Pregnancy intention in relation to maternal and neonatal outcomes in women with vs without psychiatric diagnoses 95 Interpretation Psychiatric diagnoses and UPs Our findings consolidate previous research that establishes psychiatric disorders as a predictor of UPs11. There are several hypotheses that explain why. First, psychiatric symptoms can influence psychological mechanisms that are key for adequate use of contraceptive methods, such as planning, overview and impulse control regarding reproductive decision making30. Moreover, reduced autonomy, lack of information, perceived stigma and worries about safety of contraceptive methods complicate pregnancy planning31. Studies also showed that stress levels and depressive symptoms in young women with mental health problems32 and longer disease duration in patients with severe mental illnesses33 predict UPs. Alternatively, an overlap between psychiatric disorders and social and psychological predictors of ineffective contraceptive use could explain risk for UPs34. Intimate partner violence, lack of social support35,36 and low self-esteem37 are related to both reproductive decision making and psychiatric disorders. In our study, presence of UPs was found in the overall group of women with a current/past psychiatric diagnosis (39.0% UPs, p<0.001), and even higher in women with depressive (43.2% UPs, p=0.001), substance use (66.7% UPs, p=0.001) and personality disorders (49.1% UPs, p=0.004). As depressive disorders are a common psychiatric disorder, especially for women of reproductive age,38,39 the risk for UPs in this group is highly relevant. Previous studies show comparable findings amongst women with personality disorders and substance use disorders28,29. Contrary to expectations, we did not report and increased odds of UPs in women with schizophrenia and eating disorders11,40. Analyses in these relatively small samples of women could have been underpowered to find associations. This could explain relatively low UP rates in women with these severe mental illness compared to UP rates in literature41. Also, our data did not show increased odds of UPs for women with anxiety disorders, which accords with previous data from a Japanese birth cohort42. However, Tenkku et al. found a lower incidence of UPs in women with anxiety disorders, as opposed to a similar incidence between women with versus without anxiety disorders in our cohort. As qualitative studies on the psychological mechanisms behind UPs amongst women with anxiety disorders are currently lacking, it is challenging to hypothesize why women with anxiety disorders are less likely to become pregnant unintendedly. One of the possibilities is that individuals with anxiety disorders in general show harm avoidance and a drive to maintain control, which positively impact pregnancy planning behavior.
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