Chapter 4 94 perform this assessment. Instead, we used registrations in medical charts by health care professionals. Moreover, pregnancy planning could be perceived as a sensitive topic that women do not wish to discuss during a pregnancy intake, resulting in underreporting. Another important source of uncertainty is the severity of psychiatric symptoms at conception. We included women with a current/past psychiatric diagnosis but could not adjust for severity, current presence, or duration of the diagnosis. In fact, as mental health symptoms are more common than psychiatric diagnoses amongst women in the fertile stage of life, UPs amongst all women with mental health symptoms might be even more prevalent. Our study was however limited in the possibility to assess mental health symptoms, and the presence of current/past psychiatric diagnoses was found to be a more reliable predictor variable in our retrospective design. Although the overall sample size of the study was adequate for the performed main analyses, caution must be applied for subgroup analyses of individual psychiatric disorders, specifically with small samples of patients with substance use disorders and personality disorders. As women with psychiatric disorders might underreport the presence thereof, our main predictor (current/past psychiatric diagnosis) may have created a significant bias as it is partially based on self-reported history of diagnosis. Nonetheless, our findings are in concordance with previous studies that also found that women with substance use disorders and personality disorders have an increased odd of UPs28,29. Finally, we used the ethnicity variable according to the Dutch obstetric system as this is recorded in the patient file by all health professionals. However, since country of birth of the mother's parents does not always correspond to the ethnical background, this may be only partially correct and may have influenced our findings with regards of ethnicity. Notwithstanding these limitations, our findings have value as they are based on a large dataset that was compiled independently by several researchers which decreases the possibility of researcher bias. Information bias was diminished by performing manual checks on chart data. The hospital provides with thousands of well documented patient charts including data from pregnant patients with psychiatric diagnoses, enabling us to collect detailed data on psychiatric history and pregnancy intention. Although prospective measurement of pregnancy intention is ideal, our work offers valuable insights in the incidence UPs amongst women with current/past psychiatric diagnoses.
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