Chapter 2 42 Strengths and limitations Our review has several strengths. First, the extensive search in electronic databases that included all psychiatric disorders, allowed us to gain insight in various specific psychiatric disorders in relation to UPs in addition to an overview of the overall presence of psychiatric vulnerability in relation to UPs. Moreover, we accepted both ongoing pregnancies and induced abortions as outcomes of UPs as previous studies underscored the importance of identifying abortions in women with psychiatric conditions as elective abortions can be a result of UPs20,61. However, our review also has several limitations. We only included studies that were written in English language which may reduce generalizability, however, peer-reviewed studies in other languages were relatively rare. Also, the studies included in the review had fair to poor quality ratings for the primary outcome, used varying psychiatric disorders as control group within studies, used various methods to assess the outcome pregnancy intention (by live births or abortions), differed in timing of measurement of pregnancy intention (which is key in preventing recall bias62), and showed divergent results. Pregnancy intention was only measured with validated tools in a few studies37,38,42, while most studies used a single question which may lack nuance32-34,36, or the way of measuring was not reported at all35,40. Abortion was in one study self-reported and in another based on a large obstetric dataset which included surgical abortion registrations39,41. In addition, important confounders such as age, educational level and environmental influences were considered in varying degrees18. In particular partner violence and poor partner relationship were posed as risk factor for UPs previously63 and in women with psychiatric vulnerability, reproductive coercion appears to be common [64,65]. Lastly, our meta-analysis was limited to only four studies with comparison groups and the overall low quality of this body of evidence limited our capacity to draw definitive conclusions. Research recommendations Ideally, assessment of pregnancy intention is performed 1) by means of a validated tool, and 2) as early in pregnancy as possible. At the same time, prospective settings are time-consuming and might overestimate UP rates since pregnancy intention can change over time62. However, prospective designs ensure that psychiatric vulnerability was present before the onset of the UPs, which could give insight in the causality between psychiatric vulnerability and UPS and limit recall bias. Regarding psychiatric vulnerability, we conclude that the onset, duration, and severity of psychiatric vulnerability are important to include, to understand the relation between psychiatric vulnerability and UPs. Last, we recommend that relevant confounders like race,
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