Fifteen million out of 16.7 million unwanted pregnancies a year could be avoided in 35 low- and middle-income countries if women had the opportunity to use modern methods of contraception, according to a study that applies to about one-third of the world's population.
The authors of the study point out that women who become pregnant unintentionally in these countries may face a stark future including death, disease, disability or lower educational or employment opportunities. In addition, many unintended pregnancies end in induced abortions. The burden of unwanted pregnancies falls hardest on the poor and less well educated. The study is published online today (Wednesday) in Human Reproduction , one of the world's leading reproductive medicine journals.
The researchers compared contraceptive use among 12,874 women who became pregnant unintentionally with 111,301 sexually active women  who were neither pregnant nor wanting to be. They collected the information by using demographic and health surveys, which are standardised globally and involve trained interviewers who conducted face-to-face interviews with the women in 49 low- and middle-income countries between 2005 and 2012. Data from 35 of these countries, ranging from Armenia to Zimbabwe, were available for the analysis, and an average of 96% of 15 to 49-year-old eligible women took part in the survey. Using the data, the researchers calculated the undesired pregnancies for the countries studied, and the proportion that were attributable to not using modern contraception.
Contraceptive methods were classified as modern, traditional or non-use. Modern methods included combined oral contraceptives, progestogen-only pills, implants, injectable contraceptives, intrauterine devices, male and female condoms, sterilisation and lactational amenorrhea method . Traditional methods included withdrawal and calendar methods - trying to time sexual intercourse outside the fertile period of a woman's menstrual cycle.
The women were also asked to give one main reason for not using contraception: 1) fear of side-effects/health concerns, 2) opposition, including the woman's, her partner's or some other person's opposition or religious prohibition, 3) lack of knowledge, including not knowing where to buy contraceptives or the types of methods available, 4) method-related reasons, such as costing too much or the provider being too far away, 5) underestimation of the risk of pregnancy, including the husband being away, infrequent sex and marital separation, and 6) other, including fatalism (the idea that an event is predetermined by fate and, therefore, unalterable).
They found that the use of traditional methods of contraception was associated with a 2.7-fold increase in the likelihood of an undesired pregnancy when compared with the use of modern methods. Non-use of any method was associated with a 14.5-fold increase. These increases corresponded to an estimated 16.7 million undesired pregnancies every year in the 35 countries, of which 15 million could have been prevented by the correct use of modern contraception (13.5 million women did not use modern methods and 1.5 million used modern methods incorrectly).
The poorest and least well-educated women were the least likely to use modern contraception. Among the 14,893 women who did not use contraception and did not want to get pregnant, the main reason given for non-use was fear of side-effects and health concerns; 5,559 women (37%) gave this reason, and, interestingly, this response was evenly distributed among women in all wealth categories, although the majority of them (67%) had not completed secondary education.
Opposition was cited by 3,331 (22.4%) women; 2,620 (17.6%) women underestimated the risk of pregnancy, 516 (2.4%) mentioned the cost and the same number said they didn't know how to obtain modern contraceptives.
One of the authors of the paper, Dr Howard Sobel, regional coordinator of the reproductive, maternal, newborn, child and adolescent division at the World Health Organisation, Western Pacific Regional Office, said: "This study has many implications. For instance, 'health concerns' was the most common reason given for not using modern contraception, yet these concerns are not backed up by evidence. Health workers have an important role to play in reassuring, educating, treating symptoms and finding the methods that best suits an individual. However, frontline health workers need the skills to do this, and our experience has been that many have the same misconceptions. We could prevent the overwhelming majority of pregnancies if we could debunk the myths and misperceptions about modern methods and use long-term methods of contraception, such as implants and intrauterine devices.
"National strategies need to be put in place to address unfounded health concerns, fear of side-effects, opposition and underestimated risk of pregnancy. These need to be coupled with good quality contraception that is available and affordable."
The researchers point out that "universal access to reproductive health" was one of the Millennium Development Goals agreed by the United Nations in 2005. "Of all the health-related Millennium Development Goals, universal access to reproductive health is the one that is most off-track," said Dr Sobel. "In the next era of the Sustainable Development Goals, strategic investment in methods like implants, though expensive upfront, are far less costly to families, governments and society than having larger families due to undesired pregnancies."
 "Underuse of modern methods of contraception: underlying causes and consequent undesired pregnancies in 35 low- and middle-income countries", by Saverio Bellizzi, Howard L. Sobel, Hiromi Obara, and Marleen Temmerman. Human Reproduction journal. doi:10.1093/humrep/deu348
 Sexually active women were defined as those who had had sexual intercourse at least once in the past month before the interview.
 The lactational amenorrhea method works on the principle that women who breast feed exclusively for the first few months of a baby's life tend not to re-start their periods while they are doing so, and, therefore, are less likely to become pregnant.