Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study

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A...", "datePublished": "2021-12-10T10:45:42", "dateModified": "2022-11-14T16:41:23", "author": [ { "@type": "Person", "name": "Ratna Dwi Wulandari" }, { "@type": "Person", "name": "Agung Dwi Laksono" }, { "@type": "Person", "name": "Nikmatur Rohmah" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": "Background: Unmarried women who experience unintended pregnancy tend to hide their pregnancy and not perform pregnancy care. The study analyzed the effect of unintended pregnancy on antenatal care (ANC) visits among unmarried women in Indonesia. Methods: The study employed secondary data from the 2017 IDHS. This cross-sectional study involved unmarried women aged 15-49 who gave birth in the last five years. The 2017 IDHS used stratification and multistage random sampling, and the task got 508 as weighted samples. The variables analyzed included ANC, unintended pregnancy, residence, age, marital, education, employment, wealth, and health insurance. The study used the binary logistic regression test at the final stage. Results: The results show that the proportion of unmarried women who have experienced an unintended pregnancy in the last five years in Indonesia is 26.0%. Unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). The analysis indicates that unmarried women who have unintended pregnancies in Indonesia are less likely to complete ANC visits. Conclusion: The study concluded that unmarried women who experienced unintended pregnancies in Indonesia were less likely to complete ANC visits." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/10-1270/v2", "name": "Antenatal care visits performance among unmarried women in Indonesia:..." } } ] } Home Browse Antenatal care visits performance among unmarried women in Indonesia:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Wulandari RD, Laksono AD and Rohmah N. Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.12688/f1000research.24693.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] Ratna Dwi Wulandari https://orcid.org/0000-0003-4365-5747 1,2 , Agung Dwi Laksono 2,3 , Nikmatur Rohmah https://orcid.org/0000-0002-5393-1517 4 Ratna Dwi Wulandari https://orcid.org/0000-0003-4365-5747 1,2 , Agung Dwi Laksono 2,3 , Nikmatur Rohmah https://orcid.org/0000-0002-5393-1517 4 PUBLISHED 14 Nov 2022 Author details Author details 1 University Airlangga, Surabaya, East Java, 60115, Indonesia 2 The Airlangga Centre for Health Policy (ACeHAP), Surabaya, East Java, Indonesia 3 National Research and Innovation Agency Republic of Indonesia, Jakarta, 10340, Indonesia 4 Muhammadiyah Jember University, Jember, East Java, Indonesia Ratna Dwi Wulandari Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Resources, Supervision, Validation, Writing – Review & Editing Agung Dwi Laksono Roles: Data Curation, Formal Analysis, Investigation, Software, Visualization, Writing – Original Draft Preparation Nikmatur Rohmah Roles: Funding Acquisition, Investigation, Project Administration, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Health Services gateway. This article is included in the Sociology of Health gateway. Abstract Background: Unmarried women who experience unintended pregnancy tend to hide their pregnancy and not perform pregnancy care. The study analyzed the effect of unintended pregnancy on antenatal care (ANC) visits among unmarried women in Indonesia. Methods: The study employed secondary data from the 2017 IDHS. This cross-sectional study involved unmarried women aged 15-49 who gave birth in the last five years. The 2017 IDHS used stratification and multistage random sampling, and the task got 508 as weighted samples. The variables analyzed included ANC, unintended pregnancy, residence, age, marital, education, employment, wealth, and health insurance. The study used the binary logistic regression test at the final stage. Results: The results show that the proportion of unmarried women who have experienced an unintended pregnancy in the last five years in Indonesia is 26.0%. Unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). The analysis indicates that unmarried women who have unintended pregnancies in Indonesia are less likely to complete ANC visits. Conclusion: The study concluded that unmarried women who experienced unintended pregnancies in Indonesia were less likely to complete ANC visits. READ ALL READ LESS Keywords Unintended pregnancy, antenatal care, maternal health, unmarried women, public health Corresponding Author(s) Ratna Dwi Wulandari ( [email protected] ) Close Corresponding author: Ratna Dwi Wulandari Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2022 Wulandari RD et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Wulandari RD, Laksono AD and Rohmah N. Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.12688/f1000research.24693.2 ) First published: 10 Dec 2021, 10 :1270 ( https://doi.org/10.12688/f1000research.24693.1 ) Latest published: 14 Nov 2022, 10 :1270 ( https://doi.org/10.12688/f1000research.24693.2 ) Revised Amendments from Version 1 The author revised several sentences for typos to improving the study's meaning. Responses are also intended to respond to suggestions from Reviewer 1. The author revised several sentences for typos to improving the study's meaning. Responses are also intended to respond to suggestions from Reviewer 1. See the authors' detailed response to the review by Manoja Das READ REVIEWER RESPONSES Introduction During 2015–2019, there were at least 121.0 million unintended pregnancies each year 1 . Unintended pregnancy is untimely, unplanned, unwanted at conception, or pregnancy which occurs earlier than desired 2 . The definition of unintended pregnancies has complex considerations. The condition influenced the terms by how they (a person or the partner) feel about the pregnancy itself, or generally, their reproductive plans. Unintended pregnancy occurs when a woman wishes to become pregnant at a future date but not at the time she became pregnant, or pregnancy occurs when the woman does not want to become pregnant at the time or at any time in the future 3 . Unintended pregnancy can result from not using contraception or using contraception inadequately during sex. Despite having no desire to become pregnant, women with low perceived susceptibility were more likely not to have used contraception at the previous sex 4 . Unintended pregnancy has the risk of causing various disorders to women and their babies. Women who experience unintended pregnancy are at risk of experiencing decreased physical function, general health, vitality, and social function. The mental health of women who experienced an unintended pregnancy was 9.19 times more likely to decline than women with a desired pregnancy. Women with unintended pregnancies are at risk of developing poor mental health in the future, depression, and parenting stress 5 – 7 . Besides, other threats that can occur are increased body weight during inadequate pregnancy, the increased risk of giving birth by Sectio Caesarea, the duration of breastfeeding is shorter, and children born from unintended pregnancy at the age of under five have a low developmental score 8 , 9 . Various conditions that arise from unintended pregnancy can threaten a woman's health during pregnancy and childbirth and affect the infant's birth development. The government should take measures to reduce unintended pregnancy. However, the reality is that unintended pregnancy in Indonesia is still relatively high. For example, the proportion of unintended pregnancy among women of childbearing age in Indonesia was 15.4% in 2012 10 and increased to 16.3% in 2020 11 . Most unintended pregnancies occur in women with the intention of not wanting any more children 11 . Women with high parity and experiencing pregnancy complications are more likely to experience unintended pregnancy 12 . Meanwhile, the majority of unintended pregnancies in Indonesia occurred in married women. As many as 3.26% of unintended pregnancies occurred in women who were never married or had no partners (widows) 12 . Moreover, a study conducted by Rohmah et al. reported that pregnancy among teenagers in Indonesia was 5.7% in women who were not married or had no partners 13 . Although the proportion of unintended pregnancies among unmarried women in Indonesia is small, the problems they cause are more complex than those of married women. Pregnancy in unmarried women is much more likely to happen accidentally and have adverse effects 14 . In a qualitative study in the Nagari Sungayang community, one of Indonesia's western regions, an unmarried woman's pregnancy is considered an act that religion prohibits. The situation contradicts the traditional values and culture of the local community 15 . On the other hand, in Indonesia, where most of the population is Muslim; they believe that a child born due to pregnancy outside or before a legal marriage is considered a child born out of adultery 16 . Therefore pregnancy for an unmarried woman is regarded as a disgrace. Some people try to cover up this disgrace by getting married even though their age is not sufficient. As a result, underage marriages occur, causing depression, anxiety, fear, and stress 17 . The main burden of unintended pregnancy for single or divorced/widowed women is physical changes during pregnancy. The added responsibility is gaining a negative status from society. The unfavorable position of this society is even more dominant for unmarried women. Some of the burdens of unmarried mothers due to pregnancy outside of marriage include the financial responsibility of child care, conflict, no support from family, negative labels from others, and past regrets 18 . Women who are unable to bear the burden of unintended pregnancy often decide to have an abortion. During 2010–2014, 59% of unintended pregnancies in developed countries and 55% of unintended pregnancies in developing countries ended with abortion 19 . During 2015–2019 the proportion of unintended pregnancies that ended with abortion increased 1 . Thus, women bear a double burden, and if they were making inappropriate decisions about unintended pregnancy, it would create more complex problems. These problems include medical complications due to unhealthy abortion, post-traumatic stress, the legal burden of an abortion, socioeconomic issues, childbirth in adolescence, and more susceptibility to divorce if women carried out marriage after pregnancy 19 . Unintended pregnancy in unmarried women is one of the most difficult challenges faced by the health system. A previous study reported the case of an unmarried woman who became pregnant twice out of wedlock and had not received antenatal care (ANC) services, either in the public or private health sector. We should note that unmarried women who experience unintended pregnancy tend to hide their pregnancies and not carry out pregnancy care 10 . Unmarried women are less innovative in finding information related to pregnancy 14 . Considering the huge impact caused by unintended pregnancy on unmarried women, it is necessary to evaluate the implementation of ANC. This evaluation aims to ensure that unmarried women receive adequate services during pregnancy and obtain good delivery outcomes. Based on the background narration, the study aims to analyze the effect of unintended pregnancy on ANC visits performance among unmarried women in Indonesia. Methods Data source The research used secondary data from the Indonesian Demographic and Health Survey in 2017 (the 2017 IDHS). The 2017 IDHS is part of the Demographic and Health Survey (DHS) series conducted by the Inner City Fund (ICF). The ICF designed the 2017 IDHS sampling design to be able to present national and provincial estimates. Implementation of the 2017 IDHS used four types of questionnaires: households, women of childbearing age, married men, and young men. This study specifically took a sub-sample of women of childbearing age, with criteria aged 15–49 years. The survey used the household questionnaire to record all household members and guests who stayed the night before the interview in the selected households. The primary purpose of this household questionnaire is to determine respondents who are eligible to be interviewed individually (eligible respondents). Data collection carried out on women of childbearing age refers to the 2015 DHS phase 7 questionnaire, which accommodates several of the latest issues according to international comparability. The survey conducted data collection between 24 July - 30 September 2017. The 2017 IDHS determined samples through stratification and multistage random sampling. The survey collected 50,730 eligible women in the final stage and successfully interviewed 49,627 women (97.8%). In this study, the 2017 IDHS was chosen as the analysis material because it can estimate national representation. The data used in this study are from the 'IDIR71FL_Individual Recode' dataset of the Indonesia 2017 Standard DHS. The analytical research units were unmarried women aged 15–49 years who gave birth in the last five years (IDIR71FL_Individual Recode dataset). Some respondents do not represent the desired population in the study. To avoid bias, the study defines a target population with a sample of only unmarried women of childbearing age who have given birth in the last five years. In this study, the researcher carried out the sampling step by selecting based on two criteria: marital status (never in a union, or widowed, or divorced, or no longer living together/separated) and giving birth in the last five years. In the final, the study described 508 women as the sample. Variables The study employed ANC visits as an outcome variable. The Ministry of Health of the Republic of Indonesia recommends that the ANC be performed at least four times during pregnancy, i.e. one time in the first trimester, one time in the second trimester, and two times in the third trimester 20 . Therefore, the operational description of ANC utilization used in this study was the respondent's awareness of ANC use during pregnancy. The ANC used consists of two parameters, namely < four visits and ≥ four visits 21 . The research used unintended pregnancy as an exposure variable. The study defines unintended pregnancy as an unwanted pregnancy or mistimed pregnancy. Women endured an unwanted pregnancy when they did not want to be pregnant or have any children. However, a mistimed pregnancy occurred at this time when a woman did not want to be pregnant, but later 22 . The author captured unintended pregnancy as a specific variable in the 2017 IDHS (IDIR71FL dataset: v367). The unintended pregnancy consists of two categories: no and yes. Apart from unintended pregnancy, other independent variables, as control variables, were analyzed: residence type, age group, marital status, education level, employment status, wealth status, and health insurance ownership. The residence type consists of urban and rural. The age group consists of seven categories: 15–19 years, 20–24 years, 25–29 years, 30–34 years, 35–39 years, 40–44 years, and 45–49 years. Marital status consists of two classifications: never in a union and divorced/widowed. Meanwhile, education level consists of four categories: no formal education, primary, secondary, and higher. Employment status consists of two types: unemployed and employed. Finally, the health insurance ownership consists of the uninsured and insured. The IDHS measured wealth status based on the wealth quintile of each family. Households were scored based on the number and types of existing items, such as televisions, bicycles, cars, and housing characteristics, such as drinking water sources, sanitation facilities, and primary flooring materials. The study calculated scores of these variables using the principal component analysis. National wealth quintiles were arranged based on household scores for each person in the household and then divided by the distribution into the same five categories, of which accounted for 20% of the population, namely quintile 1 (poorest), quintile 2 (poorer), quintile 3 (middle), quintile 4 (richer), and quintile 5 (richest) 23 . Data analysis The researcher used the Chi-Square test to see the relationship between ANC visit performance and other variables in the initial stage. Then, the researcher employed binary logistic regression to determine the predictors and see their odds ratios in the final step. The analysis carried out all the statistical processes using the IBM SPSS Statistic 21 software. Moreover, the researchers created a distribution map of the percentage of unintended pregnancy among unmarried women by the province in Indonesia. The study issued a shapefile of administrative boundary polygons by the Indonesian Bureau of Statistics for the task. Ethical approval The 2017 Indonesia DHS follows the Standard DHS survey protocol under The Demographic and Health Surveys (DHS) Program (DHS-7) approved by The Institutional Review Board of Inner City Fund (ICF) International, which was previously reviewed and approved by the ORC Macro IRB in 2002. DHS surveys that follow the standard are categorized under the approval of the DHS-7 Program, and the approval document is attached. The Institutional Review Board of ICF International complied with the United States Department of Health and Human Services requirements for the Protection of Human Subjects (45 CFR 46). The IDHS removed from the dataset the names of the respondents. Besides, for their participation in this report, the respondents have given written approval. The IDHS obtained informed consent from all subjects. For participants under 18 years, the survey received informed consent from a parent or legal guardian. On https://dhsprogram.com , the authors have obtained permission to use ICF International's 2017 IDHS dataset. Results The result shows the proportion of unmarried women who have experienced an unintended pregnancy in the last five years in Indonesia is 26.0%. This study presents the distribution map of the percentage of unintended pregnancy among unmarried women by the province in Indonesia in Figure 1 . The figure shows a trend towards a higher distribution of unintended pregnancy rates in Indonesia's central region. Figure 1. Distribution map of the percentage of unintended pregnancy among unmarried women by the province in Indonesia in 2017. Based on the type of residence, unmarried women living in rural areas drove both ANC visits categories. Meanwhile, unmarried women in the 20–24 age group dominated the ANC visits category < four times based on the age group. Moreover, unmarried women aged 25–29 populated the ANC category for ≥ four visits. Table 1 shows that the marital status of unmarried women with the divorced/widowed category occupied the two types of ANC visits. However, according to education level and employment status, unmarried women with secondary education and employment dominate the two categories of ANC visits. Table 1. The descriptive statistics of the unmarried women in Indonesia (n = 508). Variables ANC visits p-value < four times ≥ four times Unintended pregnancy *** 0.000 • No 62.9% 76.4% • Yes 37.1% 23.6% Residence • Urban 49.2% 49.8% • Rural 50.8% 50.2% Age *** 0.000 • 15–19 13.2% 6.5% • 20–24 30.1% 24.9% • 25–29 17.6% 27.4% • 30–34 16.6% 15.2% • 35–39 11.4% 16.0% • 40–44 10.8% 6.4% • 45–49 0.2% 3.6% Marital *** 0.000 • Never in a union 3.8% 2.1% • Divorced/Widowed 96.2% 97.9% Education *** 0.000 • No education 3.8% 1.0% • Primary 35.1% 28.8% • Secondary 50.9% 61.3% • Higher 10.2% 8.8% Employment *** 0.000 • Unemployed 44.1% 32.8% • Employed 55.9% 67.2% Wealth *** 0.000 • Poorest 44.5% 25.5% • Poorer 18.1% 19.6% • Middle 14.9% 23.1% • Richer 15.5% 19.1% • Richest 7.0% 12.7% Health insured *** 0.000 • Uninsured 52.2% 50.0% • Insured 47.8% 50.0% *** p < 0.001. Based on wealth status, the most deficient unmarried women occupied both categories of ANC visits. However, according to health insurance ownership, uninsured unmarried women dominate the ANC visits < four times. Meanwhile, in various ANC visits ≥ four times, the two types of health insurance ownership have an equal frequency. Table 2 shows the results of binary logistic regression of ANC visit performance among unmarried women in Indonesia. This final stage analysis uses “ANC visits < four times” as a reference. Table 2. Results of binary logistic regression of ANC visits performance among unmarried women in Indonesia (n = 508). Predictor ANC visits ≥ four times p-value AOR 95% CI Lower bound Upper bound Unintended pregnancy: No - - - - Unintended pregnancy: Yes *** 0.000 0.588 0.587 0.588 Residence: Urban - - - - Residence: Rural *** 0.000 1.406 1.405 1.407 Age: 15–19 - - - - Age: 20–24 *** 0.000 1.276 1.274 1.277 Age: 25–29 *** 0.000 2.478 2.475 2.480 Age: 30–34 *** 0.000 1.720 1.718 1.721 Age: 35–39 *** 0.000 2.414 2.411 2.417 Age: 40–44 *** 0.000 1.228 1.226 1.229 Age: 45–49 *** 0.000 35.009 34.849 35.170 Marital: Never in union *** 0.000 1.513 1.511 1.516 Marital: Divorced/ Widowed - - - - Education: No education - - - - Education: Primary *** 0.000 4.404 4.396 4.412 Education: Secondary *** 0.000 4.875 4.867 4.883 Education: Higher *** 0.000 2.504 2.499 2.509 Employment: Unemployed - - - - Employment: Employed *** 0.000 1.305 1.304 1.306 Wealth: Poorest - - - - Wealth: Poorer *** 0.000 2.073 2.072 2.075 Wealth: Middle *** 0.000 3.010 3.008 3.013 Wealth: Richer *** 0.000 2.313 2.311 2.315 Wealth: Richest *** 0.000 3.950 3.946 3.955 Health insurance: Uninsured - - - - Health insurance: Insured *** 0.000 1.219 1.218 1.220 *** p < 0.001; AOR: adjusted odds ratio; CI: confidence interval. Table 2 shows that unmarried women who experienced an unintended pregnancy were 0.588 times less likely than those who did not experience an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). Thus, this analysis indicates that unmarried women who have an unintended pregnancy in Indonesia are less likely to complete ANC visits. Apart from unintended pregnancy, the study found all the independent variables as a significant determinant of ANC visit performance. Based on the type of residence, unmarried women living in rural areas are 1.406 times more likely than unmarried women living in urban areas to make ANC visits ≥ four times (AOR 1.406; 95% CI 1.405-1.407). These results indicate that living in rural areas is a protective factor for unmarried women to complete ANC visits. Table 2 also indicates that the age group is a determinant of the ANC visits performance. For example, unmarried women in the 20–24 age group were 1.276 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 1.276; 95% CI 1.274-1.277). Meanwhile, unmarried women in the 35–39 age group were 2.414 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 2.414; 95% CI 2.411-2.417). Moreover, unmarried women in the 45–49 age group are 35.009 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 35.009; 95% CI 34.849-35.170). According to marital status, unmarried women never in union are 1.513 times more likely than unmarried women who are divorced/widowed to have ANC visits ≥ four times (AOR 1.513; 95% CI 1.511-1.516). Thus, unmarried women who have experienced marriage in Indonesia are less likely to have complete ANC visits. The analysis also found that women in all education levels were more likely than those with no education to make ≥ four ANC visits. Unmarried women with primary education were 4.404 times more likely than unmarried women to have ANC visits ≥ four times (AOR 4.404; 95% CI 4.396-4.412). Unmarried women with secondary education are 4.875 times more likely to make ANC visits ≥ four times (AOR 4.875; 95% CI 4.867-4.883). Besides, unmarried women with higher education are 2.504 times more likely than unmarried women to make ANC visits ≥ four times (AOR 2.504; 95% CI 2.499-2.509). Based on employment status, employed unmarried women have a probability of 1.305 times than unemployed unmarried women to make ANC visits ≥ four times (AOR 1.305; 95% CI 1.304-1.306). This information shows that employment is a protective factor for unmarried women in Indonesia to complete ANC visits. The binary logistic regression results found that all wealth status categories were more likely than the poorest to complete ANC visits. Unmarried women with the more deficient category's wealth status are 2.073 times more likely than the most deficient unmarried women to make ANC visits ≥ four times (AOR 2.073; 95% CI 2.072-2.075). Unmarried women with a wealth status in the middle category are 3.010 more likely to make ANC visits ≥ four times (AOR 3.010; 95% CI 3.008-3.013). Unmarried women with wealth status in the more affluent category were 2.313 times more likely than the poorest unmarried women to make ANC visits ≥ four times (AOR 2.313; 95% CI 2.311-2.315). Moreover, the richest unmarried women have 3,950 times the probability of making ANC visits ≥ four times than the most deficient unmarried women (AOR 3.950; 95% CI 3.946-3.955). Finally, according to health insurance ownership, insured unmarried women have a probability of 1.219 times more likely than uninsured unmarried women to make ANC visits ≥ four times (AOR 1.219; 95% CI 1.218-1.220). This analysis indicates that insured is a protective factor for unmarried women in Indonesia to complete ANC visits. Discussion The analysis found that unmarried women who had an unintended pregnancy in Indonesia were less likely to complete ANC visits. Less than optimal prenatal care in women with an unintended pregnancy is common in many countries on various continents, such as Africa, Asia, the USA, and Europe 24 . Several previous studies in the USA, Iran, Kenya, and Ethiopia also revealed a strong association between pregnancy unwantedness and the frequency and timing of ANC visits 25 – 29 . Many factors can explain the finding, including socio-cultural and psychological factors. Marriage in Indonesia symbolizes a religious, social order while experiencing pregnancy in an unmarried woman will carry social stigma 30 , 31 . The health value of people who share extramarital incubation, which the community sees as a disgrace, is considered less important than social values. By conducting ANC visits, the surrounding community will be aware of extramarital pregnancies, a massive social threat. The women even felt stigma until the fetus in the womb grew into a child and had a severe psychological impact 31 . Social stigma and psychological burden for unmarried women who experience pregnancy do not only occur in Indonesia. In many communities in some developing countries, unmarried woman pregnancies tend to be associated with poverty and low education 32 . For example, a study in Sri Lanka found that women who became pregnant outside of wedlock realized that they had violated social norms, so they tended to blame themselves; some even attempted suicide 33 . This study indicates that living in rural areas is a protective factor for unmarried women to complete ANC visits. The situation means that unmarried women living in rural areas have better ANC visits than unmarried women in cities. Rural regions in Indonesia are characterized by high community awareness and togetherness compared to urban areas. Social relations in rural communities are heightened and tend to last longer 34 , thus building a good interaction pattern who cares about each other in the neighborhood. Bullying and negative social sanctions are not common in rural areas due to the politeness culture, which is still firmly attached 35 . Thus, we felt this condition reduces the psychological burden of a woman who experiences an unwanted pregnancy. Contrary to rural areas, urban areas have more modern culture, and politeness in the interaction pattern is lower. As a result, there is a fear among women who experience unwanted pregnancies of receiving bullies from their environment 36 , 37 . This phenomenon makes women with unintended pregnancies in urban areas reluctant to have regular pregnancy checks. The study also found age group as a determinant of the ANC visits performance. Although previous research has found variations in knowledge about pregnancy health, the older the mother is during pregnancy, more aware they are of their health risk 38 , 39 . The situation influences the decision-making of pregnant women whether to use ANC according to standards or not. The study results can explain why the ANC of four visits is significant in the 45–49 year age group. The results align with a lesson in Thailand that found that pregnant women over 35 years old had the highest score in promoting completed ANC visits 40 . Several other studies widely revealed the low utilization of ANC in the age group of 15–19 years old 41 , 42 . The incidence of unwanted pregnancy at an early age is generally experienced by those who are still students. The younger the gestational age, the higher the social burden borne by the family. Adolescents who experience unintended pregnancies tend to be in a terrible condition, feel sad, depressed, and not receive support from their parents 43 . The situation is their barrier to utilizing ANC according to standards. Unmarried women who have experienced marriage in Indonesia are less likely to have complete ANC visits. The status of widowed or divorced in several regions in Indonesia is stigmatized, especially for those who became divorced 30 . This stigmatization will undoubtedly worsen for widows or divorced women who experience pregnancy because the “naughty woman” label will be attached 31 . The socio-psychological burden faced by widows or divorced women who experience unwanted pregnancies is much heavier than the other women's. The situation was what became an obstacle for the widow or divorced women to carry out ANC checks regularly. Many previous studies have found that widows or divorced women are more likely to experience unsafe sex because doing it without contraception 12 . Meanwhile, the study results found that all education levels led a better chance of making ANC visits ≥ four times than no education. These results indicate that the higher a person's education, the higher her understanding of pregnancy risk 44 , 45 . Even though pregnant women still feel the social burden, higher education can better control the situation. Educated pregnant women can choose healthier behavior due to sufficient background knowledge 46 . Several other studies have shown a direct influence between education and health behavior in pregnant women 46 , 47 . Finally, several previous studies often found education a strong determinant of better health sector performance 48 – 51 . On the other side, the results of the analysis indicate that the employment is a protective factor for unmarried women in Indonesia to complete ANC visits. Society saw working women as more independent women. Some jobs also require specific educational levels. Thus, working women generally have a more educated social environment than women who do not work 52 . There is a growing trend of women joining the workforce, and more and more women are working in the formal sector. The condition is in line with the increasing education level of women 53 . The higher a person's education level, the more modern their mindset tends to be, accepting changes more efficiently, and being more resilient. Previous research has shown that working women's self-image is higher than that of unemployed women 54 . Women with a better self-image can better control their behavior, including being more independent in making decisions about their health. These conditions make employment a protective factor for unmarried women who experience unintended pregnancies. Moreover, results of the binary logistic regression test found that women in all the above poorest wealth status categories are more likely than the poorest to complete ANC visits. This study's products align with previous research that found that wealth significantly affects the fair use of antenatal care 55 . Previous studies have also confirmed inequality in receiving health services between the rich and the poor 56 . Finally, the analysis found that insurance ownership is a protective factor for unmarried women in Indonesia to complete ANC visits. However, spending to pay for health services remains a consideration in utilizing health services. Health insurance participants no longer need to think about paying for the health services they receive. Meanwhile, people who do not have health insurance still have to pay a fee every time they attend health services. The condition is a barrier to health services for people who do not have insurance 57 . Even though Indonesia's primary health services can be obtained free of charge for ANC services, not all people access the Puskesmas (public health centers) 58 . In Indonesia, many people use private practicing midwives to receive ANC services, namely 40.5%, because private practicing midwives are more affordable 59 . Of course, people who do not have health insurance have to pay a fee to receive ANC services from private midwives. It becomes natural if people do not have insurance, the ANC utilization rate is lower than those with insurance. Study limitations The author performed the analysis using a secondary dataset from the 2017 IDHS to analyze the phenomenon superficially because it was unable to capture the reasons behind each finding. Several previous studies could not capture the complexity of the problem of unmarried women's in Indonesian culture 60 – 62 . As a result, we require more qualitative research to capture the reason for each phenomenon. Conclusions Based on the analysis results, the study concluded that women who experienced an unintended pregnancy in Indonesia had a lower probability of having complete ANC visits. Apart from unintended pregnancy, the study also found seven independent variables to determine ANC visit performance. The seven variables are residence, age group, marital status, education level, employment, wealth status, and health insurance ownership. Data availability Data used in this study are from the IDIR71FL_Individual Recode dataset of the Indonesia 2017 Standard DHS, available from the Demographic and Health Survey (DHS) website https://dhsprogram.com . Access to the dataset requires registration and is granted only for legitimate research purposes. A guide for how to apply for dataset access is available at: https://dhsprogram.com/data/Access-Instructions.cfm . 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Wulandari RD, Putri NK, Laksono AD: Socioeconomic Disparities in Antenatal Care Utilisation in Urban Indonesia. Int J Innov Creat Chang. 2020; 14 (2): 498–514. Reference Source 56. Makar M, Worple E, Dove J, et al. : Disparities in care: Impact of socioeconomic factors on pancreatic surgery: Exploring the national cancer database. Am Surg. 2019; 85 (4): 327–334. PubMed Abstract 57. Johar M, Soewondo P, Pujisubekti R, et al. : Inequality in access to health care, health insurance and the role of supply factors. Soc Sci Med. 2018; 213 : 134–145. PubMed Abstract | Publisher Full Text 58. Laksono AD, Wulandari RD: Determinant of the Puskesmas Utilization in Madura Island. Indian J Public Health Res Dev. 2019; 10 (11): 576–581. Reference Source 59. Nurjasmi E: The situation of midwifery services during the Covid-19 pandemic and entering the new-normal era (Situasi pelayanan kebidanan pada masa pandemi Covid-19 dan memasuki era new-normal). Jakarta, Indonesia: Indonesian Midwives Association; 2020; 1–32. 60. Widyastari DA: Revisiting the New Indonesia's Marriage Act 2019: will it be effective to prevent adolescent marriage? INSIGHTS Public Health J. 2020; 1 (1): 3–7. Publisher Full Text 61. Panjaitan AA: Model of Prevention of Adolescent Unwanted Pregnancy in Indonesia: Review Article. Int J Res Law Econ Soc Sci. 2019; 1 (2): 60–73. Publisher Full Text 62. Laksono AD, Soedirham O, Saptandari P, et al. : Study of family size among tenggerese in Indonesia. Int J Innov Creat Chang. 2020; 13 (4): 964–978. Reference Source Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 10 Dec 2021 ADD YOUR COMMENT Comment Author details Author details 1 University Airlangga, Surabaya, East Java, 60115, Indonesia 2 The Airlangga Centre for Health Policy (ACeHAP), Surabaya, East Java, Indonesia 3 National Research and Innovation Agency Republic of Indonesia, Jakarta, 10340, Indonesia 4 Muhammadiyah Jember University, Jember, East Java, Indonesia Ratna Dwi Wulandari Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Resources, Supervision, Validation, Writing – Review & Editing Agung Dwi Laksono Roles: Data Curation, Formal Analysis, Investigation, Software, Visualization, Writing – Original Draft Preparation Nikmatur Rohmah Roles: Funding Acquisition, Investigation, Project Administration, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 14 Nov 2022, 10:1270 https://doi.org/10.12688/f1000research.24693.2 version 1 Published: 10 Dec 2021, 10:1270 https://doi.org/10.12688/f1000research.24693.1 Copyright © 2022 Wulandari RD et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Wulandari RD, Laksono AD and Rohmah N. Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.12688/f1000research.24693.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 14 Nov 2022 Revised Views 0 Cite How to cite this report: Tey NP. Reviewer Report For: Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.5256/f1000research.140579.r280133 ) The direct URL for this report is: https://f1000research.com/articles/10-1270/v2#referee-response-280133 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Jun 2024 Nai Peng Tey , Population Studies Unit, Faculty of Business and Economics, University of Malaya, Kuala Lumpur, Malaysia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.140579.r280133 General comments Title : Recommend removal of the word "performance" Consider a more nuanced approach to the number of antenatal visits, dividing them into 0 (or none), 1-3, and 4+, and using ordinal regression analysis instead of binary ... Continue reading READ ALL General comments Title : Recommend removal of the word "performance" Consider a more nuanced approach to the number of antenatal visits, dividing them into 0 (or none), 1-3, and 4+, and using ordinal regression analysis instead of binary logistic regression. This method could provide a more accurate understanding of the relationship between antenatal care utilization and unintended pregnancies. However, the authors can ignore this suggestion if more than 95% of the respondents had at least one antenatal visit. It's crucial to include variables such as healthcare accessibility (besides health insurance coverage) and cultural beliefs in the analysis. If these variables were excluded due to non-availability of data, it's important to acknowledge this as a limitation of the study, as their inclusion could significantly enhance the comprehensiveness of the findings. Give more weight to the analysis of the intersectionality between unintended pregnancy and other variables like demographics, education, socioeconomic and cultural factors, geographic location, and healthcare access in influencing antenatal visit patterns. The analysis could be done by cross-tabulating the percentage who had four or more antenatal visits by unintended pregnancy with age, marital status (never married/widowed or divorced), location, employment and wealth status. This could help policymakers to address the barriers and reach the targeted service recipients more effectively to improve antenatal care utilization. The authors should clearly describe the distribution of 508 unmarried women who had given birth in the last five years, by showing a table on the profiles of the respondents - number and percentage distribution by antenatal visits (None, 1-3, 4 or more), had an unintended pregnancy (yes or no), [or better still, if the last pregnancy is intended or unintended, in case there are two or more pregnancies within the last five years]. according to age, education, place of residence, employment status, insurance coverage (yes, no), and wealth quantiles. Table 1 needs to be correctly presented and must be recalculated. The authors show the distribution of the independent variables by the dependent variables. Instead, the authors should show the antenatal attendance (0, 1-3, 4+) by each category of the independent variables. For example, how many percent of those with unintended pregnancy had not gone to antenatal checks, had visited 1-to 3 times, or four times or more, compared to those who did not have an unintended pregnancy? Beware of the small sample size in categories of the independent variables. Some groups may have to be combined, e.g., those aged 40-44 and 45-49 as one group and those below 25 as another. Please check the sample distribution. Discussion and conclusion. These two sections merely restate the results. It would be better if the authors elaborated on the implications and what the government, society, and individuals need to do to ensure compliance with antenatal visits and reduce health risks and complications during delivery. Some references to past studies would also be helpful. In the recommendation section, the authors can propose targeted education or intervention, such as programs to increase awareness about the importance of antenatal care, especially in places and communities with high rates of unintended pregnancies. They can also recommend improving access to MCH services, promoting the use of modern contraception to reduce unintended pregnancy, and calling for efforts to desensitize antenatal visits among those with unintended pregnancies, especially among urban women. Ensure all references are relevant to the issues being discussed and cite correctly. The manuscript requires language editing. Specific comments: Unintended pregnancy is untimely, unplanned, unwanted at conception, or pregnancy which occurs earlier than desired - rewrite as :An unintended pregnancy is a pregnancy that is unwanted (occurred when no children or no more children were desired) or mistimed (occurred earlier than desired. As many as 3.26% of unintended pregnancies occurred in women who were never married or had no partners (widows) - rewrite as: Unmarried or widowed women contributed only 3.2% of unintended pregnancy ...reported that pregnancy among teenagers in Indonesia was 5.7% in women who were not married or had no partner -rewrite as:unmarried women contributed only 5.7% of the pregnancy among Indonesian teenagers ....getting married even though their age is not sufficient., rewrite as: getting married before reaching the legal age of marriage ....include medical complications due to unhealthy abortion, rewrite as unsafe abortion. ...shows that unmarried women who experienced an unintended pregnancy were 0.588 times less likely than those who did not experience an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). Thus, this analysis indicates that unmarried women who have an unintended pregnancy in Indonesia are less likely to complete ANC visits.- rewrite as: that unmarried women who experienced an unintended pregnancy were less likely than those who did not experience an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). Thus, this analysis indicates that unmarried women who have an unintended pregnancy in Indonesia are less likely to complete ANC visits ....Moreover, unmarried women in the 45–49 age group are 35.009 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 35.009; 95% CI 34.849-35.170).- comments: I presumed that the sample size for the age group 45-49 and 15-19 is very small, and this affects the reliability of the estimates. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tey NP. Reviewer Report For: Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.5256/f1000research.140579.r280133 ) The direct URL for this report is: https://f1000research.com/articles/10-1270/v2#referee-response-280133 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 10 Dec 2021 Views 0 Cite How to cite this report: Das M. Reviewer Report For: Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.5256/f1000research.27237.r148531 ) The direct URL for this report is: https://f1000research.com/articles/10-1270/v1#referee-response-148531 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Oct 2022 Manoja Das , The INCLEN Trust International, New Delhi, Delhi, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.27237.r148531 The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract ... Continue reading READ ALL The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. 3.2. If there are any findings on the type of delivery care received by them and places of delivery and infant outcomes, it would be useful. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Child health and maternal health, health systems, implementation research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Das M. Reviewer Report For: Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.5256/f1000research.27237.r148531 ) The direct URL for this report is: https://f1000research.com/articles/10-1270/v1#referee-response-148531 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 14 Nov 2022 Ratna Dwi Wulandari , Airlangga University, Surabaya, 60115, Indonesia 14 Nov 2022 Author Response The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the ... Continue reading The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). Response: The author revised the sentence, "The results show that unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? Response: The author deletes the statement, and focuses only on the purpose of the study, to analyze the effect of unintended pregnancy on ANC visits among unmarried women in Indonesia. 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. Response: The author captured unintended pregnancy as a specific variable in the 2017 IDHS (IDIR71FL dataset: v367) 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. Response: total sample: 49,627; unmarried women: 15,160; unmarried women who births in the last five years: 508; Unintended: 129 The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). Response: The author revised the sentence, "The results show that unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? Response: The author deletes the statement, and focuses only on the purpose of the study, to analyze the effect of unintended pregnancy on ANC visits among unmarried women in Indonesia. 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. Response: The author captured unintended pregnancy as a specific variable in the 2017 IDHS (IDIR71FL dataset: v367) 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. Response: total sample: 49,627; unmarried women: 15,160; unmarried women who births in the last five years: 508; Unintended: 129 Competing Interests: The authors declare that they have no competing interests. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 14 Nov 2022 Ratna Dwi Wulandari , Airlangga University, Surabaya, 60115, Indonesia 14 Nov 2022 Author Response The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the ... Continue reading The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). Response: The author revised the sentence, "The results show that unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? Response: The author deletes the statement, and focuses only on the purpose of the study, to analyze the effect of unintended pregnancy on ANC visits among unmarried women in Indonesia. 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. Response: The author captured unintended pregnancy as a specific variable in the 2017 IDHS (IDIR71FL dataset: v367) 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. Response: total sample: 49,627; unmarried women: 15,160; unmarried women who births in the last five years: 508; Unintended: 129 The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). Response: The author revised the sentence, "The results show that unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? Response: The author deletes the statement, and focuses only on the purpose of the study, to analyze the effect of unintended pregnancy on ANC visits among unmarried women in Indonesia. 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. Response: The author captured unintended pregnancy as a specific variable in the 2017 IDHS (IDIR71FL dataset: v367) 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. Response: total sample: 49,627; unmarried women: 15,160; unmarried women who births in the last five years: 508; Unintended: 129 Competing Interests: The authors declare that they have no competing interests. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 10 Dec 2021 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 14 Nov 22 read Version 1 10 Dec 21 read Manoja Das , The INCLEN Trust International, New Delhi, India Nai Peng Tey , University of Malaya, Kuala Lumpur, Malaysia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Tey N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Jun 2024 | for Version 2 Nai Peng Tey , Population Studies Unit, Faculty of Business and Economics, University of Malaya, Kuala Lumpur, Malaysia 0 Views copyright © 2024 Tey N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions General comments Title : Recommend removal of the word "performance" Consider a more nuanced approach to the number of antenatal visits, dividing them into 0 (or none), 1-3, and 4+, and using ordinal regression analysis instead of binary logistic regression. This method could provide a more accurate understanding of the relationship between antenatal care utilization and unintended pregnancies. However, the authors can ignore this suggestion if more than 95% of the respondents had at least one antenatal visit. It's crucial to include variables such as healthcare accessibility (besides health insurance coverage) and cultural beliefs in the analysis. If these variables were excluded due to non-availability of data, it's important to acknowledge this as a limitation of the study, as their inclusion could significantly enhance the comprehensiveness of the findings. Give more weight to the analysis of the intersectionality between unintended pregnancy and other variables like demographics, education, socioeconomic and cultural factors, geographic location, and healthcare access in influencing antenatal visit patterns. The analysis could be done by cross-tabulating the percentage who had four or more antenatal visits by unintended pregnancy with age, marital status (never married/widowed or divorced), location, employment and wealth status. This could help policymakers to address the barriers and reach the targeted service recipients more effectively to improve antenatal care utilization. The authors should clearly describe the distribution of 508 unmarried women who had given birth in the last five years, by showing a table on the profiles of the respondents - number and percentage distribution by antenatal visits (None, 1-3, 4 or more), had an unintended pregnancy (yes or no), [or better still, if the last pregnancy is intended or unintended, in case there are two or more pregnancies within the last five years]. according to age, education, place of residence, employment status, insurance coverage (yes, no), and wealth quantiles. Table 1 needs to be correctly presented and must be recalculated. The authors show the distribution of the independent variables by the dependent variables. Instead, the authors should show the antenatal attendance (0, 1-3, 4+) by each category of the independent variables. For example, how many percent of those with unintended pregnancy had not gone to antenatal checks, had visited 1-to 3 times, or four times or more, compared to those who did not have an unintended pregnancy? Beware of the small sample size in categories of the independent variables. Some groups may have to be combined, e.g., those aged 40-44 and 45-49 as one group and those below 25 as another. Please check the sample distribution. Discussion and conclusion. These two sections merely restate the results. It would be better if the authors elaborated on the implications and what the government, society, and individuals need to do to ensure compliance with antenatal visits and reduce health risks and complications during delivery. Some references to past studies would also be helpful. In the recommendation section, the authors can propose targeted education or intervention, such as programs to increase awareness about the importance of antenatal care, especially in places and communities with high rates of unintended pregnancies. They can also recommend improving access to MCH services, promoting the use of modern contraception to reduce unintended pregnancy, and calling for efforts to desensitize antenatal visits among those with unintended pregnancies, especially among urban women. Ensure all references are relevant to the issues being discussed and cite correctly. The manuscript requires language editing. Specific comments: Unintended pregnancy is untimely, unplanned, unwanted at conception, or pregnancy which occurs earlier than desired - rewrite as :An unintended pregnancy is a pregnancy that is unwanted (occurred when no children or no more children were desired) or mistimed (occurred earlier than desired. As many as 3.26% of unintended pregnancies occurred in women who were never married or had no partners (widows) - rewrite as: Unmarried or widowed women contributed only 3.2% of unintended pregnancy ...reported that pregnancy among teenagers in Indonesia was 5.7% in women who were not married or had no partner -rewrite as:unmarried women contributed only 5.7% of the pregnancy among Indonesian teenagers ....getting married even though their age is not sufficient., rewrite as: getting married before reaching the legal age of marriage ....include medical complications due to unhealthy abortion, rewrite as unsafe abortion. ...shows that unmarried women who experienced an unintended pregnancy were 0.588 times less likely than those who did not experience an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). Thus, this analysis indicates that unmarried women who have an unintended pregnancy in Indonesia are less likely to complete ANC visits.- rewrite as: that unmarried women who experienced an unintended pregnancy were less likely than those who did not experience an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588). Thus, this analysis indicates that unmarried women who have an unintended pregnancy in Indonesia are less likely to complete ANC visits ....Moreover, unmarried women in the 45–49 age group are 35.009 times more likely than unmarried women in the 15–19 age group to have ANC visits ≥ four times (AOR 35.009; 95% CI 34.849-35.170).- comments: I presumed that the sample size for the age group 45-49 and 15-19 is very small, and this affects the reliability of the estimates. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Tey NP. Peer Review Report For: Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.5256/f1000research.140579.r280133) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-1270/v2#referee-response-280133 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2022 Das M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Oct 2022 | for Version 1 Manoja Das , The INCLEN Trust International, New Delhi, Delhi, India 0 Views copyright © 2022 Das M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. 3.2. If there are any findings on the type of delivery care received by them and places of delivery and infant outcomes, it would be useful. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Child health and maternal health, health systems, implementation research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 14 Nov 2022 Ratna Dwi Wulandari, Airlangga University, Surabaya, 60115, Indonesia The authors present the status of ANC in women with unintended pregnancies in Indonesia and the associated risk factors. The manuscript may be improved with attention to some of the following components. 1. Abstract 1.1. Results - The statement "The results show that unmarried women who had an unintended pregnancy were 0.588 times more likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." It is better to say that these women had lower complete ANC contacts (not more likely, as mentioned). Response: The author revised the sentence, "The results show that unmarried women who had an unintended pregnancy were 0.588 times less likely than those who did not have an unintended pregnancy to have ANC visits ≥ four times (AOR 0.588; 95% CI 0.587-0.588)." 1.2. The statement "Apart from unintended pregnancy, the study found seven other independent variables as significant determinants of ANC visit performance: type of residence, age group, marital status, education level, employment status, wealth status, and health insurance ownership." It may be useful to report the specific findings for these variable with significant inference. Any report on the outcome of these unintended pregnancies? Response: The author deletes the statement, and focuses only on the purpose of the study, to analyze the effect of unintended pregnancy on ANC visits among unmarried women in Indonesia. 2. Methods 2.1. Variables - Please clarify if the unintended pregnancy was captured as a specific variable in the IDHS survey or a derived variable. If derived, please indicate how was it derived. Response: The author captured unintended pregnancy as a specific variable in the 2017 IDHS (IDIR71FL dataset: v367) 3. Results 3.1. Please indicate the total sample collected under IDHS 2017, the number of total pregnancies and outcomes, and the number of unintended deliveries. Response: total sample: 49,627; unmarried women: 15,160; unmarried women who births in the last five years: 508; Unintended: 129 View more View less Competing Interests The authors declare that they have no competing interests. reply Respond Report a concern Das M. Peer Review Report For: Antenatal care visits performance among unmarried women in Indonesia: Does unintended pregnancy matter? A cross-sectional study [version 2; peer review: 2 approved with reservations] . F1000Research 2022, 10 :1270 ( https://doi.org/10.5256/f1000research.27237.r148531) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-1270/v1#referee-response-148531 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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