Pregnancy Intention and Its Relationship to Birth and Maternal Outcomes

Depression, Contraception, and Ambivalence Concerning Fertility

Individuals suffering from depression exhibit a higher rate of unintended pregnancies, which are associated with negative outcomes for both parents and children. Often, unintended pregnancies result from contraceptive mistakes. Here, we examine the relationship between depression and the consistency of contraceptive behavior, testing ambivalence as a possible mediator. The analyses were based on cross-sectional data from the second and third waves of the German Relationship and Family Panel Pairfam. A German-speaking sample without children (N = 190; 117 female, 73 male), who reported not attempting to conceive or become pregnant during the last 12 months, was analyzed in comparison with a propensity score matched sample. Ambivalence was operationalized as the difference between the ideal and realistic number of children in wave 2. Data from wave 3 were used to assess contraceptive behavior. Depressed mood in wave 2 and consistency of contraceptive behavior in wave 3 were negatively correlated. After including ambivalence in wave 2 as a mediator in the model, the direct path between depressed mood and consistency of contraceptive behavior remained significant, with no significant mediation found. For men only, we observed a significant negative association of ambivalence with the consistency of contraceptive behavior in the last 3 months. No significant relationship was found between depressed mood and ambivalence. We conclude that future research aiming to better understand the consistency of contraceptive behavior should incorporate measures of ambivalence.

The Association Between Unintended Pregnancy and Perinatal Outcomes in Low-Risk Pregnancies: A Retrospective Registry Study in the Netherlands

INTRODUCTION

People with unintended pregnancies might be at increased risk of adverse perinatal outcomes due to structural factors, distress, or delayed prenatal care. Existing studies addressing this association yielded inconsistent findings. Using contemporary data from a large Dutch midwifery care registry, we investigated the association between unintended pregnancy ending in birth and neonatal outcomes, parental morbidity, and obstetric interventions. We extend previous research by exploring whether delayed initiation of prenatal care mediates these associations.

METHOD

This study used data (N = 9803) from a Dutch nationally representative registry of people with low-risk pregnancies receiving primary midwife-led care in the Netherlands between 2012 and 2020. Using logistic (mediation) regression analyses adjusted for potential confounders we investigated associations between unintended pregnancy and neonatal outcomes (low Apgar score, small for gestational age, and prematurity), parental morbidity (hypertension and gestational diabetes mellitus), and obstetric interventions (induction of labor, pain medication, assisted vaginal birth, and cesarean birth) and whether delayed initiation of prenatal care mediated these associations.

RESULTS

Unintended pregnancies were associated with increased odds of low Apgar scores (odds ratio [OR], 1.68; 95% CI, 1.09 -2.59), preterm birth (OR, 1.27; 95% CI, 1.02-1.58), small for gestational age (OR, 1.19; 95% CI, 1.00-1.41), and induction of labor (OR, 1.14; 95% CI, 1.01-1.28). Conversely, unintended pregnancy was associated with a decreased odds of cesarean birth (OR, 0.83; 95% CI, 0.71-0.97). The timing of prenatal care initiation did not mediate any of these associations.

DISCUSSION

Our findings suggest that people in primary midwifery-led care with unintended pregnancies ending in birth are at increased risk for adverse perinatal health outcomes and that structural factors might underlie this link. Health care professionals and policy makers should attend to their own biases and offer nonjudgmental, tailored preventive preconception care and antenatal care strategies for people with higher vulnerabilities.

Psychosocial Stressors and Postpartum Depressive Symptoms Are Linked to Postpartum Contraceptive Use

Background: Postpartum contraception plays a critical role in reducing the occurrence of rapid subsequent pregnancy, offering individuals reproductive choice, and promoting overall reproductive planning and well-being. In this study, we investigated the relationship between psychosocial stress during pregnancy, postpartum depressive symptoms (PDS), and postpartum contraceptive use. Materials and Methods: We analyzed data from the Pregnancy Risk Assessment Monitoring System (2012-2019), which included comprehensive information about maternal experiences, views, and needs before, during, and after pregnancy from four states and a large city, with a total sample size of N = 36,356. We conducted descriptive analyses as well as adjusted multivariable logistic regression models. Main Findings: Our findings demonstrate significant negative associations between partner-related (adjusted odds ratio [aOR] = 0.82, 95% confidence interval [95% CI]: 0.76-0.89, p ≤ 0.001) and trauma-related (aOR = 0.83, 95% CI: 0.75-0.92, p ≤ 0.001) stressors and postpartum contraceptive use. Additionally, we observed a negative association between PDS and postpartum contraceptive use (OR = 0.88, 95% CI: 0.80-0.97, p ≤ 0.01), indicating that individuals experiencing PDS are less likely to utilize contraception after giving birth. Furthermore, our study highlights racial/ethnic, socioeconomic, and parity postpartum contraceptive use disparities. Conclusions: Our findings emphasize the importance of incorporating psychosocial stressors and mental health into the promotion of effective postpartum contraception practices. These results have valuable implications for health care providers, policymakers, and researchers as they can guide the development of targeted interventions and support systems to contribute to improved reproductive health outcomes.

Pregnancy planning and neonatal outcome - a retrospective cohort study

BACKGROUND

Unplanned pregnancy is common, and although some research indicates adverse outcomes for the neonate, such as death, low birth weight, and preterm birth, results are inconsistent. The purpose of the present study was to investigate associated neonatal outcomes of an unplanned pregnancy in a Swedish setting.

METHODS

We conducted a retrospective cohort study in which data from 2953 women were retrieved from the Swedish Pregnancy Planning Study, covering ten Swedish counties from September 2012 through July 2013. Pregnancy intention was measured using the London Measurement of Unplanned Pregnancy. Women with unplanned pregnancies and pregnancies of ambivalent intention were combined and referred to as unplanned. Data on neonatal outcomes: small for gestational age, low birth weight, preterm birth, Apgar score < 7 at 5 min, and severe adverse neonatal outcome defined as death or need for resuscitation at birth, were retrieved from the Swedish Medical Birth Register.

RESULTS

The prevalence of unplanned pregnancies was 30.4%. Compared with women who had planned pregnancies, those with unplanned pregnancies were more likely to give birth to neonates small for gestational age: 3.6% vs. 1.7% (aOR 2.1, 95% CI 1.2-3.7). There were no significant differences in preterm birth, Apgar score < 7 at 5 min, or severe adverse neonatal outcome.

CONCLUSIONS

In a Swedish setting, an unplanned pregnancy might increase the risk for birth of an infant small for gestational age.

Sexual and Reproductive Health Among Cisgender Women With HIV Aged 18-44 Years

INTRODUCTION

The sexual and reproductive health of cisgender women with HIV is essential for overall health and well-being. Nationally representative estimates of sexual and reproductive health outcomes among women with HIV were assessed in this study.

METHODS

Data from the Centers for Disease Control and Prevention's Medical Monitoring Project-including data on sexual and reproductive health-were collected during June 2018-May 2021 through interviews and medical record abstraction among women with HIV and analyzed in 2023. Among women with HIV aged 18-44 years (n=855), weighted percentages were reported, and absolute differences were assessed between groups, highlighting differences ≥|5%| with CIs that did not cross the null.

RESULTS

Overall, 86.4% of women with HIV reported receiving a cervical Pap smear in the past 3 years; 38.5% of sexually active women with HIV had documented gonorrhea, chlamydia, and syphilis testing in the past year; 88.9% of women with HIV who had vaginal sex used ≥1 form of contraception in the past year; and 53.4% had ≥1 pregnancy since their HIV diagnosis-of whom 81.5% had ≥1 unintended pregnancy, 24.6% had ≥1 miscarriage or stillbirth, and 9.8% had ≥1 induced abortion. Some sexual and reproductive health outcomes were worse among women with certain social determinants of health, including women with HIV living in households <100% of the federal poverty level compared with women with HIV in households ≥139% of the federal poverty level.

CONCLUSIONS

Many women with HIV did not receive important sexual and reproductive health services, and many experienced unintended pregnancies, miscarriages/stillbirths, or induced abortions. Disparities in some sexual and reproductive health outcomes were observed by certain social determinants of health. Improving sexual and reproductive health outcomes and reducing disparities among women with HIV could be addressed through a multipronged approach that includes expansion of safety net programs that provide sexual and reproductive health service coverage.

Associations of unintended pregnancy with autism spectrum disorders and the modification of folic acid supplements

There is limited evidence on the associations of unintended pregnancy with autism spectrum disorders (ASD). This study aimed to examine this relationship and the modification of pre-conceptional and prenatal folic acid supplements. Six thousand and five toddlers aged 16 to 30 months from seven cities of six provinces in China were eligible for participation. Information on unintended pregnancy and folic acid supplements was obtained via questionnaires from caregivers of toddlers. The diagnosis of ASD was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the Chinese version of the Childhood Autism Rating Scale (CARS). Of the 6005 toddlers in the study (3337 boys and 2668 girls), 71 (1.18%) received the diagnosis of ASD. Generalized linear models with a logit link function showed unintended pregnancy was positively associated with ASD (odds ratios [OR] = 1.69, 95% confidence interval [CI], 1.05-2.79). Stratified estimates indicated that the association remained stable among toddlers of mothers without pre-conceptional and prenatal folic acid supplements (OR = 2.75, 95% CI, 1.04-7.27; n = 1243, 20.70%). Unintended pregnancy was associated with higher odds of ASD in 16-30 months of toddlers, and the association was consistent among toddlers of mothers without prenatal folic acid supplements. Our findings emphasize the need to raise awareness of the risk of unintended pregnancy and the benefits of folic acid supplements among Chinese women.

Overcoming barriers to oral contraception in Italy an expert opinion to empower women

Oral contraceptives are among the most commonly used contraceptive methods. However, Italian women underused reliable hormonal contraceptives as compared with other European women. There is a need to streamline access to oral contraception, with expected benefits on emotional well-being of women and potential savings for health system in Italy. Indeed, women can only access to oral contraceptives through mandatory medical prescription. This is one of the most important barrier experienced by women. We hereby provide an expert opinion on the potential reclassification, extending pharmacy services to include responsible and appropriate use of POP, as an opportunity also in Italy to increase the use of safe and effective contraceptive methods.

The preconception health status of nongravid women aged 18 to 45 years in Arima, Trinidad: a cross-sectional study

BACKGROUND

Preconception care (PCC) is the term used for activities and interventions designed to address and prevent problems related to pregnancy, the neonatal period and childhood. This study assessed maternal health status prior to conception in Trinidad by means of a screening tool, physical measurements, and laboratory samples.

METHODS

A cross-sectional study was conducted among women aged 18-45 years at a primary care centre in Arima, Trinidad. A de novo PCC screening tool was used to assess 13 domains of high-risk pregnancy in participants. These domains included dietary details, gynaecological and obstetric histories, and genetic and vaccination histories, among others. Blood pressure, weight, height, and waist circumference were recorded, and a capillary blood sample was used to determine random blood glucose and HbA1c levels. All data were coded and entered into SPSS ver. 21.

RESULTS

A total of 400 nongravid participants were recruited, of whom 366 were included in the final analysis. Most (96.7%) had one or more risk factors for adverse pregnancy outcomes. These included overweight (27%), obesity (35%), central obesity (69.4%), and impaired glucose tolerance/diabetes mellitus (IGT/DM) (26.2%). Additionally, a sedentary lifestyle and diet high in processed food/fats were self-reported by 74.9% and 88.8% of participants, respectively. Only 13.1% had planned to conceive, and of those who had no immediate plans to conceive, 76.4% were currently sexually active, and many (60.7%) did not use birth control techniques. More than half (57.1%) had never had a pap smear. On the other hand, 86.3% knew their HIV status. Self-reported percentages for vaccination were as follows: MMR (100%), tetanus (17.5%), hepatitis B (11.5%) and influenza (2.7%). The majority (82.8%) of participants had not visited the dentist in the past year, with 35.9% of these individuals reporting symptoms of periodontitis. Segments of the population had multiple risk factors; for example, 23.7% of participants were overweight or obese and had an elevated HbA1c level.

CONCLUSIONS

Unexpectedly, most participants had a risk factor for an adverse pregnancy outcome, and many had multiple risk factors. There is a strong case for enhanced preconception care for women in Trinidad.

Association between unplanned pregnancies and maternal exacerbations in cystic fibrosis

INTRODUCTION

Following availability of the highly effective cystic fibrosis (CF) transmembrane conductance regulator modulator, elexacaftor/tezacaftor/ivacaftor, there was a near doubling of pregnancies reported in the United States (US) in people with CF. We sought to determine health impacts of planned (PP) versus unplanned pregnancies (UP).

METHODS

We collected retrospective pregnancy data from January 2010-December 2020 from 11 US CF centers. After adjusting for potential confounding effects, we conducted multivariable, multilevel longitudinal regression analysis using mixed effect modeling to assess whether changes in percent predicted forced expiratory volume in one second (ppFEV1), body mass index (BMI), and pulmonary exacerbations (PEx) 1-year-pre- to 1-year-post-pregnancy were associated with pregnancy planning.

RESULTS

Our analysis included 163 people with 226 pregnancies; the cohort had a mean age at conception of 29.6 years, mean pre-pregnancy ppFEV1 of 75.4 and BMI of 22.5 kg/m2. PpFEV1 declined in both PP (adjusted decline of -2.5 (95% CI: -3.8, -1.2)) and UP (adjusted decline of -3.0 (95% CI: -4.6, -1.4)) groups, they did not differ from each other (p = 0.625). We observed a difference in change in the annual number of PEx pre- to post-pregnancy (PP: 0.8 (0.7, 1.1); UP: 1.3 (1.0, 1.7); interaction effect p = 0.029). In a subset of people with available infant data, infants resulting from UP had more preterm births, lower APGAR scores, and more intensive care unit stays.

CONCLUSIONS

Following UP, there is an increased trajectory for PEx and potentially for infant complications compared to PP. Clinicians should consider increased surveillance in the setting of UP.

Levonorgestrel Emergency Contraception Information Accuracy From West Virginia Community Pharmacies: A Mystery Caller Approach

BACKGROUND

To ensure access to effective levonorgestrel (LNG) emergency contraception (EC), pharmacies must keep medication in stock or available for quick delivery, and pharmacists must be knowledgeable about sales restrictions and the therapeutic window for EC. We conducted a mystery caller study to assess LNG EC availability and information accuracy provided by staff in West Virginia community pharmacies.

METHODS

A female research team member posed as a 16-year-old caller to ask pharmacy staff questions about whether LNG EC was in stock, the requirements for purchase, and when it should be taken for effectiveness. Data were analyzed with SPSS using the Pearson's χ2 test to determine if there was a relationship between pharmacy type and response accuracy to our questions about point-of-sale requirements and timing for effectiveness for LNG EC.

RESULTS

Of the 506 pharmacies in the sample, 275 (54.3%) were chain pharmacies and 231 (45.7%) were independent. Overall, chain pharmacies provided significantly more accurate answers than independent pharmacies on all point-of-sale requirements. Regarding timing for effectiveness, 49.2% of all pharmacies provided an accurate response (62.9% for chain pharmacies vs. 32.9% for independent pharmacies).

CONCLUSIONS

Overall, availability and accuracy regarding LNG EC were poor in West Virginia pharmacies. Pharmacists, particularly those at independent pharmacies serving rural communities, are in a critical and powerful position to influence community health by providing accurate and timely information and access to all contraceptive options, including LNG EC.

Changes in Socioeconomic Inequalities in Unintended Pregnancies Among Currently Married Women in India

Background

Despite the consistent prevalence of unintended pregnancies in India and its adverse impact on maternal and neonatal mortality, the literature discussing socioeconomic inequality remains scarce. This study aims to assess the change in wealth-related inequalities in unintended pregnancy in India from 2005-2006 to 2019-20 and to quantify the contribution of various factors towards inequality.

Methods

The present study analyzed cross-sectional data from the third and fifth rounds of the National Family Health Survey (NFHS). The information on fertility preferences and pregnancy intention of most recent live birth during the five years preceding the survey was collected from eligible women. The concentration index and Wagstaff decomposition were used to analyze wealth-related inequality and the contributing factors.

Results

Our results show that the prevalence of unintended pregnancy has declined in 2019-20 to 8% from 22% in 2005-2006. With the increase in education and wealth status, unintended pregnancy decreases significantly. The results of the concentration index depict that unintended pregnancy is more concentrated among the poor than the rich in India, and the individual's wealth status has the highest contribution to unintended pregnancy inequality. Other factors like mothers' BMI, place of residence and education also contribute majorly to the inequality.

Conclusions

The study results are critical and increase the need for strategies and policies. Disadvantaged women need education and family planning information, plus access to reproductive health resources. Governments should improve accessibility and quality of care in family planning methods to prevent unsafe abortions, unwanted births, and miscarriages. Further research is needed to investigate the impact of social and economic status on unintended pregnancies.

Unplanned pregnancy and the association with maternal health and pregnancy outcomes: A Swedish cohort study

OBJECTIVES

Unplanned pregnancies are common and associated with late initiation and inadequate antenatal care attendance, which may pose health risks to mother and child. How pregnancy planning relates to maternal health and delivery in Sweden, a country with free antenatal care and free abortion, has not been studied previously. Our aims were to study whether pregnancy planning was associated with antenatal care utilization and pregnancy outcomes in a Swedish setting.

METHODS

Data for 2953 women, who answered a questionnaire when recruited at antenatal clinics in Sweden and later gave birth, was linked to the Swedish Medical Birth Register. The degree of pregnancy planning was estimated using the London Measure of Unplanned Pregnancy. Unplanned (comprising unplanned and ambivalent intention to pregnancy) was compared to planned pregnancy. Differences between women with unplanned and planned pregnancy intention and associated pregnancy outcomes were analyzed using Fisher's exact test and logistic regression.

RESULTS

There were 31% unplanned (2% unplanned and 29% ambivalent) pregnancies, whereas most woman (69%) reported their pregnancy to be planned. Women with an unplanned pregnancy enrolled later to antenatal care, but there was no difference in number of visits compared with planned pregnancy. Women with an unplanned pregnancy had higher odds to have induced labor (17% versus 13%; aOR 1.33 95% CI 1.06-1.67) and a longer hospital stay (41% versus 37%; aOR 1.21 95% CI 1.02-1.44). No associations were found between pregnancy planning and pregnancy-induced hypertension, gestational diabetes mellitus, preeclampsia, epidural analgesia use, vacuum extraction delivery, Caesarean section or sphincter rupture.

CONCLUSIONS

Unplanned pregnancy was associated with delayed initiation of antenatal care, higher odds for induction of labor and longer hospital stay, but not with any severe pregnancy outcomes. These findings suggest that women with an unplanned pregnancy cope well in a setting with free abortion and free health care.

Racial disparities in pregnancy options counseling and referral in the US South

OBJECTIVE

The objective of this study is to examine racial variation in receipt of counseling and referral for pregnancy options (abortion, adoption, and parenting) following pregnancy confirmation. Equitable offering of such information is a professional and ethical obligation and an opportunity to prevent racial disparities in maternal and child health.

DATA SOURCE

Primary data from patients at southern United States publicly funded family planning clinics, October 2018-June 2019.

STUDY DESIGN

Patients at 14 clinics completed a survey about their experiences with pregnancy options counseling and referral following a positive pregnancy test. The primary predictor variable was patients' self-reported racial identity. Outcomes included discussion of pregnancy options, referral for those options, and for support services.

DATA COLLECTION

Data from eligible patients with non-missing information for key variables (n = 313) were analyzed using descriptive statistics, χ² tests, and multivariable logistic regression.

PRINCIPAL FINDINGS

Patients were largely Black (58%), uninsured (64%), and 18-29 years of age (80%). Intention to continue pregnancy and receipt of prenatal care referral did not differ significantly among Black as compared to non-Black patients. However, Black patients had a higher likelihood of wanting an abortion or adoption referral and not receiving one (abortion: marginal effect [ME] = 7.68%, p = 0.037; adjusted ME [aME] = 9.02%, p = 0.015; adoption: ME = 7.06%, p = 0.031; aME = 8.42%, p = 0.011). Black patients intending to end their pregnancies had a lower probability of receiving an abortion referral than non-Black patients (ME = -22.37%, p = 0.004; aME = -19.69%, p = 0.023). In the fully adjusted model, Black patients also had a higher probability of wanting access to care resources (including transportation, childcare, and financial support) and not receiving them (aME = 5.38%, p = 0.019).

CONCLUSIONS

Clinical interactions surrounding pregnancy confirmation provide critical opportunities to discuss options, coordinate care, and mitigate risk, yet are susceptible to systemic bias. These findings add to limited evidence around pregnancy counseling and referral disparities. Ongoing assessment of pregnancy counseling and referral disparities can provide insight into organizational strengths or the potential to increase structural equity.

Preconception paternal alcohol exposure decreases IVF embryo survival and pregnancy success rates in a mouse model

Increasingly, couples struggling with fertility turn to assisted reproductive techniques, including IVF, to have children. Despite the demonstrated influence of periconception male health and lifestyle choices on offspring development, studies examining IVF success rates and child health outcomes remain exclusively focused on maternal factors. Using a physiologically relevant mouse model, we tested the hypothesis that chronic paternal preconception alcohol intake adversely affects IVF success and negatively impacts IVF offspring fetoplacental growth. Using a voluntary, binge-like mouse model, we exposed sexually mature C57BL/6J males to three preconception treatments (0% (Control), 6% EtOH or 10% EtOH) for 6 weeks, isolated and cryopreserved caudal sperm from treated males, and then used these samples to fertilize oocytes before assessing IVF embryo developmental outcomes. We found that preconception paternal alcohol use reduced IVF embryo survival and pregnancy success rates in a dose-dependent manner, with the pregnancy success rate of the 10% EtOH treatment falling to half those of the Controls. Mechanistically, we found that preconception paternal alcohol exposure disrupts embryonic gene expression, including Fgf4 and Egfr, two critical regulators of trophectoderm stem cell growth and placental patterning, with lasting impacts on the histological organization of the late-term placenta. The changes in placental histoarchitecture were accompanied by altered regulation of pathways controlling mitochondrial function, oxidative phosphorylation and some imprinted genes. Our studies indicate that male alcohol use may significantly impede IVF success rates, increasing the couple's financial burden and emotional stress, and highlights the need to expand prepregnancy messaging to emphasize the reproductive dangers of alcohol use by both parents.

Exploring Family Planning Perspectives Among Men Receiving Medications for Opioid Use Disorder: Implications for Service Development

OBJECTIVE

Studies have consistently found high rates of unintended pregnancy among women with substance use disorder. While research efforts have begun to focus on understanding needs and providing family planning services for women in treatment, few studies have included men. This has resulted in a gap in the literature regarding men's reproductive health experiences and family planning desires.

METHODOLOGY

Between December 2019 and February 2020, we conducted semistructured qualitative interviews with adult men receiving medications for opioid use disorder at a safety-net healthcare system in Denver, Colorado. Interviews were recorded and analyzed using the Rapid Assessment Process.

RESULTS

Fifteen men participated in an interview. Overall, men described feeling excluded from family planning education and services as well as from decision making with their partners. Participants desired knowledge and resources related to contraceptive methods, partner communication, and parenting. Additional themes included loss of autonomy around pregnancy decisions, the importance of fatherhood, and the importance of addressing family planning during recovery. Participants expressed interest in a family planning intervention but indicated that engaging men on this topic may be challenging.

CONCLUSIONS

Our findings suggest that men in treatment desire education and involvement in family planning. Participants endorsed access to a subject expert within the treatment environment, but engagement strategies that underscore topic relevance to men will be critical. Initiating a conversation involving education and service navigation in the treatment setting may be a promising strategy for engaging men in recovery in family planning and improving men's access to needed services and resources.

Measures of Pregnancy Intention: Why Use Them and What Do They Tell Us?

Understanding pregnancy intention is an important public health measure that captures the ability of individuals to access information, resources, and services needed to plan the timing and spacing of pregnancies. Pregnancy intention is a complex construct impacted by social, emotional, financial, cultural, and contextual factors. In this review, we will examine the range of available tools for individuals and populations to evaluate pregnancy intention, the timing of the tools in relation to pregnancy, their interpretation, and use for policy and practice. Traditionally, pregnancy intention was only assessed in population health surveys; however, more sophisticated tools and measures have been developed. These tools can be used at several time points: before pregnancy, during pregnancy, or after the pregnancy has ended. It is important to appreciate the varied contexts globally for women and their partners when assessing pregnancy intention, and the ability of a given tool to capture this when used retrospectively or prospectively. These tools can inform targeted delivery of services for a person or couple before, during, and after pregnancy. This knowledge can inform strategies at an individual, community, and population level as an indicator of access to sexual and reproductive health information and knowledge and uptake of preconception health.

Interpregnancy interval and adverse pregnancy outcomes among pregnancies following miscarriages or induced abortions in Norway (2008-2016): A cohort study

BACKGROUND

The World Health Organization recommends to wait at least 6 months after miscarriage and induced abortion before becoming pregnant again to avoid complications in the next pregnancy, although the evidence-based underlying this recommendation is scarce. We aimed to investigate the risk of adverse pregnancy outcomes-preterm birth (PTB), spontaneous PTB, small for gestational age (SGA) birth, large for gestational age (LGA) birth, preeclampsia, and gestational diabetes mellitus (GDM)-by interpregnancy interval (IPI) for births following a previous miscarriage or induced abortion.

METHODS AND FINDINGS

We conducted a cohort study using a total of 49,058 births following a previous miscarriage and 23,707 births following a previous induced abortion in Norway between 2008 and 2016. We modeled the relationship between IPI and 6 adverse pregnancy outcomes separately for births after miscarriages and births after induced abortions. We used log-binomial regression to estimate unadjusted and adjusted relative risk (aRR) and 95% confidence intervals (CIs). In the adjusted model, we included maternal age, gravidity, and year of birth measured at the time of the index (after interval) births. In a sensitivity analysis, we further adjusted for smoking during pregnancy and prepregnancy body mass index. Compared to births with an IPI of 6 to 11 months after miscarriages (10.1%), there were lower risks of SGA births among births with an IPI of <3 months (8.6%) (aRR 0.85, 95% CI: 0.79, 0.92, p < 0.01) and 3 to 5 months (9.0%) (aRR 0.90, 95% CI: 0.83, 0.97, p = 0.01). An IPI of <3 months after a miscarriage (3.3%) was also associated with lower risk of GDM (aRR 0.84, 95% CI: 0.75, 0.96, p = 0.01) as compared to an IPI of 6 to 11 months (4.5%). For births following an induced abortion, an IPI <3 months (11.5%) was associated with a nonsignificant but increased risk of SGA (aRR 1.16, 95% CI: 0.99, 1.36, p = 0.07) as compared to an IPI of 6 to 11 months (10.0%), while the risk of LGA was lower among those with an IPI 3 to 5 months (8.0%) (aRR 0.84, 95% CI: 0.72, 0.98, p = 0.03) compared to an IPI of 6 to 11 months (9.4%). There was no observed association between adverse pregnancy outcomes with an IPI >12 months after either a miscarriage or induced abortion (p > 0.05), with the exception of an increased risk of GDM among women with an IPI of 12 to 17 months (5.8%) (aRR 1.20, 95% CI: 1.02, 1.40, p = 0.02), 18 to 23 months (6.2%) (aRR 1.24, 95% CI: 1.02, 1.50, p = 0.03), and ≥24 months (6.4%) (aRR 1.14, 95% CI: 0.97, 1.34, p = 0.10) compared to an IPI of 6 to 11 months (4.5%) after a miscarriage. Inherent to retrospective registry-based studies, we did not have information on potential confounders such as pregnancy intention and health-seeking bahaviour. Furthermore, we only had information on miscarriages that resulted in contact with the healthcare system.

CONCLUSIONS

Our study suggests that conceiving within 3 months after a miscarriage or an induced abortion is not associated with increased risks of adverse pregnancy outcomes. In combination with previous research, these results suggest that women could attempt pregnancy soon after a previous miscarriage or induced abortion without increasing perinatal health risks.

Associations of Unintended Pregnancy With Maternal and Infant Health Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current US populations are lacking.

OBJECTIVE

To evaluate associations of unintended pregnancy with maternal and infant health outcomes during pregnancy and post partum with studies relevant to current clinical practice and public health in the US.

DATA SOURCES

Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE databases (January 1, 2000, to June 15, 2022) and manual review of reference lists.

STUDY SELECTION

Epidemiologic studies relevant to US populations that compared key maternal and infant health outcomes for unintended vs intended pregnancies and met prespecified eligibility criteria were included after investigators' independent dual review of abstracts and full-text articles.

DATA EXTRACTION AND SYNTHESIS

Investigators abstracted data from publications on study methods, participant characteristics, settings, pregnancy intention, comparators, confounders, and outcomes; data were validated by a second investigator. Risk of bias was independently dual rated by investigators using criteria developed by the US Preventive Services Task Force. Results of studies controlling for confounders were combined by using a profile likelihood random-effects model.

MAIN OUTCOMES AND MEASURES

Prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth, and infant low birth weight.

RESULTS

Thirty-six studies (N = 524 522 participants) were included (14 cohort studies rated good or fair quality; 22 cross-sectional studies); 12 studies used large population-based data sources. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92]; I2 = 85.0%; 15 studies [n = 41 054]) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70]; I2 = 7.1%; 10 studies [n = 82 673]), interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91]; I2 = 64.1%; 5 studies [n = 42 306]), preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31]; I2 = 1.7%; 10 studies [n = 94 351]), and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21]; I2 = 0.0%; 8 studies [n = 87 547]). Results were similar in sensitivity analyses based on controlling for history of depression for prenatal and postpartum depression and on study design and definition of unintended pregnancy for relevant outcomes. Studies provided limited sociodemographic data and measurement of confounders and outcomes varied.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of epidemiologic observational studies relevant to US populations, unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42020192981.

Do unwanted children face growth penalties in resource poor environments? Evidence from Roma Settlements in Serbia

In a high fertility context, research on the relationship between parental investment, unwanted births and child nutritional outcomes is limited. The implications may be especially relevant for children coming from the most disadvantaged backgrounds and at increased risk of nutritional deprivation. This study assessed the association between maternal investment, unwanted births disaggregated into mistimed and unwanted children, and child nutritional outcomes in a poor population of Serbian Roma. Multiple Indicator Cluster Surveys rounds 5 and 6 data for Serbian Roma settlements were used to account for the association between two measures of maternal investment: weight at birth and parity, and mistimed and unwanted children, and children height-for-age z-score (HAZ), weight-for-age z score (WAZ) and weight-for- height z-score (WHZ). The sample included 130 children aged 0-24 months. The child variables were age, gender, and birth order, while maternal independent variables included age, literacy and access to improved toilet facility as proxies for socioeconomic status. Children born with low birth weight (lower maternal investment in utero) face a significant deficit in terms of their nutritional outcomes, measured by HAZ and WAZ. The effect was aggravated for height if the child was unwanted while there was a positive relationship between access to improved toilet facility and WHZ. Unwanted children were of higher birth order, with older, higher parity mothers than mistimed children. Many of the Roma children may be at risk of undernutrition, however, Roma children who received lower maternal investment in utero, unwanted and living in poorest households may face additional risk.

Association of pregnancy attitudes and intentions with sexual activity and psychiatric symptoms in justice-involved youth

Context

With over one-third of detained girls experiencing teenage pregnancy, it is critical that the juvenile justice system better addresses the sexual and reproductive health (SRH) needs of youth. Although pregnancy attitudes and intentions (PAI) are associated with pregnancy outcomes among the general adolescent population, this relationship has not been examined among justice-involved youth.

Methods

Participants were drawn from a longitudinal study characterizing trajectories of behavioral and reproductive health and recidivism among newly justice-involved youth in a Northeast family court. Baseline and four-month follow-up data from 288 justice-involved youth (JIY) were analyzed to characterize PAI; examine associations between pregnancy intentions and unprotected sexual activity (i.e., no hormonal, intrauterine, or barrier protection against pregnancy); and explore the relationship between pregnancy intentions and psychiatric symptoms.

Results

At baseline, 39% of JIY youth were sexually active, 44% of these youth reported inconsistent condom use and 14% had not used birth control at last sexual intercourse. Nearly half of sexually active youth reported some intent around pregnancy and those with any pregnancy intentions were more likely to report depression, low self-esteem, substance use, and trauma history. Pregnancy intentions at baseline predicted higher rates of unprotected sexual activity at four months (OR: 16.9, CI = 2.48-115.7).

Conclusions

This study highlights the importance of developing and implementing more comprehensive SRH assessments and brief interventions for youth entering the justice system.

Bacteriuria in Pregnant Adolescents and Behavioral Risk Factors: A Cross-Sectional Study at a Brazilian Teaching Hospital

INTRODUCTION

Bacteriuria during pregnancy is a frequent and important cause of morbidity and complications. Data on its occurrence in pregnant adolescents are still scarce.

METHODS

A cross-sectional study was conducted at a tertiary teaching hospital in São Paulo, Brazil. All adolescents (≤18 years) who came for prenatal care between January 2010 and January 2016 were included. Sociodemographic characteristics, medical history, obstetric history, and the results of laboratory tests were selected. A urine sample was aseptically collected from each patient to undergo microscopic and culture analysis.

RESULTS

A total of 388 pregnant adolescents averaging 15.30 ± 1.24 years of age were included. The frequency of bacteriuria in this group was 17.01% (66/388). The lack of sports practice (OR = 8.65; 95% CI, 1.09-68.39), the fact that pregnancy was desired (OR = 2.17; 95% CI, 1.08-4.34), and the use of hormonal methods of contraception (OR = 2.46; 95% CI, 1.04-5.84) turned out to be independent risk factors for bacteriuria. Protective factors were identified as late coitarche (OR = 0.75; 95% CI, 0.57-0.98) and a urine culture analysis at a later gestational age (OR = 0.94; 95% CI, 0.90-0.98). The most often isolated pathogens were Escherichia coli (49%) and Streptococcus agalactiae (18%).

CONCLUSION

Bacteriuria among pregnant adolescents is a relatively common condition. The infection risk of the urinary tract was increased by physical inactivity and seemingly by the influence of behavioral and sexual factors. Such results can help to identify patients at risk, favoring the early diagnosis of urinary tract infections and optimizing prenatal care.

The role of intervening pregnancy loss in the association between interpregnancy interval and adverse pregnancy outcomes

OBJECTIVE

To investigate whether intervening miscarriages and induced abortions impact the associations between interpregnancy interval after a live birth and adverse pregnancy outcomes.

DESIGN

Population-based cohort study.

SETTING

Norway.

PARTICIPANTS

A total of 165 617 births to 143 916 women between 2008 and 2016.

MAIN OUTCOME MEASURES

We estimated adjusted relative risks for adverse pregnancy outcomes using log-binomial regression, first ignoring miscarriages and induced abortions in the interpregnancy interval estimation (conventional interpregnancy interval estimates) and subsequently accounting for intervening miscarriages or induced abortions (correct interpregnancy interval estimates). We then calculated the ratio of the two relative risks (ratio of ratios, RoR) as a measure of the difference.

RESULTS

The proportion of short interpregnancy interval (<6 months) was 4.0% in the conventional interpregnancy interval estimate and slightly increased to 4.6% in the correct interpregnancy interval estimate. For interpregnancy interval <6 months, compared with 18-23 months, the RoR was 0.97 for preterm birth (PTB) (95% confidence interval [CI] 0.83-1.13), 0.97 for spontaneous PTB ( 95% CI 0.80-1.19), 1.00 for small-for-gestational age ( 95% CI 0.86-1.14), 1.00 for large-for-gestational age (95% CI 0.90-1.10) and 0.99 for pre-eclampsia (95% CI 0.71-1.37). Similarly, conventional and correct interpregnancy intervals yielded associations of similar magnitude between long interpregnancy interval (≥60 months) and the pregnancy outcomes evaluated.

CONCLUSION

Not considering intervening pregnancy loss due to miscarriages or induced abortions, results in negligible difference in the associations between short and long interpregnancy intervals and adverse pregnancy outcomes.

Association of Prepregnancy Substance Use and Substance Use Disorders with Pregnancy Timing and Intention

Background: Limited research exists on the association between substance use disorders (SUDs) and dimensions of pregnancy intention. This study sought to examine the independent relationships between prepregnancy substance use and SUDs with pregnancy timing and intentions. Materials and Methods: Secondary analysis of data from three prenatal care sites in Connecticut, Massachusetts, and Michigan, 2016-2017. Associations were estimated using modified Poisson regression with robust error variance to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), controlling for relevant covariates. Results: The total sample size was 1115 women. Respectively, 61.1% and 15.5% of women used any substance in the 30 days prepregnancy or had any SUD in the past 12 months. After adjustment, any prepregnancy substance use was associated with a reduced likelihood of a well-timed (aPR 0.85; 95% CI: 0.77-0.93) and intended (aPR 0.80; 95% CI: 0.72-0.89) pregnancy; similarly, any SUD was associated with a reduced likelihood of a well-timed (aPR 0.66; 95% CI: 0.55-0.80) and intended (aPR 0.79; 95% CI: 0.67-0.93) pregnancy. Conclusions: Women with prepregnancy substance use or SUD have decreased prevalence of well-timed and intended pregnancies. Greater efforts are needed to address substance use and family planning in routine, well-woman, prenatal, and postpartum care.

Epilepsy and Pregnancy

PURPOSE OF REVIEW

Seizure disorders are the most frequent major neurologic complication in pregnancy, affecting 0.3% to 0.8% of all gestations. Women of childbearing age with epilepsy require special care related to pregnancy. This article provides up-to-date information to guide practitioners in the management of epilepsy in pregnancy.

RECENT FINDINGS

Ongoing multicenter pregnancy registries and studies continue to provide important information on issues related to pregnancy in women with epilepsy. Valproate poses a special risk for malformations and cognitive/behavioral impairments. A few antiseizure medications pose low risks (eg, lamotrigine, levetiracetam), but the risks for many antiseizure medications remain uncertain. Although pregnancy rates differ, a prospective study found no difference in fertility rates between women with epilepsy who were attempting to get pregnant and healthy controls. During pregnancy, folic acid supplementation is important, and a dose greater than 400 mcg/d during early pregnancy (ie, first 12 weeks) is associated with better neurodevelopmental outcome in children of women with epilepsy. Breastfeeding is not harmful and should be encouraged in women with epilepsy even when they are on antiseizure medication treatment.

SUMMARY

Women with epilepsy should be counseled early and regularly about reproductive health. Practitioners should discuss the risks of various obstetric complications; potential anatomic teratogenicity and neurodevelopmental dysfunction related to fetal antiseizure medication exposure; and a plan of care during pregnancy, delivery, and postpartum. Women with epilepsy should also be reassured that the majority of pregnancies are uneventful.

Access to Reproductive Healthcare for Persons Who Have Experienced Sexual Violence

Pregnancy resulting from abuse is a public health concern that millions of persons will experience in their lifetimes. Access to professional and safe reproductive healthcare, including sex education, contraception, and abortion, is essential to protecting the rights of persons to control their reproductive health. Currently, access to safe and timely reproductive healthcare is at particular peril. Affirming a patient's right to choose or, advocating autonomy in healthcare decisions is a key component of trauma-informed care. It is the position of the International Association of Forensic Nurses that access to, and autonomy in decision making about reproductive healthcare, including safe and legal contraception and abortion, is a basic human right.

Maternal Pregnancy Intention and Developmental Outcomes in Brazilian Preschool-Aged Children

OBJECTIVE

This study aims to characterize the association between maternal pregnancy intention and socioemotional developmental outcomes in a Brazilian sample of preschool-aged children.

METHODS

Data from children aged 4 to 5 years and their primary caregivers in Embu das Artes, a Brazilian municipality in the state of São Paulo, were collected in 2016. Maternal pregnancy intention was defined as intended or unintended, which was then further stratified as mistimed or unwanted. Outcomes included socioemotional developmental delay, internalizing and externalizing behaviors, and school readiness. We estimated risk ratios (RRs) for unadjusted and inverse-probability-weighted regression adjustment (IPWRA) analyses using 2-level (intended vs unintended) and 3-level (intended vs mistimed vs unwanted) exposure definitions.

RESULTS

Of 1,034 total mothers, 40.7% reported their pregnancy as intended, 46.0% as mistimed, and 13.4% as unwanted. In both unadjusted and IPWRA analyses comparing intended and unintended pregnancies, all associations failed to reach statistical significance. In the IPWRA analysis using the 3-level exposure definition, unwanted pregnancies were associated with higher risk of socioemotional developmental delay (RR = 1.14; 95% confidence interval [CI], 1.01-1.28) and co-occurring internalizing and externalizing behaviors (RR = 1.11, 95% CI, 1.00-1.22), compared with intended pregnancies.

CONCLUSION

There was higher risk of poor child outcomes among unwanted compared with intended pregnancies, whereas mistimed pregnancies were not associated with poor outcomes. Further research using standardized definitions of pregnancy intention along with targeted interventions that increase access to family planning services and counseling for parents of children born after unintended pregnancies is needed.

Association of State Gestational Age Limit Abortion Laws With Infant Mortality

INTRODUCTION

A growing number of state legislatures have passed laws that restrict access to abortion care after a specified gestational age (gestational age limit laws). The impact of these laws on maternal and child population health outcomes and inequities is unknown. The objective of this study is to determine whether states that implement gestational age limit laws experience subsequent changes in rates of infant mortality.

METHODS

Using U.S. population‒based data from the National Center for Health Statistics Linked Infant Birth-Death Files (2005-2017), difference-in-differences models were estimated using multivariable linear regressions to compare the trends in infant mortality (all-cause and cause-specific rates) in states with gestational age limit laws with the trends in states without such laws. Models stratified by maternal racial/ethnic group explored racial heterogeneity in the law's impact. Data were analyzed in 2020.

RESULTS

This study included 16,232,133 births in states that enacted a gestation age limit abortion law and 36,472,309 births in states that did not from 2005 to 2017. In difference-in-difference analyses, gestational age limit laws were associated with 0.23 excess infant deaths per 1,000 live births (95% CI=0.09, 0.37, p<0.01). In cause-specific analyses, gestational age limit laws were associated with 0.10 additional infant deaths owing to congenital anomalies per 1,000 live births (95% CI=0.03, 0.17, p=0.01). Associations between gestational age limit laws and infant mortality in models stratified by maternal racial/ethnic group were not statistically significant.

CONCLUSIONS

On the basis of data from 2005 to 2017, states that enacted gestational age limit abortion laws subsequently experienced increased infant mortality rates.

Maternal sociodemographic characteristics, early pregnancy behaviours, and livebirth outcomes as congenital heart defects risk factors - Northern Ireland 2010-2014

BACKGROUND

Congenital Heart Defects (CHD) is the most commonly occurring congenital anomaly in Europe and a major paediatric health care concern. Investigations are needed to enable identification of CHD risk factors as studies have given conflicting results. This study aim was to identify maternal sociodemographic characteristics, behaviours, and birth outcomes as risk factors for CHD. This was a population based, data linkage cohort study using anonymised data from Northern Ireland (NI) covering the period 2010-2014. The study cohort composed of 94,067 live births with an outcome of 1162 cases of CHD using the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes and based on the European Surveillance of Congenital Anomalies (EUROCAT) grouping system for CHD. CHD cases were obtained from the HeartSuite database (HSD) at the Royal Belfast Hospital for Sick Children (RBHSC), maternal data were extracted from the Northern Ireland Maternity System (NIMATS), and medication data were extracted from the Enhanced Prescribing Database (EPD). STATA version 14 was used for the statistical analysis in this study, Odds Ratio (OR), 95% Confident intervals (CI), P value, and logistic regression were used in the analysis. Ethical approval was granted from the National Health Service (NHS) Research Ethics Committee.

RESULT

In this study, a number of potential risk factors were assessed for statistically significant association with CHD, however only certain risk factors demonstrated a statistically significant association with CHD which included: gestational age at first booking (AOR = 1.21; 95% CI = 1.04-1.41; P < 0.05), family history of CHD or congenital abnormalities and syndromes (AOR = 4.14; 95% CI = 2.47-6.96; P < 0.05), woman's smoking in pregnancy (AOR = 1.22; 95% CI = 1.04-1.43; P < 0.05), preterm birth (AOR = 3.01; 95% CI = 2.44-3.01; P < 0.05), multiple births (AOR = 1.89; 95% CI = 1.58-2.60; P < 0.05), history of abortion (AOR = 1.12; 95% CI = 1.03-1.28; P < 0.05), small for gestational age (SGA) (AOR = 1.44; 95% CI = 1.22-1.78; P < 0.05), and low birth weight (LBW) (AOR = 3.10; 95% CI = 2.22-3.55; P < 0.05). Prescriptions and redemptions of antidiabetic (AOR = 2.68; 95% CI = 1.85-3.98; P < 0.05), antiepileptic (AOR = 1.77; 95% CI = 1.10-2.81; P < 0.05), and dihydrofolate reductase inhibitors (DHFRI) (AOR = 2.13; 95% CI = 1.17-5.85; P < 0.05) in early pregnancy also showed evidence of statistically significant association with CHD.

CONCLUSION

The results of this study suggested that there are certain maternal sociodemographic characteristics, behaviours and birth outcomes that are statistically significantly associated with higher risk of CHD. Appropriate prevention policy to target groups with higher risk for CHD may help to reduce CHD prevalence. These results are important for policy makers, obstetricians, cardiologists, paediatricians, midwives and the public.

Higher Rates of Twinning Among Repeat Vs First-Time Teenage and Young Adult Mothers in the United States, 2009-2018

STUDY OBJECTIVE

Few studies examining predictors of twinning consider younger mothers who do not use assisted reproductive technologies (ART). Higher parity is associated with greater odds of having a twin birth, but it is unclear whether this association is present among young women. We tested the hypothesis that the rates and odds of twinning would increase with parity among teenage and young adult mothers who did not use ART.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective, population-based cohort study using 2009-2018 United States National Vital Statistics data on 11,383,370 (58.94% first, 41.06% repeat) births to adolescent and adult women aged 15-24 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Rates and odds of twinning by parity among teenage (15-19 years) and young adult (20-24 years) mothers.

RESULTS

The adjusted twin birth rate among first-time teenage mothers was 13.28 per 1000 births compared to 16.62 twins per 1,000 births among repeat teenage mothers. This difference by parity was present but smaller among mothers aged 20-24 (18.31 vs 21.44 twins per 1000 births for first-time and repeat young adult mothers, respectively).

CONCLUSION

Repeat young mothers, particularly teenage mothers, are a high-risk group in terms of infant and maternal health outcomes; their higher rate of twinning puts them at an additional risk for adverse birth outcomes. Practitioners may counsel young mothers at risk for subsequent unintended pregnancy on elevated risk of twinning.

Pregnancy Intention: Associations with Maternal Behaviors and Experiences During and After Pregnancy

Background: The associations between levels of pregnancy intention and adverse behaviors or experiences during pregnancy and postpartum have not been well described. Materials and Methods: We used 2018 Pregnancy Risk Assessment Monitoring System data from 31 jurisdictions in the United States (n = 32,777) to estimate prevalence of inadequate prenatal care (PNC), inappropriate gestational weight gain, depression during pregnancy, intimate partner violence (IPV) during pregnancy, third trimester smoking, no breastfeeding, no postpartum visit, postpartum depressive symptoms, and postpartum smoking by categories of pregnancy intention: unwanted, ambivalent (i.e., unsure), mistimed (i.e., wanted later), or wanted (i.e., wanted then/sooner). Regression models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) of associations between pregnancy intention and maternal behaviors or experiences. Results: Approximately 16% of women reported pregnancy ambivalence. Women with pregnancy ambivalence (versus wanted pregnancies) had higher prevalence of all adverse maternal behaviors and experiences. Separate models found women with unwanted pregnancy (vs. ambivalent) had higher prevalence for depression during pregnancy (aPR: 1.40, 95% CI: 1.21-1.63), IPV (aPR: 1.75, 95% CI: 1.11-2.77), no breastfeeding (aPR: 1.22, 95% CI: 1.04-1.44), no postpartum visit (aPR: 1.28, 95% CI: 1.06-1.55), and postpartum depressive symptoms (aPR: 1.19, 95% CI: 1.00-1.42); Women with mistimed pregnancy (vs. ambivalent) had lower prevalence for inadequate PNC (aPR: 0.89, 95% CI: 0.81-0.98), third trimester smoking (aPR: 0.68, 95% CI: 0.57-0.80), no breastfeeding (aPR: 0.85, 95% CI: 0.74-0.98), and postpartum smoking (aPR: 0.83, 95% CI: 0.73-0.95). Discussion: The results emphasize the importance of recommended screening and care during the preconception, prenatal, and postpartum periods.

Contraceptive values and preferences of adolescents and young adults: A systematic review

OBJECTIVE

We sought to systematically review the literature on values and preferences for contraception among adolescents and young adults globally.

STUDY DESIGN

We searched ten electronic databases for articles from January 1, 2005 through July 27, 2020 regarding end-users' values and preferences for contraception. We included studies that report specifically on people up to 25 years old.

RESULTS

Fifty-five studies out of 7,846 met our inclusion criteria. These studies included participants aged 10-25 years and were conducted in 16 countries. Through open coding, we identified 18 content areas. The five most commonly discussed content areas were: (1) general preferences regarding contraception, (2) contraceptive method benefits, (3) contraceptive method drawbacks, (4) the influence of the social context, and (5) the influence of myths and misconceptions, including safety and side effects, on contraceptive choice. Privacy and autonomy were important overarching themes, along with safety of the method. These considerations affected participants' access to and use of contraception.

CONCLUSION

Various social, cultural, and method-specific factors influence a young person's values and preferences around contraceptive methods. Understanding their values and preferences can help providers and programs improve contraceptive care for young people.

The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017

OBJECTIVE

To explore the relationship between abortion restrictions and maternal mortality in the United States.

STUDY DESIGN

This was a retrospective study examining maternal mortality in the United States from 1995 to 2017. We used the Global Health Data Exchange and the Centers for Disease Control and Prevention WONDER databases to extract maternal mortality data for all 50 states for each year from 1995 to 2017. We categorized states as restrictive, neutral, or protective of abortion access according to policy information published by the Guttmacher Institute. We assessed associations between abortion restrictions and maternal mortality ratios (maternal deaths per 100,000 live births).

RESULTS

In 1995, the mean maternal mortality ratios were similar across all groups of states (Restrictive 12.6, 95% CI 11.4-13.6; Neutral 12.2, 95% CI 10.9-13.4; Protective 10.9, 95% CI 9.6-11.9). Maternal mortality ratios increased for each group of states over time and in 2017, the mean maternal mortality ratio was higher in restrictive states than in protective states (Restrictive 28.5, 95% CI 20.7-35.1; Neutral 22.9, 95% CI 16.1-28.6; Protective 15.7, 95% CI 10.7-19.9). Regressions accounting for policy, state and year showed a statistically significant increase in maternal mortality ratios in restrictive states relative to neutral states (1.06, 95% CI 1.01-1.11) and a non-significant decrease associated with protective states (0.89, 95% CI 0.78-1.01).

CONCLUSIONS

States that restrict abortion have higher maternal mortality than states that either protect or are neutral towards abortion. Further investigation is needed to determine how abortion restrictions are associated with increased maternal mortality.

IMPLICATIONS

The association between abortion restrictions and maternal mortality may reflect the overall legislative priorities of individual states as restrictive states are less likely to pass proactive legislation demonstrated to improve maternal outcomes.

Unintended pregnancy and viral suppression in pregnant women living with HIV

BACKGROUND

Approximately half of pregnancies in the United States are unintended; the likelihood of unintended pregnancy may be even higher for women living with HIV. Women with unintended pregnancies often have worse obstetrical outcomes than women who planned their pregnancies, although the relationship of unintended pregnancy to outcomes among women living with HIV in the United States is unknown.

OBJECTIVE

This study aimed to determine whether pregnancy intendedness among women living with HIV attending a specialty obstetrical clinic was associated with achievement of maternal viral suppression by delivery, a key component of preventing perinatal transmission of HIV.

STUDY DESIGN

This is a retrospective cohort study of pregnant women living with HIV who received prenatal care and had a live-born infant at a single tertiary center (2007-2014). Women were asked as part of routine clinical care whether they intended their current pregnancy. Women who expressed at their initial obstetrician visit that their pregnancy was mistimed or undesired were determined to have an unintended pregnancy. Women were considered virally suppressed when the HIV RNA viral load was <20 copies/mL. We examined whether pregnancy intendedness was associated with whether the viral load was undetectable at the time of delivery. We also determined whether women with unintended pregnancies were less likely to be on antiretroviral therapy at the time of entry to prenatal care. Wilcoxon rank-sum tests and chi-square tests were used for bivariable analyses, and logistic and linear regression were used for multivariable analyses.

RESULTS

Of the 215 women who met inclusion criteria, 201 (93.5%) had complete data on pregnancy intendedness. Of these 201 women, 137 (68.2%) had an unintended pregnancy. Unintended pregnancy was associated with lower odds of viral suppression at delivery (95.3% of women with planned pregnancies were virally suppressed at delivery compared with 76.6% of women with unplanned pregnancies; adjusted odds ratio, 0.22; 95% CI, 0.05-0.89, after adjusting for potential confounders). In this study, 48.9% of women with unintended pregnancies presented later in pregnancy for prenatal care (after the first trimester) compared with 21.9% of women with intended pregnancies (P<.001). Women with unintended pregnancies were also less likely to be on antiretroviral therapy before entry to prenatal care (20.4% of women with unintended pregnancies vs 50.0% of women with intended pregnancies; adjusted odds ratio, 0.35; 95% CI, 0.15-0.81; P<.001).

CONCLUSION

Among pregnant women living with HIV, women with an unintended pregnancy were less likely to be on antiretroviral therapy before initiating prenatal care and were less likely to be virally suppressed at the time of delivery.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study

BACKGROUND

An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes.

METHODS

The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight.

RESULTS

Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention.

CONCLUSIONS

We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

The importance of pregnancy planning in lupus pregnancies

OBJECTIVE

In seeking new approaches to improve lupus pregnancy outcomes, we study the association between pregnancy planning, behaviors recommended by American College of Rheumatology's Reproductive Health Guideline 2020, and pregnancy and infant outcomes.

METHODS

Lupus pregnancies in a prospective registry (1/1/2018 to 4/1/2020) were classified as planned or not-planned using the patient-reported London Measure of Unplanned Pregnancy. These groups were compared for demographics, pre-pregnancy disease activity, pregnancy planning behaviors, and delivery outcomes.

RESULTS

Among 43 women with 43 singleton pregnancies the average age was 29.4 years and 42% were Black. Overall, 60% were planned pregnancies and 40% were not-planned (16 ambivalent, 1 unplanned). Women with not-planned pregnancies had lower age, income, and education, and more required Medicaid. Women with not-planned pregnancies were more likely to conceive when lupus activity was higher (p = 0.001), less likely to receive pre-pregnancy counseling with a rheumatologist (p = 0.02), and less likely to continue pregnancy-compatible medications (p = 0.03). Severe PROMISSE adverse pregnancy outcomes (APOs) and severe neonatal outcomes were higher among women with not-planned than planned pregnancies (43% vs 0% p = 0.003; 70% vs 30% p = 0.06).

CONCLUSION

This study identifies pregnancy intention as a potentially modifiable risk factor for poor outcomes in women with lupus. It highlights a unique population of women with lupus at high risk for pregnancy and infant complications: those ambivalent about pregnancy. These women may not be effectively engaging in health behaviors that prevent pregnancy nor those that will prepare for a safe pregnancy. With effective pregnancy planning and contraception guidance, we may decrease their risk for maternal-fetal morbidity and mortality.

Proportion of unplanned pregnancies, their determinants and health outcomes of women delivering at a teaching hospital in Sri Lanka

BACKGROUND

Unplanned pregnancy is a significant public health issue in both low- and high-income countries. The burden of unplanned pregnancy is reflected in women opting for pregnancy terminations and it can be detrimental to the women and her family as well as the health system and society. Solid data on the proportion of unplanned pregnancies are using more specific tools such as the London Measure of Unplanned Pregnancy (LMUP) needed to address the issue in Sri Lankan contexts. The objective was to describe the proportion of unplanned pregnancies, their determinants and the health outcomes of women delivering at Colombo North Teaching Hospital-Ragama (CNTH).

METHODS

A cross-sectional study was carried out among 494 consecutive pregnant women selected by non-probability consecutive sampling who were admitted for the confinement at CNTH. A pre-tested structured interviewer-administered questionnaire was used to collect data on antenatal women and intentionality measured by self-administered six-item LMUP. Maternal and newborn health outcomes were ascertained in each post-partum women before discharge. Data were analyzed with the Mann-Whitney U tests, Kruskal-Wallis tests and spearman rank correlation. We also evaluated the psychometric properties of the Sinhalese version of LMUP.

RESULTS

The response rate was 97.8 and 17.2% of pregnancies ending at birth were unplanned, 12.7% were ambivalent and 70.1% were planned. Associated factor profile of women with unplanned pregnancies includes; not married women (p = 0.001), educated up to the passing of GCE ordinary level by women (p <  0.001) and spouse (p <  0.001), primiparity (p = 0.002) and inadequate knowledge on emergency contraceptives (p = 0.037). Less planned pregnancies were also significantly associated with anemia (p = 0.004), low mood for last 2 weeks (p <  0.001), having a partner with problematic alcohol consumption (p <  0.001), presence of Gender-Based Violence (GBV) (p < 0.001), poor relationship satisfaction with partner (p < 0.001) and family (p < 0.001). Inadequate pre-pregnancy preparation and antenatal care were associated with an unplanned pregnancy. No differences were found in neonatal outcomes. Sinhalese version of the LMUP scale was found to be accepted, valid and reliable with the Cronbach's alpha of 0.936.

CONCLUSIONS

A sizeable proportion of pregnancies were unplanned. Teenage pregnancies, non-marital relationships and inadequate knowledge on emergency contraceptives, maternal anemia, low mood, and GBV were modifiable associated factors which could be prevented by evidence-based locally applicable approaches.

Psychosocial status and prenatal care of unintended pregnancies among low-income women

Background

Nearly half of all pregnancies in the United States are reported as unintended and rates are highest among women of low socioeconomic status. The purpose of this study was to examine the associations between unintended pregnancies and maternal mental health and timing of prenatal care among low-income women.

Methods

In this cross-sectional study, 870 women, whom were participating in the First 1000 Days program in three community health centers in the Boston area, were enrolled at their first prenatal visit from August 2016 – September 2017. We assessed pregnancy intention by self-report using the Pregnancy Risk Assessment Monitoring System. We used self-reported survey information and electronic health record data to assess the following outcomes: current stress, current depression, and timing of initial prenatal visit. We used multivariable logistic regression models to examine associations and adjusted for sociodemographic factors.

Results

Women were a mean (SD) age of 29.3 (6.1), and 39.2% reported that their pregnancy was unintended. 50.6% of women were Hispanic, 28.4% were White, 10.1% were Black, and 10.9% were other races. 78.9% of women reported an annual household income <$50,000. Overall, 26.7% of women reported current stress, 8.2% reported current depression, and 18.3% of women initiated prenatal care after their first trimester. In multivariable analyses, women with unintended pregnancies had higher odds of experiencing current stress (OR: 1.72; 95% CI: 1.22, 2.41), current depression (OR: 1.83; 95% CI: 1.04, 3.20), and initiation of prenatal care post-first trimester (OR: 1.84; 95% CI: 1.23, 2.74).

Conclusions

Unintended pregnancies were associated with current stress and depression, and delayed prenatal care in this sample of low-income women suggesting the importance of identifying high-risk women and tailoring interventions to support women’s needs.

Trial registration

ClinicalTrials.gov (NCT03191591; Retrospectively registered on June 19, 2017).

Effect of unintended pregnancy on skilled antenatal care uptake in Bangladesh: analysis of national survey data

Background

Around 48% of all pregnancies in low- and middle-income countries are unintended. Unintended pregnancy may contribute to lower use of antenatal care (ANC); however, current research in the area is largely inconclusive due to the methodological approaches applied.

Methods

Responses from 4493 women extracted from the 2014 Bangladesh Demographic and Health Survey (BDHS) were used to assess the association between unintended pregnancy and subsequent uptake of at least one and at least four skilled ANC visits. For this, Bayesian multilevel logistic regression models with informative priors (representing a range of values within which the researcher is certain the true effect of the parameters included lies) were used, adjusting for other factors that affect ANC uptake. Informative priors were selected from the BDHS data collected in 2004, 2007, and 2011.

Results

Around 64% of women in Bangladesh who had at least one pregnancy within 3 years prior to the survey (that ended in a live birth) received ANC at least once, and of these around 32% used ANC at least four times. Mistimed (aOR, 0.73, 95% Cred I, 0.66–0.81) and unwanted (aOR, 0.69, 95% Cred I, 0.64–0.75) pregnancy were associated with reduced odds of attending the recommended minimum of four skilled ANC visits compared with wanted pregnancy. These likelihoods were even lower for at least one skilled ANC visit among women with a mistimed (aOR, 0.59, 95% Cred I, 0.53–0.65) or an unwanted pregnancy (aOR, 0.67, 95% Cred I, 0.61–0.74) than women with a wanted pregnancy.

Conclusions

In Bangladesh, more than one-quarter of women who report an unintended pregnancy at conception and do not terminate the pregnancy are at high risk of not using ANC. It is important for policies to include women with unintended pregnancy in mainstream healthcare services. This will increase the use of ANC and reduce associated adverse consequences.

Association between pregnancy intention and late initiation of antenatal care among pregnant women in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Antenatal care is one of the continua of reproductive health care, and inadequate antenatal care utilization results in an adverse feto-maternal outcome. Pregnancy intention is an essential factor that plays a paramount role on timing of antenatal care service. The finding of a few studies conducted on the association between pregnancy intention and late initiation of ANC among pregnant women in Ethiopia presented inconclusive. Therefore, the objective of this systematic review and meta-analysis was to determine the pooled estimate of the association between pregnancy intention and late initiation of ANC among pregnant women in Ethiopia.

METHODS

Both published and unpublished studies were accessed through electronic search from databases such as MEDLINE, Scopes, PubMed, CINAHL, PopLine, MedNar, Cochrane library, the JBI Library, the Web of Science, and Google Scholar. All observational studies that were conducted on the association between pregnancy intention and late initiation of ANC among pregnant women in Ethiopia were included. STATA 14.1 version was used for data analysis. A random effects model was used to estimate the pooled estimate with a 95% confidence interval (CI). The Cochrane Q test statistic and I² tests were used to assess heterogeneity. Presence of publication bias was checked by funnel plots and Egger's statistical tests.

RESULTS

A total of 670 published and unpublished studies were identified from several databases and fourteen studies fulfilled inclusion criteria and included in the meta-analysis. The overall pooled estimate indicates the odds of late initiation of antenatal care were 2.16 times higher among pregnant women who had unintended pregnancy as compared to pregnant women who had intended pregnancy (OR 2.16, 95% CI 1.62, 2.88).

CONCLUSION

The systematic review and meta-analysis found a statistically significant effect of pregnancy intention on late initiation of antenatal care among pregnant women in Ethiopia. Increased effort should be made to improve women's behavior towards contraceptive use through health education and counseling, especially those with unintended pregnancies. Furthermore, health education, counseling, and communication campaigns related to the timing of ANC and frequency should be promoted nationally.

A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America

Racial/ethnic disparities in maternal care exist, even as medicine continues to progress on several aspects, medical care continues to fail countless women each year, particularly minority women and women of color. Black and American Indian/Alaska Native women experienced exponentially more pregnancy-related deaths. Recognizing factors that underlie disparities in pregnancy-related deaths and implementing preventive approaches to resolve them may mitigate racial/ethnic disparities in pregnancy-related mortality. Future research on these disparities should focus on strategies for reducing racial/ethnic inequalities in pregnancy-related deaths, including improving access to high-quality preconception, maternity, and postpartum care for minority women, multi-ethnic education for physicians and healthcare providers in a bid to eliminate implicit biases, adequate funding, and improvement of healthcare facilities in minority areas, education of healthcare providers on variation in the incidence of some certain conditions in different ethnic groups so that care is patient-centered and culturally appropriate. All of these can be enforced through the community, healthcare facility, patient, family, physician, and system-level collaboration.

Prevalence of and factors associated with unplanned pregnancy among women in Koshu, Japan: cross-sectional evidence from Project Koshu, 2011-2016

Background

Unplanned pregnancy is a public health issue with adverse consequences for maternal and neonatal health. In Japan, the prevalence of unplanned pregnancy was 46.2% in 2002. However, few studies have investigated this topic, and there is little recent data from Japan. We described and examined the prevalence and determinants of unplanned pregnancy among rural women in Japan from 2011 to 2016.

Methods

We used cross-sectional data from a community-based cohort study (Project Koshu). Data were collected from 2011 to 2016 via a self-report questionnaire included in the Maternal and Child Health Handbook of Japan. Pregnancy intention was measured as a binary variable (planned or unplanned). Univariate and multivariate logistic regression analyses were performed to examine factors associated with unplanned pregnancy, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). We conducted sensitivity analyses with different definitions of pregnancy intention to assess the robustness of the results. The significance level was set at 5%.

Results

Of the 932 participants (mean ± standard deviation age at baseline: 31.3 ± 5.2 years), 382 (41%) pregnancies were reported as unplanned. The multivariate analyses showed that maternal age (+ 1 year: OR = 0.94, 95% CI: 0.92–0.97, p <  0.001), ‘other’ family structure (OR = 2.76, 95% CI: 1.12–6.76, p = 0.03), three or more pregnancies (OR = 2.26, 95% CI: 1.66–3.08, p <  0.001), current smoking (OR = 2.60, 95% CI: 1.26–5.35, p = 0.01), balanced diet (OR = 0.62, 95% CI: 0.47–0.83, p <  0.001) and current depression (OR = 1.63, 95% CI: 1.24–2.16, p <  0.001) were strongly associated with unplanned pregnancy. These associations were consistent across definitions of pregnancy intention, supporting the robustness of our results.

Conclusions

The prevalence of unplanned pregnancy in the study population was high (41%). Risk factors for unplanned pregnancy were age, number of pregnancies, smoking, having a balanced diet and current depression. These results suggest greater efforts are needed to enhance sex education for young people, improve access to family planning services and provide comprehensive health care for high-risk women to help reduce unplanned pregnancies.

An Intervention Delivered by Mobile Phone Instant Messaging to Increase Acceptability and Use of Effective Contraception Among Young Women in Bolivia: Randomized Controlled Trial

Background

Although the most effective methods of contraception are available in Bolivia, unmet need for contraception among women aged 15 to 19 years is estimated to be 38% (2008), and the adolescent fertility rate is 71 per 1000 women (2016). Mobile phones are a popular mode to deliver health behavior support. We developed a contraceptive behavioral intervention for young Bolivian women delivered by mobile phone and guided by behavioral science. The intervention consists of short instant messages sent through an app over 4 months.

Objective

This trial aimed to evaluate the effect of the intervention on young Bolivian women’s use of and attitudes toward the effective contraceptive methods available in Bolivia.

Methods

This was a parallel group, individually randomized superiority trial with a 1:1 allocation ratio. Women were eligible if they were aged 16 to 24 years, owned a personal Android mobile phone, lived in La Paz or El Alto, reported an unmet need for contraception, and could read Spanish. The target sample size was 1310 participants. Participants allocated to the intervention had access to an app with standard family planning information and intervention messages. Participants allocated to the control group had access to the same app and control messages. Coprimary outcomes were use of effective contraception and acceptability of at least one method of effective contraception at 4 months. Secondary outcomes were use of effective contraception during the study, acceptability of the individual methods, service uptake, unintended pregnancy, and abortion. Process outcomes included knowledge, perceived norms, personal agency, and intention. Outcomes were analyzed using logistic and linear regression. We also asked participants about physical violence.

Results

A total of 640 participants were enrolled, and 67.0% (429) of them contributed follow-up data for the coprimary outcome, the use of effective contraception. There was no evidence that use differed between the groups (33% control vs 37% intervention; adjusted odds ratio [OR] 1.19, 95% CI 0.80 to 1.77; P=.40). There was a borderline significant effect regarding acceptability (63% control vs 72% intervention; adjusted OR 1.49, 95% CI 0.98 to 2.28; P=.06). There were no statistically significant differences in any of the secondary or process outcomes. The intervention dose received was low. In the control group, 2.8% (6/207) reported experiencing physical violence compared with 1.9% (4/202) in the intervention group (Fisher exact test P=.75).

Conclusions

This trial was unable to provide definitive conclusions regarding the effect of the intervention on use and acceptability of effective contraception because of under recruitment. Although we cannot strongly recommend implementation, the results suggest that it would be safe and may increase the acceptability of effective contraception if the intervention messages were offered alongside the download of the app.

Trial Registration

ClinicalTrials.gov NCT02905526; https://clinicaltrials.gov/ct2/show/NCT02905526

Effect of Changes in Response Options on Reported Pregnancy Intentions: A Natural Experiment in the United States

Objectives

The Pregnancy Risk Assessment Monitoring System (PRAMS), conducted by the Centers for Disease Control and Prevention in collaboration with state health departments, is the largest state-level surveillance system that includes a question on the intention status of pregnancies leading to live birth. In 2012, the question was changed to include an additional response option describing uncertainty before the pregnancy about the desire for pregnancy. This analysis investigated how this additional response option affected women’s responses.

Methods

We used the change in the pregnancy intention question in 2012 as a natural experiment, taking advantage of relatively stable distributions of pregnancy intentions during short periods of time in states. Using PRAMS data from 2009-2014 (N = 222 781), we used a regression discontinuity-in-time design to test for differences in the proportion of women choosing each response option in the periods before and after the question change.

Results

During 2012-2014, 13%-15% of women chose the new response option, “I wasn’t sure what I wanted.” The addition of the new response option substantially affected distributions of pregnancy intentions, drawing responses away from all answer choices except “I wanted to be pregnant then.” Effects were not uniform across age, parity, or race/ethnicity or across states.

Conclusions

These effects could influence estimated levels and trends of the proportion of births that are characterized as intended, mistimed, or unwanted, as well as estimates of differences between demographic groups. These findings will help to inform new strategies for measuring pregnancy and childbearing desires among women.

Expanding choice through online contraception: a theory of change to inform service development and evaluation

BACKGROUND

This study presents the theory of change underpinning an intervention to provide online contraceptive care in an inner London area with high rates of unplanned pregnancy. It aims to suggest attributes of an effective service and to identify key questions for its evaluation.

METHODS

Thematic analysis of an online sexual and reproductive health programme funding application and 21 semi-structured interviews with a purposive sample of stakeholders selected to provide expertise in contraception and online health.

RESULTS

A theory of change model summarised the positive processes of change which could be initiated through increased access to contraceptive supplies, online information and remote interaction and support. Stakeholders predicted that perceptions of convenience and anonymity of online access would vary across the target population. They stressed the importance of trusting service-users' capabilities for autonomous contraceptive decision-making, but expressed concerns that online access could be detrimental for those requiring more complex care. Concerns were alleviated by the prospect of responsive support through text messaging and phone calls, and when the online service was positioned as part of a broader system of provision including physical services.

CONCLUSIONS

This study has revealed priority areas for the ongoing development of an online contraception service and pertinent evaluation questions. Evaluative research should test assumptions within the theory of change model, exploring the characteristics and circumstances of those preferring online access over existing services and the value of convenience, anonymity, autonomous access and responsive support in executing effective contraceptive choices within a new landscape of contraceptive delivery.

Unintended pregnancy and maternal health complications: cross-sectional analysis of data from rural Uttar Pradesh, India

BACKGROUND

This study aims to explore the potential association between unintended pregnancy and maternal health complications. Secondarily, we test whether antenatal care (ANC) and community health worker (CHW) visits moderate the observed association between unintended pregnancy and maternal health complications.

METHODS

Cross sectional data were collected using a multistage sampling design to identify women who had a live birth in the last 12 months across 25 highest risk districts of Uttar Pradesh (N = 3659). Participants were surveyed on demographics, unintendedness of last pregnancy, receipt of ANC clinical visits and community outreach during pregnancy, and maternal complications. Regression models described the relations between unintended pregnancy and maternal complications. To determine if receipt of ANC and CHW visits in pregnancy moderated associations between unintended pregnancy and maternal complications, we used the Mantel-Haenzel risk estimation test and stratified logistic models testing interactions of unintended pregnancy and receipt of health services to predict maternal complications.

RESULTS

Around one-fifth of the women (16.9%) reported that their previous pregnancy was unintended. Logistic regression analyses revealed that unintended pregnancy was significantly associated with maternal complications- pre-eclampsia (AOR:2.06; 95% CI:1.57-2.72), postpartum hemorrhage (AOR:1.46; 95% CI: 1.01-2.13) and postpartum pre-eclampsia (AOR:2.34; 95% CI:1.47-3.72). Results from the Mantel Haenszel test indicated that both ANC and CHW home visit in pregnancy significantly affect the association between unintended pregnancy and postpartum hemorrhage (p < 0.001).

CONCLUSION

Unintended pregnancy is associated with increased risk for maternal health complications, but provision of ANC clinical visits and CHW home visits in pregnancy may be able to reduce potential effects of unintended pregnancy on maternal health.

Pregnancy Intendedness by Maternal Disability Status and Type in the United States

CONTEXT

Societal views about sexuality and parenting among people with disabilities may limit these individuals' access to sex education and the full range of reproductive health services, and put them at increased risk for -unintended pregnancies. To date, however, no national population-based studies have examined pregnancy -intendedness among U.S. women with disabilities.

METHODS

Cross-sectional analyses of data from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth were conducted; the sample included 5,861 pregnancies reported by 3,089 women. The proportion of pregnancies described as unintended was calculated for women with any type of disability, women with each of five types of disabilities and women with no disabilities. Multivariate logistic regression analyses were conducted to examine the relationship of disability status and type with pregnancy intendedness while adjusting for covariates.

RESULTS

A higher proportion of pregnancies were unintended among women with disabilities than among women without disabilities (53% vs. 36%). Women with independent living disability had the highest proportion of unintended pregnancies (62%). In regression analyses, the odds that a pregnancy was unintended were greater among women with any type of disability than among women without disabilities (odds ratio, 1.4), and were also elevated among women with hearing disability, cognitive disability or independent living disability (1.5-1.9).

CONCLUSIONS

Further research is needed to understand differences in unintended pregnancy by type and extent of disability. People with disabilities should be fully included in sex education, and their routine care should incorporate discussion of reproductive planning.

Sexual Orientation Differences in Pregnancy and Abortion Across the Lifecourse

OBJECTIVES

We examined sexual orientation-related differences in various pregnancy outcomes (e.g., teen pregnancy, abortion) across the lifespan.

METHODS

We collected data from 124,710 participants in three U.S. longitudinal cohort studies, the Nurses' Health Study 2 and 3 and Growing Up Today Study 1, followed from 1989 to 2017. Multivariate regression was used to calculate differences of each outcome-ever had pregnancy, teen pregnancy, ever had abortion, and age at first birth-by sexual orientation groups (e.g., heterosexual, mostly heterosexual, bisexual, lesbian), adjusting for potential confounders of age and race/ethnicity.

RESULTS

All sexual minority groups-except lesbians-were generally more likely than heterosexual peers to have a pregnancy, a teen pregnancy, and an abortion. For example, Growing Up Today Study 1 bisexual participants were three times as likely as heterosexuals to have had an abortion (risk ratio, 3.21; 95% confident interval, 1.94-5.34). Lesbian women in all of the cohorts were approximately half as likely to have a pregnancy compared with heterosexual women. Few sexual orientation group differences were detected in age at first birth.

CONCLUSIONS

The increased risk of unintended pregnancy among sexual minority women likely reflects structural barriers to sexual and reproductive health services. It is critical that sex education programs become inclusive of sexual minority individuals and medical education train health care providers to care for this population. Health care providers should not make harmful heteronormative assumptions about pregnant patients and providers must learn to take sexual histories as well as offer contraceptive counseling to all patients who want to prevent a pregnancy regardless of sexual orientation.

Association of Unintended Pregnancy With Spontaneous Fetal Loss in Women With Epilepsy: Findings of the Epilepsy Birth Control Registry

Importance

If unintended pregnancy is common among women with epilepsy and is associated with increased risk of spontaneous fetal loss (SFL), it is important to develop guidelines for safe and effective contraception for this community.

Objective

To assess whether planned pregnancy is a determinant of SFL in women with epilepsy.

Design, Setting, and Participants

The Epilepsy Birth Control Registry conducted this web-based, retrospective survey between 2010 and 2014. It gathered demographic, epilepsy, antiepileptic drug (AED), contraceptive, and reproductive data from 1144 women with epilepsy in the community between ages 18 and 47 years. Data were analyzed between March 2018 and May 2018.

Main Outcomes and Measures

The primary outcome was the risk ratio (RR) with 95% confidence intervals for SFL in unplanned vs planned pregnancies. The secondary outcome was the identification of some potentially modifiable variables (maternal age, pregnancy spacing, and AED category) of SFL vs live birth using binary logistic regression.

Results

The participants were proportionally younger (mean [SD] age, 28.5 [6.8] years), and 39.8% had household incomes of $25 000 or less. Minority women represented only 8.7% of the participants. There were 530 of 794 unplanned pregnancies (66.8%) and 264 of 794 planned pregnancies (33.2%). The risk for SFL in 653 unaborted pregnancies in women with epilepsy was greater for unplanned (n = 137 of 391; 35.0%) than planned (n = 43 of 262; 16.4%) pregnancies (RR, 2.14; 95% CI, 1.59-2.90; P < .001). Regression analysis found that the risk for SFL was greater when planning was entered alone (odds ratio [OR], 2.75; 95% CI, 1.87-4.05; P < .001) and more so when adjusted for maternal age, interpregnancy interval, and AED category (OR, 3.57; 95% CI, 1.54-8.78; P = .003). Interpregnancy interval (OR, 2.878; 95% CI, 1.8094-4.5801; P = .008) and maternal age (OR, 0.957; 95% CI, 0.928-0.986 for each year from 18 to 47 years; P = .02), but not AED category, were also associated. The risk was greater when interpregnancy interval was less than 1 year (n = 56 of 122; 45.9%) vs greater than 1 year (n = 56 of 246; 22.8%) (RR, 2.02; 95% CI, 1.49-2.72; P < .001). Relative to the younger than 18 years cohort (n = 15 of 29; 51.7%), the risks were lower for the intermediate older cohort aged 18 to 27 years (n = 118 of 400; 29.5%; RR, 0.57; 95% CI, 0.39-0.84; P < .004) and the cohort aged 28 to 37 years (n = 44 of 212; 20.8%; RR, 0.40; 95% CI, 0.26-0.62; P < .001) but not significantly different for the small number of participants in the aged 38 to 47 years cohort (n = 3 of 12; 25.0%). No individual AED category's SFL frequency differed significantly from the no AED category.

Conclusions and relevance

The Epilepsy Birth Control Registry retrospective survey finding that unplanned pregnancy in women with epilepsy may double the risk for SFL warrants prospective investigation with outcome verification.