The impact of social determinants on health outcomes in a region in the North of England: a structural equation modelling analysis

OBJECTIVES

The aim of this study was to identify the impact of social determinants of health on physical and mental health outcomes in a UK population.

STUDY DESIGN

Structural equation modelling was used to hypothesise a model of relationships between health determinants and outcomes within a region in the North of England using large-scale population survey data (6208 responses).

METHODS

We analysed responses from a population survey to assess the influence of a deprivation-based index at the environmental level, education and income on a behaviour index (smoking, alcohol consumption, physical activity, and dietary habits) and the influence of all these factors on self-reported physical health and the influence of the behaviour index and income on mental wellbeing.

RESULTS

The proposed model was well supported by the data. Goodness-of-fit statistics, most notably a low value of the root mean square error of approximation (RMSEA), supported the validity of the proposed relationships (RMSEA = 0.054). The model revealed all examined paths to be statistically significant. Income and education were influential in determining an individual's behaviour index score, which, with income was the most important predictor of both the correlated outcomes of physical health and mental wellbeing (P < 0.001 in all cases).

CONCLUSIONS

Findings challenge the traditional view of singular causal pathways, emphasising that interventions should consider the underlying influencing socio-economic conditions, which would influence behaviour and therefore physical and mental wellbeing. The extent to which the model is supported by the data, and the statistical significance of individual relationships accentuates the imperative for comprehensive public health strategies that integrate multiple socio-economic factors.

Investigating the impact of non-gated thoracic CT prior to CTCA to reduce layered testing

AIM

To determine the proportion of computed tomography (CT) coronary angiography (CTCA) referrals with coronary artery calcification (CAC) evident on previous non-cardiac CT imaging and how this impacted the diagnostic yield for CTCA, the requirement for additional diagnostic testing, and the associated costs to confirm or refute obstructive coronary artery disease (CAD).

MATERIALS AND METHODS

A retrospective review of CTCA examinations was undertaken between 01/05/2018 and 31/05/2020 in which the examinations were cross referenced for previous non-gated thoracic CT at Royal United Hospitals Bath. Major epicardial vessel CAC on baseline CT was re-evaluated by published semi-quantitative methods, giving a per-patient CAC score (mild = 1-3, moderate = 4-6, severe >6). Subsequent incomplete CTCA diagnostic yield, further testing, and cost implications were examined.

RESULTS

Of the 2140 CTCA examinations identified, 13% (280/2140) had a preceding non-gated thoracic CT (53% female, age 63 ± 11 years). The incomplete diagnostic rate increased with CAC grade, mild 32%, (RR 12; 95% CI 4-40), moderate 64% (RR 25; 95% CI 8-80), severe 75%, (RR 29; 95% CI 9-94). Additional diagnostic testing occurred in 4% for the mild CAC category, and 14% and 42% for moderate and severe, respectively. When severe CAC was identified on a non-gated thoracic CT a cost saving of £171/patient (dobutamine stress echo [DSE]) and £61/patient (myocardial perfusion scintigraphy [MPS]) was established with a direct to functional testing pathway.

CONCLUSIONS

In patients referred for CTCA where severe CAC was identified on a preceding non-gated thoracic CT a direct to functional testing altered management in 42% of cases and was cost-effective.

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.

Women's preconception health in England: a report card based on cross-sectional analysis of national maternity services data from 2018/2019

OBJECTIVE

To present the first national-level report card on the state of women's preconception health in England.

DESIGN

Cross-sectional population-based study.

SETTING

Maternity services, England.

POPULATION

All pregnant women in England with a first antenatal (booking) appointment recorded in the national Maternity Services Dataset (MSDS) from April 2018 to March 2019 (n = 652 880).

METHODS

We analysed the prevalence of 32 preconception indicator measures in the overall population and across socio-demographic subgroups. Ten of these indicators were prioritised for ongoing surveillance based on modifiability, prevalence, data quality and ranking by multidisciplinary UK experts.

RESULTS

The three most prevalent indicators were the proportion of the 22.9% of women who smoked 1 year before pregnancy who did not quit smoking before pregnancy (85.0%), those who had not taken folic acid supplementation before pregnancy (72.7%) and previous pregnancy loss (38.9%). Inequalities were observed by age, ethnicity and area-based deprivation level. The ten indicators prioritised were not taking folic acid supplementation before pregnancy, obesity, complex social factors, living in the most deprived areas, smoking around the time of conception, overweight, pre-existing mental health condition, pre-existing physical health condition, previous pregnancy loss and previous obstetric complication.

CONCLUSIONS

Our findings suggest important opportunities to improve the state of preconception health and reduce socio-demographic inequalities for women in England. In addition to MSDS data, other national data sources that record further and possibly better quality indicators could be explored and linked to build a comprehensive surveillance infrastructure.

How common is natural conception in women who have had a livebirth via assisted reproductive technology? Systematic review and meta-analysis

STUDY QUESTION

What is the proportion of women who experience natural conception after a livebirth via assisted reproductive technology (ART)?

SUMMARY ANSWER

Current evidence suggests that natural conception pregnancy may occur in at least one in five women after having a baby via IVF or ICSI.

WHAT IS KNOWN ALREADY

It is widely known that some women having babies via ART go on to conceive naturally. This reproductive history is of media interest and often described as 'miracle' pregnancies.

STUDY DESIGN, SIZE, DURATION

A systematic review with meta-analysis was carried out. Ovid Medline, Embase, and PsycINFO were searched until 24 September 2021 for English language, human studies from 1980. Search terms were used for the concepts of natural conception pregnancy, assisted reproduction, and livebirth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criterion was studies with an outcome measure of the proportion of women experiencing natural conception pregnancy after an ART livebirth. Quality of studies was assessed using the Critical Appraisal Skills Programme cohort study checklist or AXIS Appraisal tool for cross-sectional studies, and a risk of bias assessment was carried out. No studies were excluded based on quality. Random-effects meta-analyses were adopted to produce a pooled effect estimate of the proportion of natural conception pregnancy after ART livebirth.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1108 distinct studies were identified, resulting in 54 studies after screening by title and abstract. Eleven studies including 5180 women were selected for this review. The included studies were mostly of moderate quality with a maximum follow-up period ranging from 2 to 15 years. Four studies reported natural conception livebirths which were used as known underestimates of natural conception pregnancies. The pooled estimate for the proportion of women having natural conception pregnancies after ART livebirth was 0.20 (95% CI, 0.17-0.22).

LIMITATIONS, REASONS FOR CAUTION

The studies varied widely according to methodology, population, cause of subfertility, type and outcome of fertility treatment, and length of follow-up, leading to potential bias relating to confounding, selection bias, and missing data.

WIDER IMPLICATIONS OF THE FINDINGS

Current evidence suggests that contrary to widely held views, natural conception pregnancy after ART livebirth is far from rare. National, data-linked studies are needed to provide more accurate estimates of this incidence and analysis of associated factors and trends over time to facilitate tailored counselling of couples considering further ART.

STUDY FUNDING/COMPETING INTEREST(S)

This work was conducted as part of an academic clinical fellowship awarded to AT by the National Institute for Health Research (NIHR). NIHR has had no input into the study design, data collection, and analysis, nor the writing of this study. No authors have any conflicts of interest.

REGISTRATION NUMBER

PROSPERO (CRD42022322627).

The physical-mental health interface in the preconception period: Analysis of 131,182 women planning pregnancy in the UK

OBJECTIVE

physical and mental health of women prior to conception can have a significant impact on pregnancy and child outcomes. Given the rising burden of non-communicable diseases, the aim was to explore the relationship between mental health, physical health and health behaviour in women planning a pregnancy.

METHODS

cross-sectional analysis of responses from 131,182 women to a preconception health digital education tool, providing data on physical and mental health and health behaviour. Logistic regression was used to explore associations between mental health and physical health variables.

RESULTS

physical health conditions were reported by 13.1% and mental health conditions by 17.8%. There was evidence for an association between self-reported physical and mental health conditions (OR 2.22; 95% CI 2.14 to 2.3). Those with a mental health condition were less likely to engage with healthy behaviour at preconception such as folate supplementation (OR 0.89; 95% CI 0.86 to 0.92) and consumption of the recommended amount of fruit and vegetables (OR 0.77; 95% CI 0.74 to 0.79). They were more likely to be physically inactive (OR 1.14; 95% CI 1.11 to 1.18), smoke tobacco (OR 1.72; 95% CI 1.66 to 1.78) and use illicit substances (OR 2.4; 95% CI 2.25 to 2.55).

CONCLUSIONS

greater recognition of mental and physical co-morbidities is needed and closer integration of physical and mental healthcare in the preconception period, which could support people to optimise their health during this time and improve long term outcomes.

Interventions to support contraceptive choice and use: a global systematic map of systematic reviews

BACKGROUND

To review the highest level of available evidence, a systematic map identified systematic reviews that evaluated the effectiveness of interventions to improve contraception choice and increase contraception use.

METHODS

Systematic reviews published since 2000 were identified from searches of nine databases. Data were extracted using a coding tool developed for this systematic map. Methodological quality of included reviews was assessed using AMSTAR 2 criteria.

FINDINGS AND CONCLUSION

Fifty systematic reviews reported evaluations of interventions for contraception choice and use addressing three domains (individual, couples, community); Meta-analyses in 11 of the reviews mostly addressed interventions for individuals. We identified 26 reviews covering High Income Countries, 12 reviews covering Low Middle-Income Countries and the rest a mix of both. Most reviews (15) focussed on psychosocial interventions, followed by incentives (6) and m-health interventions (6). The strongest evidence from meta-analyses is for the effectiveness of motivational interviewing, contraceptive counselling, psychosocial interventions, school-based education, and interventions promoting contraceptive access, demand-generation interventions (community and facility based, financial mechanisms and mass media), and mobile phone message interventions. Even in resource constrained settings, community-based interventions can increase contraceptive use. There are gaps in the evidence on interventions for contraception choice and use, and limitations in study designs and lack of representativeness. Most approaches focus on individual women rather than couples or wider socio-cultural influences on contraception and fertility. This review identifies interventions which work to increase contraception choice and use, and these could be implemented in school, healthcare or community settings.

A mixed methods study investigating sources of fertility and reproductive health information in the UK

OBJECTIVES

This study aimed to assess the different sources used by individuals when seeking fertility information in order to understand what's working, what isn't, and opportunities for improvement.

METHODS

A mixed-method study was conducted via UK-wide cross-sectional survey and semi-structured interviews. 1082 survey-participants were recruited nationwide via online-newspaper and social-media adverts. Of those who agreed to follow-up interview, 35 were purposively sampled to reflect the diversity of gender, age-range, ethnicity and education. Tableau software was used for surveys and NVIVO for interviews. Interview data was transcribed and analysed via thematic framework analysis.

RESULTS

Sources of information identified included: school-education; healthcare-professionals; internet, social-media, smartphone-apps, online-forums and blogs; family, friends, and communities; books, magazines, newspapers; fertility-products; workplace, communities and sexual-health clinics/centres, charities, and third-party organisations. Participants reported varying levels of access, reliability, and trust, in relation to these sources. Interview themes around veracity showed that healthcare-professionals were highly trusted but not easily accessible. The internet was very popular due to accessibility and perceived anonymity but untrusted, and "the plethora of information can be overwhelming." There were recurring themes around discomfort. A respondent recalled that her first discussion of sex with her mother was on her wedding night stating, "…Mum, I'm 28! And you're just discussing this with me now?"

CONCLUSIONS

School education remains a consistent but sometimes inadequate source of fertility information. In addition to online-platforms and products based on robust scientific evidence, opportunities for improvement include using underexploited sources, such as workplace and community settings, with training for providers.

Pre-pregnancy health of women with pre-existing diabetes or previous gestational diabetes: Analysis of pregnancy risk factors and behavioural data from a digital tool

AIMS

To examine health behaviours and risk factors in women with pre-existing diabetes or previous gestational diabetes mellitus who are planning pregnancy.

METHODS

Health behaviour, risk factor and demographic data obtained from a digital pregnancy planning advisory tool (Tommy's charity UK) were analysed. Descriptive statistical analysis was performed, stratified by diabetes type.

RESULTS

Data from 84,359 women, including 668 with type 1 diabetes, 707 with type 2 diabetes and 1785 with previous gestational diabetes obtained over a 12-month period (September 2019-September 2020) were analysed. 65%, 95%CI (61,68%) of women with type 2 diabetes and 46%, 95%CI (43,48%) with previous gestational diabetes were obese (BMI ≥30 kg/m² ), compared with 26%, 95%CI (26,26%) without diabetes. Use of folic acid supplements was low; 41%, 95%CI (40,41%) of women without diabetes and 42%, 95%CI (40,45%) with previous gestational diabetes reported taking folic acid (any dose) while 47%, 95%CI (43.50%) women with type 1 diabetes and 44%, 95%CI (40,47%) women with type 2 diabetes respectively reported taking the recommended dose (5 mg). More women with type 1 diabetes and type 2 diabetes reported smoking (20%, 95%CI [17,23%] and 23%, 95%CI [20,26%] respectively) and taking illicit/recreational drugs (7%, 95%CI [6,10%] and 9%, 95% CI [7,11%]) compared to women without diabetes (smoking 17%, 95% CI [16,17%], drug use 5%, 95%CI [5,5%]). Alcohol consumption, low levels of physical activity and of fruit and vegetable intake were also evident.

CONCLUSIONS

This study highlights the potential of online pregnancy planning advisory tools to reach high-risk women and emphasises the need to improve pre-pregnancy care for women with pre-existing diabetes and previous gestational diabetes, many of whom are actively seeking advice. It is also the first to describe pre-pregnancy health behaviours in women with previous gestational diabetes.

Exploring fertility knowledge amongst healthcare professional and lay population groups in the UK: a mixed methods study

As the average age of first-time parents continues to rise, there has been a concerted effort by educators, policy makers and several reproductive health groups to improve fertility awareness. This study explored fertility knowledge of lay men and women and healthcare professionals (HCPs) using the same test instrument, providing a new and unique perspective compared with previous studies. Results were obtained from 1082 survey respondents: 347 HCPs, 319 men and 413 women, 105 of whom were trying to conceive (TTC). A total of 35 interviewees were purposively sampled to include 9 HCPs, 13 men and 13 women from the reproductive age range and of varying ethnic and educational backgrounds. Interview data were transcribed and analysed using the framework method. The proportion of HCPs correctly answering the survey knowledge questions was 47.1 (95% CI = 41.7%, 52.5%) compared to 44.4% for women (95% CI = 38.9%, 50.1%); 49.9% (95% CI = 39.0, 59.9%) for women TTC; and 32.5% (95% CI = 27.1%, 37.9%) for men. HCPs were ranked as the most trusted source for seeking fertility information. Overall HCPs did not demonstrate better fertility knowledge than lay participants, with inconsistencies regarding where responsibility lies for providing the right information to patients. HCPs need to improve their knowledge about fertility to help improve patient's fertility awareness.

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

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

Emotional experiences of women who access early pregnancy assessment units: a qualitative investigation

Purpose: Early pregnancy complications are common and often result in pregnancy loss, which can be emotionally challenging for women. Research on the emotional experiences of those attending Early Pregnancy Assessment Units [EPAUs] is scarce. This analysis explored the emotions which women spontaneously reported when being interviewed about their experiences of using EPAU services.Materials and methods: Semi-structured telephone interviews were conducted with a purposive sample of 38 women. Using Thematic Framework Analysis, we identified six unique emotional typologies which mapped onto women's clinical journeys.Results: Women with ongoing pregnancies were characterized as having: "Anxious Presentation" or "Sustained Anxiety due to Diagnostic Uncertainty", dependent on whether their initial scan result was inconclusive. Women with pregnancy loss had one of four emotional typologies, varying by diagnostic timing and required interventions: "Anxious-Upset"; "Anxious-Upset after Diagnostic Uncertainty"; "Anxious-Upset with Procedural Uncertainty"; "Anxious with Sustained Uncertainty".Conclusions: We provide insights into the distinct emotions associated with different clinical pathways through EPAU services. Our findings could be used to facilitate wider recognition of women's emotional journeys through early pregnancy complications and stimulate research into how best to support women and their partners, in these difficult times.

What does family building mean? A qualitative exploration and a new definition: a UK-based study

Background

The importance of improving men’s and women’s knowledge of sexual and reproductive health has been emphasised in numerous global health policies. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, recent concerted effort to improve fertility-awareness warrants a closer investigation of basic reproductive health terminologies. The objective of this study is to explore participants’ views of “family building” and provide a definition.

Methods

We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. We asked participants about terms such as ‘family planning’ and ‘family building’ to elicit views and explored the appropriateness of the term “family building.” Data were transcribed and analysed via Framework analysis.

Results

When asked what ‘family planning’ meant to them, study participants stated that the term meant the avoidance of pregnancy. They viewed it as an “umbrella term for the use of contraception methods,” that “paradoxically, the term family planning almost has a negative connotation regarding having a family,” but could not state similar terminology for planning a family. Reasons cited for this perspective include the focus of school education and usage in clinical settings.

Conclusions

In the absence of an explicit definition in literature, we generated a new definition for family building as follows: “Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has.” Some balance in the global public health messages, including bridging the gap in reproductive health literature, policies, processes and practices may contribute to the effort to improve fertility knowledge. Use of appropriate terminologies help optimise reproductive health services in order to enable men and women achieve their desired fertility intentions, whatever they may be.

Trial registration Not applicable

Global health policies have emphasised the importance of improving individual’s knowledge of sexual and reproductive health. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, the recent concerted effort to improve fertility awareness warrants a closer investigation of basic terminologies in the field. For example, although the term family planning encompasses attaining the desired number of children and spacing pregnancies, it is almost synonymous with not having children, while there is currently no widely accepted equivalent terminology for planning to have children, either in general usage or clinical settings. We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. When asked what ‘family planning’ meant to them, study participants stated avoidance of pregnancy. They viewed it as an “umbrella term for the use of contraception methods”, that “paradoxically, the term family planning almost has a negative connotation regarding having a family,” but could not state similar terminology for planning a family. We introduced family building and provided a new definition. We believe that some balance in the global public health messages, including revisiting widely used terminologies can help bridge the gap in reproductive health literature, and contribute to the effort to improve fertility knowledge. Additionally, this has implications for promotion of preconception and optimising reproductive health in relevant policies, processes and practices, in order to help people achieve their desired fertility intentions, whatever they may be.

Factors influencing contraception choice and use globally: a synthesis of systematic reviews

BACKGROUND

Unintended pregnancy has a huge adverse impact on maternal, child and family health and wealth. There is an unmet need for contraception globally, with an estimated 40% of pregnancies unintended worldwide.

METHODS

We systematically searched PubMed and specialist databases for systematic reviews addressing contraceptive choice, uptake or use, published in English between 2000 and 2019. Two reviewers independently selected and appraised reports and synthesised quantitative and qualitative review findings. We mapped emergent themes to a social determinants of health framework to develop our understanding of the complexities of contraceptive choice and use.

FINDINGS

We found 24 systematic reviews of mostly moderate or high quality. Factors affecting contraception use are remarkably similar among women in very different cultures and settings globally. Use of contraception is influenced by the perceived likelihood and appeal of pregnancy, and relationship status. It is influenced by women's knowledge, beliefs, and perceptions of side effects and health risks. Male partners have a strong influence, as do peers' views and experiences, and families' expectations. Lack of education and poverty is linked with low contraception use, and social and cultural norms influence contraception and expectations of family size and timing. Contraception use also depends upon their availability, the accessibility, confidentiality and costs of health services, and attitudes, behaviour and skills of health practitioners.

INTERPRETATION

Contraception has remarkably far-reaching benefits and is highly cost-effective. However, women worldwide lack sufficient knowledge, capability and opportunity to make reproductive choices, and health care systems often fail to provide access and informed choice.

P-489 The ABC of fertility intentions: a mixed-methods study exploring the spectrum of attitudes towards family building

Study question

What are the intentions of men and women of reproductive age in the UK regarding fertility and family building?

Summary answer

We identified six main categories of people; Avoiders, Betweeners, Completers, Desirers, Expectants and Flexers, for whom fertility-education strategies should be tailored differently to suit intentions.

What is known already

Several studies have highlighted poor fertility awareness across men and women of reproductive age. As the average age of first-time parents continues to rise, there has been a concerted effort from educators, healthcare professionals, charities, reproductive health groups and government policy makers, to improve fertility awareness. In order to ensure that these messages are effective and to deploy the best strategies, it is important to understand people’s reproductive health needs. This study therefore aimed to explore the different family building intentions in order to aid tailoring of information to help individuals and couples achieve their family building intentions.

Study design, size, duration

Mixed method research was conducted via a UK-wide cross-sectional survey and semi-structed interviews. Results were obtained from 1,082 survey respondents and in-depth interviews with 15 men and 20 women. Interviewees were purposively sampled to include men and women from the reproductive age range (18-45 years) and of varying ethnic and educational backgrounds.

Participants/materials, setting, methods

Survey participants were recruited nationwide via online newspaper and social media adverts and of those who agreed to a follow-up interview, 35 were included this study. Interviews lasted an hour on average. Data was transcribed and analysed via thematic framework analysis. Favourable ethical opinion was given by University College London Research Ethics Committee.

Main results and the role of chance

From the survey and interviews, we identified six key categories of people, grouped alphabetically, in a user-friendly manner to highlight a spectrum of fertility intentions: Avoiders describe respondents who have no children and do not want to have children in the future; Betweeners describe those who already have child(ren) and want more in the future but are not actively trying to conceive; Completers describe those who have child(ren) but do not want more; Desirers describe those who are actively trying to conceive; Expectants describe those who were pregnant at the time of the study and Flexers describe those who may or may not already have and are unsure but open to having child(ren) in the future. A majority of the survey population were trying to get pregnant; were pregnant; or planning to have a child in the future - whether actively, passively or simply open to the idea, with interviews providing deep insights into their family building decision-making.

Limitations, reasons for caution

Due to the online recruitment method, there may be a bias toward more educated respondents.

Wider implications of the findings

We developed a user-friendly, alphabetical categorisation of fertility intentions, which can be used by individuals, healthcare professionals, educators, special interest groups, charities, and policymakers to support and enable individuals and couples in making informed choices to achieve their desired intentions, if and when they choose to start a family.

Trial registration number

not applicable

P-496 “The plethora of information can be overwhelming…”: A mixed methods study exploring the sources of fertility information

Study question

What sources are used when seeking fertility information and how informed do individuals feel about these sources?

Summary answer

Sources discussed with varying levels of access, reliability, and trust included: school education; healthcare-professionals; websites (general/government/medical); social-media/online-forums; family/friends; smartphone-apps; books/magazines/newspapers; fertility-products; sexual-health clinics/centres and charities.

What is known already

As the average age of first-time parents continues to rise, health policies have highlighted the importance of optimising reproductive health through better knowledge. There has also been a concerted effort by various reproductive health groups to improve fertility awareness. Understanding the different sources of information used by the target audience is important for disseminating and improving fertility knowledge. This mixed-methods study therefore aimed to assess the different sources used by individuals when seeking fertility information and the perceived accessibility and reliability of these sources in order to understand what’s working, what isn’t, and opportunities for improvement.

Study design, size, duration

Mixed method research was conducted via a UK-wide cross-sectional survey and semi-structed interviews. Results were obtained from 1,082 survey respondents and in-depth interviews with 15 men and 20 women. Interviewees were purposively sampled to include men and women from the reproductive age range (18-45 years) and of varying ethnic and educational backgrounds.

Participants/materials, setting, methods

Survey participants were recruited nationwide via online newspaper and social media adverts and of those who agreed to a follow-up interview, 35 were included this study. Interviews lasted an hour on average. Data was transcribed and analysed via thematic framework analysis. Favourable ethical opinion was given by University College London Research Ethics Committee.

Main results and the role of chance

When asked about knowledge from school education, 89.3% of survey respondents selected ‘good’/’some knowledge’ on the biology of reproduction and pregnancy-prevention, contrasting with 76.4% who reported having ‘no knowledge’/’do not recall’ of factors affecting fertility or protection of fertility.

While healthcare-professionals were ranked the most trusted but not easily accessible source, the internet was the most used, due to accessibility and perceived anonymity. However, many internet sources weren’t trusted, with a respondent citing “the plethora of information can be overwhelming, you don’t know what you can trust.” Male, 27, White.

Interviews highlighted family and friends as important sources, but with recurring themes around awkwardness and embarrassment discussing the topic. For example, one respondent recalled that her first discussion of sex with her mother was on her wedding night stating, “…Mum, I'm 28! And you’re just discussing this with me now?” Female, 36, Asian.

Social media was seen as a useful tool for wider reach of different population groups. Mobile apps (e.g. cycle-trackers) were cited but with concerns over information reliability; while others discussed using fertility products like sperm and ovulation kits to better understand their fertility. Other sources discussed include health centres, sexual health clinics, charities and other third-party organisations.

Limitations, reasons for caution

A key methodological limitation of this study is that the interviewees were self-selected, which has implications for generalisability. The results necessarily reflect the views of those who were willing to participate. Additionally, the online recruitment method could result in potential bias towards respondents of higher socioeconomic status.

Wider implications of the findings

School education remains a consistent but sometimes inadequate source of fertility information. Ensuring better fertility information during school education may offset the impact of unreliable sources. In addition to websites, apps and products based on robust scientific evidence, there remains an important need for additional training for primary healthcare-professionals.

Trial registration number

N/A

P-734 How common is spontaneous pregnancy after In vitro Fertilisation (IVF) Livebirth? Systematic review and meta-analysis

Study question

How common is spontaneous pregnancy after IVF resulting in livebirth? How can this evidence inform future pregnancy planning by women who have successful IVF?

Summary answer

Current evidence suggests that spontaneous pregnancy occurs in at least one in five women in the first three years after having a baby via IVF.

What is known already

It is known that some women having IVF go on to conceive naturally. This reproductive history is of media interest often described as “miracle” pregnancies (1). Women with this experience also identify themselves as a rarity, and their subsequent pregnancies include rapid-repeat, unplanned and unwelcomed pregnancies (2).

Study design, size, duration

An initial scoping review revealed few, heterogeneous studies reporting rates of spontaneous pregnancy or livebirth after successful IVF. These studies suggested that this event is not rare, prompting this first systematic review and meta-analysis. This aims to identify, appraise and synthesise the current evidence on the rate of spontaneous pregnancy after successful IVF.

Participants/materials, setting, methods

Ovid Medline, Embase and PsycINFO were searched on 24/09/2021 using a strategy containing thesaurus and free text terms for the concepts of spontaneous pregnancy, assisted reproduction and livebirth. The search was limited to English language, human studies and publications from 1980. Results were de-duplicated and managed in EndNote, screened by title/abstract and then full text. Random-effects meta-analyses were used to produce a pooled effect estimate of the incidence of spontaneous pregnancy after IVF livebirth.

Main results and the role of chance

1108 distinct references were identified, reducing to 54 when screened by title and abstract. On evaluation of full text, 11 studies were included in this review. Rates of spontaneous pregnancy after IVF livebirth ranged from 10-33% of women. However, studies varied widely according to methodology, population, cause of subfertility, type and outcome of fertility treatment and length of follow-up. Different covariates were investigated and inconsistently found to be associated with spontaneous conception after IVF including younger age, shorter duration of subfertility, fewer number of treatment cycles prior to first delivery and specific causes of subfertility (unexplained, no male factor). The pooled estimate for the rate of spontaneous pregnancy after IVF livebirth was 19% (95% CI, 16%-22%). The pooled estimate was robust when stratifying by IVF/intracytoplasmic sperm injection (ICSI), outcome measure and follow up period. It is a likely underestimate as some studies reported on livebirths (i.e. excluding adverse pregnancy outcomes) and did not include spontaneous births that occurred outside of the study region. Moreover, no studies gave due consideration to contraception, plannedness of pregnancies, change in partner, nor serial spontaneous pregnancies in the same woman.

Limitations, reasons for caution

The current evidence is relatively scarce and diverse. Sample sizes are typically small with only two studies of over a thousand women. Better evidence, in the form of national, data-linked studies, is needed to provide more accurate estimates of this rate, analysis of associated factors and trends over time.

Wider implications of the findings

These findings refute a widely held misconception that spontaneous pregnancy after IVF livebirth is a rare phenomenon. They should be used to counsel women having babies via IVF and inform their decision-making regarding the timing and mode of conception of future pregnancies and contraception use.

Trial registration number

N/A

The ABC of reproductive intentions: a mixed-methods study exploring the spectrum of attitudes towards family building

STUDY QUESTION

What are the intentions of men and women of reproductive age in the UK regarding reproduction and family building?

SUMMARY ANSWER

We identified six main categories of people; Avoiders, Betweeners, Completers, Desirers, Expectants and Flexers, for whom reproduction education strategies should be tailored differently to suit intentions.

WHAT IS KNOWN ALREADY

Several studies have highlighted poor fertility awareness across men and women of reproductive age. As the average age of first-time parents continues to rise, there has been a concerted effort from educators, healthcare professionals, charities, reproductive health groups and government policymakers, to improve fertility awareness. In order to ensure that these messages are effective and to deploy the best strategies, it is important to understand people's reproductive health needs. This study therefore aimed to explore different reproductive intentions to aid tailoring of information to help individuals and couples achieve their family building desires.

STUDY DESIGN, SIZE, DURATION

We conducted a mixed-method study via a UK-wide cross-sectional survey with 1082 participants and semi-structured interviews of 20 women and 15 men who agreed to follow-up interviews. Interviews lasted an hour on average. Ethics approval from UCL Research Ethics Committee.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Survey participants were recruited nationwide via online newspaper and social media adverts. Interviewees were purposely sampled to include men and women from the reproductive age range (18-45 years), varying ethnicity and education background. Survey data were analysed using the Minitab statistical software package. Interview data were transcribed and analysed using the framework method.

MAIN RESULTS AND THE ROLE OF CHANCE

From the survey and interviews, we identified six key categories of people, grouped alphabetically, in a user-friendly manner to highlight a spectrum of reproductive intentions: Avoiders describes respondents who have no children and do not want to have children in the future; Betweeners describes those who already have child(ren) and want more in the future but are not actively trying to conceive; Completers describes those who have child(ren) but do not want more; Desirers describes those who are actively trying to conceive or plan to have child(ren) in the future; Expectants describes those who were pregnant at the time of the study; and Flexers describes those who may or may not already have and are unsure but or open to having child(ren) in the future. Analysis of survey data identified the following proportions in our study: Avoiders, 4.7%; Betweeners, 11.3%; Completers, 13.6%; Desirers, 36.9%; Expectants, 4.1%; and Flexers 28.4% and 2.4% preferring not to answer. There was one 'other' group from qualitative analysis, who would like to have children in the future but were unsure whether they could or had changing views. We recommend classifying as 'Desirers' or 'Flexers' for the purposes of fertility education. A majority of the survey population were trying to get pregnant; were pregnant; or planning to have a child in the future-whether actively, passively or simply open to the idea, with interviews providing deep insights into their family building decision-making.

LIMITATIONS, REASONS FOR CAUTION

Due to the online recruitment method, there may be a bias towards more educated respondents.

WIDER IMPLICATIONS OF THE FINDINGS

We developed a user-friendly, alphabetical categorization of reproductive intentions, which may be used by individuals, healthcare professionals, educators, special interest groups, charities and policymakers to support and enable individuals and couples in making informed choices to achieve their desired intentions, if and when they choose to start a family.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. The authors report no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Characterising and monitoring preconception health in England: a review of national population-level indicators and core data sources

Initiatives to optimise preconception health are emerging following growing recognition that this may improve the health and well-being of women and men of reproductive age and optimise health in their children. To inform and evaluate such initiatives, guidance is required on indicators that describe and monitor population-level preconception health. We searched relevant databases and websites (March 2021) to identify national and international preconception guidelines, recommendations and policy reports. These were reviewed to identify preconception indicators. Indicators were aligned with a measure describing the prevalence of the indicator as recorded in national population-based data sources in England. From 22 documents reviewed, we identified 66 indicators across 12 domains. Domains included wider (social/economic) determinants of health; health care; reproductive health and family planning; health behaviours; environmental exposures; cervical screening; immunisation and infections; mental health, physical health; medication and genetic risk. Sixty-five of the 66 indicators were reported in at least one national routine health data set, survey or cohort study. A measure of preconception health assessment and care was not identified in any current national data source. Perspectives from three (healthcare) professionals described how indicator assessment and monitoring may influence patient care and inform awareness campaign development. This review forms the foundation for developing a national surveillance system for preconception health in England. The identified indicators can be assessed using national data sources to determine the population's preconception needs, improve patient care, inform and evaluate new campaigns and interventions and enhance accountability from responsible agencies to improve preconception health.

Contraception after in vitro fertilisation (IVF): a qualitative study of the views of women who have had spontaneous pregnancies after successful IVF

Background

The use of in vitro fertilisation (IVF) has increased rapidly since its inception in 1978. Women seeking IVF have a wide range of subfertility causes including unexplained subfertility. A growing subgroup of women seek treatment for other reasons than fertility problems, for example, women in same sex relationships and single women. This study aims to better understand the contraceptive needs of women after successful IVF pregnancy in order to improve service delivery and prevent unplanned and rapid-repeat pregnancies.

Methods

A qualitative study of views of women who have had spontaneous pregnancies after successful IVF. Participants were recruited using purposive and snowballing sampling methods from social media and peer networks. The framework method was used for analysis using NVivo12.

Results

The sample comprised 21 interviewees from the United Kingdom (UK), having a range of spontaneous pregnancy outcomes, including single and multiple livebirths, miscarriage, ectopic pregnancy and termination of pregnancy. Contraceptive choices were subject to a complex and dynamic interaction of influencing factors including beliefs regarding subfertility, desire for children and views on contraception. None of the women recalled receiving any information or useful counselling about contraception during fertility or maternity care. After IVF pregnancy, most women (n = 16) used no or ineffective contraception. Spontaneous pregnancy was not universally welcomed in this group and inter-pregnancy intervals were often short (n = 16, less than 18 months). Even after subsequent spontaneous pregnancy, use of contraception and the most effective methods remained low. Women held persistent beliefs regarding their subfertility despite subsequent spontaneous pregnancy. They associated aspects of the IVF process with a sense of personal failure, despite an ultimately “successful” outcome of livebirth. These aspects may reinforce their self-belief in subfertility. Other barriers to contraception use in women having IVF included: lack of knowledge of likelihood of spontaneous pregnancy, lack of contraceptive experience and inherent incentives towards shorter inter-pregnancy intervals.

Conclusions

The contraceptive needs of women having IVF pregnancies are real and are being overlooked. Fertility services should take responsibility for providing information on the risks of subsequent spontaneous pregnancy. Maternity and community healthcare professionals must address women’s perceptions of their fertility in order to engage them in contraception counselling.

OUP accepted manuscript

STUDY QUESTION

What are the intentions of men and women of reproductive age in the UK regarding reproduction and family building?

SUMMARY ANSWER

We identified six main categories of people; Avoiders, Betweeners, Completers, Desirers, Expectants and Flexers, for whom reproduction education strategies should be tailored differently to suit intentions.

WHAT IS KNOWN ALREADY

Several studies have highlighted poor fertility awareness across men and women of reproductive age. As the average age of first-time parents continues to rise, there has been a concerted effort from educators, healthcare professionals, charities, reproductive health groups and government policymakers, to improve fertility awareness. In order to ensure that these messages are effective and to deploy the best strategies, it is important to understand people’s reproductive health needs. This study therefore aimed to explore different reproductive intentions to aid tailoring of information to help individuals and couples achieve their family building desires.

STUDY DESIGN, SIZE, DURATION

We conducted a mixed-method study via a UK-wide cross-sectional survey with 1082 participants and semi-structured interviews of 20 women and 15 men who agreed to follow-up interviews. Interviews lasted an hour on average. Ethics approval from UCL Research Ethics Committee.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Survey participants were recruited nationwide via online newspaper and social media adverts. Interviewees were purposely sampled to include men and women from the reproductive age range (18–45 years), varying ethnicity and education background. Survey data were analysed using the Minitab statistical software package. Interview data were transcribed and analysed using the framework method.

MAIN RESULTS AND THE ROLE OF CHANCE

From the survey and interviews, we identified six key categories of people, grouped alphabetically, in a user-friendly manner to highlight a spectrum of reproductive intentions: Avoiders describes respondents who have no children and do not want to have children in the future; Betweeners describes those who already have child(ren) and want more in the future but are not actively trying to conceive; Completers describes those who have child(ren) but do not want more; Desirers describes those who are actively trying to conceive or plan to have child(ren) in the future; Expectants describes those who were pregnant at the time of the study; and Flexers describes those who may or may not already have and are unsure but or open to having child(ren) in the future. Analysis of survey data identified the following proportions in our study: Avoiders, 4.7%; Betweeners, 11.3%; Completers, 13.6%; Desirers, 36.9%; Expectants, 4.1%; and Flexers 28.4% and 2.4% preferring not to answer. There was one ‘other’ group from qualitative analysis, who would like to have children in the future but were unsure whether they could or had changing views. We recommend classifying as ‘Desirers’ or ‘Flexers’ for the purposes of fertility education. A majority of the survey population were trying to get pregnant; were pregnant; or planning to have a child in the future—whether actively, passively or simply open to the idea, with interviews providing deep insights into their family building decision-making.

LIMITATIONS, REASONS FOR CAUTION

Due to the online recruitment method, there may be a bias towards more educated respondents.

WIDER IMPLICATIONS OF THE FINDINGS

We developed a user-friendly, alphabetical categorization of reproductive intentions, which may be used by individuals, healthcare professionals, educators, special interest groups, charities and policymakers to support and enable individuals and couples in making informed choices to achieve their desired intentions, if and when they choose to start a family.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. The authors report no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Differences in the organisation of early pregnancy units and the effect of senior clinician presence, volume of patients and weekend opening on emergency hospital admissions: Findings from the VESPA Study

OBJECTIVE

To determine whether the participation of consultant gynaecologists in delivering early pregnancy care results in a lower rate of acute hospital admissions.

DESIGN

Prospective cohort study and emergency hospital care audit; data were collected as part of the national prospective mixed-methods VESPA study on the "Variations in the organization of EPAUs in the UK and their effects on clinical, Service and PAtient-centred outcomes".

SETTING

44 Early Pregnancy Assessment Units (EPAUs) across the UK randomly selected in balanced numbers from eight pre-defined mutually exclusive strata.

PARTICIPANTS

6606 pregnant women (≥16 years old) with suspected first trimester pregnancy complications attending the participating EPAUs or Emergency Departments (ED) from December 2016 to July 2017.

EXPOSURES

Planned and actual senior clinician presence, unit size, and weekend opening.

MAIN OUTCOME MEASURES

Unplanned admissions to hospital following any visit for investigations or treatment for first trimester complications as a proportion of women attending EPAUs.

RESULTS

205/6397 (3.2%; 95% CI 2.8-3.7) women were admitted following their EPAU attendance. The admission rate among 44 units ranged from 0% to 13.7% (median 2.8). Neither planned senior clinician presence (p = 0.874) nor unit volume (p = 0.247) were associated with lower admission rates from EPAU, whilst EPAU opening over the weekend resulted in lower admission rates (p = 0.027). 1445/5464 (26.4%; 95%CI 25.3 to 27.6) women were admitted from ED. There was little evidence of an association with planned senior clinician time (p = 0.280) or unit volume (p = 0.647). Keeping an EPAU open over the weekend for an additional hour was associated with 2.4% (95% CI 0.1% to 4.7%) lower odds of an emergency admission from ED.

CONCLUSIONS

Involvement of senior clinicians in delivering early pregnancy care has no significant impact on emergency hospital admissions for early pregnancy complications. Weekend opening, however, may be an effective way of reducing emergency admissions from ED.

The association between obesity and quality of life: a retrospective analysis of a large-scale population-based cohort study

BACKGROUND

The relationship between obesity and health-related quality of life (HRQoL) may be confounded by factors such as multimorbidity. The aim of the study was to explore this relationship, controlling for long-term conditions and other health, lifestyle and demographic factors in a general adult population. There was specific interest in the impact of high weight status, measured by body mass index (BMI) levels (obesity, morbid obesity) compared with individuals of normal weight.

METHODS

Health, lifestyle and demographic data were collected from 64,631 individuals aged 16 years and over registered in the Yorkshire Health Study; a long-term cohort study. Data were collected in 2 waves: from patients attending GP surgeries in the South Yorkshire region; and using online recruitment across the entire Yorkshire and Humber area. Univariable and multivariable regression methods were utilised to identify factors associated with HRQoL as measured by the EQ-5D summary score. Long-term conditions were tested as both covariates and mediating factors on the causal pathway between obesity and HRQoL.

RESULTS

Increasing levels of obesity are associated with reduced HRQoL, although this difference is negligible between those of normal weight and those who are overweight. Individuals with obesity and morbid obesity score 4.9 and 11.3 percentage points less on the EQ-5D summary scale respectively than those of normal weight. Concurrent physical, and particularly mental health-related long-term conditions are substantively related to HRQoL: those with 3 or more reported mental or physical health conditions score 29.8 and 14.6 percentage points less on the EQ-5D summary scale respectively than those with fewer conditions. Long-term conditions can be conceptualised as lying on the causal path between obesity and HRQoL, but there is weak evidence for a partial mediating relationship only.

CONCLUSIONS

To conclude, in agreement with the established literature we have found a clear inverse relationship between increasing weight status and decreasing HRQoL and confirmed the mediating role of long-term conditions in the reduction of HRQoL in people with obesity. Nevertheless, a high BMI remains independently related to HRQoL, suggesting that 'healthy people with obesity' may be in transition to an unhealthy future.

Women's experiences of early pregnancy assessment unit services: a qualitative investigation

OBJECTIVE

To explore the experiences of women who had used an Early Pregnancy Assessment Unit (EPAU) service in the UK and make recommendations for their improvement.

DESIGN

Qualitative interview study.

SETTING

Early Pregnancy Assessment Units in the UK.

SAMPLE

A maximum variation sample of women who had consented to be interviewed having attended one of 26 EPAUs involved in the VESPA study in 2018.

METHODS

In-depth telephone interviews with 38 women. A thematic framework analysis was conducted, with a focus on how experiences varied according to EPAU service configuration and clinical pathway.

MAIN OUTCOME MEASURES

Women's experiences of EPAU services.

RESULTS

We found that EPAUs are highly valued, and women's experiences were generally positive. However, women reported a range of issues that negatively affected their experience. These included difficulties accessing the service, insensitive management of the investigation and treatment options of pregnancy loss, poor communication, insufficient information and a lack of support for their psychological health. These issues were not strongly associated with EPAU configuration or clinical pathway.

CONCLUSIONS

Recommendations to improve women's experiences include the separation of EPAUs from general maternity services, and we make suggestions on how to remove barriers to access by reviewing opening hours, how to provide sensitive patient management, such as automatically cancelling appointments and scans following pregnancy loss, and how to improve communication, both with women and their partners as well as with other parts of the health service.

P–483 “It’s a bigger deal for her”: Understanding differences in partner involvement in reproductive health decision-making

Study question

What is the level of partners involvement in family-building and reproductive health decisions?

Summary answer

Level of Involvement ranges from active decision-makers and equal-partnerships to indifferent or no partners. Fertility education needs to be tailored according to level of involvement.

What is known already

Partner involvement is very important in alleviating stress associated with fertility and reproductive health decisions. Recent global health policies have recognised the importance of improving knowledge and awareness of fertility and reproductive health among couples, additionally there has been a concerted effort among reproductive health groups, to improve fertility awareness. Understanding the role partners play in decision-making is therefore important in order to ensure that men and women achieve their family building intentions. In this study, we interviewed men and women, to understand partners involvement in decision-making.

Study design, size, duration

The study was a qualitative component of a wider mixed methods study. We carried out 35 in-depth interviews with 15 men and 20 women. Interviewees were purposively sampled to include men and women from the reproductive age range (18–45 years) and of varying ethnic and educational backgrounds.

Participants/materials, setting, methods

Interviewees were sampled from a UK cross-sectional survey on Fertility Awareness. Survey participants were recruited nationwide via online newspaper and social media adverts and of those who agreed to a follow-up interview, 35 were included this study. Interviews lasted an hour on average. Data was transcribed and analysed via framework analysis. Favourable ethical opinion was given by University College London Research Ethics Committee.

Main results and the role of chance

We identified four kinds of partner involvement and impact, as follows:

Drivers: These are active decision-makers who play a bigger role. The decision is usually clear and directive and are typically women. Quotes describing drives include: “Her body her rights”, “I just went with her [views]”, MP5 - Male, Age 38. “She carries the pregnancy, and it’s a bigger deal for her so it’s important for her to choose.” MP1 - Male, Age 45.

Sharers: In these equal partnerships, joint decisions are important. Being similarly minded and aligned is key to achieving desired family building decisions. . “It was very mutual because he’d actually been talking about it for a long time… so we were both completely ready.” Female, Age 31.

Neutrals: general indifference to family-building decision-making and are not as proactive as the drivers.

Solo: includes individuals with no partners or those who haven’t met a suitable partner at the right time or until later in life, or those for whom singleness by choice is key to their decision-making. “If I did meet the right person yeah, I would love one more child, because I’ve always wanted two” Female, Age 36.

Limitations, reasons for caution

One of the main methodological limitations of this study is that the interviewees were self-selected, which has implications for generalisability. The results necessarily reflect the views of those who were willing to participate. Online recruitment method could result in potential bias towards respondents of higher socioeconomic status.

Wider implications of the findings: To improve fertility awareness, current initiatives need to further explore the impact of partners in family-building decision-making in order to have effective campaigns which can help men and women achieve their desired fertility intentions.

Trial registration number

Not applicable

P–743 The fertility paradox: the need for contraception after in vitro fertilisation

Study question

What are a woman’s contraceptive needs after successful in vitro fertilisation (IVF) pregnancy? and how should services respond to help prevent unintended pregnancies?

Summary answer

Women who have IVF pregnancies require tailored, postnatal contraception counselling. Services must provide evidence-based information about the risks of spontaneous conception to engage them effectively.

What is known already

Women undergoing IVF are an increasingly heterogeneous group with a wide range of causative subfertility factors. Furthermore, increasingly, women are accessing treatment primarily for reasons other than subfertility. The evidence relating to rates of spontaneous conception post assisted conception varies widely according to population, cause of subfertility, type and outcome of fertility treatment and length of follow-up. A recent large retrospective UK cohort study estimated the treatment-independent live birth rate after IVF live birth over 5 year follow up as 15% [https://doi.org/10.1093/humrep/dez099]. We aim to explore the experiences and views about contraception among this diverse group of women.

Study design, size, duration

A qualitative study of the views of women who have had spontaneous pregnancies after successful IVF was conducted in September/October 2020. A qualitative approach of in-depth interviews was chosen to allow exploration of individual experiences in an area not much studied previously. The sample consisted of twenty interviewees from around the UK.

Participants/materials, setting, methods

Purposive and snowballing sampling methods were used with eligible participants recruited from a range of sources including social media and peer networks. The sample included a wide range of spontaneous pregnancy outcomes after successful IVF, including single and multiple livebirths, miscarriage, ectopic pregnancy and termination of pregnancy. The framework method was used for analysis using NVivo12 software.

Main results and the role of chance

Contraceptive choices were subject to a complex and dynamic interaction of influencing factors including i) beliefs regarding their own subfertility, ii) desire for more children and iii) their views on contraception. After IVF pregnancy, the majority of women (n = 15) used no contraception or ineffective methods (inconsistent condom use or withdrawal) before their next pregnancy with only two women using hormonal methods (progesterone-only pill). Spontaneous pregnancy was not universally welcomed in this group and the inter-pregnancy intervals were often short (n = 15, less than 18 months) or very short (n = 6, less than 12 months). After subsequent spontaneous pregnancy, use of contraception and the most effective (long-acting reversible) methods remained low. Women held persistent beliefs regarding their subfertility despite subsequent spontaneous pregnancy (or pregnancies). Women associated aspects of the IVF process (e.g. need for multiple cycles, low numbers of eggs collected etc.) with a sense of personal failure, despite an ultimately “successful” outcome resulting in livebirth. This may contribute to or reinforce their self-belief in subfertility. Other specific barriers to contraception use, in women having IVF, included lack of knowledge of the likelihood of spontaneous pregnancy, lack of contraceptive experience and inherent incentives towards shorter inter-pregnancy intervals.

Limitations, reasons for caution

There is potential recall bias with some women recalling experiences associated with IVF treatment more than ten years ago. However our sample included women who were currently pregnant as well as women who were further towards the end of their reproductive life to capture a range of experiences.

Wider implications of the findings: The contraceptive needs of women having IVF pregnancies are being overlooked. Fertility services should take responsibility for providing accurate information on the risks of subsequent spontaneous pregnancy in this population. Maternity and community healthcare professionals must address women’s perceptions of their fertility in order to engage them in contraception counselling.

Trial registration number

N/A

Health behaviours in 131,182 UK women planning pregnancy

BACKGROUND

A woman's health at the time of conception lays the foundation for a healthy pregnancy and the lifelong health of her child. We investigated the health behaviours of UK women planning pregnancy.

METHODS

We analysed survey data from the 'Planning for Pregnancy' online tool (Tommy's, UK). We described all women planning pregnancy and compared the frequency of non-adherence to preconception recommendations in women who had already stopped contraception (active planners) and those who had not (non-active planners).

RESULTS

One hundred thirty-one thousand one hundred eighty-two women from across the UK were included, of whom 64.8% were actively planning pregnancy. Of the whole cohort, twenty percent were smokers and less than one third took folic acid supplements (31.5%). Forty two percent engaged in less than the recommended 150 min of weekly physical activity and only 53.3% consumed five portions of fruit or vegetables 4 days a week. Smokers were 1.87 times more likely to be active planners than non-smokers (95% CI 1.79-1.94), and women who took folic acid were 7 times more likely to be active planners (95% CI 6.97-7.59) compared to women who did not. Smoking, drug use and lack of folic acid supplementation were common in younger women and those who were underweight.

CONCLUSIONS

This unique survey of UK women has identified poor adherence to preconception recommendations in those planning pregnancies and supports the need for a greater public health focus on preconception health. This study provides a contemporary basis from which to inform preconception health advice and a benchmark to measure changes over time.

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.

Provision of the progestogen-only pill by community pharmacies as bridging contraception for women receiving emergency contraception: the Bridge-it RCT

INTRODUCTION

Unless women start effective contraception after using emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies that are unable to provide ongoing contraception (apart from barrier methods which have high failure rates). This means that women need an appointment with a general practitioner or at a sexual and reproductive health clinic. We conducted a pragmatic cluster randomised cohort crossover trial to determine whether or not pharmacist provision of a bridging supply of a progestogen-only pill plus the invitation to attend a sexual and reproductive health clinic resulted in increased subsequent use of effective contraception (hormonal or intrauterine).

METHODS

Twenty-nine pharmacies in three UK cities recruited women receiving emergency contraception (levonorgestrel). In the intervention, women received a 3-month supply of the progestogen-only pill (75 µg of desogestrel) plus a card that provided rapid access to a local sexual and reproductive health clinic. In the control arm, pharmacists advised women to attend their usual contraceptive provider. The primary outcome was reported use of an effective contraception (hormonal and intrauterine methods) at 4 months. Process evaluation was also conducted to inform any future implementation.

RESULTS

The study took place December 2017 and June 2019 and recruited 636 women to the intervention (n = 316) and control groups (n = 320). There were no statistically significant differences in demographic characteristics between the groups. Four-month follow-up data were available for 406 participants: 63% (198/315) of the control group and 65% (208/318) of the intervention group. The proportion of participants reporting use of effective contraception was 20.1% greater (95% confidence interval 5.2% to 35.0%) in the intervention group (58.4%, 95% confidence interval 48.6% to 68.2%) than in the control group (40.5%, 95% confidence interval 29.7% to 51.3%) (adjusted for recruitment period, treatment arm and centre; p = 0.011). The proportion of women using effective contraception remained statistically significantly larger, when adjusted for age, current sexual relationship and history of past use of effective contraception, and was robust to the missing data. There were no serious adverse events.

CONCLUSION

Provision of a bridging supply of the progestogen-only pill with emergency contraception from a pharmacist and the invitation to a sexual and reproductive health clinic resulted in a significant increase in self-reported subsequent use of effective contraception. This simple intervention has the potential to prevent more unintended pregnancies for women after emergency contraception.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN70616901.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 27. See the NIHR Journals Library website for further project information.

Young women's and midwives' perspectives on improving nutritional support in pregnancy: The babies, eating, and LifestyLe in adolescence (BELLA) study

RATIONALE

Teenage pregnancy has a high risk of poor outcomes for both mother and baby. Teenage girls have the poorest diets of any population group in the UK, which compounds the risk of poor pregnancy outcomes. Pregnant teenagers trust advice from their midwives, but midwives feel they do not have time, confidence, or knowledge to discuss nutrition.

OBJECTIVE

This study examined how the relationship between pregnant teenagers and their midwives could be utilised to deliver support to improve diet quality.

METHOD

Qualitative interviews were conducted across three urban sites in the UK: Manchester, Doncaster, and Southampton with adolescent mothers and their midwives regarding diet and lifestyle, and what form of support would be helpful. In total, 106 young women and 20 midwives were interviewed. Most of the young mothers were 19 or younger (67%). Half had had their first child in the past year (52%) and 21% were pregnant during the study. Thematic analysis was used to identify ways to better support young mothers to eat well.

RESULTS

Young women found it difficult to prioritise healthy eating; they often felt isolated and not in control of their own lives and wanted support from their midwife. Midwives felt that it was their role to support young mothers with diet in pregnancy but were anxious about initiating conversations and felt they lacked clear guidance.

CONCLUSIONS

Pregnant teenagers and their midwives lack reliable resources and strategies for healthy eating support. An effective intervention to improve pregnant teenagers' diet quality must empower, inform, and motivate young mothers and their midwives, and enable connections between young mothers.

Participant views and experiences of sexual health research: The Contraception Choices online trial

BACKGROUND

Online sexual health research can be convenient, efficient and low cost, but there are debates about the adequacy of online informed consent, privacy, and the acceptability of different methods of follow-up.

OBJECTIVES

To explore women's views and experiences of the Contraception Choices feasibility trial procedures and the place of digital interventions for contraception decision making.

METHODS

We analysed data from two sources: (1) Qualitative interviews. Eighteen interviews were conducted with women who had taken part in the Contraception Choices pre-trial feasibility study, to evaluate recruitment and online trial procedures. (2) Free-text comments. Women in the main Contraception Choices randomised controlled trial were followed up at 3 and 6 months, and asked 'Please tell us what you liked or disliked about the website' and 'Has being in the study had any good or bad effects on your life?' A total of 387 and 414 comments were made at 3 and 6 months respectively. Data were analysed thematically.

RESULTS

Participants liked being involved in a study about contraception, although recruitment from an abortion clinic was less acceptable than in other sexual health settings. Women found the trial procedures straightforward, and expressed no major concerns about online self-registration, informed consent or online data collection. Online survey questions about contraception and fertility were acceptable, and participants liked the convenience of being followed up by email or text.

CONCLUSIONS

Participants appreciated the advantages of the online research design and did not express concerns about consent or privacy. Women would welcome digital interventions for contraception in a variety of settings.

Variations in the organisation of and outcomes from Early Pregnancy Assessment Units: the VESPA mixed-methods study

Background

Early pregnancy complications are common and account for the largest proportion of emergency work in gynaecology. Although early pregnancy assessment units operate in most UK acute hospitals, recent National Institute of Health and Care Excellence guidance emphasised the need for more research to identify configurations that provide the optimal balance between cost-effectiveness, clinical effectiveness and service- and patient-centred outcomes [National Institute for Health and Care Excellence (NICE). Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. URL: http://guidance.nice.org.uk/CG154 (accessed 23 March 2016)].

Objectives

The primary aim was to test the hypothesis that the rate of hospital admissions for early pregnancy complications is lower in early pregnancy assessment units with high consultant presence than in units with low consultant presence. The key secondary objectives were to assess the effect of increased consultant presence on other clinical outcomes, to explore patient satisfaction with the quality of care and to make evidence-based recommendations about the future configuration of UK early pregnancy assessment units.

Design

The Variations in the organisations of Early Pregnancy Assessment Units in the UK and their effects on clinical, Service and PAtient-centred outcomes (VESPA) study employed a multimethods approach and included a prospective cohort study of women attending early pregnancy assessment units to measure clinical outcomes, an economic evaluation, a patient satisfaction survey, qualitative interviews with service users, an early pregnancy assessment unit staff survey and a hospital emergency care audit.

Setting

The study was conducted in 44 early pregnancy assessment units across the UK.

Participants

Participants were pregnant women (aged ≥ 16 years) attending the early pregnancy assessment units or other hospital emergency services because of suspected early pregnancy complications. Staff members directly involved in providing early pregnancy care completed the staff survey.

Main outcome measure

Emergency hospital admissions as a proportion of women attending the participating early pregnancy assessment units.

Methods

Data sources – demographic and routine clinical data were collected from all women attending the early pregnancy assessment units. For women who provided consent to complete the questionnaires, clinical data and questionnaires were linked using the women’s study number. Data analysis and results reporting – the relationships between clinical outcomes and consultant presence, unit volume and weekend opening hours were investigated using appropriate regression models. Qualitative interviews with women, and patient and staff satisfaction, health economic and workforce analyses were also undertaken, accounting for consultant presence, unit volume and weekend opening hours.

Results

We collected clinical data from 6606 women. There was no evidence of an association between admission rate and consultant presence (p = 0.497). Health economic evaluation and workforce analysis data strands indicated that lower-volume units with no consultant presence were associated with lower costs than their alternatives.

Limitations

The relatively low level of direct consultant involvement could explain the lack of significant impact on quality of care. We were also unable to estimate the potential impact of factors such as scanning practices, level of supervision, quality of ultrasound equipment and clinical care pathway protocols.

Conclusions

We have shown that consultant presence in the early pregnancy assessment unit has no significant impact on key outcomes, such as the proportion of women admitted to hospital as an emergency, pregnancy of unknown location rates, ratio of new to follow-up visits, negative laparoscopy rate and patient satisfaction. All data strands indicate that low-volume units run by senior or specialist nurses and supported by sonographers and consultants may represent the optimal early pregnancy assessment unit configuration.

Future work

Our results show that further research is needed to assess the potential impact of enhanced clinical and ultrasound training on the performance of all disciplines working in early pregnancy assessment units.

Trial registration

Current Controlled Trials ISRCTN10728897.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 46. See the NIHR Journals Library website for further project information.

Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial

BACKGROUND

Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception.

METHODS

We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 μg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete).

FINDINGS

Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred.

INTERPRETATION

Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception.

FUNDING

National Institute for Health Research (Health Technology Assessment Programme project 15/113/01).

An interactive website to aid young women's choice of contraception: feasibility and efficacy RCT

BACKGROUND

Effective use of contraception can reduce numbers of unintended pregnancies, but misunderstandings and concerns about contraception abound. Increasingly, women seek health-care information online.

OBJECTIVES

To develop an interactive website to aid informed choice of contraceptive method, including long-acting reversible contraception (Phase I), and test its effectiveness in a parallel, single-blind randomised trial (Phase II). Approval came from London - Camden & King's Cross Research Ethics Committee (reference 17/LO/0112).

SETTING AND PARTICIPANTS

For both phases, women aged 15-30 years were recruited from general practice, sexual health services, maternity services, community pharmacies and an abortion service.

DESIGN

In Phase I, we conducted three systematic literature reviews, a review of YouTube (YouTube, LLC, San Bruno, CA, USA) videos about contraception, and focus groups and interviews with young women to explore barriers to and concerns and misperceptions about contraception. We then iteratively co-designed an interactive website, Contraception Choices [URL: www.contraceptionchoices.org (accessed June 2020)], with young women and a software company. In Phase II, we evaluated the website through a randomised trial that began as a feasibility trial. Early demand for Contraception Choices stimulated a design change from a feasibility to an efficacy trial, with follow-up for clinical outcomes at 3 and 6 months. A randomisation list was incorporated into the trial software program to allocate participants to the intervention (website) or control group (standard care).

INTERVENTION

Contraception Choices is a co-designed, evidence-based, interactive website to aid informed choice of contraception. It provides information about different methods, addresses common concerns and offers tailored contraceptive options in response to individual preferences.

MAIN OUTCOME MEASURES

Qualitative - participant views and experience of the intervention, assessed through qualitative interviews. Quantitative primary outcomes - follow-up rate at 6 months in the initial feasibility trial, using a long-acting reversible contraception method, and satisfaction with contraceptive method at 6 months in the efficacy trial.

RESULTS

A total of 927 women were randomised online to the website (n = 464) or control group (n = 463), of whom 739 (80%) provided follow-up data at 6 months [786 women (85%) provided data at 3 and/or 6 months that were included in the analysis of primary outcomes]. There was little difference between groups in the proportion using long-acting reversible contraception at 6 months [30.4% intervention vs. 31.0% control, adjusted odds ratio after imputation 0.87 (95% confidence interval 0.60 to 1.27)] or in satisfaction with contraceptive method [proportion being 'satisfied' or 'very satisfied', 82.6% intervention vs. 82.1% control, adjusted odds ratio 0.93 (95% confidence interval 0.69 to 1.25)]. Qualitative evaluation indicated highly positive views about the website and increased knowledge of contraceptive methods that could dispel misperceptions. Women appreciated having information tailored to their specific needs and felt better prepared before consultations.

LIMITATIONS

We did not include intermediate measures, such as knowledge of contraceptive methods, intention to change method or confidence in discussing contraception with a health-care professional, which may have indicated other benefits of using the website. In future, the website should be studied in different settings (e.g. schools and in routine practice) to see whether or not it improves the quality or efficiency of contraceptive consultations.

CONCLUSIONS

Our systematic review indicated wide-ranging influences on women's use of contraception globally. The website, Contraception Choices, was very popular with young women and contraception service providers. It was not associated with statistically significant differences in use of long-acting reversible contraception or satisfaction with contraceptive method at 6 months.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13247829.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 56. See the NIHR Journals Library website for further project information.

A novel cardiac signal processing system for electrophysiology procedures: early insights from the pure ep 2.0 study

Background

Intracardiac electrogram data remain one of the primary diagnostic inputs guiding complex ablation procedures. However, the technology to collect, process, and display intracardiac signals has remained relatively unchanged for the past two decades.

Purpose

We test a new platform, the PURE EP™ 2.0 system (PEP; BioSig Technologies) for signal processing and display.

Methods

Identical electrocardiographic and intracardiac signal data were recorded during 15 AF ablation procedures from the PEP system, the signal recording system, and the 3D mapping system (Figure). The collected signals underwent blinded, controlled evaluation by three independent electrophysiologist reviewers to determine whether the PEP signals are a viable alternative to conventional sources and if it provides additional or clearer diagnostic information. Reviewers were asked to record the quality of each signal sample on a scale of 1–10 and select a rationale for their rating in a dropdown menu. Each paired signal rating was collected and unblinded for the analysis. If the reviewer rated the samples in the set within 1 point of each other, the PEP sample was deemed equivalent to the control. Using a 2+1 statistical method, the ratings from the three reviewers were then compared looking for at least two positive reviews for each PEP sample.

Results

Based on the ratings for each pair of signals, a cumulative total of 29 PEP signals out of 34 (85.3%) were rated as statistically equivalent or better for this dataset. In 35.5% of samples, the reviewers selected PEP because “more signal components were visible”.

Conclusion

The PURE EP 2.0 system is able to produce reliable and high-quality signals when compared to available standard of care systems. Further studies with larger dataset across multiple sites are needed to validate these results.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): BioSig Technologies

Prevention of noncommunicable diseases by interventions in the preconception period: A FIGO position paper for action by healthcare practitioners

With the increase in obesity prevalence among women of reproductive age globally, the risks of type 2 diabetes, gestational diabetes, pre-eclampsia, and other conditions are rising, with detrimental effects on maternal and newborn health. The period before pregnancy is increasingly recognized as crucial for addressing weight management and reducing malnutrition (both under- and overnutrition) in both parents to reduce the risk of noncommunicable diseases (NCDs) in the mother as well as the passage of risk to her offspring. Healthcare practitioners, including obstetricians, gynecologists, midwives, and general practitioners, have an important role to play in supporting women in planning a pregnancy and achieving healthy nutrition and weight before pregnancy. In this position paper, the FIGO Pregnancy Obesity and Nutrition Initiative provides an overview of the evidence for preconception clinical guidelines to reduce the risk of NCDs in mothers and their offspring. It encourages healthcare practitioners to initiate a dialogue on women's health, nutrition, and weight management before conception. While acknowledging the fundamental importance of the wider social and environmental determinants of health, this paper focuses on a simple set of recommendations for clinical practice that can be used even in short consultations. The recommendations can be contextualized based on local cultural and dietary practices as part of a system-wide public health approach to influence the wider determinants as well as individual factors influencing preconception health.

Global Health in Preconception, Pregnancy and Postpartum Alliance: development of an international consumer and community involvement framework

BACKGROUND

The goal of the Global Health in Preconception, Pregnancy and Postpartum (HiPPP) Alliance, comprising consumers and leading international multidisciplinary academics and clinicians, is to generate research and translation priorities and build international collaboration around healthy lifestyle and obesity prevention among women across the reproductive years. In doing so, we actively seek to involve consumers in research, implementation and translation initiatives. There are limited frameworks specifically designed to involve women across the key obesity prevention windows before (preconception), during and after pregnancy (postpartum). The aim of this paper is to outline our strategy for the development of the HiPPP Consumer and Community (CCI) Framework, with consumers as central to co-designed, co-implemented and co-disseminated research and translation.

METHOD

The development of the framework involved three phases: In Phase 1, 21 Global HiPPP Alliance members participated in a CCI workshop to propose and discuss values and approaches for framework development; Phase 2 comprised a search of peer-reviewed and grey literature for existing CCI frameworks and resources; and Phase 3 entailed collaboration with consumers (i.e., members of the public with lived experience of weight/lifestyle issues in preconception, pregnancy and postpartum) and international CCI experts to workshop and refine the HiPPP CCI Framework (guided by Phases 1 and 2).

RESULTS

The HiPPP CCI Framework's values and approaches identified in Phases 1-2 and further refined in Phase 3 were summarized under the following five key principles: 1. Inclusive, 2. Flexible, 3. Transparent, 4. Equitable, and 5. Adaptable. The HiPPP Framework describes values and approaches for involving consumers in research initiatives from design to translation that focus on improving healthy lifestyles and preventing obesity specifically before, during and after pregnancy; importantly it takes into consideration common barriers to partnering in obesity research during perinatal life stages, such as limited availability associated with family caregiving responsibilities.

CONCLUSION

The HiPPP CCI Framework aims to describe approaches for implementing meaningful CCI initiatives with women in preconception, pregnancy and postpartum periods. Evaluation of the framework is now needed to understand how effective it is in facilitating meaningful involvement for consumers, researchers and clinicians, and its impact on research to improve healthy lifestyle outcomes.

Evaluation of the Psychometric Properties of a Version of the London Measure of Unplanned Pregnancy for Women’s Partners

BackgroundThe role of women’s partners in pregnancy planning has gained importance with the development of preconception care. The measurement of pregnancy planning/intention has also changed in the last two decades with the development of psychometric measures such as the London Measure of Unplanned Pregnancy (LMUP). This analysis aimed to evaluate the psychometric properties of a version of the LMUP for women’s partners in the UK. MethodsThe LMUP items, adapted for completion by partners, were piloted and included in a survey of (mainly male) partners in three antenatal clinics in London, UK, as part of a study of pre-pregnancy health and care. The psychometric properties of the partner LMUP were assessed according to the principles of Classical Test Theory. ResultsThere were 575 partners of pregnant women in the sample, 573 (99.7%) being men. There were high comple-tion rates for all the LMUP items. The distribution of LMUP scores ranged from 1–12, with a negative skew (biased towards planned/intended pregnancies). In terms of reliability (internal consistency), Cronbach’s alpha was 0.69, item-rest correlations were >0.2 for five items, and all inter-item correlations were positive. In terms of construct validity, principal components analysis showed that measurement was unidimensional, confirmatory factor analysis showed good model fit, and the convergent validity hypothesis of non-perfect, moderate-to-good agreement between couples’ LMUP scores was met. ConclusionsThe partner LMUP performed well in terms of reliability and validity according to internationally-accepted criteria for the performance of psychometric measures and can be used in future research on men and couples. However, we recommend further research relating to the concept of pregnancy planning/inten-tion among partners of all gender identities to understand whether additional content would enhance the measurement of the construct. In particular, we recommend further conceptual exploration with men who have experienced unplanned pregnancies.  

Evaluation of the Krio Language Version of the London Measure of Unplanned Pregnancy in Western Area, Sierra Leone

New ways of measuring pregnancy planning/intention such as the London Measure of Unplanned Pregnancy (LMUP), which recognise the complexity of the construct, are being adopted worldwide. The aim of this study was to evaluate the psychometric properties of the Krio version of the LMUP in Sierra Leone. An interviewer-administered version of the LMUP was translated into Krio and pre-tested with 12 pregnant women. Field testing involved 172 pregnant women aged 15-42, with 87 completing a re-test. Completion rates of LMUP items were 100%. LMUP scores 1-12 were captured. Reliability: the scale was internally consistent (Cronbach's alpha 0.84) and stable (weighted Kappa 0.93). Construct validity: all hypotheses were confirmed. Principal components analysis revealed five items (items 2-6) related to one construct. Mokken scaling procedure selected the same five items. Removal of item 1 (which had 97% endorsement of the ‗no contraception' response option) brought about only a very slight improvement in LMUP performance, therefore we recommend retaining all six items. The Krio LMUP is reliable, valid and suitable to use in Sierra Leone.

An interactive website for informed contraception choice: randomised evaluation of Contraception Choices

OBJECTIVE

Improving use of effective contraception to prevent unintended pregnancy is a global priority, but misperceptions and concerns about contraception are common. Our objective was to evaluate an interactive website to aid informed choice of contraception.

METHODS

The Contraception Choices website is an interactive digital intervention which offers tailored advice to aid contraception decision-making (www.contraceptionchoices.org). In a parallel single-blind trial, we randomised 927 women aged 15-30 years from six clinic settings to access the intervention website (n = 464) or to a waiting-list control group (n = 463). The study was initially a feasibility trial, evolving into an evaluation of efficacy, with two primary outcomes at six months: long-acting reversible contraception (LARC) use, and satisfaction with contraceptive method. Secondary outcomes included self-reported pregnancy and sexually transmitted infection diagnoses. Free-text comments on the 3 and 6 month outcome surveys were analysed thematically.

FINDINGS

There was no significant difference between intervention and control groups in the proportion of women using LARC [30.4% intervention versus 31.0% control; adjusted odds ratio 0.87 (95% confidence interval 0.60 to 1.28)]; satisfaction with contraceptive method [82.6% versus 82.1%; adjusted ordinal odds ratio 0.93 (95% CI 0.69 to 1.25)]; self-reported pregnancy [3.3% versus 4.1%; adjusted odds ratio 0.90 (95% CI 0.45 to 1.79)] nor sexually transmitted infection [5.3% versus 4.7%; adjusted odds ratio 0.72 (95% CI 0.55 to 2.36)]. Highly positive free-text comments from intervention participants indicated that the website facilitates contraception choice and can help women feel better prepared before consultation with healthcare providers.

INTERPRETATION

The Contraception Choices website was popular for its design, trustworthy information and decision aids but it was not associated with significant differences in use of LARC or satisfaction with contraceptive method. An interactive website can aid contraception choice, but interventions that address factors beyond women's control, such as access to services, and partner, family or community influences are needed to complement this approach.

RESEARCH IN CONTEXT

Preventing unintended pregnancy through effective use of contraception is essential for women's health, but choosing between different contraceptive methods can be challenging, and the opportunity for adequate discussion during routine consultations is often constrained.

EVIDENCE BEFORE THIS STUDY

We conducted two systematic literature reviews: 1) Factors influencing contraception choice, uptake and use: a meta-synthesis of systematic reviews; and 2) Effectiveness of interactive digital interventions (IDI) for contraception choice, uptake and use. For the first review we searched PubMed, CDSR, Epistemonikos, DoPHER, DARE, NHS Economic Evaluation Database, Campbell Library, NIHR Health Technology Assessment, and Health Evidence Canada databases for systematic reviews which addressed contraceptive choice, uptake or use, from 2000 to 2017. PROSPERO registration number: CRD42017081521 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81521. We synthesised the findings of 18 systematic reviews of mostly moderate or high quality. They highlighted the importance of women's knowledge, beliefs, perceptions of side effects and health risks, as well as relationship status, social network, economic and healthcare factors on contraception choice and use. For the second review, we searched 23 electronic databases, trials registers and reference lists for randomised controlled trials of IDI for contraception, including CENTRAL, MEDLINE, EMBASE, CINAHL, ERIC, ASSIA and PsycINFO, from start date to June 2017. PROSPERO registration number: CRD42017081636. We found only five randomised trials of IDI, all from the USA. Risk of bias prevented synthesis of results. www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81636.

ADDED VALUE OF THIS STUDY

Women's common concerns about contraception - fear of hormones, weight gain, cancer, infertility, mood changes, breaks from contraception and changes in bleeding patterns - underpinned development of a new interactive website (www.contraceptionchoices.org). Contraception Choices addresses women's concerns through succinct text; Q and A format (Frequently Asked Questions, Did you Know?; videos of women and health professionals); an effectiveness infographic, and an interactive decision aid (What's right for me?).In an online randomised trial with 927 women attending clinics, we found no association of the Contraception Choices intervention with the primary outcomes - satisfaction with contraceptive method and uptake of long-acting reversible methods at 6 months. Nor did we find an association with secondary adverse outcomes - sexually transmitted infections or pregnancy. Comments from women indicated that the website can meet young women's need for information on the benefits and drawbacks of contraception, help them to make informed decisions, and feel better prepared before healthcare consultations. Contraception Choices is now available on the NHS website: www.nhs.uk/conditions/contraception/which-method-suits-me.

IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE

Interactive digital interventions (websites) can aid contraception choice, but other intervention research is needed to address wider influences on unintended pregnancy, including partner views, friends, family, the media, wider society and experiences with healthcare professionals. Future research could examine the impact of the website in different settings, e.g. schools or different countries. We hypothesise that use of the website during contraceptive consultations might improve the efficiency or quality of consultation, for both patients and healthcare providers. Appropriate methodology and time-scale for evaluating digital health interventions remains a key question.

Health in Preconception, Pregnancy and Postpartum Global Alliance: International Network Preconception Research Priorities for the Prevention of Maternal Obesity and Related Pregnancy and Long-Term Complications

The preconception period is a key public health and clinical opportunity for obesity prevention. This paper describes the development of international preconception priorities to guide research and translation activities for maternal obesity prevention and improve clinical pregnancy outcomes. Stakeholders of international standing in preconception and pregnancy health formed the multidisciplinary Health in Preconception, Pregnancy, and Postpartum (HiPPP) Global Alliance. The Alliance undertook a priority setting process including three rounds of priority ranking and facilitated group discussion using Modified Delphi and Nominal Group Techniques to determine key research areas. Initial priority areas were based on a systematic review of international and national clinical practice guidelines, World Health Organization recommendations on preconception and pregnancy care, and consumer and expert input from HiPPP members. Five preconception research priorities and four overarching principles were identified. The priorities were: healthy diet and nutrition; weight management; physical activity; planned pregnancy; and physical, mental and psychosocial health. The principles were: operating in the context of broader preconception/antenatal priorities; social determinants; family health; and cultural considerations. These priorities provide a road map to progress research and translation activities in preconception health with future efforts required to advance evidence-translation and implementation to impact clinical outcomes.

2201Coronary angioplasty patients' preferences for information about treatment risks: a survey study

Background

Percutaneous Coronary Intervention (PCI) is the commonest invasive procedure in cardiology. Before treatment consent must be given. As part of this communication process patients receive information about the risks and benefits of PCI and alternative treatments. Published studies tell us that the amount and quality of the information received by patients undergoing PCI is variable; benefits are often overestimated, risks forgotten and alternative treatments not always considered. Very little is known about patients' preferences for PCI risk information. Aim: To describe patients' preferences for formation about PCI treatment risk as part of the informed consent process Methods: A cross-sectional survey was distributed to 350 participants treated with PCI across 10 PCI centres in England.

Results

Three hundred and twenty six participants completed the survey. Thirty percent of the sample reported needing help to understand written medical information. Fifty-one percent were treated with elective PCI, 75% were male, average age of 66.5 years. Recall and comprehension of PCI information given during the consent process was generally limited; 47% and 61% agreed that patients do not usually understand, or remember, the information given to them respectively. Eighty-eight percent of urgent PCI patients wanted to know about all possible risks compared to 90% of elective cases. Most participants (88% urgent and 94% elective) believed that PCI would reduce their risk of a future heart attack.

Conclusion

A significant proportion of PCI patients find it difficult to recall or understand information about treatment risks. It is recommended that patients are given health-related information designed to accommodate different health literacy levels in advance of their treatment.

Acknowledgement/Funding

National Institute for Health Research Research for Patient Benefit Programme Grant Reference Number PB-PG-0712-28089

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.

Alcohol, smoking, folic acid and multivitamin use among women attending maternity care in London: A cross-sectional study

OBJECTIVES

This study describes the patterns of change in health behaviours that pregnant women adopt before and during pregnancy.

STUDY DESIGN

A cross-sectional survey of pregnant women asked questions about pregnancy planning, health knowledge, and health behaviour. Analysis was descriptive with associations examined using logistic regression models.

MAIN OUTCOME MEASURES

Health behaviours before and during pregnancy (smoking, alcohol consumption, and folic acid and multivitamin (supplement) intake), and recall of healthcare professional advice.

RESULTS

1173 women completed the survey (mean age 32 ± 5 years, 68% white) of whom 73% indicated that their pregnancy was highly planned. 38% of women reported having never smoked, 45% quit smoking before becoming pregnant, and fewer (5%, 95% CI 3-6%) reported currently smoking. Current smokers reported reduced cigarette consumption compared to pre-pregnancy, and higher recall of health professional information. Nine percent (95% CI 5-8%) reported currently drinking, reducing the number of units consumed from 6 units weekly before pregnancy (IQR 2-10) to 1 unit weekly during pregnancy (IQR 1-2, p < 0.001). Most (62%) women were currently taking supplements, of whom 81% reported daily use. Women with more planned pregnancies had higher odds of adopting healthier behaviours of stopping smoking or drinking before pregnancy compared to those who stopped during pregnancy or continued the behaviour.

CONCLUSIONS

Most women adopted one or more healthy behaviours during pregnancy, with a small minority continuing to smoke or drink alcohol. For women who continued smoking in pregnancy and recalled information from health professionals, additional tailored approaches need to be explored.