Unintended pregnancy is a risk factor for depressive symptoms among socio-economically disadvantaged women in rural Bangladesh

Unintended pregnancies are a major problem worldwide, with 40% of pregnancies estimated to be unintended in less developed regions [1, 2]. Unintended pregnancies refer to pregnancies not wanted at the time (mistimed) or at any time (unwanted) [3]. Econometric analyses indicate that contraception is cost-effective relative to the consequences of unintended pregnancies [4]. As such, family planning initiatives have attempted to curb unwanted pregnancies; however, major socio-economic disparities in access to contraception still exist in developing countries [5]. In Bangladesh, a substantial number of unwanted pregnancies are terminated legally through ‘menstrual regulation’ for which manual vacuum aspiration is used to safely establish non-pregnancy up to 8–10 weeks after a women’s missed period; yet, according to the 2007 Demographic and Health Survey about 30% of term live births are reported to be unintended [6].

A review of the literature suggested that, although findings are mixed, unwanted pregnancy is associated overall with adverse consequences, including limited antenatal care, short duration of breast feeding, adverse birth outcomes, and elevated infant and child mortality [7]. While there is a substantial literature on unintended pregnancy and mental health in developed countries, little is known about the relation between unwanted pregnancy and maternal mental health in lower- and middle- income countries [8]. Yet, high levels of common mental disorders, being predominantly maternal depressive symptoms, during pregnancy and postpartum (16 and 19%, respectively) have been estimated in lower- and middle-income countries [9]. In eastern Bangladesh, about one-third of women reported depressive symptoms between 34 and 35 weeks of pregnancy and 22% at 6–8 weeks postpartum [10, 11]. Furthermore, gendered inequalities related to reproductive decision-making and control exist within South Asia, with 48% of women in Bangladesh reporting that their husbands make decisions about their health and accessing healthcare services [12, 13]. Given this context, we were particularly interested in studying discordance of wantedness between couples in relation to depressive symptoms.

The principal aim of this study was to evaluate the relation between maternal and paternal pregnancy intentions and prenatal (in the 3rd trimester) and postnatal maternal depressive symptoms (at six months postpartum) among rural Bangladeshi women. In South Asia, women are often dependent on their husbands due to gaps in age, education, and control of financial resources [14]. Therefore, a second aim was to assess women’s reports of the couple’s discordance in intentions and unwantedness on the part of both parents in relation to women’s perinatal depressive symptoms.

This study is a secondary analysis of data collected during the course of a cluster randomized, double-masked, placebo-controlled, community trial (JiViTA-1) of the effects of vitamin A or beta-carotene supplementation on all-cause, pregnancy-related mortality [15, 16]. The ClinicalTrials.gov identifier for that previous study was: NCT00198822, registered on 9/12/2005. JiVitA-1 was conducted between August 2001 and October 2007.

A total of 127,282 women were placed under 5-weekly pregnancy surveillance, of whom 59,666 became pregnant, of whom 16,792 were in the subsample that was eligible for assessment of depressive symptoms while pregnant during the eligible period that, for pregnant women, ran from February 2004 through November 2006. Excluding pregnancies in this subset who delivered, refused or died being assessed and mothers not meeting the gestational age window of eligibility, we assessed 14,629 3rd trimester gravida for depressive symptoms at a median gestational age of 32.1 weeks (IQR = 31.9–32.7 wks; mean = 32.4 wks, SD = 1.06 wks) (Fig. 1). Among all 59,666 pregnant women, 38,292 delivered a live, singleton birth such that they were eligible for the 6 month post-partum depressive symptom assessment during the active period of this study protocol, from February 2004 through July 2007. Among these, 36,851 mothers were assessed postpartum; however, because this assessment occurred across a wider postpartum interval, this analysis has been restricted to mothers whose depressive symptom interview occurred between 150 to 240 days (5–8 months), inclusive, leaving 31,422 women in the present analytical cohort (Fig. 1).

Finally, 8 and 13% of the mothers had ≥3 depressive symptoms during the prenatal and postnatal periods, respectively (Table 1). Mothers reporting a mistimed or unwanted pregnancy had a greater risk of prenatal depressive symptoms (RR 1.21, 95% CI 1.07, 1.37; RR 2.32, 95% CI 2.02, 2.66, respectively) than mothers with wanted pregnancies. Women reporting unwanted (RR 1.73, 95% CI 1.60, 1.87) but not mistimed pregnancies (RR 1.02, 95% CI 0.95, 1.10) were at greater risk for postnatal depressive symptoms (Table 1).

Perception of mistimed pregnancy for husbands was not related to prenatal or postnatal depressive symptoms. Maternal report of not wanting the pregnancy and also perceiving her husband to not want the pregnancy was associated with a 34% higher risk of prenatal depressive symptoms (Adjusted RR 1.34, 95%CI 1.19, 1.52) compared to when both parents wanted the pregnancy. Similarly, having the mother not want the pregnancy but perceive her husband want it was associated with a 51% higher risk of prenatal depressive symptoms (Adjusted RR 1.51, 95% CI 1.29, 1.78), compared to cases in which both parents wanted the pregnancy. Finally, maternal report of wanting the pregnancy but perceiving that her husband did not want it was associated with a 30% higher risk of prenatal depressive symptoms (Adjusted RR 1.30, 95% CI 0.97, 1.74) compared to when both parents wanted the pregnancy (Table 3) compared to mothers who wanted the pregnancy and perceived that their husbands’ also wanted it. A similar, but less pronounced, increase in the risk of depressive symptoms associated with unintended pregnancy was observed in the postpartum period, i.e. a 13% increased risk for mothers who did not want the pregnancy and perceived their husbands did not want it (Adjusted RR 1.13, 95% CI 1.06, 1.21), a 24% increased risk for mothers who did not want the pregnancy but perceived their husbands wanted it (Adjusted RR 1.24, 95% CI 1.12, 1.37); and a 19% increased risk for mothers who wanted the pregnancy but perceived their husbands did not want it (Adjusted RR 1.19, 95% CI 0.99, 1.44).

Table 2 also shows multivariable results for the socio-demographic covariates and maternal depressive symptoms. Low maternal education was a risk factor for prenatal and postnatal depressive symptoms. Poor living standards showed an increased risk only for postnatal depressive symptoms. Older maternal age was associated with a higher risk of both prenatal and postnatal depressive symptoms. Anemia also was associated with greater risk of prenatal (Adjusted RR 2.08, 95% CI 1.85, 2.33) and postnatal (Adjusted RR 1.49, 95% CI 1.40, 1.58) symptoms. Religion, mid-upper arm circumference and child sex were not associated with depressive symptoms in any models (Table 2).

Our results suggest pregnancy intentions, especially unwanted pregnancies, are related to maternal depressive symptoms during and after the pregnancy among impoverished rural Bangladeshi women. The likelihood of maternal prenatal depressive symptoms was 60 and 26% higher among women reporting unwanted or mistimed pregnancies, respectively, after adjustment. During the postpartum period, having an unwanted pregnancy was associated with 32% higher risk of maternal depressive symptoms. Mothers’ perception that the pregnancy was unwanted by their husbands was also associated with a higher risk of prenatal and postnatal depressive symptoms. Finally, maternal perception of discordance between her own and her husband’s pregnancy intentions conferred a higher risk especially of prenatal depressive symptoms, with over a 50% higher estimated risk occurring when the mother did not want the pregnancy but perceived her husband did want it. This elevated risk remained at 6 months postpartum, but was attenuated.

Our results are consistent with existing literature for South Asia. In Pakistan, women with higher levels of depressive symptoms between 20 and 26 weeks of pregnancy were also more likely to report unwanted pregnancies [17]. In an Indian study, unplanned pregnancy was associated with depression in women at 6–8 weeks postpartum [22]. A meta-analysis, including five studies from lower- and middle-income countries, estimated 1.6 to 8.8 greater odds of maternal depressive symptoms associated with unwanted or unintended pregnancy [9]. In Bangladesh fathers’ intentions appear to have more influence on a birth occurring than mothers’ intentions [23]. Given these studies, it is possible that lack of control of fertility decisions in this context may contribute to women’s depressive symptoms associated with unwanted pregnancy.

We found pregnancies unwanted by the husband, as reported by the mother, were associated with subsequent maternal depressive symptoms, a finding consistent with studies conducted in the United States and Japan [24–26]. As poor quality spousal relationships and interpersonal violence are linked to depression in Bangladeshi women, it is possible that a husband not wanting a pregnancy may reflect less family involvement or a poor quality relationship with the mother and child [27]. We found that the scenario in which mothers reported not wanting the pregnancy but perceived their husbands wanted it was the kind of pregnancy discordance most highly associated with the risk of maternal prenatal depressive symptoms. It is possible that this reporting pattern, i.e. the mother’s perception that she did not want the pregnancy, but her husband did, may in some cases reflect sexual violence in which women are being forced to have sex in the context of their marital relationships.

We found an increased risk of prenatal and postnatal depressive symptoms for both discordant scenarios as well as for when the mother perceived that the child was unwanted by both parents, in comparison to when she perceived the pregnancy was desired by both husband and wife. To our knowledge only one study has examined this relation. In this US study of marital status and postpartum depressive symptoms, disagreement about pregnancy was significantly related to maternal depressive symptoms [28]. Perceived discordant pregnancy intentions may reflect conflict in the relationship or poorer relationship quality. Research from Bangladesh on pregnancy-intention discordance suggests fathers’ desires may carry more weight; women have a higher likelihood of a birth if the father desires the pregnancy and the mother does not but a lower likelihood of a birth if the mother, but not the father, desires the pregnancy [23]. Thus, it is possible that pregnancy-intention discordance may partially reflect circumstances in which woman’s desires are unfulfilled. When mothers did not want the pregnancy and perceived their husbands as not wanting the pregnancy may reflect circumstances in which the couple agreed that their condition was not ideal for having a child, either because of economic concerns or because they already had the number of children they desired.

The relation between unintended pregnancy and depressive symptoms can be viewed through a stressful life event lens [29]. Pregnancy and childbirth have been regarded as stressful life events and unintended pregnancy often exacerbates stress; for example, because of disruption of other life plans, being unprepared for parenthood, or lack of support [30]. Gender-based violence is pervasive in Bangladesh; over half of ever-married women age 15–49 report having experienced a form of physical or sexual violence from their husbands [31]. Of these women, 18% reporting his physically forcing her to have sex at some point, with 11% of those saying this occurred often or sometimes [31]. Spousal violence has been linked to suicidal ideation in Bangladesh and to poor mental health outcomes in India [32, 33]. Although we lacked data to examine the role of interpersonal violence, it is possible that sexual assault is a pathway to unintended pregnancy and is a root cause of the depressive symptoms we observed.

Maternal depressive symptoms and pregnancy intentions have been virtually unexplored among rural socio-economically disadvantaged women in developing countries, where unintended pregnancies are common and views toward childbearing and its cultural meaning may be different than in industrialized settings. The opportunity to follow a large cohort prior to pregnancy is rare in developing countries, with prospective data on pregnancy intentions gathered during the first trimester of pregnancy. Retrospective data on pregnancy intentions is thought to underestimate unwanted pregnancies. We also had data on perceived paternal pregnancy intentions, a topic with almost no published literature. The fact that mothers reported on their husbands’ pregnancy intentions is a limitation. However, mother’s perception of her husband’s attitude and perception of pregnancy-discordance between them may be, nevertheless particularly relevant to her mental health irrespective of his actual view. Another limitation was that there was no validated depression scale in Bangladesh at the time of our study, such that we used items drawn from several validated scales and suicide-related questions. As a result, we developed our own depressive symptom scales. The prenatal depressive symptom scale showed relatively low reliability based on Cronbach’s alpha. This low alpha value may have been due to having relatively few items in these scales or may reflect poor interrelatedness of these items. The generalizability of our study is limited to women who are married, carried their baby throughout pregnancy, and had singleton births.

In summary, we found that maternal and paternal unwanted pregnancy, maternal report of mistimed pregnancy, and maternal report of couple pregnancy-intention discordance were risk factors for maternal depressive symptoms. Given that these symptoms may have important adverse consequences for mothers and children, knowledge that unwanted pregnancy is associated with an increased risk of depressive symptoms could be used to help identify women at risk. Especially in developing-country settings like rural Bangladesh where there is little funding and infrastructure for mental health, prevention efforts may take into account initiatives to prevent unwanted pregnancies and/or integrate family planning and mental health services. Future research is needed to understand the factors that determine whether pregnancies are unwanted or mistimed. Our results highlight an unmet need in Bangladesh, and likely other similar settings, for family planning services to target both wife and husband when offering pregnancy counseling to newly married couples in order to avoid unwanted pregnancies.