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The Consequences of Unintended Pregnancy for Maternal and Child Health in

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Matern Child Health J (2013) 17:493–500
DOI 10.1007/s10995-012-1023-x
The Consequences of Unintended Pregnancy for Maternal
and Child Health in Rural India: Evidence from Prospective Data
Abhishek Singh • Ashish Singh •
Bidhubhusan Mahapatra
Published online: 18 April 2012
Ó Springer Science+Business Media, LLC 2012
Abstract To investigate the relationship between preg-
nancy intendedness and utilization of recommended pre-
natal care for mothers and vaccinations for children against
six vaccine preventable diseases in rural India using a
prospective dataset. To examine the association between
pregnancy intention and neonatal and infant mortality in
rural India. The study is based upon a prospective follow-
up survey of a cohort selected from the National Family
Health Survey 1998–1999, carried out in 2002–2003 in
rural areas of four Indian states of Bihar, Jharkhand,
Maharashtra and Tamil Nadu. Data for 2108 births for
which pregnancy intendedness was assessed prospectively
was analyzed using bivariate analysis, logistic regressions
and discrete-time survival analysis. Mothers reporting
unwanted births were 2.32 (95 % CI: 1.54–3.48) times as
likely as mothers reporting wanted births to receive inad-
equate prenatal care. Moreover, unwanted births were 1.38
(95 % CI: 1.01–1.87) times as likely as wanted births to
receive inadequate childhood vaccinations. Likewise,
births that were identified as mistimed/unwanted had 83 %
higher risk of neonatal mortality compared to wanted
births. The association between pregnancy intendedness
A. Singh (&)
Department of Public Health & Mortality Studies, International
Institute for Population Sciences, Mumbai 400 088, India
e-mail: abhi_iips@yahoo.co.in
A. Singh
Indira Gandhi Institute of Development Research,
Mumbai 400 065, India
e-mail: aashish.igidr@gmail.com
B. Mahapatra
HIV and AIDS Program, Population Council, 142, Golf links,
New Delhi 110003, India
e-mail: bbmahapatra@gmail.com
and infant mortality was only marginally significant. This
is the first study of its kind which has investigated the
relationship between prospectively assessed pregnancy
intendedness and early childhood mortality in rural India.
The study provides additional and more conclusive evi-
dence that unwanted births are disadvantaged in terms of
maternal and child health outcomes. Findings argue for
enhanced focus on family planning to reduce the high
prevalence of unintended pregnancy in rural India.
Keywords Pregnancy intendedness
Prospective data

Recommended prenatal care for mothers
Recommended
set of vaccinations for children
Neonatal and infant
mortality
Rural India
Introduction
A number of demographic studies have highlighted the
high levels of unintended (mistimed/unwanted) pregnancy
in both developed and developing countries. Recent data
from the Demographic and Health Surveys indicate that
14–62 % of recent births were unintended [1]. The highest
levels of unintended pregnancies are found in the Latin
American, Caribbean and South-Southeast Asia regions.
Recent estimates from Indian National Family Health
Survey-3 conducted in 2005–2006 indicate that 21 % of
recent births in India were unintended [2], and approxi-
mately 10 % of them were not wanted at all.
Unintended fertility is a concern from both a family
planning and a public health perspective. Unintended fer-
tility is often a cause for higher fertility in developing
countries including India [3–9]. A substantial body of
research exists that highlights the negative consequences of
unintended pregnancies for both mothers and children.
123
494
A number of studies from the developed world have found
a significant and positive association between pregnancy
intention and delayed initiation of antenatal care and/or
decreased number of antenatal care visits [10–21]. How-
ever, it is difficult to draw similar inference for the
developing world because on one hand there are studies
that have reported a positive association between unin-
tended pregnancy and antenatal or delivery care [22, 23]
and at the other hand there are also studies which have
found mixed results [24–27]. It is important to note that
these studies are predominantly based on DHS data.
Evidence on the relationship between pregnancy
intendedness and early childhood mortality is even more
limited and inconclusive [1]. For example, Montgomery
et al. [28, 29] found weak or no effect of unintended fer-
tility on childhood mortality. Whereas, Chalasani et al.
[30], using prospective data on pregnancy intendedness
found high odds of neonatal and postneonatal mortality
among children who were unwanted. A recent study by
Singh et al. [27] also revealed higher risk of early child-
hood mortality among children who were unwanted.
A key issue in investigating the negative consequences
of unintended pregnancy is the measurement of unintended
pregnancy. A majority of the previous studies rely on ret-
rospective responses from women on whether the indexed
child was unwanted or mistimed at the time of birth. Ret-
rospective responses on pregnancy intendedness are likely
to suffer from recall bias and ex-post rationalization, i.e., a
significant proportion of children who were unwanted or
mistimed at the time of pregnancy might be reported as
wanted at the time of survey due to various reasons. All
these might lead to only ‘most unwanted’ children being
reported as unwanted and all others being reported as either
mistimed or wanted. These biases collectively might result
into systematic under-reporting of unwanted births. A
recent study by Koenig et al. [31] which was based in rural
India revealed a pronounced tendency for births prospec-
tively classified as unwanted to be retrospectively descri-
bed as having been wanted or mistimed [31]. The study
found substantial difference between the retrospective and
prospective assessment of pregnancy intendedness (50 vs.
72 %). The study also provided compelling evidence to
infer that the relationship between pregnancy intendedness
and negative health outcomes might be biased due to the
biases that are inherent in the retrospective responses on
pregnancy intendedness.
Given the aforementioned limitations of the previous
studies and the inconclusive evidence regarding the rela-
tionship between unintended pregnancy and maternal and
child health outcomes, we used prospective assessment of
pregnancy intendedness to investigate (for rural India) the
relationship between pregnancy intendedness and utiliza-
tion of recommended prenatal care for mothers on one
123
Matern Child Health J (2013) 17:493–500
hand and pregnancy intendedness and uptake of a recom-
mended childhood vaccinations for children on the other.
We further investigated the relationship between preg-
nancy intendedness and neonatal and infant mortality.
Data and Methods
Data
Two linked datasets were utilized for this analysis: data
from the second round of the Indian National Family
Health Survey (NFHS-2) conducted in 1998–1999, and
from a prospective follow-up survey of a cohort selected
from NFHS-2 carried out in 2002–2003. The NFHS is an
Indian version of the Demographic and Health Survey
(DHS) and provides consistent and reliable estimates of
fertility, mortality, family planning, utilization of maternal
and child health care services and other related indicators
at the national, state and regional levels. The NFHS-2
(1998–1999) covered nearly 91,196 sample households and
89,199 ever-married women in the 15–49 years age group.
The response rates in NFHS-2 were consistently above
90 % for the states selected in our study.
The currently married women in the age-group
15–39 years who were usual residents of households in the
states of Bihar, Jharkhand, Maharashtra, and Tamil Nadu at
the time of NFHS-2 interviews were followed up in
2002–2003. Bihar and Jharkhand belong to the Northern
region (Jharkhand was part of Bihar at the time of
NFHS-2), Maharashtra belongs to the Western region
whereas Tamil Nadu belongs to the Southern region. These
four states together represent the diversity in different
demographic, socio-economic and service-delivery indi-
cators in India.
The survey instrument included questions pertaining to
respondent’s background characteristics, reproductive
behaviour and intentions, quality of family planning, use of
family planning methods, an event calendar covering the
intervening months between the baseline (NFHS-2) and the
follow-up survey, and domestic violence experience [32].
The re-interview rates were high in each of the four states
and the re-interviewed and non-reinterviewed samples of
women were generally similar in terms of characteristics,
indicating that there was no significant selectivity in the
re-interviewed sample [32–34]. The details of the follow-
up survey can be obtained elsewhere [33].
Outcome Variables
Four outcome variables were included in the analysis. The
first outcome variable was the utilization of recommended
prenatal care for mother as suggested by the World Health
Matern Child Health J (2013) 17:493–500
Organization (WHO 2006)—at least four antenatal visits
and first antenatal visit in the first trimester of pregnancy
[35]. The second outcome variable was the utilization of
recommended childhood vaccinations against six vaccine
preventable diseases, also referred to as full immunization
in India. The recommended childhood vaccinations
includes—three doses of DPT, three doses of oral polio
vaccine (OPV) and one dose each of measles vaccine and
BCG [2]. The other two outcome variables were mortality
during first month of life (i.e. neonatal period) and mor-
tality during first 11 months of life (i.e. infant mortality).
Deaths during the post-neonatal period (1–11 months of
life) were too few, and therefore not estimated. We could
not estimate mortality under 5 years of age due to the short
birth-history available in the follow-up survey (details of
births to women during 1998–1999 and 2002–2003 is only
available). Recommended prenatal care, neonatal and
infant mortality were based on maternal report. The
information on recommended set of childhood vaccinations
was based on maternal reports that were compared with the
content of the routine immunization card. The discrepan-
cies between the maternal report and the content of the
routine immunization card were further probed in the
survey.
Exposure Variables
The exposure variable included in the analysis was a pro-
spective measure of pregnancy intendedness in the two
linked dataset. The prospective assessment of pregnancy
intendedness was made using the procedure devised by
Koenig et al. [31]. The responses to questions on fertility
preferences in NFHS-2 allowed the assessment of preg-
nancy intendedness for the inter-survey (between NFHS-2
and the follow-up survey) births. The questions on fertility
preferences were:
For non-pregnant women:
1. Would you like to have (a/another) child or would you
prefer not to have any more children?
2. How long would you like to wait from now before the
birth of (a/another) child?
For pregnant women:
1. After the child you are expecting now, would you like
to have another child, or would you prefer not to have
any more children?
2. After the birth of the child you are expecting now,
how long would you like to wait before the birth of
another child?
Births to women (during the inter-survey period) who
stated at the time of NFHS-2 survey that they do not want
any more children were classified as unwanted. On the
other hand, the births occurring 1 year or more before the
495
preferred time stated by the mother at the time of NFHS-2
interview were classified as mistimed. Births occurring
(during the inter-survey period) \1 year earlier, around the
same time, or later than the women’s stated preference
were all classified as wanted.
Overall, 3,900 non-multiple live births occurred during
the inter-survey period. Since the NFHS-2 survey asked
only about the mother’s desire for an additional child for
the non-pregnant women and additional child after the
current pregnancy outcome for the pregnant women, it was
not possible to determine the intendedness status for the
second or higher-order inter-survey births among the non-
pregnant women and first, third or higher-order inter-sur-
vey births among the pregnant women. We therefore, had
to exclude the second or high-order inter-survey births for
the non-pregnant women and first, third or higher-order
inter-survey births for the pregnant women from our
analysis. In addition, we had to exclude women who were
sterilized or believed themselves to be infecund at the time
of NFHS-2, and were therefore not asked about their fer-
tility preferences. Further, we also had to exclude births to
mothers who reported additional children to be ‘up to
GOD’ and births where prospective fertility preferences
were not obtained. The result was a sample of 2,347 births
for which we could prospectively determine the pregnancy
intendedness. Moreover, 239 births in the prospective
assessment were wanted-timing unsure, and were thus
excluded from the analysis. This resulted in a final sample
size of 2,108 births which was used for the analysis.
The other exposure variables included were maternal
age (\25 years; 25–34 years; [34 years), woman’s edu-
cation (none; primary; middle or higher), woman’s auton-
omy (no autonomy; some autonomy), media exposure (no
exposure; partial exposure; full exposure), sex of child
(male; female), household standard of living (low; med-
ium; high), and caste (Scheduled Castes (SC)/Scheduled
Tribes (ST); Other Backward Classes (OBC); others).
Woman’s autonomy was estimated using woman’s
responses to three questions about the extent of her deci-
sion-making power in her household. Similarly, woman’s
media exposure was estimated using woman’s responses on
three questions about television, radio, and newspaper use.
Women who had no exposure to any of the three media
were coded into ‘no exposure’ category, those having
exposure to one or two sources of media were coded into
‘partial exposure’ category, and women who had exposure
to all the three media were coded into ‘full exposure’
category. We could not include birth order and birth
intervals in the analysis pertaining to neonatal and infant
mortality because of the unavailability of such information
in the follow-up survey. Instead, we controlled for parity
(first; others) as done by Koenig et al. [32]. Our categori-
zation of parity into ‘first’ and ‘others’ is also in line with
123
496
the study by Singh et al. [27] who found that ‘first order’
births were at higher risk of early childhood mortality
compared to children of ‘other’ birth orders. For analyzing
mortality, we merged the mistimed and unwanted catego-
ries of births as well as partial and full exposure categories
of media exposure together. We did this in order to adjust
the cell frequencies.
Methods
We used bivariate analysis to examine the unadjusted
association between pregnancy intendedness and maternal
and child health outcomes. Appropriate sample weights
were used while estimating bivariate results. We further
used binary logistic regression models to examine the
adjusted association of pregnancy intendedness with inad-
equate prenatal care for mother and utilization of inade-
quate childhood vaccinations for the resultant newborns. In
addition we used discrete-time survival models to examine
the adjusted association of pregnancy intendedness with
neonatal and infant mortality. Survival models were also
used to generate the unadjusted estimates of neonatal and
infant mortality for the different categories of ‘pregnancy
intendedness’. We tested the exposure variables for possi-
ble multicollinearity before including them in the multi-
variate models.
Results
Figure 1 presents the prospective assessment of pregnancy
intendedness in rural India. 27 % of the births were
unwanted and 12 % of the births were mistimed. For
approximately 10 % of the births, the wanted-timing was
unsure. Interestingly, only 11 % of the inter-survey births
were unwanted and 17 % were mistimed when retrospec-
tive responses were used (Results not shown). The char-
acteristics of the 2,108 births shown in Table 1 suggest that
Fig. 1 Prospective assessment of pregnancy intendedness, rural
India, 2002–2003
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Matern Child Health J (2013) 17:493–500
about three-fifths of births occurred to women \25 years.
Only a little more than 4 % of the births were contributed
by women [34 years. 73 % of births occurred to women
who had no education and approximately 62 % occurred to
women who did not have any autonomy. Media exposure
was limited—a little more than two-thirds of the births
occurred to women who had no exposure to media. Almost
three-fifths of the households in the sample belonged to low
standard of living and a little more than half of the
households belonged to the Other Backward Clasess
(OBC).
Reporting of unwanted births was higher among women
aged [25 years, women who had no education, women
who had no exposure to mass media, and women who lived
in households with low standard of living (Table 1). On the
other hand mistimed births were more common among
women aged \25 years, women who had middle or higher
education, women who had full exposure to mass media,
and women who lived in wealthier households.
Figure 2 shows utilization of recommended prenatal
care for mother and recommended childhood vaccinations
for the resultant newborns by the different categories of
pregnancy intendedness. Findings suggest stark variations
in utilization of recommended prenatal care and childhood
vaccinations by the categories of pregnancy intendedness.
For example, 15 % of the wanted births received the rec-
ommended prenatal care compared to only 6 % of the
unwanted births. Likewise, 39 % of the wanted births
received recommended childhood vaccinations compared
to only 27 % of the unwanted births. Surprisingly, rec-
ommended prenatal care and childhood vaccinations were
highest among mistimed births.
Unwanted/mistimed births were also disadvantaged in
terms of neonatal and infant mortality. The neonatal mor-
tality rate was about 33 per 1,000 live births among the
mistimed/unwanted births. This compares with a neonatal
mortality rate of only 20 per 1,000 live births among the
wanted births. The infant mortality rates among the
unwanted/mistimed and wanted births were 49 and 34 per
1,000 live births, respectively (Fig. 3).
Table 2 presents the results of the adjusted binary
logistic regressions. The results adjusted for other socio-
economic and demographic characteristics suggest that
unwanted births were 2.32 (95 % CI: 1.54–3.48) times as
likely as wanted births to receive inadequate prenatal care.
Likewise, unwanted births were 1.38 (95 % CI: 1.01–1.87)
times as likely as wanted births to receive inadequate
childhood vaccinations. But the mistimed births were no
different from wanted births to have received inadequate
prenatal care or inadequate childhood vaccinations. Births
to mothers (1) having primary or higher education, (2)
having some autonomy, (3) having exposure to mass
media, and (4) living in high standard of living households
Matern Child Health J (2013) 17:493–500 497

Table 1 Distribution of
Covariate Percentage N Pregnancy intendedness
independent variables and
and category
pregnancy intendedness, rural Wanted Mistimed Unwanted
India, 2002–2003 (n = 2,108)
Maternal age, years
\25 59.2 1,247 69.4 17.0 13.6
25–34 36.5 770 41.7 7.6 50.7
[34 4.3 91 19.8 7.9 72.3
Woman’s education
None 73.2 1,543 55.6 11.1 33.2
Primary 11.3 239 63.3 15.5 21.2
Woman’s autonomy was
estimated using woman’s Middle/higher 15.5 326 59.6 21.2 19.3
responses to three questions Woman’s autonomya
about the extent of her decision- No autonomy 62.5 1,317 54.8 13.9 31.3
making power in her household.
Similarly, media exposure was Some autonomy 37.5 790 60.8 12.1 27.1
estimated using woman’s Media exposure
responses on three questions No exposure 66.9 1,410 54.5 11.5 34.0
about television, radio, and
Partial exposure 28.7 606 62.8 15.0 22.2
newspaper use. Women who
had no exposure to any of the Full exposure 4.4 92 59.9 26.9 13.2
three media were coded into ‘no Sex of child
exposure’ category, those Male 52.3 1,102 56.7 13.4 29.9
having exposure to one or two
sources of media were coded Female 47.7 1,006 57.6 12.9 29.5
into ‘partial exposure’ category, Household standard of livinga
and women who had exposure Low 57.4 1,203 54.8 11.4 33.8
to all the three media were
Medium 35.9 752 61.3 13.8 24.9
coded into ‘full exposure’
category High 6.7 142 54.4 24.6 21.1
SC/ST Scheduled Castes/ Caste
Scheduled Tribes, OBC Other SC/ST 32.8 692 57.2 11.7 31.1
Backward Classes OBC 51.9 1,094 58.0 13.8 28.2
a
Sample size may not add to Others 15.3 322 53.9 14.4 31.8
2,108 due to few missing cases

Fig. 2 Recommended prenatal care for mother and recommended

childhood vaccinations for the resultant newborn by pregnancy
intendedness, rural India, 2002–2003
were significantly less likely to receive inadequate prenatal
care or childhood vaccinations.
The results of discrete-time survival models for neonatal
and infant mortality are presented in Table 3. The findings
clearly suggest a disadvantage for the unwanted/mistimed
births in terms of child survival. For example, mistimed/
unwanted births were 1.83 times more likely than the
wanted births to die during the neonatal period. Similarly,
Fig. 3 Neonatal and infant mortality per 1,000 live births by
pregnancy intendedness, rural India, 2002–2003
mistimed/unwanted births were 1.52 times more likely than
wanted births to die during infancy. Surprisingly, there was
no association between either household standard of living
and neonatal mortality or household standard of living and
infant mortality. Sex of the newborn was also not associ-
ated with the mortality outcomes.

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498 Matern Child Health J (2013) 17:493–500

Table 2 Adjusted odds ratios from logistic regression models for Table 3 Adjusted odds ratios from survival models for neonatal and
inadequate prenatal care and inadequate childhood vaccinations, rural infant mortality, rural India, 2002–2003
India, 2002–2003
Covariate and category Neonatal mortality Infant mortality
Covariate Inadequate prenatal Inadequate childhood
and category care for mother vaccinations Pregnancy intendednessa
Wanted thenÒ
Pregnancy intendedness
Mistimed/unwanted 1.83 (1.01, 3.34)* 1.52 (0.95, 2.45)*
Wanted thenÒ
Maternal age, years
Mistimed 0.82 (0.56, 1.18) 0.90 (0.65, 1.27)
\25Ò
Unwanted 2.32 (1.54, 3.48)* 1.38 (1.01, 1.87)*
25–34 0.96 (0.51, 1.78) 0.85 (0.52, 1.40)
Maternal age, years
[34 1.67 (0.54, 5.14) 1.12 (0.42, 3.01)
\25Ò
Parity
25–34 0.78 (0.56, 1.07) 0.95 (0.72, 1.26)
First
[34 1.16 (0.40, 3.38) 1.44 (0.71, 2.92)
Others 0.69 (0.26, 1.88) 0.89 (0.39, 2.05)
Woman’s education
Woman’s education
NoneÒ
NoneÒ
Primary 0.36 (0.24, 0.55)* 0.37 (0.25, 0.54)*
Primary 0.58 (0.21, 1.58) 0.45 (0.18, 1.11)*
Middle/higher 0.28 (0.19, 0.42)* 0.29 (0.19, 0.44)*
Middle/higher 0.85 (0.36, 1.99) 0.65 (0.30, 1.40)
Woman’s autonomy
Woman’s autonomy
No autonomyÒ
No autonomyÒ
Some autonomy 0.74 (0.56, 0.99)* 0.53 (0.41, 0.68)*
Some autonomy 0.70 (0.39, 1.27) 0.84 (0.53, 1.34)
Media exposure a
Media exposure
No exposureÒ
No exposureÒ
Partial exposure 0.40 (0.28, 0.56)* 0.19 (0.14, 0.25)*
Some exposure 2.70 (1.39, 5.23)* 1.76 (1.02, 3.04)*
Full exposure 0.34 (0.19, 0.62)* 0.31 (0.16, 0.60)*
Sex of child
Sex of child
MaleÒ
MaleÒ
Female 0.83 (0.48, 1.44) 0.82 (0.53, 1.27)
Female 1.17 (0.92, 1.49)
Household standard of living
Household standard of living
LowÒ
LowÒ
Medium 1.01 (0.53, 1.91) 0.90 (0.54, 1.51)
Medium 1.03 (0.73, 1.46) 1.18 (0.88, 1.59)
High 0.52 (0.14, 2.00) 0.40 (0.11, 1.47)
High 0.54 (0.32, 0.90)* 1.94 (1.14, 3.30)*
Caste
Caste
SC/STÒ
SC/STÒ
OBC 1.07 (0.57, 2.00) 0.97 (0.59, 1.61)
OBC 0.94 (0.67, 1.33) 0.92 (0.69, 1.22)
Others 0.78 (0.30, 1.99) 1.18 (0.59, 2.35)
Others 1.24 (0.78, 1.97) 1.13 (0.76, 1.68)
Values in the parenthesis are 95 % confidence interval
Values in the parenthesis are 95 % confidence interval
Woman’s autonomy was estimated using woman’s responses to three
Woman’s autonomy was estimated using woman’s responses to three questions about the extent of her decision-making power in her
questions about the extent of her decision-making power in her household. Similarly, media exposure was estimated using woman’s
household. Similarly, media exposure was estimated using woman’s responses on three questions about television, radio, and newspaper use.
responses on three questions about television, radio, and newspaper use. Women who had no exposure to any of the three media were coded into
Women who had no exposure to any of the three media were coded into ‘no exposure’ category, those having exposure to one or two sources of
‘no exposure’ category, those having exposure to one or two sources of media were coded into ‘partial exposure’ category, and women who had
media were coded into ‘partial exposure’ category, and women who had exposure to all the three media were coded into ‘full exposure’ category
exposure to all the three media were coded into ‘full exposure’ category
SC/ST Scheduled Castes/Scheduled Tribes, OBC Other Backward
SC/ST Scheduled Castes/Scheduled Tribes, OBC Other Backward Classes
Classes a
The mistimed and unwanted categories were merged to take care of
* p \ 0.05 the small cell frequencies. Similarly, partial and full exposure cate-
gories were merged
Conclusions * p \ 0.05

Our findings clearly indicate that unwanted births were likely to be accompanied with inadequate prenatal care for
disadvantaged in terms of maternal and child health out- mothers and inadequate childhood vaccinations for resul-
comes. Findings reveal that unwanted births were more tant newborns. Similarly, unwanted births were more likely

123
Matern Child Health J (2013) 17:493–500
to die during the neonatal period and during infancy.
Interestingly, the sex of the newborn was not associated
with mortality outcomes.
Over the last two decades, there has been a spurt in the
number of studies examining the negative consequences of
unintended pregnancies for maternal and child health.
However, most of these studies utilized data from the
developed world. Studies examining the relationship
between pregnancy intendedness and negative health out-
comes for mothers and children in developing countries
including India are rather limited, even though the levels of
unintended pregnancy are unexpectedly high in these parts
of the world. Studies investigating the relationship between
pregnancy intendedness and early childhood mortality are
even sparser. To date, we could come across only one study
that has investigated the relationship between pregnancy
intendedness and early childhood mortality for India [27].
Moreover, most of the previous studies on pregnancy
intendedness have relied on retrospective responses on
pregnancy intendedness collected through a cross-sectional
survey. Our study for the first time has used a more rig-
orous prospective dataset and supports the ongoing debate
on the negative consequences of unintended pregnancy for
the mothers and the children in a developing country set-
ting, like India. Overall, we found that unwanted births
were less likely than wanted births to receive recom-
mended prenatal care and recommended childhood vacci-
nations. Our findings provide additional support to the
studies that also document lower utilization of recom-
mended prenatal care and childhood vaccinations for
unwanted children compared to children that were wanted
[22, 23, 27]. At the same time, mistimed/unwanted births
were more likely to die during the neonatal period and
during infancy. Our findings add to the findings of Singh
et al. [27] who used a cross-sectional dataset and found a
similar relationship. Our findings are also consistent with
the findings of Chalasani et al. [30], who using a pro-
spective dataset, also found higher odds of neonatal and
postneonatal mortality among children who were unwanted
compared to children who were wanted.
The potential limitations of our study must also be
highlighted. The follow-up of NFHS-2 was conducted in
the year 2002–2003. However, it is the only prospective
data that can be used for prospective assessment of
unintended pregnancies in India. Also, this data has been
effectively used in past epidemiological studies [31, 32,
34]. So we had no other choice than to utilize the follow-
up of NFHS-2. Secondly, there are chances of recall bias
on the part of mothers regarding prenatal care visits.
However, the chances of such errors are least in the
carefully designed follow-up survey. Moreover, this is the
standard way in which information on prenatal care and
499
childhood vaccinations are collected in the Demographic
and Health Surveys. Therefore such biases are not likely
to affect our results tremendously. Thirdly, we could not
control for the birth order and the birth interval, which are
known to affect mortality during early childhood, in the
discrete-time survival models due to the unavailability of
information in the prospective dataset. However, we
controlled for parity. As in Koenig et al. [32], in our
analysis also, parity was neither associated with neonatal
mortality nor with infant mortality. Another potential
limitation of our study is that in the analysis of neonatal
and infant mortality, we could not separate the effect of
being mistimed from that of being unwanted due to data
limitations. So, the effects associated with mistimed/
unwanted must be taken as a lower bound for the effect
associated with unwanted. While we note that our study
has some limitations, the merits of prospective data
clearly outweigh those limitations by allowing us to
establish temporal association between pregnancy in-
tendedness and negative health outcomes for both mothers
and children. Our findings are not only relevant for India
but are also relevant for other developing countries that
are still in the phase of fertility transition. The countries
that are still undergoing fertility transition are likely to
face even higher burden of unintended pregnancies.
A key finding of the study was the much lower utiliza-
tion of recommended prenatal care and recommended
childhood vaccinations even in the case of wanted preg-
nancies—only 15 % of women received the recommended
prenatal care and only 39 % of the resultant newborns
received the recommended childhood vaccinations. This
clearly reflects a major problem regarding access to
maternal and child health services across all the groups in
rural India. Our findings are consistent with the national
averages for rural areas in India [2] and call for greater
attention to improving access to maternal and child health
services.
In India, unintended pregnancy is not only a reason to
worry from the perspective of fertility but is also a cause
for concern from the point of view of public health.
Therefore, greater attention is required to curb the high
levels of unintended pregnancies in India. A recent study
has highlighted the role that family planning can play in
averting unintended births and in reducing the burden of
unintended pregnancy [20]. The authors clearly identify
improving access to quality contraception as an important
intervention. Our analysis complements the existing liter-
ature and argues for re-positioning of family planning
(which probably has lost its significance in the years after
the International Conference on Population and Develop-
ment held in Cairo in 1994) in the national reproductive
and child health programmes.
123
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