Family planning decision-making in relation to psychiatric disorders in women 123 Introduction Literature suggests that psychiatric disorders and family planning decision-making are related. Recent studies revealed that women with psychiatric disorders more often experience unintended pregnancies compared to counterparts without such vulnerability1-3. Moreover, childlessness is associated with having chronic illnesses, among which are psychiatric illnesses4,5. However, there is limited knowledge about contributing factors that shape family planning decision-making in women with psychiatric disorders6,7. Family planning decision-making defines the process through which individuals make choices about whether to have children, when to have them, and how many children to have8. It involves contemplating economic, social, cultural, and health-related factors9. Understanding family planning decision-making is fundamental for estimating the need for contraception, predicting reproductive patterns, and developing programs aimed at preventing unintended pregnancies10. The use of (emergency) contraceptives11, improved accessibility to abortion services12, and increased understanding of risk factors11,13,14 have reduced unintended pregnancies. However, in 2010–2019, more than half of all pregnancies worldwide were still unintended15. Unintended pregnancies are particularly common among women with psychiatric disorders, reaching rates of up to 65%16,17. Aside from difficulties with planning, women with psychiatric disorders face elevated risks of psychiatric problems after pregnancy, leading to additional risks for adverse outcomes for both mothers and children18-21. The preconception phase is crucial for women planning to conceive by offering an opportunity to enhance nutrition and lifestyle choices to minimize maternal and child health risks22. Pregnancy planning is especially important for women with psychiatric disorders because they may need to make medication adjustments, take precautionary measures regarding the relapse of psychiatric disorders, and optimize mother–child attachment18-21. Indeed, women with unintended pregnancies encounter significant additional challenges due to the absence of the pregnancy planning phase, such as limited access to prenatal care, financial strain, and emotional stress1. Several frameworks exist for describing the factors that shape family planning decision-making23-29. However, most frameworks are past-driven and focus predominantly on cognitive factors30. We hypothesize that these frameworks are inadequate for capturing the uncertainty about the future faced by women with psychiatric disorders. The “Narrative Framework” provides a different perspective on family planning decision-making, particularly amid the amplified uncertainty and stress of the COVID-19 pandemic. It integrates past experiences, psychological predispositions, and socioeconomic factors, termed the “Shadow of the past,”
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