Underestimation of pregnancy risk among women in Vietnam
Londeree et al. BMC Women's Health
(2020) 20:159
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
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
concerns and lost educational opportunities among chil-
Of pregnancies occurring worldwide from 2000 to 2014, dren [5, 6]. Despite these consequences, a large gap re-
an estimated 44% of were unintended [1]. Unintended mains between the availability of contraceptive methods
pregnancies, defined as pregnancies that are unwanted and their use. An estimated 80% of the 85 million
or mistimed at the time of conception, pose a substantial women annually who have an unintended pregnancy are
social and economic burden for women and their fam- not using contraception at the time of conception [4]. In
ilies. Consequences of these pregnancies include poor lower and middle-income countries, where most unin-
birth outcomes [2], increased levels of pregnancy-related tended pregnancies occur [1, 4], and where the health
morbidity and mortality [3, 4], as well as mental health infrastructure is often ill-equipped to handle the conse-
quences of unintended pregnancy, understanding the
* Correspondence: gallo.86@osu.edu
barriers to contraception use among women who desire
to prevent pregnancy is critical.
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
© 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
appropriate 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 Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Londeree et al. BMC Women's Health
(2020) 20:159
Page 2 of 7
According to the health belief model, appropriate per- report being comfortable using a computer, be sexually
ception of susceptibility to a given health outcome is a active (defined as ≥1 penile-vaginal act in past month),
key determinant of health behavior and behavior change not be pregnant or breastfeeding, and not want a preg-
[7, 8]. A woman’s cognizance of her risk of unintended nancy within the next 12 months. Written consent was
pregnancy then may play a crucial role in contraceptive provided by participants before enrollment, and the re-
behavior and adherence. Indeed, underestimation of search was approved by institutional review boards at
pregnancy risk has been found to lead to unmet contra- The Ohio State University and the Hanoi School of
ceptive need [9, 10] and, subsequently, unintended preg- Public Health.
nancy [11, 12].
We administered a questionnaire on demographics
Several studies across a range of settings have revealed and contraception-related beliefs and behaviors. As part
a significant discrepancy between perceived and actual of this questionnaire, we asked participants to report the
pregnancy risk. In a study among reproductive-age likelihood (“very unlikely, somewhat unlikely, somewhat
women in France, Moreau and Bohet found that, among likely and very likely”) they would become pregnant in
women who reported inconsistent use of contraception the next year. For the present study, we restricted our
or unprotected intercourse in the last 4 weeks, 63% did analysis to women who were not currently using a highly
not think they could become pregnant unintentionally effective method of contraception, specifically either a
[13]. Sinai et al. observed that, among women in Mali tier 1 (i.e., implant, intrauterine device, tubal ligation or
and Benin, 33.7% of women at risk of pregnancy (i.e., vasectomy) or a tier 2 method (i.e., injectable contracep-
women who were fecund and sexually active) believed tion, lactational amenorrhea, oral contraception, patch
that they could not become pregnant [14]. In another or vaginal ring) [16]. Thus, we excluded 261 women
study of women attending reproductive healthcare who were using a tier 1 or 2 method and 2 women who
clinics in the United States, Biggs et al. found that 27% were missing data on perceived likelihood of pregnancy
of women planning to use no method or a low-efficacy over the next year (Fig. 1).
contraceptive method (i.e., natural family planning, with-
Based on responses regarding the perceived likelihood
drawal, diaphragm, or sponge) underestimated their risk of pregnancy, we dichotomized women into those who
of pregnancy from engaging in 1 year of unprotected underestimated pregnancy likelihood (i.e., women who
intercourse [15].
reported it was ‘very unlikely’ they would become preg-
Although addressing inaccurate perceptions of preg- nant in the next year), and those who did not underesti-
nancy risk may be central to preventing unintended mate pregnancy likelihood (i.e., women who reported it
pregnancy, few studies to date have evaluated the factors was ‘somewhat unlikely,’ ‘somewhat likely,’ or ‘very
associated with underestimation of pregnancy risk likely’ they would become pregnant in the next year).
among women at risk. Assessing these factors could help Based on the literature, we selected the following demo-
identify target populations for interventions to address graphic characteristics to evaluate as potential correlates
the gap between perceived and actual pregnancy risk of pregnancy likelihood underestimation [13, 15, 17]: age
and, accordingly, the gap between the existence of effect- (categorized into 21–31 years, 32–36 years, and 37–45
ive contraception and its use. The aim of the present years); residence (city vs. town or rural area); marital
study was then to assess the prevalence and correlates of status (married vs. other); ethnicity (Kinh vs. other); edu-
underestimation of pregnancy risk among sexually- ac- cation (secondary or lower vs. higher); and monthly
tive women in Hanoi, Vietnam, who were not using a household income (< 15 million Vietnamese dong
highly-effective method of contraception and yet did not [equivalent to ~ 650 U.S. dollars] vs. higher). We also
desire pregnancy.
assessed the following contraception-related beliefs and
behaviors: current use of male condoms (yes vs. no),
current use of traditional contraceptive methods (i.e.,
Methods
We analyzed data from cross-sectional, convenience rhythm, withdrawal; yes vs. no), ever been pregnant (yes
study of women in Hanoi, Vietnam. The parent study’s vs. no), experience ever discussing contraceptive
primary objective was to assess a method of measuring methods with health provider (yes vs. no), and ambiguity
beliefs concerning contraception safety and naturalness, towards becoming pregnant (ambiguous vs. not-
and these findings will be reported elsewhere. The par- ambiguous). In response to the question “How import-
ent study enrolled 500 adult women of reproductive age ant is it to you to not become pregnant in the next
(18–45 years) attending the obstetrics-gynecology de- year?” women who reported it was ‘very important’ or
partment of a large public hospital for routine care or ‘important’ were categorized as not-ambiguous toward
accompanying someone at the facility during November becoming pregnant, while those who reported it was
2017 to September 2018. To participate in the study, ‘neutral’ or ‘not important’ were categorized as ambigu-
women had to have at least a minimal level of literacy, ous towards becoming pregnant.
Londeree et al. BMC Women's Health
(2020) 20:159
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Fig. 1 Participant disposition
In separate bivariable logistic regression models, we area had four-fold greater odds of pregnancy risk under-
assessed the relationship between potential correlates estimation relative to women living in a city (OR, 4.0;
and pregnancy risk underestimation. We then ran a mul- 95% CI, 1.0–15.9). Compared to women who were not
tivariable logistic regression model fitted with all corre- ambivalent about becoming pregnant, women who were
lates that were associated with the outcome in the ambivalent about pregnancy had lower odds of preg-
bivariable analysis using a p-value of < 0.25 [18]. We nancy risk underestimation (OR: 0.12; 95% CI, 0.1–0.2).
used SAS 9.4 (SAS, Cary, NC) for all analyses.
Women who underestimated their pregnancy risk did
not differ significantly from women who did not under-
estimate their risk by marital status, ethnicity, income,
Results
The analysis is based on 237 women who were suscep- reported use of condoms or traditional contraceptive
tible to unintended pregnancy (i.e., sexually-active, methods (i.e., rhythm or withdrawal), frequency of sex-
reproductive-age women who were not using a tier 1 or ual intercourse or by experience with health provider
2 method of contraception and did not wish to become discussing contraception use.
pregnant in the next year). Most participants resided in
In multivariable analysis, which was fit with variables
a city (88.2%), had attended education beyond upper sec- associated with pregnancy risk underestimation at p <
ondary school (73.0%), were married (93.7%), were eth- 0.25 in bivariate analysis, only pregnancy ambiguity
nically Kinh (93.7%), and reported a household income remained statistically significantly associated with preg-
of > 15 million Vietnamese dong (71.7%) (Table 1). The nancy risk underestimation (aOR: 0.11; 95% CI, 0.05–
median age of participants was 34.1 years (standard devi- 0.25; Table 2). Age and residence within a town or rural
ation, 5.3; range, 21–45 years). Participants reported the area were associated with greater pregnancy risk under-
following methods of contraception (based on a hier- estimation; however, this association was not significant
archical categorization, in which those reporting mul- at alpha = 0.05 level.
tiple methods only had their first response in the
following ordered list included): male condom (n = 166), Discussion
female condom (n = 7), withdrawal (n = 53), rhythm/ Underestimation of pregnancy risk was prevalent among
periodic abstinence (n = 4) or no method (n = 9). Overall, this population of women at risk of unintended preg-
67.9% of women believed it was very unlikely that they nancy in Vietnam, with most women (67.9%) perceiving
would become pregnant, while 9.7% believed it was it to be ‘very unlikely’ they could become pregnant. Risk
somewhat unlikely, 17.2% believed it was somewhat underestimation was greater among women who were
likely and 2.9% believed it was very likely.
older, among women who lived in town or rural areas
In bivariable analysis, age, residence and pregnancy and among women who were not ambivalent about be-
ambivalence were statistically significantly associated coming pregnant in the next year (i.e., perceived avoid-
with pregnancy risk underestimation (Table 2). Com- ing pregnancy as important or very important).
pared to women in the younger age group (21–31 years), Pregnancy risk underestimation did not appear to vary,
women ages 32–36 years and 37–45 years had 3.2 (95% though, by marital status, ethnicity, education or other
confidence interval [CI], 1.6–6.5) and 2.8 (95% CI, 1.4– behaviors and beliefs relating to contraceptive use.
5.6) times the odds of pregnancy risk underestimation,
We restricted our study population to women who
respectively (Table 2). Women living in a town or rural were sexually-active (defined as at least one act in the
Londeree et al. BMC Women's Health
(2020) 20:159
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Table 1 Demographic and behavioral characteristics of women at risk of unintended pregnancya in Hanoi, Vietnam by perceived
pregnancy risk (N = 237)
Perceived pregnancy risk
Overall
n (%)
Underestimated (n = 166)
Not underestimated (n = 71)
n (%)
n (%)
Age in years
21–31
87 (36.7)
74 (31.2)
76 (32.1)
48 (29.0)
59 (35.5)
59 (35.5)
39 (54.9)
15 (21.1)
17 (24.0)
32–36
37–45
Residence
Town or rural area
28 (11.8)
25 (15.1)
3 (4.2)
City
209 (88.2)
141 (84.9)
68 (95.8)
Highest level of education completed
Upper secondary or less
64 (27.0)
49 (29.5)
15 (21.1)
56 (78.9)
Higher
173 (73.0)
117 (70.5)
Marital status
Married
222 (93.7)
15 (6.3)
157 (94.6)
9 (5.4)
65 (91.5)
6 (8.5)
Other
Ever been pregnant
Yes
219 (92.4)
4 (1.7)
161 (97.0)
1 (0.6)
58 (81.7)
3 (4.2)
No
Missing
14 (5.9)
4 (2.4)
10 (14.1)
Ethnicity
Kinh
222 (93.7)
15 (6.3)
156 (94.0)
10 (6.0)
66 (93.0)
5 (7.0)
Non-Kinh
Monthly household income
≥ 15,000,000 Vietnamese dong
170 (71.7)
44 (18.6)
23 (9.7)
117 (70.5)
30 (18.1)
19 (11.4)
53 (74.6)
14 (19.7)
4 (5.6)
< 15,000,000 Vietnamese dong
Missing
Current male condom use
Yes
165 (69.6)
72 (30.4)
117 (70.5)
49 (29.5)
48 (67.6)
23 (32.4)
No
Current traditional contraception useb
Yes
147 (62.0)
90 (38.0)
100 (60.2)
66 (39.8)
47 (66.2)
24 (33.8)
No
Frequency of sexual intercourse
At least once per week
187 (78.9)
41 (17.3)
9 (3.8)
131 (78.9)
31 (18.7)
4 (2.4)
56 (78.9)
10 (14.1)
5 (7.0)
Less than once per week
Missing
Health provider discussed contraception
Yes
126 (53.2)
110 (46.4)
1 (0.4)
83 (50.0)
82 (49.4)
1 (0.6)
43 (60.6)
28 (39.4)
0 (0)
No
Missing
Pregnancy ambivalence
Ambivalent
Not-ambivalent
49 (20.7)
16 (9.6)
33 (46.5)
37 (52.1)
187 (78.9)
150 (90.4)
Londeree et al. BMC Women's Health
(2020) 20:159
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Table 1 Demographic and behavioral characteristics of women at risk of unintended pregnancya in Hanoi, Vietnam by perceived
pregnancy risk (N = 237) (Continued)
Perceived pregnancy risk
Overall
n (%)
Underestimated (n = 166)
Not underestimated (n = 71)
n (%)
n (%)
Missing
1 (0.4)
0 (0)
1 (1.4)
aWomen 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
bTraditional contraception included use of rhythm and withdrawal
past month) and not currently using highly-effective potential source of bias; the women in our sample who
contraception. Women having less frequent sex (includ- were not ambiguous about avoiding pregnancy were
ing those who experience forced sex) or those using a more likely to underestimate the probability they would
highly-effective contraceptive method can face the risk become pregnant. Initially, this finding may seem un-
unintended pregnancy. However, we focused our study usual as one may expect that those who are most adam-
on assessing correlates of reported unintended preg- ant about avoiding pregnancy would be more aware of
nancy risk among women who are most susceptible to their pregnancy risk. However, we may also expect that
unintended pregnancy, and thus should be the target of most women who choose not to use contraceptives, des-
public health interventions. As perceived susceptibility pite having great desire to avoid pregnancy, would be-
to a health outcome is a key determinant of behavior lieve it is improbable they could naturally conceive. In
change, the high prevalence of pregnancy risk underesti- short, by selecting on non-use of highly-effective contra-
mation in our sample reinforces the need for interven- ception, we observe an association between pregnancy
tions to address inaccurate perceptions of pregnancy ambiguity and risk underestimation that may otherwise
risk, especially among women who are older and who not be observed in a sample of all women of reproduct-
live in non-urban settings. Future studies should assess ive age. Indeed, in a study of contraceptive users and
the effect of interventions shown to improve reproduct- non-users in the United States, Rahman et al. found that
ive and contraceptive knowledge, such as entertainment women who were ambivalent about pregnancy were
education (e.g., radio drama) [19], tailored oral education more likely to have accurate perceptions of their risk of
[20], or other health promotion materials (e.g., posters, pregnancy [17], in contrast to our own findings.
brochures) [21, 22], on correcting inaccurate perceptions
of pregnancy risk in this setting.
Regarding the association between pregnancy risk
underestimation and age, we acknowledge that the abil-
Our study also reinforces the need for a more nuanced ity to become pregnant naturally declines with increas-
categorization of contraceptive need. At present, contra- ing age. Women’s fecundity begins to gradually lessen at
ceptive use is commonly categorized into ‘met’ and ‘un- age 32, before dropping rapidly at the age of 37 with the
met’ need, based on fecundity, sexual activity and onset of perimenopausal menstrual irregularity [23].
current contraceptive use. Incorporating perception of Thus, though all women in this sample were of repro-
contraceptive need into the categorization of contracep- ductive age, the low perceived pregnancy likelihood
tive use could further elucidate why some women fail to among older women could be based – in part – on bio-
use effective contraceptive methods, despite their avail- logic reality. Nonetheless, if reproductive age women are
ability. One such strategy of categorization, known as sexually active and not using highly-effective contracep-
the Tékponon Jikuagou approach, splits contraceptive tion, the risk of unintended pregnancy persists. There-
use into five categories: real met need (current users of a fore, the belief that pregnancy is very unlikely remains
modern method), perceived met need (current users of a an underestimation of pregnancy likelihood, especially
traditional method), real no need, perceived no need for women under the age of 37 years. Additionally, we
(those with a physiological need for family planning who observed that the level of pregnancy risk underestima-
perceive no need), and perceived unmet need (those tion was similar in older age groups: women ages 32–37
who realize they have a need but do not use a method) years had nearly identical odds of pregnancy risk under-
[14]. The use of this categorization could better inform estimation relative to women ages 38–45 years. These
targeted behavioral interventions to prevent unintended findings further suggest that women’s perception of their
pregnancy.
ability to become pregnant does not fully align with the
We note that our results should not be generalized to natural decline in fecundity with age.
users of highly-effective contraception as such general-
Our study population was relatively homogenous;
izations could be subject to selection bias. Our findings most participants in our sample were married, of the
concerning pregnancy ambivalence illustrate this Kinh ethnicity and resided in an urban setting. This
Londeree et al. BMC Women's Health
(2020) 20:159
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Table 2 Bivariable and multivariable analyses of correlates of pregnancy risk underestimation among women at risk of unintended
a
pregnancy in Hanoi, Vietnam (N = 237)
OR
(95% CI)
aORb
(95% CI)
Age in years
21–31
Ref
–
Ref
–
32–36
3.20
2.82
(1.58–6.48) c
(1.42–5.60) c
2.21
1.95
(0.95–5.16)
(0.86–4.45)
37–45
Residence
Town or rural area
4.02
Ref
(1.17–13.78) c
3.91
Ref
(0.96–13.78)
City
–
–
Highest level of education completed
Upper secondary or less
1.56
Ref
(0.81–3.03) c
1.37
Ref
(0.61–3.08)
Higher
–
–
Marital status
Married
1.61
Ref
(0.55–4.71)
–
–
–
–
Other
–
Ever been pregnant
Yes
8.33
Ref
(0.85–81.66) c
5.76
Ref
(0.50–65.83)
No
–
–
Ethnicity
Kinh
1.18
Ref
(0.39–3.59)
–
–
–
–
Non-Kinh
–
Monthly household income
≥ 15,000,000 Vietnamese dong
0.97
Ref
(0.48–1.98)
–
–
–
–
< 15,000,000 Vietnamese dong
–
Current male condom use
Yes
1.14
Ref
(0.63–2.08)
–
–
–
–
No
–
Current traditional contraception used
Yes
0.77
Ref
(0.43–1.38)
–
–
–
–
No
–
Frequency of sexual intercourse
At least once per week
Less than once per week
Health provider discussed contraception
Yes
0.75
Ref
(0.35–1.64)
–
–
–
–
–
0.65
Ref
(0.37–1.16) c
0.71
Ref
(0.35–1.43)
No
–
–
Pregnancy ambivalence
Ambivalent
0.12
Ref
(0.06–0.24) c
0.11
Ref
(0.05–0.25)
Not-ambivalent
–
–
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
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homogeneity 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.
Received: 11 June 2019 Accepted: 6 July 2020
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two educational posters on contraceptive knowledge and intentions: a
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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.
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