Psychiatric vulnerability and the risk for unintended pregnancies, a systematic review and meta-analysis 41 Comparison with existing literature Several mechanisms have been proposed to explain the relation between psychiatric vulnerability and UPs. Planning capacities, perception of risks related to unprotected intercourse and subsequent ability to prevent UPs by use of contraception, even as compliance with contraception methods could be impaired by decreased cognitive or emotional functioning during active (severe) mental disorders like mood disorders, schizophrenia or related psychotic conditions23,34,51,52. Manic symptoms in women with bipolar disorder could lead to impulsivity and hypersexuality, resulting in risky sexual behavior53. In eating disorders there are a few other mechanisms that should also be considered: oligomenorrhea is common and can be misinterpreted as a lower risk of pregnancy or even beliefs about infertility, which could subsequently lead to unintended pregnancies in case of unexpected ovulation. Also, oral contraceptives will not provide prevention of UPs in case of (frequent) purging22,33. Moreover, previous data suggest that in women who requested a termination of pregnancy, traumatic experiences such as sexual violence were prevalent, even as depression and anxiety symptoms54. Unfortunately, the extent to which women in the studies included in this review were facing active and/or severe psychiatric symptoms at time of conception was not always clearly described. Some authors, like Micali et al., separately analyzed women with symptoms in the year prior to their pregnancy and found they were more prone to UPs than women with a history of psychiatric disorders33. Based on available data in our review, we were not able to conclude whether this finding applies to all psychiatric diagnostic categories. Gaps in literature Although we included studies covering a variety of psychiatric disorders, we conclude that studies on common psychiatric disorders like personality disorders, attention deficit hyperactivity disorder and autism spectrum disorder are lacking. Further studies are needed to investigate UPs in women with these disorders. Although several studies included women with mood and anxiety disorders, absolute numbers of participants were small. As mood and anxiety disorders are known to be the most prevalent mental disorders, that are almost twice as common in women than in men, it is especially important to understand the role of these disorders in relation to UPs, hence further studies in this field should also be encouraged55-57. As none of the studies included in this review were conducted in low-income countries our findings may not apply for low-income countries. Several studies have described that UP rates are similarly high or even higher in low-income countries compared to high-income countries1,58,59, and that the adverse effects of UPs in low-income countries are severe60.
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