General discussion and future directions 245 Possibly, women with psychiatric vulnerability have higher occurrences of ACE and adverse life events. From cross-sectional data it was shown that lifetime exposure to violence, symptoms of posttraumatic stress disorder and symptoms of anxiety and depressive disorder were common amongst women who opted for pregnancy terminations39. Studies on veteran women with various psychiatric vulnerabilities showed a high prevalence of UPs33,51. As veteran women had high rates of posttraumatic stress disorder, sexual trauma and homelessness, there may be an interaction between psychiatric symptoms, social factors and history of ACE/traumatic experiences in this subgroup. Results from interviews (Chapter 7) and focus groups (Chapter 6) showed that women with psychiatric vulnerability often experienced ACE and other types of (sexual) trauma during life. The possibility of transmitting trauma or hereditary psychiatric vulnerability to their offspring, in addition to fear of being an inadequate parent gave rise to doubts about motherhood. Ambivalence towards pregnancy intentions can put women at risk for both unwanted children, but also unwanted childlessness (12, Chapter 6). Figure 3 shows the pathway through which ACE could directly and indirectly (via psychiatric vulnerability) attribute to the risk of UPs and unwanted childlessness. Figure 9.3 - Hypothesis 3: UPs indirectly resulting from adverse childhood experiences. A further qualitative exploration of family planning decision-making in women with psychiatric vulnerability (Chapter 6) exemplified how past experiences (among which childhood trauma, adverse life events and inadequate parenting), present circumstances and future ideations influenced the prospect of motherhood (see Figure 9.4). An important limitation of Chapter 6 is the retrospective nature of the data. On the one hand, the data illustrate the profound emotional impact of past decision-
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