Factors Influencing Abortion Decision-Making of Adolescents and Young Women: A Narrative Scoping Review

INTRODUCTION

Globally, about half of all induced abortions have been estimated to be unsafe, which results in 13% of maternal deaths yearly. Of these induced abortions, 41% of unsafe abortions have been reported in young women who are dependent on their parents for their livelihood. They are often left in a vulnerable position and may have difficulty in making a decision regarding abortion. This study aimed to (1) characterize and map factors that influence abortion decision-making of adolescents and young women, and (2) identify the care and support that they need in their decision-making process.

METHODS

We conducted a scoping review following the JBI method and PRISMA-ScR checklist. We comprehensively searched MEDLINE (PubMed), Embase, Cochrane Library, CINAHL, and PsycInfo, and hand searched publications in the Google Scholar database between November 2021 and October 2023. The search included all English language qualitative and mixed methods research articles published on the database up to October 2023 that included participants aged 10-24 years. The CASP checklist was used as a guide for the qualitative analysis. NVivo was used to synthesize the findings.

RESULTS

There were 18 studies from 14 countries (N = 1543 young women) that met the inclusion criteria. Three domains and eleven categories were included as follows: personal (desire for self-realization and unwanted pregnancy), interpersonal (parental impact, reaction of partner, roles of peers and friends, existence of own child, and lack of support), and social circumstances (sexual crime, financial problem, limitation of choice, and underutilized healthcare services). Decision-making factors regarding abortions were also found across all three domains.

CONCLUSION

The abortion decision-making of young women is influenced by various external factors regardless of country. Parents are especially influential and tend to force their daughters to make a decision. Young women experienced suffering, frustration, and lack of autonomy in making decisions based on their preference. This emphasizes the importance of autonomous decision-making. In this regard, healthcare services should be used. However, there are barriers to accessing these services. To improve such access, the following are required: staff training to provide adolescent and youth-friendly health services, counseling based on women's needs, counseling including the parents or guardians that is confidential and ethical, promotion of decision aids, and affordable accessible care.

Sequencing of Births by Wantedness: Implications for Changes in Mid-Life Health Among Aging NLSY79 Women

OBJECTIVES

As life course frameworks highlight and gerontological studies confirm, the health implications of early birth timing (e.g., adolescent births) and unplanned births (e.g., unwanted or mistimed births) extend years after those births into mid and later life. Yet past research often overlooks the considerable diversity in sequencing and timing of unplanned births even within the same individual (e.g., having both wanted and unwanted births), which are likely fundamental for women's long-term health trajectories. We develop a holistic understanding of birth timing and wantedness to provide insight into when and how childbearing histories matter for aging women's health.

METHODS

We use sequence analysis with hierarchical cluster method and estimate regression models using the 1979 National Longitudinal Survey of Youth (N = 3,231) to examine how timing and patterning of births by wantedness are associated with changes in physical and mental health from ages 40 to 50.

RESULTS

We identify 7 clusters of childbearing sequences. Of those 7 clusters, respondents with sequences characterized by wanted births in their 20s and 30s had the smallest declines in health in mid-life, whereas respondents with sequences with mainly unwanted births at any age or with mainly mistimed births beginning in adolescence had the greatest health declines. Adjusting for social and economic variables accounted for some, but not all, health differences across childbearing clusters.

DISCUSSION

This project demonstrates the need for comprehensive life course perspectives on long-term health implications of birth wantedness and timing, recognizing diversity within and between individuals.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The influence of mindfulness-based stress reduction (MBSR) on stress, anxiety and depression due to unwanted pregnancy: a randomized clinical trial

Background

Individuals with unwanted pregnancies often experience high levels of anxiety, stress and depression that associated with maternal-neonatal outcomes. Mindfulness training is a safe and acceptable strategy to support mental health before parturition.

Purpose

The main objective of present study was to evaluate the influence of eight-week application of mindfulness-based stress reduction on stress, anxiety and depression caused by unplanned pregnancy.

Method

In this study, 60 women with unwanted pregnancy before 32 weeks of gestational age were selected and randomly divided into two groups. Intervention group received MBSR sessions, practice at home and the recorded sound. Mental health was evaluated before intervention and at the end of the eight sessions by standard stress, anxiety and depression DASS-21 questionnaire. Data were analyzed using Chi-square, Mann-Whitney U and Wilcoxon tests.

Findings

In order to compare pre-test and post-test scores in each group, the Wilcoxon Test was used. The results revealed that the participants in the intervention group reported a significant decrease in mean scores of stress, anxiety and depression compared to baseline (P = 0.0). Whereas no significant decrease in mean stress, anxiety and depression score were found in control group. P-value was estimated to be 0.346, 0.212 and 0.343 respectively.

Conclusions

The mindfulness program has effectively reduced stress, anxiety and depression. Further research is needed to investigate the mechanisms and effects of mindfulness on maternal-neonatal outcomes.

Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana

Introduction

Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana.

Materials and methods

In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique.

Results

The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty.

Conclusions

We found that severity of pain from complications, stigma and financial constraints were factors that influenced women’s decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

Initiating Hormonal Contraception

Most patients can safely begin using hormonal contraception at any point in their menstrual cycle. An evidence-based, flexible, patient-centered approach to initiating contraception promotes health and enhances patients' reproductive autonomy. A recent Papanicolaou test is not necessary before prescribing hormonal contraception. Most patients can begin using progestin-only contraceptives immediately after childbirth. Patients can begin any appropriate contraceptive method immediately after an abortion or early pregnancy loss, except for an intrauterine device following septic abortion. Delaying contraception to wait for the next menses or for an appointment creates unnecessary barriers for patients. Clinicians can facilitate the use of hormonal contraception by providing anticipatory guidance about common side effects (e.g., spotting, other menstrual cycle changes), giving comprehensive information about available contraceptive choices, honoring patients' preferences, and eliminating office-related barriers. Prescribing or dispensing a one-year supply of contraceptives lowers costs and improves adherence. Counseling via telemedicine or a patient portal eliminates unnecessary office visits.

Prevalence of Self-Managed Abortion Among Women of Reproductive Age in the United States

IMPORTANCE

Increasing evidence indicates that people are attempting their own abortions outside the formal health care system. However, population-based estimates of experience with self-managed abortion (SMA) are lacking.

OBJECTIVE

To estimate the prevalence of SMA attempts among the general US population.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study was fielded August 2 to 17, 2017 among English- and Spanish- speaking, self-identified female panel members from the GfK web-based KnowledgePanel. Women ages 18 to 49 years were approached to complete a 1-time survey. Data were analyzed from September 22, 2017, to March 26, 2020.

MAIN OUTCOMES AND MEASURES

SMA was defined as "some women may do something on their own to try to end a pregnancy without medical assistance. For example, they may get information from the internet, a friend, or family member about pills, medicine, or herbs they can take on their own, or they may do something else to try to end the pregnancy." SMA was assessed using the question, "Have you ever taken or used something on your own, without medical assistance, to try to end an unwanted pregnancy?" Participants reporting SMA were asked about methods used, reasons, and outcomes. Factors associated with SMA experience, including age, race/ethnicity, socioeconomic status, nativity, reproductive health history, and geography, were assessed. Projected lifetime SMA prevalence was estimated using discrete-time event history models, adjusting for abortion underreporting.

RESULTS

Among 14 151 participants invited to participate, 7022 women (49.6%) (mean [SE] age, 33.9 [9.0] years) agreed to participate. Among these, 57.4% (95% CI, 55.8%-59.0%) were non-Hispanic White, 20.2% (95% CI, 18.9%-21.5%) were Hispanic, and 13.3% (95% CI, 12.1%-14.5%) were non-Hispanic Black; and 15.1% (95% CI, 14.1%-16.3%) reported living at less than 100% federal poverty level (FPL). A total of 1.4% (95% CI, 1.0%-1.8%) of participants reported a history of attempting SMA while in the US. Projected lifetime prevalence of SMA adjusting for underreporting of abortion was 7.0% (95% CI, 5.5%-8.4%). In bivariable analyses, non-Hispanic Black (prevalence ratio [PR], 3.16; 95% CI, 1.48-6.75) and Hispanic women surveyed in English (PR, 3.74; 95% CI, 1.78-7.87) were more likely than non-Hispanic White women to have attempted SMA. Women living below 100% of the FPL were also more likely to have attempted SMA compared with those at 200% FPL or greater (PR, 3.43; 95% CI, 1.83-6.42). At most recent SMA attempt, 20.0% (95% CI, 10.9%-33.8%) of respondents used misoprostol, 29.2% (95% CI, 17.5%-44.5%) used another medication or drug, 38.4% (95% CI, 25.3%-53.4%) used herbs, and 19.8% (95% CI, 10.0%-35.5%) used physical methods. The most common reasons for SMA included that it seemed faster or easier (47.2% [95% CI, 33.0%-61.8%]) and the clinic was too expensive (25.2% [95% CI, 15.7%-37.7%]). Of all attempts, 27.8% (95% CI, 16.6%-42.7%) of respondents reported they were successful; the remainder reported they had subsequent facility-based abortions (33.6% [95% CI, 21.0%-49.0%]), continued the pregnancy (13.4% [95% CI, 7.4%-23.1%]), had a miscarriage (11.4% [95% CI, 4.2%-27.5%]), or were unsure (13.3% [95% CI, 6.8%-24.7%]). A total of 11.0% (95% CI, 5.5%-21.0%) of respondents reported a complication.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that approximately 7% of US women reported having attempted SMA in their lifetime, commonly with ineffective methods. These findings suggest that surveys of SMA experience among patients at abortion clinics may capture only one-third of SMA attempts. People's reasons for attempting SMA indicate that as abortion becomes more restricted, SMA may become more common.

Quality of family planning services for women of reproductive age in Lao PDR

BACKGROUND

In Lao PDR, 15% of the married women want to postpone or prevent having a child, yet most are not using contraceptives to achieve this. Literature shows that usage of contraceptives is strongly dependent on the quality of family planning services. However, little is known about the quality of family planning services in Lao PDR.

OBJECTIVE

To assess the quality of family planning services provided in public health facilities in Lao PDR.

METHODS

Using a cross-sectional study design, public health facilities in three provinces in Lao PDR were assessed on structure, process and outcome measures of quality. Following the Quick Investigation of Quality approach, client exit interviews (n = 393), structured observations (n = 218) and facility audits (n = 17) were conducted.

RESULTS

Facility audits, observations and client exit interviews painted different pictures of the overall quality of family planning services. Taking all together, the quality was rated as moderate to high. Only marginal differences in quality were found between family planning services located in different geographical areas. Notably, only married women with children were using these services. Although contraceptives were provided, little attention was given to the information provided during consultations and to the interpersonal relationship between client and provider.

CONCLUSION

The results suggest that although improvements are needed to enhance quality of individual consultations, the greatest gain in reducing unwanted pregnancies would be made by ensuring access for all women of reproductive age.

Racial Disparities in Emotional Well-Being during Pregnancy

In light of persistent racial disparities in maternal and child health, it is important to understand the dynamics shaping outcomes for black mothers. We examine racial patterns in women's emotional well-being regarding pregnancy (i.e., women's reported happiness to be pregnant), which has been shown to have health consequences. Using the 2002-2017 National Survey of Family Growth (N = 6,163 pregnancies ending in birth), we find that black women are less happy about their pregnancies than white women both for intended and mistimed pregnancies. The happiness gap in intended pregnancies is partially attributable to differences in economic strain and partner support. In addition, child gender shapes happiness differently by race: Black women who previously had sons are unhappier about current intended pregnancies than those who did not (with no difference for white women). We argue there are pregnancy- and parenthood-related stressors that disproportionately impact black women, with potential implications for mothers and children.

Sexual Assault in Adolescents

Child sexual abuse is a severely underreported crime in the United States. The consequences of child sexual abuse extend beyond physical injury, including an increased likelihood to develop chronic physical and mental diseases/disorders, including substance abuse and suicide. Care involves trauma-informed screening, assessment, and documentation, education of, and access to sexually transmitted infection prophylaxis and emergency contraception, safety interventions, and access to community resources. Medical providers should know the response process their facility, community, and state practices for victims of sexual abuse. Acknowledging and responding to victims of sexual abuse as a multidisciplinary team will ensure comprehensive care for the patient.

Does unwanted pregnancy lead to adverse health and healthcare utilization for mother and child? Evidence from low- and middle-income countries

OBJECTIVES

Unwanted pregnancy is an important public health concern in low- and middle-income countries (LMICs). Using a pooled dataset from 48 Demographic Health Surveys conducted in Africa, Asia, Latin America and Europe (n = 494,778), we examined the effect of unwanted pregnancy on maternal and child healthcare utilization and child health outcomes in LMICs.

METHODS

We used logistic regression models to estimate the effect of unwanted pregnancy on antenatal care use, supervised delivery, childhood vaccination and three indicators of child health, viz. stunting (height-for-age), underweight (weight-for-age) and wasting (weight-for-height).

RESULTS

We found that mothers of children whose pregnancies had been unwanted had a lower probability of attending four or more antenatal care visits by 3.6% (95% confidence interval = 1.9-5.4%) compared to those whose pregnancy was wanted. We did not find significant impacts of unwanted pregnancy on supervised delivery, childhood vaccination uptake or child health indicators.

CONCLUSIONS

Birth characteristics, household-level determinants and country-level characteristics seem to be more closely related to maternal and child healthcare utilization as well as child health outcomes than whether the pregnancy was wanted or unwanted in LMICs.

Experiences of Reproductive Coercion Among Latina Women and Strategies for Minimizing Harm: "The Path Makes Us Strong"

INTRODUCTION

Latina women disproportionately report experiencing reproductive coercion (RC), a set of behaviors that interfere with autonomous reproductive decision making. Given RC's associations with intimate partner violence (IPV) and unintended pregnancy, it is critical to identify and address RC to assist women to achieve safety, autonomy, and reproductive life plans. The purpose of this study was to describe and understand the context of RC and the use of RC safety strategies among Latina women receiving services at an urban clinic, through listening to the experiences of the women in their own words.

METHODS

Qualitative descriptive methodology was used. Semistructured interviews were conducted with a purposive sample of 13 Latina women recruited from a Federally Qualified Health Center in the Washington, DC, area.

RESULTS

Data were organized into 3 a priori categories: (1) RC behaviors, (2) co-occurrence of RC and IPV, and (3) RC harm reduction strategies. New RC behaviors emerged, and immigration status was used as a method of coercive control. From these a priori categories emerged 4 themes: impact of immigrant and citizenship status, machismo, strength and bravery, and importance of family. Harm reduction strategies included less detectable contraception; some sought community services, but others resorted to deception and stalling as the only tools available to them.

DISCUSSION

Less detectable methods of contraception remained useful harm reduction strategies for women experiencing RC. Midwives should inquire about method fit and be mindful of honoring the request when patients ask to change methods. Women's strength and resilience emerged as a vital source of power and endurance. This diverse sample and the powerful voices of the women who participated make a significant contribution to the understanding of RC experienced by Latina women in the United States.

Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion

OBJECTIVE

To prospectively assess perceptions of abortion stigma after receiving or being denied an abortion over 5 years, the factors associated with perceived abortion stigma, and the effects of perceived abortion stigma on psychological well-being.

METHODS

We recruited people seeking abortion from 30 facilities across the US, and interviewed them by phone one week post-abortion seeking, then semiannually for 5 years. We used adjusted mixed effects regression analyses to examine the abortion stigma trajectories of those who obtained an abortion near a facility's gestational age limit (Near-limits) compared to those denied an abortion because they were just over the limit and carried their pregnancies to term (Turnaway-births).

RESULTS

Of the 956 people recruited, we removed 28 due to ineligibility or missing data, leaving a final sample of 928. In unadjusted analyses, at one-week post-abortion seeking, over half of those seeking abortion perceived that if others knew they had sought an abortion, they would be looked down upon at least "a little bit" by people close to them (60%) or by people in their community (56%). In longitudinal adjusted analyses, people denied an abortion and who carried their pregnancies to term (Turnaway-birth group) reported significantly lower baseline perceived abortion stigma from people close to them (-0.38; 95% CI, -0.59, -0.16) and from people in their community (0.30; 95% CI, -0.52, -0.08), than Near-limits, differences that remained statistically significant for 1.5 years. Overall perceived abortion stigma declined significantly (p < .001) for both study groups. High perceived abortion stigma at baseline was associated with higher odds of experiencing psychological distress years later (adjusted Odds Ratio, 3.98; 95% CI, 1.39, 11.37).

CONCLUSIONS

Most people considering abortion perceive some abortion stigma, which is associated with psychological distress years later.

Exploring the Risks of Repeated Pregnancy Among Adolescents and Young Women in the Philippines

Objective Knowledge of the factors which influence repeat pregnancy can inform much needed evidence-based prevention programs. This study aims to identify correlates of repeat pregnancy in the Philippines. Methods We used data from five Philippine Demographic and Health Surveys (1993-2013). A total of 4757 women 15-24 years old who had experienced ≥ 1 pregnancy were included. Individual and partner-related factors were fitted into a series of logistic regression stepwise models with deformalized survey weights. Stratified analyses using two age groups (15-19, 20-24) were also conducted. Interaction terms were included to test for statistical differences between the groups. Results Lower wealth quintiles [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.17-2.49] and partner characteristics such as age of ≥ 30 years (OR = 1.99, CI = 1.41-2.82), multiple partners (OR = 4.19, CI = 1.57-11.19) and live-in status (OR = 1.38, CI = 1.02-1.87) were found to be highly correlated with repeat pregnancy in fully adjusted analysis. Receiving prenatal care from traditional healers (OR = 1.93, CI = 1.02-3.63) during the first pregnancy and giving birth for the first time before 18 years of age (OR = 1.12, CI = 1.04-1.20) showed increased risks among 15-19 years old compared to 20-24 years old in stratified analysis. Conclusions for practice In general, partner characteristics were associated with repeat pregnancy among young women suggesting male involvement, especially older partners, in family planning. High risks for repeat pregnancy were observed among adolescent women who reported younger age at first birth and received prenatal care from a traditional healer which entail promotion of trained prenatal care. Further analysis is needed to validate these findings in other developing countries.

To keep or not to keep? Decision making in adolescent pregnancies in Jamestown, Ghana

Background

Jamestown, an urban coastal slum in Accra, Ghana, has one of the highest adolescent pregnancy rates in the country. We sought to understand the decision (to keep or terminate) factors and experiences surrounding adolescent pregnancies.

Methods

Thirty semi-structured indepth interviews were carried out among adolescents (aged 13–19 years) who had been pregnant at least once. Half of these were adolescent mothers and the other half had at least one past experience of induced abortion. A pretested and validated questionnaire to assess the awareness and use of contraception in adolescent participants was also administered. To aid social contextualization, semi-structured in depth interviews were carried out among 23 purposively selected stakeholders.

Results

The main role players in decision making included family, friends, school teachers and the partner, with pregnant adolescents playing the most prominent role. Adolescents showed a high degree of certainty in deciding to either abort or carry pregnancies to term. Interestingly, religious considerations were rarely taken into account. Although almost all adolescents (96.1%) were aware of contraception, none was using any prior to getting pregnant. Of the 15 adolescents who had had abortion experiences, 13 (87.0%) were carried out under unsafe circumstances. The main barriers to accessing safe abortion services included poor awareness of the fairly liberal nature of the Ghanaian abortion law, stigma, high cost and non-harmonization of safe abortion service fees, negative abortion experiences (death and bleeding), and distrust in the health care providers. Adolescents who chose to continue their pregnancies to term were motivated by personal and sociocultural factors.

Conclusion

Decision-making in adolescent pregnancies is influenced by multiple external factors, many of which are modifiable. Despite legal access to services, options for the safe termination of pregnancy or its prevention are not predominantly taken, resulting in a high number of negative experiences and outcomes. Including safe abortion care within the sexual and reproductive health package, could diminish barriers to safe abortion services. Given the vulnerability of the Jamestown setting, a comprehensive sexual education package that addresses the main decision factors is recommended. Interventions aiming to reduce adolescent pregnancy rates should also recognize that adolescent pregnancies are culturally acceptable in some settings, and under certain circumstances, are desired by the adolescents themselves.

Mental disorders/difficulties in the postpartum period

INTRODUCTION

Mental difficulties are common in the postpartum period. They can manifest in a mild form, but also as serious disorders which need to be treated in a timely manner. The most common psychological problem is "Baby blues" characterized by relatively short duration without consequences and treatment is largely unnecessary. Postpartum depression is characterized by a sense of sadness, loss of interest, insomnia, discomfort, loss of energy, reduced concentration. Postpartum psychosis is the most serious disorder but is also rare and may have serious consequences for the mother and child. Important factors in the postpartum mental problems/difficulties are genetic factors, situation of unwanted pregnancy, a feeling of discomfort with the role of motherhood and sudden hormonal changes.

AIM

to investigate the frequency and type of mental problems in postpartum period, as well as possible type of help needed by the women in postpartum period.

SUBJECTS AND METHODS

One hundred (112) respondents participated in the survey. The survey was conducted from November to December 2017 through a "google docs" application. The survey was placed on different social networks, and the participation in the survey was voluntary and anonymous. A series of 14 questions with the offered answers was used in the survey.

RESULTS

The results of the survey have shown that psychological difficulties and disturbances in the postpartum period to be common problems encountered by almost 50% of women (44.46%). The most common difficulty is Baby blues, followed by postpartum depression and anxiety disorders. Age and the mode of birth did not affect the emergence of changes, while social factors such as family support had a great impact.

CONCLUSION

The provision of information to the mothers can help, but inaccurate information can do the opposite. Thus, the role of health care professionals is important for helping mothers in that period to prevent certain difficulties as well as in identifying and referring mothers to seek help in a timely fashion.

Association of Infant Exclusive Breast Feeding with Household Food Security and Maternal Mental Health

BACKGROUND

Exclusive breastfeeding (EBF) is emphasized by the World Health Organization (WHO) as the most desirable way of infant feeding in the first 6 months. EBF has beneficial health effects on mothers and infants. The aim of this study was to examine factors influencing EBF, with emphasis on household food security status and maternal mental health.

METHODS

This cross-sectional study was carried out on 325 women referring to community health centers in west Tehran. Data were collected using questionnaires, including Edinburgh Postnatal Depression Scale (EPDS) and the USDA (US Department of Agriculture) 18-item questionnaire. The data was analyzed using both descriptive and analytical methods such as the chi-squared test, t test and logistic regression with SPSS 22.

RESULTS

The prevalence of EBF was 82.5% (CI = 0.70, 0.94), 63.9% (CI = 0.57, 0.70) and 72.3% (CI = 0.62, 0.82) in 3-month, 3-6-month and 6-8-month-old infants, respectively. The results of this study showed a significant association between EBF and infant gender satisfaction (P < 0.001, OR = 4.85, CI = 2.12, 11.12), economic satisfaction score (P = 0.028, OR = 0.82, CI = 0.69, 0.98), infant birth weight (P = 0.013, OR = 0.99, CI = 0.99, 1.00) and unwanted pregnancy (P = 0.098, OR = 1.82, CI = 0.89, 3.70). However, we did not find any significant association between EBF and other variables such as household food security status, mother's postpartum depression, parents' education and age, type of delivery and pregnancy numbers.

CONCLUSION

Infant gender satisfaction, economic satisfaction, unwanted pregnancy and infant birth weight were the significant factors for predicting EBF in this study. Since EBF is important for infants and mothers' health, policy-makers should devise strategies to promote and encourage EBF in the society.

The role of motivational interview in the request for termination of pregnancy: A case report

In Malaysia, induced termination of pregnancy is legal, if a registered medical practitioner is the one who terminates the pregnancy, and is acting in good faith without the risk to the life or injury to the mental health of the pregnant woman; in the event that continuation of the pregnancy is greater than the risk if the pregnancy is terminated. This case report highlights the approach of motivational interviewing in evoking a change of the behaviour of a patient wishing termination of pregnancy for psychosocial reasons.

Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study

Unsafe abortion continues to impact negatively on women’s health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub-Saharan Africa. This qualitative study assessed women’s knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤ 20 years; almost one-third were students. Common reasons for terminating a pregnancy were: “too young/still in school/training”; “has enough number of children”; “last baby too young” and “still breastfeeding”. Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women’s narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.

Intimate partner violence and its associated factors among pregnant women in Bale Zone, Southeast Ethiopia: A cross-sectional study

BACKGROUND

Intimate partner violence (IPV) against women is a major public health concern in low income countries. Violence against pregnant women has adverse effects on maternal and newborn outcomes. This study aimed to assess the prevalence and associated factors of intimate partner violence in Southeast Ethiopia pregnant women.

METHODS

Institutional based cross-sectional study was conducted on pregnant women who were attending antenatal care (ANC) in Bale Zone health institution during study period. Face to face interviews were conducted using a pre-tested structured questionnaire. Data related to socio-demographic characteristic, pregnancy and reproductive history, intimate partner behavior and IPV encountered during recent pregnancy was gathered for this study. Descriptive analysis and logistic regression were used for the data analysis. Odds ratio with 95% CI was computed to determine the presence and strength of associated factors with IPV.

RESULTS

A total of 612 pregnant women participated in the study. Of these, 361 (59.0%) pregnant women faced at least one type of IPV during the recent pregnancy. Physical violence (20.3%), sexual violence (36.3%), psychological/emotional violence (33.0), controlling behavior violence (30.4%) and economic violence (27.0) were the type of IPV encountered by participants. An intimate partners who were drank alcohol [AOR = 2.9; 95% CI: (1.5-5.4)], partners who were chewed Khat [AOR = 1.7; 95% CI: (1.1-2.6)], partners who were smoked cigarette [AOR = 2.6; 95% CI: (1.4-4.9)], partners who had aggressive behavior [AOR = 2.8; 95% CI: (1.7-4.6)], having partner age ≥30 year old [AOR = 1.8; 95% CI: (1.2-2.9)], unwanted pregnancy [AOR = 3.3; 95% CI: (1.9-5.5)] and history of adverse pregnancy outcome [AOR = 2.1; 95% CI: (1.2-3.6)] that were the factors that significantly associated with IPV of the pregnant women.

CONCLUSION

The prevalence of IPV during pregnancy was high among the study participants. Intimate partners' use of substance, intimate partners' aggressive behavior, older intimate partners, unwanted pregnancy and history of adverse birth outcome were identified as associated factors for IPV. IPV needs to be considered during ANC service and integrated into the sexual and reproductive health education. Community-based interventions should be advocated as a way of health promotion. Counseling, awareness creation, service provision and program design on IPV is mandatory to minimize the victim.

[Pregnancy in university students]

For the integral formation of college students requires strategies and programs that prepare them completely and committed to motherhood and fatherhood. Education as a preventive mechanism leads to improved family and social communication, and therefore prevents an unwanted pregnancy that could result in school dropouts.

Dimensions of decision difficulty in women's decision-making about abortion: A mixed methods longitudinal study

Relatively little is known about the ease or difficulty with which women decide to have an abortion, and most research uses single-item measurements. We used a mixed methods approach to combine data from the Dutch Abortion and Mental Health Study (DAMHS, n = 325) with data from a qualitative study about the decision process with a small subsample (n = 69) of the DAMHS study. We used the findings from the qualitative study to develop the Dimensions of Abortion Decision Difficulty [DADD] scale, and tested this scale among a larger sample of women who took part in the second wave of the cohort study (n = 264). Qualitative analyses revealed six dimensions of decision difficulty. The DADD scale was based on these six dimensions. Results from the DADD scale at follow-up reduced these to four dimensions: (1) unrealistic fears about the abortion and fantasies about the pregnancy; (2) decision conflict; (3) negative abortion attitudes; and (4) general indecisiveness. Decision conflict was the only dimension related to previous mental disorders. The findings suggest that the concept of decision difficulty seems multidimensional, rather than unidimensional. On a clinical level, it could be important to separate the more general fears, attitudes, and indecisiveness from strong decision conflict, because the latter might involve pressure of others, lack of decision ownership, and might be related to previous mental health.

Unmet need for modern contraception and associated factors among reproductive age group women in Eritrean refugee camps, Tigray, north Ethiopia: a cross-sectional study

OBJECTIVE

Millions of women want to delay or avoid pregnancy, but they are not using contraception, especially in refugee settings. Due to lack of contraception, one fifth of reproductive age group women suffered from unwanted pregnancy and unsafe abortion, which accounted for 78% of maternal mortality in refugee camps. Therefore, the aim of this study was to assess the prevalence of unmet need for modern contraception and its associated factors among reproductive age group women in Eritrean refugee camps, Tigray, Northern Ethiopia, 2016.

RESULTS

400 women of reproductive age group interviewed. Prevalence of unmet need for modern contraception in this study was found to be 41.8% (95% CI 36.99%, 46.63%).Respondents' unfavorable attitude towards modern contraceptive methods [AOR = 0.372, 95% CI 0.170, 0.818] and the availability of modern contraceptive methods [AOR = 3.501, 95% CI 1.328, 9.231] were factors significantly associated with unmet need for modern contraception. Respondents' attitude towards modern contraceptive methods and availability of modern contraceptives were independent predictors of unmet need. Governmental and non-governmental organizations should design programs to create behavioral change in women's attitude towards contraceptive use and to secure the availability of contraceptive methods in refugee camp settings.

Does Postpartum Contraceptive Use Vary By Birth Intendedness?

CONTEXT

Women with an unintended birth have an elevated risk of subsequent unintended pregnancy, and multiple unintended pregnancies could exacerbate any negative consequences of such births. It is therefore important to understand whether postpartum contraceptive use differs by birth intendedness.

METHODS

Data on 2,769 births reported in the 2011-2015 cycles of the National Survey of Family Growth were used to examine postpartum contraceptive use. Life-table estimates were employed to assess differences by birth intendedness in timing of postpartum contraceptive use, and multinomial logistic event history methods were used to model initial contraceptive uptake and efficacy by birth intendedness.

RESULTS

Compared with postpartum women whose births were on time or too late, those with seriously mistimed and those with unwanted births were more likely to first adopt a highly effective method (e.g., implant or IUD), rather than no method (relative risk ratios, 1.9 and 1.7, respectively); mothers with unwanted births were also more likely to first use least effective methods (e.g., condoms or withdrawal) instead of no method (1.5). Mothers with seriously mistimed births had a reduced likelihood of using either effective methods (e.g., the pill or injectable) or least effective methods, rather than highly effective ones (0.5 for each).

CONCLUSION

The elevated risk of repeat unintended fertility does not seem to be due to mothers' initial postpartum contraceptive behavior. Whether mothers with unintended births use contraceptives less consistently, discontinue use sooner or switch methods more often than those with intended births remains to be seen.

Abortion Knowledge and Experiences Among U.S. Servicewomen: A Qualitative Study

CONTEXT

U.S. servicewomen have a higher rate of unintended pregnancy than civilian women, yet the military does not provide or cover abortion, except in limited circumstances. Servicewomen's experiences with abortion care have received little research attention.

METHODS

Twenty-one in-depth interviews with servicewomen who had had an abortion during active-duty service in the prior two years were conducted between January 2015 and July 2016. Women reported on their experiences accessing abortion, as well as their knowledge and opinions of the military's abortion policy. Data were analyzed thematically using inductive and deductive codes.

RESULTS

In regard to their pregnancy and abortion experiences, servicewomen cited concerns about confidentiality, stigma and negative effects on their career, which prevented half of participants from seeking care from the military. Of those who visited a military treatment facility during pregnancy, some reported feeling upset or abandoned by the lack of options counseling and referral. Women reported that the military's abortion policy had negative health and emotional consequences for servicewomen, and negative financial and logistical consequences for both servicewomen and the military. Most did not have accurate knowledge of the abortion policy. Upon learning the law, the majority believed that the military should provide and cover abortion; yet, servicewomen also expressed apprehension about the military's involvement in abortion care, because of concerns about privacy and negative effects on women's careers.

CONCLUSIONS

Policy recommendations to better meet the needs of servicewomen include wider dissemination of the military's abortion policy, establishing abortion referral and support guidelines, and improving confidentiality in military health services.

Motivating factors for dual-method contraceptive use among adolescents and young women: a qualitative investigation

OBJECTIVE

This qualitative study explores how adolescents and young women perceive the need for and describe the use of dual method contraception.

STUDY DESIGN

We interviewed 20 sexually active women aged 16-24 who attended an adolescent-focused Title X family-planning clinic and were using a non-barrier contraceptive method. We used a semi-structured interview guide that included domains related to sexual activity, knowledge of and use of contraceptives and condoms, and relationship factors. We coded transcripts using grounded theory techniques and used an iterative process to develop overarching themes.

RESULTS

Dual method contraceptive users primarily discussed pregnancy prevention as their motivating factor. Many expressed anxieties over an unplanned pregnancy and reported condom use as "back-up" contraception. Risk perception for pregnancy or STI acquisition did not necessarily change as relationship trust increased, but rather, their anxiety regarding the negativity of such outcomes decreased. Dual-method contraception use decreased when participants reported that condoms were not readily available, or when they self-described immaturity. Less frequently, participants reported dual method use for sexually transmitted infection (STI) prevention, and many substituted STI testing for condom use. Contraceptive type (short-acting vs. long-acting) did not influence reported attitudes towards dual method use.

CONCLUSION

Health educators and clinicians encourage condom use in young women due to the significant morbidity associated with STI acquisition. Most participants in our study view condoms as a way to improve pregnancy prevention. Acknowledging and addressing this divergence in motivation will allow caregivers to improve strategies for communicating the importance of dual method use.

IMPLICATIONS

Young women primarily describe pregnancy prevention as the reason for dual method use, STI protection is less salient. Consideration of this viewpoint by health educators and clinicians will allow us to communicate more effectively to prevent STI morbidity.

Pregnancy context and women's health-related quality of life

OBJECTIVE

The objective was to quantify the association of pregnancy context and health-related quality of life (HRQoL).

STUDY DESIGN

English- or Spanish-speaking women, aged 16-44, with pregnancies <24 weeks' gestation were enrolled in this cross-sectional study between June 2014 and June 2015. Participants completed self-assessments of pregnancy "context," including timing, intention, wantedness, desirability, happiness, and planning (measured with the London Measure of Unplanned Pregnancy). HRQoL was measured using the Patient Reported Outcomes Measurement Information System Global Short Form. Associations between measures of pregnancy context and HRQoL scores in the lowest tertile were examined using multivariable logistic regression to adjust for potential confounding variables.

RESULTS

We enrolled 161 participants (mean age=27.2±6.6 years). Only 14% self-identified as White, non-Hispanic; 42% Hispanic; 37% Black, non-Hispanic; and 7% multiracial. Most (79%) participants were unmarried, and 75% were parenting. Mean gestational age was 9±4.6 weeks. In unadjusted models, women reporting mixed feelings about wanting to have a baby, an undesired pregnancy or feeling unhappy about learning of their pregnancy more frequently had low mental and physical HRQoL compared to women reporting wanted, desired, happy pregnancies. Women with an unplanned pregnancy or pregnancy occurring at the wrong time also had lower physical HRQoL than women reporting pregnancies that were planned or happened at the right time. However, after multivariate adjustment, including history of depression, pregnancy contexts were not associated with low mental or physical HRQoL.

CONCLUSIONS

After adjusting for multiple confounders, pregnancy context is not significantly associated with HRQoL.

IMPLICATIONS

The focus on pregnancy intention in public health programs may not sufficiently assess multidimensional aspects of pregnancy context and may not align with patient-centered outcomes such as HRQoL.

Beyond love: a qualitative analysis of factors associated with teenage pregnancy among young women with pregnancy experience in Bolgatanga, Ghana

Globally, an estimated 16 million young women aged 15 to 19 years give birth every year. Most teenage pregnancies are unintended and being pregnant or delivering a baby as a teenager can have serious adverse consequences. Knowledge of the environmental factors and social cognitive determinants influencing young women's failure to protect against unintended pregnancy is necessary to address the high rate of teenage pregnancies. We conducted semi-structured in-depth interviews with 21 young women, who had experience of pregnancy, in Bolgatanga, Ghana. The interview protocol included themes (relationships, sex, pregnancy, family planning) and determinants (knowledge, attitudes, self-efficacy, norms, risk perceptions) derived from empirical studies and theories related to sexuality behaviour. Findings show that young women's motivations for sexual relationships are mostly 'beyond love' and seem to focus on economic factors. The main means of sexual protection seems to be condom use. Other forms of contraception were believed to be linked to infertility. Sexuality remains a largely taboo topic for open discussion and sex education in schools seems limited to abstinence-only messages. The need for more open communication on matters of sexuality with young people and the provision of a more comprehensive sexuality education in school to address teenage pregnancies in Ghana, is discussed.

Subjective meanings of 'unintended' pregnancy: interviews from understanding fertility management in contemporary Australia

Unintended pregnancy can be difficult to identify and conceptualise. We aimed to understand how unintended pregnancies are constructed, explained and situated in a reproductive life. A total of 41 women and 7 men aged 20-50 years were interviewed in depth. Transcripts were analysed using iterative hermeneutic techniques informed by narrative theory. Of 34 participants who had been pregnant or had a partner in pregnancy, 12 women and 1 man described 23 'unintended' pregnancies, about half of which ended in abortion. Their accounts reveal that an unintended pregnancy is identified subjectively, that the same pregnancy may be identified by one partner in the pregnancy as unintended and by the other as intended, and that a researcher's supposedly objective assessment of an unintended pregnancy may be inconsistent with the assessment of the woman who experienced it. A pejorative discourse was evident, predominantly among participants who did not report having an unintended pregnancy: women use an 'unintended' pregnancy to entrap men. Accounts from five participants reporting an unintended pregnancy were selected for illustration. An appreciation of the role such a pregnancy might play in an individual life requires a nuanced understanding of the complexity of human experience and a resistance to simple binary categorisation.

Change and consistency in US women's pregnancy attitudes and associations with contraceptive use

OBJECTIVES

This study examines the cognitive and affective dimensions of pregnancy attitudes in order to better recognize the role of each in pregnancy ambivalence as well as the relative importance of each in understanding contraceptive use.

STUDY DESIGN

Data from a national sample of 2894 women aged 18-39, gathered at baseline and 6 months later, were used to examine a measure of pregnancy avoidance (cognitive) and a measure of happiness about pregnancy (affective), both separately and jointly. I used bivariate and multivariate analysis to examine associations between attitudinal measures and consistent contraceptive use. I also examined changes in attitudes over time and associations between changes in attitudes and changes in consistent contraceptive use.

RESULTS

While a majority of women, 53%, indicated that it was very important to avoid pregnancy, a substantially lower proportion, 23%, would have been very unhappy to be pregnant. In logistic regression models that included both measures, only pregnancy avoidance was associated with consistent contraceptive use. Cognitive attitude was less likely than affective attitude to change over time; additionally, change in pregnancy avoidance, but not happiness, was associated with change in consistent contraceptive use.

CONCLUSION(S)

Pregnancy avoidance appears to play a more important role in understanding consistent contraceptive use. Findings from this study provide support for the idea that positive feelings about a pregnancy do not contradict a desire to avoid conception and that feelings and intentions may be distinct concepts for many women.

IMPLICATIONS

Health care providers should assess patients' pregnancy avoidance attitude but also recognize that this can change over a short period of time for some women and should be evaluated regularly.

Incidence and recurrence of common mental disorders after abortion: Results from a prospective cohort study

Research in the field of mental health consequences of abortion is characterized by methodological limitations. We used exact matching on carefully selected confounders in a prospective cohort study of 325 women who had an abortion of an unwanted pregnancy and compared them 1-to-1 to controls who did not have this experience. Outcome measures were incidence and recurrence of common DSM-IV mental disorders (mood, anxiety, substance use disorders, and the aggregate measure 'any mental disorder') as measured with the Composite International Diagnostic Interview (CIDI) version 3.0, in the 2.5-3 years after the abortion. Although non-matched data suggested otherwise, women in the abortion group did not show significantly higher odds for incidence of 'any mental disorder', or mood, anxiety and substance use disorders, compared to matched controls who were similar in background variables but did not have an this experience. Having an abortion did not increase the odds for recurrence of the three disorder categories, but for any mental disorder the higher odds in the abortion group remained significant after matching. It is unlikely that termination of an unwanted pregnancy increases the risk on incidence of common mental disorders in women without a psychiatric history. However, it might increase the risk of recurrence among women with a history of mental disorders.

Adolescents' Responses to an Unintended Pregnancy in Ghana: A Qualitative Study

STUDY OBJECTIVE

To investigate the experiences and perceptions of adolescents who have experienced a recent pregnancy and undergone a termination of pregnancy.

DESIGN

A vignette-based focus group approach was used to have adolescents reflect on scenarios that happen to others during an unwanted pregnancy.

SETTING

The study was conducted in public health facilities in the 3 major urban areas of Ghana-Accra, Kumasi, and Tamale.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

Adolescents, aged 10-19 years, who had a recent termination of pregnancy were recruited from public health facilities in the 3 sites. Fifteen focus groups were conducted and digitally recorded in English, Twi, Ga, and Dagbani. Transcripts were transcribed and translated, and thematic analysis was used for the analysis.

RESULTS

Adolescents reported that the characters in the vignettes would feel sadness, depression, and regret from an unintended pregnancy and some male partners would "deny" the pregnancy or suggest an abortion. They suggested some parents would "be angry" and "sack" their children for becoming pregnant while others would "support" them. Parents might send the pregnant girl to a distant friend or grandparents until she delivers to avoid shame and gossip. Health professionals might encourage the pregnant girl or insult/gossip about the girl.

CONCLUSION

Adolescent unintended pregnancies in Ghana are met with a range of reactions and these reactions influence the pregnancy choices young women make for continuation or termination of pregnancy.

Pregnancy intentions-a complex construct and call for new measures

OBJECTIVE

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

DESIGN

Cross-sectional survey.

SETTING

Not applicable.

PATIENT(S)

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

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

[Knowledge and attitude of young people regarding HIV prevention and unwanted pregnancy in Bobo-Dioulasso, Burkina Faso]

Introduction: Despite health education efforts, young people are still faced with major health problems. The objective of this study was to assess the knowledge and attitude regarding HIV prevention and unwanted pregnancy among young people in Bobo-Dioulasso, Burkina Faso. Methods: Based on two-level sampling, representing 94,947 households in the Bobo-Dioulasso municipality, 573 young people between the ages of 15 and 24 years were interviewed. This data collection was conducted from September 2014 to January 2015 in the three districts of the municipality. A questionnaire was used to assess the knowledge and attitudes of young people. Results: The interviewees had a poor knowledge about HIV transmission and prevention and contraception Very few young people (9%) had complete knowledge about the modes of transmission and 5% had no knowledge. Persistent misperceptions about the effectiveness of condoms (25%) and contraception (32%) did not prevent some young people from using them (79% used condoms and 46% used contraceptives). Knowledge and attitudes of young people regarding HIV and contraception varied according to age, sex, education level and type of parental supervision. Conclusion: A significant proportion of young people still has incomplete knowledge about HIV/AIDS and contraception. Actions designed to reinforce the knowledge of young people are of paramount importance. The capacities of parents and healthcare providers also need to be reinforced to improve the quality of relationship with young people.

Concealed pregnancy and newborn abandonment: a contemporary 21st century issue Part 2

This second of a two-part article explores the consequences of concealed pregnancy and the association with newborn abandonment, with reference to recent cases of public interest. Concealed pregnancy is a complex process which involves hiding a pregnancy, and can lead to tragic consequences, such as maternal or neonatal morbidity or mortality (Murphy Tighe and Lalor 2016; Chen et al 2007).The psychosocial issues involved will also be explored and points for midwifery practice are presented and considered (Murphy Tighe and Lalor 2016).

Abusive Experiences and Young Women's Sexual Health Outcomes: Is Condom Negotiation Self-Efficacy a Mediator?

CONTEXT

Intimate partner violence and reproductive coercion are associated with unintended pregnancies and STDs. Greater condom negotiation self-efficacy among young women may mediate these associations.

METHODS

A sample of 841 female adolescents (aged 16-19) and 1,387 young adult women (aged 20-24) recruited from 24 family planning clinics in western Pennsylvania in 2011-2012 reported on intimate partner violence, reproductive coercion, condom negotiation self-efficacy and sexual health outcomes at baseline and four- and 12-month follow-ups. Mixed models were used to test associations of intimate partner violence and reproductive coercion with unintended pregnancy and STD diagnosis. The Sobel test of mediation was used to measure indirect effects of condom negotiation self-efficacy.

RESULTS

At baseline, 15% of adolescents and 11% of young adults reported recent intimate partner violence victimization; 7% and 6%, respectively, reported recent reproductive coercion. For both age-groups, intimate partner violence and reproductive coercion were associated with a reduced level of condom negotiation self-efficacy (coefficients, -0.27 to -0.13) and increased odds of STD diagnosis (odds ratios, 1.03-1.1). However, only reproductive coercion was associated with unintended pregnancy (odds ratios, 1.1 for each group). The only association that condom negotiation self-efficacy mediated was between reproductive coercion and unintended pregnancy among young adults (17% of total effect).

CONCLUSIONS

Targeting condom negotiation self-efficacy alone in abusive relationships would likely not translate into improved sexual health outcomes in this population. Other strategies are needed to prevent unintended pregnancy and STDs.

Relationship between Unwanted Pregnancy and Health-Related Quality of Life in Pregnant Women

OBJECTIVE

To determine the relationship between unwanted pregnancy and health-related quality of life in pregnant women.

STUDY DESIGN

Case-control study.

PLACE AND DURATION OF STUDY

Department of Community Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran, from October 2013 to July 2014.

METHODOLOGY

Of the pregnant women who presented to primary healthcare centers of Kermanshah, Iran to receive prenatal care at 6 - 10 weeks of their pregnancy, those with unwanted pregnancy were selected as cases and those with wanted pregnancy were selected as control group. The selection process was done using multi-stage stratified random sampling. Frequency matching was applied to match the two groups. Quality of life was measured by the SF-36 questionnaire and was compared by the t-test. Relationship power between pregnancy type (wanted or unwanted pregnancy) and impairment of quality of life subscales as the outcome was assessed using odds ratio (OR).

RESULTS

Frequency distribution of matched variables was not statistically different between the two studied groups. Mean scores of mental component summary and physical component summary as well as eight subscales (physical functioning, role, bodily pain, general health, vitality, social functioning, role emotional, and mental health) were lower in the unwanted pregnancy group compared to women with wanted pregnancy (p < 0.001). The highest high impairment odds ratio was highest for the mental component summary (MCS) (OR = 9.19; 95% CI = 5.17- 16.32) and vitality subscale (OR = 5.2; 95% CI = 2.89- 9.33).

CONCLUSION

Mental health of the pregnant women with unwanted pregnancy is affected more than their physical health. Mental health in women with unwanted pregnancy is 9.19 times more likely to be reduced. Among mental health subscales, vitality (energy/fatigue) showed the highest decrease.

Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma

Better understanding of the impact of unintended childbearing on infant and early childhood health is needed for public health practice and policy. Data from the 2004-2008 Oklahoma Pregnancy Risk Assessment Monitoring System survey and The Oklahoma Toddler Survey 2006-2010 were used to examine associations between a four category measure of pregnancy intentions (intended, mistimed <2 years, mistimed ≥2 years, unwanted) and maternal behaviors and child health outcomes up to age two. Propensity score methods were used to control for confounding. Births mistimed by two or more years (OR .58) and unwanted births (OR .33) had significantly lower odds than intended births of having a mother who recognized the pregnancy within the first 8 weeks; they were also about half as likely as intended births to receive early prenatal care, and had significantly higher likelihoods of exposure to cigarette smoke during pregnancy. Breastfeeding was significantly less likely among unwanted births (OR .68); breastfeeding for at least 6 months was significantly less likely among seriously mistimed births (OR .70). We find little association between intention status and early childhood measures. Measured associations of intention status on health behaviors and outcomes were most evident in the prenatal period, limited in the immediate prenatal period, and mostly insignificant by age two. In addition, most of the negative associations between intention status and health outcomes were concentrated among women with births mistimed by two or more years or unwanted births. Surveys should incorporate questions on the extent of mistiming when measuring pregnancy intentions.

Are Pregnancy Intentions Associated with Transitions Into and Out of Marriage?

CONTEXT

In addition to having associations with health outcomes, pregnancy intentions may be associated with social outcomes, including marital transitions.

METHODS

Linked data from the 2004-2008 Oklahoma Pregnancy Risk Assessment Monitoring System and The Oklahoma Toddler Survey for 2006-2010 on 3,617 women who were married and 2,123 who were unmarried at conception were used to examine the relationship between pregnancy intention status (intended, mistimed by less than two years, mistimed by two or more years, or unwanted) and marital formation or dissolution by the time of the birth and two years later. Logistic regression analyses were conducted, and propensity score methods were used to adjust for confounding characteristics.

RESULTS

Intention status was associated with marital transition two years after the birth, but not between conception and birth. In adjusted models, among women married at conception, those with a birth resulting from an unwanted pregnancy were more likely than those with a birth resulting from an intended pregnancy to transition out of marriage by the time their child was two years old (odds ratio, 2.2). Among women unmarried at conception, those with a birth following an unwanted pregnancy were less likely than those with a birth following an intended pregnancy to marry by the time their child was two (0.5). Births following mistimed pregnancies were not associated with marital transition.

CONCLUSIONS

The findings should motivate researchers to broaden the scope of research on the consequences of unintended childbearing. Future research should distinguish between mistimed and unwanted births.

Does abortion increase women's risk for post-traumatic stress? Findings from a prospective longitudinal cohort study

OBJECTIVE

To prospectively assess women's risk for post-traumatic stress disorder (PTSD) and of experiencing post-traumatic stress symptoms (PTSS) over 4 ears after seeking an abortion, and to assess whether symptoms are attributed to the pregnancy, abortion or birth, or other events in women's lives.

DESIGN

Prospective longitudinal cohort study which followed women from approximately 1 week after receiving or being denied an abortion (baseline), then every 6 months for 4 years (9 interview waves).

SETTING

30 abortion facilities located throughout the USA.

PARTICIPANTS

Among 956 women presenting for abortion care, some of whom received an abortion and some of whom were denied due to advanced gestational age; 863 women are included in the longitudinal analyses.

MAIN OUTCOME MEASURES

PTSS and PTSD risk were measured using the Primary Care PTSD Screen (PC-PTSD). Index pregnancy-related PTSS was measured by coding the event(s) described by women as the cause of their symptoms.

ANALYSES

We used unadjusted and adjusted logistic mixed-effects regression analyses to assess whether PTSS, PTSD risk and pregnancy-related PTSS trajectories of women obtaining abortions differed from those who were denied one.

RESULTS

At baseline, 39% of participants reported any PTSS and 16% reported three or more symptoms. Among women with symptoms 1-week post-abortion seeking (n=338), 30% said their symptoms were due to experiences of sexual, physical or emotional abuse or violence; 20% attributed their symptoms to non-violent relationship issues; and 19% said they were due to the index pregnancy. Baseline levels of PTSS, PTSD risk and pregnancy-related PTSS outcomes did not differ significantly between women who received and women who were denied an abortion. PTSS, PTSD risk and pregnancy-related PTSS declined over time for all study groups.

CONCLUSIONS

Women who received an abortion were at no higher risk of PTSD than women denied an abortion.

Mobile Technology for Improved Family Planning (MOTIF): the development of a mobile phone-based (mHealth) intervention to support post-abortion family planning (PAFP) in Cambodia

BACKGROUND

The objective of this paper is to outline the formative research process used to develop the MOTIF mobile phone-based (mHealth) intervention to support post-abortion family planning in Cambodia.

METHODS

The formative research process involved literature reviews, interviews and focus group discussions with clients, and consultation with clinicians and organisations implementing mHealth activities in Cambodia. This process led to the development of a conceptual framework and the intervention.

RESULTS

Key findings from the formative research included identification of the main reasons for non-use of contraception and patterns of mobile phone use in Cambodia. We drew on components of existing interventions and behaviour change theory to develop a conceptual framework. A multi-faceted voice-based intervention was designed to address health concerns and other key determinants of contraception use.

CONCLUSIONS

Formative research was essential in order to develop an appropriate mHealth intervention to support post-abortion contraception in Cambodia. Each component of the formative research contributed to the final intervention design.

Level, Trend and Correlates of Mistimed and Unwanted Pregnancies among Currently Pregnant Ever Married Women in India

Unintended pregnancy accounts for more than 40% of the total pregnancies worldwide. An Unintended pregnancy can have serious implications on women and their families. With more than one-fourth of the children in India born out of unintended pregnancies such pregnancies are considered to be one of the major public health concerns today. The present study is aimed at determining major predictors of unintended pregnancy among currently pregnant ever-married women in India. The present study has used National Family Health Survey (NFHS) data, conducted by the International Institute for Population Sciences (IIPS), Mumbai, to show the trend, pattern and determinants of mistimed and unwanted pregnancies. Bivariate and multinomial logistic regression model have been used with the help of Stata 13 software. The results show that the likelihood of a mistimed pregnancy is more prevalent among young women whereas the prevalence of unwanted pregnancy is observed more among the women aged 35 years or more. The results also show that the risk of experiencing mistimed pregnancy decreases if the woman belongs to 'other' castes and has higher education. The likelihood of unwanted pregnancy decreases among married women aged 18 years and above, those women having higher education, some autonomy and access to any mode of mass communication. Knowledge of these predictors of mistimed and unwanted pregnancy will be helpful in identifying the most vulnerable group and prioritize the intervention strategies of the reproductive health programmes for the population in need.

Factors associated with induced abortion among female entertainment workers: a cross-sectional study in Cambodia

OBJECTIVE

To explore risk factors associated with induced abortion among sexually active female entertainment workers (FEWs) in Cambodia.

DESIGN

Cross-sectional study.

SETTING

Phnom Penh and Siem Reap, Cambodia.

PARTICIPANTS

This study included 556 FEWs aged 18-47 years randomly selected from entertainment establishments in the two cities in 2014 using a two-stage cluster sampling method. Data were collected through face-to-face interviews using a structured questionnaire.

PRIMARY OUTCOME MEASURE

History of induced abortion during the time working as a FEW.

RESULTS

Of the total sample, 45.6% reported currently using a contraceptive method with condom (42.4%) being the most common method, followed by pills (25.6%). One-fourth (25%) of the respondents reported having been pregnant at least once, and 21.4% reported having at least one induced abortion during the time working as a FEW. After controlling for other covariates in a multivariate logistic regression model, FEWs with a history of induced abortion remained significantly more likely to be currently working in a karaoke bar (AOR=1.75, 95% CI 1.10 to 2.78), to have worked longer as a FEW (AOR=1.42, 95% CI 1.06 to 1.43), to have had a greater number of sexual partners in the past 12 months (AOR=1.86, 95% CI 1.02 to 1.54), to be currently using a contraceptive method (AOR=1.52, 95% CI 1.01 to 2.29), to be able to find condoms when they needed them (AOR=2.03, 95% CI 1.09 to 3.82), and to report inconsistent condom use with non-commercial partners in the past 3 months (AOR=1.62, 95% CI 1.06 to 3.44).

CONCLUSIONS

This study highlights the high rates of unwanted pregnancies that ended in induced abortions among FEWs in Cambodia. Access of FEWs to quality sexual and reproductive healthcare services is deemed a high priority. Integrated interventions to improve sexual and reproductive health among these vulnerable women should be tailored to reach the most-at-risk groups.

Use of Contraception and Attitudes towards Contraceptive Use in Swedish Women--A Nationwide Survey

OBJECTIVE

To describe contraceptive use and attitudes towards contraceptive use in Sweden which has the highest abortion rate in Western Europe. Secondary objectives were to investigate knowledge of contraceptive methods and outcomes of unplanned and unwanted pregnancies.

DESIGN

Telephone survey.

SETTING

National survey of women living in Sweden.

POPULATION

Women between 16 and 49 years.

METHODS

The survey contained 22 questions with free text and multi choice answers on demographics, contraceptive use, knowledge of and attitudes towards contraception, the importance of monthly bleeding and experience of unintended pregnancy.

MAIN OUTCOME MEASURES

Distribution of use of contraceptive methods and non-use of contraception among Swedish women. Prevalence and outcome of unintended pregnancies.

RESULTS

A total of 1001 women participated in the survey. Of all women, 721/1001 (72.1%) currently used contraception whereas 268/1001 (26.8%) women did not. Long acting reversible contraception, (LARC; implant and intra uterine contraception) was used by 24.3% of women. The unmet need of contraception in Sweden was estimated at 8.9% (89/1001 women). A total of 781 (78%) women had never experienced an unintended pregnancy whereas 220 (22%) women had had at least one unintended pregnancy. Users and non-users alike stated that one of the most important characteristics of a contraceptive method is its effectiveness.

CONCLUSIONS

Sweden has a large unmet need for contraception. Furthermore, a large proportion of women have experienced at least one unintended pregnancy. Increasing contraceptive use and promotion of LARC is a possible way forward in the effort to reduce the rates of unwanted pregnancies.

Options for women with unintended pregnancy

Unintended pregnancy refers to unwanted, unplanned, or mistimed pregnancies. One-half of all pregnancies in the United States are unintended, and family physicians are often asked to provide counseling, support, and resources for women with unintended pregnancies. Options include carrying the infant to term and raising the child, carrying the infant to term and choosing adoption, or having an induced abortion. Family physicians should be equipped to direct women who choose to raise the infant to appropriate care and resources. Most U.S. women do not choose adoption, but there are multiple resources for women interested in this option. Physicians should not broker adoptions, match potential parents with mothers, or adopt children of their own patients. Induced abortion is performed in the first or second trimester of pregnancy. Medical management is comparable with surgical management, and both methods are safe and effective. Combination regimens with mifepristone and misoprostol are the most effective medical methods. Dilation and curettage and vacuum aspiration are the most common surgical methods.

Design and development of a film-based intervention about teenage men and unintended pregnancy: applying the Medical Research Council framework in practice

Following the UK Medical Research Council's (MRC) guidelines for the development and evaluation of complex interventions, this study aimed to design, develop and optimise an educational intervention about young men and unintended teenage pregnancy based around an interactive film. The process involved identification of the relevant evidence base, development of a theoretical understanding of the phenomenon of unintended teenage pregnancy in relation to young men, and exploratory mixed methods research. The result was an evidence-based, theory-informed, user-endorsed intervention designed to meet the much neglected pregnancy education needs of teenage men and intended to increase both boys' and girls' intentions to avoid an unplanned pregnancy during adolescence. In prioritising the development phase, this paper addresses a gap in the literature on the processes of research-informed intervention design. It illustrates the application of the MRC guidelines in practice while offering a critique and additional guidance to programme developers on the MRC prescribed processes of developing interventions. Key lessons learned were: (1) know and engage the target population and engage gatekeepers in addressing contextual complexities; (2) know the targeted behaviours and model a process of change; and (3) look beyond development to evaluation and implementation.

Which young adults are most likely to use withdrawal? The importance of pregnancy attitudes and sexual pleasure

OBJECTIVES

Use of withdrawal (coitus interruptus) has consequences for reproductive health, but few nationally representative studies exist. We (1) examined patterns of withdrawal among 15- to 24-year-old women and men, and (2) explored withdrawal's associations with sociodemographic, psychological, and sexual factors.

STUDY DESIGN

Using data from the 2006-2010 National Survey of Family Growth, we assessed reports of any and only withdrawal use at last sexual episode in the last month from 3517 sexually active 15 to 24 year-old women and men at risk of unintended pregnancy. Logistic regression documented associations with withdrawal.

RESULTS

Fourteen percent of young women and 17% of young men reported any use of withdrawal at last sex; 7% and 6%, respectively, reported only use of withdrawal. Though associated with few sociodemographic factors, withdrawal was significantly linked with pregnancy- and condom attitudes. In regression models, compared to those who said they would be upset if they discovered they were pregnant, young women who said they would be pleased about a pregnancy were 2.2-2.6 times as likely to have used any/only withdrawal (p<.01). For both women and men, those who felt that condoms were likely to diminish sexual pleasure were more likely to have used any/only withdrawal (odds ratio=1.8-2.6, p<.05).

CONCLUSIONS

At their last sexual episode, a greater proportion of young adults used withdrawal in conjunction with other methods than by itself. The psychological and sexual variables of orientation toward pregnancy and attitudes about condoms and pleasure were more strongly linked with withdrawal practices than most sociodemographic variables.

IMPLICATIONS STATEMENT

Since a substantial minority of young adults use withdrawal, providers may wish to speak directly to contraceptive clients about this method, though they should distinguish between only versus any withdrawal use. Practitioners may also be well served by assessing and responding to pregnancy orientation and pleasure attitudes in contraceptive counseling.

Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy

CONTEXT

When a woman who seeks an abortion cannot obtain one, having a child may reshape her relationship with the man involved in the pregnancy. No research has compared how relationship trajectories are affected by different outcomes of an unwanted pregnancy.

METHODS

Data from the Turnaway Study, a prospective longitudinal study of women who sought abortion in 2008-2010 at one of 30 U.S. facilities, are used to assess relationships over two years among 862 women who had abortions or were denied them because they had passed the facility's gestational age limit. Mixed-effects models analyze effects of abortion or birth on women's relationships with the men involved.

RESULTS

At conception, most women (80%) were in romantic relationships with the men involved. One week after seeking abortion, 61% were; two years later, 37% were. Compared with women who obtained an abortion near the facility's gestational age limit, women who gave birth had greater odds of having ongoing contact with the man (odds ratio at two years, 1.7). The odds of romantic involvement at two years did not differ by group; however, the decline in romantic involvement was initially slower among those giving birth. Relationship quality did not differ between groups.

CONCLUSIONS

Giving birth temporarily prolonged romantic relationships of women in this study; most romantic relationships ended soon, whether or not the woman had an abortion. However, giving birth increased the odds of nonromantic contact between women and the men involved throughout the ensuing two years.