Evaluation of the London Measure of Unplanned Pregnancy in a United States population of women

The Reasoning through Evidence versus Advice (EvA) Scale: Scale Development and Validation

Our well-being can improve when people heed evidence rather than simply follow familiar or charismatic advisors who neglect evidence. We developed the Reasoning through Evidence versus Advice (EvA) scale to measure individual differences in reasoning through evidence like science and statistics versus following advisors such as politicians and celebrities. No existing scales directly measure these tendencies; moreover, it was theoretically unknown whether they reflect a single dimension (from evidence- to advice-based) or distinct tendencies to value or distrust each. Our scale validation process included qualitative interviews and four studies that involved 1583 respondents (753 college graduates, 830 non-college graduates) in which we conducted exploratory and confirmatory factor analyses and tests of convergent validity, discriminant validity, and measurement invariance by gender and education. This process yielded a 16-item EvA scale with four dimensions: Pro-evidence, Anti-evidence, Pro-advice, and Anti-advice. In assessing criterion validity, these tendencies identified individual differences in important, real-world attitudes and behaviors, including susceptibility to health misinformation, adherence to CDC guidelines on social distancing, confidence in the COVID vaccine, science curiosity, and religiosity. The EvA scale extends our understanding of individual differences in reasoning tendencies that shape critical attitudes, decisions, and behaviors and can help promote informed decisions.

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.

Unintended pregnancy and childhood maltreatment: The protective effect of positive relationships

BACKGROUND

Childhood maltreatment is associated with sexual risk-taking behaviors in adulthood but can also have generational effects on maternal/child health.

METHODS

This cross-sectional study examined the relationship between childhood abuse and neglect and unintended pregnancy, and then assessed the effect of relationship attributes on this outcome.

RESULTS

Findings indicate parenting women (n = 153) in long-term relationships who experienced childhood emotional abuse had higher scores of unintended pregnancies (p = .023). Yet women with moderate/high partner appraisal (perceptions of their partner's attributes used to assess interpersonal conflicts) showed no difference in unintended pregnancies between those with and without emotional abuse in childhood. Women with emotional abuse and low partner appraisal had higher unintended pregnancy scores (p = .002).

DISCUSSION/CONCLUSION

This study has implications for public health nursing and life course research demonstrating that a positive adult interpersonal environment can reduce the sequelae of adverse health outcomes associated with childhood emotional abuse. The results reinforce the importance of screening adults for childhood maltreatment to establish early risk for unintended pregnancy.

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.

Incorporating HIV Pre-Exposure Prophylaxis Care for Patients Seeking Induced Abortion and Pregnancy Loss Management

BACKGROUND

Family planning clinical encounters are important opportunities for HIV prevention. Our objectives were to 1) estimate the proportion of patients seeking induced abortion and early pregnancy loss management eligible for HIV pre-exposure prophylaxis (PrEP) and 2) compare PrEP eligibility and uptake between patients with unintended and intended pregnancy.

METHODS

We conducted a cross-sectional survey and a nested prospective cohort study of patients seeking an induced abortion or early pregnancy loss management. We assessed pregnancy intendedness, PrEP awareness, HIV risk and risk perception, desire for same-day PrEP start, and PrEP continuation at 30 days. We used the χ² and Fisher's exact tests to assess differences between the participants with intended and unintended pregnancy. We had 80% power to detect a 14% difference in PrEP eligibility between the groups.

RESULTS

We enrolled 250 women. Fifty-six percent (139) had an unintended pregnancy and 44% (110) had an intended pregnancy. PrEP eligibility did not differ significantly between the patients with intended and unintended pregnancy (16% vs. 10%; p = .18). More than one-half (54%, 135/250) were unaware of PrEP before their study visit, and 93% (232/250) considered themselves unlikely to acquire HIV. Of 33 women who were PrEP eligible, 11 accepted same-day start and 1 continued PrEP at 30 days.

CONCLUSIONS

Intendedness of pregnancy was unrelated to PrEP eligibility in women seeking induced abortion and early pregnancy loss management. Most patients seeking these services are unaware of PrEP. Integrating PrEP into family planning care is likely to increase awareness and uptake of PrEP in women.

Parity and Pregnancy Intention related to the Use of Contraceptives in Women of Reproductive

Background: The use of contraceptives in reproductive women is still a problem today. The association between contraceptive use and parity and pregnancy intention amongs legally married reproductive women has never been studied  Objectives: To determine the relationship between parity and pregnancy intention with contraceptive use among legally married women.  Methods: A cross-sectional study was conducted with the involvement of 262 legally-married reproductive women, aged 15-49 years, in Bantul District, Indonesia.  Socio-demographic data including age, education, income, parity, pregnancy intentions, and use of contraceptives were collected using a structured questionnaire by trained enumerators. Chi-square test was used to test the association between socio-demographic data and parity and pregnancy intention, while simple logistic regression models were used to examine the relationship between contraceptive use and parity and pregnancy intention. Data analysis was performed using statistical software by SPSS.   Results: Thirty-eight point five per cent of women of reproductive age who have ≥ 3 children and 16.5% of women of reproductive age who do not want to have children do not use contraception. Parity in women of childbearing age was not related to contraceptives (OR=2.58; 95%:0.67-1.76). Women of reproductive age who had intention of getting pregnant were 61% less likely (OR= 0.39; 95%: 0.37-0.74) to use contraceptives than those who did not have intention of getting pregnant.  Conclusions: The pregnancy intention is associated with a low contraceptive use in reproductive-age women. Thus, it is necessary to educate women in the reproductive age, their partners and family regarding the importance of birth spacing.  

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.

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.

The importance of pregnancy planning in lupus pregnancies

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A preconception intervention targeted at women with modifiable risk factors before pregnancy to improve outcomes; protocol for the Get Ready! feasibility trial

Background

The health of a woman before conception not only influences the outcome of her pregnancy but also the lifelong health of mother and child. Many women in the UK are inadequately prepared for pregnancy, with reports of a high prevalence of smoking, low folic acid supplement use, and suboptimal diet and physical activity. Get Ready! will link an online digital tool to identify women planning pregnancy most at risk of complications with a personalised intervention to improve health behaviours and biomarkers of metabolic health.

Methods

Women planning pregnancy will be identified from a free and widely used online preconception tool. A short online screening questionnaire will then be used to recruit women considered to be at high metabolic risk. Eligibility criteria include resident in the UK, age > 18–< 50 years, BMI ≥ 23 kg/m² (South Asian) or ≥ 25 kg/m² (all other ethnicities), and plus one or more of the following: 1st degree relative with type 2 diabetes, previous gestational diabetes (GDM), previous baby > 4 kg, or high risk ethnicity for GDM. Eligible women who consent to participate will be enrolled in a commercially available preconception intervention (Prepare Plans, LiveSmart UK Ltd). Following an online health assessment and home blood test, women will be provided with individualised lifestyle advice and coaching by dietitians. Process evaluation will provide an assessment of implementation of the intervention. Change in health behaviours and biomarkers of metabolic health will also be examined.

Discussion

Suboptimal health behaviours amongst women planning pregnancy are widely prevalent in the UK. Personalised health checks and coaching are especially important for women at risk of pregnancy complications. Get Ready! introduces a novel approach to identifying high risk women planning pregnancy and provision of a targeted intervention.

Registration

Trial sponsor: King’s College London.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions

CONTEXT

Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use.

METHODS

We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy.

RESULTS

After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively).

CONCLUSIONS

Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

The Impact of the COVID-19 Pandemic on Pregnancy Planning Behaviors

Background: Our understanding of how the coronavirus disease 2019 (COVID-19) pandemic has impacted decision-making for women planning to conceive is unclear. We aimed to investigate how the COVID-19 pandemic has influenced pregnancy planning behaviors.

Methods: An online questionnaire of closed- and open-ended questions was utilized to capture pregnancy planning behaviors and reported behavioral changes during the COVID-19 pandemic in women planning pregnancy between January and July 2020. Closed-ended questions were analyzed quantitatively, and thematic framework analysis was utilized for open-ended responses.

Results: A total of 504 questionnaires were included for analysis. The majority of respondents lived in the United Kingdom. Ninety-two percent of the women were still planning a pregnancy but over half (n = 267) reported that COVID-19 had affected their plans, with 72% of these (n = 189) deliberately postponing pregnancy. Concerns were predominantly over changes in antenatal care, but also fear of adverse effects of the virus on mother and baby. From the thematic analysis (n = 37), lack of services to remove contraceptive devices and provide fertility treatment were also cited. In contrast, 27% (n = 71) reported bringing their pregnancy plans forward; common themes included recalibration of priorities and cancelled or changed plans.

Conclusions: The COVID-19 pandemic influenced pregnancy-planning behaviors with many women reporting postponement of pregnancy. These alterations in behavior could impact the health and wellbeing of women planning pregnancy while having important implications for health care services worldwide. Continued provision of family planning and fertility services should be ensured to mitigate the effect of future outbreaks or pandemics.

Certainty and intention in pregnancy decision-making: An exploratory study

OBJECTIVE

Abortion is often characterized as an inherently difficult decision, despite research demonstrating high decision certainty among abortion patients. Minimal research has examined decision certainty among people planning to continue a pregnancy. We examined whether women seeking abortion experience lower decision certainty than those planning to continue pregnancies and whether certainty differs by pregnancy intendedness.

STUDY DESIGN

We administered the decisional conflict scale (DCS) to pregnant women (n = 149) at 8 U.S. primary and reproductive health clinics. Using Poisson regression models adjusted for sociodemographic and pregnancy characteristics, we evaluated differences in DCS scores (<25/100 vs ≥25/100) by pregnancy decision and whether pregnancy intention modified the effect of pregnancy decision on certainty.

RESULTS

Over one-half (58%) of respondents planned to have an abortion, 32% to continue the pregnancy, and 10% were unsure. DCS scores were low overall (median 9.4/100; IQR: 1.6, 25.0), indicative of high certainty, and the percentage scoring ≥25/100, reflecting any uncertainty, did not differ by pregnancy decision (23% abortion vs 19% continuing, p = 0.55). In a multivariable model, there was no statistically significant interaction between pregnancy decision (abortion vs continuing pregnancy) and intention. However, the predicted percentage reporting any uncertainty among respondents with intended pregnancies was comparable among those decided on abortion (13%) and continuing the pregnancy (16%). Among those with unintended pregnancies, these figures were 25% among those decided on abortion vs 36% among those continuing.

CONCLUSION

Levels of certainty about a pregnancy decision were high and appeared to depend more on whether the pregnancy was intended or unintended than on the pregnancy decision itself.

IMPLICATIONS

Similar levels of uncertainty among individuals who decided to have an abortion versus continue a pregnancy challenge the narrative that abortion is a particularly difficult medical and personal decision. The prevalence of some uncertainty among respondents continuing pregnancies suggests voluntary options counseling may be useful for some patients in prenatal care settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adaptation and validation of social accountability measures in the context of contraceptive services in Ghana and Tanzania

BACKGROUND

Changes in the values, attitudes, and interactions of both service users and health care providers are central to social accountability processes in reproductive health. However, there is little consensus on how best to measure these latent changes. This paper reports on the adaptation and validation of measures that capture these changes in Tanzania and Ghana.

METHODS

The CaPSAI theory of change determined the dimensions of the measure, and we adapted existing items for the survey items. Trained data collectors used a survey to collect data from 752 women in Tanzania and 750 women in Ghana attending contraceptive services. We used reliability analysis, exploratory, and confirmatory factor analysis to assess the validity and reliability of these measures in each country.

RESULTS

The measure has high construct validity and reliability in both countries. We identified several subscales in both countries, 10 subscales in Tanzania, and 11 subscales in Ghana. Many of the domains and items were shared across both settings.

CONCLUSION

The study suggests that the multi-dimensional scales have high construct validity and reliability in both countries. Though there were differences in the two country contexts and in items and scales, there was convergence in the analysis that suggests that this measure may be relevant in different settings and should be validated in new settings.

TRIAL REGISTRATION

ACTRN12619000378123 .

Systematic Review of Contraceptive Use Among Sex Workers in North America

OBJECTIVE

To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making.

DATA SOURCES

We searched PubMed, CINAHL, and Embase databases using the search terms "sex work(ers)," "transactional sex," "exchange sex," "prostitution," "contraception," "contraceptive agents," "birth control," "female," and "women."

STUDY SELECTION

Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria.

DATA EXTRACTION

Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell's theory of gender and power as an analytic framework to further identify factors that limited reproductive agency.

DATA SYNTHESIS

Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion.

CONCLUSION

The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.

Young adult US-born Latina women's thoughts, feelings and beliefs about unintended pregnancy

Current measures of unintended pregnancy underestimate the co-occurring, complex set of social, cultural, economic and structural factors that influence how women interpret unintended pregnancy. The purpose of this study was to prospectively explore young adult US-born Latinas' thoughts, feelings and beliefs about pregnancy, specifically unintended pregnancies and the sociocultural factors identified as contributors to those beliefs. In-depth interviews (n = 20) were conducted with US-born, English-speaking Latinas aged 18-25 years in south Florida. Seventeen participants did not intend to get pregnant, while the remaining participants (n = 3) reported that their intentions kept changing. Participants' beliefs regarding their unintended pregnancy were influenced by social and economic hardship and cultural factors such as fatalism and familismo. Ideas and the meaning of pregnancy differed based on the woman's pregnancy resolution decision. Many women felt the term 'unintended pregnancy' placed blame on women and was stigmatising. When discussing pregnancy planning, most participants felt that women should not plan their pregnancies and doing so was going against fate. Findings suggest that salient influences such as culture and the social determinants related to unintended pregnancy should be incorporated into measurements examining unintended pregnancy.

Stability of Retrospective Pregnancy Intention Reporting Among Women with Unwanted Pregnancies in the United States

Objectives Retrospective assessment of pregnancy intention may be unreliable as women's perceptions of a past conception can change over time. We compared the stability of retrospective pregnancy intention reporting over 5 years among women who sought and either received, or were denied, an abortion. Methods We recruited women from 30 abortion facilities across the United States in 2008-2010. Participants, some who received abortions and others who were denied care because they presented beyond facilities gestational limits, were followed prospectively for 5 years (n = 827). At enrollment and semiannually from year-2 to year-5, women completed the London Measure of Unplanned Pregnancy (LMUP), a six-item measure (scored 0-12), regarding the index pregnancy. We used multivariable mixed-effects models to assess the stability of retrospective reports of index pregnancy intendedness and compared trajectories by group, accounting for site and participant clustering. Our hypotheses were that intention would tend towards "more intended" over time among women denied abortions, who carried the pregnancies to term, and remain stable among women who received the abortion. Results Baseline LMUP scores were low (mean: 2.8) and similar by study group. Scores increased among women denied the abortion by year-2 (from 2.9 to 3.5; p < 0.001) and were steady through year-5. For women having near-limit abortions, reported intentions were steady between baseline (mean: 2.7) and year-2 (2.8), and declined thereafter through year-5 (to 2.5; p < 0.001). Conclusions Women somewhat shifted their perceptions of their intentions in correspondence with the pregnancy outcome. Retrospective estimates may underestimate the degree to which births result from unintended pregnancy.

Comparing Prospective and Retrospective Reports of Pregnancy Intention in a Longitudinal Cohort of U.S. Women

CONTEXT

Measurement of pregnancy intentions typically relies on retrospective reporting, an approach that may misrepresent the extent of unintended pregnancy. However, the degree of possible misreporting is unclear, as little research has compared prospective and retrospective reports of intention for the same pregnancies.

METHODS

Longitudinal data collected between 2010 and 2015 on 174 pregnancies were used to analyze the magnitude and direction of changes in intendedness (intended, ambivalent or unintended) between prospective and retrospective measurements of intendedness using versions of the London Measure of Unplanned Pregnancy (LMUP). Changes were assessed both continuously and categorically. Differences in the degree of change-by pregnancy outcome and participant characteristics-were examined using mixed-effects linear and logistic regression models.

RESULTS

Over two and one-half years of follow-up, 143 participants reported 174 pregnancies. Approximately half showed changes in intention between the prospective and retrospective assessments, with 38% of participants reporting increased intendedness and 10% decreased intendedness. Reported intendedness increased more among those who gave birth (mean change in continuous LMUP score, 2.2) than among those who obtained an abortion (0.7), as well as among individuals with a college degree (4.1) than among those with a high school diploma (1.2). Participants who reported recent depression or anxiety symptoms showed more stable intentions (0.02) than those who did not (2.1).

CONCLUSIONS

Retrospective measurement of pregnancy intentions may underestimate the frequency of unintended pregnancy, with such underestimation being greater among certain subgroups. Estimates based on retrospective reports thus may produce inaccurate impressions of intentionality. Further efforts to refine the measurement of pregnancy preferences are needed.

Oxytocin during breastfeeding and maternal mood symptoms

This study aimed to quantify the relationship between postpartum depression and anxiety, oxytocin, and breastfeeding. We conducted a longitudinal prospective study of mother-infant dyads from the third trimester of pregnancy to 12 months postpartum. A sample of 222 women were recruited to complete the Beck Depression Inventory II and Spielberger State-Trait Anxiety Inventory-state subscale, participate in observed infant feeding sessions at 2 and 6 months postpartum, and provide venous blood samples during feeding. Maternal venous oxytocin levels in EDTA-treated plasma and saliva were determined by enzyme immunoassay with extraction and a composite measure of area under the curve (AUC) was used to define oxytocin across a breastfeeding session. Linear regression was used to estimate associations between postpartum depression and anxiety as predictors and oxytocin AUC during breastfeeding as the outcome at both 2 and 6 months postpartum. Mixed models accounting for correlations between repeated oxytocin measures were used to quantify the association between current depression and/or anxiety symptoms and oxytocin profiles during breastfeeding. We found no significant differences in oxytocin AUC across a feed between depressed or anxious women and asymptomatic women at either 2 or 6 months postpartum. Repeated measures analyses demonstrated no differences in oxytocin trajectories during breastfeeding by symptom group but possible differences by antidepressant use. Our study suggests that external factors may influence the relationship between oxytocin, maternal mood symptoms, and infant feeding.

Perceptions and Behaviors Related to Contraceptive Use in the Postpartum Period Among Women With Pregestational Diabetes Mellitus

OBJECTIVE

To describe perceptions and behaviors related to contraception and preconception care and to test the association between these perceptions and contraceptive use in the postpartum period among women with pregestational diabetes mellitus.

DESIGN

Cross-sectional, descriptive survey.

SETTING

Three high-risk obstetric clinics in the Southeastern United States.

PARTICIPANTS

Fifty-five women who were 18 years or older with pregestational Type 1 or Type 2 diabetes mellitus.

METHODS

Between 4 and 8 weeks after birth, we used investigator-developed items and psychometrically validated scales to measure participants' perceptions and behaviors related to contraception and preconception care. We dichotomized use of contraception in the postpartum period as procedure/prescription or nonprescription/no method. We used multiple logistic regression to test the hypothesis that perceptions are associated with contraceptive use.

RESULTS

When data were collected 4 to 8 weeks after birth, almost half (49%, n = 27) of the participants had resumed sexual activity; however, most (95%, n = 52) did not want another pregnancy in the next 18 months. Fifty-six percent (n = 31) of participants used procedure/prescription contraception, and 44% (n = 24) used nonprescription/no method. Those who perceived contraception use and preconception care to be beneficial were more likely to use procedure/prescription contraception (adjusted odds ratio = 1.52; 95% confidence interval [1.07, 2.17]).

CONCLUSION

When caring for women in the postpartum period, providers should be mindful that women's perceptions of the benefits of contraception and preconception care may have implications for whether their use aligns with their reproductive goals and optimizes outcomes for future pregnancies.

A qualitative assessment of perspectives on getting pregnant: the Social Position and Family Formation study

BACKGROUND

Intentions-oriented approaches to measuring pregnancy do not necessarily align with how people view and approach pregnancy. Our objective was to obtain an in-depth understanding of the notions women and men hold regarding pregnancy.

METHODS

We conducted semi-structured in-depth interviews with 176 heterosexual women and men ages 18-35, in the United States. Data were analyzed using grounded theory methodology.

RESULTS

Participants described notions of getting pregnant in one of three ways. One group of participants used language that solely described pregnancy as a deliberate process, either premeditated or actively avoided. Another described pregnancy as a predetermined phenomenon, due to fate or something that 'just happens.' The third group represented a blending of both notions.

CONCLUSIONS

Our findings underscore the need to shift the current paradigm of deliberate intentions to one that recognizes that pregnancy can also be viewed as predetermined. These findings can be used to improve measurement, health services, and better direct public health resources.

On the Stability of Reported Pregnancy Intentions from Pregnancy to 1 Year Postnatally: Impact of Choice of Measure, Timing of Assessment, Women's Characteristics and Outcome of Pregnancy

OBJECTIVES

Retrospective, cross-sectional estimates of pregnancy intention, as used in the Demographic Health Survey (DHS), are the global norm. The London Measure of Unplanned Pregnancy (LMUP) is a newer, psychometrically validated measure which may be more reliable. This paper assesses the reliability of the LMUP and the DHS question over the first postnatal year and explores the effects of maternal characteristics or pregnancy outcome on reported pregnancy intention.

METHODS

We compared the test-retest reliability of the LMUP (using the AC coefficient) and DHS question (using the weighted Kappa) over the first postnatal year using data from Malawian women. We investigated the effect of maternal characteristics and pregnancy outcome using t-tests, Chi squared or Fisher's exact tests, and calculated odds ratios to estimate effect size.

RESULTS

The DHS question was associated with a statistically significant decrease in the prevalence of unplanned pregnancies from 1-to-12 months postnatally; the LMUP was not. The LMUP had moderate to substantial reliability (0.51-0.66); the DHS had moderate reliability (0.56-0.58). The LMUP's stability was not related to any of the factors examined; the stability of the DHS varied by marital status (p = 0.033), number of children (p = 0.048) and postnatal depression (p < 0.001). Both underestimated unintended pregnancy postnatally vis-à-vis the LMUP in pregnancy.

CONCLUSIONS FOR PRACTICE

The LMUP is a more reliable measure of pregnancy intention than the DHS in the first postnatal year and does not vary by maternal characteristics or pregnancy outcome. The LMUP should become the gold-standard for measuring pregnancy intention and should be collected in pregnancy or at the first postnatal opportunity.

Validation of the London Measure of Unplanned Pregnancy among pregnant Australian women

Introduction

Globally, over half of pregnancies in developed countries are unplanned. Identifying and understanding the prevalence and complexity surrounding pregnancy preparation among Australian women is vital to enable sensitive, responsive approaches to addressing preconception and long-term health improvements for these women with varying motivation levels.

Aim

This study evaluated the reliability and validity of a comprehensive pregnancy planning/intention measure (London Measure of Unplanned Pregnancy) in a population of pregnant women (over 18 years of age) in Australia.

Methods

A psychometric evaluation, within a cross-sectional study comprising cognitive interviews (to assess comprehension and acceptability) and a field test. Pregnant women aged over 18 years were recruited in early pregnancy (approximately 12 weeks’ gestation). Reliability (internal consistency) was assessed using Cronbach’s alpha, corrected item-total correlations and inter-item correlations, and stability via a test-retest. Construct validity was assessed using principal components analysis and hypothesis testing.

Results

Six women participated in cognitive interviews and 317 in the field test. The London Measure of Unplanned Pregnancy was acceptable and well comprehended. Reliability testing demonstrated good internal consistency (alpha = 0.81, all corrected item-total correlations >0.20, all inter-item correlations positive) and excellent stability (weighted kappa = 0.92). Validity testing confirmed the unidimensional structure of the measure and all hypotheses were confirmed.

Conclusions

The London Measure of Unplanned Pregnancy is a valid and reliable measure of pregnancy planning/intention for the Australian population. Implementation of this measure into all maternity healthcare, research and policy settings will provide accurate population-level pregnancy planning estimates to inform, monitor and evaluate interventions to improve preconception health in Australia.

Contraceptive use, prevalence and predictors of pregnancy planning among female sex workers in Uganda: a cross sectional study

BACKGROUND

Unintended pregnancies are associated with negative consequences to both mother and baby. Female Sex Workers (FSWs) are at high risk of unintended/unplanned pregnancies. However, prevalence of pregnancy planning and its predictors among FSWs has not been comprehensively investigated. This study was designed to determine contraceptive use, the prevalence, and predictors of pregnancy planning among FSWs in Uganda.

METHODS

In this cross-sectional study, 819 FSWs attending most at risk populations initiative (MARPI) clinics were recruited using systematic sampling and interviewed with a pretested questionnaire that included collection of data on pregnancy intention using the London Measure of Unplanned Pregnancy (LMUP). Data were analysed using STATA version 14.0. Multinomial logistic regression model was used to identify predictors of pregnancy planning, RESULTS: Of the 819 study participants, only 90 (11.0%) had planned pregnancies. Overall, 462 (56.4%) were hazardous alcohol users and 335 (40.9%) abused drugs; 172 (21.0%) had been raped in the last 2 years and 70 (40.7%) of these accessed emergency contraception post-rape. Dual contraception use (condom and other modern method) was 58.0%. Having a non-emotional partner as a man who impregnated the FSW compared to emotional partner was significantly associated with less planned relative to unplanned pregnancy, (aRR = 0.15 95%Cl =0.08, 0.30), so was lack of reported social support compared to support from friends, (aRR = 0.44; 95% CI = 0.22-0.87), keeping all factors constant in the model. Being raped (aRR = 0.51; 95% CI = 0.31-0.84) or abuse of substances (aRR = 0.65; 95% CI = 0.45-0.93) were significantly associated with lower ambivalence relative to unplanned pregnancy but not with planned relative to unplanned pregnancy.

CONCLUSION

Compared to women in the general population, pregnancy planning was low among FSWs amidst modest use of dual contraceptive. There is an urgent need to promote dual contraception among FSWs to prevent unplanned pregnancies especially with non-emotional partners, drug users, and post-rape.

Reassessing pregnancy intention and its relation to maternal, perinatal and neonatal outcomes in a low-income setting: A cohort study

BACKGROUND

It is unclear whether unintended pregnancies are associated with adverse outcomes. Data are predominantly from high-income countries and have methodological limitations, calling the findings into question. This research was designed to overcome these limitations and assess the relationships between pregnancy intention and miscarriage, stillbirth, low birthweight, neonatal death and postnatal depression in a low-income country.

METHODS

The pregnancy intention of 4,244 pregnant women in Mchinji District, Malawi, was measured using the validated Chichewa version of the London Measure of Unplanned Pregnancy (LMUP). Women were re-interviewed postnatally to assess pregnancy outcome. Postnatal depression was assessed using the WHO's Self-Reporting Questionnaire. Multivariable regressions were conducted, with the choice of confounders informed by a pre-existing conceptual epidemiological hierarchy.

RESULTS

Planned pregnancies are associated with a reduced risk of any (adjusted RR 0.90 [95%CI 0.86, 0.95]) or high symptoms of depression (adjusted RR 0.76 [95%CI 0.63, 0.91]) compared to unplanned pregnancies in rural Malawi. There was no relationship between pregnancy intention and the composite measure of miscarriage, stillbirth, low birthweight and neonatal death. There was some evidence that greater pregnancy intention was associated with reduced adjusted risk of stillbirth (0·93 [95%CI 0·87, 1·00]).

CONCLUSION

Our study is the first to use a psychometrically valid measure of pregnancy intention, and to do so antenatally. As pregnancy intention increases, the risk of postnatal depression and, possibly, stillbirth decreases. This suggests a new, clinical use for the LMUP; identifying women antenatally who are at risk of these adverse pregnancy outcomes.

Intended pregnancy after receiving vs. being denied a wanted abortion

OBJECTIVES

To understand how having or being denied an abortion affects the likelihood of trying to become pregnant, overall pregnancy rates, and the rate and timing of an intended pregnancy in the future.

STUDY DESIGN

The Turnaway Study is a prospective cohort study of women who received or were denied a wanted abortion. Women were recruited from one of 30 US abortion facilities. We examined subsequent intended pregnancy among those who presented just under the facility's gestational limit and received an abortion (Near-Limit Abortion Group, n=413) and those who presented for abortion just beyond the facility's gestational limit, were denied an abortion and went on to parent the child (Parenting Turnaways, n=146). First, we modeled the probability of trying to become pregnant using multivariable mixed-effects logistic regression. We then used Cox proportional-hazards models to compare overall pregnancy rates and intended pregnancy rates over 5 years.

RESULTS

Parenting Turnaways had lower predicted probabilities of reporting trying to become pregnant in the first 1.5 years after birth/abortion than the Near-Limit Abortion Group. They also had lower pregnancy rates overall [40.4 per 100 woman-years vs. 53.5 per 100 woman-years, adjusted hazards ratio (aHR)=0.69, 95% confidence interval (CI): 0.54-0.89]. The 5-year intended pregnancy rate was low among both groups, but compared to the Near-Limit Abortion Group, Parenting Turnaways had a lower intended pregnancy rate (2.2 per 100 woman-years vs. 7.5 per 100 woman-years, aHR=0.29, 95% CI: 0.10-0.85).

CONCLUSION

Being able to obtain a wanted abortion may enable women to have an intended pregnancy later.

IMPLICATIONS

Ensuring that women can obtain an abortion for an unwanted pregnancy may enable them to have a subsequent pregnancy when they are ready to have a baby.

Comparing the order of the London Measure of Unplanned Pregnancy and the Demographic and Health Survey question on pregnancy intention in a single group of postnatal women in Malawi - the effect of question order on assessment of pregnancy intention

Objective

To investigate the effect of question order on women’s responses to the London Measure of Unplanned Pregnancy (LMUP) or the pregnancy intention question of the Demographic and Health Survey (DHS) when both are asked in the same survey. We collected data on pregnancy intention from a cohort of 4244 pregnant women in Malawi who were re-interviewed at 1, 6 and 12 months postnatally. Women in Zone 1 were asked the LMUP, then antenatal questions, then the DHS pregnancy intention question, women in Zone 2 were asked the DHS pregnancy intention question, then antenatal questions, then the LMUP; women in Zone 3 were only asked the DHS pregnancy intention question. We used linear regression to compare the LMUP score and ordinal regression to compare DHS categorisations of pregnancy intention across Zones, adjusting for baseline socioeconomic differences between the Zones.

Results

We found no effect of question order on the assessment of pregnancy intention by the LMUP. There were differences in the assessment of pregnancy intention when the pregnancy intention question in the DHS was used, however this seemed to be due to baseline sociodemographic differences between the groups of pregnant women being compared, and not due to question order.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3577-1) contains supplementary material, which is available to authorized users.

Birth Planning and Women's and Men's Health in Malawi

Despite the frequency with which it occurs, we know little about unintended fertility in sub-Saharan Africa and even less about its implications for the health of the women and men who experience it. We use longitudinal data from southern Malawi to explore how young adults report on the planning of their births and to identify changes in their self-rated health and subjective well-being associated with having more- or less-planned births. Our data feature a comprehensive scale of pregnancy planning, the London Measure of Unplanned Pregnancy (LMUP), that extends beyond the conventional focus on timing-based pregnancy intentions to incorporate information about contraception, desires, intentions, partner discussion, and preconception preparations. Women and men have similar bimodal distributions on the LMUP, with the majority of births clearly unplanned or planned but a sizeable minority that falls in the middle. Change score models demonstrate that, for women, an unplanned birth is associated with a decline in self-rated health. In contrast, men whose births were ambivalently-planned experience a decline in subjective well-being. Our findings highlight the value of considering the full spectrum of birth planning and demonstrate the health consequences of unplanned fertility for both women and men in this sub-Saharan context.

Before the beginning: nutrition and lifestyle in the preconception period and its importance for future health

A woman who is healthy at the time of conception is more likely to have a successful pregnancy and a healthy child. We reviewed published evidence and present new data from low-income, middle-income, and high-income countries on the timing and importance of preconception health for subsequent maternal and child health. We describe the extent to which pregnancy is planned, and whether planning is linked to preconception health behaviours. Observational studies show strong links between health before pregnancy and maternal and child health outcomes, with consequences that can extend across generations, but awareness of these links is not widespread. Poor nutrition and obesity are rife among women of reproductive age, and differences between high-income and low-income countries have become less distinct, with typical diets falling far short of nutritional recommendations in both settings and especially among adolescents. Several studies show that micronutrient supplementation starting in pregnancy can correct important maternal nutrient deficiencies, but effects on child health outcomes are disappointing. Other interventions to improve diet during pregnancy have had little effect on maternal and newborn health outcomes. Comparatively few interventions have been made for preconception diet and lifestyle. Improvements in the measurement of pregnancy planning have quantified the degree of pregnancy planning and suggest that it is more common than previously recognised. Planning for pregnancy is associated with a mixed pattern of health behaviours before conception. We propose novel definitions of the preconception period relating to embryo development and actions at individual or population level. A sharper focus on intervention before conception is needed to improve maternal and child health and reduce the growing burden of non-communicable diseases. Alongside continued efforts to reduce smoking, alcohol consumption, and obesity in the population, we call for heightened awareness of preconception health, particularly regarding diet and nutrition. Importantly, health professionals should be alerted to ways of identifying women who are planning a pregnancy.

Psychometric properties of the Dutch version of the London Measure of Unplanned Pregnancy in women with pregnancies ending in birth

Objective

To evaluate the psychometric properties of the Dutch version of the London Measure of Unplanned Pregnancy in women with pregnancies ending in birth.

Methods

A two-phase psychometric evaluation design was set-up. Phase I comprised the translation from English into Dutch and pretesting with 6 women using cognitive interviews. In phase II, the reliability and validity of the Dutch version of the LMUP was assessed in 517 women giving birth recently. Reliability (internal consistency) was assessed using Cronbach’s alpha, inter-item correlations, and corrected item-total correlations. Construct validity was assessed using principal components analysis and hypothesis testing. Exploratory Mokken scale analysis was carried out.

Results

517 women aged 15–45 completed the Dutch version of the LMUP. Reliability testing showed acceptable internal consistency (alpha = 0.74, positive inter-item correlations between all items, all corrected item-total correlations >0.20). Validity testing confirmed the unidimensional structure of the scale and all hypotheses were confirmed. The overall Loevinger’s H coefficient was 0.57, representing a ‘strong’ scale.

Conclusion

The Dutch version of the LMUP is a reliable and valid measure that can be used in the Dutch-speaking population in Belgium to assess pregnancy planning. Future research is necessary to assess the stability of the Dutch version of the LMUP, and to evaluate its psychometric properties in women with abortions.

Subsequent Unintended Pregnancy Among US Women Who Receive or Are Denied a Wanted Abortion

INTRODUCTION

Seventeen percent of women in the United States experience more than one unintended pregnancy in their lifetimes. However, few studies examine how the resolution of unintended pregnancy, whether in birth or abortion, affects the likelihood of a subsequent unintended pregnancy. Our objective was to determine whether receiving or being denied a wanted abortion is associated with subsequent unintended pregnancy.

METHODS

The Turnaway Study, a 5-year, prospective cohort study, followed women who sought an abortion at one of 30 abortion facilities across the United States between 2008 and 2010. Secondary analysis of the Turnaway data analyzed the effects of various factors on time to subsequent unintended pregnancy.

RESULTS

By 5 years, the rate of unintended pregnancy was 42 per 100 women with no difference between those who received and those who were denied a wanted abortion. Women aged 35 to 46 years (vs those aged 20-24 years), women with a college degree (vs women who had completed high school or obtained a general education diploma), and foreign-born (vs native-born) women had a reduced rate of a subsequent unplanned pregnancy (adjusted hazard ratio [AHR], 0.30; 95% confidence interval [CI], 0.16-0.57; AHR, 0.54, 95% CI, 0.30-0.97; AHR, 0.44; 95% CI, 0.25-0.77, respectively). Higher parity and a history of depression were positively associated with a higher rate of subsequent unintended pregnancy. There was no difference in the outcomes of these unintended pregnancies by study group; approximately one-sixth ended in miscarriage and one-quarter of subsequent unintended pregnancies ended in abortion.

DISCUSSION

Neither receiving nor being denied abortion is associated with subsequent unintended pregnancy risk. Other factors such as nativity, parity, age, and mental health history are associated with multiple unintended pregnancies. Ensuring access to abortion services will not increase the likelihood that women will experience subsequent unintended pregnancies.

Ambivalence in pregnancy intentions: The effect of quality of care and context among a cohort of women attending family planning clinics in Kenya

Context

Ambivalence in pregnancy intentions is well-documented in sub-Saharan African (SSA) settings and has been associated with inconsistent use of contraception, thereby exposing women using contraception to the possibility of unintended pregnancies. A better understanding of the potential role for client counseling interventions in enabling women to achieve their pregnancy intentions is essential for aiding program efforts to reduce unintended pregnancies.

Objective

To measure ambivalence in pregnancy intentions longitudinally and determine its association with the quality of care received, controlling for demographic, socio-economic and contextual factors among a cohort of family planning (FP) clients in Kenya.

Methods

This paper uses data drawn from a prospective cohort study of FP clients to investigate the relationship between the quality of care received during FP service delivery and the decisiveness of their pregnancy intentions over time. The study tests the hypothesis that higher quality of care enables women to be less ambivalent about their pregnancy intentions. Binary logistic regression with random effects and multinomial logistic regression were used to assess the predictive effect of the quality of care received by a woman on the decisiveness or ambivalence of her pregnancy intentions, and on any shifts in ambivalence over time, controlling for background characteristics. The study recruited 1,957 women aged 15–49 years attending twelve family planning clinics in four counties in Central Kenya; of these, 1,053 women were observed for four rounds of data collection over a period of 24 months and form the sample for analysis.

Findings

A substantial proportion (43%) of women expressed ambivalence about their intentions to become pregnant at some point during the study period, while over half (57%) remained unequivocal throughout the study. Almost one third of women (31%) shifted from being unequivocal to ambivalent and 12% shifted from ambivalence to being unequivocal. Women experiencing higher quality of care have lower odds of ever expressing ambivalence and higher odds of remaining unequivocal over time, net of other factors. Quality of care was not associated with a shift in ambivalence over time.

Conclusion

FP programs offering higher quality of care are likely to support women to be more decisive in their pregnancy intentions. Improving the quality of care can contribute to reduced ambivalence and consequently reduced likelihood of unintended pregnancy among contraceptive users. This study provides further evidence of the benefits gained through providing high quality services.

Trial registration

ClinicalTrials.gov NCT01694862

Re-Evaluating the Possible Increased Risk of HIV Acquisition With Progestin-Only Injectables Versus Maternal Mortality and Life Expectancy in Africa: A Decision Analysis

OBJECTIVE

The association between increased risk of HIV acquisition and use of progestin-only injectables (POIs) is controversial. We sought to compare the competing risks of maternal mortality and HIV acquisition with use of POIs using updated data on this association and considering an expanded number of African countries.

METHODS

We designed a decision-analytic model to compare the benefits and risks of POIs on the competing risks of maternal mortality and HIV acquisition on life expectancy for women in 9 African countries. For the purposes of this analysis, we assumed that POIs were associated with an increased risk of HIV acquisition (hazards ratio of 1.4). Our primary outcome was life-years and the population was women of reproductive age (15-49 years) in these countries, who did not have HIV infection and were not currently planning a pregnancy. Probabilities for each variable included in the model, such as HIV incidence, access to antiretroviral therapy, and contraceptive prevalence, were obtained from the literature. Univariate and multivariate sensitivity analyses were performed to check model assumptions and explore how uncertainty in estimates would affect the model results.

RESULTS

In all countries, discontinuation of POIs without replacement with an equally effective contraceptive method would result in decreased life expectancy due to a significant increase in maternal deaths. While the removal of POIs from the market would result in the prevention of some new cases of HIV, the life-years gained from this are mitigated due to the marked increase in neonatal HIV cases and maternal mortality with associated life-years lost. In all countries, except South Africa, typical-use contraceptive failure rates with POIs would need to exceed 39%, and more than half of women currently using POIs would have to switch to another effective method, for the removal of POIs to demonstrate an increase in total life-years.

CONCLUSION

Women living in sub-Saharan Africa cope with both high rates of HIV infection and high rates of pregnancy-related maternal death relative to the rest of the world. Based on the most current estimates, our model suggests that removal of POI contraception from the market without effective and acceptable contraception replacement would have a net negative effect on maternal health, life expectancy, and mortality under a variety of scenarios.

Concordance between intention to use and current use of contraceptives among six-month postpartum women in Brazil: The role of unplanned pregnancy

OBJECTIVE

to examine the effect of pregnancy planning status in the concordance between intention to use and current use of contraceptives among postpartum women.

DESIGN AND SETTING

a prospective study was conducted in 12 primary health care facilities in São Paulo, Brazil, from November 2013 to September 2014.

PARTICIPANTS

A total of 264 woman aged 15-44 years old completed a face-to-face interview when they were pregnant (baseline), and were interviewed by phone at 6 months postpartum.

MEASUREMENTS

At baseline, participants were questioned about the contraceptive method they would prefer to be using at 6 months postpartum. At 6 months postpartum, they answered about the contraceptive method they were currently using. Pregnancy planning status was measured using the Brazilian Portuguese London Measure of Unplanned Pregnancy. We conducted logistic regression, considering contraceptive preference-use concordance as the dependent variable and the main covariate as pregnancy planning status.

FINDINGS

Only 28.9% of postpartum women were using the method they preferred to use when they were pregnant. The agreement between preference and contraceptive use was higher for injectables (60.9%) and lowest for IUD, as nobody who preferred it was actually using it. Women who were not sure about what method they intended to use after childbirth more frequently reported no use at six months postpartum. Multivariate logistic regression showed that postpartum women whose pregnancy was unplanned were less likely to use the contraceptive methods that they intended to use when they were pregnant [aOR=0.36; 95%CI=0.14-0.97].

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Brazilian women were able to access contraceptives in the postpartum period. However, there is a considerable discordance between their contraceptive intention to use and use at the sixth postpartum month. A higher unmet demand for IUD and sterilization should be highlighted. The pregnancy planning status is associated to postpartum contraceptive preference-use concordance, so interventions before pregnancy may affect postpartum contraceptive use. Women with unintended pregnancies present an important opportunity to offer additional family planning counseling.

Prevalence and determinants of unintended pregnancies amongst women attending antenatal clinics in Pakistan

BACKGROUND

Unintended pregnancies are a global public health concern and contribute significantly to adverse maternal and neonatal health, social and economic outcomes and increase the risks of maternal deaths and neonatal mortality. In countries like Pakistan where data for the unintended pregnancies is scarce, studies are required to estimate its accurate prevalence and predictors using more specific tools such as the London Measure of Unplanned Pregnancies (LMUP).

METHODS

We conducted a hospital based cross sectional survey in two tertiary care hospitals in Pakistan. We used a pre tested structured questionnaire to collect the data on socio-demographic characteristics, reproductive history, awareness and past experience with contraceptives and unintended pregnancies using six item the LMUP. We used Univariate and multivariate analysis to explore the association between unintended pregnancies and predictor variables and presented the association as adjusted odds ratios. We also evaluated the psychometric properties of the Urdu version of the LMUP.

RESULTS

Amongst 3010 pregnant women, 1150 (38.2%) pregnancies were reported as unintended. In the multivariate analysis age < 20 years (AOR 3.5 1.1-6.5), being illiterate (AOR 1.9 1.1-3.4), living in a rural setting (1.7 1.2-2.3), having a pregnancy interval of = < 12 months (AOR 1.7 1.4-2.2), having a parity of >2 (AOR 1.4 1.2-1.8), having no knowledge about contraceptive methods (AOR 3.0 1.7-5.4) and never use of contraceptive methods (AOR 2.3 1.4-5.1) remained significantly associated with unintended pregnancy. The Urdu version of the LMUP scale was found to be acceptable, valid and reliable with the Cronbach's alpha of 0.85.

CONCLUSIONS

This study explores a high prevalence of unintended pregnancies and important factors especially those related to family planning. Integrated national family program that provides contraceptive services especially the modern methods to women during pre-conception and post-partum would be beneficial in averting unintended pregnancies and their related adverse outcomes in Pakistan.

London Measure of Unplanned Pregnancy: guidance for its use as an outcome measure

Background

The London Measure of Unplanned Pregnancy (LMUP) is a psychometrically validated measure of the degree of intention of a current or recent pregnancy. The LMUP is increasingly being used worldwide, and can be used to evaluate family planning or preconception care programs. However, beyond recommending the use of the full LMUP scale, there is no published guidance on how to use the LMUP as an outcome measure. Ordinal logistic regression has been recommended informally, but studies published to date have all used binary logistic regression and dichotomized the scale at different cut points. There is thus a need for evidence-based guidance to provide a standardized methodology for multivariate analysis and to enable comparison of results. This paper makes recommendations for the regression method for analysis of the LMUP as an outcome measure.

Materials and methods

Data collected from 4,244 pregnant women in Malawi were used to compare five regression methods: linear, logistic with two cut points, and ordinal logistic with either the full or grouped LMUP score. The recommendations were then tested on the original UK LMUP data.

Results

There were small but no important differences in the findings across the regression models. Logistic regression resulted in the largest loss of information, and assumptions were violated for the linear and ordinal logistic regression. Consequently, robust standard errors were used for linear regression and a partial proportional odds ordinal logistic regression model attempted. The latter could only be fitted for grouped LMUP score.

Conclusion

We recommend the linear regression model with robust standard errors to make full use of the LMUP score when analyzed as an outcome measure. Ordinal logistic regression could be considered, but a partial proportional odds model with grouped LMUP score may be required. Logistic regression is the least-favored option, due to the loss of information. For logistic regression, the cut point for un/planned pregnancy should be between nine and ten. These recommendations will standardize the analysis of LMUP data and enhance comparability of results across studies.

Pregnancy intentions-a complex construct and call for new measures

OBJECTIVE

To estimate the prevalence of unintended pregnancies under relaxed assumptions regarding birth control use compared with a traditional constructed measure.

DESIGN

Cross-sectional survey.

SETTING

Not applicable.

PATIENT(S)

Nationally representative sample of U.S. women aged 15-44 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence of intended and unintended pregnancies as estimated by [1] a traditional constructed measure from the National Survey of Family Growth (NSFG), and [2] a constructed measure relaxing assumptions regarding birth control use, reasons for nonuse, and pregnancy timing.

RESULT(S)

The prevalence of unintended pregnancies was 6% higher using the traditional constructed measure as compared with the approach with relaxed assumptions (NSFG: 44%, 95% confidence interval [CI] 41, 46; new construct 38%, 95% CI, 36, 41). Using the NSFG approach, only 92% of women who stopped birth control to become pregnant and 0 women who were not using contraceptives at the time of the pregnancy and reported that they did not mind getting pregnant were classified as having intended pregnancies, compared with 100% using the new construct.

CONCLUSION(S)

Current measures of pregnancy intention may overestimate rates of unintended pregnancy, with over 340,000 pregnancies in the United States misclassified as unintended using the current approach, corresponding to an estimated savings of $678 million in public health-care expenditures. Current constructs make assumptions that may not reflect contemporary reproductive practices, so improved measures are needed.

Comparison of a Timing-Based Measure of Unintended Pregnancy and the London Measure of Unplanned Pregnancy

CONTEXT

Unintended pregnancy is a universal benchmark for reproductive health, but whether variations reflect differences in measurement and how well measures predict pregnancy outcomes warrant further examination. U.S. and British measures of unintended and unplanned pregnancy offer a useful comparison.

METHODS

Some 220 women seeking pregnancy testing at the Columbia University Medical Center in 2005 responded to three pregnancy measures: a binary timing-based measure of unintended pregnancy (TMUP); a multi-item measure of timing-based intentions and planning behaviors, the London Measure of Unplanned Pregnancy (LMUP); and a measure combining intentions (from the TMUP) and how women would feel about a positive pregnancy test. Six-month pregnancy status was assessed among 159 respondents. Estimates of unintended and unplanned pregnancy were calculated using the TMUP and the LMUP, and receiver operating characteristic (ROC) curves were generated to assess congruence.

RESULTS

According to the TMUP, 76% of pregnancies were unintended; by contrast, LMUP scores categorized 39% as unplanned. The ROC curve indicated that expanding the range of scores for classifying pregnancies as unplanned on the LMUP would achieve greater congruence between these measures. At six months, the proportion of pregnancies that had ended in abortion was 42% of those classified as unintended using the TMUP, 60% of those classified as unplanned using the LMUP and 71% of those that women said they had not intended and were very upset about.

CONCLUSIONS

U.S. and British measures of unintended pregnancy are not directly comparable, and a measure combining intentions and feelings may better predict pregnancy outcomes.

Evaluation of the psychometric properties of the London Measure of Unplanned Pregnancy in Brazilian Portuguese

BACKGROUND

Estimates of unplanned pregnancy worldwide are of concern, especially in low and middle-income countries, including Brazil. Although the contraceptive prevalence rate is high in Brazil, almost half of all pregnancies are reported as unintended. The only source of nationally representative data about pregnancy intention is the Demographic and Health Survey, as with many other countries. In more recent years, however, it has been realized that concept of unintended pregnancy is potentially more complex and requires more sophisticated measurement strategies, such as the London Measure of Unplanned Pregnancy (LMUP). The LMUP has been translated and validated in other languages, but not Portuguese yet. In this study, we evaluate the psychometric properties of the LMUP in the Portuguese language, Brazilian version.

METHODS

A Brazilian Portuguese version of the LMUP was produced via translation and back-translation. After piloting, the mode of administration was changed from self-completion to interviewer-administration. The measure was field tested with pregnant, postpartum, and postabortion women recruited at maternity and primary health care services in Sao Paulo city. Reliability (internal consistency) was assessed using Cronbach's alpha and item-total correlations. Construct validity was assessed using principal components analysis and hypothesis testing. Scaling was assessed with Mokken analysis.

RESULTS

759 women aged 15-44 completed the Brazilian Portuguese LMUP. There were no missing data. The measure was acceptable and well targeted. Reliability testing demonstrated good internal consistency (alpha = 0.81, all item-rest correlations >0.2). Validity testing confirmed that the measure was unidimensional and that all hypotheses were met: there were lower LMUP median scores among women in the extreme age groups (p < 0.001), among non-married women (p < 0.001) and those with lower educational attainment (p < 0.001). The Loevinger H coefficient was 0.60, indicating a strong scale.

CONCLUSION

The Brazilian Portuguese LMUP is a valid and reliable measure of pregnancy planning/intention that is now available for use in Brazil. It represents a useful addition to the public health research and surveillance toolkit in Brazil.

Identifying women at risk of unintended pregnancy: a comparison of two pregnancy readiness measures

PURPOSE

Recently, there has been interest in developing a predictive measure to assess pregnancy readiness/intention in clinical settings. Two such measures have been created but tested primarily in pregnant or postpartum populations. This study examined agreement between the pregnancy readiness measures in a diverse population of nonpregnant women.

METHODS

Women completed short questionnaires while waiting for clinical appointments. Participants' responses to the pregnancy readiness measures were cross-tabulated to assess the level of agreement between the measures. Logistic regression was used to determine factors related to disagreement between the measures. Complete information was available for 220 women.

RESULTS

Almost 55% of women had disagreement between the pregnancy readiness measures. Women with a high school education or less had 2.60 times the odds of disagreement (95% confidence interval 1.23-5.49), and women who did not use contraception had 2.40 times the odds of disagreement (95% confidence interval 1.18-4.87).

CONCLUSIONS

Although both pregnancy readiness measures are promising tools that could potentially be adapted for use in public health or clinical settings, there are limitations to these measures. These measures should be further tested and refined through the use of qualitative methods to ensure that a valid measure is created for use in non-pregnant populations.

The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

BACKGROUND

Unplanned pregnancy is a key public health indicator. We describe the prevalence of unplanned pregnancy, and associated factors, in a general population sample in Britain (England, Scotland, and Wales).

METHOD

We did a probability sample survey, the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), of 15,162 men and women aged 16-74 years in Britain, including 5686 women of child-bearing age (16-44 years) who were included in the pregnancy analysis, between Sept 6, 2010, and Aug 31, 2012. We describe the planning status of pregnancies with known outcomes in the past year, and report the annual population prevalence of unplanned pregnancy, using a validated, multicriteria, multi-outcome measure (the London Measure of Unplanned Pregnancy). We set the findings in the context of secular trends in reproductive health-related events, and patterns across the life course.

FINDINGS

9·7% of women aged 16-44 years had pregnancies with known outcome in the year before interview, of which 16·2% (95% CI 13·1-19·9) scored as unplanned, 29·0% (25·2-33·2) as ambivalent, and 54·8% (50·3-59·2) as planned, giving an annual prevalence estimate for unplanned pregnancy of 1·5% (1·2-1·9). Pregnancies in women aged 16-19 years were most commonly unplanned (45·2% [30·8-60·5]). However, most unplanned pregnancies were in women aged 20-34 years (62·4% [50·2-73·2]). Factors strongly associated with unplanned pregnancy were first sexual intercourse before 16 years of age (age-adjusted odds ratio 2·85 [95% CI 1·77-4·57], current smoking (2·47 [1·46-4·18]), recent use of drugs other than cannabis (3·41 [1·64-7·11]), and lower educational attainment. Unplanned pregnancy was also associated with lack of sexual competence at first sexual intercourse (1·90 [1·14-3·08]), reporting higher frequency of sex (2·11 [1·25-3·57] for five or more times in the past 4 weeks), receiving sex education mainly from a non-school-based source (1·84 [1·12-3·00]), and current depression (1·96 [1·10-3·47]).

INTERPRETATION

The increasing intervals between first sexual intercourse, cohabitation, and childbearing means that, on average, women in Britain spend about 30 years of their life needing to avert an unplanned pregnancy. Our data offer scope for primary prevention aimed at reducing the rate of unplanned conceptions, and secondary prevention aimed at modification of health behaviours and health disorders in unplanned pregnancy that might be harmful for mother and child.

FUNDING

Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

Understanding pregnancy planning in a low-income country setting: validation of the London measure of unplanned pregnancy in Malawi

Background

The London Measure of Unplanned Pregnancy (LMUP) is a new and psychometrically valid measure of pregnancy intention that was developed in the United Kingdom. An improved understanding of pregnancy intention in low-income countries, where unintended pregnancies are common and maternal and neonatal deaths are high, is necessary to inform policies to address the unmet need for family planning. To this end this research aimed to validate the LMUP for use in the Chichewa language in Malawi.

Methods

Three Chichewa speakers translated the LMUP and one translation was agreed which was back-translated and pre-tested on five pregnant women using cognitive interviews. The measure was field tested with pregnant women who were recruited at antenatal clinics and data were analysed using classical test theory and hypothesis testing.

Results

125 women aged 15–43 (median 23), with parities of 1–8 (median 2) completed the Chichewa LMUP. There were no missing data. The full range of LMUP scores was captured. In terms of reliability, the scale was internally consistent (Cronbach’s alpha = 0.78) and test-retest data from 70 women showed good stability (weighted Kappa 0.80). In terms of validity, hypothesis testing confirmed that unmarried women (p = 0.003), women who had four or more children alive (p = 0.0051) and women who were below 20 or over 29 (p = 0.0115) were all more likely to have unintended pregnancies. Principal component analysis showed that five of the six items loaded onto one factor, with a further item borderline. A sensitivity analysis to assess the effect of the removal of the weakest item of the scale showed slightly improved performance but as the LMUP was not significantly adversely affected by its inclusion we recommend retaining the six-item score.

Conclusion

The Chichewa LMUP is a valid and reliable measure of pregnancy intention in Malawi and can now be used in research and/or surveillance. This is the first validation of this tool in a low-income country, helping to demonstrate that the concept of pregnancy planning is applicable in such a setting. Use of the Chichewa LMUP can enhance our understanding of pregnancy intention in Malawi, giving insight into the family planning services that are required to better meet women’s needs and save lives.