Institute for Global Health


What are the relationships between degree of pregnancy intention, key neonatal & maternal outcomes?

What are the relationships between the degree of pregnancy intention and key neonatal and maternal outcomes in the Mchinji district of Malawi?

Project Summary 

There are three main aims of this project:

  1. To validate the London Measure of Unplanned Pregnancy in the Malawian language Chichewa in the district of Mchinji.
  2. To investigate the relationships between pregnancy intention and maternal and neonatal health outcomes in the Mchinji district of Malawi and model the likely impact of meeting the unmet need for family planning.
  3. To describe the provision and experience of, and access and attitudes to, family planning services through focus groups and interviews leading to suggestions to reduce the unmet need for family planning in the Mchinji district of Malawi.

Every year there are approximately 86 million unintended pregnancies globally because so many women do not have access to family planning. It is possible that these unintended pregnancies are more likely to result in death or illness in the mother and/or their baby than intended pregnancies. This may be because of the additional stress and anxiety an unintended pregnancy may cause or because women whose pregnancy is unintended may be less likely to use services such as antenatal care.

This project, which will be carried out in Malawi, will investigate the relationships between how intended the pregnancy is, women's behaviour during pregnancy and the health of the woman and baby after birth. If we find that unintended pregnancies do carry greater risks for mother and baby we will be able to strengthen the arguments for providing family planning to women who would like to use it.

At the same time we will explore the attitudes of men, women and communities to family planning and examine the provision of family planning in Malawi to provide information on how to improve women's access to family planning and reduce the burden of unintended pregnancies.

Pregnancy intention is a complex concept that encompasses 'affective, cognitive, cultural and contextual dimensions' [1]. Current measurements use the Demographic and Health Survey's single question asking women to report whether their last pregnancy was planned or unplanned. This is unsatisfactory as it diminishes a complex concept to two categories, introduces recall bias and overestimates intention because reported intention is greater after delivery then during pregnancy [2].

The London Measure of Unplanned Pregnancy (LMUP) is a new, validated measure of the degree of pregnancy intention during pregnancy [3]. It scores intention as a continuous variable with each increase in score reflecting an increase in pregnancy intention. This tool has not yet been widely used but has the potential to greatly enhance our understanding of pregnancy intention. As part of this research the LMUP will be validated in the Chichewa language.

A 2010 review concluded that scant attention has been paid to investigating the relationships between pregnancy intention, health behaviours and maternal and child health outcomes and that the existing research is 'older and methodologically limited' [4]. Current research is also predominately conducted in high-income countries; another review found 'persistent gaps in the literature, indicating a need for more studies in developing countries' [5].

This project aims to help fill the gap in our knowledge about the relationships between pregnancy intention and important health outcomes for mother and baby in a low-income country. We hypothesise that unintended pregnancies are associated with poorer neonatal and maternal outcomes.

Globally unintended pregnancies account for 41% of all pregnancies in part because 215 million women have an unmet need for family planning (FP) [6]. Fully meeting the need for FP in developing countries could reduce maternal deaths by 25% and neonatal deaths by 640,000 per year [6]. However, if unintended pregnancies have poorer outcomes they would contribute disproportionately to maternal and neonatal deaths making these figures underestimates of the benefits of FP.

This study will be conducted in the Mchinji district of Malawi. Malawi has a high total fertility rate (6.3 births per woman) [7], a high unmet need for family planning (27%) [8] resulting in a high rate of unplanned pregnancy (41%) [8], a neonatal mortality rate of 31/1000 live births [7] and a maternal mortality ratio of 1140/100,000 live births [9].

The cross-cutting nature of the benefits of FP and the fact that they are intergenerational make FP an extremely cost effective intervention [10]. Although funding has fallen and progress stalled there are now signs of renewed interest [11, 12]. To capitalise on this qualitative work will be undertaken to assess the current FP situation in Malawi and Mchinji.

Malawi's 2009 sexual and reproductive health policy outlines the challenges of 'early and unwanted pregnancies' and places family planning as its number one priority [13]. The accompanying strategy is awaited [14] but the present roadmap for accelerating the reduction of maternal and neonatal mortality has family planning as a key tenet [15]. This research will consider the ways in which the unmet need for FP in Malawi can be reduced by actions at community, health service, district and national levels.


1. Santelli J, Rochat R, Hatfield-Timajchy K, Gilbert B, Curtis K, Cabral R, Hirsh JS, Schieve L and other members of the Unintended Pregnancy Working Group. The Measurement and Meaning of Unintended Pregnancy. Perspectives on Sexual and Reproductive Health. 2003; 35: p. 94-101.

2. Joyce T, Kaestner R, Korenman S. On the validity of retrospective assessments of pregnancy intention. Demography. 2002; 39: p. 199-213

3. Barrett G, Smith SC, Wellings K. Conceptualisation, development and evaluation of a measure of unplanned pregnancy. J Epidemiol Community Health. 2004; 58: p.426-433. For more information on the LMUP please see http://measure.ascody.co.uk/index.htm

4. Tsui A, McDonald-Mosley R, Burke A. Family Planning and the Burden of Unintended Pregnancies. Epidemiologic Reviews. 2010; 32(1): p. 152-174.

5. Gipson J, Koenig M, Hindin M. The effects of Unintended Pregnancy on Infant, Child and Parental Health: A Review of the Literature. Studies in Family Planning. 2008; 39: p. 18-38.

6. Singh S, Darrich J, Ashford L, Vlasoff M. Adding it up: the costs and benefits of investing in family planning and maternal and newborn care. New York: UNFOA and Guttmacher Institute; 2009.

7. NSO, UNICEF. Multiple Cluster Indicator Survey 2006. Lilongwe, Malawi: National Statistics Office and UNICEF; 2008.

8. Malawi Demographic Health Survey 2004. Zomba, Malawi and Maryland, USA: National Statistics Office and ORC Macro Calverton; 2005.

9. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R and Murray CJL. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010; 375: 1609-23

10. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006; 368: p. 1810-1827.

11. Gwatkin D. Where next for family planning? The Lancet. 2009; 674: p. 1663-1664.

12. DFID. Choices for women: Planned pregnancies, safe births and healthy newborns. 2010 [cited March 5th 2011. http://www.dfid.gov.uk/Global-Issues/Emerging-policy/Reproductive-matern... ]

13. Reproductive Health Unit, Ministry of Health 2009. National Sexual and Reproductive Health and Rights Policy. Lilongwe: Ministry of Health

14. Personal communication with Fannie Kachale at the Reproductive Health Unit, Ministry of Health, Lilongwe, Malawi

15. Ministry of Health 2007. Roadmap for the reduction of Maternal and Neonatal Mortality and Morbidity in Malawi. Third revised version. March 2007. Ministry of Health: Liliongwe, Malawi.

Links to other research

Other research from IGH on Newborn HealthWomen's & Reproductive Health and Child Health.

Other research from IGH in Malawi