Using a validated instrument to assess pregnancy planning and preconception care at antenatal booking visits: a retrospective cohort study

To determine the completion rate for the London Measure of Unplanned Pregnancy (LMUP), a psychometrically validated measure of a woman's intention with regard to a current or recent pregnancy, during booking visits at two metropolitan antenatal care clinics; to identify socio‐demographic characteristics associated with unplanned pregnancy.

Design, setting, participants: Retrospective cohort study; analysis of LMUP data for women attending antenatal care booking consultations as public patients in the Sydney Local Health District, 31 December 2019 -30 November 2020.
Main outcome measures: Proportions of women with LMUP scores indicating unplanned (0-9) or planned pregnancies (10-12); associations between planned pregnancy and socio-demographic characteristics, crude and adjusted for age, parity, and socioeconomic status (Index of Relative Socioeconomic Disadvantage).

Conclusion:
Seven in ten women who completed the LMUP had planned their pregnancies, but fewer than half had undertaken health-related actions prior to conceiving.Higher parity was associated with unplanned pregnancy, indicating the importance of postpartum contraception advice.Overcoming barriers to implementing the LMUP more widely would enhance preconception health monitoring.
The known: Preconception health shapes the wellbeing of future parents and their children in both the short and longer terms.
The new: Preconception health behaviour can be monitored by incorporating the London Measure of Unplanned Pregnancy (LMUP) into the antenatal booking visit.In our study, LMUP scores indicated that 71% of women had planned their pregnancies, but 54% had not undertaken any health-related actions prior to pregnancy.The likelihood of pregnancy planning declined as the number of previous births increased.
The implications: Better postpartum contraception advice could reduce the number of women who have multiple unplanned pregnancies.Broader use of the LMUP could improve the management of preconception health.

Methods
We analysed data for women who gave birth in the Sydney LHD during 1 December 2019 -30 November 2020.About 8% of New South Wales births take place in this LHD. 12The LHD includes two public maternity services: a tertiary referral hospital and a secondary metropolitan facility.At the start of the study, we provided training at the two sites on the use of the LMUP; we also provided a video describing the purpose and components of the LMUP that was retained on the antenatal clinic computers.About 15% of women are admitted as private patients and receive antenatal care from private obstetricians; as their booking visit details are not included in the LHD database, they were not included in this study.
Demographic and parity information for included women was obtained from the Sydney LHD electronic maternity medical record system, into which routine pregnancy, birth, and postpartum data can be entered by all health care providers.Deidentified data were supplied to the investigators for analysis.We defined residential socio-economic status according to the Index of Relative Socioeconomic Disadvantage (IRSD), a national census-based index of measures of area-level disadvantage, such as low educational attainment, low household income, and high unemployment. 13

Outcome
The primary outcome was the LMUP score recorded at the first antenatal visit, derived from responses to six questions regarding contraception use prior to conception, timing of motherhood, intendedness of the pregnancy, desire for a baby, discussion with the partner about having a child, and actions taken to prepare for pregnancy (eg, folate supplementation, avoidance of alcohol).Two points are allocated to each question, yielding a total score of 0 to 12. Using the original LMUP version, we classified responses as indicating an unplanned (score, 0-9) or a planned pregnancy (10-12).

Statistical analysis
In complete case analyses, crude (univariable) associations between planned pregnancy (LMUP score, 10-12) and sociodemographic characteristics were assessed using logistic regression models; we report odds ratios (ORs) with 95% confidence intervals (CIs).Multivariable analyses were adjusted for age, parity, and socio-economic status (greatest disadvantage: IRSD deciles 1-4; intermediate disadvantage, deciles 5-7; least disadvantage: deciles 8-10); we report adjusted ORs (aORs) with 95% CIs.We determined the LMUP completion rate at each hospital, and assessed in χ 2 tests whether the socio-demographic characteristics of women who completed the LMUP differed from those who did not.For women who completed the LMUP, we also examined whether LMUP findings differed between those for whom age or socio-economic status data were or were not available.Analyses were conducted in SPSS 28 (IBM).

Results
During 1 December 2019 -30 November 2020, 4993 women had antenatal care bookings as public patients at the two Sydney LHD hospitals.The LMUP was completed in 2385 cases (47.8%; 1142 of 3564 women at the tertiary referral hospital [32.0%], 1118 of 1160 women at the secondary hospital [96.3%], and 125 of 269 women for whom the hospital was not specified [46.5%]).At the tertiary hospital, the LMUP was completed by smaller proportions of women born overseas (549 of 1949, 28.2%) than of those born in Australia (593 of 1615, 36.7%), and of women whose preferred language was not English (185 of 753, 24.6%) than of those for whom it was English (957 of 2811, 34.0%).The LMUP completion rate at the tertiary hospital increased with socioeconomic status (deciles 1-4: 125 of 463, 26.9%; deciles 5-7: 375 of 1265, 29.6%; deciles 8-10: 571 of 1582, 36.0%).The characteristics of the women at the secondary hospital who did or did not complete the LMUP were similar (data not shown).
The age group including the largest proportion of women who completed the LMUP in the Sydney LHD was that of women aged 30-34 years (842 women; 35.3%); 1405 were born overseas (58.9%), 487 preferred a language other than English (20.4%), 1137 had residential postcodes in the three least socio-economically disadvantaged deciles (47.6%), and for 1171 women it was their first ongoing pregnancy (Box 1).

Discussion
We report the first study of the integration of the LMUP, a validated measure of the prior pregnancy intention of pregnant women, into antenatal routine data collection in Australia.
Completing the measure was not mandatory for women, and was undertaken at about half the antenatal booking visits over a 12-month period, but the completion rate was markedly different at the tertiary and secondary hospitals in this study.
In the secondary hospital, in-person booking visits continued during the coronavirus disease 2019 (COVID-19) pandemic, and support from midwives for the measure was strong.In contrast, as booking consultations at the tertiary hospital shifted to telehealth during this period and leadership support was less strong, the completion rate was much lower, particularly among women whose preferred language was not English.Our qualitative study of how midwives experienced the introduction of the LMUP found that many supported its use, but they also noted barriers, including time constraints, the impact of COVID-19, and uncertainty about referral pathways. 14 found that, according to LMUP responses, 29% of pregnancies were unplanned, and planned pregnancies were less likely for women aged 24 years or less, living in postcodes of greater socioeconomic disadvantage, or pregnant with a third or later child.These findings are consistent with those of our 2010-11 study in the Sydney LHD tertiary hospital, for which women were invited to complete questionnaires during antenatal clinic visits other than the midwifery booking, in which 67.6% of pregnancies were planned (824 of 1218).Unplanned pregnancies were more frequent for women under 25 years of age, but postcode-based socio-economic status did not influence intention; information on parity was not collected. 15In a validation study in the Netherlands, LMUP responses by 515 women indicated that 84.4% of pregnancies had been planned. 16e peri-conception period is critically important for fetal development, and suboptimal maternal health and diet at this time can lead to impaired fetal growth, poorer birth outcomes, and long term effects on the child's cardiovascular and metabolic health. 2 Among the best established preconception interventions is folate supplementation, which reduces the risk of neural tube defects (including spina bifida and anencephaly) by 70%. 17n our study, only 46% of women who completed the LMUP undertook any health-related precautions prior to pregnancy, including folate supplementation.In a United Kingdom study of women who had used the online Tommy's Pregnancy Planning tool, adherence to preconception recommendations was also generally poor, including recommended vitamin supplementation by women with planned pregnancies (44%); 20% of women reported smoking, 54% alcohol use, and 42% inadequate exercise levels. 18 2021, 51% of Australian mothers were overweight or obese (based on standard body mass index definitions) when they gave birth. 19Awareness of the implications of unhealthy weight, both during pregnancy (for the mother: gestational diabetes, hypertension in pregnancy, pre-eclampsia, need for caesarean delivery; for the child: prematurity, stillbirth, congenital

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anomalies, macrosomia) 20 and longer term (for the child: overweight, cardiovascular and metabolic disease) 2 should be improved by public health campaigns.
Of the variables that influence pregnancy planning, parity perhaps warrants the most attention.Many women return to health services with successive unplanned pregnancies, suggesting that postpartum advice regarding contraception could be improved.A comprehensive postpartum contraception service is not generally provided by Australian hospitals, as it is expected that contraception will be discussed at the routine six-week postpartum general practice consultation.In the United States, however, about 50% of women do not attend such appointments. 21In an Australian study, women reported receiving inconsistent information about the time and details of the postnatal general practice visit, and general practitioners commented that they lacked the resources to advise women about postpartum care. 22Comprehensive postpartum care guidelines could reduce these problems, as well as ensuring that contraception is more accessible and affordable, as recommended by a recent Senate enquiry into sexual, maternity, and reproductive health care. 23creasing the uptake of preconception care can be challenging.International leaders in this field have recently described an evidence-based model of preconception care, including contraception advice.They specifically recommend that public education about preconception health should begin in schools and include social media and other national campaigns, as well as recommending that training and system-level support for health care professionals to implement the care model. 24

Limitations
Our study was limited to public patients in a single New South Wales LHD over twelve months and coincided with the first year of the COVID-19 pandemic in Sydney.Further, only half the eligible women completed the LMUP.Less than onethird of the women attending the tertiary site completed the LMUP, and differences in completion rates by country of birth, preferred language, and socio-economic status were noted; only socio-economic status influenced the likelihood of pregnancy planning.The generalisability of our findings is consequently uncertain.
We modified the final LMUP question to broadly assess the number of behaviour changes, but we did not assess the specific actions women undertook.In 2020, the LMUP question about the mother's partner was modified in the United Kingdom to reflect changes in family composition over the preceding two decades

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(eg, same sex relationships, co-parenting, pregnancy without a partner). 25The new wording would also be appropriate in Australia, but its use would not have affected our overall findings.

Conclusion
We document the first twelve months of the integration of the LMUP into routine antenatal bookings visit at two Sydney hospitals.Higher parity was the factor most closely associated with unplanned pregnancies, and improved access to postpartum contraception could help reduce the likelihood of unplanned pregnancies after a previous birth.If Australia is to develop preconception health indicators, as in the United Kingdom, 26 overcoming service barriers to implementing the LMUP will be important.Specifically, public awareness of the importance of pregnancy planning should be raised, and senior midwifery leaders should be educated about the purpose of the LMUP, including its facilitation of personalised care and early consideration of postnatal contraception.

2 Responses of the 2385 women seeking antenatal care in the Sydney Local Health District who completed the London Measure of Unplanned Pregnancy, 1 December 2019 - 30 November 2020 Questions/response options (score) Number
* For example: folic acid supplementation, smoking cessation or reduction, alcohol cessation or reduction, seeking medical advice.◆

3 Socio-demographic characteristics and planned pregnancies (London Measure of Unplanned Pregnancy scores of 10-12) among 2385 women, 1 December 2019 -30 November 2020: univariable and multivariable analyses
CI = confidence interval; NA = not applicable (not statistically significant in univariate analysis).* Adjusted for age, parity, and socio-economic status.Data for 2070 women were included in the final analysis † Index of Relative Socio-economic Disadvantage. 13◆