(2024) 24:567
Mekonnen et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-05036-y

BMC Pediatrics

RESEARCH

Open Access

Association between pregnancy intention
and completion of newborn and infant
continuum of care in Sub‑Saharan Africa:
systematic review and meta‑analysis
Birye Dessalegn Mekonnen1,2* , Vidanka Vasilevski1,3 , Ayele Geleto Bali1,3   and Linda Sweet1,3   

Abstract
Background The newborn and infant continuum of care such as essential newborn care, early initiation and exclusive breastfeeding, and immunisation are highly recommended for improving the quality of life and survival of infants.
However, newborn and infant mortality remains high across Sub-Saharan African countries. While unintended
pregnancies are associated with adverse newborn and infant health outcomes, there is inconclusive evidence
on whether pregnancy intention influences newborn and infant continuum of care completion. Therefore, this review
aimed to pool findings reported in the literature on the association between pregnancy intention and newborn
and infant health care across the continuum of care in Sub-Saharan Africa.
Methods We searched MEDLINE Complete, EMBASE, CINAHL Complete, and Global Health databases for studies
potentially eligible for this systematic review and meta-analysis. Two researchers independently screened the identified articles by abstract and title, and then full-text using Covidence. We used the Newcastle–Ottawa Scale to assess
the quality of the included studies. The Cochran’s Q test and ­I2 were executed to detect and quantify the presenceof statistical heterogeneity in the studies. Meta-analysis was done for each outcome when more than one original
study reported relevant data, using Stata statistical software version 18.
Results Eleven studies were included from a total of 235 articles identified by the search. The odds of completing
essential newborn care (pooled odds ratio: 3.04, 95% CI: 1.56, 5.90), early initiation of breastfeeding (pooled odds ratio:
1.30, 95% CI: 1.13, 1.52), exclusive breastfeeding (pooled odds ratio: 2.21, 95% CI: 1.68, 2.89), and being fully immunised (pooled odds ratio: 2.73, 95% CI: 1.16, 6.40) were higher among infants born to women with intended pregnancies as compared to women with unintended pregnancies.
Conclusion Intended pregnancy was positively associated with essential newborn care completion, early initiationand exclusive breastfeeding, and full immunisation of infants in SSA countries. Thus, policy-makers and stakeholders
should strengthen the provision of quality family planning services to prevent unintended pregnancy. Furthermore,
follow-up of women with unintended pregnancies is needed to increase women’s opportunity to access essential
newborn health care services that further reduce the risk of newborn and infant morbidity and mortality.
Systematic review registration PROSPERO registration number CRD42023409148.

*Correspondence:
Birye Dessalegn Mekonnenb.mekonnen@deakin.edu.au
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as longas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article orparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicatedotherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To
view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Mekonnen et al. BMC Pediatrics(2024) 24:567

Page 2 of 14

Keywords Intended pregnancy, Unintended pregnancy, Essential newborn care, Breastfeeding, Immunisation, SubSaharan Africa, Systematic review

Introduction
Improving the quality of life and survival chances of newborns, and children remains an urgent global challenge[1]. Worldwide, considerable progress has been made to
reduce neonatal mortality from 5 million in 1990 to 2.4
million in 2019 [2], and under-five mortality from 12.5
million in 1990 to 5.3 million in 2018 [2]. However, substantial differences in child mortality continue to exist
across regions where Sub-Saharan Africa (SSA) holds
the highest perinatal mortality rates of 34.7 deaths per
1,000 live births [3], infant mortality rate of 53 deaths
per 1,000 live births [4], and under-five mortality rateof 78 deaths per 1,000 live births [2]. In addition, about
41% of children in SSA are highly affected by stunting,which possibly contributes to increasing child morbidity
and mortality [5]. Many of these deaths are preventableor curable using interventions that are simple and costeffective such as adequate nutrition, vaccination, andappropriate newborn and infant care [6, 7] as well as byimproving access to maternal health care services [8].
Parental adherence to children’s preventive and curative health care sets children up for better long-term
health and considerably reduces the risk for child morbidity and mortality [9–11]. Similarly, maternal pregnancy intention has a significant effect on parent–childattachment and bonding, with a potential impact on children’s long-term physical, developmental, and psychological health outcomes [12–14]. Women with unintended
pregnancies face more difficulty in establishing a strong
attachment with their babies, poor childcare practices,and breastfeeding difficulties [12, 15, 16]. Literature has
shown that children born to mothers with unintended
pregnancies had less secure mother-to-child attachment
during infancy, poor preventive and curative care, andpoor behavioural and educational outcomes than womenwith intended pregnancies [12, 16, 17]. In addition, unintended pregnancy was associated with childhood illness,stunting and underweight, and higher risks of infant
and child mortality [16, 18]. Furthermore, adverse birthoutcomes, such as congenital anomalies, preterm birth,and low birthweight were observed among children
born from unintended pregnancies [18, 19]. Conversely,
intended pregnancy was associated with a reduced risk ofstillbirth compared to unintended pregnancies [14].
Mounting evidence has shown that women who experienced unintended pregnancy had lower likelihoods oftimely initiation of breastfeeding, continuing to breastfeed, and exclusive breastfeeding than women withintended pregnancy [20, 21], resulting in poorer physical health of their children [13]. Furthermore, children born from unintended pregnancy were less likely
to receive childhood immunisation [20, 22, 23]. These
effects could be caused by maternal behaviours during
pregnancy, and late initiation, or low use of antenatal care [24–27]. Hence, the prevention of unintended
pregnancy and effective implementation of the maternity continuum of care are highly recommended toenhance the survival of newborns and infants throughpromoting preventive health care practices for children[28, 29]. A recent study has shown that completing thematernity continuum of care, which includes the useof antenatal care, birthing at health facility, and useof postnatal care can considerably improve the use of
essential newborn care practices [30].
The World Health Organization and United Nations
Children’s Fund [2, 31] strongly recommended strategies for the newborn and infant continuum of care,such as exclusive and timely initiation of breastfeeding, improving child nutrition, and child vaccination.
This is anticipated to achieve the Sustainable Development Goal aimed to decrease the high rates of neonatal deaths to 12 per 1000 live births and under-five
deaths to 25 per 1000 live births by 2030 [32, 33].
Though strong emphasis has been given to the newborn and infant continuum of care, in SSA, only 56.5%
of children were fully vaccinated [34], 47% of infants
were breastfed within one hour of birth and 35% ofchildren received exclusive breastfeeding in the firstsix months of life [35]. However, none of these studies
have analysed the association between maternal pregnancy intention and completion of the newborn andinfant continuum of care including essential newborncare practices, exclusive and timely initiation of breastfeeding, and infant immunisation. Moreover, while
unintended pregnancies are associated with adverse
newborn and infant health outcomes, there is inconsistent and inconclusive evidence on whether pregnancy intention influences newborn and infant healthcare across the newborn and infant continuum of care.
Up-to-date evidence with pooled estimates isrequired to understand whether developing interventions targeting preventing unintended pregnancies
with the aim of child survival is required. Therefore,
this study aimed to pool findings reported in literatureon the association between pregnancy intention andessential newborn and infant health care across theMekonnen et al. BMC Pediatrics(2024) 24:567

newborn and infant continuum of care in SSA to contribute reliable evidence that would inform newborn
and infant health policy and practice.

Methods
Registration and reporting

We used the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist[36] to prepare and report this review (SupplementaryFile 1). After checking for a lack of other similar existing
reviews and protocols, this systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with registration number
CRD42023409148.
Information sources and search strategy

The search terms were prepared based on the following concepts: pregnancy intention, essential newborncare practice, early initiation of breastfeeding, exclusive
breastfeeding, full immunisation status, and Sub-SaharanAfrica. The search keywords included free text keywords
and Medical Subject Headings (MeSH) using Boolean
operators, truncation, wildcards, and phrases in various
databases. A comprehensive literature search was done inmajor databases such as MEDLINE Complete (EBSCOhost platform), EMBASE, CINAHL Complete (EBSCOhost platform), and Global Health (EBSCOhost platform)on August 13, 2023. These databases were selected asthey index health and medical-related research. Furthermore, bibliographies of reviews and the identified studies
were reviewed in Google Scholar for potentially relevant
studies. The EBSCOhost MEDLINE was used to develop
the initial search strategy, which was then adapted forother databases. Details of search strategies for eachdatabase are provided in Supplementary File 2. A scholarly expert librarian reviewed the search plans and provided advice to improve the search.
Eligibility criteria
Inclusion criteria

We included observational studies that reported essential
newborn care practice, or early initiation of breastfeeding, or exclusive breastfeeding, or child immunisation
status as an outcome variable and pregnancy intention
as an exposure variable. Furthermore, we included peerreviewed studies published in the English language andconducted in SSA countries. Moreover, studies thatreported the odds ratios (OR) with a 95% confidence
interval (CI) or have raw data that allowed us to calculate the odds ratios with a 95% confidence interval were
included.

Page 3 of 14

Exclusion criteria

We excluded studies that did not report the associations of pregnancy intention with essential newborn carepractice, or early initiation of breastfeeding, or exclusive
breastfeeding, and full immunisation status. Review articles, qualitative studies, case reports, commentaries, casestudies, conference abstracts, case series, and opinion
pieces were excluded.
Study selection

We used Covidence systematic review software to screen
studies. Two researchers (BDM, VV) independently conducted title and abstract screening after removing duplicates. Similarly, potentially eligible studies for full-text
review were retrieved and then systematically screened
against the eligibility criteria. The third reviewer (AGB)
resolved any conflicts during the screening process. The
results of the search in each database, screening, andselection process are summarised in a PRISMA 2020 flow
diagram (see Fig. 1).
Quality assessment

Two researchers (BDM, AGB) assessed the quality ofeach primary study using the Newcastle–Ottawa Scale(NOS) for assessing the quality of non-randomised studies [37], with no discrepancies observed. The NOS tool
has selection, comparability, and outcome domains andrate articles with a maximum of ten stars. The selection
domain focuses on sample size, representativeness of thetarget population, response rate, and ascertainment ofrisk factors with a maximum of five stars. The comparability domain focuses on controlling the confounding
factors that potentially influence the outcome of the variable with a maximum of two stars. The outcome domain
assesses the outcomes of interest and appropriateness ofthe statistical tests with a maximum of three stars. The
quality of the studies was ranked based on the overall
number of stars. Accordingly, studies with a star numberof 9 or 10, 7 or 8, and 5 or 6 were deemed to be very-good
quality, good quality, and satisfactory quality respectively(Suplementary file 3). Studies with four or less stars weredeemed unsatisfactory quality and were to be excluded
from the review due to poor quality. The NOS tool has
been used in previous similar studies [38–40].
Data extraction

Two researchers (BDM, VV) independently extracted
data in a Microsoft Excel spreadsheet. No discrepancies
occurred during data extraction. All relevant data items
such as author(s), study setting and design, sample size,
study population, data collection methods, response
rate, publication year, odds ratio with a 95% CI for theMekonnen et al. BMC Pediatrics(2024) 24:567

Page 4 of 14

Fig. 1 PRISMA flow diagram of the studies screening process

association of pregnancy intention with each of the four
outcome variables (essential newborn care, early initiation of breastfeeding, exclusive breastfeeding, andfull immunisation status), and the definition of all four
outcome variables were extracted from each included
study. The pregnancy intention of participants was also
extracted for each outcome variable.
Outcome measurement

The association between pregnancy intention and newborn and infant health care across the continuum ofcare was the outcome of interest in this review. For thisresearch, the newborn and infant health continuumof care includes essential newborn care, early initiation of breastfeeding, exclusive breastfeeding, and fullimmunisation status. Essential newborn care is definedin this research as the newborn has received all the recommended elements of the services, including safe cordcare, initiating skin-to-skin contact, eye care, and delayed
baby bathing for at least 24 h after birth [41]. Early initiation of breastfeeding is defined as the provision of
mother’s breast milk to the baby within the first hour ofbirth [42]. Exclusive breastfeeding is defined as an infant
receiving only breast milk from birth until six monthsof age without adding water or any other food except
for mineral supplements, vitamins, or prescribed medicines [42]. Full immunisation is defined as a child who

has received a single dose of Bacillus Calmette–Guérin(BCG) vaccine, four poliomyelitis vaccines, three doses ofpentavalent vaccines (diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenza type B), three dosesof pneumococcal conjugate vaccine (PCV), two dosesof Rota vaccine, and one dose of measles vaccine before
their first birthday [43].
Pregnancy intention has been classified into intended
and unintended [44]. For this study, intended pregnancy was when the woman reported that she planned
or wanted her last pregnancy at the time of conception;otherwise, a pregnancy is considered an unintended
pregnancy. Both unwanted pregnancies (no children aredesired at all) and mistimed pregnancies (wanted at sometime but occurred sooner than desired) were considered
as unintended pregnancies [45].
Data analysis

The adjusted odds ratios (AOR) of the association
between pregnancy intention and each outcome variable were extracted from each primary study as themeasure of effect. For the outcome of early initiationof breastfeeding, the crude odds ratios (COR) andconfidence intervals were calculated from the raw
data. The COR was used for the outcome of early initiation of breastfeeding due to the lack of AOR data in
the included studies. Since COR was calculated from

Mekonnen et al. BMC Pediatrics(2024) 24:567

all included studies for this outcome, this approachensured that we did not mix AOR with COR in thesame analysis. Logit transformations were made forthe individual measure of effect before computing thepooled summary. When two or more studies reported
relevant data, a quantitative meta-analysis was donefor each outcome. Forest plots and tables are used tographically display the summary of effect sizes with
95% CI and other results. The random-effects model
was employed for the outcomes of essential newborncare, early initiation breastfeeding and child immunisation status. The random-effect model was employed
to assume the variations or heterogeneity in the effectestimates across the studies [46, 47]. For the outcomeof exclusive breastfeeding, the fixed effects model wasused as the number of included studies was only two,
which makes it inappropriate to perform the randomeffects model because the precision in estimating variability in studies is limited [46, 48]. The weight of eachstudy in the pooled estimates was calculated using theinverse of the variance. The potential variation between
the primary studies was statistically estimated using
Cochran’s Q test and quantified by ­I2 with significant
heterogeneity to be deemed at p-value < 0.1 or ­I2 > 50%[49, 50]. Since very few studies were included in themeta-analysis of each outcome, publication bias, subgroup analysis, and sensitivity analysis were not conducted [48, 51]. In this analysis, early initiation ofbreastfeeding, while a component of essential newborncare, was analysed separately to better understand how
pregnancy intention specifically influences this practice. The studies used for the early initiation of breastfeeding analysis differed from those included in the
broader essential newborn care analysis, ensuring that
our findings on early initiation are based on a unique
set of data. Furthermore, unwanted and mistimed pregnancies were used interchangeably if the original studies had reported one of the two instead of unintended
pregnancy. Likewise, wanted and planned pregnancy
were used interchangeably if the original studies hadreported one of the two instead of intended pregnancy.
All statistical analyses were executed using Stata statistical software version 18.

Results
The database searches produced a total of 231 records,
with a further 4 articles identified from manual searchesof bibliographies of relevant studies. After a comprehensive screening, eleven studies met the inclusion criteria and retained for the review [52–62]. The steps andPage 5 of 14

outcomes of the study selection process are shown in the
PRISMA flow diagram (see Fig. 1).
Studies characteristics

All the studies included in the review used cross-sectional study designs and were published between 2016
and 2022. A total of 18,781 study participants wereinvolved in the original studies. Many studies (n = 9)
were set in Ethiopia [52–54, 56, 57, 59–62]. Eight studies collected the data via face-to-face surveys developed
from literature reviews [52–54, 57–60, 62], two studies used the demographic and health survey [56, 61],
and the remaining one study used data from multiple
indicator cluster survey [55]. Of the included studies in
the review, eight studies employed multistage random
sampling [52–56, 58, 59, 61], two studies used systematic random sampling [60, 62], and one study used simple random sampling to collect data [57]. Almost all(n = 10) of the studies were of good quality methodological rigour (7 or 8 stars) on the NOS assessment. The
summary of the 11 papers is shown in Table 1.
Association between pregnancy intention and newborn
and infant continuum of careThree studies examined the association between pregnancy intention and essential newborn care practice[52–54]. The results of the meta-analysis showed thatwomen whose pregnancy was intended were about
three times (AOR: 3.04, 95% CI: 1.56, 5.90) more likely
to practice essential newborn care as compared to
women with unintended pregnancy (Fig. 2).
Three studies were included to estimate the association between pregnancy intention and early initiationof breastfeeding [55–57]. Meta-analysis of the threestudies showed that women with intended pregnancy
had 1.31 times (COR: 1.30, 95% CI: 1.13, 1.52) higher
odds of early initiation of breastfeeding than women
who had an unintended pregnancy (Fig. 3).
Two studies reported the association between pregnancy intention and exclusive breastfeeding [58, 59].
Meta-analysis of the two studies showed that womenwith an intended pregnancy had 2.21 times (AOR: 2.21,
95% CI: 1.68, 2.89) higher odds of exclusive breastfeeding
than women who had an unintended pregnancy (Fig. 4).
Three studies reported the association between pregnancy intention and child immunisation status [60–62].
Accordingly, the pooled odds of being fully immunised
was 2.73 times (AOR: 2.73, 95% CI: 1.16, 6.40) higher
in children born from mothers with an intended pregnancy than children born from mothers with an unintended pregnancy (Fig. 5).

Studycountry

Ethiopia

Ethiopia

Ethiopia

Authors, year

Alemu and Eshete,
2020 [53]Chichiabellu et al.
2018 [54]Habte et al. 2022
[52]

Cross-sectional

Cross-sectional

Cross-sectional

Study design

450

Mothers who 818
had infants
under sixmonths of age

Reproductiveage women
who hadgiven birth
at home888

Essential newborn care

Essential newborn care

Essential newborn care

33.1

24

24.1

Sample size NOS score Reported
Outcomeoutcome type prevalence(%)

Mothers who 834
had infants
under sixmonths of age

Studypopulation

77.6

14.9

72.3

22.4

85.1

27.7

Intended (%) Unintended(%)

Pregnancy intention

2.66 (1.56,
4.51)

7.0 (3.73,
11.81)

1.7 (1.2, 2.2)

Associationof outcome
withpregnancy
intention(OR)

Table 1 Characteristics of studies included in the review of the association between pregnancy intention and newborn and infant continuum of care in SSA, 2023

Mother’s age,mother’s
educational
level, wealthindex, family
size, parity, birthpreparedness
and complication readinessplan, modeof delivery, timing of postnatal
visits, knowledge on danger
signs, time
to reach nearby
health facility,
and attending
monthly pregnant women
conference

Receive antenatal care, advice
about essential
newborn care,postnatal carevisits, residence,birth preparedness, knowledge
about newborn
danger signs,
and knowledge
about newborn
care

Maternal
education,
employment,
birth interval,
and antenatal
care

Controlled
confounding
factors

Mekonnen et al. BMC Pediatrics(2024) 24:567
Page 6 of 14

Studycountry

Ghana

Ethiopia

Ethiopia

Cape Verde

Ethiopia

Authors, year

Apanga and Kumbeni, 2021 [55]Gebremeskel et al.
2019 [57]

Gedefaw et al.
2020 [56]Duarte Lopes et al.
2022 [58]Mamo et al. 2020
[59]

Table 1 (continued)

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Study design

Mothers
with infants
aged 6–9
monthsMothersof children aged
under two
years

Mothersof children
under five
years of age

Mothersof children aged
less than 12
monthsMothersof children aged
less than two
years

Study
population

725

1,765

7,115

809

3,466

8

8

8

7

7

Exclusive
breastfeeding

Exclusive
breastfeeding

Early initiationof breastfeeding

Early initiationof breastfeeding

Early initiationof breastfeeding

65.4

32.5

75

61.9

52.3

Sample size NOS score Reported
Outcomeoutcome type prevalence
(%)

61.3

-

74

81

51

38.7

-

26

19

49

Intended (%) Unintended(%)

Pregnancy intention

4.73 (3.22,
6.95)

1.06 (0.73,
1.54)

1.3 (1.15, 1.49)

1.8 (1.25, 2.57)

1.19 (1.04,
1.36)

Associationof outcome
withpregnancy
intention(OR)

Marital status,
residence,
antenatal care,postnatal careattendance,mode of delivery, counsellingon exclusive
breastfeeding,sex of the child

Maternal age,education,
marital status,
family income,residence,parity, prenatalcare, numberof prenatal
visits, maternity
leave, child’sbirth weight,
breastfeedingin the first hour
after delivery

Not adjusted

Not adjusted

Not adjusted

Controlled
confounding
factors

Mekonnen et al. BMC Pediatrics(2024) 24:567
Page 7 of 14

Studycountry

Ethiopia

Ethiopia

Authors, year

Fenta and Fenta,
2021 [61]Gualu and Dilie,
2017 [62]Table 1 (continued)

Cross-sectional

Cross-sectional

Study design

Mothers
with children
aged 12–23
monthsWomenwith children
aged 12–23
monthsStudy
population

298

1,929

8

9

Child’s immunisation status

Child’s immunisation status

91.7

48.6

Sample size NOS score Reported
Outcomeoutcome type prevalence
(%)

78.8

80.1

21.2

19.9

Intended (%) Unintended(%)

Pregnancy intention

2.89 (1.17,
7.17)

1.44 (1.08,
1.91)

Associationof outcome
withpregnancy
intention(OR)

Mother’s occupational status,
child’s sex, placeof delivery,
antenatal care,knowledgeof time of vaccination schedule,
and distancefrom the vaccination site

Maternal education status,
number of antenatal care visits,
place of delivery, presenceof vaccination
card, maternal
occupation, husband education
status, husband
occupational
status, religion,
wealth index,
mother tetanus
injections
received, placeof residence,
communitylevel maternal
education,communitylevel wealthindex, community-level
media exposure,the placeof delivery,
regionControlled
confounding
factors

Mekonnen et al. BMC Pediatrics(2024) 24:567
Page 8 of 14

Studycountry

Mebrate et al. 2022 Ethiopia[60]

Authors, year

Table 1 (continued)

Cross-sectional

Study design

Mothers
with children
aged 12–23
monthsStudy
population

664

8Child’s immunisation status72.6

Sample size NOS score Reported
Outcomeoutcome type prevalence
(%)

93.3

6.7

Intended (%) Unintended(%)

Pregnancy intention

5.9 (2.4, 11.3)

Associationof outcome
withpregnancy
intention(OR)

Mother’sage, educational statusof the mother,
district numberof antenatal carevisits, at least
one postnatal
care by a healthcare worker,
number of children the motherhas, child’s age
in months, attitude to vaccination, knowledgeof vaccination
schedule

Controlled
confounding
factors

Mekonnen et al. BMC Pediatrics(2024) 24:567
Page 9 of 14

Mekonnen et al. BMC Pediatrics(2024) 24:567

Fig. 2 Pooled odds ratio of the association between essential newborn care and pregnancy intention

Fig. 3 Pooled odds ratio of the association between early initiation of breastfeeding and pregnancy intention

Fig. 4 Pooled odds ratio of the association between exclusive breastfeeding and pregnancy intention

Fig. 5 Pooled odds ratio of the association between child immunisation status and pregnancy intention

Page 10 of 14

Mekonnen et al. BMC Pediatrics(2024) 24:567

Discussion
Adjusted effect estimates were used to determine theassociation between pregnancy intention and newborn
and infant continuum of care, including essential newborn care, early initiation and exclusive breastfeeding,and full immunisation. However, the studies did notcontrol for the same mix of confounders. Furthermore,
the association between pregnancy intention and early
initiation of breastfeeding is likely to be affected by several other factors, as the analysis was executed basedon an unadjusted effect measure. The results of the present meta-analyses did however suggest that intended
pregnancy was associated with greater completion of
essential newborn care practices, early initiation andexclusive of breastfeeding, and being fully immunised.
Women with intended pregnancy had higher odds
of essential newborn care practice, early initiation andexclusive breastfeeding and fully immunised infants
than women with unintended pregnancy. This could
be explained by the fact that mothers with intended
pregnancy may have greater psychological preparedness for providing care to their newborn infants [63].
Conversely, women experiencing an unintended pregnancy may not feel equipped to take on a maternalrole, leading to poor mother-to-child attachment andlow engagement with essential newborn practices [13,64]. Previous studies have indicated that negligence,carelessness, aggression, and maltreatment of children
were observed more often in mothers with unintended
pregnancies [65, 66]. Furthermore, these women may
have low health-seeking behaviour for themselves andtheir infants due to stress associated with unintended
pregnancy, and less support from their partners orfamilies [24, 67, 68]. Women who experience an unintended pregnancy may also receive little informationand counselling regarding the benefit of appropriate
newborn and infant feeding practices and care becauseof absent or delayed engagement with the continuum of
perinatal health services [27, 69–72].
This review implies that preventing unplanned pregnancy may have an important role in improving essential
newborn care, early initiation and exclusive breastfeeding, and completion of immunisation of infants in SSA
and possibly other low-resource settings. The prevention of unintended pregnancy could be achieved throughimproving access to quality family planning services [73,74]. Strengthening preconception services and information about the consequences of unintended pregnancy
on newborn and infant health outcomes could improvenewborn and infant health and survival [75]. Furthermore, counselling about maternal-child attachment in
women with an unplanned pregnancy could contributeto better newborn and infant health outcomes [71].

Page 11 of 14

Post-conception responses from partners, family
and community members, and psychological consequences such as depression and anxiety following anunintended pregnancy possibly influence newborn andinfant health care practices among women with unintended pregnancies [68, 76, 77]. Furthermore, womenwith unintended pregnancies may have several socioeconomic and cultural challenges to visiting healthfacilities [78, 79]. Previous studies in low- and middle-income countries reported that multiple visits tohealthcare facilities, which require travel, money, andassistance from others, substantially deter women fromusing antenatal care, skilled birth attendance, and postnatal care following the occurrence of an unintended
pregnancy [80–82]. Hence, encouraging perinatal service use and preventive and curative care of infants
resulting from unintended pregnancies may requirepolicies and practices that support identification of
women with unintended pregnancies. Behaviouralchange approaches regarding unintended pregnancy
also need to be considered at individual, family, andcommunity levels [83–85]. This may reduce the humiliation of women from unsolicited post-conception
responses from partner, family and community members following unintended pregnancies [86, 87].
This systematic review has the following limitations.
In all the included studies, pregnancy intention was
examined with other multiple determinants of newborn
and infant continuum of care in cross-sectional studies for each outcome; it is thus not possible to establish causal effect relationships with certainty. Although
there was significant heterogeneity among the included
studies, addressing the sources of heterogeneity was
not undertaken due to the limited number of studies included for each outcome. In addition, sensitivity
analysis, publication bias and subgroup analyses were
not conducted because of the limited number of studies
included in each sub-topic. Furthermore, some studies were excluded due inconsistent categorisation of
the exposure variable. Moreover, studies published ina language other than English and non-peer-reviewed
articles may have been missed as only peer-reviewed
articles published in English were included. While grey
literature may exist on this topic, we included only
peer-reviewed studies to ensure a robust approach andconsistency across studies. Finally, the generalizability of this review may be limited because the included
studies were not representative of all regions of SSA,
with the majority of studies coming from Ethiopia.
Nevertheless, this review used adjusted effect measures to quantitatively estimate the association between
pregnancy intention on newborn and infant healthacross the continuum of care in SSA.

Mekonnen et al. BMC Pediatrics(2024) 24:567

Conclusions
This review pinpointed that there were statistically significant positive associations between intended pregnancy and increased completion of essential newborncare practices, early initiation and exclusive breastfeeding and full immunisation of infants in SSA. Thereis a need for collaboration among stakeholders, policy-makers and health care providers to strengthen
the provision of quality family planning services andenhancing preconception care services to prevent
unintended pregnancy. Furthermore, strategies that
help identify women with unintended pregnancies areneeded to increase women’s access to essential maternal and neonatal/infant healthcare services that further
reduce the risk of newborn and infant deaths. Moreover, further research with better design is needed toclearly understand the relationship between pregnancy
intention and completion of newborn and infant healthpractices across the continuum of care.
Abbreviations
CINAHL	Cumulative Index to Nursing and Allied Health Literature
NOS	Newcastle-Ottawa scale
PROSPERO	International Prospective Register of Systematic Reviews
PRISMA	Preferred Reporting Items for Systematic Reviews and Meta-Analyses
SSA	Sub-Saharan African countries

Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12887-​024-​05036-y.
Supplementary Material 1.
Supplementary Material 2.
Supplementary Material 3.
Acknowledgements
The authors would like to thank Olivia Larobina (Scholarly Services Librarianat Deakin University) for her assistance in developing the systematic searchstrategy. We also would like to acknowledge Deakin University for providing
PhD scholarship for the principal investigator of this research.
Author’s contributions
All authors developed the conception of the review and study design. BDM
conducted the literature review, study screening, data extraction, quality
assessment, data analysis, interpretation of results, and drafting of the manuscript. VV, AGB and LS contributed to study screening, quality assessment,
data extraction, assist data analysis, and critically reviewed the manuscript. All
authors read and approved the final manuscript.
Funding
The first author is supported by Deakin University with a PhD researchscholarship.
Availability of data and materials
All relevant data is included either in the manuscript or as supplementary files.
Data availability
No datasets were generated or analysed during the current study.

Page 12 of 14

Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
School of Nursing and Midwifery, Centre for Quality and Patient Safety
Research in the Institute for Health Transformation, Deakin University Geelong,
Victoria, Australia. 2 Amhara Public Health Institute, Bahir Dar, Ethiopia. 3 Western Health Partnership, Victoria, Australia.
Received: 18 December 2023 Accepted: 27 August 2024

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