Pregnancy Intention and Pregnancy Outcome: Systematic Review and Meta-Analysis

Introduction Previous systematic reviews concluded that rigorous research on the relationships between pregnancy intentions and pregnancy outcomes is limited. They further noted that most studies were conducted in high-income countries and had methodological limitations. We aim to assess the current evidence base for the relationship between pregnancy intention and miscarriage, stillbirth, low birthweight (LBW) and neonatal mortality. In March 2015 Embase, PubMed, Scopus and PsychInfo were searched for studies investigating the relationship between pregnancy intention and the outcomes of interest. Methods Studies published since 1975 and in English, French or Spanish were included. Two reviewers screened titles and abstracts, read the full text of identified articles and extracted data. Meta-analyses were conducted where possible. Results Thirty-seven studies assessing the relationships between pregnancy intention and LBW were identified. A meta-analysis of 17 of these studies found that unintended pregnancies are associated with 1.41 times greater odds of having a LBW baby (95%CI 1.31, 1.51). Eight studies looking at miscarriage, stillbirth or neonatal death were found. The limited data concerning pregnancy loss and neonatal mortality precluded meta-analysis but suggest these outcomes may be more common in unintended pregnancies. Discussion While there seems to be an increased risk of adverse pregnancy outcome in unintended pregnancies, there has been little improvement in either the quantity of evidence from low-income countries or in the quality of evidence generally. Longitudinal studies of pregnancy intention and pregnancy outcome, where pregnancy intention is assessed prospectively with a validated measure and where analyses include confounding or mediating factors, are required in both high- and low-income countries

London measure of Unplanned Pregnancy: guidance for its use as an outcome measure

Background: The London Measure of Unplanned Pregnancy (LMUP) is a psychometrically validated measure of the degree of intention of a current or recent pregnancy. The LMUP is increasingly being used worldwide, and can be used to evaluate family planning or ­preconception care programs. However, beyond recommending the use of the full LMUP scale, there is no published guidance on how to use the LMUP as an outcome measure. Ordinal logistic regression has been recommended informally, but studies published to date have all used binary logistic regression and dichotomized the scale at different cut points. There is thus a need for evidence-based guidance to provide a standardized methodology for multivariate analysis and to enable comparison of results. This paper makes recommendations for the regression method for analysis of the LMUP as an outcome measure. Materials and methods: Data collected from 4,244 pregnant women in Malawi were used to compare five regression methods: linear, logistic with two cut points, and ordinal logistic with either the full or grouped LMUP score. The recommendations were then tested on the original UK LMUP data. Results: There were small but no important differences in the findings across the regression models. Logistic regression resulted in the largest loss of information, and assumptions were violated for the linear and ordinal logistic regression. Consequently, robust standard errors were used for linear regression and a partial proportional odds ordinal logistic regression model attempted. The latter could only be fitted for grouped LMUP score. Conclusion: We recommend the linear regression model with robust standard errors to make full use of the LMUP score when analyzed as an outcome measure. Ordinal logistic regression could be considered, but a partial proportional odds model with grouped LMUP score may be required. Logistic regression is the least-favored option, due to the loss of information. For logistic regression, the cut point for un/planned pregnancy should be between nine and ten. These recommendations will standardize the analysis of LMUP data and enhance comparability of results across studies

What are the relationships between the degree of pregnancy intention and key maternal and neonatal health outcomes in the Mchinji district of Malawi?

Background Every year 85 million women experience an unintended pregnancy. Unintended pregnancies may pose increased risks to mother and baby but the evidence is scarce and methodologically limited. This research aims to fill the gap in our knowledge about the pattern of pregnancy intention and the relationships between pregnancy intention and miscarriage, stillbirth, low birthweight, neonatal death and postnatal depression in a low-income country. Methods I validated the London Measure of Unplanned Pregnancy (LMUP) in the Chichewa language and used it to assess the degree of pregnancy intention of 4,244 pregnant women in Mchinji District, Malawi. Pregnancy outcome was ascertained after the neonatal period. I analysed these data to examine the determinants of pregnancy intention and the relationships between pregnancy intention and pregnancy outcomes using multivariate hierarchical regressions. I conducted focus group discussions on postpartum family planning (PPFP). Results The Chichewa LMUP is valid in Malawi and shows a similar pattern of pregnancy intention to the UK. Young, unmarried women having their first child, older, married women who have completed their family or who have recently given birth and women who have experienced depression or intimate partner violence are at increased risk of unintended pregnancies. The more unplanned a woman’s pregnancy is, the less likely she is to access adequate care. More planned pregnancies have a lower risk of postnatal depression and possibly stillbirth; there was no significant relationship between pregnancy intention and miscarriage, low birthweight or neonatal death. Conclusion To prevent unintended pregnancies, at-risk women should be targeted by family planning services. These services, particularly PPFP, need strengthening. Including the LMUP in routine antenatal care would identify women who are at risk of inadequate care uptake, stillbirth and postnatal depression. During pregnancy these women should be given additional support to mitigate these risks. They should be followed-up postnatally to detect depression and prevent future unintended pregnancies through PPFP

How do women prepare for pregnancy in a low-income setting? Prevalence and associated factors

Background Despite growing evidence of pregnancy preparation benefits, there is little knowledge on how women in developing countries prepare for pregnancy and factors influencing their preparedness for pregnancy. Here, we determine how women in Malawi prepare for pregnancy and factors associated with pregnancy preparation. Methods We used data from a previous cohort study comprising 4,244 pregnant mothers, recruited between March and December 2013 in Mchinji district, Malawi. Associations of pregnancy preparation with socio-demographic and obstetric factors were tested for using mixed effects ordinal regression, with the likelihood ratio and Wald's tests used for variable selection and independently testing the associations. Results Most mothers (63.9%) did not take any action to prepare for their pregnancies. For those who did (36.1%), eating more healthily (71.9%) and saving money (42.8%) were the most common forms of preparation. Mothers who were married (adjusted odds-ratio (AOR 7.77 (95% CI [5.31, 11.25]) or with no or fewer living children were more likely to prepare for pregnancy (AOR 4.71, 95% CI [2.89,7.61]. Mothers with a period of two to three years (AOR 2.51, 95% CI [1.47, 4.22]) or at least three years (AOR 3.67, 95%CI [2.18, 6.23]) between pregnancies were more likely to prepare for pregnancy than women with first pregnancy or shorter intervals. On the other hand, teenage and older (≥ 35 years old) mothers were less likely to prepare for pregnancy (AOR 0.61, 95%CI [0.47, 0.80]) and AOR 0.49 95%CI [0.33, 0.73], respectively). Conclusion While preconception care may not be formally available in Malawi, our study has revealed that over a third of mothers took some action to prepare for pregnancy before conception. Although this leaves around two thirds of women who did not make any form of pregnancy preparation, our findings form a basis for future research and development of a preconception care package that suits the Malawian context

Health Economic Studies of Colorectal Cancer and the Contribution of a National Administrative Data Repository: a Systematic Review

Introduction: Several forces are contributing to an increase in the number of people living with and surviving colorectal cancer (CRC). However, due to the lack of available data, little is known about the implications of these forces. In recent years, the use of administrative records to inform research has been increasing. The aim of this paper is to investigate the potential contribution that administrative data could have on the health economic research of CRC. Methods: To achieve this aim, we conducted a systematic review of the health economic CRC literature published in the United Kingdom and Europe within the last decade (2009–2019). Results: Thirty-seven relevant studies were identified and divided into economic evaluations, cost of illness studies and cost consequence analyses. Conclusions: The use of administrative data, including cancer registry, screening and hospital records, within the health economic research of CRC is commonplace. However, we found that this data often come from regional databases, which reduces the generalisability of results. Further, administrative data appear less able to contribute towards understanding the wider and indirect costs associated with the disease. We explore several ways in which various sources of administrative data could enhance future research in this area

Community physiotherapy for people with dementia following hip fracture: fact or fiction

This is the author accepted manuscript. The final version is available from SAGE Publications via the DOI in this record.Background Physiotherapy is a core component of rehabilitation following a hip fracture. Approximately 40% of people sustaining a hip fracture will have dementia, but there is little evidence to guide physiotherapy interventions in this population. Objective This study forms part of a process evaluation seeking to explore reasons why people with dementia were not referred for physiotherapy following a hip fracture and challenges that are faced treating these people in the community. Methods We undertook a series of structured focus groups and interviews with physiotherapists based in community-rehabilitation services in the South West of England. Qualitative data sought to explain reasons why people with dementia were not being referred for onward physiotherapy following discharge from the acute setting after hip fracture. Framework analysis was used to make sense of the data. Results Four focus groups and interviews were undertaken with physiotherapists and assistants working in community settings. Three main themes were determined – beliefs, the importance of pathways of care and the effect of resources on decision making. Discussion Out data suggest that people with dementia were often labelled as having ‘no rehabilitation potential’ in the acute setting and this excluded them from receiving ongoing therapy in the community setting. It was also suggested that physiotherapists were judging this potential using biomedical measures of outcome which fails to recognise the importance of person centred care for this population. Conclusion There was suggestion of therapeutic nihilism when considering rehabilitation for this population, whereby it is assumed that people with dementia cannot be rehabilitated, so they are not given the opportunity. It is unsurprising that outcomes for this population are poor considering the reluctance to provide physiotherapy to people with dementia following hip fracture.National Institute for Health Research (NIHR)AGIL

Neogene history of fluvial to shallow marine successions in the Kendari Basin, SE Sulawesi, Indonesia

Collision between Australia and SE Asia began in Sulawesi, the world's eleventh-largest island, in the Early Miocene and subsequently Neogene sediments were deposited largely in coastal to shelf environments throughout the island. These sediments have been assigned to the Celebes Molasse, previously considered as a single post-orogenic unit deposited unconformably on pre-Neogene sedimentary, metamorphic and ophiolitic rocks. The most complete and extensive sequences of Neogene sediments are in the Kendari Basin, situated at the southern end of the SE Arm of Sulawesi, where an outcrop-based sedimentological study was undertaken to interpret depositional environments, palaeogeography and stratigraphy. The oldest Neogene sediments are shallow marine carbonates and deltaic siliciclastics of the Bungku Formation. They are unconformably overlain by the Upper Miocene Pandua Formation which consists of sediments deposited in a variety of environments including braided river channels, fluvio-tidal channels, tidal flats, mouth bar complex and shoreface deposits. A Mio-Pliocene subaerial unconformity separates the marginal marine serpentinite-rich sediments of the Pandua Formation from the overlying fluviatile quartz-rich Langkowala Formation. The sediments of the lower part of the Langkowala Formation include conglomeratic channel fill, while the sediments of the upper part are transgressive deposits decreasing in maximum grain-size, marked by a reduction in channel/overbank ratio and increasing tidal influence. The transgressive Pliocene Eemoiko Formation is characterised by transgressive lags or onlap shell beds and deposits of a landwards-backstepping carbonate platform. The improved understanding of the Kendari Basin will aid the interpretation of the sedimentation history of frontier basins surrounding SE Sulawesi, many of which have not yet been drilled

Prevalence and Determinants of Unintended Pregnancy in Mchinji District, Malawi; Using a Conceptual Hierarchy to Inform Analysis

Background: In 2012 there were around 85 million unintended pregnancies globally. Unintended pregnancies unnecessarily expose women to the risks associated with pregnancy, unsafe abortion and childbirth, thereby contributing to maternal mortality and morbidity. Studies have identified a range of potential determinants of unplanned pregnancy but have used varying methodologies, measures of pregnancy intention and analysis techniques. Consequently there are many contradictions in their findings. Identifying women at risk of unplanned pregnancy is important as this information can be used to help with designing and targeting interventions and developing preventative policies. Methods: 4,244 pregnant women from Mchinji District, Malawi were interviewed at home between March and December 2013. They were asked about their pregnancy intention using the validated Chichewa version of the London Measure of Unplanned Pregnancy, as well as their socio-demographics and obstetric and psychiatric history. A conceptual hierarchical model of the determinants of pregnancy intention was developed and used to inform the analysis. Multiple random effects linear regression was used to explore the ways in which factors determine pregnancy intention leading to the identification of women at risk of unplanned pregnancies. Results: 44.4% of pregnancies were planned. On univariate analyses pregnancy intention was associated with mother and father’s age and education, marital status, number of live children, birth interval, socio-economic status, intimate partner violence and previous depression all at p<0.001. Multiple linear regression analysis found that increasing socio-economic status is associated with increasing pregnancy intention but its effect is mediated through other factors in the model. Socio-demographic factors of importance were marital status, which was the factor in the model that had the largest effect on pregnancy intention, partner’s age and mother’s education level. The effect of mother’s education level was mediated by maternal reproductive characteristics. Previous depression, abuse in the last year or sexual abuse, younger age, increasing number of children and short birth intervals were all associated with lower pregnancy intention having controlled for all other factors in the model. This suggests that women in Mchinji District who are either young, unmarried women having their first pregnancy, or older, married women who have completed their desired family size or recently given birth, or women who have experienced depression, abuse in the last year or sexual abuse are at higher risk of unintended pregnancies. Conclusion: A simple measure of pregnancy intention with well-established psychometric properties was used to show the distribution of pregnancy planning among women from a poor rural population and to identify those women at higher risk of unintended pregnancy. An analysis informed by a conceptual hierarchical model shed light on the pathways that lead from socio-demographic determinants to pregnancy intention. This information can be used to target family planning services to those most at risk of unplanned pregnancies, particularly women with a history of depression or who are experiencing intimate partner violence