Chapter 9 242 opportunity to break transgenerational patterns, but also offer a change for finding meaning in life and diving into existential questions. Future qualitative work should further explore these opportunities for women with psychiatric vulnerability. Unintended pregnancies and psychiatric disorders: is there evidence for a causal relationship? In the following section three hypotheses regarding the potential link between psychiatric vulnerability and UPs are given. Hypothesis 1: there is a causal relationship between psychiatric vulnerability and UPs First, psychiatric symptoms could directly influence behavior that is related to prevention of unwanted pregnancies. Figure 9.1 summarizes the possible pathway through which psychiatric vulnerability attribute to the risk of UPs. We specifically found that women with personality disorders, substance use- and related disorders and depressive disorders have an increased risk of UPs compared to controls without psychiatric vulnerability prior to the pregnancy (Chapter 4). Previous literature on these psychiatric disorders consolidates these findings, especially in young women31-33. We could not find evidence for an increased risk of UPs amongst women with severe psychiatric vulnerability such as schizophrenia, psychotic and related disorders or bipolar disorders, contrary to earlier research34,35. The analyses conducted within these relatively small groups of women may have lacked sufficient power to detect associations (Chapter 4). Survey respondents highlighted the inability to protect against UPs, through cases of involuntary intercourse, forced non-use of contraceptive methods, and interactions between contraceptive methods and other medications (Chapter 3). Earlier research indicates a link between UPs and 1) limited sexual autonomy, 2) engagement in violent relationships, 3) insufficient knowledge about UPs, or 4) challenges in accessing or using contraceptives36,37. Intimate partner violence and low self-esteem are interconnected with both reproductive decisionmaking and psychiatric vulnerability38,39. It is possible that psychiatric symptoms cause behavior that is related to sexual risk taking, resulting in UPs. Contrary to this hypothesis, we found little evidence of a direct link between psychiatric vulnerability (symptoms) and UPs in our (semi-)qualitative work (Chapter 3, Chapter 6, Chapter 7, Chapter 8). One focus group participant illustrated how she forgot taking her oral contraceptive pills, which she related to having attention deficit hyperactivity disorder (Chapter 6). Also, alcohol abuse led to inability to adhere to contraceptive methods (Chapter 3). Interviews yielded a fear of infertility or reduced fertility, which
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