Conceptualisation, development, and evaluation of a measure of unplanned pregnancy

Implementation of the London Measure of Unplanned Pregnancy in routine antenatal care: A mixed-methods evaluation in three London NHS Trusts

INTRODUCTION

Unplanned pregnancies are associated with increased risks. Despite this, they are currently not routinely detected during antenatal care. This study evaluates the implementation of the London Measure of Unplanned Pregnancy (LMUP) - a validated measure of pregnancy planning - into antenatal care at University College London Hospital, Homerton Hospital, and St Thomas' Hospital, England, 2019-2023.

METHODS

We conducted a mixed methods evaluation of the pilot. Uptake and acceptability were measured using anonymized data with non-completion of the LMUP as a proxy measure of acceptability overall. We conducted focus groups with midwives, and one-to-one interviews with women, to explore their thoughts of asking, or being asked the LMUP, which we analyzed with a Framework Analysis.

RESULTS

Asking the LMUP at antenatal appointments is feasible and acceptable to women and midwives, and the LMUP performed as expected. Advantages of asking the LMUP, highlighted by participants, include providing additional support and personalizing care. Midwives' concerns about judgment were unsubstantiated; women with unplanned pregnancies valued such discussions.

CONCLUSIONS

These findings support the implementation of the LMUP in routine antenatal care and show how it can provide valuable insights into the circumstances of women's pregnancies. This can be used to help midwives personalize care, and potentially reduce adverse outcomes and subsequent unplanned pregnancy. Integration of the LMUP into the Maternity Services Data Set will establish national data collection of a validated measure of unplanned pregnancy and enable analysis of the prevalence, factors, and implications of unplanned pregnancies across subpopulations and over time to inform implementation.

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.

A Multidimensional and Longitudinal Exploratory Study of the Stability of Pregnancy Contexts in the United States

Objective

Evaluate the longitudinal stability of six pregnancy contexts, including intention, in a diverse cohort of individuals experiencing delivery, abortion, or miscarriage.

Methods

We enrolled individuals 16-44 years of age with pregnancies <24 weeks gestation in this longitudinal study between June 2014 and June 2015 in four US urban clinics. We assessed six pregnancy contexts (intention, wantedness, planning, timing, desirability, and happiness) at enrollment and 3-month follow-up. We constructed three-level categorical measures for each context defined as favorable, ambivalent, or unfavorable. We used Wilcoxon sign tests to evaluate changes in paired observations between pregnancy context measures over time and by pregnancy outcome.

Results

Among 121 participants at median gestational age of 7 weeks and 3 days, we found intention, wantedness, planning, timing, and happiness remained unchanged from enrollment in early pregnancy to 3-month follow-up. Individuals demonstrated changes in desirability; pregnancy assessments shifted toward less desirable from enrollment to follow-up (p = 0.01) (i.e., desired to ambivalent, or ambivalent to undesired). Among participants choosing delivery (57%), assessments shifted toward more favorable planning (i.e., unplanned to ambivalent, or ambivalent to planned) (p < 0.01), and less favorable desirability (i.e., desired to ambivalent or ambivalent to undesired) (p < 0.01) at follow-up. Among participants choosing abortion (28%), assessments shifted toward more unfavorable planning (i.e., planned to ambivalent, or ambivalent to unplanned) at follow-up (p < 0.01).

Conclusion

In multidimensional, longitudinal assessment, pregnant participants' perspectives on five of six pregnancy contexts remained unchanged between enrollment and 3-month follow-up; only desirability shifted. Pregnancy planning perspectives differed by pregnancy outcome.Human Research Subjects Protection Program: 1310012926.

Prenatal Substance Use Among Young Pregnant Sexual Minority People

Purpose: Sexual minority (SM) youth have higher rates of substance use and pregnancy but are absent from the prenatal substance use literature. We modeled the impact of SM identity and syndemic factors on prenatal substance use among 14- to 21-year-olds. Methods: Pregnant people completed an online survey (n = 357). Prenatal substance use was regressed on SM identity, controlling for other syndemic factors (e.g., depressive symptoms, intimate partner violence) and household substance use. Results: Pregnant SM participants (n = 125) were primarily bisexual and were more likely to use tobacco and illicit drugs than heterosexual participants (n = 232). The association between SM identity and prenatal tobacco use was not attenuated by syndemic factors, prenatal cannabis use, or household tobacco use. Conclusion: SM people need increased support for smoking cessation to redress health inequities in tobacco use, prevent prenatal exposures to tobacco, and limit the long-term consequences of tobacco use on health.

Pregnancy and pregnancy intention after experiencing infertility: A longitudinal study of women in Malawi

BACKGROUND

Infertility is a common experience among individuals and couples. Infertility may resolve without intervention, but little is known about pregnancy intentions and incidence of pregnancy following infertility, particularly in low-resource settings.

METHODS

Data come from UTHA, a longitudinal cohort study in Central Malawi, with baseline and follow up surveys conducted from 2014-2019 (N = 1,030 reproductive-aged women). We assessed bivariable and multivariable relationships between reported infertility at baseline and subsequent pregnancy and retrospective pregnancy intentions. Pregnancy intention was measured with the London Measure of Unplanned Pregnancy (LMUP), a scale validated in Malawi (Range = 0-12).

RESULTS

Approximately 20% of the sample reported that they had ever experienced infertility (tried to become pregnant for at least two years without conceiving in that time) at baseline. The proportion of women who reported a new pregnancy during the follow up period (mean = 4.3 years) was the same (65%) for women who had and had not experienced infertility. Among women who became pregnant, levels of pregnancy intendedness were similar between women who had and had not experienced infertility. Prospective desire for a/another child at baseline was associated with subsequent pregnancy (AOR: 1.59; 95%CI: 1.06-2.39) and was also associated with higher levels of pregnancy intendedness measured retrospectively (LMUP of 9.4 vs. 8.4).

CONCLUSIONS

Experienced infertility was not associated with differential odds of having a subsequent pregnancy or the intendedness of a subsequent pregnancy. Thus, women who have experienced infertility should be included in family planning programs and research to support all women in achieving their reproductive goals.

Pregnancy intention and preconception contraceptive behaviors and substandard prenatal care in France

OBJECTIVE

Evaluate the association between a combined measure of time-based pregnancy intention and preconception contraceptive behavior and suboptimal prenatal care.

POPULATION AND METHOD

Women delivering a live birth in all maternity units during one week in March 2016 were interviewed in the postpartum ward (N = 13,132). Multinomial logistic regression models were used to assess the association between the indicator of pregnancy intention and substandard prenatal care (late initiation of care and less than the recommended number of prenatal visits (<60% recommended)).

RESULTS

83.6% of women had timed pregnancies, 4.7% had mistimed pregnancies but discontinued contraception to conceive, 8.0% had mistimed pregnancies without discontinuing contraception to conceive and 3.7% had unwanted pregnancies. Women with timed pregnancies or mistimed pregnancies despite discontinuing contraception to conceive were more socially advantaged than those who had an unwanted pregnancy or a mistimed pregnancy without discontinuing contraception to conceive. 3.3% of women had a substandard number of prenatal visits and 2.5% had delayed prenatal care initiation. The adjusted odds ratios (aOR) of substandard prenatal visits were high among women with unwanted pregnancies (aOR=2.78; 95% confidence interval [1.91-4.05]) and women with mistimed pregnancies who had not discontinued contraception to conceive (aOR=1.69; [1.21-2.35]) compared to women with timed pregnancies. No difference was observed for women with mistimed pregnancies who discontinued contraception to conceive (aOR=1.22; [0.70-2.12]).

CONCLUSION

Using routinely collected information on preconception contraception allows a more nuanced assessment of pregnancy intentions that can help caregivers identify women at greater risk of substandard prenatal care.

Exploring Multiple Measures of Pregnancy Preferences and Their Relationship with Postpartum Contraceptive Uptake Using Longitudinal Data from PMA Ethiopia

There are significant gaps in our understanding of how the experience of an unintended pregnancy affects subsequent contraceptive behavior. Our objective was to explore how three measures of pregnancy preferences-measuring timing-based intentions, emotional orientation, and planning status-were related to the uptake of postpartum family planning within one year after birth. Additionally, we tested whether the relationship between each measure and postpartum family planning uptake differs by parity, a key determinant of fertility preference. Adjusted hazards regression results show that the timing-based measure, specifically having a mistimed pregnancy, and the emotional response measure, specifically being unhappy, were associated with contraceptive uptake in the extended postpartum period, while those related to pregnancy planning, as measured by an adapted London Measure of Unplanned Pregnancy, were not. This effect differed by parity; high parity women were consistently the least likely to use contraception in the postpartum period, but the effect of experiencing an unwanted pregnancy or having a mixed reaction to a pregnancy was significantly stronger among high parity compared to low parity women. Greater attention to the entirety of women's responses to unanticipated pregnancies is needed to fully understand the influence of unintended pregnancy on health behaviors and outcomes for women and their children.

A partner-specific critique of mistimed and unwanted fertility: Results from an analysis of the 2017-2019 United States National Survey of Family Growth

CONTEXT

Despite substantial critiques of retrospective measures of fertility intentions, researchers widely use the metrics of unwanted and mistimed pregnancies as tools for monitoring patterns and trends in reproductive health. However, in focusing exclusively on the timing and numeric elements of fertility these constructs ignore partner-specific desires, which may lead to considerable measurement error and threaten their validity.

METHODOLOGY

We use data on births in the last 5 years from the 2017-2019 United States National Survey of Family Growth to compare responses to the standard retrospective measure of fertility intentions with responses to a partner-specific question that asks respondents about whether they had ever desired a child with that partner.

RESULTS

We find that women's responses to questions on retrospective fertility desires with and without reference to a particular partner vary in ways that suggest that women and researchers interpret these questions differently.

DISCUSSION

Despite a long history in fertility research, the standard approach to measuring mistimed and unwanted fertility is both conceptually and operationally flawed. In the context of complicated sexual and reproductive lives that do not start and end with a single partner, researchers should reevaluate the usefulness of the constructs of mistimed and unwanted fertility. We conclude by offering recommendations for analysts and survey designers as well as by calling for a move away from the terms entirely to focus instead on the pregnancies that women themselves view as most problematic.

Unintended pregnancy and its associated factors among women with disabilities in central Sidama National Regional State, Ethiopia: a multilevel analysis

BACKGROUND

Unintended pregnancy is one of the most common reproductive health problems. The problem makes women with disabilities doubly burdened by their disabilities. The previous evidences are inconsistent and do not address all women with disabilities. The study aimed to assess the prevalence of unintended pregnancy and its associated risk factors among women with disabilities in Dale and Wonsho districts and Yirgalem city administration central Sidama National Regional State, Ethiopia.

METHODS

A community-based cross-sectional study design was conducted among 355 randomly selected women with disabilities living in the selected districts from June 20 to July 15, 2022. The data were collected through face-to-face interviews using a structured questionnaire. A multilevel logistic regression analysis model was employed to identify factors associated with an unintended pregnancy. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to report the measures of associations.

RESULTS

In this study, the prevalence of unintended pregnancy among women with disabilities was 65.6% (95% CI: 60.4, 70.6). After adjusting for potential confounding variables, middle economic status (AOR = 2.07; 95% CI: 1.02, 4.20), giving birth (AOR = 2.20; 95% CI: 1.21, 3.99), extremity paralysis types of disability (AOR = 0.26; 95% CI: 0.12, 0.57), living in urban residences (AOR = 0.22; 95% CI: 0.12, 0.40) and alcohol using (AOR = 0.28; 95% CI: 0.11, 0.74) were risk factors with unintended pregnancy.

CONCLUSIONS

Unintended pregnancy among women with disabilities is remarkably high in central Sidama National Regional State, Ethiopia. Economic status, giving birth, types of disability, residence, and alcohol use were factors associated with an unintended pregnancy. As a result, economic empowerment, strengthening education and information about unintended pregnancy and its prevention strategies in rural settings are vital.

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.

The prevalence and variations in unintended pregnancy by socio-demographic and health-related factors in a population-based cohort of young Australian women

OBJECTIVE

The aim of this study is toestimate the prevalence of unintended pregnancy and associated socio-demographic and health-related factors among a national cohort of young Australian women.

METHODS

Secondary analysis of three waves (2013-2015) of the Australian Longitudinal Study on Women's Health new young cohort. Women born between 1989 and 1995 were recruited through internet and traditional media, and peer referral. Respondents completed a baseline web-based survey in 2013 (n=17,010) on their health and healthcare use and were followed up annually. This analysis uses data from women reporting ever having vaginal sex in waves 2 (n=9,726/11,344) and 3 (n=6,848/8,961). We assessed correlates of lifetime and recent unintended pregnancy using multivariable regression models.

RESULTS

At wave 2, among women aged 19-24, lifetime prevalence of unintended pregnancy was 12.6%, rising to 81.0% among ever pregnant women. Pregnancy outcomes among women with a history of unintended pregnancy differed by geographical residence. Disparities in odds of unintended pregnancy were seen by relationship and educational status, contraceptive use, sexual coercion and risky alcohol use.

CONCLUSIONS

Unintended pregnancy among young Australians is disproportionally experienced by women with structural disadvantages and exposure to sexual coercion.

PUBLIC HEALTH IMPLICATIONS

Service improvements to achieve equitable distribution of contraception and abortion services must be integrated with initiatives responding to sexual coercion.

Evaluation of the London Measure of Unplanned Pregnancy (LMUP) among a nationally representative sample of pregnant and postpartum women Ethiopia

Objectives

Rigorous measurement of pregnancy preferences is needed to address reproductive health needs. The London Measure of Unplanned Pregnancy (LMUP), developed in the UK, has been adapted for low-income countries. Psychometric properties of LMUP items remain uncertain in contexts with limited access to and use of health services.

Study design

This cross-sectional study examines the six-item LMUP's psychometric properties among a nationally representative sample of 2855 pregnant and postpartum women in Ethiopia. Principal components analysis (PCA) and confirmatory factor analysis (CFA) estimated psychometric properties. Hypothesis testing examined associations between the LMUP and other measurement approaches of pregnancy preferences using descriptive statistics and linear regression.

Results

The six-item LMUP had acceptable reliability (α = 0.77); two behavioral items (contraception, preconception care) were poorly correlated with the total scale. A four-item measure demonstrated higher reliability (α = 0.90). Construct validity via PCA and CFA indicated the four-item LMUP's unidimensionality and good model fit; all hypotheses related to the four-item LMUP and other measurement approaches were met.

Conclusions

Measurement of women's pregnancy planning in Ethiopia may be improved through use of a four-item version of the LMUP scale. This measurement approach can inform family planning services to better align with women's reproductive goals.

Implications

Improved pregnancy preference measures are needed to understand reproductive health needs. A four-item version of the LMUP is highly reliable in Ethiopia, offering a robust and concise metric for assessing women's orientations toward a current or recent pregnancy and tailoring care to support them in achieving their reproductive goals.

Factors associated with ever using cannabidiol in a cohort of younger pregnant people

One in four Americans have used cannabidiol (CBD) products in the past year, and use has become prevalent in many Western countries with recent deregulation from a controlled or illicit substance to an unrestricted product. CBD is also marketed to pregnant people to treat common medical conditions. However, preclinical work has linked cannabidiol exposure to embryotoxicity, as well as neuroendocrine, reproductive, and behavioral effects in offspring. No studies have examined the prevalence or correlates of CBD use among pregnant people. Demographic, medical, and psychosocial correlates of cannabidiol use were examined in the YoungMoms study, a cohort of pregnant people under the age of 22, a population that is at high risk for cannabis use during pregnancy. Few of the participants (n = 186; 75% Black or Biracial) reported use of cannabidiol during pregnancy, but one in five had tried these products. Participants who reported ever using CBD were more likely to report alcohol and other drug use prior to pregnancy, controlling for race.As the use of CBD among people of reproductive age is increasingly prevalent, more research on CBD use in pregnant human populations is needed to investigate the effects of CBD on fetal development and infant outcomes.

The impact of depression at preconception on pregnancy planning and unmet need for contraception in the first postpartum year: a cohort study from rural Malawi

BACKGROUND

The impact of depression on women's use of contraception and degree of pregnancy planning in low-income settings has been poorly researched. Our study aims to explore if symptoms of depression at preconception are associated with unplanned pregnancy and nonuse of contraception at the point of conception and in the postpartum period.

METHODS

Population-based cohort of 4244 pregnant women in rural Malawi were recruited in 2013 and were followed up at 28 days, 6 months and 12 months postpartum. Women were asked about symptoms of depression in the year before pregnancy and assessed for depression symptoms at antenatal interview using the Self-Reporting Questionnaire-20, degree of pregnancy planning using the London Measure of Unplanned Pregnancy and use of contraception at conception and the three time points postpartum.

RESULTS

Of the 3986 women who completed the antenatal interview, 553 (13.9%) reported depressive symptoms in the year before pregnancy and 907 (22.8%) showed current high depression symptoms. History of depression in the year before pregnancy was associated with inconsistent use of contraception at the time of conception [adjusted relative risk (adjRR) 1.52; 95% confidence interval (1.24-1.86)] and higher risk of unplanned [adjRR 2.18 (1.73-2.76)] or ambivalent [adj RR 1.75 (1.36-2.26)] pregnancy. At 28 days post-partum it was also associated with no use of contraception despite no desire for a further pregnancy [adjRR 1.49 (1.13-1.97)] as well as reduced use of modern contraceptives [adj RR 0.74 (0.58-0.96)]. These results remained significant after adjusting for socio-demographic factors known to impact on women's access and use of family planning services, high depression symptoms at antenatal interview as well as disclosure of interpersonal violence. Although directions and magnitudes of effect were similar at six and 12 months, these relationships were not statistically significant.

CONCLUSIONS

Depression in the year before pregnancy impacts on women's use of contraception at conception and in the early postpartum period. This places these women at risk of unplanned pregnancies in this high fertility, high unmet need for contraception cohort of women in rural Malawi. Our results call for higher integration of mental health care into family planning services and for a focus on early postnatal contraception.

The Effect of Maternal-Foetal Attachment-Based Training Programme on Maternal Mental Health Following an Unintended Pregnancy

INTRODUCTION

Unintended pregnancy is a risk factor for less maternal-fetal attachment (MFA) and low levels of psychological well-being. This study was conducted to determine the effect of an MFA-based training programme on maternal anxiety, depression and worries following an unintended pregnancy.

METHODS

This randomised clinical trial was conducted on 68 women with an unintended pregnancy in north of  Iran during 2018-2019. Participants were allocated to the trained and control groups through simple randomisation. The trained group received the MFA-based training for three 90-min sessions. Demographic questionnaire, London measure of unplanned pregnancy, Cranley's MFA scale, Edinburgh postnatal depression, Spielberger anxiety and prenatal distress questionnaires were used. Data were analysed by descriptive statistics, chi square, Fisher's exact test, independent and paired-samples t-tests, Mann-Whitney U, analysis of covariance, and multivariate analysis of variance.

RESULTS

After the intervention, the mean MFA, anxiety and depression scores were not significantly different between the trained and control groups Worry was significantly decreased in the trained group (p = 0.001) and increased in the control group (p = 0.03).

DISCUSSION

Although the MFA-based training could not significantly improve MFA, maternal anxiety and depression, it has been effective on worry in women with the unintended pregnancies.

Interpersonal relationships modulate subjective ratings and electrophysiological responses of moral evaluations

This study explored how interpersonal relationships modulate moral evaluations in moral dilemmas. Participants rated moral acceptability in response to altruistic (prescriptive) and selfish (proscriptive) behavior conducted by allocators (i.e., a friend or stranger), toward the participants themselves or another stranger in a modified Dictator Game (Experiments 1 and 2). Event-related potential (ERP) data were recorded as participants observed the allocators' behavior (Experiment 2). Moral acceptability ratings showed that when the allocator was a friend, participants evaluated the friend's altruistic and selfish behavior toward another stranger as being less morally acceptable than when their friend showed the respective behavior toward the participants themselves. The ERP results showed that participants exhibited more negative medial frontal negativity (MFN) amplitude whether observing a friend's altruistic or selfish behavior toward a stranger (vs. participant oneself), indicating that friends' altruistic and selfish behaviors toward strangers (vs. participants) were processed as being less acceptable at the earlier and semi-automatic processing stage in brains. However, this effect did not emerge when the allocator was a stranger in subjective ratings and MFN results. In the later-occurring P3 component, no interpersonal relationship modulation occurred in moral evaluations. These findings suggest that interpersonal relationships affect moral evaluations from the second-party perspective.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

BACKGROUND

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies.

METHODS

We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data.

RESULTS

407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively.

CONCLUSION

The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

Addressing reproductive health needs across the life course: an integrated, community-based model combining contraception and preconception care

Prevention of pregnancy (contraception) and preparation for pregnancy (preconception care) are services that most people need during their reproductive life course. Despite increased attention, and growing recognition that health before pregnancy is crucial to addressing disparities in maternity outcomes, service provision is far from routine. We bring together evidence from the literature, new quantitative and qualitative data on women's preferences, and case studies of existing practice, to develop an integrated, community-based model that synthesises reproductive life planning, contraception, and preconception care. Our model provides a holistic, life course approach, encompassing school-based education, social media, and national campaigns, and highlights the need for training and system-level support for the range of health-care professionals who can deliver it. This high-level model can be adapted across settings, leading to a step change in the provision of preconception care in the community with consequent improvements in health and wellbeing, and reductions in inequalities at population level.

Carrying an unintended pregnancy to term and long-term maternal psychological distress: Findings from the Dutch prospective Amsterdam Born Children and their Development study

BACKGROUND

Given the estimated high rate of unintended pregnancies, it is important to investigate long-term effects on psychological distress in women carrying an unintended pregnancy to term. However, research into associations between unintended pregnancies carried to term and psychological distress postpartum is mixed, and especially, evidence on long-term associations is scarce.

OBJECTIVE

To examine whether carrying an unintended pregnancy to term is associated with maternal psychological distress later in life, up to 12 years postpartum.

DESIGN

This study is based on the population-based birth cohort study 'Amsterdam Born Children and their Development' study, which included pregnant people in 2003 (n = 7784) and followed them up until 12 years postpartum.

METHODS

Unintended pregnancy was measured as a multidimensional construct, based on self-reported data around 16 weeks gestation on pregnancy mistiming, unwantedness and unhappiness. Symptoms of maternal psychological distress were assessed around 3 months, 5 years and 12 years postpartum using multiple questionnaires measuring symptoms of depression, anxiety and stress. Multiple structural equation modelling models were analysed, examining the associations between dimensions of unintended pregnancy and maternal psychological distress per time point, while controlling for important co-occurring risks.

RESULTS

Pregnancy mistiming and unhappiness were significant predictors of more maternal psychological distress around 3 months postpartum. Around 5 years postpartum, only pregnancy mistiming was positively associated with maternal psychological distress. Dimensions of unintended pregnancy were no longer associated with maternal psychological distress around 12 years postpartum. Strikingly, antenatal psychological distress was a much stronger predictor of maternal psychological distress than pregnancy intention dimensions.

CONCLUSION

Those who carried a more unintended pregnancy to term reported more symptoms of psychological distress at 3 months and 5 years postpartum. People carrying an unintended pregnancy to term may benefit from extra support, not because of the pregnancy intentions per se, but because they may be related to antenatal psychological distress.

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.

The effect of a locally tailored intervention on the uptake of preconception care in the Netherlands: a stepped-wedge cluster randomized trial (APROPOS-II study)

BACKGROUND

The preconception period provides a window of opportunity for interventions aiming to reduce unhealthy lifestyle behaviours and their negative effect on pregnancy outcomes. This study aimed to assess the effectiveness of a locally tailored preconception care (PCC) intervention in a hybrid-II effectiveness implementation design.

METHODS

A stepped-wedge cluster randomized controlled trial was performed in four Dutch municipalities. The intervention contained a social marketing strategy aiming to improve the uptake (prospective parents) and the provision (healthcare providers) of PCC. Prospective parents participated by administering a questionnaire in early pregnancy recalling their preconceptional behaviours. Experiences of healthcare providers were also evaluated through questionnaires. The composite primary outcome was adherence to at least three out of four preconceptional lifestyle recommendations (early initiation of folic acid supplements, healthy nutrition, no smoking or alcohol use). Secondary outcomes were preconceptional lifestyle behaviour change, (online) reach of the intervention and improved knowledge among healthcare providers.

RESULTS

A total of 850 women and 154 men participated in the control phase and 213 women and 39 men in the intervention phase. The composite primary outcome significantly improved among women participating in the municipality where the reach of the intervention was highest (Relative Risk (RR) 1.57 (95% Confidence Interval (CI) 1.11-2.22). Among women, vegetable intake had significantly improved in the intervention phase (RR 1.82 (95%CI 1.14-2.91)). The aimed online reach- and engagement rate of the intervention was achieved most of the time. Also, after the intervention, more healthcare providers were aware of PCC-risk factors (54.5% vs. 47.7%; p = 0.040) and more healthcare providers considered it easier to start a conversation about PCC (75.0% vs. 47.9%; p = 0.030).

CONCLUSION

The intervention showed some tentative positive effects on lifestyle behaviours among prospective parents. Primarily on vegetable intake and the knowledge and competence of healthcare providers. The results of this study contribute to the evidence regarding successfully implementing PCC-interventions to optimize the health of prospective parents and future generations.

TRIAL REGISTRATION

Dutch Trial Register: NL7784 (Registered 06/06/2019).

Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial

BACKGROUND

Counseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care.

METHODS

We describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected.

RESULTS

The trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing.

CONCLUSIONS

Results will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings.

TRIAL REGISTRATION

http://ClinicalTrials.gov Identifier: NCT04584294 Trial Status: Recruiting.

Assessment of person-centeredness in healthcare and social support services for women with unintended pregnancy (CarePreg): protocol for a mixed-method study

INTRODUCTION

For women with unintended pregnancy, access to high-quality care has been found limited due to social stigma and legal restrictions, especially when seeking abortion. To foster person-centeredness (PC), recognising the experiences and needs of women is the first premise. This study aims to (1) identify relevant dimensions of PC (2) evaluate PC in healthcare and social support services, (3) develop recommendations for further actions in healthcare and social support services for women with unintended pregnancy.

METHODS AND ANALYSIS

We will use a mixed-methods approach. Phase 1: expert workshops with 10-15 healthcare professionals and counsellors and semistructured interviews with 15-20 women with unintended pregnancy will be conducted to assess the relevance of PC dimensions. Phase 2: quantitative assessment of PC dimensions within healthcare and support services will be conducted. We aim to include 600 women with an unintended pregnancy (1) until 24 weeks of pregnancy or (2) who sought abortion within the past 8 weeks, over three measurement points within 12 months. To deepen the results, semistructured interviews will be conducted. Phase 3: a workshop with 10-15 experts and an online survey with 100-150 experts will be used to indicate recommendations. Participants will be gained through relevant care facilities. An ethical advisory board and an advisory board of affected women will be involved throughout the study.

ETHICS AND DISSEMINATION

The study will be carried out in accordance to the latest version of the Helsinki Declaration of the World Medical Association and principles of good scientific practice. The study was approved by the Local Psychological Ethics Committee of the University Medical Center Hamburg-Eppendorf, Germany (LPEK-0260). Written informed consent will be sought prior to study participation. The study results will be disseminated in scientific journals, through collaboration partners and plain language press releases.

Women's Life Experiences and Shifting Reports of Pregnancy Planning

BACKGROUND

Unplanned pregnancy is associated with adverse consequences for women. Yet, these associations are typically based on women's reports of pregnancy planning provided post birth. Therefore, women's recollection of their pregnancy planning may be influenced by their adverse life circumstances following the pregnancy, artificially driving these associations.

METHODS

To understand how post-birth experiences pattern women's recall of their pregnancy planning, we conducted 17 in-depth interviews with young women (24-34 years old) enrolled in a longitudinal study in southern Malawi. Respondents who were pregnant at the time of data collection in 2015 answered close-ended questions about the planning of their pregnancy. During in-depth interviews three years later, women discussed their life experiences since the pregnancy and were re-asked a subset of the same questions about the planning of the 2015 pregnancy. We thematically coded respondents' narratives about their relationships, parenting, and economic situations in the three years following their pregnancy and mapped these onto changes in women's pre- and post-birth reports of their pregnancy planning.

RESULTS

More than one-half of respondents recalled their pregnancy planning differently than they did pre-birth-some as more planned, others as less planned. The presence and direction of women's changing reports were patterned by the quality of their relationship with the child's father, the father's involvement as a partner and parent, and their economic situation.

CONCLUSIONS

Women's life experiences following a birth correspond with changes in their pregnancy planning reports, emphasizing the limitations of using retrospective measures to study the consequences of unplanned fertility.

Achieving proportional representation in a reproductive health survey through social media: process and recommendations

Background

The narrative surrounding women’s reproductive health has shifted from a medical model to an emphasis on reproductive well-being over different life-stages. We developed and piloted a tracker survey for monitoring women’s reproductive health and well-being in England, recruiting respondents online. This paper reports on the success of the online recruitment strategies in achieving a sample proportionally representative of the England general population.

Methods

Recruitment was through Facebook and Instagram advertisements and dissemination through Twitter and a blog. At the end week one, the sample was reviewed and compared to the 2011 Census England population. From week two, recruitment targeted under-represented groups. Key data were compared with prevalence estimates from the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

Results

Between 1 July-17 August 2021, 13,962 people initiated the online survey, with 11,578 completing it. Numbers were low initially, but peaked at 1700 survey initiations per day after increasing the daily advertisement budget on day seven. At the end of week one, minority ethnic groups and people without a degree or equivalent were under-represented. From week two, we altered the advertisement settings to show to people whose profile indicated they were a ‘high school leaver’ had ‘up to some high school’, worked in industries that do not typically require a degree or lived in local authorities with a high proportion of ethnic minority residents. This had a modest effect, with the final sample short of proportional representation in terms of ethnicity and education but close in terms of region and age. Compared to Natsal-3, we found consistency in the proportion of respondents reporting an abortion and a live birth in the last year, however, the proportion of our sample reporting ever having experienced infertility was significantly higher than in Natsal-3, as was the proportion of ‘planned’ pregnancies in the last year.

Conclusions

It is possible to recruit large numbers of respondents online, relatively quickly, to complete a reproductive health survey. This will be valuable to track reproductive health and well-being at a national level over time. More work is needed to understand reasons for non-response among under-represented groups.

Evaluation of Preconception Dietary Patterns in Women Enrolled in a Multisite Study

Background

Diet indices are widely used in nutritional research across communities but do not "capture" the full extent of diet variability across multiple countries. Empirically derived dietary patterns can provide additional information because they reflect combinations of foods potentially associated with health outcomes. Limited studies have evaluated preconception dietary patterns in heterogeneous populations.

Objectives

In the multisite Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose Metabolism and Offspring Health (NiPPeR) study, the secondary aims included: 1) derive pooled and site-specific preconception dietary patterns, and 2) evaluate these patterns using anthropometric measures and metabolic biomarkers.

Methods

Women planning pregnancy (n = 1720) in the United Kingdom, Singapore, and New Zealand completed interviewer-administered harmonized FFQs and lifestyle questionnaires at recruitment. Across-cohort ("pooled") and site-specific dietary patterns were derived, and associations between dietary pattern scores and BMI, waist-to-hip ratio, plasma lipids, and glycemia assessed using multivariable linear regression, expressing results as SD change in outcome per SD change in dietary pattern score.

Results

The pooled analysis identified 3 dietary patterns: "Vegetables/Fruits/Nuts" ("Healthy"), "Fried potatoes/Processed meat/Sweetened beverages" ("Less Healthy"), and "Fish/Poultry/Noodles/Rice" ("Mixed"). The "Healthy" and "Less Healthy" pooled pattern scores were highly correlated with their corresponding site-specific dietary pattern scores ("Healthy": ρ = 0.87-0.93; "Less Healthy": ρ = 0.65-0.88). Women with higher scores for the "Healthy" pooled pattern had a lower waist-to-hip ratio (standardized β: -0.10; 95% CI: -0.18, -0.01); those with higher scores for the "Less Healthy" pooled pattern had a higher BMI (standardized β: 0.17; 95% CI: 0.09, 0.24), higher LDL cholesterol (standardized β: 0.10; 95% CI: 0.01, 0.19), and less optimal glucose profiles. However, we noted higher adherence to the "Healthy" pooled pattern with higher BMI.

Conclusions

The "Healthy" and "Less Healthy" pooled patterns were comparable to the corresponding site-specific patterns. Although the associations between these patterns and objective anthropometric/metabolic measures were largely in the expected directions, future studies are required to confirm these findings.This trial is registered at clinicaltrials.gov (NCT02509988).

Evaluation of the Amharic version of the London measure of unplanned pregnancy in Ethiopia

Background

Unplanned pregnancy is an important public health problem in both the developing and developed world, as it may cause adverse social and health outcomes for mothers, children, and families as a whole. London Measure of Unplanned Pregnancy (LMUP) has been formally and informally validated in multiple and diverse settings. However, there is a dearth of literature on the validation of LMUP in Ethiopia either in the Amharic version or other languages.

Objective

The general objective of this study was to translate the LMUP into Amharic and evaluate its psychometric properties in a sample of Amharic-speaking women receiving antenatal care (ANC) service at public health facilities in Arbaminch and Birbir towns.

Methods

A cross-sectional study design was used for the study. Forward and backward translation of original English LMUP to Amharic was done. A cognitive interview using a pretested structured questionnaire was used to collect the data from respondents. The collected data was analyzed using SPSS version 25. Reliability was assessed using Cronbach’s alpha, inter-item correlations, and corrected item-total correlations while construct validity was assessed using principal components analysis and hypothesis testing.

Results

Data was collected from 320 women attending antennal care services at selected public health care facilities. LMUP range of 1to 11 was captured. The prevalence of unplanned pregnancies was 19(5.9%), while 136(42.5 were ambivalent and 165(51.6%) were planned pregnancies. The reliability testing demonstrated acceptable internal consistency (Cronbach’s alpha = 0.799) and the validity testing confirmed the unidimensional structure of the scale. In addition, all hypotheses were confirmed.

Conclusions

Amharic version of LMUP is a valid and reliable tool to measure pregnancy intention so that it can be used by Amharic speaking population in Ethiopia. It can also be used in research studies among Amharic-speaking women to measure unplanned pregnancy.

Views of clinicians towards providing contraceptive advice and contraception to women following early pregnancy loss: a qualitative study

INTRODUCTION

National guidelines advise that clinicians caring for women post-pregnancy should give women opportunities to discuss contraception, regardless of pregnancy outcome, and provide contraception to women who choose to take up a method. This study aimed to explore knowledge, views and needs of Early Pregnancy Unit (EPU) clinicians around discussing and offering contraception and discussing pregnancy intendedness with women after early pregnancy loss using a qualitative approach.

METHODS

Semi-structured, audio-recorded interviews with 11 clinicians from a single regional EPU in Edinburgh, Scotland. Interviews were transcribed verbatim and analysed thematically.

RESULTS

Clinicians were reluctant to discuss contraception as they believed women would find the topic overwhelming and distressing. Thoughts on discussing pregnancy intendedness were polarised; some considered it insensitive, and others essential. Barriers to discussing contraception and providing it were numerous and included time pressure, and inadequate knowledge and training on contraception. Participants suggested training on contraception, closer working with sexual and reproductive health (SRH) services, and availability of information on contraception specifically aimed at women who have experienced an early pregnancy loss could facilitate discussions and method provision.

CONCLUSIONS

EPU clinicians require ongoing training and support to be effective at discussing pregnancy intendedness and discussing and providing post-pregnancy contraception. This will require close working with SRH services and development of sensitive information around contraception for women experiencing an early pregnancy loss.

Predicting perinatal health outcomes using smartphone-based digital phenotyping and machine learning in a prospective Swedish cohort (Mom2B): study protocol

INTRODUCTION

Perinatal complications, such as perinatal depression and preterm birth, are major causes of morbidity and mortality for the mother and the child. Prediction of high risk can allow for early delivery of existing interventions for prevention. This ongoing study aims to use digital phenotyping data from the Mom2B smartphone application to develop models to predict women at high risk for mental and somatic complications.

METHODS AND ANALYSIS

All Swedish-speaking women over 18 years, who are either pregnant or within 3 months postpartum are eligible to participate by downloading the Mom2B smartphone app. We aim to recruit at least 5000 participants with completed outcome measures. Throughout the pregnancy and within the first year postpartum, both active and passive data are collected via the app in an effort to establish a participant's digital phenotype. Active data collection consists of surveys related to participant background information, mental and physical health, lifestyle, and social circumstances, as well as voice recordings. Participants' general smartphone activity, geographical movement patterns, social media activity and cognitive patterns can be estimated through passive data collection from smartphone sensors and activity logs. The outcomes will be measured using surveys, such as the Edinburgh Postnatal Depression Scale, and through linkage to national registers, from where information on registered clinical diagnoses and received care, including prescribed medication, can be obtained. Advanced machine learning and deep learning techniques will be applied to these multimodal data in order to develop accurate algorithms for the prediction of perinatal depression and preterm birth. In this way, earlier intervention may be possible.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Swedish Ethical Review Authority (dnr: 2019/01170, with amendments), and the project fully fulfils the General Data Protection Regulation (GDPR) requirements. All participants provide consent to participate and can withdraw their participation at any time. Results from this project will be disseminated in international peer-reviewed journals and presented in relevant conferences.

The role of pregnancy acceptability in maternal mental health and bonding during pregnancy

BACKGROUND

Pregnancy is an important time for women's mental health and marks the foundations of the emerging bond between mother and baby. This study aimed to investigate the role of pregnancy acceptability and intendedness in maternal mental health and bonding during pregnancy.

METHODS

Data were collected from a community sample of 116 Australian pregnant women (M = 29.54, SD = 5.31) through a series of self-report questionnaires pertaining to mental health and antenatal bonding.

RESULTS

Lower pregnancy acceptability was correlated with higher depression, anxiety and total distress, lower physical and environmental quality of life and lower antenatal bonding. Women who reported their pregnancy was intended reported higher physical quality of life than those who reported their pregnancy was unintended. The relationship between total distress and antenatal bonding was moderated by women's degree of pregnancy acceptability (low versus high). For women with low acceptability, higher distress was associated with lower bonding, but there was no such association for women with high pregnancy acceptability. The moderation model examining associations between distress and pregnancy acceptability explained 15% of the variance in antenatal bonding scores.

CONCLUSION

Consideration of women's appraisal of their pregnancy acceptability may provide a valuable framework for identifying individuals who may be at risk for mental health and bonding difficulties.

Association between viral suppression during the third trimester of pregnancy and unintended pregnancy among women on antiretroviral therapy: Results from the 2019 antenatal HIV Sentinel Survey, South Africa

Objectives

About half of the pregnancies among women living with HIV (WLWH) receiving antiretroviral therapy (ART) in sub-Saharan African countries are reported to be unintended. Unintended pregnancy is associated with late initiation of antenatal care (ANC), and may delay provision of viral load monitoring services, antenatal adherence counselling and support, and other services that promote sustained viral suppression throughout pregnancy. This study examines the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy.

Methods

This was an analysis of data from a national antenatal survey conducted at 1 589 public health facilities in South Africa between 1 October and 15 November 2019. Consenting pregnant women aged 15–49 years attending ANC during the survey period were enrolled. Demographic and clinical data were collected through interview and medical record review. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy, and responses were categorized as “unintended,” “undecided,” and “intended.” Blood specimens were collected from all women and tested for HIV; and if positive, a viral load test was performed. A survey domain-based poisson regression model examined the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy. Viral suppression was defined as viral load <50 copies/mL.

Results

Of 10 901 WLWH with viral load data available, 63.3% (95% confidence interval (CI): 62.4%-64.1%) were virally suppressed. Among the 2 681 women (representing 24.1% of all WLWH with viral load data) who initiated ART before pregnancy and were in their third trimester at the time of enrolment, 74.4% (95% CI: 73.0%-75.8%) were virally suppressed. In the same population, the proportion virally suppressed was lower among women whose current pregnancies were unintended (72.1%, 95% CI: 70.1%-74.1%) compared to women whose pregnancies were intended (78.3%, 95% CI: 75.9%-80.5%). In multivariable analyses adjusted for age, gravity, marital status, education, location of facility and syphilis status, unintended pregnancy was associated with unsuppressed viral load during the third trimester (adjusted relative risk: 1.3, 95% CI: 1.1–1.4) among women who initiated ART before pregnancy.

Conclusion

The identified association between unsuppressed viral load and unintended pregnancy among pregnant women who initiated ART before pregnancy highlights the need to strengthen routine assessment of fertility preferences and provision of contraceptive services to reproductive age WLWH receiving ART.

How do women prepare for pregnancy in a low-income setting? Prevalence and associated factors

Background

Despite growing evidence of pregnancy preparation benefits, there is little knowledge on how women in developing countries prepare for pregnancy and factors influencing their preparedness for pregnancy. Here, we determine how women in Malawi prepare for pregnancy and factors associated with pregnancy preparation.

Methods

We used data from a previous cohort study comprising 4,244 pregnant mothers, recruited between March and December 2013 in Mchinji district, Malawi. Associations of pregnancy preparation with socio-demographic and obstetric factors were tested for using mixed effects ordinal regression, with the likelihood ratio and Wald’s tests used for variable selection and independently testing the associations.

Results

Most mothers (63.9%) did not take any action to prepare for their pregnancies. For those who did (36.1%), eating more healthily (71.9%) and saving money (42.8%) were the most common forms of preparation. Mothers who were married (adjusted odds-ratio (AOR 7.77 (95% CI [5.31, 11.25]) or with no or fewer living children were more likely to prepare for pregnancy (AOR 4.71, 95% CI [2.89,7.61]. Mothers with a period of two to three years (AOR 2.51, 95% CI [1.47, 4.22]) or at least three years (AOR 3.67, 95%CI [2.18, 6.23]) between pregnancies were more likely to prepare for pregnancy than women with first pregnancy or shorter intervals. On the other hand, teenage and older (≥ 35 years old) mothers were less likely to prepare for pregnancy (AOR 0.61, 95%CI [0.47, 0.80]) and AOR 0.49 95%CI [0.33, 0.73], respectively).

Conclusion

While preconception care may not be formally available in Malawi, our study has revealed that over a third of mothers took some action to prepare for pregnancy before conception. Although this leaves around two thirds of women who did not make any form of pregnancy preparation, our findings form a basis for future research and development of a preconception care package that suits the Malawian context.

Sexual and Reproductive Health and Reproductive Coercion in Women Victim/Survivors Receiving Housing Support

Housing instability and intimate partner violence (IPV) compromise women's sexual and reproductive health (SRH) through reduced contraceptive access and increased risk of unintended pregnancy. This study describes the reproductive health status and needs of IPV survivors receiving housing support and explores factors influencing their experience of reproductive coercion (RC), specifically. Cross-sectional baseline data from a quasi-experimental study of 70 IPV survivors enrolled in housing programs in the Baltimore, MD, metropolitan area from June 2019 through December 2020 were analyzed. Of the 70 women enrolled in the study, 70.3 percent (n = 45) desired to avoid pregnancy, but 57.4 percent were either using no contraceptive method (31.2%) or methods with low effectiveness (26.2%). Approximately, 1 in 6 women (16.4%, n = 11) experienced RC in the past 3 months, which was associated with frequency and severity of IPV (p = 0.001 to 0.005) and PTSD (p = 0.001), as well as not sharing children with the abusive partner (p = 0.002). This study highlights reproductive health risks in an important and under-studied population of women seeking housing due to IPV. Leaving an abusive relationship is a uniquely vulnerable time, and also a time of opportunity, as women are accessing services that can be tailored to their SRH needs. Significant results highlight vulnerability to and consequences of RC in this population. This study has implications for IPV support programs and housing programs that serve women.

Desire, acceptability, and expected resolution: A latent class analysis of current pregnancy orientation in the United States

BACKGROUND

Scant research has examined latent and contextual dimensions of pregnancy intentions, conventionally classifying unintended pregnancies as mistimed (wanted later) or unwanted (not wanted at all). Being at risk of mistimed pregnancy likely encompasses a broad spectrum of emotions and expectations regarding pregnancy and merits further exploration.

METHOD

Using a national sample from GfK's online KnowledgePanel of women aged 15-39 considered at risk of mistimed pregnancy in 2017 (n = 1278), we conducted a latent class analysis to assess underlying patterns of current pregnancy orientation using three items: pregnancy desire, pregnancy acceptability, and expected pregnancy resolution. As class structure varied by relationship status (serious or not), we stratified analyses by relationship status.

RESULTS

Among women in serious relationships, three classes emerged: "No," "Slightly okay," and "Acceptable." For those not in serious relationships, there were two classes: "Strong no" and "Ambiguous." Overall, the classes indicate varied patterns of wantedness, acceptability, and anticipated resolution to potential pregnancy.

CONCLUSIONS

This analysis reinforces that the construct of mistimed pregnancy is too restrictive to reflect the inherent diversity of prospective pregnancy orientation. The combination of relationship type as a grouping variable for stratified analyses, financial hardships' impact, and the overall effect of increasing age on increasing interest in pregnancy suggest the importance of locating pregnancy intentions within the broader reproductive life course. Scholars, clinicians, and public health programs should allow for multidimensionality of pregnancy perspectives, locate them within the broader life course, and acknowledge the potential impacts of stratified relationship formation on eventual pregnancy intentions.

Pregnancy planning and acceptance and maternal psychological distress during pregnancy: results from the National Perinatal Survey, France, 2016

Background

Studies report heightened risks of mental health problems among women who experience an unintended pregnancy, but few consider the complexity of pregnancy intentions. In this study, we evaluate how different dimensions of pregnancy intentions (pregnancy planning and pregnancy acceptance) relate to two maternal depressive symptoms and perceived psychological distress.

Methods

This study draws from a cross-sectional national survey conducted in all maternities in France over a one-week period in 2016. All mothers 18 years and older who had a live birth during the study period were invited to participate. After excluding women who underwent infertility treatment, our analytical sample included 10,339 women. We first described levels and correlates of pregnancy planning and acceptance, defined in four categories; planned/welcomed, unplanned/welcomed, planned/unwelcomed, unplanned/unwelcomed. We then assessed the bivariate and multivariate associations between pregnancy planning and acceptance and two outcomes: women’s self-perceived psychological health and the presence of two depressive symptoms during pregnancy. We used multivariate logistic regressions to evaluate these associations, after adjusting for socio-demographic and medical factors.

Results

Altogether 7.5 to 24.1% of mothers perceived their psychological health during pregnancy was poor, according to pregnancy planning and acceptance categories and 10.3 to 22.4% indicated feelings of sadness and loss of interest during pregnancy, according to pregnancy planning and acceptance categories. As compared to women with planned/welcomed pregnancies, the odds of perceived poor psychological health and depressive symptoms were 2.55 times (CI 2.20–2.95) and 1.75 times higher (CI 1.51–2.02), respectively, among unplanned/unwelcomed pregnancies and 2.02 (CI 1.61–2.53) and 2.07 (CI 1.7–2.5) higher, among planned/unwelcomed pregnancies. Among women with unplanned pregnancies, we also found higher odds of perceived poor psychological health among women whose pregnancy was unwelcomed while the odds of depressive symptoms were not different by pregnancy planning status among women with unwelcomed pregnancies.

Conclusions

These findings consolidate previous reports of the association between pregnancy intentions and maternal psychological distress, while further specifying the relationship, which mostly depends on the acceptance of pregnancy timing rather than on pregnancy planning. Identifying women with low pregnancy acceptance can potentially enhance current medical practice by improving early detection of maternal depression.

Getting Intentional about Intention to Use: A Scoping Review of Person-Centered Measures of Demand

In recent years, there has been much reflection on the measures used to assess and monitor contraceptive programming outcomes. The meaning and measurement of intention‐to‐use (ITU) contraception, however, has had less attention and research despite its widespread inclusion in many major surveys. This paper takes a deeper look at the meaning and measurement of ITU around contraception. We conducted a scoping review guided by the following questions: What is the existing evidence regarding the measurement of ITU contraception? What definitions and measures are used? What do we know about the validity of these measures? We searched databases and found 112 papers to include in our review and combined this with a review of the survey instruments and behavioral theory. Our review found growing evidence around the construct of ITU in family planning programming and research. However there are inconsistencies in how ITU is defined and measured, and this tends not to be informed by advances in behavioral theory and research. Further work is needed to develop and test measures that capture the complexity of intention, examine how intention differently relates to longer‐range goals compared to more immediate implementation, and demonstrate a positive relationship between ITU and contraceptive use.

Reproductive Coercion, Intimate Partner Violence, and Unintended Pregnancy Among Latina Women

Reproductive coercion (RC) describes a range of behaviors that restrict reproductive autonomy including pregnancy coercion, birth control sabotage, and controlling the outcome of a pregnancy. RC is associated with pregnancies that are mistimed and unwanted (i.e., unintended). Past research demonstrates that Latina women have higher risk for RC and for unintended pregnancy. This cross-sectional descriptive study with Latina women (n = 482) examined prevalence and risk factors for RC, evaluated the association of RC and unintended pregnancy among women with a past-year pregnancy, and explored use of safety and harm reduction strategies. A tablet survey was administered to women attending a community health center, between the ages of 15 and 45, who self-identified as Latina and who had a dating or sexual partner in the past year. Approximately one in six (16.8%) experienced past-year RC and risk factors included younger age (adjusted odds ratio [AOR] = 0.95, 95% confidence interval [CI] = [0.91, 1.00], p = .038) and concurrent intimate partner violence (IPV; AOR = 4.47, 95% CI = [2.06, 9.70], p < .001). IPV questions were specific to the partner involved with RC behaviors. For the 185 participants who reported a past-year pregnancy, RC was associated with lower pregnancy planning scores (β = -.27, 95% CI = [-0.41, -0.13], p < .001). The combination of experiencing RC and IPV appeared particularly potent in lowering pregnancy planning scores (β = -.15, 95% CI = [-0.29, 0.00], p = .052). Approximately 10.6% of participants engaged in harm reduction strategies, most commonly ending an unhealthy or abusive relationship (6.1%) and using less detectable methods of contraception so that partners would not find out (3.4%). The study articulates the risk of RC and its intersection with IPV and unintended pregnancy for Latina women. Providers working with racially and ethnically marginalized women have an important role in promoting safety and harm reduction strategies that include offering less detectable methods of contraception and support in leaving unhealthy and abusive relationships.

Intendedness of pregnancies and preconception contraceptive use in women of Swedish and non-European origins seeking emergency care in early pregnancy

INTRODUCTION

Unintended pregnancies in Europe have been estimated to constitute 43% of all pregnancies, with the proportion in Sweden being unknown. In striving for equitable healthcare, increased knowledge about unintended pregnancies among women born outside Europe is needed. We aimed to estimate the proportion of unintended pregnancies in women born in Sweden compared with women born outside Europe in an unselected population seeking gynaecological emergency care in early pregnancy. Our secondary aim was to compare contraceptive use at the time of conception in unplanned pregnancies between women born in Sweden and women born outside Europe.

METHODS

Pregnant women seeking gynaecological emergency care in early pregnancy at a tertiary hospital were asked to fill out a questionnaire in their native language. The questionnaire contained questions from the London Measure of Unplanned Pregnancy (LMUP) and questions regarding sociodemographic data, gynaecological health and previous contraception.

RESULTS

Of 180 pregnancies, 66 were unintended (36.7%) according to the LMUP. Among patients born in Sweden, 49/129 (38.0%) of the pregnancies were unintended compared with 17/51 (33.3%) among patients born outside Europe (p=0.56). 86% of participants with unintended pregnancy did not use any form of contraception during the month of conception, with no difference between women born in Sweden and those born outside Europe.

CONCLUSIONS

Among women seeking gynaecological emergency care in early pregnancy, unintended pregnancies are common. Women with unintended pregnancies had low use of preconception contraceptives, which highlights a need for further interventions aimed at avoiding unintended pregnancies.

Impact of the SARS-CoV-2 pandemic on access to contraception and pregnancy intentions: a national prospective cohort study of the UK population

OBJECTIVE

Evaluate the impact of the COVID-19 pandemic on access to contraception and pregnancy intentions.

DESIGN

Nationwide prospective cohort study.

SETTING

United Kingdom.

PARTICIPANTS

Women in the UK who were pregnant between 24 May and 31 December 2020.

MAIN OUTCOME MEASURES

Access to contraception and level of pregnancy intentions, using the London Measure of Unplanned Pregnancy (LMUP) in women whose last menstrual period was before or after 1 April 2020. While the official date of the first UK lockdown was 23 March, we used 1 April to ensure that those in the post-lockdown group would have faced restrictions in the month that they conceived.

RESULTS

A total of 9784 women enrolled in the cohort: 4114 (42.0%) conceived pre-lockdown and 5670 (58.0%) conceived post-lockdown. The proportion of women reporting difficulties accessing contraception was higher in those who conceived after lockdown (n=366, 6.5% vs n=25, 0.6%, p<0.001) and continued to rise from March to September 2020. After adjusting for confounders, women were nine times more likely to report difficulty accessing contraception after lockdown (adjusted odds ratio (aOR) 8.96, 95% CI 5.89 to 13.63, p<0.001). There is a significant difference in the levels of pregnancy planning, with higher proportions of unplanned (n=119, 2.1% vs n=55, 1.3%) and ambivalent pregnancies (n=1163, 20.5% vs n=663, 16.1%) and lower proportions of planned pregnancies (n=4388, 77.4% vs n=3396, 82.5%) in the post-lockdown group (p<0.001). After adjusting for confounders, women who conceived after lockdown were still significantly less likely to have a planned pregnancy (aOR 0.88, 95% CI 0.79 to 0.98, p=0.025).

CONCLUSIONS

Access to contraception in the UK has become harder during the COVID-19 pandemic and the proportion of unplanned pregnancies has almost doubled.

The association of unplanned pregnancy with perinatal depression: a longitudinal cohort study

Perinatal depression is common, affecting approximately 7-13% of women. Studies have shown an association between unplanned pregnancy and perinatal depressive symptoms, but many used a cross-sectional design and limited postnatal follow-up. The current study investigated the association of unplanned pregnancy with perinatal depressive symptoms using a longitudinal cohort study that followed women from the first trimester until 12 months postpartum. Pregnant women (N = 1928) provided demographic and clinical data and information about pregnancy intention at the first trimester. Depressive symptoms were assessed during each trimester of pregnancy and five times postpartum using the Edinburgh Postnatal Depression Scale (EPDS) until 12 months postpartum. Mixed model analyses were used to investigate the association between an unplanned pregnancy and the level of depressive symptoms. Women with an unplanned pregnancy (N = 111, 5.8%) reported persistently higher levels of depressive symptoms during the entire perinatal period compared to women with a planned pregnancy, after adjustment for confounders (p < 0.001). However, the course of depressive symptom scores over time in women with an unplanned pregnancy was similar to that of women with a planned pregnancy. Lower age (p = 0.006), unemployment (p = 0.004), and history of depression (p < 0.001) were significantly associated with higher levels of perinatal depressive symptoms. An unplanned pregnancy may have a long-lasting negative impact on a woman's perinatal mental health. Therefore, women with an unplanned pregnancy may benefit from systematic follow-up during the perinatal period with contingent mental health support.

The prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa, a national antenatal survey, 2019

To describe the prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa. A cross-sectional survey was conducted between October and mid-November 2019 among pregnant women aged 15–49 years in 1589 selected public antenatal care facilities. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy. Survey logistic regression examined factors associated with unintended pregnancy. Among 34,946 participants, 51.6% had an unintended pregnancy. On multivariable analysis, the odds of unintended pregnancy was higher among women who knew their HIV-positive status before pregnancy but initiated treatment after the first antenatal visit (adjusted odds ratio [aOR], 1.5 [95% confidence interval (CI):1.2–1.8]), women who initiated treatment before pregnancy (aOR, 1.3 [95% CI:1.2–1.3]), and women with a new HIV diagnosis during pregnancy (aOR, 1.2 [95% CI:1.1–1.3]) compared to HIV-negative women. Women who were single, in a non-cohabiting or a cohabiting relationship, and young women (15–24 years) had significantly higher risk of unintended pregnancy compared to married women and women aged 30–49 years, respectively. A comprehensive approach, including regular assessment of HIV clients’ pregnancy intention, and adolescent and youth-friendly reproductive health services could help prevent unintended pregnancy.

Factors Associated with Unplanned Pregnancy Among Cancer Survivors

Background: Approximately half of all pregnancies in the United States are unintended. However, women who are diagnosed with cancer in their reproductive years may be a unique population. This study examines the prevalence of and identifies factors associated with unplanned pregnancy among cancer survivors. Methods: Female cancer survivors aged 22-45 years, diagnosed between ages 20-35 years and at least 2 years postdiagnosis, and women with no history of cancer were interviewed about their reproductive histories, including pregnancy intention. Using a random matching process, comparison women were assigned an artificial age at cancer diagnosis equal to that of her cancer survivor match. An adjusted Cox model was fit examining time to unintended pregnancy after cancer for each of 1,000 matches. Cox proportional hazards models were also fit to assess associations between participant characteristics and unplanned pregnancy after cancer among survivors. Results: Cancer survivors (n = 1,282) and comparison women (n = 1,073) reported a similar likelihood of having an unplanned pregnancy in models adjusted for race, income, history of sexually-transmitted infection, and history of unplanned pregnancy before diagnosis (adjusted hazard ratio [aHR] 1.06, 95% simulation interval 0.85-1.36). After adjusting for confounders, unplanned pregnancy among survivors was associated with age <30 years at diagnosis (hazard ratio [HR]: 1.79, 95% confidence interval [CI]: 1.32-2.44), black race (HR: 1.55, 95% CI: 1.13-2.12; referent: white), receiving fertility counseling (aHR: 1.41, 95% CI: 1.04-1.92), and having at least one child before diagnosis (aHR: 1.44, 95% CI: 1.05-1.97). Conclusion: Cancer survivors and comparison women had similar likelihood of unplanned pregnancy. Rates of unplanned pregnancy after cancer were not higher for cancer survivors compared with comparison women, but 46.4% of survivors with a postcancer pregnancy reported an unplanned pregnancy. Cancer patients may benefit from patient-centered guidelines and counseling before cancer treatment that covers both risks of infertility and risks of unplanned pregnancy.

Home pregnancy test use and timing of pregnancy confirmation among people seeking health care

OBJECTIVES

Understanding the timing of pregnancy suspicion and confirmation, including the role of home pregnancy tests, can facilitate earlier entry into pregnancy-related care and identify individuals likely to be impacted by gestation-based abortion restrictions.

STUDY DESIGN

We use data from 259 pregnant individuals participating in a cross-sectional survey at 8 primary and reproductive health care clinics in 6 U.S. states (2016-2017). We use regression models to identify differences in utilization of HPTs, barriers to use, and to compare gestational duration at pregnancy confirmation.

RESULTS

Three-quarters (74%) of respondents took a home pregnancy test as the first step in confirming pregnancy; this figure was lower among adolescents versus young adults (65 vs 81%, p = 0.01). Two-thirds (64%) reported delays in home testing, higher among adolescents (85%). People taking a test at home confirmed pregnancy 10 days earlier than those first testing at a clinic (41.3 vs 51.8 days gestation, p = 0.02). Those that did not test at home cited concerns about test accuracy (42%) and difficulties accessing one (26%). While overall 21% confirmed pregnancy at ≥7 weeks gestation, and 35% at ≥6 weeks, confirmation at ≥7 weeks was higher among adolescents versus young adults (47 vs 13%, p = 0.001), Latina versus white women (28 vs 11%, p = 0.02), food insecure versus secure women (28 vs 17%, p = 0.06), and people with unplanned versus planned/mistimed pregnancies (25 vs 13%, p = 0.07).

CONCLUSIONS

Home pregnancy testing is common and associated with earlier pregnancy confirmation. Still, barriers to at-home testing are evident, particularly among adolescents. Efforts to expand access to home pregnancy tests and increase knowledge about their accuracy may be impactful in increasing utilization.

IMPLICATIONS

While at home pregnancy testing is common and facilitates earlier confirmation of pregnancy, one in 5 confirm pregnancy at 7 weeks gestation or later (and one in 3 do so at 6 weeks or later). Gestational bans in the first trimester will disproportionately prevent young people, people of color, and those living with food insecurity from being able to access abortion.

"Un abrazo a la distancia": An Exploration of Spanish-Speaking Women's Experiences with Pregnancy and Social Isolation in an Urban U.S. Setting

Introduction: Research on Spanish-speaking Latina/Hispanic women's experiences during pregnancy is limited. Methods: We recruited women from urban, walk-in pregnancy testing clinics from June 2014 to June 2015. Women aged 16-44 years, at less than 24 weeks gestational age, who spoke either English or Spanish were eligible and completed an enrollment questionnaire and individual interview according to language preference. During qualitative interviews, we explored pregnancy intentions, initial reactions to a new pregnancy, and feelings about the impact of this pregnancy on relationships and daily life. Qualitative narrative content analysis was conducted using Atlas.ti software. Results: Among interviews with 31 Spanish-speaking Latina/Hispanic pregnant women, participants' average age was 28 years old with a mean gestational age of 7 weeks. We identified social isolation as the most common theme, characterized by four interwoven and overlapping subthemes: (1) sola-the experience of feeling alone; (2) familismo cercano-the importance of close relationships; (3) familismo lejano-overcoming long distance relationships; and (4) mi patria-preserving homeland cultural connectedness. Conclusions: Spanish-speaking Latina/Hispanic pregnant women described experiencing multiple aspects of social isolation. Language preference may suggest risk of social isolation, necessitating provider awareness and support initiatives to improve social support and lessen social isolation among newly pregnant, Spanish-speaking Latina women.

Evaluation of the Hindi version of the London Measure of Unplanned Pregnancy among pregnant and postnatal women in urban India

BACKGROUND

Valid and reliable measures such as London Measure of Unplanned Pregnancy (LMUP) are imperative for understanding fertility-related behaviors and estimating unintended pregnancy. The aim of this study was to validate the LMUP in the Hindi language for a wider reach in India.

METHODS

An interviewer administered version of the LMUP was translated and pretested in Hindi. The LMUP was field tested with married women in the reproductive age group across forty informal settlements in Mumbai in the post intervention census of a cluster randomized control trial to improve the health of women and children. Analyses involved the full sample and sub-groups according to time-from-conception. Reliability (internal consistency) was assessed using Cronbach's alpha, inter-item correlations, and item-rest correlations. Construct validity was assessed by hypothesis testing and confirmatory factor analysis.

RESULTS

4991 women were included in the study (1180 were pregnant, 2126 in their first- and 1685 in their second postnatal year). LMUP item completion rates were 100 % and the full range of LMUP scores was captured. Reliability: the scale was internally consistent (Cronbach's α = 0.84), inter-item correlations were positive, and item-rest correlations were above 0.2 for all items except item six (0.07). Construct validity: hypotheses were met, and confirmatory factor analysis showed that a one-factor model was a good fit for the data, confirming unidimensional measurement. The sub-group analysis (by pregnant, first-, and second postnatal year) showed that the psychometric properties of the LMUP were similar across the groups. In terms of LMUP scores, the women in the postnatal groups were very slightly, but significantly, more likely to have an LMUP score of 10 + compared to pregnant women; the difference between the first and second postnatal year was not significant.

CONCLUSIONS

The Hindi LMUP is valid and reliable measure of pregnancy intention that may be used in India.

TRIAL REGISTRATION

This study is registered with ISRCTN, number ISRCTN56183183, and Clinical Trials Registry of India, number CTRI/2012/09/003004.

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.

Evaluating the Chichewa version of the London Measure of Unplanned Pregnancy in Malawi: a validation update

Objective

To investigate the psychometric properties of the validated Chichewa version of the London Measure of Unplanned Pregnancy in a large representative community-based sample in Malawi, a low-income country. We collected data on pregnancy intention from a cohort of 4244 pregnant women in Malawi using the validated Chichewa version of the London Measure of Unplanned Pregnancy (LMUP). We evaluated the psychometric properties of the Chichewa LMUP using classical test theory and confirmatory factor analysis to re-assess the performance of items one and six, which had weaker performance in the original smaller, facility-based validation sample.

Results

The Chichewa version of the LMUP met all pre-set criteria for validation. There are now nine validations of the LMUP in different low-and-middle-income countries, confirming the validity and applicability of the LMUP in these settings.

Does the Impact of Motherhood on Women's Employment and Wages Differ for Women Who Plan Their Transition Into Motherhood?

Women's ability to control their fertility through contraception and abortion has been shown to contribute to improvements in education and employment. At the same time, their employment and wages decline substantially when they transition to motherhood. About one-third of births are unintended, and it is unknown whether the impact of motherhood on employment, hours, and wages is smaller for women who planned their transition into motherhood compared with those who did not. To explore this, we examine fixed-effects models that estimate labor market outcomes using panel data from the National Longitudinal Survey of Youth, 1979-2014. We estimate models for Black and White women and find that the relationship between motherhood and employment is significantly more negative among White women who plan their transition into motherhood than among those who have an unplanned first birth. Among those who remain employed, we find that those with a planned first birth work fewer hours and have lower wages relative to those with unplanned births. We do not find significant evidence that the association between motherhood and labor market outcomes differs by fertility planning among Black women. Prior research shows how women's choices are structurally constrained by sociocultural norms and expectations and by a labor market that may not readily accommodate motherhood. In this context, our findings may reflect differences in women's motherhood and employment preferences and their ability to act on those preferences. Our analysis also makes a novel contribution to the large body of research that associates unplanned births with negative outcomes.