Title: Planning for pregnancy: an integrated pathway to plan or prevent pregnancy and mitigate the adverse health effects of unplanned pregnancy to improve outcomes for women and their families
Funder: Department of Health and Social Care

Abstract: Aim To provide the research and practical evidence base to deliver quality improvement in preconception care, to prevent unplanned pregnancies and abortion, and to mitigate the adverse impacts of unplanned pregnancies.Background Preconception care has been overlooked at every level of the NHS, despite a strong evidence base for the benefits to women and their children. Only 55% of women planned their last pregnancy, and most will have done so with little or no help from the NHS. To improve pregnancy planning and the uptake of preconception care, clinicians need a rapid, low-cost way of assessing a woman's prospective pregnancy intentions. If she wishes to become pregnant in the next year, preconception health advice can be given. If not, discussion can focus on contraceptive needs to prevent unplanned pregnancies and abortions, of which nearly 200,000 take place in the NHS each year. Unplanned pregnancies are a marker of, and contribute to, health inequalities and are associated with adverse outcomes, such as low birthweight, preterm birth and postnatal depression. However, women with unplanned pregnancies are not identified during antenatal care, unplanned pregnancy is not recognised as a risk factor for adverse birth outcomes, and services are not offered to these women to mitigate their risk.Methods I will refine and field-test the Desire to Avoid Pregnancy' (DAP) scale, a set of questions that assesses a non-pregnant woman's stance towards future pregnancy. This can be used to triage women to preconception care or contraception advice. For this 1000 women will complete the DAP at baseline and I will follow them up for one year to determine the predictive value of the DAP. Simultaneously I will work with women and clinicians to design the implementation of the DAP in a range of primary care settings.To detect women with a current unplanned pregnancy, I will pilot the London Measure of Unplanned Pregnancy (LMUP) in antenatal care at University College London Hospital. The LMUP is a psychometrically validated measure of pregnancy intention, using six questions to score a pregnancy from zero (most unplanned) to twelve (most planned). Building on my PhD research, I will map the causal pathways from unplanned pregnancy to maternal behaviours and adverse outcomes to understand how unplanned pregnancy leads to adverse outcomes. I will then work with women, midwives and clinicians to design referral pathways to mitigate the impact of unplanned pregnancies.Benefit to patients and NHS Patients will benefit from this work because NHS services will be better equipped to meet their reproductive needs regarding pregnancy planning and prevention. Women will be in better health prior to pregnancy, increasing their chances of a healthy pregnancy and better health outcomes for mother and baby in the short and long-term. Women receiving personalised contraceptive care will be at lower risk of an unplanned pregnancy and abortion, but those who do experience an unplanned pregnancy will be identified and supported to reduce the associated adverse outcomes.The NHS will benefit from this work through savings from the unplanned pregnancies and abortions avoided, estimated to cost ~200,000,000 per year. The DAP will result in a more efficient use of clinician time. Using the LMUP in routine antenatal care will provide a public health surveillance system which can be used to estimate the incidence of (un)planned pregnancy, monitor health inequalities, determine which groups of women are most at risk and tailor services accordingly. Overall the research will lead to a package of services that will contribute to national targets related to reducing health inequalities, preventing unplanned pregnancy and improving pregnancy outcomes, including perinatal mental health, birthweight, stillbirth and neonatal and maternal death.

Lay abstract: Aim: Our research aims to help women have babies by choice, not by chance, to attain the best health they can before becoming pregnant, and to prevent poor pregnancy outcomes, particularly in women with unplanned pregnancies.Background: For most women there are times in their life when they want to avoid pregnancy, and times when they want to have a baby. When they want to get pregnant, there are some things that women and men can do to improve their health and the chances of a healthy pregnancy. This includes stopping smoking, reaching a healthy weight and taking folic acid. But not everyone knows about this and it can be hard to get the right advice at the right time. When they do not want to get pregnant, women need help to choose the method of contraception that suits them best, else they are at risk of having an unplanned pregnancy.We plan to tackle both of these issues. We will test a set of quick and simple questions to determine whether women are thinking about becoming pregnant in the next year. Doctors and nurses can then discuss with women either how to prepare for a pregnancy or which methods of contraception might be right for them. In this way pregnancy planning can be improved and unplanned pregnancies and abortions reduced.Yet unplanned pregnancies will always occur. We know that they are linked with poor outcomes, such as low birthweight, being born too early and depression after birth. We will work to find out how and why this is the case. Then we can design services to support women with an unplanned pregnancy to try stop these poor outcomes from happening. Design and methods used: At the moment, doctors and nurses do not routinely ask women whether they are thinking about getting pregnant in the next year. We are going to test the Desire to Avoid Pregnancy' (DAP) scale to fill this gap. The DAP is a set of questions about feelings and preferences regarding pregnancy and what the practical consequences would be if pregnancy were to occur.First we will conduct interviews with women who are not pregnant to see what they think of the DAP. Next we will recruit 1000 women who are not pregnant from services across the NHS, such as general practice, family planning, health visitor, fertility and abortion clinics, and through adverts on social media. These women will complete the DAP and will be followed up three times over one year. We will be looking to see how many of them become pregnant and if this matches their results using the DAP.While we are testing the DAP we will interview women, doctors and nurses to find out how they would like to use the DAP. For example, would women prefer to answer the DAP questions themselves online or to have the doctor or nurse ask them the questions? We will also explore how doctors and nurses can use the results to start a conversation around planning for or avoiding pregnancy. We will use the results of this work to inform how best to start using the DAP in the NHS to improve a couple's health before pregnancy and to prevent unplanned pregnancies and abortions.To find women with unplanned pregnancies we will pilot the use of the London Measure of Unplanned Pregnancy' (LMUP) in antenatal care at University College London Hospital. The LMUP uses six questions to assess how planned or unplanned the current pregnancy is. To know how best to support women with an unplanned pregnancy we need to know how unplanned pregnancies are linked to poor outcomes. We will be using data we already have to explore this. We will use these findings, and interviews with women with unplanned pregnancies, midwives and doctors, to design services to meet the needs of these women. The aim of these services will be to prevent poor outcomes such as low birthweight.Dissemination: The focus for the feedback of our results will be on the policy makers and service providers. They are the people who are in the right place to make changes to services. All the women who take part in the research will be asked whether and how they would like to be told about the study results.

Research activity codes: 3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH