A local study conducted by SingHealth Polyclinics (SHP) shows that unplanned pregnancy is on the rise, with more than 10 per cent of the women having records of repeated referrals for abortion. Unplanned pregnancies greatly impose on the physical, mental, and emotional well-being of women, their families and the community. In addition, abortion is not absolutely safe, and is associated with certain morbidity and mortality risk, which is preventable. The results revealed the magnitude of the problem and the potential burden towards women’s health, and the healthcare system in managing unplanned pregnancies, with possible unmet family planning and gaps between women’s intention to reproduce and their contraceptive behaviour. 

The study, entitled ‘Surveillance of Abortion and Family planning in primary carE’, also known as the SAFE study, aimed to identify the profile of women that visited polyclinics for a referral on their unplanned pregnancy, and if there was an increasing trend.

More than 9,700 women’s data aged 15 to 54 years old who visited 8 polyclinics under SingHealth located in Bedok, Bukit Merah, Outram, Marine Parade, Pasir Ris, Punggol, Sengkang and Tampines between July 2017 and June 2020, were collated. Data such as their age, nationality, marital status, ethnicity, contraceptive use, Community Health Assist Scheme (CHAS) status, any concurrent medical conditions and any previous history of abortions were analysed. 

The study revealed that 1 in 10 pregnant women sought gynaecologist referrals to manage their unplanned pregnancy, of which more than 10 per cent had records of repeated referrals for abortions. Women seeking referrals are more likely single, aged below 20 or above 40 years of age, CHAS cardholders, and of Indian ethnicity.

Majority of the referred women in the study did not have any medical records of taking contraception, such as oral contraceptive pills (OCP) and progesterone injections or intrauterine contraceptive devices (IUCDs), which is the key to reducing unplanned pregnancies. However, they may have obtained them from other private healthcare providers such as General Practitioners. Their spouse or partners could have also used barrier methods, such as condoms as a form of contraception, which would not be documented in their electronic medical records.

A local 2018 survey reported poor knowledge about contraceptives among local youths.1 About 60 per cent of those aged 18 years and below who engaged in sexual activity did not take any precautions to avoid pregnancy or sexually transmitted diseases. They tend to seek sexual health information from friends and partners, and parents were ranked as the least popular portal of communication due to skepticism of their openness to this topic discussion. More initiatives may need to be implemented to coach parents to educate and initiate conversations on sexual matters at home. For older women with unplanned pregnancy, they may misperceive declined fertility after the age of 40 years, and hence stop using contraceptive.

Overall, there was an annual increase in the referrals over the 3-year period in 2017 to 2020, from 26, 28.9 and 47.6 per cent among the Chinese, Malay and Indian groups from 2017 to 2018 respectively, followed by 33.3, 4.3 and 48.4 per cent in year 2019 to 2020. Indian women showed significantly higher odds of unplanned pregnancy referrals compared with Chinese and Malays.

Foreign women of various ethnicities comprised 15.7 per cent of women referred for unplanned pregnancy, with a significant increased number of almost two-fold, from year 2017 to 2019.

“That sharp increase in foreigners referred for unplanned pregnancy is a growing concern. Every year, about 100 foreign domestic workers are sent home because they are discovered to be pregnant, which breaches the legislation2. This number could be under-reported, as an unknown fraction of them may have proceed with the abortion quietly. The rise may be due to issues, such as language barriers, poor awareness and knowledge of health, and lack of healthcare accessibility,” said Ms Stephanie Quak, Medical Student, Duke-NUS Medical School. Ms Quak is also the main author of this research paper.

“In Singapore, data from 2015-2019 showed that 39 per cent of pregnancies were unplanned. Of all unplanned pregnancies, 1 in 4 ended in abortion. Unplanned pregnancies are common, whether it is through having unprotected sex, a failure of contraception, or improper use of contraception. An unplanned pregnancy can raise confusing feelings and thoughts, whether a woman chooses to continue with the pregnancy or terminate it through an abortion,” Ms Quak shared. 

“Contraception and family planning are the cornerstones to preventing unplanned pregnancy. However, despite the array of contraceptives available, unplanned pregnancy continues to occur, accounting to abortions. Studies have shown that more than 120 million women globally do not use any form of contraception, even though they reported that they are sexually active and do not wish to become pregnant3. This reflects the urgency to address modifiable factors to underpin unplanned pregnancy,” added Ms Quak.

“Primary care professionals (PCPs) are usually the front-liners to provide family planning services in the local communities. They are also often the healthcare providers to receive women’s requests for gynecologist referrals to manage unplanned pregnancy. Hence, there will be ample opportunities in the primary care setting to mitigate this problem,” said Clinical Associate Professor Tan Ngiap Chuan, Director of Research, SHP and Vice-chair, Research, SingHealth-Duke NUS Family Medicine Academic Clinical Programme (FM ACP).

“Leveraging on the results of the study, there are plans to conduct interviews with individual women with unplanned pregnancies to gain fresh insight into their struggles and perception of the issue. This will help us develop and design person-centric measures and primary care services to potentially reduce unplanned pregnancy in the community, mitigate the gaps in family planning, and improve women’s health. A study is currently in progress to assess the experience of post-natal mothers. Their views on post-partum contraception will be covered when these mothers are interviewed,” added A/Prof Tan.

1 Association of Women for Action and Research (AWARE), Singapore. (2021). Many Young People Unsure of Contraceptive Use, and Feel They Can’t Talk to Parents About Sexual Health. Available online at: https://www.aware.org.sg/2018/11/many-young-people-unsure-of-contraceptive-use-and-feel-they-canttalk-to-parents-about-sexual-health/ (accessed July 4, 2022).
2 The Straits Times. (2010). Available online at: https://eresources.nlb.gov.sg/newspapers/digitised/issue/straitstimes20100929-1 (accessed July 4, 2022).
3 Strauss III JF, Nass SJ. New Frontiers in Contraceptive Research: A Blueprint for Action.Washington: National Academies Press (2004). doi: 10.17226/10905