's residence, in terms of which island in Indonesia they were from, influenced the decision to terminate an unwanted pregnancy. Women who live in regions that are far from government centres, such as in Sulawesi, may be less likely to decide to terminate as a result of low information dissemination in these locations; regional factors affecting information distribution may mean women are not aware of the services available to allow them to safely terminate their pregnancy.

There are regional disparities in health status and the quality, availability and capacity of health services (Mahendradhata et al, 2017). The government has decentralised to increase the reach of health services, but there are still disparities. Additionally, local developments and culture need to be considered. Culturally, there is a behaviour known as lokika sangraha, where a man has sexual intercourse with a woman until she becomes pregnant and then does not marry her (Sarmita, 2015). Women who become pregnant as a result of this tend to hide, because of cultural perceptions of shame; the lack of openness and ability to seek assistance can make it harder for women to gather information and come to an informed decision regarding the pregnancy (Smith et al, 2016).

In Sulawesi, especially the south, women with an unwanted pregnancy or who become pregnant outside of marriage are traditionally isolated and often decide to terminate their pregnancy (Pramono, 2022). To avoid scandal, a woman may be married to an appointed man, who may or may not be the father of the child (Ubbe, 2005). This marriage can benefit the mother and child, because of the associated social status and by providing a father figure for the child, but may result in a lack of support from the partner. Customary law regarding unwanted or extramarital pregnancies has been implemented and can help reduce the burden of these pregnancies in terms of the associated cultural stigma; this law protects a pregnant woman's human rights and grants them the right to a legal marital status. This can help women avoid the social stigma of having a child while being unmarried, as well as protecting the rights of pregnant adolescent women, including their right to receive formal education. However, it is beneficial if a counsellor assists in the law's application.

Although, the present study's results reported that age was not associated with the decision to terminate an unwanted pregnancy, women who are older may be more likely to have greater autonomy and self-confidence. Previous research has reported that older women are more likely to participate in healthcare decisions (Acharya et al, 2010; Rizkianti et al, 2020), and knowledge of contraception and awareness of reproductive health tends to be greater in older women (Al-Rabee, 2003). In Indonesia, a person is considered to be an adult when they reach 21 years old; by law, they become capable of making legal decisions and being responsible for themselves (Dharma, 2015). Women who have more autonomy can participate in health decision making, such as the decision to visit a health facility (Nadeem et al, 2021) and pregnancy-related matters, including unwanted pregnancies (Rahman, 2012). However, women under 21 years old are not yet legally able to make their own decisions (Hanifa and Kurniawati, 2020). In Indonesia, younger women have less autonomy, and parents, friends and partners often have greater influence on these decisions (Ralph et al, 2014; Skosana et al, 2020). Others often take over decision making, including a woman's family or parents.

Women with higher education may have a greater understanding of the advantages and disadvantages of terminating or continuing a pregnancy. In the present study, women with lower education were more likely to terminate an unwanted pregnancy. Formal education can foster educational empowerment (Nkhoma et al, 2020) and knowledge of health services for reproduction and family planning is greater in well-educated women (Tegegn et al, 2008; Ahmed and Hafez, 2014). With more knowledge, women may be more capable of and confident in making decisions on their pregnancy or fertility (Testa, 2014). In addition, women with higher education may be more able to provide for their children and access health services such as vaccinations (Kusnanto et al, 2020; Mediarti et al, 2020; Arifin et al, 2021), making them more likely to decide to continue with the pregnancy.

Women from rural areas were more likely to terminate their unwanted pregnancy. This may be related to education and knowledge on family planning; those living in urban areas typically have better education, knowledge, access to family planning programmes and contraception, and a better understanding of the consequence of termination (Sarder et al, 2021). Women who live in rural areas also often have a strong culture related to behaviour. Stigma that assumes that an unwanted pregnancy or pregnancy outside of marriage is bad may mean women experiencing this stigma prefer to abort their pregnancy.

Women from a lower wealth index may find it more difficult to make a decision regarding an unwanted pregnancy. Women with lower economic status were more likely to terminate the pregnancy in the present study compared to those with high economic status. Several studies have reported a similar association (Sopiatun, 2011; Dehlendorf et al, 2013). This decision may be based on avoiding the negative consequences of having more dependents in a household (Kiranantika, 2013). Women from a higher wealth index may have more resources and are more able to meet the needs of their children.

Women who are undecided on fertility preferences were less likely to terminate their pregnancy. A previous study showed that women with a low psychological burden found it easier to make decisions related to pregnancy than those who were uncertain (Murugesu et al, 2021). Women who plan to have more children are more likely to accept their pregnancy and continue with it, even if it was unplanned (Zeleke et al, 2021).

Women who experienced physical violence were more likely to terminate their unwanted pregnancies. In the present study, most domestic violence was the result of the reaction to a participant going out without telling their partner. Domestic violence is a serious issue that can affect physical and psychological conditions (Sharma et al, 2019; Newnham et al, 2022), and previous studies have shown that unwanted pregnancies increase the likelihood of domestic violence (Acharya et al, 2019; Sharman et al, 2019). Physical violence can occur alongside fertility control in the form of contraceptive sabotage, pregnancy pressure or forced pregnancy, and this can influence a woman's decision about their pregnancy (Moore et al, 2010; Silverman and Raj, 2014). Violence by those closest to them also increases the likelihood of a woman experiencing an unwanted pregnancy and abortion (Maxwell et al, 2017). Parents usually take over decision making regarding a woman's pregnancy when there is no available counselling process, because an unwanted pregnancy is viewed negatively in this cultural context (Mulyanti, 2017). For women with an unwanted pregnancy, counselling and the assurance that those closest to them will not commit violence or stigmatise the woman provide support for managing an unwanted pregnancy and may influence the decision to continue.

Conclusions

Participants' residence, education, wealth index and experience of physical partner violence affected the decision to terminate an unwanted pregnancy. Those who were undecided on whether or not they wanted another pregnancy in future were less likely to terminate than those who knew whether they did or did not want to become pregnant again. Government and health workers should formulate policies related to unwanted pregnancy, taking these factors into account. Health education and interventions such as counselling should be made available to ensure women are able to make an informed decision about their pregnancy, avoiding the influence of stigmatisation or economic burdens.

Key points

• The decision to terminate an unwanted pregnancy among women in Indonesia is taken by almost 20% of this population, and 25% of these suffer physical partner violence.
• The present study analysed data from the Indonesian demographic and health survey of 2017.
• Respondents' residence, education, preference for future pregnancies and experience of physical partner violence influenced their decision to terminate their unwanted pregnancy.
• Cross–collaboration between the government, healthcare workers and parents to educate and empower women with an unwanted pregnancy should be initiated.

CPD reflective questions

• In the case of an unwanted pregnancy, how can midwives support young women in their decision making?
• What strategic programmes can be implemented to prevent unwanted pregnancies?
• What counselling can be given to assist women to make a decision regarding an unwanted pregnancy