Prevalence and determinants of unintended pregnancy in Ethiopia: A systematic review and meta-analysis of observational studies.

BACKGROUND: Unintended pregnancy has significant consequences for the health and welfare of women and children. Despite this, a number of studies with inconsistent findings were conducted to reduce unintended pregnancy in Ethiopia; unavailability of a nationwide study that determines the prevalence of unintended pregnancy and its determinants is an important research gap. Thus, this study was conducted to determine the overall prevalence of unintended pregnancy and its determinants in Ethiopia.
METHODS: We searched from Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library databases for studies. Each of the original studies was assessed using a tool for the risk of bias of observational studies. The heterogeneity of studies was also assessed using I2 test statistics. Data were pooled and a random effect meta-analysis model was fitted to provide the overall prevalence of unintended pregnancy and its determinants in Ethiopia. In addition, the subgroup analyses were performed to investigate how the prevalence of unintended pregnancy varies across different groups of studies.
RESULTS: Twenty-eight studies that satisfy the eligibility criteria were included. We found that the overall prevalence of unintended pregnancy in Ethiopia was 28% (95% CI: 26-31). The subgroup analyses showed that the highest prevalence of unintended pregnancy was observed from the Oromiya region (33.8%) followed by Southern Nations Nationalities and Peoples' region (30.6%) and the lowest was in Harar. In addition, the pooled prevalence of unintended pregnancy was 26.4% (20.8-32.4) and 30.0% (26.6-33.6) for community-based cross-sectional and institution-based cross-sectional studies respectively. The pooled analysis showed that not communicating with one's husband about family planning was more likely to lead to unintended pregnancy (OR: 3.56, 95%CI: 1.68-7.53). The pooled odds ratio also showed that unintended pregnancy is more likely among women who never use family planning methods (OR: 2.08, 95%CI: 1.18-3.69). Furthermore, the narrative review of this study showed that maternal education, age, and household wealth index are strongly associated with an unintended pregnancy.
CONCLUSIONS: In this study, the prevalence of unintended pregnancy was high. Lack of spousal communication, never using family planning, maternal education, and household wealth level were significantly associated with an unintended pregnancy. This study implies the need to develop plans and policies to improve the awareness of contraceptive utilization and strengthen spousal communication related to pregnancy.

Introduction

Unintended pregnancy is a pregnancy which is either mistimed or unwanted [1,2]. It is a public health problem and a risk factor for adverse health outcomes, particularly for maternal and child health [3]. Though the rate of unintended pregnancy fell worldwide between 1990 and 2014, it dropped less sharply in developing regions than in developed regions [3]. Ethiopia is one of the developing countries with a high prevalence of unintended pregnancy. In Ethiopia, more-than one-third (38%) of pregnancies were unintended in 2014; slightly lower than in 2008 which was 42%. According to results from the 2016 Ethiopian Demographic and Health Survey (EDHS) of all births in the past five years and current pregnancies, 25% are unintended. Also, the 2016 EDHS report showed that the overall difference between the wanted fertility rate and the total fertility rate is one child, which suggests that Ethiopian women are currently having, on average, one child more than they want [4].

Pregnancies should be planned before conception; otherwise, a woman may not be in optimal health for childbearing [2]. Unintended pregnancy leads to maternal mortality and morbidity due to the complications of unsafe abortion, miscarriage, and unplanned births, which burdens the health system at all [5-7]. Annually, more than 1 in 10 pregnancies end in abortion, and 1 in 27 mothers die due to the complications of pregnancy or childbirth in Ethiopia [8]. A woman with an unintended pregnancy is more likely to have low physical and mental health, low self-care, and depression during pregnancy. These lead to poor Antenatal Care (ANC) service utilization and postpartum depression, which is risky for unfavorable pregnancy outcome, and maternal morbidity and mortality [7,9]. Consequently, the newborns of unintended pregnancies are faced with low birth weight and inadequate vaccinations which increases the risk for childhood illnesses [5,7,10-12]. Previous evidence showed that unintended pregnancy mainly results from inconsistent or incorrect use of contraceptive methods, and women are less likely than men to want more children no matter how many children they already have [2,13].

In Ethiopia, a number of studies were conducted to estimate the magnitude and to identify the determinants of unintended pregnancy. However, the reported prevalence and determinants in these fragmented studies vary depending on the characteristics of study participants, the type of design employed and the variables analyzed. Combined findings of existing studies significantly strengthen the quality of evidence investigating the national prevalence and determinants of unintended pregnancy. Thus, this systematic review and meta-analysis was conducted to determine the overall prevalence and determinants of unintended pregnancy in Ethiopia. This review is intended to bring an improvement in the design of future studies related to unintended pregnancy. The findings of this study are also intended to improve health workers’ interventions in the area of reproductive health.

Materials and methods

Study design and setting

A systematic review and meta-analysis, which aimed to estimate the overall prevalence of unintended pregnancy and its determinants was conducted in Ethiopia. Ethiopia is situated in the horn of Africa, and bordered by Eritrea to the north, Sudan and South Sudan to the west, Kenya to the south, and Djibouti and Somalia to the east. Nearly eight in ten women (78%) live in rural areas in Ethiopia, and half of women age 15–49 (48%) have no education [4].

Eligibility criteria

In this systematic review and meta-analysis, studies were included with the following criteria: 1) only studies conducted in Ethiopia. 2) Only studies reported in English language. 3) Only studies involving pregnant women or women had given birth at least once preceding the survey. 4) All observational studies reporting the prevalence and determinants of unintended pregnancy. Both published and unpublished articles were included. Studies, which were not fully accessible after at least two-email contact with the primary authors, were excluded, because of the inability to assess the quality of studies without their full text.

Searching for studies

A comprehensive search strategy was done by three (MA, LY, and RY) of the authors. Both published and unpublished articles on unintended pregnancy were searched from international (Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library), and national (Ethiopian Journal of Public Health and Nutrition) electronic databases. First, articles were searched by examining the full titles (“Prevalence and determinants of unintended pregnancy in Ethiopia”) and then keywords (unintended pregnancy, unplanned pregnancy, unwanted pregnancy, mistimed pregnancy, determinants, risk factors, associated factors, Ethiopia). These keywords were used separately and in combination using Boolean operators “OR” or “AND”. In addition, we searched from the reference lists of all the included studies (snowball technique) to identify any other studies that may have been missed by our search strategy. Finally, all studies were imported into reference management software (Mendeley Desktop).

Outcome measures and data extraction

Unintended pregnancy, which is either mistimed or unwanted, was the primary outcome of the study. Unwanted pregnancy occurred when a woman did not want to have any more pregnancies, whereas mistimed pregnancy is a pregnancy that was wanted by the woman at some time, but which occurred sooner than they wanted. The pregnancy intention for the included studies was assessed by interviewing current pregnant women or women who had given birth at least once preceding the survey.

All essential data from the included studies were extracted independently by two (MA and LY) of the authors using a predesigned data abstraction form. This form includes the last name of the first author, publication year, data collection period, study design, region of the study conducted, study population, sample size, response rate, and the magnitude of unintended pregnancy. In addition, we extracted the adjusted odds ratios with corresponding 95% confidence intervals to measure the strength of effects. Deviation in a data extraction process was resolved by discussion and consensus involving all authors.

Quality assessment for studies

The quality of meta-analysis depends on the included studies [14]. Two authors (MA and YB) assessed the risk of bias for the included studies using the tool of risk of bias assessment for observational studies [15]. This tool includes 10 items. The first four items assess the external validity, while the other six items evaluate the internal validity of the study. All items of the tool were filled in for each included study and categorized as low risk bias (if the response is “yes”), higher risk (if the response is “no”), and not clear. The quality of the study was determined by summing the score given for each item. Lastly, unclear risk of bias was categorized as high risk of bias then; the summary assessment risk of bias for each study was categorized according to the number of high risk of bias: low (≥2), moderate (3–4), and high (≥5).

Data processing and analysis

After extracting all relevant data using Microsoft excel software, data were exported to R statistical software for meta-analysis. The double arcsine transformation which stabilizes the sampling variance was applied to estimate the weighted average prevalence, and the transformed summary prevalence are converted back for ease of interpretation [16].

We assessed the consistency of studies using I test statistics [17]. This test examines the null hypothesis that all the included studies are evaluating the same effect. Consequently, since there was heterogeneity between the original studies (I = 96%, p<0.01) a random effect model is needed, and to account for between-study variance a random effect meta-analysis with an estimation of DerSimonian and Laird method was performed. The possible sources of heterogeneity among studies might be differences in study participants, study design, risk of bias and data collection period. Furthermore, subgroup analyses were conducted to investigate how the prevalence of unintended pregnancy varied across different subgroups of studies.

Results

Search results

Our comprehensive search for studies was between the 15th of February and the 30th of April, 2019. The flow chart diagram that shows our literature search, study selection, and the number of included studies is presented in (). Initially, a total of 273 articles were identified during our search, and then 158 articles were excluded due to duplication. Finally, 28 studies that satisfied the eligibility criteria were included in this systematic review and meta-analysis.

Description of the included studies

The detail descriptions of the included studies are shown in (). All studies included in this review were published between 2006 and 2019. Of all the included studies, twelve [10,18,19-26,27,28] were community-based cross-sectional, while twelve were institutional-based cross-sectional studies [29,30,31-38,39]. The data for the two studies were also taken from the 2011 EDHS [40,41]. The majority of respondents of the original studies were pregnant mothers. The number of participants in each study varied from the lowest of 165 [29] to the highest of 7,759 [41]. A study with the smallest study participants was an institutional-based cross-sectional study, while the data for the highest study participants were taken from the 2011 EDHS. Furthermore, nine studies were conducted in the Amhara region, six studies in the Oromiya region, six studies in Southern Nations, Nationalities, and Peoples’ Region (SNNPR), two studies in Addis Ababa, two studies in Tigray, one study in Harar, and two studies from the national survey. Moreover, the prevalence of unintended pregnancy ranged from 13.7% [25] to 41.5% [21].

Risk of bias assessment for the included studies

We assessed the risk of bias for each of the original studies using the existing risk-of-bias assessment tool (). Of the total included studies, our summary assessment showed that more-than half (53.6%) of the studies had a low risk of bias, and one-fourth (25%) of studies had a moderate risk of bias. Additionally, less than one-fifth (17.9%) of the included studies had a high risk of bias.

Prevalence of unintended pregnancy in Ethiopia

In this study, the overall prevalence of unintended pregnancy in Ethiopia was 28% (95% CI: 25–31) (). We had conducted subgroup analyses to investigate how the prevalence of unintended pregnancy varies across different subgroups of studies (). Consequently, the pooled prevalence of unintended pregnancy was 26.4% (20.8–32.4) and 30.0% (26.6–33.6) for community-based cross-sectional and institution-based cross-sectional studies, respectively. The subgroup analysis based on the region where studies were conducted also showed that the highest prevalence of unintended pregnancy was observed from the Oromiya region [33.8% (29.0–38.7)] followed by SNNPR [30.6% (25.2–36.2)] and Addis Ababa [28.0% (14.0–44.7)]. The lowest prevalence was also noted in Harar [22.9% (20.3–25.5)]. Furthermore, the pooled prevalence of unintended pregnancy was 28.2% (25.1–31.4) and 28.8% (23.7–34.0) for studies conducted prior and post 2014, respectively.

We assessed the issue of publication bias by visual inspection of funnel plot and by using the Egger’s regression test. Though the funnel plot looks asymmetrical (), the Egger's test showed that no relationship between the effect size and its precision (P-value = 0.776). This might be due to heterogeneity in true effects.

Determinants of unintended pregnancy in Ethiopia

The significant determinants of unintended pregnancy reported from each study are presented in ().

In six studies, researchers examined the association between spousal communication about family planning and unintended pregnancy. Of this, five studies [25,36,37,39,42] showed that spousal communication about family planning was associated with an unintended pregnancy. The result of this meta-analysis showed that not communicating with one’s husband about family planning was more likely to lead to unintended pregnancy (OR: 3.56, 95%CI: 1.68–7.53) (). Ten studies were examined the association between the use of modern family planning methods and unintended pregnancy[10,21,25,30,34,37,38,40,42,43]. Consequently, the result of this study showed that unintended pregnancy is more likely among women who never used family planning methods (OR: 2.08, 95%CI: 1.18–3.69) ().

Of 21 studies that examined the association of maternal education level with unintended pregnancy, ten studies reported that maternal education status was associated with an unintended pregnancy [30-32,34-36,38,40,41]. Furthermore, among the included studies, women’s age, time to reach the nearest health facility, household wealth, and marital status showed significant association with unintended pregnancy.

Discussion

Unintended pregnancy has significant consequences for the health and welfare of women and children [7]. Pregnancy intention in developing countries is influenced by socio-cultural, environmental, individual and health service-related factors [44]. This systematic review and meta-analysis was conducted to determine the overall prevalence of unintended pregnancy and to identify its determinants in Ethiopia.

We found that the overall prevalence of unintended pregnancy in Ethiopia was 28% (95% CI: 26–31). This finding is consistent with the 2016 EDHS result [4], which reported that from all births in the past 5 years and current pregnancies, one-fourth (25%) were unintended. Additionally, in the previous two consecutive EDHS reports, we noted that the proportion of women who want no more births declined from 42% in 2005 to 37% in 2011. The prevalence of unintended pregnancy found in this study agreed with other previous studies conducted in Egypt [45], Ghana [46], and Bangladesh [9], which reported that nearly one-third (30.7%), 29.8% and 29% of pregnancies were unintended, respectively. However, the magnitude of unintended pregnancy found in this study was lower than previous studies conducted in Malawi, South Africa, and the Republic of Congo [47-50]. This variation might be attributed to methodological differences in the assessment of pregnancy intention. The other possible reason for inconsistency in the prevalence of unintended pregnancy could be explained by the difference in the socio-economic characteristics of study participants [51-53].

In this study, we found that the pooled prevalence of unintended pregnancy was 26.6% and 30% for community-based cross-sectional and institutional-based cross-sectional studies, respectively. This variation could be explained by institution-based studies that include women who visit health facilities for legal abortion services, which is probably unintended pregnancy. About 97% of women seeking an abortion reported having an unintended pregnancy [51]. The highest prevalence of unintended pregnancy was observed from the Oromiya region (33.8%), and the lowest was in Harar (22.9%). The possible explanation might be due to the difference in the utilization of family planning methods.

In this systematic review and meta-analysis, we noted that a number of factors were found to be associated with an unintended pregnancy. Consequently, we found that women who hadn’t communicated with their husbands about family planning methods were more likely to have an unintended pregnancy. The possible explanation for this result might be women’s perception that their husbands oppose family planning, which is one of the dominant factors for discouraging the contraceptive practice in a wide variety of settings [19]. Partner awareness of contraceptives and open discussion about family planning methods will decrease the risk of unintended pregnancy. The result of this study also showed that unintended pregnancy is more likely among women who never used family planning methods. This is due to the fact that awareness and proper utilization of modern contraceptives are crucial to reduce unintended pregnancy.

In this systematic review, unintended pregnancy was less likely among married women. The possible reason for this result might be in Ethiopian culture, pregnancy without marriage is unacceptable in most communities. This result is supported by previous studies conducted in South Africa and Kenya [54,55].

Though previous evidence stated that youngest women experience the highest rate of unintended pregnancy [56], in this systematic review, we observed controversial results regarding the association between women’s age and unintended pregnancy. Some of the studies reported that younger women are more likely to have an unintended pregnancy, while other studies showed that older women are more likely to have unintended pregnancy.

Due to the inconsistent classification of maternal education level, time-lapse to reach the nearest health facility, parity, occupation and religion, we couldn’t pool quantitatively, in this systematic review and meta-analysis. Contradictory results are observed between individual studies. Four studies [30,32,36,41] reported that women who have relatively better education were less likely to have an unintended pregnancy as compared to those who didn’t have formal education. It is reasonable that as educational level increases, the awareness of reproductive health also increases. Additionally, as the educational level increases, the spousal communication on pregnancy, awareness of long‐term family planning, and receiving adequate ANC also increases. However, two studies reported that women who had relatively better education were more likely to have unintended pregnancy [31,40].

Moreover, in this study, we observed that as the time-lapse to reach the nearest health facility for providing contraceptives increased, women were more likely to have unintended pregnancy [10,30,43]. It is also reasonable that as the time-lapse to reach the nearest health facility increases, the probability of missing ANC visits also increase, which in turn is associated with unintended pregnancy [13,19].

In this study, we noted that the parity of respondents showed a significant relationship with an unintended pregnancy. Consequently, multiparous women were more likely to experience an unintended pregnancy than nulliparous [34,35,41,57]. This might be because of women who have attained their desired number of children will perceive any additional child as unwanted [58]. Furthermore, the pregnancy of unemployed women is more likely to be unintended than employed women [30,37].

Moreover, in this study, another important variable which significantly associated with unintended pregnancy was religion. Muslim mothers were less likely to report having an unintended pregnancy as compared to orthodox mothers. This finding is consistent with a study conducted in Ghana [59]. This might be as a result of doctrinal differences among the women, along with different religions.

Limitations

This study was not without limitations. Firstly, the review was limited to only articles published in the English language. Secondly, all of the included studies were cross-sectional, which limits assessment of the cause-effect relationships. Thirdly, we were unable to show the pooled odds ratio for all variables associated with unintended pregnancy because the included studies classified the variables in different ways.

Conclusions

In this study, a high prevalence of unintended pregnancy was observed. Lack of spousal communication, never using family planning, maternal education, and household wealth level were significantly associated with an unintended pregnancy. This study implies the need to develop plans and policies to improve the awareness of contraceptive utilization and strengthen spousal communication related to pregnancy. Emphasis should be given to those women at a distant from health facilities, unmarried and teenagers.

(DOC)

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List of excluded references and reasons for exclusion.

(DOCX)

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Assessing the risk of bias for the included studies.

(XLSX)

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Significant determinants of unintended pregnancy reported from each study.

(DOCX)

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1 Oct 2019

PONE-D-19-21662

Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

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Reviewer #1: I do not have major comments on this article. The objective and findings are generally clear. The authors identified the prevalence of unintended pregnancy in Ethiopia, and associated risk factors.

Minor suggestion : delete first sentence of abstract - many people may take offense to the claim that pregnancies should be planned. Unintended pregnancy is well recognised, but this term is not interchangeable with the claim that all pregnancies should be planned. Women are allowed to choose whether they want to plan their pregnancies. Delete the dfirst sentence, and this should fix the problem.

The quality of the English needs major work.

Reviewer #2: 1. Was a time period determined for the search? If yes, what was it? If no, then please mention that.

2. How did you search for unpublished studies?

3. Was any attempt made to contact authors of studies for which full papers were not obtained?

4. The writing needs quite a bit of improvement in terms of flow. It is not an easy and smooth read. There is a lot of repetition. Sentences need to be clearer and more precise. The use of the word "Accordingly" in several places does not make sense. Also, punctuation needs to be revised.

Reviewer #3: This well written manuscript is a systematic review and meta-analysis of observational studies prevalence and determinants of unintended pregnancy in Ethiopia. This review addresses an important Issue (prevalence of unintended pregnancies) for Ethiopia but may not be highly relevant to the general readers of the journal.

The methodology sounds fine; however, I have a few concerns:

1. Literature search: it is limited to 2 data bases and google scholar, which is not comprehensive. The authors should have searched more relevant data bases. They mentioned that they searched national data bases, however, there is no description of such data base. The search was limited to English language. As this study is investigating the prevalence of unintended pregnancy in a specific county/ region, it must have been included the articles in local language. This may increase the risk of reporting and publication bias.

2. Statistical analysis: authors should explain the reasons in heterogeneity among studies. Why it exists, and how it affects the credibility of the overall results?

3. Discussion: there is no mention of women’s age, time to reach the nearest health facility, household wealth, being married… in results section, but they show up in dissuasion as the potential determinants on the prevalence of unintended pregnancies

I have not checked any original studies for double checking of the abstracted data, nor perform any literature review to rechecking included studies.

Reviewer #4: This is an interesting review on prevalence and determinants of unintended pregnancy in Ethiopia. Below I provide some comments which may help in improving the manuscript:

Please provide reference for unintended pregnancy definition.

Parity, occupation, religion and economic status are important determinants of unintended pregnancy. Could the authors provide insight into why they were not significantly associated with unintended pregnancy in the review?

As readers may not be familiar with Ethiopia, please define SNNPR at first instance.

Reviewer #5: There are 195 English language corrections that I strongly suggest you follow in the Comments section of the attached PDF file. This is an important topic, and the research is very valuable for the public health of Ethiopia.

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19 Oct 2019

Author's response to reviews

Title: Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

Authors

Author’s email addresses

MA: mulunehadis@gmail.com

LY: lielt.yismaw@gmail.com

YB: yebelay.ma@gmail.com

BK: bekalukassiedmu@gmail.com

RY: reta.yeshambel@gmail.com

MAA: agazhemoges@gmail.com

Date: 17 October 2019

Dear Editor,

We thank you for the chance to resubmit our revised manuscript. Also, we would like to thank the reviewers for sharing the view and experience. The comments are very important that will improve the manuscript. The point-by-point responses for each of the comments are provided in the following pages. We hope that the revisions meet your standards and that the paper would be published in your journal. We look forward to working with you towards a final published product.

Sincerely,

Muluneh Alene, MPH

On behalf of co-authors

Point by point responses to queries

Reviewer#1

Comments and points raised Authors response

1. “Delete first sentence of abstract?” Answer: thank you dear reviewer for your constructive comments!

o Based on the suggestion given, we make modification on the first sentence of the abstract section in the revised form of the manuscript.

2. “The quality of the English needs major work.”

Answer: Thank you!

o The issue of English language is resolved using English language professionals in the revised form of the manuscript.

Reviewer#2

Comments and points raised Authors response

1. “Was a time period determined for the search? If yes, what was it? If no, then please mention that.”

Answer: thank you dear reviewer for your constructive comments!

o The searching time period was already stated and it was between the 15th of February and 30th of April 2019

2. “How did you search for unpublished studies?”

Answer: Thank you!

o To find unpublished papers relevant to this study, some research centers including Addis Ababa digital library were searched.

3. “Was any attempt made to contact authors of studies for which full papers were not obtained?”

Answer: Thank you!

o We were planned to contact the primary author by email at least three times if a study is not fully available. But, studies searched for this systematic review and meta-analysis were fully obtained.

4. “The writing needs quite a bit of improvement in terms of flow.” Answer: Thank you!

o Based on your suggestion, we revised the flow of idea in the revised form of the manuscript and we make highlight for changes.

Reviewer#3

Comments and points raised Authors response

1. “Literature search: it is limited to 2 data bases and Google scholar, which is not comprehensive. The authors should have searched more relevant databases. They mentioned that they searched national databases, however, there is no description of such database. The search was limited to English language. As this study is investigating the prevalence of unintended pregnancy in a specific county/ region, it must have been included the articles in local language. This may increase the risk of reporting and publication bias.”

Answer: thank you dear reviewer for your constructive comments!

o Based on the comments given and to make comprehensive, in the revised form of the manuscript, we extend our searches for studies from PubMed/MEDLINE, Web of Science, CINAHL, Google Scholar, Science Direct and Cochrane Library.

o We were searched the “Ethiopian Journal of Public Health and Nutrition” for the national databases.

o You are right dear reviewer; not including articles published in local language may increase the risk of reporting and publication bias.

o But, we were searched for articles published in local language related to this study, but we can’t get such articles.

2. “Authors should explain the reasons in heterogeneity among studies. Why it exists, and how it affects the credibility of the overall results?”

Answer: Thank you!

o Based on the comment given, we included the possible reasons for heterogeneity among included studies.

o In this systematic review and meta-analysis, the possible sources of heterogeneity among studies are differences in study participants, study design, risk of bias and data collection period.

o To account the heterogeneity among the included studies, subgroup analysis and a random effect meta-analysis with an estimation of DerSimonian and Laird method was performed.

3. “Discussion: there is no mention of women’s age, time to reach the nearest health facility, household wealth, being married… in results section, but they show up in dissuasion as the potential determinants on the prevalence of unintended pregnancies”

o Based on the comments given, we included the stated variables in the result section.

Reviewer#4

Comments and points raised Authors response

1. “Parity, occupation, religion and economic status are important determinants of unintended pregnancy. Could the authors provide insight into why they were not significantly associated with unintended pregnancy in the review?” Answer: thank you dear reviewer for your constructive comments!

o In the revised form of the manuscript, we already considered the association between the mentioned variables and unintended pregenancy.

2. “As readers may not be familiar with Ethiopia, please define SNNPR at first instance.”

Answer: Thank you!

o Based on the comment given, we already define the word “SNNPR” at first instance in the revised form of the manuscript.

Reviewer#5

Comments and points raised Authors response

1. “There are 195 English language corrections that I strongly suggest you follow in the Comments section of the attached PDF file.” Answer: thank you dear reviewer for your constructive comments!

o We thank you for your revision, and we considered all English language corrections in the revised form of the manuscript.

Thank you!!!

Submitted filename: Response to Reviewers.docx

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6 Nov 2019

PONE-D-19-21662R1

Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

PLOS ONE

Dear Mr. Addis,

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Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #1: No further comments.

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Reviewer #2: The authors have not addressed the comments I have raised in my previous review.

The time period of the search is still not mentioned. Also in the flowchart, the further breakdown of how many studies were excluded because the full study was not available to them and how many did not have the outcome of interest is needed. What all efforts were done to try and get the full study? Were the authors contacted?

Reviewer #4: (No Response)

Reviewer #5: The authors have done a wonderful job making so many suggested English grammar corrections. The manuscript is significantly improved. However, there are still 12 more minor corrections remaining. See the comments in the attached file.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

Reviewer #5: No

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Submitted filename: PONE-D-19-21662_R1_reviewer (2).pdf

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27 Nov 2019

Author's response to reviews

Title: Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

Authors

Author’s email addresses

MA: mulunehadis@gmail.com

LY: lielt.yismaw@gmail.com

YB: yebelay.ma@gmail.com

BK: bekalukassiedmu@gmail.com

RY: reta.yeshambel@gmail.com

MAA: agazhemoges@gmail.com

Date: 27 November 2019

Dear Editor,

We thank you for the chance to resubmit our revised manuscript. Also, we would like to thank the reviewers for sharing the view and experience. The comments are very important that will improve the manuscript. The point-by-point responses for each of the comments are provided in the following pages. We hope that the revisions meet your standards and that the paper would be published in your journal. We look forward to working with you towards a final published product.

Sincerely,

Muluneh Alene, MPH

On behalf of co-authors

Point by point responses to queries

Reviewer#2

Comments and points raised Authors response

The time period of the search is still not mentioned. Also in the flowchart, the further breakdown of how many studies were excluded because the full study was not available to them and how many did not have the outcome of interest is needed. What all efforts were done to try and get the full study? Were the authors contacted? Answer: thank you dear reviewer for your constructive comments!

o The searching time period was already stated in the previous revised form of the manuscript: Page 6, line 168-169.

o In Fig. 1 (flow chart diagram), we included the number of studies excluded because the outcome of interest did not report, having data that were not extractable and conducted in other countries.

o We were planned to contact the primary author by email at least three times if a study is not fully available. But, studies searched for this systematic review and meta-analysis were fully obtained.

Reviewer#5

Comments and points raised Authors response

1. “There are still 12 more minor corrections remaining.”

Answer: thank you dear reviewer for your constructive comments!

o We thank you again for your revision, and we considered all English language corrections in the revised form of the manuscript.

o In addition, we used English language professionals to write the manuscript in Standard English.

Submitted filename: Response to Reviewers .docx

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10 Jan 2020

PONE-D-19-21662R2

Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

PLOS ONE

Dear Mr. Addis,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Please include the following items when submitting your revised manuscript:

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We look forward to receiving your revised manuscript.

Kind regards,

Seth Adu-Afarwuah

Academic Editor

PLOS ONE

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Comments to the Author

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Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Line 73 "...25% WERE unintended..."

Line 82 it is not 100% that a woman WILL have low mental and physical health, I would reword it and say that women with unintended pregnancy are more likely to have low mental and physical health.

My question about the time period of articles that were searched still remains unclear, the time period mentioned 15 February to 30 April 2019 is the time period during which the search was conducted or only articles published within this time period was included? Because if it is the latter, which I doubt it is, then that is a very very short time period.

This needs to be clearly mentioned in the article.

**********

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Reviewer #2: Yes: Tarannum Behlim

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

28 Jan 2020

Author's response to reviews

Title: Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

Authors

Author’s email addresses

MA: mulunehadis@gmail.com

LY: lielt.yismaw@gmail.com

YB: yebelay.ma@gmail.com

BK: bekalukassiedmu@gmail.com

RY: reta.yeshambel@gmail.com

MAA: agazhemoges@gmail.com

Date: 25 January 2020

Dear Editor,

We thank you for the chance to resubmit our revised manuscript. Also, we would like to thank the reviewers for sharing the view and experience. The comments are very important that will improve the manuscript. The point-by-point responses for each of the comments are provided in the following pages. We hope that the revisions meet your standards and that the paper would be published in your journal. We look forward to working with you towards a final published product.

Sincerely,

Muluneh Alene, MPH

On behalf of co-authors

Point by point responses to queries

Reviewer#2

Comments and points raised Authors response

1. Line73"...25% were unintended...", Line 82 it is not 100% that a woman WILL have low mental and physical health, I would reword it and say that women with unintended pregnancy are more likely to have low mental and physical health

Answer: thank you dear reviewer for your constructive comments!

� In the revised form of the manuscript, we already incorporate your suggestion.

2. My question about the time period of articles that were searched still remains unclear, the time period mentioned 15 February to 30 April 2019 is the time period during which the search was conducted or only articles published within this time period was included? Because if it is the latter, which I doubt it is, then that is a very short time period. This needs to be clearly mentioned in the article. Answer: thank you dear reviewer for your constructive comments which are very important to improve the manuscript!

� The time period what we mentioned in page 6, Line 169-170 (15 February to 30 April 2019) is only the period what we search for studies.

� In this study, we included all existing articles without considering the year of publication. So, as it indicates in page 6, Line 177-178 the publication year among the included studies was between 2006 and 2019.

� We make highlight for changes in the revised form of the manuscript.

Thank you!!!

Submitted filename: Response to Reviewers.docx

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16 Mar 2020

Prevalence and determinants of unintended pregnancy in Ethiopia: a systematic review and meta-analysis of observational studies

PONE-D-19-21662R3

Dear Dr. Addis,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Seth Adu-Afarwuah

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

**********

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Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

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Reviewer #2: Yes: Tarannum Behlim

Table 1

Descriptions of the included studies conducted in Ethiopia on unintended pregnancy.

First author (publication year)	Study area (Region)	Study design	Data collection period	Study population	Sample size	Response rate	Prevalence of unintended pregnancy
Abame et al (2019)	SNNPR	CBCS	March 13, 2017 to April 13, 2017	pregnant mothers	748	97%	36.2%
Abayu et al (2015)	Tigray	CBCS	24/09/2012 to 18/10/2012	Pregnant women	626	96.3%	26%
Admasu et al (2018)	Amhara	CBCS	NR	pregnant women or with under 1 child age	680	91%	15.8%
Ayele et al (2017)	Oromiya	IBCS	June 10, 2017 to July 24, 2017	pregnant women following ANC	165	96%	35.2%
Darega et al (2015)	Oromiya	IBCS	May, 2014	Women following ANC	362	100%	37.3%
Feyisso et al (2017)	SNNPR	IBCS	February to June, 2016	Women following ante natal and post natal ANC	290	NR	36.9%
Fite et al (2018)	Oromiya	CBCS	May 01–July 30, 2017	Pregnant women	704	91.5%	41.5%
Gebreamlak et al (2014)	Amhara	IBCS	June to July 2012	Pregnant women	454	NR	26%
Gite et al (2016)	SNNPR	CBCS	February 15- March 11,2015	Pregnant women	311	95.4%	19.4%
Gizaw et al (2018)	SNNPR	IBCS	February 24 to April 24, 2017	Pregnant women	224	100%	22.3%
Goshu et al (2019)	Amhara	IBCS	April 01 to May 30, 2018	Pregnant women	398	100%	26.1%
Habte et al (2013)	National level	EDHS	NA	Pregnant women	1267	NA	24%
Hamdela et al (2012)	SNNPR	CBCS	April 02 to 15, 2011	pregnant married women	385	100%	34%
Kahasay et al (2015)	Addis Abeba	IBCS	NR	female students aged from 16–19 years	576	100%	20.4%
Kassa et al (2012)	Oromiya	KDSHRC	December 2009 to November 2010	Pregnant women	2072	100%	27.9%
Kassie et al (2017)	Addis Abeba	IBCS	February to May 2015	Pregnant women	393	100%	36.4%
Kibret et al (2014)	Amhara	IBCS	April 15 to May 14, 2012	Pregnant women	413	100%	32.9%
Liyew et al (2017)	Amhara	IBCS	NR	Pregnant women	285	100%	28.4%
Melese et al (2016)	Amhara	CBCS	NR	Pregnant women	690	NR	23.5%
Mohammed et al (2016)	Oromiya	IBCS	January 10 to April 13, 2015	Pregnant women	413	97.9%	27.1%
Mulat et al (2017)	SNNPR	IBCS	NR	Pregnant women	362	100%	33.7%
Tebekaw et al (2014)	National level	EDHS	EDHS, 2011	Women who had at least one birth	7,759	NA	32%
Teshome et al (2010)	Amhara	CBCS	NR	currently married women	576	NR	40.8%
Tsegaye et al (2018)	Amhara	CBCS	August to September 2015	Married pregnant women	619	95.6%	13.7%
Wado et al (2013)	Oromiya	HDSS	March,2012	mothers with alive birth in the two years	1456	94%	35%
Worku et al (2006)	Harar	CBCS	November to December 2001	Reproductive age women	983	98.3%	33.3%
Yenealem et al (2019)	Amhara	CBCS	April 1–May 30, 2014	Pregnant women	325	100%	20.6%

CBCS = Community-Based Cross-Sectional Study, EDHS = Ethiopia Demographic and Health Survey, HDSS = Health and Demographic Surveillance System, IBCS = Institution-Based Cross Sectional Study, KDS-HRC = Kersa Demographic Surveillance and Health Research Center, NA = Not Applicable, NR = Not Report, SNNRP = Southern Nations, Nationalities, and Peoples’ Region

Table 2

Subgroup analysis of studies included in meta-analysis on prevalence and determinants of unintended pregnancy in Ethiopia.

Subgroup	Random effects (95%CI)	Test of heterogeneity (I2)
By study design
CBCS	26.4% (20.8–32.4)	96.6%
IBCS	30.0% (26.6–33.6)	84.4%
Overall	28.2% (24.1–32.5)	82.5%
By region
Amhara	24.9% (19.2–31.0)	95.2%
Oromiya	33.8% (29.0–38.7)	91.2%
SNNPR	30.6% (25.2–36.2)	87.6%
Addis Ababa	28.0% (14.0–44.7)	96.6%
National level	28.0% (20.5–36.1)	97.1%
Tigray	26.5% (23.1–30.0)	-
Harar	22.9% (20.3–25.5)	-
Overall	26.5%(24.8–28.2)	88.8%
By data collection period
2014 and before	28.2% (25.1–31.4)	94.6%
After 2014	28.8% (23.7–34.0)	94.5%
Overall	28.4% (25.7–31.1)	87.2%