Changing lives, dynamic plans: Prospective assessment of 12-month changes in pregnancy timing intentions and personal circumstances using data from HER Salt Lake

Childbearing plans' predictive value for birth outcomes: A systematic review to inform mode of delivery decisions

OBJECTIVE

Rising cesarean delivery (CD) rates significantly impact maternal health, underscoring the need for comprehensive counseling. This review examines the consistency of childbearing plans over time and their predictive value for childbirth events.

DATA SOURCES

PubMed, EMBASE, Web of Science, and PsycINFO databases up to October 2023.

STUDY ELIGIBILITY CRITERIA

Studies assessing women's childbearing plans at baseline (T1) and following up with subsequent plans and/or outcomes (T2).

STUDY APPRAISAL AND SYNTHESIS METHODS

Meta-analyses calculated risk ratios and standardized mean differences using random-effects models. Bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Forty-four studies (n = 132,846 women) were included. Average desired family size at T1 was 2.63 (95 %CI: 2.03-3.23), remaining stable at follow-up (p = 0.135). While no significant change in plans was observed for women who initially wanted children, negative plans showed significant instability (pooled effect size: 0.18, 95 %CI: 0.03-0.33; p = 0.0162). Estimated rates of stable, decreasing, and increasing childbearing plans were 74 %, 12 %, 11 %, respectively. Positive plans strongly predicted childbirth (RR = 3.95, 95 % CI: 2.46, 6.35; p < 0.0001; I2 = 98 %). Follow-up childbirth rates for initially negative plans were 5 % (95 % CI: 0-44 %) for nulliparae, 13 % (95 % CI: 2-57 %) for primiparae, and 64 % (95 % CI: 61-68 %) formultiparae.

CONCLUSIONS

On average, women desire 2.63 children (95 % CI: 2.03-3.23). Childbearing plans are largely stable, but around 10 % of women with negative or uncertain plans later desired children. Positive plans nearly quadrupled childbirth likelihood. Negative plans were less predictive, particularly in multiparous women. Future research should explore age, socioeconomics, and cultural contexts, particularly for nulliparous women over 35 considering elective CD.

Evaluating Pregnancy Rates in Fertility Awareness-Based Methods for Family Planning: Simulated Comparison of Correct Use to Avoid, Method-Related, and Total Pregnancy Rates

Fertility awareness-based methods (FABMs), also known as natural family planning (NFP), enable couples to identify the days of the menstrual cycle when intercourse may result in pregnancy ("fertile days"), and to avoid intercourse on fertile days if they wish to avoid pregnancy. Thus, these methods are fully dependent on user behavior for effectiveness to avoid pregnancy. For couples and clinicians considering the use of an FABM, one important metric to consider is the highest expected effectiveness (lowest possible pregnancy rate) during the correct use of the method to avoid pregnancy. To assess this, most studies of FABMs have reported a method-related pregnancy rate (a cumulative proportion), which is calculated based on all cycles (or months) in the study. In contrast, the correct use to avoid pregnancy rate (also a cumulative proportion) has the denominator of cycles with the correct use of the FABM to avoid pregnancy. The relationship between these measures has not been evaluated quantitatively. We conducted a series of simulations demonstrating that the method-related pregnancy rate is artificially decreased in direct proportion to the proportion of cycles with intermediate use (any use other than correct use to avoid or targeted use to conceive), which also increases the total pregnancy rate. Thus, as the total pregnancy rate rises (related to intermediate use), the method-related pregnancy rate falls artificially while the correct use pregnancy rate remains constant. For practical application, we propose the core elements needed to assess correct use cycles in FABM studies.

Summary

Fertility awareness-based methods (FABMs) can be used by couples to avoid pregnancy, by avoiding intercourse on fertile days. Users want to know what the highest effectiveness (lowest pregnancy rate) would be if they use an FABM correctly and consistently to avoid pregnancy. In this simulation study, we compare two different measures: (1) the method-related pregnancy rate; and (2) the correct use pregnancy rate. We show that the method-related pregnancy rate is biased too low if some users in the study are not using the method consistently to avoid pregnancy, while the correct use pregnancy rate obtains an accurate estimate.

Short Summary

In FABM studies, the method-related pregnancy rate is biased too low, but the correct use pregnancy rate is unbiased.

Women's Work Characteristics and Fertility Expectations

Previous research has shown that employment is an important social context affecting fertility, yet relatively little is known about the extent to which work characteristics affect fertility expectations. Using over 25 years of data from the 1979 National Longitudinal Survey of Youth, we analyzed the associations between part-time work and characteristics associated with autonomy over working time, specifically self-employment and managerial/professional occupation, and childbearing expectations among women ages 18-45 (N=4,415). Logistic regression models for longitudinal data reveal that work characteristics are significantly associated with fertility expectations, but that the specific nature of the relationship varies by parity. Among women with one child, those working part-time had predicted probabilities of expecting to have additional children that were 2% higher than those working full-time. In contrast, among women without any children, those working part-time had predicted probabilities that were 2% lower than those working full-time. Similar contrasting relationships by parity were found when comparing self-employed women to employees and managers/professionals to those in other occupations. Findings were consistent across racial and ethnic groups. These results suggest that different mechanisms link work characteristics to fertility plans for mothers and non-mothers, specifically that role incompatibility and work-family conflict are more salient for mothers but that financial strain is so for non-mothers.

The effect of changing pregnancy intentions on preconception health behaviors: a prospective cohort study

PURPOSE

Pregnancy intentions are associated with preconception health behaviors but are understudied among female adolescent and young adult (AYA) cancer survivors. Preconception health is critical for survivors because they face unique risks to fertility and pregnancy from late effects of cancer treatments. This study prospectively assessed the effect of pregnancy intention on physical activity (PA) and smoking behaviors among female AYA survivors.

METHODS

A cohort of 1049 female AYA survivors were recruited between 2013 and 2017. Participants were 18-39 years and had completed primary cancer treatment. Longitudinal mixed effects analysis was conducted on participants who completed at least 2 of 4 questionnaires over 1.5 years. Two measures were used to capture multiple dimensions of pregnancy intention. The pregnancy intention score (PIS) captured wanting and planning dimensions and represented a scaled response of low to high intention. The trying dimension captured urgent intention and ranged from not trying, ambivalent (neither attempting nor avoiding pregnancy), and trying now. Intention change was assessed between each consecutive time points. Final analysis was conducted with multiple imputations.

RESULTS

Survivors with increased intention measured by trying was associated with increased PA over time (adjusted B [95%CI]: 0.3 [0.01, 0.5]) compared to survivors with no changes or decreased trying intention. PIS was not significantly associated with preconception behaviors. No measure of intention was associated with smoking behavior.

CONCLUSIONS

Increasingly urgent pregnancy intention (trying dimension) was associated with higher preconception PA.

IMPLICATIONS FOR CANCER SURVIVORS

Screening for immediate intentions can identify AYA survivors in need of early preconception health promotion.

Predictive ability of the Desire to Avoid Pregnancy scale

BACKGROUND

A longstanding gap in the reproductive health field has been the availability of a screening instrument that can reliably predict a person's likelihood of becoming pregnant. The Desire to Avoid Pregnancy Scale is a new measure; understanding its sensitivity and specificity as a screening tool for pregnancy as well as its predictive ability and how this varies by socio-demographic factors is important to inform its implementation.

METHODS

This analysis was conducted on a cohort of 994 non-pregnant participants recruited in October 2018 and followed up for one year. The cohort was recruited using social media as well as advertisements in a university, school, abortion clinic and outreach sexual health service. Almost 90% of eligible participants completed follow-up at 12 months; those lost to follow-up were not significantly different on key socio-demographic factors. We used baseline DAP score and a binary variable of whether participants experienced pregnancy during the study to assess the sensitivity, specificity, area under the ROC curve (AUROC) and positive and negative predictive values (PPV and NPV) of the DAP at a range of cut-points. We also examined how the predictive ability of the DAP varied according to socio-demographic factors and by the time frame considered (e.g., pregnancy within 3, 6, 9 and 12 months).

RESULTS

At a cut-point of 2 on the 0-4 range of the DAP scale, the DAP had a sensitivity of 0.78, a specificity of 0.81 and an excellent AUROC of 0.87. In this sample the cumulative incidence of pregnancy was 16% (95%CI 13%, 18%) making the PPV 43% and the NPV 95% at this cut-point. The DAP score was the factor most strongly associated with pregnancy, even after age and number of children were taken into account. The association between baseline DAP score and pregnancy did not differ across time frames.

CONCLUSIONS

This is the first study to assess the DAP scale as a screening tool and shows that its predictive ability is superior to the limited pre-existing pregnancy prediction tools. Based on our findings, the DAP could be used with a cut-point selected according to the purpose.

Desire to Avoid Pregnancy scale: clinical considerations and comparison with other questions about pregnancy preferences

BACKGROUND

Clinicians and women of reproductive age would benefit from a reliable way to identify who is likely to become pregnant in the next year, in order to direct health advice. The 14-item Desire to Avoid Pregnancy (DAP) scale is predictive of pregnancy; this paper compares it with other ways of assessing pregnancy preferences to shortlist options for clinical implementation.

METHODS

A cohort of 994 UK women of reproductive age completed the DAP and other questions about pregnancy preferences, including the Attitude towards Potential Pregnancy Scale (APPS), at baseline and reported on pregnancies quarterly for a year. For each question, DAP item and combinations of DAP items, we examined the predictive ability, sensitivity, specificity, area under the receiver operating curve (AUROC), and positive and negative predictive values.

RESULTS

The AUROCs and predictive ability of the APPS and DAP single items were weaker than the full DAP, though all except one had acceptable AUROCs (>0.7). The most predictive individual DAP item was 'It would be a good thing for me if I became pregnant in the next 3 months', where women who strongly agreed had a 66.7% chance of pregnancy within 12 months and the AUROC was acceptable (0.77).

CONCLUSION

We recommend exploring the acceptability to women and healthcare professionals of asking a single DAP item ('It would be a good thing for me if I became pregnant in the next 3 months'), possibly in combination with additional DAP items. This will help to guide service provision to support reproductive preferences.

Pregnancy Intention, Changes in Pregnancy Intention, and Pregnancy Incidence Among Female Nurses in North America

Importance

Pregnancy intention assessment is a key element of preconception and contraceptive care. The association between a single screening question and the incidence of pregnancy is unknown.

Objective

To prospectively evaluate the dynamics of pregnancy intention and pregnancy incidence.

Design, Setting, and Participants

This prospective cohort study (the Nurses' Health Study 3) was conducted from June 1, 2010, to April 1, 2022, in 18 376 premenopausal, nonpregnant female nurses aged 19 to 44 years.

Main Outcomes and Measures

Pregnancy intention and pregnancy status were assessed at baseline and approximately every 3 to 6 months thereafter. Cox proportional hazards regression models were used to estimate the association between pregnancy intention and pregnancy incidence.

Results

A total of 18 376 premenopausal, nonpregnant women (mean [SD] age, 32.4 [6.5] years) participated in the study. At baseline, 1008 women (5.5%) were trying to conceive, 2452 (13.3%) were contemplating pregnancy within 1 year, and the remaining 14 916 (81.2%) were neither trying to conceive nor thought they would be pregnant within 1 year. A total of 1314 pregnancies were documented within 12 months of pregnancy intention assessment. The cumulative incidence of pregnancy was 38.8% in women actively trying to conceive (median [IQR] time to pregnancy, 3.3 [1.5-6.7] months), 27.6% in women contemplating pregnancy (median [IQR] time to pregnancy, 6.7 [4.2-9.3] months), and 1.7% in women neither trying to conceive nor contemplating pregnancy (median [IQR] time to pregnancy, 7.8 [5.2-10.5] months) among those who became pregnant. Women who were actively trying to conceive were 23.1 times (95% CI, 19.5-27.4 times) and women who were contemplating pregnancy were 13.0 times (95% CI, 11.1-15.2 times) more likely to conceive within 12 months than women who were neither attempting nor contemplating pregnancy. Among women contemplating pregnancy at baseline who did not get pregnant during follow up, 18.8% were actively trying and 27.6% were not trying by 12 months. Conversely, only 4.9% of women neither trying to conceive nor contemplating pregnancy within 1 year at baseline changed pregnancy intention during follow up.

Conclusions and Relevance

In this cohort study of reproductive-aged nurses in North America, pregnancy intention was highly fluid among women who were contemplating pregnancy but relatively stable among women trying to conceive and women who were neither trying to conceive nor contemplating pregnancy. Pregnancy intention was strongly associated with pregnancy incidence, but the median time to pregnancy points to a relatively short time window to initiate preconception care.

Barriers to and facilitators of hormonal and long-acting reversible contraception access and use in the US among reproductive-aged women who use opioids: A scoping review

Existing research has found that women who use opioids (WWUO) experience challenges to hormonal and long-acting reversible contraception (HC-LARC) access and use. Facilitators of such use are unclear. We conducted a scoping review to comprehensively map the literature on barriers to and facilitators of HC-LARC access and use in the United States among reproductive-aged WWUO. In accordance with the JBI Manual of Evidence Synthesis, we conducted literature searches for empirical articles published from 1990 to 2021. Independent reviewers screened references, first by titles and abstracts, then by full-text, and charted data of eligible articles. We coded and organized HC-LARC barriers and facilitators according to a four-level social-ecological model (SEM) and categorized findings within each SEM level into domains. We screened 4,617 records, of which 28 articles focusing on HC-LARC (n = 18), LARC only (n = 6), or testing an intervention to increase HC-LARC uptake (n = 4) met inclusion criteria. We identified 13 domains of barriers and 11 domains of facilitators across four SEM levels (individual, relationship, community, societal). The most frequently cited barriers and facilitators were methods characteristics, partner and provider relations, transportation, healthcare availability and accessibility, cost, insurance, and stigma. Future studies would benefit from recruiting participants and collecting data in community settings, targeting more diverse populations, and identifying neighborhood, social, and policy barriers and facilitators. Reducing barriers and improving equity in HC-LARC access and use among WWUO is a complex, multifaceted issue that will require targeting factors simultaneously at multiple levels of the social-ecological hierarchy to effect change.

Assessing contraceptive use as a continuum: outcomes of a qualitative assessment of the contraceptive journey

BACKGROUND

Contraceptive use is often a multi-decade experience for people who can become pregnant, yet few studies have assessed how this ongoing process impacts contraceptive decision-making in the context of the reproductive life course.

METHODS

We conducted in-depth interviews assessing the contraceptive journeys of 33 reproductive-aged people who had previously received no-cost contraception through a contraceptive initiative in Utah. We coded these interviews using modified grounded theory.

RESULTS

A person's contraceptive journey occurred in four phases: identification of need, method initiation, method use, and method discontinuation. Within these phases, there were five main areas of decisional influence: physiological factors, values, experiences, circumstances, and relationships. Participant stories demonstrated the ongoing and complex process of navigating contraception across these ever-changing aspects. Individuals stressed the lack of any "right" method of contraception in decision-making and advised healthcare providers to approach contraceptive conversations and provision from positions of method neutrality and whole-person perspectives.

CONCLUSIONS

Contraception is a unique health intervention that requires ongoing decision-making without a particular "right" answer. As such, change over time is normal, more method options are needed, and contraceptive counseling should account for a person's contraceptive journey.

Unequal impacts of the COVID-19 pandemic on women's fertility preferences: Evidence from a longitudinal cohort in the United States

•The COVID-19 pandemic suppressed fertility desires among US women.•Impacts on fertility preferences persisted from summer 2020 to early 2021.•The fertility preferences of younger women, women of color and those facing financial stress were most impacted.

Shared Decision-Making: The Way Forward for Postpartum Contraceptive Counseling

There are multi-level barriers that impact uptake of postpartum contraception and result in disparities, including clinical barriers such as provider bias. Fortunately, clinicians have direct control over their contraceptive counseling practices, and thus reducing structural barriers is actionable through high quality contraceptive counseling that equips patients with the knowledge and guidance they need to fulfill their reproductive desires. Yet, many commonly employed contraceptive counseling strategies, like One Key Question and WHO tiered contraceptive counseling, are not patient-driven, do not account for the important nuances of contraceptive choices, and are not focused specifically on the postpartum period. Given the history of eugenics and reproductive coercion in the US, supporting patient through their contraceptive decision-making process is especially vital. Additionally, contraceptive preferences vary based on patient-level factors and fluctuate over time and counseling should account for such differences. Shared contraceptive decision-making occurs when patients provide input on their values, desires, and preferences and clinicians share medical knowledge and evidence-based information without judgement. This approach is considered the most ethically sound form of counseling, as it maximizes patient autonomy. Shared decision-making also has clinical benefits, including increased patient satisfaction. In sum, shared contraceptive decision-making should be universally adopted to promote ethical, high-quality care and reproductive autonomy.