Psychiatric vulnerability and the risk for unintended pregnancies, a systematic review and meta-analysis 27 Background Unintended pregnancies (UPs) are a global health problem of large scale. Every year, 120 million UPs (accounting for 48% of all pregnancies) occur worldwide, although UPs rates differ amongst geographic regions with generally higher rates of UPs in developing countries1. UPs could either be mistimed (wanted but not planned at this specific moment in life) or unwanted (not intended at this point nor in the future). UPs are known to have serious consequences as they contribute to adverse maternal and offspring outcomes2, such as antenatal and chronic depression in mothers3-7, adverse birth outcomes2,8, lower rates of breastfeeding9,10, lower quality of mother- and father child interaction11, and higher prevalence of externalizing problems in puberty in offspring12. In addition to adverse effects of unintended births, UPs can also lead to abortions, which are often performed unsafely and account for 7.9% of all maternal deaths worldwide1,13. To prevent UPs, studies investigating risk factors are of utmost importance. Although several risk factors have been identified, such as young maternal age, low educational level (of both parents), and being unmarried14-18, other potential risk factors, such as mental health, are less explored. Studies already demonstrated that in teenage women with psychiatric conditions (depression, psychosis, and personality disorders) UPs are common19, but if this also applies for adult women is yet unclear. A previous review on (awareness of) reproductive health problems in women with serious mental illness (that included studies up to 2008) described that the risk of sexually transmitted diseases, pregnancy loss and having more lifetime sex partners is high amongst women with psychiatric conditions20. However, unwanted pregnancies and abortions in women who previously reported a psychiatric vulnerability were not the focus of this review. It has been suggested that psychiatric vulnerability (a history of psychiatric disorders according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV or 5 and International Statistical Classification of Diseases and Related Health Problems (ICD)-10/11 and/or current psychiatric disorder according to DSM-IV or 5 and ICD-10/11) could influence important factors related to UPs, such as sexual behavior, including victimization of sexual violence21 or disruption of menstrual cycles due to stress, use of antipsychotic drugs or weight loss in eating disorders22,23. Also, advanced planning capacities, which are required for adequate use of contraceptive methods and family planning,23,24 has shown to be diminished in women with psychiatric vulnerability. Thus, we aimed to explore whether psychiatric vulnerability is a risk factor for UPs, by quantifying the presence of UPs amongst adult women with psychiatric vulnerability, in addition to comparing UPs in women with and without psychiatric vulnerability by means of a systematic literature search and meta-analysis.
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