Planned, unplanned and in-between: the meaning and context of pregnancy planning for young people

[Information and Counseling needs Regarding Parenthood Decisions: Are Existing Services Sufficient and what Role does Depression Play?]

OBJECTIVE

Support needs in parenting decisions and the associated desire for information and counseling services are insufficiently researched, especially in relation to groups of people with mental health burdens. The aim of this study was to assess information and counseling needs in parenting decisions. In addition, we investigated whether more severe depressive symptomatology is associated with increased needs.

METHODS

A sample of 187 individuals between the ages of 20 and 44 was surveyed in an online study.

RESULTS

Not having enough information on the topic was expressed by 45% of participants, and the desire for information related to multiple topics. A larger offer of professional coun-seling was desired by 65% of the participants, 74% (rather) did not know where to get it. Existing counseling services were used infrequently in relation to needs and with predominantly moderate satisfaction. Greater depressive symptomatology was not associated with increased information or counseling needs.

DISCUSSION AND CONCLUSION

Findings suggest an expansion of support services on parenting decisions. Further research into the needs of different groups and barriers to using existing services is essential.

Approaches to a crisis in early pregnancy: an explorative qualitative study of medical students and doctors in training in Ireland, using a story completion model

A crisis in early pregnancy can be due to an unplanned pregnancy or a suspected abnormality. Pregnant people have the right to unbiased and comprehensive advice of all options from healthcare providers. Using story completion models (SCM), the aim of this qualitative study was to explore the attitudes of medical students and doctors in training towards crisis pregnancy, specifically two scenarios: early unplanned pregnancy and fatal fetal abnormality (anencephaly). Participants were invited from medical students attending University College Dublin (UCD) and trainees in Obstetrics and Gynaecology in the Royal College of Physicians of Ireland (RCPI) from July to December 2022. SCM involve giving the consenting participant an introduction to a hypothetical situation that acts as the beginning of a story and asking them to complete it. Stories were compiled and analysed using thematic analysis. Research Ethics Committee approval was given by both UCD and the RCPI. The standards for reporting of qualitative research guidelines were followed. Eight doctors in training and six medical students consented to participate in the study; all but two medical students completed both stories to the required word count, giving 25 stories for analysis. For both situations, stories described a variety of approaches, all of which were based on the person, or couples wishes, from continuing in pregnancy to deciding to end the pregnancy. SCM allowed detailed analysis of potentially sensitive subjects such as pregnancy options. This study showed that participating medical students and doctors in training recognise that pregnant people have the right to all choices in crisis pregnancy.

Measuring non-events: infertility estimation using cross-sectional, population-based data from four countries in sub-Saharan Africa

STUDY QUESTION

Does the prevalence of 12-month infertility in Burkina Faso, Côte d'Ivoire, Kenya, and Uganda differ between women trying to conceive and the broader population of women exposed to unprotected sex, and how are prevalence estimates affected by model assumptions and adjustments?

SUMMARY ANSWER

Estimates of 12-month infertility among tryers ranged from 8% in Burkina Faso to 30% in Côte d'Ivoire, increasing substantially among a larger population of women exposed to unprotected intercourse.

WHAT IS KNOWN ALREADY

While having a child is a fundamental human experience, the extent to which women and couples experience infertility is a neglected area of research, particularly in sub-Saharan Africa. Existing estimates of infertility in this region vary widely from 2% to 32%, however, potential impacts of variability in study populations and model assumptions have not been well-examined.

STUDY DESIGN, SIZE, DURATION

We used cross-sectional nationally representative survey data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda. We employed a multi-stage cluster random sampling design with probability proportional to the size selection of clusters within each country to produce representative samples of women aged 15-49. Samples ranged from 3864 in Côte d'Ivoire to 9489 in Kenya.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We created two analytic samples in each country-tryers and a broader sample of women exposed to unprotected sex-exploring differences in population characteristics and estimating the period prevalence of 12-month infertility using the current duration (CD) approach. We also examined the impact of several model assumptions within each of the two analytic samples, including adjustments for recent injectable contraceptive use, unrecognized pregnancy, infertility treatment, underreported contraceptive use, and sexual activity.

MAIN RESULTS AND THE ROLE OF CHANCE

Employing the CD approach among tryers produced an overall 12-month infertility prevalence of 7.9% (95% CI 6.6-12.7) in Burkina Faso, 29.6% (95% CI 15.3-100.0) in Côte d'Ivoire, 24.5% (95% CI 16.5-34.6) in Kenya, and 14.7% (95% CI 8.1-22.4) in Uganda. Results among women exposed to unprotected intercourse indicated much higher levels of infertility, ranging from 22.4% (95% CI 18.6-30.8) in Uganda to 63.7% (95% CI 48.8-87.9) in Côte d'Ivoire. Sensitivity analyses suggest infertility estimates are particularly sensitive to adjustments around pregnancy recognition timing and sexual activity, with little impact of adjustments for recent injectable contraceptive use, infertility treatment, and underreporting of traditional and coital dependent contraceptive use.

LIMITATIONS, REASONS FOR CAUTION

There was substantial digit preference in responses at 12 months, particularly among the tryers, which could introduce bias. Data quality concerns in the reproductive calendar may impact the accuracy of the CD approach among the broader sample of women exposed to unprotected sex, particularly with regard to underreported contraceptive use, induced and spontaneous abortions, and unrecognized pregnancies. Lastly, we lacked information on postpartum amenorrhea or abstinence.

WIDER IMPLICATIONS OF THE FINDINGS

Understanding the inconsistencies in definition and analytic approach and their implications for infertility estimation is important for reliably monitoring population-level infertility trends, identifying factors influencing infertility, improving prevention programs, and ensuring access to quality treatment and services.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Narratives of pregnancy across 19 Countries: Analysis of a 1.5-billion-word news media database

Pregnancy is a universal experience shaped by sociocultural contexts. News media presents a unique opportunity to analyze public narratives of pregnancy and how it differs across cultures. Our study aims to (1) identify the most prevalent overall themes in news media narratives of pregnancy across 19 English-speaking countries, and (2) compare pregnancy narratives across geographic regions. We used the largest English news media corpus that included over 30 million news articles from more than 7000 news websites across 19 countries, and extracted a one-year data subset (2019; 1.5 billion words). Of the primary search terms 'pregnant' and 'pregnancy', we collated 240,464 descriptors that met criteria of lexical proximity and semantic bonding. Thereafter, we used topic modelling to identify the five most prevalent pregnancy-related themes: (1) complications and risk, (2) crime, (3) celebration, (4) celebrity births, and (5) contraception. Although there were regional differences, themes of complications and risk were most common, comprising 39.6% of all pregnancy narratives in our big-data corpus. The second-most dominant theme was crime (20.8%). Narratives of contraception were more prevalent in Europe, North America, and Oceania (27.2-31.3%) compared to Africa and Asia (11.9-19.6%). Though the vast majority of pregnancies are healthy, themes of complications and risk dominated the news media discourse; unchecked, this may be an avenue for misinformation, stress, and anxiety. In addition, lower prevalence of contraception narratives in Africa and Asia may reflect a gap that requires the attention of policymakers in building culturally-adapted programs to promote family planning and encourage open discussions about sexual health. Results contribute to the academic repository of societal representations of pregnancy through a big-data lens, providing contextual information for future development, implementation and evaluation of localized pregnancy-related campaigns.

Integrating Sexual and Reproductive Health Equity Into Public Health Goals and Metrics: Comparative Analysis of Healthy People 2030's Approach and a Person-Centered Approach to Contraceptive Access Using Population-Based Data

BACKGROUND

The Healthy People initiative is a national effort to lay out public health goals in the United States every decade. In its latest iteration, Healthy People 2030, key goals related to contraception focus on increasing the use of effective birth control (contraceptive methods classified as most or moderately effective for pregnancy prevention) among women at risk of unintended pregnancy. This narrow focus is misaligned with sexual and reproductive health equity, which recognizes that individuals' self-defined contraceptive needs are critical for monitoring contraceptive access and designing policy and programmatic strategies to increase access.

OBJECTIVE

We aimed to compare 2 population-level metrics of contraceptive access: a conventional metric, use of contraceptive methods considered most or moderately effective for pregnancy prevention among those considered at risk of unintended pregnancy (approximating the Healthy People 2030 approach), and a person-centered metric, use of preferred contraceptive method among current and prospective contraceptive users.

METHODS

We used nationally representative data collected in 2022 to construct the 2 metrics of contraceptive access; the overall sample included individuals assigned female at birth not using female sterilization or otherwise infecund and who were not pregnant or trying to become pregnant (unweighted N=2760; population estimate: 43.9 million). We conducted a comparative analysis to examine the convergence and divergence of the metrics by examining whether individuals met the inclusion criteria for the denominators of both metrics, neither metric, only the conventional metric, or only the person-centered metric.

RESULTS

Comparing the 2 approaches to measuring contraceptive access, we found that 79% of respondents were either included in or excluded from both metrics (reflecting that the metrics converged when individuals were treated the same by both). The remaining 21% represented divergence in the metrics, with an estimated 5.7 million individuals who did not want to use contraception included only in the conventional metric denominator and an estimated 3.5 million individuals who were using or wanted to use contraception but had never had penile-vaginal sex included only in the person-centered metric denominator. Among those included only in the conventional metric, 100% were content nonusers-individuals who were not using contraception, nor did they want to. Among those included only in the person-centered metric, 68% were currently using contraception. Despite their current or desired contraceptive use, these individuals were excluded from the conventional metric because they had never had penile-vaginal sex.

CONCLUSIONS

Our analysis highlights that a frequently used metric of contraceptive access misses the needs of millions of people by simultaneously including content nonusers and excluding those who are using or want to use contraception who have never had sex. Documenting and quantifying the gap between current approaches to assessing contraceptive access and more person-centered ones helps clearly identify where programmatic and policy efforts should focus going forward.

Reproductive Justice as an Alternative to the Pregnancy Planning Paradigm for Teens

In this critical commentary, we describe the many limitations of the pregnancy planning paradigm as applied to pregnant and parenting teens. We describe how this paradigm, in characterizing pregnancies as intended or unintended, has shaped campaigns to prevent teen pregnancy and remains largely embedded in formal sex education and family planning programs in the United States. We argue that a paradigm shift is long overdue and describe how the reproductive justice framework addresses the limitations of the pregnancy planning paradigm. Although reproductive justice is endorsed by a growing number of organizations, recommended policies face formidable obstacles given that comprehensive sex education, contraception, and legal abortion are increasingly at risk in a post-Dobbs world.

Comparison of a person-centered pregnancy prevention question and One Key Question to assess postpartum contraceptive needs

OBJECTIVES

To explore the relevance of pregnancy intention as a screen for contraceptive needs among postpartum individuals.

STUDY DESIGN

We surveyed 234 postpartum individuals to assess the alignment between pregnancy intentions in the next year and current desire to prevent pregnancy.

RESULTS

Most individuals (87%) desired pregnancy prevention now, including 73% of individuals who desired or were ambivalent about pregnancy in the next year.

CONCLUSION

A majority of individuals considering pregnancy in the next year desired pregnancy prevention now. Directly assessing current desire to prevent pregnancy may be more specific for contraceptive needs in postpartum individuals.

IMPLICATIONS

Our ability to ensure that all individuals who want to prevent pregnancy have access to contraception depends on the use of effective screening questions. These findings prompt consideration of broader clinical implementation of screening for desire to prevent pregnancy in lieu of questions about pregnancy intention in the next year.

Comparing Relationship Satisfaction and Body-Image-Related Quality of Life in Pregnant Women with Planned and Unplanned Pregnancies

This comparative cross-sectional study conducted at the "Pius Brinzeu" healthcare center in Timisoara explored the differential impacts of pregnancy planning status on sexual function, body image, and relationship satisfaction among pregnant women. Employing the Female Sexual Function Index (FSFI), Body Esteem Scale for Adolescents and Adults (BESAQ), and the Beck Depression Inventory (BDI-II), the study analyzed responses from 107 participants divided into groups of planned (n = 59, mean age 28.5 ± 5.2) and unplanned (n = 48, mean age 27.3 ± 4.8) pregnancies. In the first trimester, unplanned pregnancies reported higher median scores in desire (4.7 vs. 3.6, p = 0.005), arousal (4.5 vs. 3.8, p = 0.001), and lubrication (4.6 vs. 3.7, p = 0.015) compared to planned pregnancies. Satisfaction scores also favored unplanned pregnancies in the first trimester (4.8 vs. 3.9, p = 0.009). Similar trends were observed in subsequent trimesters, with unplanned pregnancies consistently reporting higher FSFI scores, indicating a robust sexual function. Risk factors significantly associated with sexual dysfunction were a higher BMI in the first trimester (beta coefficient: -0.124, p = 0.019), unmarried civil status (beta coefficient: -0.323, p = 0.045), history of previous abortion (beta coefficient: -0.451, p = 0.012), irregular menstrual cycles (beta coefficient: -0.384, p = 0.026), and rural living area (beta coefficient: -0.278, p = 0.034). Notably, unplanned pregnancy itself was not a significant risk factor for sexual dysfunction (beta coefficient: -0.054, p = 0.095). Regarding relationship dynamics, planned pregnancies exhibited significantly higher satisfaction with partner support (4.1 ± 0.9 vs. 3.7 ± 1.1, p = 0.041) and communication within the couple (4.0 ± 1.0 vs. 3.5 ± 1.2, p = 0.020), whereas unplanned pregnancies reported higher satisfaction with emotional closeness (4.3 ± 0.7 vs. 3.8 ± 1.0, p = 0.004). Concerns about managing professional activities and household chores were significantly more prevalent in the unplanned pregnancy group (62.50% vs. 33.90%, p = 0.014). Unplanned pregnancies demonstrated better initial sexual function but faced greater challenges in relationship satisfaction and managing pregnancy demands. Identifying and addressing the risk factors associated with sexual dysfunction can provide targeted interventions to improve the well-being of pregnant women, regardless of pregnancy planning status.

Assessing comprehension of the Parenting/Pregnancy Attitudes, Timing, and How Important (PATH) questions through cognitive interviewing

OBJECTIVES

PATH, "Parenting/Pregnancy Attitudes, Timing, and How Important," is a method for providers to engage in a person-centered discussion about reproductive desires. This study sought to assess patient understanding of and receptivity to PATH questions.

STUDY DESIGN

Cognitive interviews were conducted with young adult (aged 18-29 years) patients at a federally qualified health center in New York (n = 10).

RESULTS

Participants demonstrated clear comprehension and comfort with the PATH questions.

IMPLICATIONS

These data provide needed person-driven support for the Centers for Disease Control and Prevention and the Society of Family Planning's recommendation to implement PATH questions as a patient-centered method for discussing an individual's reproductive desires.

The role of legal status and uncertainty in the reproductive aspirations of 1.5 and second generation Mexican-origin immigrant young women: An exploratory study

Background

The 1.5 generation, brought to the U.S. prior to age 16, faces barriers that the second generation, U.S.-born to immigrant parents, does not, including only temporary legal protection through the Deferred Action for Childhood Arrivals (DACA) Program. Little is known about how legal status and uncertainty shape cisgender immigrant young women's reproductive aspirations.

Methods

Drawing on the Theory of Conjunctural Action with attention to the immigrant optimism and bargain hypotheses, we conducted an exploratory qualitative study using semi-structured interviews with seven 1.5 generation DACA recipients and eleven second generation Mexican-origin women, 21-33 years old in 2018. Interviews focused on reproductive and life aspirations, migration experiences, and childhood and current economic disadvantage. We conducted a thematic analysis using a deductive and inductive approach.

Results

Data resulted in a conceptual model on the pathways through which uncertainty and legal status shape reproductive aspirations. Participants aspired to complete higher education and have a fulfilling career, financial stability, a stable partnership, and parents' support prior to considering childbearing. For the 1.5 generation, uncertainty of their legal status makes the thought of parenting feel scary, while for the second generation, the legal status of their parents makes parenting feel scary. Achieving desired stability before childbearing is more challenging and uncertain for the 1.5 generation.

Conclusions

Temporary legal status constrains young women's reproductive aspirations by limiting their ability to achieve desired forms of stability prior to parenting and making the thought of parenting frightening. More research is needed to further develop this novel conceptual model.

Critiquing the Unintended Pregnancy Framework

The unintended pregnancy framework, a central tenet of sexual and reproductive health care delivery and research, has been depicted as an adverse outcome that should be prevented. There is growing criticism of the inadequacies of this framework, although little modification in public health guidelines, measurement, or clinical practice has been seen. This article critically reviews the literature on unintended pregnancy to encourage reflection on how this framework has negatively influenced practice and to inspire the advancement of more patient-centered care approaches. We begin by outlining the historical origins of the unintended pregnancy framework and review how this framework mischaracterizes patients' lived experiences, fails to account for structural inequities, contributes to stigma, and is built upon weakly supported claims of a negative impact on health outcomes. We close with a discussion of the relationship between health care provision and unintended pregnancy care and the implications and recommendations for realigning clinical practice, research, and policy goals.

Unplanned Pregnancy and Depressive Symptoms during the COVID-19 Pandemic

This is a cross-sectional study conducted with pregnant women who underwent prenatal care at basic health units in São Luís City, Maranhão State, Brazil. The authors used a semistructured questionnaire to assess the socioeconomic, demographic, and clinical characteristics of pregnant women as well as the Edinburgh Scale to investigate depressive symptoms. In order to assess the association between the explanatory variable and the outcome variable, Poisson logistic regression was performed with statistical significance at p < 0.05. A total of 205 women were interviewed, most aged between 18 and 29 years (66.83%). Of this total, 74.63% had not planned their pregnancy and 26.67% had depressive symptoms. The variables unplanned pregnancy (PR = 1.41; CI = 0.99−2.00; p = 0.05) and not undergoing psychological counseling (PR = 1.42; CI = 0.51−0.83; p ≤ 0.01) correlated with depressive symptoms during pregnancy. It is thus possible to link the variables unplanned pregnancy (p > 0.05) and not undergoing psychological counseling (p = 0.001) to depression. Therefore, it is important to monitor the mental health of pregnant women, especially in situations of vulnerability.

Lifestyle interventions in pregnancy targeting GDM prevention: looking ahead to precision medicine

Gestational diabetes mellitus (GDM) is the most prevalent pregnancy-related endocrinopathy, affecting up to 25% of pregnancies worldwide. Pregnant individuals who develop GDM have an increased risk of complications during pregnancy and birth, as well as future development of type 2 diabetes mellitus and CVD. This increased risk is subsequently passed along to the offspring, perpetuating a cycle of metabolic dysfunction across generations. GDM prevention strategies have had mixed results for many years, but more recent systematic reviews and meta-analyses have suggested potential new avenues of prevention. The objective of this review is to summarise the literature examining the efficacy of lifestyle interventions for the prevention of GDM and to uncover if specific individual-level characteristics influence this outcome. Based on the present literature, we determined that future trials should be designed to understand if initiation of lifestyle intervention in the preconception period is more effective to reduce GDM. Furthermore, trials initiated during pregnancy should be developed through the lens of precision prevention. That is, trials should tailor intervention approaches based on individual-level risk defined by the presence of modifiable and non-modifiable risk factors. Finally, future interventions might also benefit from just-in-time adaptive intervention designs, which allow for interventions to be modified in real-time based on objective assessments of an individual's response.

Recruiting and Engaging Women of Reproductive Age with Obesity: Insights from A Mixed-Methods Study within A Trial

Engaging women with obesity in health-related studies during preconception is challenging. Limited data exists relating to their participation. The aim of this study is to explore the experiences and opinions of women participating in a weight-related, preconception trial. This is an explanatory sequential (quan-QUAL) mixed-methods Study Within A Trial, embedded in the GetGutsy randomized controlled trial (ISRCTN11295995). Screened participants completed an online survey of eight questions (single or multiple choice and Likert scale) on recruitment, motivations and opinions on study activities. Participants with abdominal obesity (waist circumference ≥ 80 cm) were invited to a subsequent semi-structured, online focus group (n = 2, 9 participants) that was transcribed and analyzed using inductive thematic analysis, with a pragmatic epistemological approach. The survey (n = 102) showed the main research participation motivations were supporting health research (n = 38, 37.3%) and wanting health screening (n = 30, 29.4%). Most participants were recruited via email (n = 35, 34.7%) or social media (n = 15, 14.7%). In the FGs, participants valued flexibility, convenience and. research methods that aligned with their lifestyles. Participants had an expanded view of health that considered emotional well-being and balance alongside more traditional medical assessments. Clinical trialists should consider well-being, addressing the interconnectedness of health and incorporate a variety of research activities to engage women of reproductive age with obesity.

A Latent Class Analysis: Identifying Pregnancy Intention Classes Among U.S. Adolescents

PURPOSE

Few studies have captured the multidimensionality of pregnancy intentions for adolescents on a national level, particularly missing the perspectives of male adolescents. Therefore, this study aimed to identify and describe pregnancy intention profiles among U.S. adolescents.

METHODS

Latent class analysis was conducted using data from two cycles of the National Survey of Family Growth (2015-2017 and 2017-2019) among U.S. adolescents 15-19 years old (N = 3,812). Stratified by sex, six National Survey of Family Growth indicators around desires, feeling, timing, and social acceptability were included. Multinomial logistic regression was used to identify the correlates of class membership.

RESULTS

Three latent classes of pregnancy intention were identified for each sex, which were distinguished by immediate and future desires, feelings, timing, and social acceptability. For both females and males, Delayed Pro-pregnancy (53% vs. 82%) and Near Pro-pregnancy (28% vs. 8%) were identified. Ambivalent-pregnancy (14%) and Anti-pregnancy (10%) were specific to females and males, respectively. Near Pro-pregnancy females and Anti-pregnancy males were more likely to be sexually active, older, of Hispanic descent, report receiving public assistance, and have a teen mother than adolescents classified as Delayed Pro-pregnancy. Females with a pregnancy history were more likely to be classified as Ambivalent than Delayed Pro-pregnancy.

DISCUSSION

While most adolescents intend to delay or avoid childbearing, there are subsets of adolescents whose pregnancy intentions are in favor of early childbearing, which is often dismissed in adolescent sexual and reproductive health. Current efforts can use these distinct pregnancy intention classes to tailor sexual and reproductive health services specifically for diverse adolescent populations.

Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs

Despite its central importance to global family planning, the "unmet need for contraception" metric is frequently misinterpreted. Often conflated with a lack of access, misinterpretation of what unmet need means and how it is measured has important implications for family planning programs. We review previous examinations of unmet need, with a focus on the roles of access and demand for contraception, as well as the role of population control in shaping the indicator's priorities. We suggest that disaggregating unmet need into "demand-side unmet need" (stemming from lack of demand) and "supply-side unmet need" (stemming from lack of access) could allow current data to be leveraged into a more person-centered understanding of contraceptive need. We use Demographic and Health Survey data from seven sub-Saharan African countries to generate a proof-of-concept, dividing women into unmet need categories based on reason for contraceptive nonuse. We perform sensitivity analyses with varying conceptions of access and disaggregate by education and marital status. We find that demand-side unmet need far exceeds supply-side unmet need in all scenarios. Focusing on supply-side rather than overall unmet need is an imperfect but productive step toward person-centered measurement, while more sweeping changes to family planning measurement are still required.

"It changed the atmosphere surrounding the baby I did have": Making sense of reproduction during the COVID-19 pandemic

Objective

This study examines the schemas that women employed during the COVID-19 pandemic to make sense of their reproductive desires.

Background

Existing research on reproduction during epidemics suggests that there are variable population responses to periods of long-term social uncertainty. However, less is known about how individuals make sense of maintaining or adapting their reproductive desires during periods of social upheaval.

Method

Twenty-nine women aged 25-35 from a mid-sized Midwestern county in the United States were recruited and interviewed about their experiences during the first 8 months of the COVID-19 pandemic. They were asked about their daily lived experiences and their reproductive desires during in-depth interviews. These interviews were transcribed and analyzed using thematic coding.

Results

Participants used three normative schemas to describe their reproductive desires during the COVID-19 pandemic. Heteronormative schemas were used by many participants to articulate their commitment to a heteronormative aged-staged timeline of life events. Schemas of social support around being pregnant and giving birth were used by participants, primarily those who were currently or recently pregnant, to express grief and loss over the relational experience of having a new baby. Medicalized schemas were expressed by most participants to describe feelings of fear and risk at real or imagined encounters with medical institutions.

Conclusion

The schemas that participants used to make sense of their reproductive desires demonstrate how sense-making during a profound event that affects everyday realities allows participants to (re)articulate commitments to existing narratives that reinforce heterosexual, social, and medicalized hierarchies in reproduction.

AIM for Teen Moms: Social Support's Role in Contraception Use Among Young Mothers

PURPOSE

Rapid repeat pregnancy is associated with negative outcomes for teen mothers and their offspring. Contraceptive use can reduce this risk. We explored the impact of AIM for Teen Moms, a future-oriented behavioral intervention, on emotional and tangible support and the influence of this support on the attitudes, intentions, and past 3-month contraceptive use behaviors.

METHOD

Participants were 295 first-time moms (ages 15-19) in Los Angeles County who participated in a randomized control trial intervention to reduce rapid repeat pregnancies. Participants completed surveys at baseline and 36-months. Hypotheses were tested using multivariate and interaction analysis.

RESULTS

Teen mothers in treatment group reported more emotional (β =.13, p < .05) and tangible support (β =.13, p < .05). Higher tangible support was positively associated with birth control attitudes (β =.13, p < .05), which, in turn, predicted intention to use birth control (β =.31, p < .001). Intention to use birth control also predicted higher past 3-month birth control use (β =.18, p < .01); there was also a direct path from attitude to 3-month birth control use (β =.35, p < .001). There was no association between emotional support and birth control attitudes, intentions, or behaviors.

CONCLUSION

AIM for Teen Mom's effects on contraception use at 36 months was mediated by social support, specifically tangible support, which, in turn, affected birth control attitudes, intentions, and reported birth control use. Interventionists must consider how intervention content can specifically address the building of target support to meet the needs of teen mothers.

Factors influencing adolescents' healthy pregnancy preparation behavior: a cross-sectional gender comparison applying the health belief model

BACKGROUND

Interventions to prepare for a healthy pregnancy from an early age can ensure the health of both mother and child. This study aims to compare the factors associated with healthy pregnancy preparation behavior (HPPB) among male and female adolescents.

METHODS

A total of 690 Korean adolescents participated in this cross-sectional study from July 11 to August 24, 2018. Determinants of the likelihood of engaging in HPPB were described using hierarchical regression about the importance of and confidence in HPPB, the gender equality related to pregnancy and birth, and the health belief model (HBM) constructs about HPPB.

RESULTS

Smoking experience (β = - 0.18, p < 0.001 for boys, β = - 0.25, p < 0.001 for girls), and HBM constructs were identified as factors correlated with HPPB in both genders. The significant factors in boys were perceived susceptibility (β = - 0.13, p = 0.005), perceived severity (β = 0.12, p = 0.015), perceived benefits (β = 0.23, p < 0.001), and perceived barriers (β = - 0.18, p < 0.001), whereas the corresponding factors in girls were perceived severity (β = 0.20, p = 0.001), and perceived barriers (β = - 0.23, p < 0.001). The importance of HPPB was identified as a factor only among girls (β = 0.19, p = 0.005), while confidence in HPPB (β = 0.12, p = 0.401), gender equality related to pregnancy and childbirth (β = - 0.20, p = 0.001 for women's responsibility variable, β = 0.14, p = 0.018 for men's responsibility variable), and alcohol (β = - 0.10, p = 0.022) were factors identified only among boys.

CONCLUSIONS

The gender differences in opinions on HPPB identified in this study can help nurses and community health care professionals recognize issues for which they can develop and implement preventive interventions. For healthy pregnancy preparation, interventions based on HBM constructs and smoking should be presented for both male and female adolescents. Imparting education to females on the importance of HPPB and to males on confidence in HPPB, gender equality related to pregnancy and childbirth, and alcohol consumption, should be emphasized. In addition, as perceived susceptibility may be low in a disease prevention model using the health belief model, it is necessary to prioritize increasing the perceived susceptibility of school-age children as an intervention.

Doctor Knows Best? Provider Bias in the Context of Contraceptive Counseling in the United States

OBJECTIVES

The study examined how clinicians described their patients in relation to their practices of contraceptive counseling.

STUDY DESIGN

This qualitative study involved individual interviews with 15 clinicians working in obstetrics and gynecology in South Carolina about their approaches to contraceptive counseling. We analyzed the data using a combination of deductive and inductive approaches.

RESULTS

Clinicians attributed challenges of working with diverse patient populations to patients' race/ethnicity, socioeconomic status, and age. Clinicians often interpreted patient concerns about or refusal to use effective contraceptive methods as a problem with patients themselves. When clinicians described patients in disparaging ways, they often focused on adolescent patients.

CONCLUSION

Bias informed by structural inequalities and power relations influences how clinicians perceive their patients and approach counseling them about contraception. Such practices may limit patients' informed decision-making and autonomy when making decisions about initiating or continuing contraceptive use.

The role of education and migration background in explaining differences in folic acid supplementation intake in pregnancy: results from a German birth cohort study

OBJECTIVE

Official German recommendations advise women to start taking folic acid supplementation (FAS) before conception and continue during the first pregnancy trimester to lower the risk of birth defects. Women from lower socio-economic background and ethnic minorities tend to be less likely to take FAS in other European countries. As little is known about the determinants of FAS in Germany, we aimed to investigate the association between FAS and formal education and migration background, adjusting for demographic factors.

DESIGN

We used data (2013-2016) on nutrition and socio-economic and migration background from the baseline questionnaire of the BaBi cohort study. We performed multivariate regressions and mediation analyses.

SETTING

Bielefeld, Germany.

PARTICIPANTS

Nine-hundred forty-seven women (pregnant or who had given birth in the past 2 months).

RESULTS

16.7% of the participants (158/947) did not use FAS. Migration-related variables (e.g. language, length of stay) were not associated with FAS in the adjusted models. FAS was lower in women with lower level of formal education and in unplanned pregnancies. Reasons given by women for not taking FAS were unplanned pregnancy and lack of knowledge of FAS.

CONCLUSIONS

Health practitioners may be inclined to see migrant women as an inherently at-risk group for failed intake of FAS. However, it is primarily women who did not plan their pregnancy, and women of lower formal education level, who are at risk. Different public health strategies to counter low supplementation rates should be supported, those addressing the social determinants of health (i.e. education) and those more focused on family planning.

"Spoiled" girls: Understanding social influences on adolescent contraceptive decision-making in Kenya

OBJECTIVES

Despite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents' own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents.

METHODS

Using community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15-19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making.

RESULTS

Participants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk.

CONCLUSIONS

Contraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents' seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.

Structural Inequity and Pregnancy Desires in Emerging Adulthood

Public health discourses often claim that delaying pregnancy is associated with social and economic benefits. Yet research suggests that, for young people, structural inequity is most influential in future outcomes, regardless of childbearing. We conducted in-depth interviews with 50 young women (ages 18-24) and their male partners (n = 100) and investigated the influence of structural inequity on pregnancy desires and plans. Three themes emerged, stratified by social advantage. In the "Things Will Be Different Later" theme, socially advantaged participants envisioned that their future lives would surely be different due to achievement of educational, professional, and economic goals; thus, their pregnancy plans aligned with their desires, often reflected in use of highly effective contraception. In the "I Don't Have Everything I Need" theme, participants expressed delaying desired pregnancies (primarily through condom use) until they could contend with structural barriers. Their pregnancy plans, shifted by way of structural inequity, were not aligned with their desires. Under the "I'll Never Have Everything I Need" theme, socially disadvantaged participants expressed significant doubt about ever realizing ideal circumstances for pregnancy preparedness; as pregnancy prevention was not salient, these participants used condoms or no contraception. This analysis indicates that structural inequities constrain reproductive self-determination in emerging adulthood, creating a chasm between desired and actual childbearing that was reflected in contraceptive decision-making. Public health narratives emphasizing the importance of pregnancy prevention for socially disadvantaged groups without addressing the manifestation of structural inequity in their lives perpetuate reproductive oppression vis-à-vis emphasis on contraceptive use to ensure future economic success.

Pregnancy decision-making in women with physical disabilities

BACKGROUND

Women with physical disabilities experience barriers to knowledge about pregnancy and adequate reproductive healthcare, which impedes decision-making processes and negatively impacts their pregnancy planning.

OBJECTIVE

The purpose of this study was to learn more about pregnancy decision-making in women with physical disabilities.

METHODS

We conducted a qualitative study utilizing semi-structured interviews with women with physical disabilities. We asked questions regarding pregnancy, parenting, reproductive health, relationships and interactions with the healthcare system. We utilized interview transcripts and notes to form a codebook regarding pregnancy and parenting decision-making, knowledge, and fears. We then organized codes into themes based on pre-existing literature regarding fertility and conceptualization of the self.

RESULTS

We completed and analyzed 16 interviews. Themes overall reflected the participants grappling with their own baseline assumptions that they were infertile, as well as managing similar assumptions from others. However, many of the participants recall an exact point where they began to contemplate the fact that having children was possible for them. Finally, disability-related parenting challenges are considered very early in pregnancy decision-making process.

CONCLUSIONS

Women with physical disabilities experience barriers to contemplating pregnancy including inadequate information on pregnancy and reproductive healthcare that affects their decision-making regarding pregnancy and parenting. All healthcare providers should talk to patients with disabilities about family planning and address possible barriers to contemplating pregnancy.

"It's Worked Well for Me": Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods

STUDY OBJECTIVE

To understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.

DESIGN

In-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.

SETTING

Two youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.

PARTICIPANTS

Twenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Young women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.

RESULTS

Young women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.

CONCLUSION

Young women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

"I can try and plan, but still get pregnant": The complexity of pregnancy intentions and reproductive health decision-making for adolescents

INTRODUCTION

Teen pregnancy rates have declined in the United States; however, disparities continue to persist particularly among minority, low-income adolescents. A greater understanding of how pregnancy intentions are conceptualized for adolescents, and the role of the social context may illuminate reasons for disparities. The aim of this study was to expand the lens in which adolescents' perspectives of pregnancy are studied by exploring the contextual factors that frame how pregnancy intentions are developed among urban adolescents.

METHODS

Thirteen focus groups (N = 46) were conducted with male and female adolescents 15-19 years old in Baltimore, Maryland. Participants were recruited from local high schools, and focus groups were stratified by sex and age (15-17 and 18-19). A phenomenological approach was applied to analyze the data both deductively and inductively, allowing for themes to emerge and align within an existing conceptual framework.

RESULTS

Two themes identified were stated pregnancy intentions and shared schemas of sex and pregnancy. Participants discussed a range of pregnancy intentions and expressed five social perspectives which informed those intentions: sex is a gendered responsibility, teen pregnancy is cyclical and common, teen pregnancy is not a completely negative experience, having a child fulfills emotional and relational voids, and pregnancy should happen early, just not too early.

CONCLUSION

Pregnancy intentions for adolescents are expansive and driven by complex social perspectives set in their context. More consideration of the context is needed to provide and offer adolescents, particularly those of vulnerable communities, supports that align with their reproductive health needs.

Pathways to Modern Family Planning: A Longitudinal Study on Social Influence among Men and Women in Benin

Despite improvements in family planning (FP) knowledge and services in West Africa, unmet need for FP continues to grow. Many programs apply a demographically and biologically driven definition of unmet need, overlooking the complex social environment in which fertility and FP decisions are made. This longitudinal, qualitative cohort study captures the changing nature of FP need, attitudes and behaviors, taking into account life context to inform understanding of the complex behavior change process. Purposively sampled, 25 women and 25 men participated in three rounds of in‐depth interviews over 18 months. Analyses used a social network influence lens. Findings suggest alignment of six foundational building blocks operating at individual, couple, services, and social levels is essential to meet FP need. If one block is weak, a person may not achieve met need. Women and men commonly follow five pathways as they seek to fulfill their FP need. Some pathways achieve met need (determined users, quick converters), some do not (side effect avoiders), and some do not lead to consistent FP outcomes (male‐priority decision makers, gender–egalitarian decision makers). Findings clarify the role of social determinants of FP and offer insight into program approaches informed by user typologies and return on program investments.

The Role of Health Care Providers in Young Women's Attitudes about and Willingness to Use Emergency Contraceptive Pills

BACKGROUND

Emergency contraceptive pills (ECPs) are an underused resource among adolescent and young adult women who have unprotected sex. This analysis examines young women's attitudes about and willingness to use ECPs, with particular attention to their experiences with health care providers.

METHODS

Sexually active young women (ages 15-25, assigned female at birth, N = 212) completed a self-administered survey at 10 family planning clinics in the San Francisco Bay Area. Participants reported attitudes about ECP effectiveness, safety, effect on sex drive, and whether it should not be taken often, and their willingness to use ECPs in the next 3 months. The predictors of interest were past and current contraceptive experiences with health care providers. Data were analyzed through descriptive statistics and multivariable logistic regression analyses controlling for sociodemographic characteristics, prior contraceptive use, pregnancy history, and pregnancy intentions.

RESULTS

Most young women agreed that ECPs are effective at preventing pregnancy (75%) and safe to use (71%); few reported that they reduce sex drive (11%). Yet, the majority (62%) believed ECPs should not be taken often and only 35% reported willingness to use ECPs. In multivariable analyses, more positive health care experiences were associated with more positive attitudes about ECP safety, less concern that ECPs should not be taken often, and greater willingness to use ECPs (p < .05).

CONCLUSIONS

Health care providers play an important role in the acceptance and provision of ECPs, especially for young women who prefer ECPs over other contraceptive methods. In particular, providers can use the contraceptive visit as an opportunity to destigmatize repeat ECP use.

Development and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults

PURPOSE

We developed and validated a measure that assesses the latent construct of sexual and reproductive empowerment among adolescents and young adults. A specific measure for this group is critical because of their unique life stage and circumstances, which often includes frequent changes in sexual partners and involvement from parents in decision-making.

METHODS

After formative qualitative research, a review of the literature, and cognitive interviews, we developed 95 items representing nine dimensions of sexual and reproductive empowerment. Items were then fielded among a national sample of young people aged 15-24 years, and those who identified as sexually active completed a 3-month follow-up survey. We conducted psychometric analysis and scale validation.

RESULTS

Exploratory factor analysis on responses from 1,117 participants resulted in the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults, containing 23 items captured by seven subscales: comfort talking with partner; choice of partners, marriage, and children; parental support; sexual safety; self-love; sense of future; and sexual pleasure. Validation using logistic regression demonstrated that the subscales were consistently associated with sexual and reproductive health information and access to sexual and reproductive health services measured at baseline and moderately associated with the use of desired contraceptive methods at 3-month follow-up.

CONCLUSIONS

The Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults is a new measure that assesses young people's empowerment regarding sexual and reproductive health. It can be used by researchers, public health practitioners, and clinicians to measure sexual and reproductive empowerment among young people.

Young adult US-born Latina women's thoughts, feelings and beliefs about unintended pregnancy

Current measures of unintended pregnancy underestimate the co-occurring, complex set of social, cultural, economic and structural factors that influence how women interpret unintended pregnancy. The purpose of this study was to prospectively explore young adult US-born Latinas' thoughts, feelings and beliefs about pregnancy, specifically unintended pregnancies and the sociocultural factors identified as contributors to those beliefs. In-depth interviews (n = 20) were conducted with US-born, English-speaking Latinas aged 18-25 years in south Florida. Seventeen participants did not intend to get pregnant, while the remaining participants (n = 3) reported that their intentions kept changing. Participants' beliefs regarding their unintended pregnancy were influenced by social and economic hardship and cultural factors such as fatalism and familismo. Ideas and the meaning of pregnancy differed based on the woman's pregnancy resolution decision. Many women felt the term 'unintended pregnancy' placed blame on women and was stigmatising. When discussing pregnancy planning, most participants felt that women should not plan their pregnancies and doing so was going against fate. Findings suggest that salient influences such as culture and the social determinants related to unintended pregnancy should be incorporated into measurements examining unintended pregnancy.

"We Kind of Met In-Between": A Qualitative Analysis of Young Couples' Relationship Dynamics and Negotiations About Pregnancy Intentions

CONTEXT

The literature on reproductive decision making often focuses on women and neglects the role of men and the importance of relationship context. Research with couples is vital to understanding joint decision making regarding having children at various stages of a couple's relationship and an individual's life course.

METHODS

In-depth, individual interviews were conducted with a socioeconomically, racially and ethnically diverse sample of 50 young heterosexual women and their male partners in northern California in 2015-2016. A dyadic, thematic analytic approach was used to examine whether and how prospective pregnancy intentions and current pregnancy desires are negotiated at the couple level, and how relationship dynamics influence any negotiation and decision-making processes.

RESULTS

Twenty-three couples described engaging in joint pregnancy decision making, which required purposeful communication and, for some, compromise and acceptance. For nearly all of these couples, these processes led to aligned prospective pregnancy intentions, even when current pregnancy desires differed. The remaining 27 couples described individual pregnancy decision-making processes; many respondents reported intentions that aligned with their partner's by happenstance, despite some respondents having avoided communicating their desires to their partner. Some of these couples faced relationship difficulties, including poor communication, leading some participants to misinterpret or be unaware of their partner's pregnancy intentions and desires.

CONCLUSIONS

The relationship context is important in the formulation of prospective pregnancy intentions among young people. Counseling protocols, interventions and policies that attend to the complex factors that influence young couples' pregnancy decision making are needed to better help couples attain their reproductive goals.

Delivering family planning and preconception care to women with diabetes: Implementation challenges and promising strategies

Diabetes is increasingly prevalent among women of reproductive age and during pregnancy. The American Diabetes Association, which has called for improvements in the patient-centeredness of care, recommends preconception counseling and care for women of reproductive age with diabetes. However, data suggests this care is not sufficiently delivered. In this article, we describe demographic shifts in the need for preconception care and outline several changes at the clinical encounter as well as the health system- and community-levels that can help improve the delivery of diabetes-specific preconception care.

Continuation of Unintended Pregnancy

Background

Forty-four percent of all pregnancies worldwide are unintended. Induced abortion has drawn a lot of attention from clinicians and policy makers, and the care for women requesting it has been covered in many publications. However, abortion challenges the values of many women, is associated with negative emotions, and has its own medical complications. Women have the right to discuss their unintended pregnancy with a clinician and receive elaborate information about other options to deal with it. Continuing an unintended pregnancy, and receiving the necessary care and support for it, is also a reproductive right of women. However, the provision of medical information and support required for the continuation of an unintended pregnancy has hardly been approached in the medical literature.

Objective

This review presents a clinical approach to unintentionally pregnant patients and describes the information and support that can be offered for the continuation of the unintended pregnancy.

Discussion

Clinicians should approach patients with an unintended pregnancy with a sympathetic tone in order to provide the most support and present the most complete options. A complete clinical history can help frame the problem and identify concerns related to the pregnancy. Any underlying medical or obstetric problems can be discussed. A social history, that includes the personal support from the patient's partner, parents, and siblings, can be taken. Doctors should also be alert of possible cases of violence from the partner or child abuse in adolescent patients. Finally, the clinician can provide the first information regarding the social care available and refer the patients for further support. For women who continue an unintended pregnancy, clinicians should start antenatal care immediately.

Conclusion

Unintentionally pregnant women deserve a supportive and complete response from their clinicians, who should inform about, and sometimes activate, all the resources available for the continuation of unintended pregnancy.

Summary

Forty-four percent of all pregnancies worldwide are unintended. Induced abortion has drawn a lot of attention and the care for women requesting it has been covered in many publications. However, abortion challenges the values of many women, is associated with negative emotions, and has its own medical complications. Women have the right to discuss their unintended pregnancy with a clinician and receive elaborate information about other options to deal with it. Continuing an unintended pregnancy, and receiving the necessary care and support for it, is also a reproductive right of women. However, the provision of medical information and support required for the continuation of an unintended pregnancy has hardly been approached in the medical literature. This review presents a clinical approach to unintentionally pregnant patients and describes the information and support that can be offered for the continuation of the unintended pregnancy. Clinicians should approach patients with an unintended pregnancy with a sympathetic tone. A complete clinical history can help frame the problem and identify concerns related to the pregnancy. Any underlying medical or obstetric problems can be discussed. A social history, that includes the personal support from the patient's partner, parents, and siblings, can be taken. Doctors should also be alert of possible cases of violence from the partner or child abuse in adolescent patients. Finally, the clinician can provide the first information regarding the social care available and refer the patients for further support. For women who continue an unintended pregnancy, clinicians should start antenatal care immediately.

The Misclassification of Ambivalence in Pregnancy Intentions: A Mixed-Methods Analysis

CONTEXT

Researchers have developed various measures of pregnancy ambivalence in an effort to capture the nuance overlooked by conventional, binary measures of pregnancy intention. However, the conceptualization and operationalization of the concept of ambivalence vary widely and may miss the complexity inherent in pregnancy intentions, particularly for young people, among whom unintended pregnancy rates are highest.

METHODS

To investigate the utility and accuracy of current measures of pregnancy ambivalence, a mixed-methods study was conducted with 50 young women and their male partners in northern California in 2015-2016. Survey data were used to descriptively analyze six existing pregnancy ambivalence measures; in-depth interviews addressing pregnancy desires and plans were deductively coded and thematically analyzed to understand why some participants appeared to be ambivalent from the survey data when their interview responses suggested otherwise.

RESULTS

Eighty participants would be considered ambivalent by at least one measure. After assessment of the interview data, however, these measures were deemed to have misclassified almost all (78) participants. Qualitative analysis revealed several themes regarding misclassification: conflation of current pregnancy desires with expected postconception emotional responses; acceptability of an undesired pregnancy; tempering of survey responses to account for partners' desires; perceived lack of control regarding pregnancy; and, among participants with medical conditions perceived to impact fertility, subjugation of pregnancy desires in the interest of self-protection.

CONCLUSIONS

Current approaches to measuring pregnancy ambivalence may fail to capture the intricacies of pregnancy intentions and may be ineffective if they do not account for young people's experiences, especially when used to inform clinical practice, programs and policy.