Prenatal care utilization in pregnant women who consider but do not have abortions.

BACKGROUND: Over half of all pregnancies in the United States are unintended, and 18% result in termination of pregnancy (TOP). Some women seek TOP, but ultimately continue their pregnancy. Data are limited about their utilization of prenatal care and their perinatal outcomes. Our primary outcome was to investigate differences in guideline-based prenatal care utilization in women who consider but do not have an abortion. METHODS: Retrospective cohort study of patients having obstetrical dating ultrasound (US) from 2011-2018 at a single academic medical center that offers TOP. Contemplators completed US with intention of TOP but instead continued the pregnancy to live birth. A 2:1 group of non-contemplators completed US and continued to live birth. A prenatal care utilization scoring system was used to compare groups. Secondary outcomes investigated differences in adverse pregnancy outcomes and postpartum care. RESULTS: There were 94 contemplators and 183 non-contemplators. Inadequate prenatal care utilization initially was more common in contemplators than non-contemplators (62.8% vs 85.8%, p < 0.01) but was not significant after adjustment (aOR 1.0, 95% CI 0.40 - 2.56). There were no differences in adverse obstetric or neonatal outcomes. Contemplators were significantly more likely to have a postpartum contraceptive method (PPCM) upon hospital discharge (aOR 4.8, 95% CI 1.16 - 20.0) and significantly more likely to use a highly-effective PPCM (aOR 6.4, 95% CI 2.34 - 17.4). CONCLUSIONS: Reversal of intention for TOP is not associated with differences in prenatal care utilization, but is associated with increased uptake of postpartum contraceptive method.

Underreporting of stillbirths in Pakistan: perspectives of the parents, community and healthcare providers.

BACKGROUND: Pakistan has the highest rate of stillbirths globally. Not much attention has been given so far to exploring the sociocultural factors hindering the reportage of stillbirths and the causes of death. Therefore, the aim of this study was to assess the perspectives of parents, communities and healthcare providers regarding the sociocultural practices and health system-related factors contributing to stillbirths and their underreporting. METHODS: This study used a qualitative approach including in-depth interviews and 14 focus group discussions to collect data from four districts of Pakistan. We conducted 285 in-depth interviews and 14 focus group discussions with health professionals - mainly active in the areas of maternal and child health - and parents who had experienced stillbirth. Constant comparative method and analytical induction method were performed to analyze the data. RESULTS: The results of this study show that stillbirth is frequently misclassified and, therefore, an underreported phenomenon in Pakistan. It is an outcome of sociocultural practices, such as the social meaning of stillbirth and their understanding about the conflict between cultural and medical anatomy. In addition to grief and psychological distress, it endangers the maternal identity and worth in society in contrast to the mothers of live-born children. CONCLUSION: The misclassification of stillbirth, especially by healthcare providers, is a significant impediment to designing preventive strategies for stillbirth. We recommend that the reporting system for stillbirth should be aligned with the WHO definition of stillbirth to avoid its underreporting. Reporting procedures at a more administrative level need to be made uniform and simplified.

Understanding the consumption of folic acid during preconception, among Pakistani, Bangladeshi and white British mothers in Luton, UK: a qualitative study.

BACKGROUND: To review the similarities and differences in Pakistani, Bangladeshi and White British mothers health beliefs (attitudes, knowledge and perceptions) and health behaviour regarding their consumption of folic acid pre-conception, to reduce the risk of neural tube defects. METHODS: Our study used a descriptive qualitative research approach, implementing face-to-face focus group discussions with Pakistani, Bangladeshi or White British mothers (normal birth outcomes and mothers with poor birth outcomes) and semi-structured interviews or focus groups with service providers using semi-structured topic guides. This method is well suited for under researched areas where in-depth information is sought. There were three sample groups: 1. Pakistani, Bangladeshi and White British mothers with normal birth outcomes (delivery after 37 weeks of gestation, in the preceding 6 to 24 months, weighing 2500 g and living within a specified postcode area in Luton, UK). 2. Pakistani Bangladeshi and white British bereaved mothers who had suffered a perinatal mortality (preceding 6 to 24 months, residing within a specificied postcode area). 3. Healthcare professionals working on the local maternity care pathway (i.e. services providing preconception, antenatal, antepartum and postpartum care). Transcribed discussions were analysed using the Framework Analysis approach. RESULTS: The majority of mothers in this sample did not understand the benefits or optimal time to take folic acid pre-conception. Conversely, healthcare professionals believed the majority of women did consume folic acid, prior to conception. CONCLUSIONS: There is a need to increase public health awareness of the optimal time and subsequent benefits for taking folic acid, to prevent neural tube defects.

Anxiety, depression and relationship satisfaction in the pregnancy following stillbirth and after the birth of a live-born baby: a prospective study.

BACKGROUND: Experiencing a stillbirth can be a potent stressor for psychological distress in the subsequent pregnancy and possibly after the subsequent birth. The impact on women's relationship with her partner in the subsequent pregnancy and postpartum remains uncertain. The objectives of the study were 1) To investigate the prevalence of anxiety and depression in the pregnancy following stillbirth and assess gestational age at stillbirth and inter-pregnancy interval as individual risk factors. 2) To assess the course of anxiety, depression and satisfaction with partner relationship up to 3 years after the birth of a live-born baby following stillbirth. METHODS: This study is based on data from the Norwegian Mother and Child Cohort Study, a population-based pregnancy cohort. The sample included 901 pregnant women: 174 pregnant after a stillbirth, 362 pregnant after a live birth and 365 previously nulliparous. Anxiety and depression were assessed by short-form subscales of the Hopkins Symptoms Checklist, and relationship satisfaction was assessed by the Relationship Satisfaction Scale. These outcomes were measured in the third trimester of pregnancy and 6, 18 and 36 months postpartum. Logistic regression models were applied to study the impact of previous stillbirth on depression and anxiety in the third trimester of the subsequent pregnancy and to investigate gestational age and inter-pregnancy interval as potential risk factors. RESULTS: Women pregnant after stillbirth had a higher prevalence of anxiety (22.5%) and depression (19.7%) compared with women with a previous live birth (adjusted odds ratio (aOR) 5.47, 95% confidence interval (CI) 2.90-10.32 and aOR 1.91, 95% CI 1.11-3.27) and previously nulliparous women (aOR 4.97, 95% CI 2.68-9.24 and aOR 1.91, 95% CI 1.08-3.36). Gestational age at stillbirth (> 30 weeks) and inter-pregnancy interval <  12 months were not associated with depression and/or anxiety. Anxiety and depression decreased six to 18 months after the birth of a live-born baby, but increased again 36 months postpartum. Relationship satisfaction did not differ between groups. CONCLUSION: Women who have experienced stillbirth face a significantly greater risk of anxiety and depression in the subsequent pregnancy compared with women with a previous live birth and previously nulliparous women.

Do stillbirth, miscarriage, and termination of pregnancy increase risks of attempted and completed suicide within a year? A population-based nested case-control study.

OBJECTIVE: To investigate the risks of attempted and completed suicide in women who experienced a stillbirth, miscarriage, or termination of pregnancy within 1 year postnatally and compare this risk with that in women who experienced a live birth. DESIGN: A nested case-control study. SETTING: Linking three nationwide population-based data sets in Taiwan: the National Health Insurance Research Database, the National Birth Registry and the National Death Registry. SAMPLE: In all, 485 and 350 cases of attempted and completed suicide, respectively, were identified during 2001-11; for each case, ten controls were randomly selected and matched to the cases according to the age and year of delivery. METHODS: Conditional logistic regression. MAIN OUTCOME MEASURES: Attempted and completed suicidal statuses were determined. RESULTS: The rates of attempted suicide increased in the women who experienced fetal loss. The risk of completed suicide was higher in women who experienced a stillbirth [adjusted odds ratio (aOR) 5.2; 95% CI 1.77-15.32], miscarriage (aOR 3.81; 95% CI 2.81-5.15), or termination of pregnancy (aOR 3.12; 95% CI 1.77-5.5) than in those who had a live birth. Furthermore, the risk of attempted suicide was significantly higher in women who experienced a miscarriage (aOR 2.1; 95% CI 1.66-2.65) or termination of pregnancy (aOR 2.5; 95% CI 1.63-3.82). In addition to marital and educational statuses, psychological illness increased the risk of suicidal behaviour. CONCLUSIONS: The risk of suicide might increase in women who experience fetal loss within 1 year postnatally. Healthcare professionals and family members should enhance their sensitivity to care for possible mental distress, particularly for women who have experienced a stillbirth. TWEETABLE ABSTRACT: Suicide risk increased in women who had a stillbirth, miscarriage, or termination of pregnancy within 1 year postnatally.

Of Pain and Childbirth.

Childbirth is often understood as a paradigmatically "happy" event where good outcomes are expected and the process anticipated as a reason for celebration. Yet the narratives in this volume reflect sadness and grief, even when a healthy child is born. In this essay, I interrogate the genesis of and our relationship to grief in birth. To the extent such grief is a product of the chasm between the imagined ideal and what women experience, we may redress such grief by orienting around a more robust and woman-centered notion of the "good birth". Yet there is a way in which grief is also intrinsic to birth, and turning away from the loss that birth by its nature entails may compound the suffering of childbearing women. Beginning with the observation that the one narrative in which grief is accepted and attended to-a full term stillbirth-also stands out for the exemplary care provided, I consider the possibility that making space for grief in births, including those with good outcomes, will lead us to better ways of thinking about birth and providing care for childbearing women.

The dilemma of counseling patients about poor prognosis: live birth after IVF with autologous oocytes in a 43-year-old woman with FSH levels above 30 mIU/mL.

Providing reasonable expectations to patients with diminished ovarian reserve prior to attempting pregnancy through in vitro fertilization (IVF) is one of the most challenging aspects of fertility care. In some instances, advice from the clinician to pursue more effective treatment, such as donor oocytes, may not be acceptable to the patient. In this case report, a patient is presented who represents a poor prognosis candidate for IVF treatment. She was 43 years old with six prior failed IVF cycles and repetitive basal FSH values above 30 mIU/mL. Presented are the challenges in patient counseling and decision making. In her seventh IVF cycle, which she was strongly counseled against pursuing, the patient experienced the desired outcome of live birth. Increasing reports are emerging of live birth using autologous oocytes among women of advanced reproductive age. These instances, as well as the case of our patient, raise issues commonly encountered in patient counseling in poor prognosis patients. This discussion should include an emphasis on patient goals as well as an acknowledgement that no test for ovarian reserve has a 100% positive predictive value.

Births to Parents with Asian Origins in the United States, 1992-2012.

Despite a remarkable increase in Asian births in the U.S., studies on their birth outcomes have been lacking. We investigated outcomes of births to Asian parents and biracial Asian/White parents in the U.S. From the U.S. birth data (1992-2012), we selected singleton births to Korean, Chinese, Japanese, Filipino, Asian Indian, and Vietnamese. These births were divided into three groups; births to White mother/Asian father, Asian mother/White father, and births to the both ethnic Asian parents. We compared birth outcomes of these 18 subgroups to those of the White mother/White father group. Mean birthweights of births to the Asian parents were significantly lower, ranging 18 g to 295 g less than to the White parents. Compared to the rates of low birthweight (LBW) (4.6%) and preterm birth (PTB) (8.5%) in births to the White parents, births to Filipino parents had the highest rates of LBW (8.0%) and PTB (11.3%), respectively, and births to Korean parents had the lowest rates of both LBW (3.7%) and PTB (5.5%). This pattern of outcomes had changed little with adjustments of maternal sociodemographic and health factors. This observation was similarly noted also in births to the biracial parents, but the impact of paternal or maternal race on birth outcome was different by race/ethnicity. Compared to births to White parents, birth outcomes from the Asian parents or biracial Asian/White parents differed depending on the ethnic origin of Asian parents. The race/ethnicity was the strongest factor for this difference while other parental characteristics hardly explained this difference.

Use of selective serotonin reuptake inhibitors (SSRIs) in women delivering liveborn infants and other women of child-bearing age within the U.S. Food and Drug Administration's Mini-Sentinel program.

This study was conducted in order to assess the prevalence of use of selective serotonin reuptake inhibitors (SSRIs) among pregnant women delivering a liveborn infant in the USA. A retrospective study was conducted using the automated databases of 15 health-care systems participating in the Mini-Sentinel program. Diagnosis and procedure codes were used to identify women ages 10 to 54 years delivering a liveborn infant between April 2001 and December 2013. A comparison group of age- and date-matched women without live births was identified. The frequency of use of SSRIs was identified from outpatient dispensing data. Among the 1,895,519 liveborn deliveries, 113,689 women (6.0 %) were exposed to an SSRI during pregnancy during the period 2001-2013; 5.4 % were exposed to an SSRI during 2013. During the corresponding time period, 10.5 % of the age- and date-matched cohort of women without live births was exposed to an SSRI, with 10.1 % exposed to an SSRI during 2013. The most common agents dispensed during pregnancy were sertraline (n = 48,678), fluoxetine (n = 28,983), and citalopram (n = 20,591). Among those women exposed to an SSRI during pregnancy, 53.8 % had a diagnosis of depression and 37.3 % had a diagnosis of an anxiety disorder during pregnancy or within 180 days prior to pregnancy. Our finding that 6 % of women with live births were prescribed SSRIs during pregnancy highlights the importance of understanding the differential effects of these medications and other therapeutic options on the developing fetus and on the pregnant women.

"A renewed sense of purpose": mothers' and fathers' experience of having a child following a recent stillbirth.

BACKGROUND: Most research has focused on mothers' experiences of perinatal loss itself or on the subsequent pregnancy, whereas little attention has been paid to both parents' experiences of having a child following late perinatal loss and the experience of parenting this child. The current study therefore explored mothers' and fathers' experiences of becoming a parent to a child born after a recent stillbirth, covering the period of the second pregnancy and up to two years after the birth of the next baby. METHOD: In depth interviews were conducted with 7 couples (14 participants). Couples were eligible if they previously had a stillbirth (after 24 weeks of gestation) and subsequently had another child (their first live baby) who was now under the age of 2 years. Couples who had more than one child after experiencing a stillbirth and those who were not fluent in English were excluded. Qualitative analysis of the interview data was conducted using Interpretive Phenomenological Analysis. RESULTS: Five superordinate themes emerged from the data: Living with uncertainty; Coping with uncertainty; Relationship with the next child; The continuing grief process; Identity as a parent. Overall, fathers' experiences were similar to those of mothers', including high levels of anxiety and guilt during the subsequent pregnancy and after the child was born. Coping strategies to address these were identified. Differences between mothers and fathers regarding the grief process during the subsequent pregnancy and after their second child was born were identified. Despite difficulties with bonding during pregnancy and at the time when the baby was born, parents' perceptions of their relationship with their subsequent child were positive. CONCLUSIONS: Findings highlight the importance of tailoring support systems not only according to mothers' but also to fathers' needs. Parents', and particularly fathers', reported lack of opportunities for grieving as well as the high level of anxiety of both parents about their baby's wellbeing during pregnancy and after birth implies a need for structured support. Difficulties experienced in bonding with the subsequent child during pregnancy and once the child is born need to be normalised.

Social and emotional adjustment following early pregnancy in young Australian women: a comparison of those who terminate, miscarry, or complete pregnancy.

PURPOSE: To compare social and emotional adjustment including educational attainment and substance use in women who had a child, pregnancy termination, or miscarriage by young adulthood. METHODS: Data were from a population-based longitudinal study of the health and well-being of 1,943 young Australians (Victorian Adolescent Health Cohort Study) followed from 15 to 24 years of age. The sample was restricted to female participants and based on pregnancies reported by age 24 years. Analyses were adjusted for early teenage depressive symptoms, cigarette smoking, alcohol use, cannabis use, and parent socioeconomic context. RESULTS: A total of 208 pregnancies (in 170 women) were reported from a sample of 824 young women by 24 years of age. Compared with those who had never been pregnant, those who had a child had lower tertiary education completion and a higher risk of nicotine dependence; those who terminated a pregnancy were more commonly single and had a higher risk of smoking and alcohol use as well as nicotine and alcohol dependence; and those who had a miscarriage had a higher risk of depressive symptomatology and binge drinking as well as nicotine and cannabis dependence. CONCLUSIONS: Young women who have been pregnant by their mid-twenties report a range of difficulties in social and emotional adjustment that vary across the different pregnancy outcomes. Broad-based psychosocial health care is essential not only for young women whose pregnancies proceed to live birth, but also for those whose pregnancies end with miscarriage or induced abortion.

Contraceptive experiences among adolescents who experience unintended birth.

BACKGROUND: Adolescents are at high risk of unintended pregnancy due to contraceptive nonuse and inconsistent use. STUDY DESIGN: We examined associations between contraception and mistimed/unwanted birth among adolescents. For contraceptive nonusers, we analyzed factors contributing to unintended birth. RESULTS: Half of adolescents with unintended births did not use contraception at conception. Those ambivalent about pregnancy reported fewer unwanted [relative risk (RR)=0.06] compared to wanted births. Amongst contraceptive nonusers, difficulty accessing birth control was the only factor associated with more unwanted birth (RR=3.05). For Black adolescents, concerns of side effects (RR=7.03), access issues (RR=10.95) and perceived sterility (RR=3.20) were associated with unwanted birth. For younger teens, falsely perceived subfertility increased unwanted birth (RR=2.74), whereas access issues were significant for older teens (RR=3.97). CONCLUSIONS: Access issues and misconceptions around contraceptive side effects and fertility place adolescents at higher risk for unintended pregnancy, especially among younger and Black teens. Ambivalence represents an additional area for intervention.

Correlates of pedometer-measured and self-reported physical activity among young Australian adults.

Accurately quantifying physical activity is important for investigating relations with potential correlates, but past studies have mostly relied on self-report measures, which may be susceptible to error and biases, limiting interpretability. This study aimed to examine correlates of pedometer-determined physical activity and compare them with correlates of self-reported physical activity. Cross-sectional data were taken from 2017 Australian adults (aged 26-36 years) who were involved in the Childhood Determinants of Adult Health follow-up study during 2004-2006. Daily steps were recorded for seven days using Yamax pedometers and physical activity (total min/week) was reported via the long International Physical Activity Questionnaire. Demographic, biological, behavioral, psychological, social and environmental factors were assessed. Lower education, blue collar occupation and higher mental health score (men) and low-moderate alcohol intake (women) were positively associated with self-report and pedometer-measured activity. Among men, body mass index (BMI) was inversely and physical health score was positively associated with pedometer-measured activity while smoking, low to moderate alcohol intake, higher general health and urban area of residence were positively associated with self-reported activity. Among women, age and general health status were positively associated and number of live births inversely associated with pedometer-measured activity, while lower education, blue collar occupation, part time employment, smoking, diet, higher physical health score and higher mental health score were positively associated and white collar occupation inversely associated with self-reported activity. Many physical activity correlates differed depending on the measure employed; researchers should be mindful of these differences when selecting measures of physical activity.