THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt (2013) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2184

Review Prevalence of unwanted pregnancy in Iran: a systematic review and meta-analysis

Mahmood Moosazadeh1, Mahmood Nekoei-moghadam2, Zahra Emrani2 and Mohammadreza Amiresmaili2*
1 Research Center for Modeling in Health, Institute of Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran 2 Research Center for Health Services Administration, Institute of Future Studies in Health, Health Services Administration, Kerman University of Medical Sciences, Kerman, Iran

SUMMARY
Introduction Different studies show that a considerable number of pregnancies are unwanted and can have side effects on mothers childrens and nally societys health. Accordingly, this meta-analysis study has been carried out to estimate a relatively accurate level of unwanted pregnancies in Iran. Methods Present studies and published documents were retrieved from Persian and English electronic databases. To increase sensitivity and to select more studies, the reference list of the published studies was checked. After studying the titles and texts of documents, repeated and irrelevant ones were excluded. Data was analyzed using STATA V.11. Results Forty-nine qualied papers were selected with a 43 061 sample size. The meta-analysis of unwanted pregnancy prevalence in Iran equals 30.6% (CI = 28.133.1). Also according to the present meta-analysis the most common contraceptive methods used by couples prior to unwanted pregnancies are as follows: pills 27.1% withdrawal 38.6% IUD 11.4% injection contraceptives 2.8% vasectomy 0.28% and no method 24.5%. Discussion and conclusion The results of meta-analysis showed that about one-third of pregnancies in Iran are unwanted and a high percent of them are among women who had used contraceptives. Therefore it is necessary to adopt more appropriate policies on the following: education, proper pregnancy age, using contraceptive methods, mens role in family planning programs and quality promotion in family planning services. Copyright 2013 John Wiley & Sons, Ltd.
KEY WORDS:

unwanted pregnancy; unplanned pregnancy; Iran; meta-analysis; systematic review

INTRODUCTION Pregnancies are categorized into two broad categories: intended or unintended. Unintended pregnancy as a complex concept is a worldwide problem that often leads to legal or illegal abortion (Falk et al., 2003).
*Correspondence to: M. Amiresmaili, Health Services Administration, Kerman University of Medical Sciences, Kerman, Iran. E-mail: mohammadreza.amiresmaili@gmail.com

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M. MOOSAZADEH ET AL.

Although an unintended pregnancy may be unwanted (if it occurs when no children or no more children are desired) or mistimed (if it happens sooner than desired) (Santelli et al., 2003, Iranfar et al., 2005), for the purpose of this study, we did not aim to analyze unwanted and mistimed pregnancies separately. Furthermore, such data categories were not available. Hence, we have used unwanted and unintended pregnancy interchangeably. Unwanted pregnancy can occur for two main reasons: either the couple was not using contraceptives or the method that they were using failed (Barber et al., 1999). Research has showed that unwanted pregnancy is linked to a variety of negative outcomes for both mothers and their children (Finer and Henshaw, 2006; Xaverius et al., 2009). Women with unwanted pregnancies are also 25% less likely to initiate care in the rst trimester and 29% less likely to receive at least an adequate number of doctor visits. Babies born from teenage parents are at increased risk for a variety of health-threatening events, including physical, sexual and mental abuse; economic and educational deprivation; and neglect (Faghihzadeh et al., 2003; Finer and Henshaw, 2006; Mohllajee et al., 2007; Cunningham et al., 2009; Xaverius et al., 2009). Unwanted pregnancy is associated with child complications such as low birth weight, and infant mortality as well as decreased life opportunities and heavier demands on public services (Mohllajee et al., 2007). However, the result of research, which focused specically on the relationship between unwanted pregnancy and neonatal weight, is conicting (Faghihzadeh et al., 2003; Mohllajee et al., 2007; Cunningham et al., 2009). There are an estimated 200 million pregnancies around the world each year, approximately one-third of which are unwanted. Of them, 50 million are terminated each year; of these abortions, some 20 million are unsafe, and about 95% of these unsafe abortions take place in developing countries, resulting in the death of at least 200 women each day (Faghihzadeh et al., 2003; Finer and Henshaw, 2006; World Health Organization, 2008; Xaverius et al., 2009). According to the National Survey of Family Growth, 49% of pregnancies in the USA (excluding miscarriages) and 31% of pregnancies resulting in a live birth are unintended (Division of reproductive health, 2006). The unintended pregnancy rate has been reported in poor women in New York to be 82.1% in Canada 49% and in Japan 46.2% (Denton and Scott, 1994; Goto et al., 2002; Ma et al., 2008). Additionally, despite the wide use of contraceptive methods in France about onethird of the pregnancies are unwanted, and 65% of them are among those who used contraceptive methods before their pregnancy(Moreau et al., 2007). In Iran, despite the wide access to contraceptive methods and their use unwanted pregnancy is prevalent. According to the different study results(Nojoumi and Zeinali, 2003; Shokravi et al., 2004; Arak medical university, 2005; Vizshafar et al., 2005; Peyman et al., 2007; Pourheidari et al., 2007), the prevalence of unintended pregnancy in Iran is between 832%, and in other studies, the proportion of unwanted pregnancies have been reported from 10% to 40% (Demographic and Health Survey, 2003; Akbarzadeh, 2003). Abbasi Shavazi reported that 35% of the 5427 pregnancies in his study were unintended (Abbasi Shavazi, 2004), and according to Jahanfar et al. the unwanted pregnancy rate reported was 34.96% (Jahanfar et al., 2002)
Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

PREVALENCE OF UNWANTED PREGNANCY IN IRAN

Despite the success of family planning programs in Iran during the recent years, a signicant proportion of pregnancies are unintended; these pregnancies are associated with undesirable outcomes that put mother and neonates lives at risk. Despite negative effects of unwanted pregnancies and a signicant number of this kind of pregnancies, policy possibilities to overcome this problem in Iran are constrained to educating couples on emergency family planning methods; other options such as abortion are not legally available in Iran. According to Irans ministry of health, most of around 80 000 abortions occurring annually in Iran are illegal and unsafe ( Behjati Ardakani, 2004) (legal abortion in Iran is only available for cases in which physician diagnose a genetic problem in fetus and can only happen prior to the 16th week of pregnancy). Regarding the restricted options available in Iran to overcome the issue of unintended pregnancy, it should seriously be considered by health-care planners and decision makers. We found out in our electronic search that several studies, with various sample sizes, had reported unwanted pregnancies in Iran. The noteworthy point is that the studies are individual and the results are not valid for policy makers; if results of these studies are taken into consideration in a meta-analyses, valuable information will be extracted. Employing systematic reviews and meta-analyses for identication and analysis of ndings from observational studies allows us to synthesize research results that are needed by health-care professionals and policy makers, and provide them with important information on epidemiological indicators (Haghdoost et al., 2007). Additionally, in meta-analysis, sample size is increased as the studies are combined, resulting in a better statistical power. Meta-analysis can also explore the observed heterogeneity among the results of individual studies (Haghdoost et al., 2007). Special features of Iranian society in which unintended pregnancy is considered as a stigma encourage many who are faced with this problem to conceal it (Shahbazi et al., 2011). This makes it very difcult to have precise information on this issue. Lack of precise and reliable information on the prevalence of unwanted pregnancy, in conjunction with the considerable differences between results and the published reports, necessitated a more comprehensive study on the subject to sum up the available ndings in the literature.

MATERIALS AND METHODS Search strategy To nd studies published electronically between April 2001 and March 2012, articles published in domestic and foreign journals as well as those available in Persian databases of Scientic Information Database (SID), Iranmedex, Magiran, Medlib, Irandoc, and English databases of Pubmed, Google Scholar and the WHO site were used. In this search, Persian and English keywords and probable combination of main and important words were searched. These search was carried out with keywordsunintended pregnancy, unwanted pregnancy, mistimed pregnancies, Iran/Iranian and also names of provincesusing conjunctions and/or. The Persian keywords were equivalent
Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

M. MOOSAZADEH ET AL.

to their English word, and all probable combinations were considered. This search was carried out in March 2012. Also, a reference list of published studies was evaluated to increase sensitivity and to select more studies. Search evaluation was carried out randomly by one of the researchers (M. A.), and no studies were excluded. Selection criteria The entire text or summary of all searched articles, documents and reports were extracted. After reviewing and studying titles of documents, repeated items were excluded; then, texts of articles were carefully studied by researchers, and the relevant articles were selected and irrelevant ones excluded. All Persian and English studies that, after evaluation, obtained the necessary score and that determined prevalence of unwanted pregnancy among women in Iran were included. On the other hand, studies with the following features were excluded: (1) studies that have exclusively evaluated the relationship between unwanted pregnancy and some factors, without examining the prevalence level of unwanted pregnancy; (2) articles that have not obtained the minimum score of 8; (3) articles, documents and reports that were published before 2001; and (4) studies that have been carried out qualitatively. Quality assessment and data extraction Having determined the related studies in terms of titles and contents, we used a checklist (Figure 1) to evaluate the quality of documents; objective of the study, study method, sample Size, sampling method, data collection tool, variables evaluation status, studied target group and analysis status were examined using
Score No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Questions Are the research questions clearly stated? Is the approach appropriate for the research question? Is the study context clearly described? Is the role of the researcher clearly described? Is the sampling method clearly described? Is the sampling strategy appropriate for the research question? Is the method of data collection clearly described? Is the data collection method appropriate to the research question? Is the method of analysis clearly described? Are the main characteristics of the population well described? Is the analysis appropriate for the research question? Are the claims made supported by sufficient evidence? yes=1 No=0

Figure 1. Studies quality evaluation checklist

Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

PREVALENCE OF UNWANTED PREGNANCY IN IRAN

12 questions (one score for every question). In this checklist, the maximum score was 12, and the minimum acceptable score was 8. Finally, the articles that obtained the minimum score and more were selected, and the related information was extracted and analyzed. Data on article title, rst author, year of publication, sample size, location of study, mean age, number of children, study instrument, type of study, sampling method, contraceptive method before pregnancy and prevalence of unwanted pregnancy were extracted. Analytic strategies Analyses was performed by STATA (STATA CORP, USA) software Version11. Standard error of prevalence rate of unwanted pregnancy in every study was calculated on the basis of the binomial distribution formula. Finally, the heterogeneity index was determined using Q test. According to heterogeneity results with metacommand in meta-analysis, random effect model was used to estimate unwanted pregnancy rate. In addition, to minimize the random variation between point estimation of studies, we adjusted all ndings of the studies using Bayesian analysis. Finally, effects of variables, which were determined as probable sources of
Magiran(91) Google scholar(4080) Medlib(14) Iranmedex(160) Total number of papers resulted from primary search in electronic databases(4570) 26 Pubmed 40 Sid 131 Irandoc 28 Emro Eliminated studies after limiting search(3954) Papers Relatively relevant to the topic(616) Papers deleted due to irrelevancy to study subject after evaluation of titles and abstracts (406) Papers potentially relevant to subject (210) Deleted duplicated papers accessed from different data bases(139) papers entered to the study for text appraisal (71) Deleted papers after text appraisal (16) Papers entered to the study for checking inclusion and exclusion criteria (55) Papers entered to the study through references check (3) Relevant papers which information entered to the metaanalysis process (49) Papers deleted after checking inclusion and exclusion criteria (9)

Figure 2. Papers search and review owchart

Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

M. MOOSAZADEH ET AL.

Table 1. Description of the studies included in the meta-analysis ID First author Location of study Year of publication
2003 2002 2002 2004 2009 2011 2005 2004 2010 2002 2009 2005 2005 2002 2007 2010 2006 2009 2003 2005 2008 2004 2008 2001 2005 2003 2003 2007 2005 2011 2010 2001 2003 2004 2009 2007 2006 2005 2007 2004 2007 2010 2009 2010 2005 2008 2011 2003 2002

Sample size
560 4141 1548 260 400 102 1576 380 330 1300 530 1000 1830 414 352 328 405 229 500 268 630 508 60 1200 1925 788 400 300 410 140 1000 1240 5420 168 352 240 300 600 500 458 700 596 200 231 431 417 400 6394 600 43061 42433

Prevalence
26 31 35 37 36 40 27 21 25 28 27 24 18 35 19 61 26 32 27 39 20 20 58 28 27 42 48 31 27 30 35 40 35 31 28 4.9 31 31 37 47 16 43 23 30 18 35 26 38 25 30.6(28.133.1) Q=1557.8, p=0.0001 30.1(27.932.3) Q=1080.7p=0.0001

1 Rakhshani Zahedan 2 Khalajabadi frahani Tehran 3 Jahanfar National 4 Bayat Ghazvin 5 Mansoori Mashhad 6 Azizi Kermanshah 7 Mohammadpoorasl Tabriz 8 Khalili Ilam 9 Vakili Yazd 10 Yasaee Tehran 11 Mahvari Bandarabbas 12 Noroozi Booshehr 13 Golmohammadloo Oromeiyyeh 14 Abazari Kerman 15 Peyman Mashhad 16 Amani Ardebil 17 Shahbazi Semnan 18 Sanaeinasab Semnan 19 Kasmaee Gilan 20 Sadeghibazargani Ardebil 21 Noohja Andimeshk 22 Hajeyan Babol 23 Nasiri Mashhad 24 Fallahzadeh Yazd 25 Sereshti Shahrkord 26 Zamani Najafabad 27 Rezaeipoor Tehran 28 Khooshehmehri Tehran 29 Nojoomi Tehran 30 Hekari Tabriz 31 Moosavifar Mashhad 32 Mamoori Mashhad 33 Abbasishevazi Tehran 34 Shokravi Tehran 35 Mohammadbeigi Arak 36 Mohammadpoorasl Tabriz 37 Poorheidari Shahrood 38 Kahnemooiyaghdam Ardebil 39 Asadi Mashhad 40 Delaram Sharkord 41 Pooransari Iranshar 42 Akbarzadeh Shiraz 43 Pashah Babol 44 Karimzadeh Kerman 45 Vizshefer Shiraz 46 Majlesi Esfahan 47 Najean Ahwaze 48 Faghihzadeh Tehran 49 Haghighi Tehran Combined for unwanted pregnancy combined(after removal of the outlier data)

Copyright 2013 John Wiley & Sons, Ltd.

Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

PREVALENCE OF UNWANTED PREGNANCY IN IRAN

Method of contraceptive before pregnancy Pills Withdrawal IUD Condom

18.1 21.6 9.42 6.5 20 8.1 10 13.8 3.6 14.7 14.6 16.3 8 8.1 17.9 6.7 13.9 3.7 23.6 5 9.9 6.4 10.8 15.1 24.29 3.5 6.66 11.4 (9.713.1)

Injection contraceptives
4.3 5 3.1 2.5 1.4 6.4 1.1 3 3.8 3.1 0.5 2.1 0.3 2.7 3.5 2.8 (1.83.7)

Vasectomy
0.3 0.96 0.3 0.16 0.3 (0.10.5)

No method
19.3 38.2 27.53 19.8 8.8 50.4 19.25 5.8 13.1 6.7 29.2 23.1 15.7 36.3 7.5 9.7 39.6 51 44 24.3 34.5 18.3 16.7 21.7 35 24.5 (19.129.9)

58.62 12.8 5.2 14.2 31 36.6 25 9.42 50.72 31.9 33.8 4.8 16.3 41.3 6.3 17.4 66.6 1.3 31.5 54.3 1.4 21.3 41 40 25.5 10 41.1 24.2 5.3 8.5 44.7 15.6 4 20.2 47.1 4.8 19.7 41.6 1.5 23.2 64.6 2 15.7 60.4 1.1 43.3 20.4 3.2 34.4 25.4 4.8 15.3 38.9 5.3 13.9 47.3 5.4 25 58 12 40.3 2.9 13 30.8 56.1 5.1 40 39 34.6 15.7 4.9 32.2 24.2 7.7 19 59.5 24.29 50 43.6 13.2 16.9 9.66 5 27.1 38.6 4.9 (22.931.3) (32.544.6) (3.86.1)

Copyright 2013 John Wiley & Sons, Ltd.

Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

M. MOOSAZADEH ET AL.

heterogeneity in the study, were examined using the meta-regression method. Point estimation of prevalence of unwanted pregnancy with condence interval (CI) of 95% was calculated in forest plots; in this plot, the square size represents weight of every study, and lines in both sides of it represent CIs of 95% (Figure 3).

RESULTS After searching for keywords and applying the inclusion and exclusion criteria 49 qualied articles were selected (Figure 2 Table 1) with 43 061 sample size. The study instrument in 48 cases was the questionnaire and in one of the studies was not specied. In 47 studies, women were interviewed in the health facilities (health posts, health centers, hospital and clinics); two others collected data referring to womens living place relying on local interviewers. Types of studies were cross sectional in 30 cases descriptive-analytical in 15 cases retrospective in one case Randomized Clinical Trial (RCT) in one case secondary data in one case and not specied in one case. Methods of sampling in 36 studies were specied which were random, classied, cluster or simple sampling . In 10 studies, the average numbers of the children were reported, which equaled 1.97, and in 31 studies, the average age of the women were mentioned (mean = 27.01). Among the studies that were entered in this meta-analysis the highest rate of unintended pregnancy prevalence related to the study by Amani et al. with a 60.7% prevalence rate, which was carried out on 328 referred women to Ardabil

Figure 3. Difference the estimated prevalence of unwanted pregnancy in each study and overall; This chart shows that the range in prevalence of unwanted pregnancy is 4.91-60.7 (Based on analysis Bayes)
Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

PREVALENCE OF UNWANTED PREGNANCY IN IRAN

health-care centers, whereas the lowest rate of unintended pregnancy prevalence related to the study of Mohammadpoorasl with 4.91% prevalence rate, in a clinical trial on 240 women. To identify the source of heterogeneity, variables including mean number of children, mean age of women with unintended pregnancy and publication year were entered in a meta-regression model but did not identify any of the studied factors as the source of heterogeneity within the reviewed studies (Table 2). Three studies including those by Mohammadpoorasl (an RCT with 240 sample size), Amani et al. (a descriptive study on 328 participants) and Nasiri (a prospective study on 60 participants) were considered as outliers and were set aside from the study. After this adjustment, the range of unintended pregnancy was between 16 to 47.4%, still indicating a large discrepancy, which might have happened because different methods, instruments and study designs have been used. Meta-analysis of the 46 remaining studies indicated that the Q has declined from 1557.8 to 1080.7 without any change in heterogeneity results (p = 0.0001). The overall prevalence of unintended pregnancy was estimated 30.1% (CI = 27.932.3) (Table 1). Thirty-two studies reported contraceptive methods used by wives and husbands prior to their unintended pregnancy, in which the range of taking different methods was as follows: contraceptive pills 8.558.6%, IUD 1.116.9%, condom 3.524.9%, injection contraceptives 0.36.4%, withdrawal 12.866.6% and vasectomy 0.30.96%. Also, the frequency of the women who did not use any contraceptive was from 6.7 to 51% (Table 1). Meta-analysis of contraceptives used prior to unintended pregnancy based on random effect model indicated that the percent of different methods were as follows: pills 27.1% (CI = 22.931.3), withdrawal 38.6% (CI = 32.644.6), IUD 4.9 (CI = 3.8 6.1), condom 11.4% (CI = 9.713.1), injection contraceptives 2.8% (CI = 1.83.7), vasectomy 0.28% (CI = 0.10.4) and no contraceptive 24.5% (CI = 19.129.9). Discussion and conclusion The present study indicates that despite Irans success in family planning programs and decreasing fertility, a considerable percent of pregnancies (about one-third) are unwanted. This shows that unwanted pregnancies are one of the main challenges of Irans health system as well as mother and child health program. Similar results to this meta-analysis have been reported in nationwide studies carried out with proportionate sample sizes and appropriate designs; for example, a study based on Demographic and Health Survey results indicated that 35% of pregnancies
Table 2. Assessing the source of heterogeneity with meta-regression Univariate Predictors Year of publication Average of age Number of children Coefcient 0.02 1.2 4.3 p-value 0.9 0.2 0.5 Multivariate Coefcient 3.2 7.9 9.5 p-value 0.3 0.2 0.5

Copyright 2013 John Wiley & Sons, Ltd.

Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

M. MOOSAZADEH ET AL.

were unwanted (Abbasi Shavazi, 2004). In another study, 30.8% of pregnancies were unwanted (Kahnemoei et al., 2005). Furthermore, the frequency of unwanted pregnancies in the present meta-analysis is consistent with that of published studies in 2004, which in both more than one-third of the pregnancies are unwanted (World Health Organization, 2005). In a Spanish investigation, 29.4% of all pregnancies were unwanted; this number was 57% in the USA (Faghihzadeh et al., 2003). On the basis of the mentioned points, we can claim that unwanted pregnancies are one of the main public health problems in the world, which affects women, their families and the society as well as couples life from different aspects. Unwanted pregnancy can cause mothers to not follow healthy behaviors during pregnancy. A study indicated that mothers with unwanted pregnancy do highrisk behaviors such as smoking, drinking and not having sufcient vitamins intake, resulting in low birth weight and physical and mental problems in their children (Mamouri and Khodayi, 1999). Studies on the effects of unwanted pregnancies on the physical and mental health of mother and child (Mamouri and Khodayi, 1999; Akbarzadeh, 2003; Jahanfar et al., 2002; Abbasi Shavazi, 2004; Kahnamoei Aghdam et al., 2005) demonstrate whenever a birth becomes unwanted, the mother and child became at risk of psychological, physical, social and economic problems. Children of unwanted pregnancy are more prone to having an unsecure and chaotic family life, to be more bothered and ignored by parents, to commit crime and to be more at need of treatment for psychological and mental problems. Furthermore, legal and illegal abortions are more prevalent among unwanted pregnancies. A study estimated that 16% of unwanted pregnancies in Iran ends to abortion, which in turn can increase mother mortality (Abbasi Shavazi, 2004). The present meta-regression did not indicate a signicant relationship between mothers age and unwanted pregnancy, this might be because some studies reporting high prevalence of unwanted pregnancy did not include mother age. Also, in two studies with outlier results (Nasiri study with 60 cases and Amani study with 328 cases), the mean age of women were low, and in a study with outlier results with lowest unwanted pregnancy prevalence (Mohammadpoor study with 240 sample size), the mean age of women were high (30 years) (Table 1). But previous studies (Faghihzadeh et al., 2003; Mohllajee et al., 2007) demonstrate that unwanted pregnancy prevalence is higher among teenage mothers and mothers above 35 years than mothers aged 2035 years. Similarly, Mamouri and Khodayi (1999)) indicated that the mean age of mothers with unwanted pregnancy and planned pregnancy was 27.8 and 26.3 years, accordingly. According to multivariate meta-regression, unwanted pregnancy prevalence increases 3.2 times per year increase in the year of the study, which means that despite spread of information systems and an increase in society awareness level, unwanted pregnancy level has increased 3.2 times each year, which is a serious alarm and should be studied and analyzed from different aspects and practical solutions should be devised. According to multivariate meta-regression, unwanted pregnancy prevalence increases 9.5 times per each unit increase in the number of present live children of the family, although this gure was not statistically signicant. This might be
Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

PREVALENCE OF UNWANTED PREGNANCY IN IRAN

because in most studies, the mean number of live children have not been reported and the power of the study to test this variable have been low. The relationship between number of live children and prevalence of unwanted pregnancy is another subject, which should be placed in policy makers agenda. Amani et al. (2010) reported a signicant relation between number of previous live children and regarding the pregnancy as wanted or unwanted; that is, the prevalence of unwanted pregnancy increased with an increase in number of present live children. This study indicated that a considerable number of unwanted pregnancies (about 75%) have happened in couples who have used contraceptives. Furthermore, the most number of unwanted pregnancies have occurred in couples who have been using withdrawal, pills, condom, IUD, injection contraceptives and vasectomy as the main contraceptive method, respectively. Similarly, in a study by Abazari et al., 42% of women became pregnant, despite using contraceptives (Abazari et al., 2003); also, in a nationwide study conducted by Ghazizadeh et al. (2005), 92% of couples using withdrawal method ended with unwanted pregnancy, and in a study by Abbasishavazi (2004), the natural method was the cause of 30% of unintended pregnancies. Despite wide access to reliable contraceptives and information dissemination about the methods, unwanted pregnancy is a global problem (Finer and Henshaw, 2006; Abbasi Shavazi, 2004; Adebola, 2005; Cheng et al., 1997). On the basis of a study in the USA, 50% of unwanted pregnancies has happened among couples who use different contraceptive methods (Finer and Henshaw, 2006). In another US study, irregular use was the main cause of pregnancy in 49% of condom users and in 76% of pill takers (Abbasi Shavazi, 2004). Hence, we can conclude that contraceptive failures in Iran was higher than gures reported in previous studies. In Adebolas study (2005) on unwanted pregnancy, studied units had the history of using condom, pills, injection contraceptives and other methods. Cheng et al. (1997) indicated that contraceptives failure was the main cause of unwanted pregnancy with the highest failure attributed to condom, IUD and the rhythmic method. The relative lower failure rate of condom in Iran compared with other nations can be attributable to lower use of this method in Iran. Besides the withdrawal method, which is an unreliable method for pregnancy prevention, the cause of failure varies according to the method applied by couples. Pills failure might be due to not taking pills regularly, having low knowledge and having fear of its complications, according to a British study; forgetting to take pills regularly was the main cause of unwanted pregnancy (Palanivelu and Oswal, 2007; Grimes and Shulz, 2005); improper and irregular use is the leading factor of condoms failure (Palanivelu and Oswal, 2007); and IUD failure is because of taking it out after bleeding and its improper replacement and inability to control it (Penney et al., 2004). French et al. (2004) showed that irregular use of injection contraceptives was one of the main factor that made it unsuccessful so that 50% of those who selected this method stopped it 1 year after they had irregular bleeding. Although vasectomy is among the reliable contraceptives, some failures have been reported, which might be because of the nature of vasectomy, which takes a while after the operation to reach its maximum protection, not taking another contraceptive during this period might end to unwanted pregnancy.
Copyright 2013 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

M. MOOSAZADEH ET AL.

The present meta-analysis has provided a precise estimation on the prevalence of unwanted pregnancy in Iran because a large number of studies with a considerable sample size covering different regions of the country have been included in this study. This study indicates that unwanted pregnancy does not have a good status in Iran. Moreover, its trend is incrementally increasing because of increase in sexual relationship outside the family and the relative lower age of this kind of relations, which should be taken seriously because the risk of unwanted pregnancy increases. Future studies should focus on better techniques studying this phenomena, maybe using more ethnographically sensitive research techniques. Furthermore, because of the social rejection present for this kind of pregnancies, it requests more and careful attention of policymakers. Limitations A wide variety of tools and methods used for data collection as well as a variety of reports was one of the most important limitations of the studies entered in this meta-analysis; it prevented us from collecting sufcient information about some variables. Also, the probability of not having access to part of studies due to considerations such as publication bias was another limitation in this meta-analysis. What is more, no distinction was made between unwanted, unintended, undesired, unplanned, unsought, unexpected, resented and feared in the primary papers entered in the present meta-analysis. This limits the application of the results because there are important differences in policy implications depending on womens attitudes to their pregnancies.

ACKNOWLEDGEMENTS The authors appreciate the work of the anonymous reviewer(s), who improved the present paper by providing their invaluable comments. The authors have no competing interests.

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Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm

PREVALENCE OF UNWANTED PREGNANCY IN IRAN

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Int J Health Plann Mgmt (2013) DOI: 10.1002/hpm