General introduction and outline of this thesis 9 Background information This thesis aims to unravel the way in which psychiatric vulnerability interferes with family planning, desire for children and birth outcomes. In this chapter, we will briefly introduce the relevant topics, provide the aim, methodology and outline of this thesis. Unintended pregnancies: a global reproductive health problem Unintended pregnancies (UPs) are pregnancies that are mistimed, unplanned or unwanted at the time of conception, as defined by the U.S. Department of Health & Human Services. Hereby, UPs combine two facets of pregnancy intention: the timing and desire. UPs can be either unplanned (which means the timing was not according to plan, but the pregnancy may be greeted with happiness) or unwanted (the pregnancy was not according to plan and not greeted with happiness). UPs pose a significant and widespread global health issue. Annually, approximately 120 million UPs, accounting for 48% of all pregnancies, occur worldwide1. Rates vary among different geographic regions, typically with higher rates in developing countries1. UPs often result in abortions, and sadly, many of these procedures occur under unsafe conditions, contributing to 7.9% of global maternal deaths1,2. As a result, the Sustainable Development Goals require countries to achieve by 2030 the objective of ensuring ‘universal access to sexual and reproductive healthcare services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes’3. In the Netherlands, the average age at which women give birth to their first child is 30.3 years old, compared to 24.3 years old in 19704. The trend of an increasing maternal age at first child is visible in other high-income countries and is most likely explained by the ability to plan and postpone pregnancies5. Hereby, women can achieve personal goals such as studying, navigating their career and finding a partner to have a family with6. From a feminist perspective, this is a positive development that reflects optimal reproductive agency. However, there are obstetric risks related to birthing at increased age. Maternal age >35 years is linked to stillbirth, perinatal mortality and maternal morbidity and mortality7,8. In addition to an increasing age at first child, the absolute birth rate in the Netherlands decreases every year from 207.000 children born in the year 2000 to 168.000 born in the year 20224. The decrease of absolute birth rates could negatively impact society, as offspring aids in supporting national welfare in an aging population. Despite decreasing absolute birth rate numbers, and an increasing age at first child, the proportion of pregnancies that is unintended, remains high9. In European countries, including the Netherlands, pregnancies are unintended in approximately 25-30%10. In the Netherlands, little
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