Examining intendedness among pregnancies ending in spontaneous abortion

Sociodemographic and reproductive characteristics of pregnant women with unplanned pregnancy residing in the state of São Paulo, Brazil: a cross-sectional study

OBJECTIVE

The aim of our study was to assess the associated factors of planned and unplanned pregnancies (UPs) among pregnant women in São Paulo, Brazil.

METHODS

We conducted a cross-sectional study from March 2023 to June 2024 and invited pregnant women aged 18 to 49 years. We used the Brazilian-validated version of the London Measure of Unplanned Pregnancy to assess pregnancy intentions. We estimated absolute and relative frequencies of planned and UPs by sociodemographic and reproductive characteristics. Bivariate and multiple regression analysis were performed to evaluate the associated factors for UPs.

RESULTS

We included 534 participants; 65.7% reported an UP. Black or Biracial vs White women (74% vs. 57%, p < 0.001), with 0 to 9 years vs. those with >9 of schooling (77% vs. 51%, p < 0.001), and single vs married women (85% vs. 48%, p < 0.001) were associated with UPs. Parous women or those reporting a younger age at their sexual debut were more commonly reported UPs. The associated factors to UPs were being Black or Biracial (Odds ratio [OR] 1.68, 95% Confidence Interval [CI] 1.11;2.57), reporting fewer schooling years (OR 1.61, 95% CI 1.01;2.54), not being married [(OR 2.41, 95% CI 1.53;3.84) for cohabiters and OR 5.23, 95% CI 2.93;9.74) for single] and reporting additional births (OR 1.28, 95% CI 1.07;1.56).

CONCLUSION

Black or Biracial, with fewer years of schooling, not married, and parous women were at a higher risk of UPs. These women tend to face structural barriers to planning the size and timing of their families, requiring actions like increasing tertiary education access and guaranteeing universal modern contraceptive availability to leverage these disadvantages and fulfil their sexual and reproductive rights.

Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis

BACKGROUND

Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants.

OBJECTIVE

This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery.

STUDY DESIGN

A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies.

RESULTS

Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy.

CONCLUSION

The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

Effect of a family planning program on documented emotional support and reproductive goals counseling after previable pregnancy loss

OBJECTIVES

To evaluate the effect of the Ryan Program for family planning training on patient counseling surrounding previable pregnancy loss.

METHODS

We conducted a retrospective cohort study of patients with first- and second-trimester miscarriages, therapeutic abortions, ectopic and molar pregnancies, from years before and after establishing a Ryan Program. We compared documentation of coping and future reproductive goals by patient factors, using chi square testing and logistic regression.

RESULTS

We included 285 pregnancies: 138 pre-Ryan, 147 post-Ryan. Documentation of coping and future goals was greater post-Ryan than pre-Ryan (57.8% vs. 26.8% for coping, 72.8% vs. 50.7% for goals; both p < 0.001). Coping was less likely to be documented for adolescents (aOR 0.02), patients of Asian race (aOR 0.08), those diagnosed in the emergency department (aOR 0.22), and those with ectopic or molar pregnancy (aOR 0.14) (all p < 0.005). Coping documentation increased with second-trimester loss (aOR 6.19) and outpatient follow-up (aOR 3.41) (all p < 0.005).

CONCLUSIONS

Establishment of a Ryan Program was associated with greater attention to patient coping and goals after previable pregnancy loss. Patients experiencing medically-dangerous pregnancy losses receive less attention to their coping.

PRACTICE IMPLICATIONS

Comprehensive family planning training and outpatient access may improve patient-centeredness of care for previable pregnancy loss.

A Scoping Review of Unintended Pregnancy in Active Duty United States Military Women

INTRODUCTION

The purpose of this scoping review was to apply the Social Ecological Model for Military Women's Health to literature on unintended pregnancy (UIP) to answer the question: In United States active duty military women (population) with the potential for UIP (context), what is known about risk factors, prevention, and pregnancy outcomes (concepts)?

METHODS

We conducted this review based on a PRISMA-ScR protocol registered a priori in Open Science Framework. Following a literature search of six databases and the grey literature, we used DistillerSR to manage data screening and data charting. The Social Ecological Model for Military Women's Health served as the theoretical framework to chart findings regarding UIP at the individual, microsystem, mesosystem, exosystem, and macrosystem levels.

RESULTS

A total of 74 research, review, and grey literature articles met the inclusion criteria. Risk factors included specific demographics, military service, and recent deployment. Prevention included contraceptive practices, access, and education that should take place early in servicewomen's careers and before deployment. Outcomes included early return from deployment, personal career challenges, and seeking alternative health services outside the military health system.

CONCLUSIONS

Research and policy initiatives should focus on decreasing risk factors in the military working environment, with particular attention to the deployed environment. These initiatives should include input from military leaders, health care providers, servicewomen, and servicemen with the goal of decreasing the incidence of unintended pregnancies. Pregnancy intentionality among military women should be considered as a concept to shape intervention research to reduce unintended pregnancies.

Access to Postabortion Contraception: ACOG Committee Opinion, Number 833

ABSTRACT

All contraceptive methods are safe and effective when provided immediately after abortion procedures and when otherwise medically appropriate for a patient. Providing a contraceptive method immediately after an induced or spontaneous abortion can help individuals achieve their desired reproductive outcomes and minimize the burden of multiple appointments. Contraceptive counseling and methods should be made available to all patients who experience induced or spontaneous abortion, and the patient's right to decline or postpone this care should be respected. Recognizing the individual barriers that may exist for each patient is important to providing patient-centered care. It also is important to understand the history of reproductive rights abuses, including contraceptive coercion and forced sterilization, in the United States. Ultimately, clinicians should focus on providing access to counseling and, ideally, providing all methods of contraception, while recognizing that each patient is unique.

Prematurity and breastfeeding initiation: A sibling analysis

AIM

Studies suggest breastfeeding initiation is less common for premature infants. This association may be confounded by socio-economic characteristics that correlate with the risk of premature birth. We compared premature and term-born children to determine whether prematurity independently predicted likelihood of breastfeeding continuation and duration.

METHODS

Data were obtained from women ages 15-44 years reporting at least two live pregnancies on the 2011-2017 National Survey of Family Growth. Participants completed a pregnancy and breastfeeding history. Breastfeeding initiation was defined as breastfeeding for at least 1 week, and duration of exclusive breastfeeding was recorded in months. Sibling fixed effects regression models were used to evaluate the impact of prematurity.

RESULTS

Among families with some children who were breastfed and others who were not (n = 2848 children), preterm birth was not associated with breastfeeding initiation (odds ratio = 1.11; P = .468). Among children who were ever breastfed, exclusive breastfeeding lasted 5% fewer months among children born preterm, compared with term-born siblings (incidence rate ratio = 0.95; P = .060).

CONCLUSION

Using sibling-group analysis to control for confounding, we found no independent association between prematurity and likelihood of breastfeeding initiation. This suggests interventions supporting breastfeeding for premature infants may need to address external barriers to breastfeeding not specifically preterm birth.

Pregnancy intentions and contraceptive uptake after miscarriage

OBJECTIVE

To identify factors associated with contraceptive uptake among participants in a miscarriage management clinical trial.

STUDY DESIGN

We performed a secondary analysis of a multi-center, randomized controlled trial of medical management regimens for miscarriage between 5 and 12 completed weeks. Pregnancy intention was measured by patient report after miscarriage diagnosis. Participants were offered contraception in accordance with standard clinical care once their miscarriage was completed. We analyzed participants as a cohort and fit a multivariable model to describe demographic characteristics and pregnancy intentions independently associated with contraceptive uptake.

RESULTS

Of 244 participants with available contraceptive outcomes, 121 (50%) stated that this pregnancy was planned, and 218 (90%) stated that they had planned to continue the pregnancy to term. Ninety-seven participants (40%) initiated contraception: 33 (14%) selected a long-acting reversible method, 44 (18%) a short-acting reversible method, and 20 (8%) condoms or emergency contraception, while 147 (60%) declined contraception after miscarriage completion. In the multivariable model, unplanned pregnancy (aRR 2.13, 95% CI: 1.45-3.13) and lack of intention to continue the pregnancy (aRR 1.61, 95% CI: 1.18-2.20) were independently associated with contraceptive uptake. Of participants who declined contraception, 85 (57%) did so in order to conceive again. Nearly one-quarter of participants who declined contraception described the index pregnancy as unplanned, but after miscarriage planned to conceive a new pregnancy.

CONCLUSION

Patients with unplanned pregnancy who miscarried were twice as likely to initiate contraception as those with planned pregnancy, however pregnancy intentions sometimes changed after miscarriage.

IMPLICATIONS

Miscarriage management represents an important opportunity to clarify pregnancy goals and provide contraceptive counseling. Although unplanned pregnancy correlates with contraceptive uptake, we do not recommend using this clinically to predict contraceptive need. Future research should examine how best to measure pregnancy intention and its relationship to the experience of miscarriage.

Asthma and/or hay fever as predictors of fertility/impaired fecundity in U.S. women: National Survey of Family Growth

This study addresses whether asthma and/or hay fever predict fertility and impaired fecundity. The lifetime number of pregnancies (fertility) and spontaneous pregnancy losses (impaired fecundity) in 10,847 women representative of the U.S. population 15 to 44 years of age with histories of diagnosed asthma and/or hay fever are analyzed in the 1995 National Survey of Family Growth using multivariable Poisson regression with multiple covariates and adjustments for complex sampling. Smokers have significantly increased fertility compared to nonsmokers. Smokers with asthma only have significantly increased fertility compared to other smokers. Higher fertility is associated with impaired fecundity (ectopic pregnancy, miscarriage, stillbirth). Women with asthma (with and without hay fever) have significantly higher pregnancy losses than women without asthma. With increasing number of pregnancies, smokers have increased pregnancy losses compared to nonsmokers. Smokers, especially those with asthma only, have increased fertility and require special attention as to their family planning needs, reproductive health, and smoking cessation. Women with asthma, regardless of number of pregnancies, and smokers with higher numbers of pregnancies have high risk pregnancies that require optimal asthma/medical management prenatally and throughout pregnancy. Whether a proinflammatory asthma endotype underlies both the increased fertility and impaired fecundity associated with age and smoking is discussed.

Breast-feeding During Pregnancy and the Risk of Miscarriage

CONTEXT

Breast-feeding rates and durations have been increasing among U.S. women in recent decades. As a result, women may be more likely to practice breast-feeding during pregnancy (BDP), which has been hypothesized to increase the risk of miscarriage, yet there has been little research into the issue.

METHODS

Data on 10,661 pregnancies from several waves of the National Survey of Family Growth, covering the years 2002-2015, were used to calculate unadjusted miscarriage rates according to BDP status. Multivariate Cox proportional hazards models were employed to investigate the association between BDP and the risk of miscarriage.

RESULTS

BDP was practiced for 6% of the total time at risk of miscarriage. The miscarriage rate was higher when mothers exclusively breast-fed during pregnancy (35%) than when they practiced either complementary BDP (i.e., the child also consumed other food) or did not breast-feed (14% and 15%, respectively). After adjustment for maternal and pregnancy characteristics, the risk of miscarriage was greater when mothers exclusively breast-fed than when mothers did not breast-feed (hazard ratio, 3.9), but no increased risk was found with complementary BDP. The miscarriage risk during exclusive BDP was similar to that for women who conceived when they were 40 or older (3.2).

CONCLUSIONS

Exclusive BDP is associated with an elevated risk of miscarriage, but it remains unclear whether and how the practice is associated with health outcomes for the mother and breast-fed child. Research is needed to further explore these outcomes to inform recommendations regarding BDP.

Family Planning and Counseling Desires of Women Who Have Experienced Miscarriage

OBJECTIVE

To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling preferences of women experiencing spontaneous abortion.

METHODS

We conducted semistructured qualitative interviews with women who recently experienced spontaneous abortion to explore their feelings about conception, pregnancy, and miscarriage; their future family planning goals; and contraceptive counseling preferences. Two trained coders utilized an inductive, iterative approach to code transcripts and identify themes using Atlas.ti software to organize the analysis.

RESULTS

We interviewed 26 women reporting varied intentions in their recent pregnancies: 54% were trying to conceive, 27% were not trying but not preventing, and 19% were attempting to avoid pregnancy. Participants reported a range of feelings about the pregnancy diagnoses and eventual miscarriages with some relatively unemotional ("a little disappointed…suffering for two months for nothing") and others feeling devastated by their pregnancy losses ("in shock," "for it to be taken away was crushing"). Varying character and intensity of emotional reactions were seen across the range of initial pregnancy intentions. Some participants had consistent childbearing plans before and after miscarriage, whereas others experienced their pregnancies and losses as clarifying events leading to changed goals moving forward ("it was a wake-up call"). Although family planning needs were inconsistently addressed after spontaneous abortion, women were generally receptive to the idea of contraceptive counseling, though they had different preferences regarding timing, ranging from immediately to weeks later.

CONCLUSION

Women's reproductive goals after spontaneous abortion cannot be inferred based on initial pregnancy intention or emotional reactions to pregnancy loss. Health care providers should offer family planning counseling to all women after spontaneous abortion, remaining responsive to individual patient needs.

Association of Pharmacist Prescription of Hormonal Contraception With Unintended Pregnancies and Medicaid Costs

OBJECTIVE

To estimate unintended pregnancies averted and the cost effectiveness of pharmacist prescription of hormonal contraception.

METHODS

A decision-analytic model was developed to determine the cost effectiveness of expanding the scope of pharmacists to prescribe hormonal contraception compared with the standard of care and contraceptive access in clinics. Our perspective was that of the payor, Oregon Medicaid. Our primary outcome was unintended pregnancies averted. Secondary outcomes included: costs and quality-adjusted life years (QALYs). Model inputs were obtained from an analysis of Medicaid claims for the first 24 months after policy implementation in Oregon, and the literature. Univariate and bivariate sensitivity analyses, as well as a Monte Carlo simulation, were performed.

RESULTS

Among Oregon's Medicaid population at risk for unintended pregnancy, the policy expanding the scope of pharmacists to prescribe hormonal contraception averted an estimated 51 unintended pregnancies and saved $1.6 million dollars. Quality of life was also improved, with 158 QALYs gained per 198,000 women. Sensitivity analysis demonstrated that the model was most sensitive to the effect on contraceptive continuation rates. If contraceptive continuation rates among women receiving care from a pharmacist are 10% less than among clinicians, than pharmacist prescription of hormonal contraception will not avert unintended pregnancies.

CONCLUSION

Pharmacist prescription of hormonal contraception averts unintended pregnancies and is cost effective. Full implementation of the policy is needed for maximum benefits. Prospective data on the effect of the policy on contraceptive continuation rates are needed.

Women's experiences of miscarriage related to diagnosis, duration, and type of treatment

INTRODUCTION

Women with miscarriage experience several negative emotional feelings such as grief, isolation, coping, and despair. However, less is known about how the type of treatment and diagnosis of miscarriage influence the emotional experience.

MATERIAL AND METHODS

The present study was a randomized prospective longitudinal cohort study, in which women with spontaneous miscarriage (n = 35), and women with missed miscarriage (n = 67), were included to answer three validated questionnaires: Revised Impact of Miscarriage Scale, Perinatal Grief Scale, and Montgomery and Åsberg Depression Rating Scale, concerning experience of miscarriage, psychological well-being, and mental health 1 week and 4 months after finalized treatment.

RESULTS

There was no difference between the 2 diagnosis groups in feelings as measured by Revised Impact of Miscarriage Scale, Montgomery and Åsberg Depression Rating Scale, and Perinatal Grief Scale 1 week after the miscarriage. However, the psychological well-being improved significantly 4 months after the miscarriage. Separated by treatment, women treated with misoprostol alone had more depressive symptoms than women treated with misoprostol and subsequent vacuum aspiration.

CONCLUSIONS

It can be concluded that diagnosis of miscarriage had limited influence on the experiences of miscarriage, but shorter duration of treatment with misoprostol and subsequent vacuum aspiration resulted in fewer depressive symptoms.