General discussion and future directions 239 Third, several possible biases are related to measuring UPs. Most studies on the lifetime prevalence of UPs are limited by the possible presence of reporting bias due to their retrospective character. As pregnancy intention may be perceived as a sensitive subject that MHPs or pregnant women prefer not to address during a pregnancy intake, leading to potential underreporting of UPs versus intended pregnancies, which was an important limitation in Chapter 4. Recall bias, although inherent to changing pregnancy intentions over time, limited the trustworthiness of the findings in the MoMentUM study5. Previous literature even refers to stable fertility preferences as an ‘illusion’6. Thus, the reliability of measuring pregnancy intentions at one point in time, even with validated instruments such as the “London measurement of Unplanned Pregnancy” is questionable. Besides, it is known that pregnant women may report more positively about a continued pregnancy than it was initially anticipated7. Another source of insecurity is ambivalence, which illustrates a conflict between ideations about a pregnancy versus pregnancy-planning behavior that is (not) in line with those ideations (Chapter 6, Chapter 7,8-14). Presence of ambivalence may challenge the ability to capture pregnancy intentions with measurements. However, as ambivalence puts women at risk for UPs, the measurement of ambivalence may also increase understanding of who is at risk for UPs and why12,15. A final bias in capturing pregnancy intentions, is the variety in definitions of UPs16. In Chapter 4, we captured pregnancy intentions through searching medical records in a retrospective cohort. Retrospective assessment enabled including a large cohort and performance of analysis with sufficient power to support hypotheses. Making the distinction between planned, unplanned, wanted and unwanted pregnancies in the MoMentUm study, after including all pregnancies with unsure pregnancy intention, aided in comparing our findings to findings in other studies. However, a binary measurement of UPs does not do justice to the complexities of defining the intention of a pregnancy. Several qualitative studies showed the importance of ambivalence towards pregnancy intentions (Chapter 6, Chapter 7,17). In conclusion, various methodological considerations stress the need for careful interpreting of UP rates. Nevertheless, as UPs rates amongst women with psychiatric vulnerability are substantial (up to 65%), and differs from controls (Chapter 4), we can conclude that UPs are more prevalent amongst women with psychiatric vulnerability. Maternal and neonatal outcomes after UPs: are they really that bad? Strikingly, the outcomes from the retrospective MoMentUM cohort oppose previous studies in which adverse short- and long-term maternal and neonatal outcomes in women with UPs and in women with psychiatric vulnerability were demonstrated (Chapter 4). UPs did not significantly alter maternal or neonatal outcomes for women
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