Spatial heterogeneity in unintended pregnancy and its determinants in India.

Background: Understanding the geographic variation of unintended pregnancy is crucial for informing tailored policies and programs to improve maternal and child health outcomes. Although spatial analyses of unintended pregnancy have been conducted in several developing countries, such research is lacking in India. This study addresses this gap by investigating the geographic distribution and determinants of unintended pregnancy in India.

Methods: We analysed data from the National Family Health Survey-5 encompassing 232,920 pregnancies occurring between 2014 and 2021 in India. We conducted a spatial analysis to investigate the distribution of unintended pregnancies at both state and district levels using choropleth maps. To assess spatial autocorrelation, Global Moran's I statistic was employed. Cluster and outlier analysis techniques were then utilized to identify significant clusters of unintended pregnancies across India. Furthermore, we employed Spatial Lag Model (SLM) and Spatial Error Model (SEM) to investigate the factors influencing the occurrence of unintended pregnancies within districts.

Results: The national rate of unintended pregnancy in India is approximately 9.1%, but this rate varies significantly between different states and districts of India. The rate exceeded 10% in the states situated in the northern plain such as Haryana, Delhi, Uttar Pradesh, Bihar, and West Bengal, as well as in the Himalayan states of Himachal Pradesh, Uttarakhand, Sikkim, and Arunachal Pradesh. Moreover, within these states, numerous districts reported rates exceeding 15%. The results of Global Moran's I indicated a statistically significant geographical clustering of unintended pregnancy rates at the district level, with a coefficient of 0.47 (p < 0.01). Cluster and outlier analysis further identified three major high-high clusters, predominantly located in the districts of Arunachal Pradesh, northern West Bengal, Bihar, western Uttar Pradesh, Haryana, Delhi, alongside a few smaller clusters in Odisha, Madhya Pradesh, Uttarakhand, and Himachal Pradesh. This geographic clustering of unintended pregnancy may be attributed to factors such as unmet needs for family planning, preferences for smaller family sizes, or the desire for male children. Results from the SEM underscored that parity and use of modern contraceptive were statistically significant predictors of unintended pregnancy at the district level.

Conclusion: Our analysis of comprehensive, nationally representative data from NFHS-5 in India reveals significant geographical disparities in unintended pregnancies, evident at both state and district levels. These findings underscore the critical importance of targeted policy interventions, particularly in geographical hotspots, to effectively reduce unintended pregnancy rates and can contribute significantly to improving reproductive health outcomes across the country.