Expecting the unexpected: Unintended pregnancies and desire for children amongst persons with psychiatric vulnerability

This project utilized both quantitative and qualitative research approaches to achieve the following objectives (1) understand the frequency of unintended pregnancies (UPs) in women with psychiatric vulnerability in the Netherlands, (2) explore the experiences of current and former mental health patients regarding family and pregnancy planning, (3) investigate the experiences of patients during UPs, and (4) examine the perspectives of patients and mental health professionals (MHPs) on discussing family planning in Dutch mental healthcare settings. Results from a systematic review and meta-analysis demonstrated that women with psychiatric vulnerability face a higher likelihood of UPs compared to those without psychiatric vulnerability. A retrospective cohort study was conducted on 2312 women who delivered at OLVG, the largest maternity hospital in Amsterdam, between 2015 and 2020. Maternal and neonatal outcomes were also compared between planned and unplanned pregnancies, with an exploration of the mediating effect of psychiatric vulnerability. High rates of UPs amongst women with psychiatric vulnerability were shown (39% versus 29% in women without psychiatric vulnerability). We found comparable outcomes in all four groups for all clinically relevant maternal and neonatal outcomes like hypertensive disorders, gestational diabetes, mode of delivery, low birth weight, premature birth, Apgar score after birth and admission to a neonatal ward. An exploratory survey with members of the MIND mental health care panel showed that mental health issues significantly influenced family planning, pregnancy, sexuality, and parenthood for patients and their relatives. Focus groups, including women with psychiatric vulnerability illustrated how shadows of the past (childhood trauma and inadequate parenting), present (the burden and awareness of psychiatric vulnerability) and future (fear of motherhood and insecurity) impacted (past) family planning decisions. Interviews with women with psychiatric vulnerability who experienced UPs, as well as their partners, showed that UPs had a substantial impact on women and partners, but they adapted to the new situation, and appropriate support during pregnancy gave rise to behavioral change and installed a window of opportunity to break the chain of transgenerational trauma. Two additional surveys were conducted among the MIND panel and mental healthcare providers, specifically addressing family planning and pregnancy in mental healthcare. Despite a strong desire for discussions on family planning in mental healthcare, only one in five patients had the opportunity to engage in such conversations. We unveiled existing barriers to discussing family planning, including the fear of broaching the topic, lack of knowledge, and time constraints. The implementation of the "family check-tool" aims to facilitate more effective conversations between healthcare providers and patients on these crucial topics. Training opportunities will be facilitated for MHPs to implement the family check-tool. Also, continued affords are made to incorporate the topic of reproductive health related to psychiatry in various educational programs in the Netherlands, such as the school of medicine, psychiatry residency programs and other relevant mental health studies such as psychiatric nursing. By acknowledging the significance of the reproductive health themes of family planning, childlessness and UPs for individuals with psychiatric vulnerability, this thesis underscores the importance of addressing reproductive matters in psychiatric healthcare and literature.