Multi-level analysis of pregnancy termination among sexually active married women in developing countries – Nature

Report on Contextual Factors of Pregnancy Termination in Less Developed Countries and Implications for Sustainable Development Goals

Executive Summary

This report analyzes the contextual factors associated with pregnancy termination among married women in 61 Less Developed Countries (LDCs), framing the issue within the United Nations Sustainable Development Goals (SDGs). Data from the Demographic and Health Surveys (2015–2022) for 715,281 women reveal a significant pregnancy termination rate of 18.5%. A multilevel regression analysis, based on the socio-ecological model, identifies critical factors at the individual, household, and community levels. These findings directly impact the achievement of SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities). The report concludes that a multi-faceted policy approach is essential to address reproductive health challenges and accelerate progress towards the 2030 Agenda.

1.0 Introduction: Pregnancy Termination as a Barrier to Sustainable Development

Pregnancy termination is a major global health concern, with a disproportionate burden falling on LDCs, where rates are alarmingly high. Limited access to sexual and reproductive health (SRH) services undermines progress towards key SDGs. Addressing this issue is fundamental to achieving several global targets:

• SDG 3 (Good Health and Well-being): High rates of pregnancy termination, often linked to unsafe procedures in LDCs, are a direct contributor to maternal mortality, challenging Target 3.1 (reduce maternal mortality) and Target 3.7 (ensure universal access to SRH services).
• SDG 5 (Gender Equality): The factors influencing termination decisions—such as lack of autonomy, education, and economic opportunity—are rooted in gender inequality. Empowering women is central to Target 5.6 (ensure universal access to SRH and reproductive rights).
• SDG 10 (Reduced Inequalities): Significant disparities in termination rates based on wealth, education, and geographic location highlight deep-seated inequalities that prevent marginalized women from being left behind, a core principle of the SDGs.

This report examines the multi-level factors influencing pregnancy termination to provide evidence for targeted interventions that align with the SDG framework.

2.0 Methodology

The analysis is based on pooled data from the Demographic and Health Surveys (DHS) conducted between 2015 and 2022 across 61 LDCs. The timeframe was selected to align with the SDG implementation period.

• Sample: A weighted sample of 715,281 non-sterile, fecund, married women aged 15-49.
• Analytical Framework: The study employed a socio-ecological model to categorize variables at individual, household, and community levels.
• Statistical Analysis: A binary multilevel regression analysis was conducted to identify significant predictors of pregnancy termination.

3.0 Key Findings: A Multi-level Analysis through the SDG Lens

The overall prevalence of pregnancy termination among married women in LDCs was found to be 18.5%. The analysis identified significant predictors across three levels of influence, each with clear implications for the SDGs.

3.1 Individual-Level Factors

Individual characteristics significantly shape reproductive health outcomes, highlighting the intersection of health, gender equality, and personal empowerment.

1. Age: Older married women (25–34 and 35+) had significantly higher odds of termination compared to younger women (15-24). This may reflect decisions related to completed family size or economic pressures, impacting family well-being (SDG 3).
2. Education: Women with primary education or higher were more likely to terminate a pregnancy than those with no formal education. This suggests that education, a key component of SDG 5, empowers women with greater knowledge and autonomy over their reproductive choices.
3. Employment: Employed women exhibited increased odds of termination, indicating that economic participation (a target of SDG 5) provides women with the financial independence to make and act on reproductive health decisions.
4. Decision-Making Autonomy: Women who made decisions independently or jointly with a partner had lower odds of termination compared to those whose decisions were made by others. This directly links women’s autonomy to better-planned reproductive outcomes, reinforcing the importance of SDG 5.

3.2 Household-Level Factors

The household environment, including partner characteristics and economic status, creates conditions that either support or hinder women’s reproductive health and rights.

• Partner’s Education: Women whose partners had higher levels of education were more likely to have a pregnancy terminated. This suggests that male education can foster a more supportive environment for shared decision-making, aligning with efforts to engage men and boys in achieving SDG 5.
• Household Wealth: Women from wealthier households had higher odds of termination. This disparity points to significant inequalities in access to services and information, representing a major challenge for SDG 10. Poorer women may lack the resources or access to safe termination options, leading to underreporting or reliance on unsafe methods, which threatens SDG 3.

3.3 Community-Level Factors

Community norms and infrastructure play a crucial role in shaping access to information and services, with clear disparities that challenge the “leave no one behind” agenda.

• Place of Residence: Women in rural areas had lower odds of termination compared to their urban counterparts. This gap highlights the urban-rural divide in healthcare access, a critical dimension of SDG 10 that must be addressed to ensure equitable health outcomes (SDG 3).
• Media and Family Planning Exposure: Higher community exposure to media and family planning messages was associated with increased odds of termination. This demonstrates the power of information in raising awareness and normalizing SRH services, a key strategy for achieving universal access under SDG 3.7.
• Community Contraceptive Use: Communities with higher contraceptive use also showed higher termination rates, suggesting that in environments where reproductive health is more openly discussed and services are more available, women are more aware of all their options for managing fertility.

4.0 Conclusion and Policy Implications for Achieving the SDGs

The decision to terminate a pregnancy in LDCs is a complex outcome shaped by an interplay of factors at the individual, household, and community levels. This reality has profound implications for the 2030 Agenda for Sustainable Development.

Achieving the SDGs requires a comprehensive policy approach that recognizes these interconnected factors. To accelerate progress, the following actions are recommended:

1. Empower Women to Advance SDG 5: Invest in girls’ education and women’s economic opportunities. Policies must focus on enhancing women’s autonomy in decision-making, as this is directly linked to improved reproductive health planning and outcomes.
2. Strengthen Health Systems for SDG 3: Improve the quality and accessibility of comprehensive SRH services, including contraception, family planning counseling, and safe termination services. This is essential for reducing maternal mortality and ensuring universal health coverage.
3. Reduce Inequalities to Fulfill SDG 10: Implement targeted interventions for rural and impoverished communities to close the access gap. Public health campaigns should leverage media to disseminate accurate, destigmatizing information about SRH, ensuring that all women, regardless of their socio-economic status or location, can make informed choices.
4. Engage Men and Communities: Promote programs that involve men in family planning and reproductive health discussions to foster supportive partnerships, a critical step toward transforming gender norms and achieving SDG 5.

By adopting such a multi-level strategy, policymakers can address the root causes of high pregnancy termination rates in LDCs, thereby improving women’s health and well-being and making significant strides toward a more equitable and sustainable future for all.

Analysis of Sustainable Development Goals (SDGs) in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: The article directly connects the issue of pregnancy termination to SDG 3, stating that addressing it “contributes to SDG 3: Good Health and Well-being by reducing maternal and newborn deaths through improved healthcare.” The entire study focuses on sexual and reproductive health (SRH), a core component of this goal.
• SDG 5: Gender Equality: The article identifies a strong link to SDG 5, explaining that pregnancy termination “is also central to SDG 5: Gender Equality, as it disproportionately affects women, highlighting a lack of autonomy and the influence of patriarchal norms.” The analysis of factors like women’s education, employment, and decision-making power reinforces this connection.
• SDG 10: Reduced Inequalities: The study is explicitly aligned with SDG 10. The article notes that it “aligns with SDG 10: Reduced Inequalities by investigating disparities in access to care, with the goal of informing targeted interventions to ensure equitable health outcomes for marginalized women.” The analysis consistently examines disparities based on wealth, education, and urban/rural residence.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. SDG 3: Good Health and Well-being

   • Target 3.1: Reduce the global maternal mortality ratio. The article explicitly mentions this target, stating the study is “key in contributing to global efforts to achieve the SDGs, especially Target 3.1, which aims to reduce the maternal mortality ratio to less than 70 per 100,000 live births by 2030.” The focus on pregnancy termination, a major contributor to maternal health outcomes, directly relates to this target.
   • Target 3.7: Ensure universal access to sexual and reproductive health-care services. The article’s core theme revolves around this target. It discusses “limited access to sexual and reproductive health services,” “access to family planning services,” and the need for “comprehensive sexual and reproductive health (SRH) education.” The analysis of factors like contraceptive use and exposure to family planning messages directly addresses the components of this target.

2. SDG 5: Gender Equality

   • Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights. This target is central to the article’s discussion on women’s empowerment. The study investigates “women’s autonomy,” “decision-making,” and how patriarchal norms limit women’s control over their reproductive choices. The finding that women with greater autonomy have lower odds of termination directly supports the importance of this target.

3. SDG 10: Reduced Inequalities

   • Target 10.2: Empower and promote the social, economic, and political inclusion of all, irrespective of status. The article addresses this by analyzing how socio-economic factors create disparities. It highlights that “socio-economic disparities continue to contribute to high prevalence of pregnancy termination” and examines factors like the “wealth index,” “education level,” and “employment status” to understand these inequalities.
   • Target 10.3: Ensure equal opportunity and reduce inequalities of outcome. The study’s focus on providing “equitable health outcomes for marginalized women” and overcoming “disparities in access to care” between rural and urban populations, as well as between different wealth quintiles, directly relates to reducing inequalities of outcome in reproductive health.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicators for SDG 3 (Good Health and Well-being)

   • Maternal Mortality Ratio (Indicator 3.1.1): This is explicitly mentioned as the goal of Target 3.1 (“reduce the maternal mortality ratio to less than 70 per 100,000 live births”). The study’s focus on pregnancy termination, including unsafe abortions, is directly linked to preventing maternal deaths.
   • Proportion of women of reproductive age who have their need for family planning satisfied with modern methods (Indicator 3.7.1): The article measures and analyzes “modern contraceptive use” as a key variable, finding that less than half (42.6%) of married women were using modern methods. This serves as a direct measure for this indicator.
   • Prevalence of Pregnancy Termination: The study’s primary outcome variable, the “percentage distribution of pregnancy termination” (found to be 18.5% overall), serves as a crucial indicator of sexual and reproductive health outcomes and the potential need for better family planning and SRH services.

2. Indicators for SDG 5 (Gender Equality)

   • Proportion of women aged 15-49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care (Indicator 5.6.1): The article measures a proxy for this indicator through the “decision-making” variable, finding that 70.2% of married women “reported having decision-making autonomy, either independently or in conjunction with their partners.”
   • Proportion of women in managerial positions / Proportion of women with ownership rights to land (Indicators 5.5.2 / 5.a.1): While not direct measures, the article uses “women’s employment status” and “education level” as key indicators of women’s empowerment and economic independence, which are foundational to achieving gender equality.

3. Indicators for SDG 10 (Reduced Inequalities)

   • Disparities by Wealth Quintile: The article consistently uses the “household wealth index (poor, middle and rich)” to analyze inequalities in pregnancy termination rates, finding that women “residing in wealthier households reported a higher proportion of pregnancy terminations.”
   • Disparities by Geographic Location: The analysis of “type of place of residence (urban, rural)” reveals significant inequalities. The article finds that women in urban areas have “significantly higher rates of pregnancy termination (20.5%) than their rural counterparts (17.3%).”
   • Disparities by Education Level: The study uses “education level (none, primary, secondary and tertiary)” for both women and their partners as an indicator to measure inequality, showing that higher education is associated with higher odds of termination.

4. Table of SDGs, Targets, and Indicators

Source: nature.com