Reproductive Life Course Research Articles

First birth and total fertility rate in women with surgically verified endometriosis - A nationwide register study of 18 320 women across reproductive life course.

Endometriosis is associated with pain and infertility. However, little is known about birth rate among women with endometriosis on population level. We studied whether women with endometriosis have lower birth rate than women in the general population. This historical population-based cohort study used data from 18 320 fertile-aged women with first surgical verification of endometriosis in 1998-2012. Women with endometriosis were further divided into sub-cohorts: women with solely peritoneal (n = 5786), ovarian (n = 6519) and deep endometriosis (n = 1267). Women with combined types and rare forms of endometriosis formed a sub-cohort of combined/other endometriosis (n = 4748). The reference cohort comprised 35 788 women. The follow-up started at the age of 15 years and ended at first birth, sterilization/bilateral oophorectomy/hysterectomy, emigration, death, age of 50 years, or December 31, 2019. From Kaplan-Meier survival curves of not giving birth, that is, until the first birth, we assessed the statistical difference of first births with crude and adjusted restricted mean survival time (RMST). In addition, we studied the fertility rate of women until the end of follow-up. Altogether 12 491 (68.2%) women with endometriosis compared with 28 871 (80.7%) reference women gave birth during follow-up. Women with peritoneal and deep endometriosis had higher first birth rate (73.1% and 71.3%) compared with women with ovarian and combined/other forms of endometriosis (65.2% and 65.5%) (p < 0.001). The RMST of not giving birth was longer in women with endometriosis 18.9 (18.8-19.0) years compared with the reference cohort 15.5 (15.4-15.6) with both crude and adjusted RMST difference (p < 0.001). Moreover, each sub-cohort showed a longer RMST of not giving birth than reference cohort (p < 0.001). Total fertility rate of women was 1.33 (SD 1.16) in the endometriosis and 1.89 (1.46) in the reference cohort (p < 0.001) with smaller differences among endometriosis sub-cohorts. Findings suggest that fertility outcome is compromised depending on the endometriosis subtype. Thus, timely diagnosis and appropriate treatment might be beneficial for fertility.

Postpartum Health Disparities During the Birth Hospitalization in the United States: A Scoping Review.

Despite over 50% of maternal deaths occurring during the postpartum period, with significant disparities for structurally marginalized people, this is an understudied period in the reproductive life course. This review aims to describe the scope of the literature on postpartum health disparities during the birth hospitalization. We searched five databases (MEDLINE®, Embase, CINAHL, Web of Science, and PsychInfo) for primary research studies in the USA in English that measured a postpartum maternal outcome during the birth hospitalization and compared the outcome across at least two groups. We excluded studies that solely examined maternal mortality or severe maternal morbidity, gray literature, and review articles. We extracted data using the National Institute for Minority Health and Health Disparities (NIMHD) Research and PROGRESS-Plus Frameworks. We extracted data from the 22 studies that met inclusion criteria. All studies identified a disparity. The most commonly reported PROGRESS-Plus individual characteristic was race. No studies reported occupation, parental/maternity leave, disability, gender identity, sexual orientation, culture, acculturation, religion, social capital, or social support. Postpartum outcomes and variables explored for association with those outcomes were predominantly at the individual and interpersonal levels, with limited to no examination at the community, health system, and societal level. There is a critical gap in the literature on postpartum health disparities during the birth hospitalization. Knowledge gained from this review can guide perinatal clinicians and researchers in expanding their approach to addressing postpartum health disparities using intersectional axes of identity, socioeconomic status, and structural barriers.

Contraceptive Use and Discontinuation Among Adolescent Women in 55 Low- and Middle-Income Countries

Adolescent women aged 19 or younger make up a substantial and growing proportion of women of reproductive age in low- and middle-income countries. Several key features of the reproductive life course ground the need to disaggregate the contraceptive behaviors of adolescent women from those of older women, including relationship dynamics, resources and autonomy, and cultural and societal expectations regarding sexual activity and childbearing. Despite the importance and unique life course features of adolescent women, we lack the information about their contraceptive dynamics—especially their patterns of contraceptive discontinuation—needed to direct improvements to family planning programs for this oft-neglected group. We use Demographic and Health Surveys from 55 countries to describe contraceptive dynamics among adolescent women, comparing them with trends among women aged 20–49. We find that adolescent women tended to use reversible, short-acting methods, whereas those later in the reproductive life course tended to use long-acting methods and female sterilization. Across all regions, 12-month all-method discontinuation rates among those who discontinued their method while not wanting to get pregnant ranged from 16.7 to 34.2 discontinuations per person-month for adolescent women and from 12.0 to 28.8 discontinuations per person-month for older women. Side effects and health concerns were a leading discontinuation reason for both age groups in most regions, and infrequent sex and desire to become pregnant were more frequent discontinuation reasons for adolescent women in most regions. Not since 2009 have scholars compared contraceptive discontinuation rates across multiple countries and disaggregated by age. Furthermore, no prior publication has compared specific reasons for discontinuation between adolescent and older women. Understanding the distinct contraceptive dynamics of those earliest in their reproductive life course can help direct policy and programmatic interventions.

Associations of maternal per- and polyfluoroalkyl substance plasma concentrations during pregnancy with offspring polycystic ovary syndrome and related characteristics in project viva.

Associations of maternal per- and polyfluoroalkyl substance plasma concentrations during pregnancy with offspring polycystic ovary syndrome and related characteristics in project viva.

How and What Do Women Learn About Contraception? A Latent Class Analysis of Adolescents and Adult Women in Delaware

Background:Across the reproductive life course, women receive information about contraception that may influence their contraceptive behaviors. This study examines the information sources that adolescents and older women combine to acquire information about contraception.Methods:A state-representative survey of women aged 18–44 residing in Delaware, US, in 2017 asked from what sources respondents recently learned about contraception and the type of information obtained. The 2017 Delaware Youth Risk Behavior Survey, representative of public high school students aged 14–18, included analogous questions. Latent class analysis was applied to classify respondents in both samples of adolescents (n = 1253) and adult women (n = 1008) according to the information sources they combined. We estimated multinomial logistic regressions to assess the demographic and reproductive history predictors of using each of the information source repertoires and binomial logistic regressions to analyze their relationship to the information acquired.Results:Adolescents are more likely than adults to report having recently acquired any information about contraception (76% vs. 64%), but they are more likely to rely primarily on a single source. In contrast, adult women are more likely to combine multiple sources. Age, education, and sexual activity emerged as important predictors of information source repertoires. Adults who combine information sources and adolescents who learn mainly from health care providers or school personnel report the greatest breadth in the contraception-related information acquired.Conclusion:Interventions to provide or improve contraceptive knowledge may be more effective if they account for how women use and combine information sources, particularly at different stages of their reproductive lives.

The lifetime risk of maternal near miss morbidity in Asia, Africa, the Middle East, and Latin America: a cross-country systematic analysis

The lifetime risk of maternal near miss morbidity in Asia, Africa, the Middle East, and Latin America: a cross-country systematic analysis

Mental health outcomes across the reproductive life course among women with disabilities: a systematic review.

This systematic review examined literature on mental health outcomes among women with disabilities living in high-income countries within the context of reproductive health, spanning menstruation through menopause. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched MEDLINE, CINAHL, and PsycINFO databases for studies published through June 2023. Eligible studies were observational, quantitative, and included a comparison group without disabilities. A total of 2,520 studies were evaluated and 27 studies met inclusion criteria. These studies assessed mental health during prepregnancy, pregnancy, postpartum, and parenting among women with and without disabilities. None of the studies examined reproductive health time periods related to menstruation, fertility, or menopause. Women of reproductive age with disabilities were more likely to have poor mental health outcomes compared to women without disabilities. During pregnancy and the postpartum, women with disabilities were at greater risk of diagnosed perinatal mental disorders and psychiatric-related healthcare visits. Findings also suggested mental distress and inadequate emotional and social support related to parenting among women with disabilities. The greatest risks of poor mental health outcomes were often observed among women with intellectual and developmental disabilities and among women with multiple types of disabilities, compared to women without disabilities. Routine reproductive healthcare visits provide significant prevention and treatment opportunities for poor mental health among women with disabilities. Further research examining mental health outcomes within the context of reproductive health, especially understudied areas of menstruation, fertility, parenting, and menopause, among women with disabilities is needed.

“I will find the best method that will work for me”: navigating contraceptive journeys amongst South African adolescent girls and young women

BackgroundGiven that South Africa has one of the highest rates of pregnancy amongst adolescent girls and young women (AGYW) globally, the provision of contraceptives to this group has been a key focus in recent years. Pregnancy prevention involves an on-going continuum of decision-making around contraceptive method choice, uptake, use, experience, continuation, and discontinuation.MethodsThis paper presents analysis of data from a cross-sectional survey with 2376 AGYW, as well as qualitative in-depth interviews (IDIs) with 54 AGYW, inclusive of contraceptive journey narratives. We examine the preferences, valued characteristics, choices, beliefs, understandings and experiences of choosing and using contraceptives amongst AGYW in two South African communities characterised by high rates of pregnancy.ResultsThese findings shed light on the preferences towards, beliefs about, and experiences of choosing, using and discontinuing contraceptive methods amongst this population, with survey data suggesting that the most popular methods were the injection, followed by the implant, and then the oral pill. Findings illustrate the complexity and dynamic nature of contraceptive decision-making and the varied embodied and lived experiences of contraceptive use, and how these are impacted by contraception service provision.ConclusionsOur findings show that contraception experiences of each individual are cumulative, and comprise a continuum of method initiation, use, discontinuation, method switching and on-going circular decision-making influenced by multiple social, structural, contextual and interpersonal factors, combined with shifting preferences, values and needs. To maximise the use of contraceptives amongst South African AGYW, it is necessary to provide responsive contraception service provision to reflect the changing contexts and preferences of users, in order to ensure that pregnancy prevention needs are catered for throughout their reproductive life course.

A Counterfactual Analysis of Impact of Cesarean Birth in a First Birth on Severe Maternal Morbidity in the Subsequent Birth.

It is known that cesarean birth affects maternal outcomes in subsequent pregnancies, but specific effect estimates are lacking. We sought to quantify the effect of cesarean birth reduction among nulliparous, term, singleton, vertex (NTSV) births (i.e., preventable cesarean births) on severe maternal morbidity (SMM) in the second birth. We examined birth certificates linked with maternal hospitalization data (2007-2019) from California for NTSV births with a second birth (N = 779,382). The exposure was cesarean delivery in the first birth and the outcome was SMM in the second birth. We used adjusted Poisson regression models to calculate risk ratios and population attributable fraction for SMM in the second birth and conducted a counterfactual impact analysis to estimate how lowering NTSV cesarean births could reduce SMM in the second birth. The adjusted risk ratio for SMM in the second birth given a prior cesarean birth was 1.7 (95% confidence interval: 1.5, 1.9); 15.5% (95% confidence interval: 15.3%, 15.7%) of this SMM may be attributable to prior cesarean birth. In a counterfactual analysis where 12% of the California population was least likely to get a cesarean birth instead delivered vaginally, we observed 174 fewer SMM events in a population of individuals with a low-risk first birth and subsequent birth. In our counterfactual analysis, lowering primary cesarean birth among an NTSV population was associated with fewer downstream SMM events in subsequent births and overall. Additionally, our findings reflect the importance of considering the cumulative accrual of risks across the reproductive life course.

Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study protocol: a prospective observational cohort study of reproductive-aged women living with HIV

IntroductionOver 265 000 women are living with HIV in the USA, but limited research has investigated the physical, mental and behavioural health outcomes among women living with HIV of reproductive...

The relationship between hypertensive disorders in pregnancy and endometriosis: a systematic review and meta-analysis

BackgroundEndometriosis is a chronic and debilitating disease that can affect the entire reproductive life course of women, with potential adverse effects on pregnancy. The aim of the present study is to investigate the association between hypertensive disorders in pregnancy and endometriosis.MethodRelevant articles were searched from the Cochrane Library, PubMed, Scopus and Web of Science from inception up to December 2023. The full-text observational studies published in English that had a confirmed diagnosis of endometriosis were included. The case group included pregnant women diagnosed with endometriosis at any stage, while the control group consisted of pregnant women who had not been previously diagnosed with endometriosis. Two authors extracted and analyzed the data independently. Disagreements were reconciled by reviewing the full text by a third author. Endnote X9 was used for screening and data extraction. We used fixed and random effects models in Review Manager 5.3 to analyze the pooled data. The quality of the included studies was assessed using the Downs and Black checklist.ResultsOut of the 9863 articles reviewed, 23 were selected for meta-analysis. According to the results of this study, there was an association between endometriosis and gestational hypertension (OR = 1.11, 95% CI: 1.06, 1.16; I2 = 45%, P < 0.00001; N = 8), pre-eclampsia (OR = 1.26, 95% CI: 1.18, 1.36; I2 = 37%, P < 0.00001; N = 12), and hypertensive disorders in pregnancy (OR = 1.13, 95% CI: 1.06, 1.21; I2 = 8%, P = 0.0001; N = 8).ConclusionsThis study confirmed that endometriosis may elevate the risk of developing gestational hypertensive disorders. Raising awareness of this issue will help to identify effective strategies for screening and early diagnosis of hypertensive disorders in pregnancy.

Complexities of studying fertility across the reproductive life course.

Complexities of studying fertility across the reproductive life course.

Lifetime risk of maternal near miss morbidity: a novel indicator of maternal health

BackgroundThe lifetime risk of maternal death quantifies the probability that a 15-year-old girl will die of a maternal cause in her reproductive lifetime. Its intuitive appeal means it is a widely used summary measure for advocacy and international comparisons of maternal health. However, relative to mortality, women are at an even higher risk of experiencing life-threatening maternal morbidity called ‘maternal near miss’ (MNM) events—complications so severe that women almost die. As maternal mortality continues to decline, health indicators that include information on both fatal and non-fatal maternal outcomes are required.MethodsWe propose a novel measure—the lifetime risk of MNM—to estimate the cumulative risk that a 15-year-old girl will experience a MNM in her reproductive lifetime, accounting for mortality between the ages 15 and 49 years. We apply the method to the case of Namibia (2019) using estimates of fertility and survival from the United Nations World Population Prospects along with nationally representative data on the MNM ratio.ResultsWe estimate a lifetime risk of MNM in Namibia in 2019 of between 1 in 40 and 1 in 35 when age-disaggregated MNM data are used, and 1 in 38 when a summary estimate for ages 15–49 years is used. This compares to a lifetime risk of maternal death of 1 in 142 and yields a lifetime risk of severe maternal outcome (MNM or death) of 1 in 30.ConclusionsThe lifetime risk of MNM is an urgently needed indicator of maternal morbidity because existing measures (the MNM ratio or rate) do not capture the cumulative risk over the reproductive life course, accounting for fertility and mortality levels.

FPsim: an agent-based model of family planning

The behavioral and biological underpinnings of family planning (FP) unfold on an individual level, across a full reproductive life course, and within a complex system of social and structural constraints. Yet, much of the existing FP modeling landscape has focused solely on macro- or population-level dynamics of family planning. There is a need for an individual-based approach to provide a deeper understanding of how family planning is intertwined with individuals’ lives and health at the micro-level, which can contribute to more effective, person-centered design of both contraceptive technologies and programmatic interventions. This article introduces the Family Planning Simulator (FPsim), a data-driven, agent-based model of family planning, which explicitly models individual heterogeneity in biology and behavior over the life course. Agents in FPsim can experience a wide range of life-course events, such as increases in fecundability (and primary infertility), sexual debut, contraceptive choice, postpartum family planning, abortion, miscarriage, stillbirth, infant mortality, and maternal mortality. The core components of the model—fecundability and contraceptive choice, are represented individually and probabilistically, following age-specific patterns observed in demographic data and prospective cohort studies. Once calibrated to a setting leveraging multiple sources of data, FPsim can be used to build hypothetical scenarios and interrogate counterfactual research questions about the use, non-use, and/or efficacy of family planning programs and contraceptive methods. To our knowledge, FPsim is the first open-source, individual-level, woman-centered model of family planning.

The role of primary care in optimising women's sexual and reproductive health.

The papers in this special issue explore a range of issues and opportunities across the spectrum of sexual and reproductive health in primary care, including in relation to contraception access; support for unintended pregnancies; abortion care; preconception, pregnancy, postpartum and interconception care; and issues relating to informed consent. The special issue takes a reproductive life course perspective through consideration of both pregnancy prevention and pregnancy preparation.

Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls.

There is a fundamental disconnect between the optimal management of addiction in general and care delivery in pregnancy and postpartum. Addiction is a chronic condition requiring some degree of management across the life course. Yet, in the US, reproductive care is episodic and centers more on pregnancy than at other stages of the reproductive life course. Pregnancy is prioritized in access to insurance as almost all pregnant people are Medicaid eligible but access ends at varying points postpartum. This results in a structural mismatch: the episodic management of the chronic condition of addiction only within gestational periods. Though people with substance use disorder (SUD) may access care in pregnancy, treatment attrition is common postpartum. Postpartum is a time of increased vulnerabilities where insurance churn and newborn caretaking responsibilities collide in a context of care withdrawal from the health system and health providers. In part in consequence, return to use, SUD recurrence, overdose, and overdose death are more common postpartum than in pregnancy, and drug deaths have become a leading cause of maternal deaths in the US. This review addresses interventions to support engagement in addiction care postpartum. We begin with a scoping review of model programs and evidence-informed interventions that have been shown to increase continuation of care postpartum. We then explore the realities of contemporary care through a review of clinical and ethical principles, with particular attention to harm reduction. We conclude with suggestions of strategies (clinical, research, and policy) to improve care postpartum and highlight potential pitfalls in the uptake of evidence-based and person-centered services.

Rebuilding a Reproductive Future Informed by Disability and Reproductive Justice.

Rebuilding a Reproductive Future Informed by Disability and Reproductive Justice.

The role of parity in the relationship between endometriosis and pregnancy outcomes: a systematic review and meta-analysis.

Endometriosis is a chronic and debilitating condition which can affect the entire reproductive life course of women with a potentially detrimental effect on pregnancy. Pregnancy (and increasing parity) can affect endometriosis by modulating disease severity and suppressing symptoms. Multiparous women could be less likely to suffer from endometriosis-related pregnancy complications than primiparous women. We aimed to systematically review the evidence examining the role of parity in the relationship between pregnancy outcomes and endometriosis. A systematic search of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was performed from inception to May 2022. We searched for experimental and observational studies. Grading of Recommendations, Assessment, Development, and Evaluation was used to assess the quality of evidence with the risk of bias in non-randomised studies of interventions tool incorporated. Eleven studies were included in the meta-analysis. Primiparous women with endometriosis had almost double the risk of hypertensive disorders of pregnancy (OR: 1.99, 95% CI: 1.50-2.63, P < 0.001) compared to multiparous women with endometriosis. Primiparous women with endometriosis were at significantly increased risk of preterm delivery, caesarean delivery, and placenta praevia compared to primiparous women without endometriosis. There were no significant differences in outcomes when multiparous women with endometriosis were compared to multiparous women without endometriosis. There is limited evidence to suggest that primiparous women with endometriosis may be at higher risk of adverse pregnancy outcomes compared to multiparous women. The modulatory role of parity in the pathophysiology of endometriosis and its impact on pregnancy outcomes should be investigated. Endometriosis can adversely affect pregnancy and cause complications that can affect both mother and baby. The severity and symptoms of endometriosis are lessened in pregnancy and with increasing births. Women who have previously given birth could experience fewer pregnancy complications than women giving birth for the first time. We reviewed the literature to compare pregnancy outcomes in women with endometriosis by whether they had given birth before or not. Our review included 11 studies. More women with endometriosis giving birth for the first time had blood pressure disorders in pregnancy than women with endometriosis who had given birth before. First-time mothers with endometriosis tended to have a baby born early, caesarean delivery, and an abnormally located placenta compared to those without endometriosis. This study supports the theory that women with endometriosis in their first pregnancy are at higher risk of complications and may benefit from additional monitoring.

Lifetime Cumulative Effect of Reproductive Factors on Stroke and Its Subtypes in Postmenopausal Chinese Women

Background and ObjectivesMultiple reproductive factors are associated with stroke. Little is known about the cumulative effects of reproductive factors during a reproductive life course on stroke and its subtypes, especially among female Chinese individuals. The objective of this study was to assess the associations of lifetime cumulative estrogen exposure due to reproductive factors with stroke and its etiologic subtypes among postmenopausal Chinese women.MethodsPostmenopausal women without prior stroke at baseline (2004–2008) were selected from the China Kadoorie Biobank (CKB). Lifetime cumulative estrogen exposure due to reproductive factors was assessed using 3 composite indicators: reproductive lifespan (RLS), endogenous estrogen exposure (EEE), and total estrogen exposure (TEE). Stroke and its subtypes, ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), were identified through linkage to a disease registry system and health insurance data during follow-up (2004–2015). Multivariable-adjusted Cox proportional hazards regression models were applied to estimate the adjusted hazard ratio (aHR) and 95% CIs for the risk of stroke by quartiles of RLS, EEE, and TEE, respectively.ResultsA total of 122,939 postmenopausal participants aged 40–79 years without prior stroke at baseline were included. During a median follow-up period of 8.9 years, 15,139 cases with new-onset stroke were identified, including 12,853 cases with IS, 2,580 cases with ICH, and 269 cases with SAH. Compared with the lowest quartile (Q1) of RLS, the highest quartile (Q4) had a lower risk of total stroke (aHR: 0.95, 95% CI 0.92–0.98), IS (aHR: 0.95, 95% CI 0.92–0.98), and ICH (aHR: 0.87, 95% CI 0.81–0.94). Both EEE and TEE displayed a graded association with the subsequent descending risk of total stroke (aHR for Q4 vs Q1: EEE: 0.85, 95% CI 0.82–0.89; TEE: 0.87, 95% CI 0.84–0.90), IS (aHR for Q4 vs Q1: EEE: 0.86, 95% CI 0.83–0.90; TEE: 0.86, 95% CI 0.83–0.89), and ICH (EEE: 0.73, 95% CI 0.65–0.81; TEE: 0.83,95% CI 0.76–0.91), with a p for trend < 0.001 for all these associations.DiscussionIndividuals' cumulative estrogen exposure due to reproductive factors could potentially be a valuable indicator for risk stratification of stroke events after menopause.

Reproductomics: An impending driver for exposome research

In our quest to recognize the role of extrinsic and intrinsic environmental factors that can profoundly affect human health, the exposome paradigm proffers an exciting avenue of research. Continuous human biomonitoring would be unfeasible because the exposome is longitudinal and dynamic. Therefore, the reproductive life course of exposome should be put together from cross-sectional snapshots at critical periods such as in utero, early childhood, adolescence, and adulthood. Of course, over the following decades, the exposome paradigm will continue to evolve in terms of its conceptual and methodologic framework. Still, our overarching goal should be to delineate underlying molecular mechanisms that promote health while preventing disease at the population level.