presentation variable meaning in pregnancy

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

• Cookie Preferences

Need to talk? Call 1800 882 436. It's a free call with a maternal child health nurse. *call charges may apply from your mobile

Is it an emergency? Dial 000 If you need urgent medical help, call triple zero immediately.

Share via email

There is a total of 5 error s on this form, details are below.

• Please enter your name
• Please enter your email
• Your email is invalid. Please check and try again
• Please enter recipient's email
• Recipient's email is invalid. Please check and try again
• Agree to Terms required

Error: This is required

Error: Not a valid value

Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: October 2023

Related pages

External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

• Foetal Version
• Breech Presentation

Need more information?

Top results

Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Planned or elective caesarean

There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

Pregnancy, Birth and Baby is not responsible for the content and advertising on the external website you are now entering.

Call us and speak to a Maternal Child Health Nurse for personal advice and guidance.

Need further advice or guidance from our maternal child health nurses?

1800 882 436

Government Accredited with over 140 information partners

We are a government-funded service, providing quality, approved health information and advice

Healthdirect Australia acknowledges the Traditional Owners of Country throughout Australia and their continuing connection to land, sea and community. We pay our respects to the Traditional Owners and to Elders both past and present.

© 2024 Healthdirect Australia Limited

This information is for your general information and use only and is not intended to be used as medical advice and should not be used to diagnose, treat, cure or prevent any medical condition, nor should it be used for therapeutic purposes.

The information is not a substitute for independent professional advice and should not be used as an alternative to professional health care. If you have a particular medical problem, please consult a healthcare professional.

Except as permitted under the Copyright Act 1968, this publication or any part of it may not be reproduced, altered, adapted, stored and/or distributed in any form or by any means without the prior written permission of Healthdirect Australia.

Support this browser is being discontinued for Pregnancy, Birth and Baby

Support for this browser is being discontinued for this site

• Internet Explorer 11 and lower

We currently support Microsoft Edge, Chrome, Firefox and Safari. For more information, please visit the links below:

• Chrome by Google
• Firefox by Mozilla
• Microsoft Edge
• Safari by Apple

You are welcome to continue browsing this site with this browser. Some features, tools or interaction may not work correctly.

• Mammary Glands
• Fallopian Tubes
• Supporting Ligaments
• Reproductive System
• Gametogenesis
• Placental Development
• Maternal Adaptations
• Menstrual Cycle
• Antenatal Care
• Small for Gestational Age
• Large for Gestational Age
• RBC Isoimmunisation
• Prematurity
• Prolonged Pregnancy
• Multiple Pregnancy
• Miscarriage
• Recurrent Miscarriage
• Ectopic Pregnancy
• Hyperemesis Gravidarum
• Gestational Trophoblastic Disease
• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
• Oligohydramnios
• Polyhydramnios
• Placenta Praevia
• Placental Abruption
• Pre-Eclampsia
• Gestational Diabetes
• Headaches in Pregnancy
• Haematological
• Obstetric Cholestasis
• Thyroid Disease in Pregnancy
• Epilepsy in Pregnancy
• Induction of Labour
• Operative Vaginal Delivery
• Prelabour Rupture of Membranes
• Caesarean Section
• Shoulder Dystocia
• Cord Prolapse
• Uterine Rupture
• Amniotic Fluid Embolism
• Primary PPH
• Secondary PPH
• Psychiatric Disease
• Postpartum Contraception
• Breastfeeding Problems
• Primary Dysmenorrhoea
• Amenorrhoea and Oligomenorrhoea
• Heavy Menstrual Bleeding
• Endometriosis
• Endometrial Cancer
• Adenomyosis
• Cervical Polyps
• Cervical Ectropion
• Cervical Intraepithelial Neoplasia + Cervical Screening
• Cervical Cancer
• Polycystic Ovary Syndrome (PCOS)
• Ovarian Cysts & Tumours
• Urinary Incontinence
• Genitourinary Prolapses
• Bartholin's Cyst
• Lichen Sclerosus
• Vulval Carcinoma
• Introduction to Infertility
• Female Factor Infertility
• Male Factor Infertility
• Female Genital Mutilation
• Barrier Contraception
• Combined Hormonal
• Progesterone Only Hormonal
• Intrauterine System & Device
• Emergency Contraception
• Pelvic Inflammatory Disease
• Genital Warts
• Genital Herpes
• Trichomonas Vaginalis
• Bacterial Vaginosis
• Vulvovaginal Candidiasis
• Obstetric History
• Gynaecological History
• Sexual History
• Obstetric Examination
• Speculum Examination
• Bimanual Examination
• Amniocentesis
• Chorionic Villus Sampling
• Hysterectomy
• Endometrial Ablation
• Tension-Free Vaginal Tape
• Contraceptive Implant
• Fitting an IUS or IUD

Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

Found an error? Is our article missing some key information? Make the changes yourself here!

Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site.

We use cookies to improve your experience on our site and to show you relevant advertising. To find out more, read our privacy policy .

Privacy Overview

• Search Please fill out this field.
• Newsletters
• Sweepstakes
• Labor & Delivery

What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

• The fetus may have abnormalities involving the muscular or central nervous system
• The uterus may have abnormal growths or fibroids
• There might be insufficient amniotic fluid in the uterus (too much or too little)
• This isn’t your first pregnancy
• You have a history of premature delivery
• You have placenta previa (the placenta partially or fully covers the cervix)
• You’re pregnant with multiples
• You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

Related Articles

Position and Presentation of the Fetus

• Fetal Presentation, Position, and Lie (Including Breech Presentation)

• ACOG Clinical
• Obstetrics & Gynecology
• Resource Center
• Policy and Position Statements
• Supported Documents
• Physician FAQs
• Patient FAQs
• Patient Education Materials
• Payment Advocacy and Policy Portal
• Payment Resources
• Patient Safety and Quality
• Practice Management and COVID-19
• Health IT and Clinical Informatics
• Professional Liability
• Medical Students
• Early Career
• Career Connection
• ACOG Online Learning
• Education Search
• CME Program
• Annual Clinical & Scientific Meeting
• Annual District Meetings
• Awareness and Observances
• Congressional Leadership Conference (CLC)
• Meetings Calendar
• Abortion Advocacy
• Get Involved
• Policy Priorities
• In the Courts
• Breastfeeding
• Genetic Screening and Testing
• Gestational Diabetes
• Health Care Disparities
• Long-Acting Reversible Contraception
• Obstetric Labor
• Perinatal Mood and Anxiety Disorders
• Respiratory Syncytial Virus
• Seasonal Influenza
• View All Topics
• Practice Management

reVITALize: Obstetrics Data Definitions

Obstetrics data definitions .

The reVITALize obstetric data definitions are formally endorsed by the following organizations:

• American Academy of Family Physicians
• American College of Nurse-Midwives
• The American College of Obstetricians and Gynecologists/The American Congress of Obstetricians and Gynecologists
• Association of Women's Health, Obstetric and Neonatal Nurses
• Society for Maternal–Fetal Medicine

To add your organization to this list, please contact  [email protected] .

Please Confirm

Bulk pricing was not found for item. Please try reloading page.

For additional quantities, please contact [email protected] or call toll-free from U.S.: (800) 762-2264 or (240) 547-2156 (Monday through Friday, 8:30 a.m. to 5 p.m. ET)

• Open access
• Published: 03 September 2024

Utility of pelvic examination in assessing women with bleeding in early pregnancy: a multicenter Canadian emergency department study

• Steven Fisher 1 ,
• Stephanie Couperthwaite 1 ,
• Esther H. Yang 1 , 2 ,
• Nana Owusu Mensah Essel 1 &
• Brian H. Rowe 1 , 3  

International Journal of Emergency Medicine volume  17 , Article number:  110 ( 2024 ) Cite this article

Metrics details

Bleeding in early pregnancy is a common emergency department (ED) presentation. Although variability in approaches has been demonstrated, research is relatively uncommon on practices and outcomes. This study investigated the influence of clinical pattern of care, utility, and contribution of pelvic examination aimed at diagnosing and managing bleeding in early pregnancy at three Canadian EDs.

After obtaining informed consent, data were collected from adult women who were pregnant and from treating ED physicians using a structured questionnaire. We defined the change in management based on the initial clinical plan at the time of the initial physician assessment in the ED and any subsequent changes made after the pelvic examination was performed. Patient telephone follow-up was supplemented by linking with provincial administrative data for births. Univariable and multivariable binary logistic regression analyses were performed to identify factors associated with a change in patient management following pelvic examination in the ED.

Overall, 200 women were enrolled. The mean age was 31 years, patients had been bleeding for a median of 1 day and stayed in the ED for a median of 5 h. Of these, 166 (83.0%) received a pelvic examination, including speculum examination and/or bimanual palpation. Pregnancy outcome data were available for 192 pregnancies; 107 (56%) experienced a miscarriage. Factors significantly associated with a change in management after pelvic examination in the univariate logistic regression analysis were brown/dark-red bleeding per vaginam (physician determined), tachycardia, right lower quadrant tenderness, and bimanual palpation. In the multivariate logistic regression analysis, brown/dark-red bleeding per vaginam was independently associated with a reduced likelihood of a change in management after pelvic examination (aOR = 0.37; 95% CI: 0.14–0.98).

Among women presenting to the ED with bleeding in early pregnancy prior to 20 weeks gestation, only brown/dark-red vaginal bleeding, potentially indicative of bleeding resolution, significantly independently influenced the baseline odds of a change in management after pelvic examination. Until the debate on the utility of pelvic examination in the ED for this presentation is resolved, physician preferences and shared decision making with patients should guide practice regarding speculum examination/bimanual palpation for the management of bleeding in early pregnancy.

Bleeding in early pregnancy is a common problem, and many women present for assessment at emergency departments (EDs) primarily due to timing, symptomatic urgency, and want of reassurance out of concern that they may have miscarried. It accounts for approximately 500,000 annual visits to the ED in the United States [ 1 , 2 ], typically preceding the first prenatal visit [ 3 ]. In countries such as Canada and the United Kingdom, early pregnancy units have become commonplace for assessing and managing women with bleeding in early pregnancy; however, such units do not operate 24 h a day, not all pregnant women can access them, and they are not universally available [ 4 ]. Thus, the ED remains a common entry point for women experiencing bleeding in early pregnancy. In the ED, the management of bleeding in early pregnancy primarily focuses on excluding rare, albeit serious, conditions such as ectopic gestations, assessing fetal viability, and management of symptoms [ 5 , 6 , 7 ]. Previous authors have questioned whether abdominopelvic ultrasound can replace a formal pelvic examination, while studies conducted in non-ED settings have described the two diagnostic tools as complementary [ 8 ]. Nevertheless, in the ED, the pelvic examination is performed for a number of reasons: to document the vaginal and cervical appearance (e.g., presence/absence of tissue in the cervical os, cervical lesions that would explain the blood loss), the color and quantity of bleeding, and to rule out other serious causes of bleeding. Overall, the goal of the examination is to confirm the history and refine the diagnosis, at the same time as guiding future laboratory testing, imaging, and disposition (e.g., admit, discharge, refer) [ 9 ].

The utility of pelvic examination has been debated, with opponents citing the literature and proponents noting several methodological issues calling into question the reliability of the evidence [ 9 , 10 ]. For example, using a composite calculation to compare 30-day morbidity outcomes in an underpowered equivalence study [ 11 ], and suggesting that the actual issue could be provider unease with the procedure, rather than one based on solid evidence [ 10 ]. Rosenberg also posits that to discard the pelvic examination, it should be proven to lead to more misleading outcomes than helpful ones [ 12 ].

Although the evidence remains inconclusive, preliminary studies reveal that omitting the pelvic examination in the ED has benefits without significant untoward outcomes, especially with the given improvements in diagnostic capacity within the ED setting. Thus, despite providing additional clinical information under specific circumstances, the existing practice of always including pelvic examinations while evaluating women presenting to the ED with bleeding in early pregnancy may no longer be appropriate. Due to conflicting information in the literature, this study aimed to investigate the clinical pattern of care, utility, and contribution of pelvic examination in the ED toward diagnosing and managing bleeding in early pregnancy. To achieve this, factors that determine a change in clinical management following pelvic examination in the ED were explored. Our primary hypothesis was that the findings on pelvic examinations (speculum and bimanual palpation) performed by ED physicians would not significantly alter the clinical decision-making process or the formulation of a care plan for women presenting with bleeding in early pregnancy.

Study setting and design

This prospective cohort study was conducted at three EDs located in Edmonton, Alberta, Canada (urban population ≈ 1 million) which are three of seven high-volume EDs within the region. The study participants were recruited between January 2014 and January 2018. The University of Alberta Hospital (UAH) is a major urban, academic, tertiary care center assessing approximately 67,000 adult patients per year with an admission proportion of 23% and access to ultrasound services; however, it has no obstetric in-patient capacity and no in-house obstetric services. The Royal Alexandra Hospital (RAH) is a mixed adult and pediatric urban hospital assessing approximately 72,000 adult patients per year with in-patient obstetric beds, an obstetric service, and access to ultrasound services. The Northeast Community Health Centre (NECHC) is a mixed adult and pediatric urban emergency department assessing approximately 41,000 patients per year with no in-patient beds, ultrasound services, or obstetric consultants. All sites are staffed with full-time emergency physicians, are teaching sites for emergency medicine and other academic programs, and operate 24 h per day.

Ethical considerations

The study complied with the Declaration of Helsinki (1964) and its later amendments. Written informed consent was obtained from all study participants before enrollment. The study protocol and materials were approved by the Health Research Ethics Board (HREB; reference ID: Pro00047076) at the University of Alberta in Edmonton, Alberta, Canada . Operational and administrative approval was obtained from Alberta Health Services and a data sharing agreement was signed.

Study procedures and definitions

Pregnancy was primarily diagnosed through a combination of clinical assessment, patient history, and quantitative serum beta-human chorionic gonadotropin (β-HCG) levels. We defined bleeding in early pregnancy as the occurrence of vaginal bleeding in the first 20 weeks of pregnancy (calculated from the last normal menstrual period). When available, we also incorporated sonographic confirmation for pregnancy dating; specifically, if an ultrasound was performed during the ED visit or had been conducted recently, we used sonographic dating to refine the estimated gestational age (EGA).

For the purposes of this study, pelvic examination was defined as a composite of bimanual palpation and/or speculum examination. The primary outcome of our study was defined as a change in the management plan following the pelvic examination. We defined the change in management based on the ED physician’s response to the question: “Did the findings on pelvic examination change your management plan?” comparing their initial assessment to their thoughts after the pelvic examination was performed. Emergency physicians were not asked to record their management approach before and after completing the pelvic examination. These subjective changes included, but were not limited to: a revised diagnosis and management plan (e.g., diagnosing an ectopic pregnancy or incomplete miscarriage that necessitated different clinical actions); decisions to request further diagnostic procedures such as additional imaging (e.g., transvaginal or pelvic ultrasound) or laboratory tests; a decision to refer the patient to an obstetrician for further evaluation and management; a decision to admit the patient to the hospital for observation, treatment, or surgical intervention; and a decision to extend the period of observation within the ED to monitor the patient’s condition and response to initial management.

Sample size

No a priori sample size determination was performed. Rather, a convenience sample of women presenting to any of the three EDs with vaginal bleeding at an EGA < 20 weeks was utilized.

Physician/patient recruitment

Emergency physicians at each study site were invited to participate by completing a paper-based form to identify patients who presented with bleeding in early pregnancy. Patients were eligible if they were aged 17 years or older and presented to the ED with proven pregnancy and vaginal bleeding under 20 weeks gestation. We excluded patients who were hemodynamically unstable or experiencing excessive vaginal bleeding (passing large clots and/or soaking at least one pad per hour), non-English speaking women, and patients who did not consent to the study. In some cases, a research assistant identified potentially eligible patients using the Emergency Department Information System (EDIS), who then confirmed the patient’s eligibility with the attending physician. A general patient survey was completed by ED physicians and/or a research assistant following written informed consent.

Data collection

Completed screening forms were retrieved by research assistants and the results were entered into REDCap (Vanderbilt University, Nashville, TN, USA), a secure web-based platform, licensed through the Women and Children’s Health Research Institute (WCHRI) at the University of Alberta [ 13 ]. For each patient successfully enrolled, data were collected from the patient’s paper chart and EDIS. Characteristics of interest are shown in Table  1 and included: (1) patients’ demographics; (2) ED presentation (e.g., Canadian Triage and Acuity Scale [CTAS] score, mode of arrival, vital signs); (3) ED investigations (e.g., complete blood count, β-HCG levels, ultrasound, blood typing); (4) ED management (e.g., interventions, procedures, and drugs administered); (5) imaging findings; (6) ED length of stay (LOS) (triage to discharge) and time to assessment (triage to physician initial assessment [PIA]); (7) patient disposition and repeat visit to the ED within 30 days of discharge from the ED or discharge from hospital admission; and (8) consultations requested in the ED and post-hospital referrals. All participating EDs utilize CTAS, a five-level acuity assessment scoring system, as follows: CTAS 1 (resuscitation), CTAS 2 (emergent), CTAS 3 (urgent), CTAS 4 (semi-urgent), and CTAS 5 (non-urgent) [ 14 , 15 ]. Duplicate data extraction was completed on the first 10 charts and reviewed by a clinical research nurse to identify potential disagreements and ensure a unified data collection methodology.

Linkage of administrative data

To validate the existing follow-up data and secure missing data, four population-based linked health administrative databases from Alberta Health Services (AHS) were obtained. All databases are hosted in the AHS Enterprise Data Warehouse. The EDIS dataset captured information on all ED visits in the Edmonton area. Each EDIS record represents a unique service and includes a unique identifier, start and end dates and times, presenting complaints, the number and type of consultation services, and admitting services. These data were linked to the study cohort to secure any missing ED data on the factors mentioned above. The provincial laboratory data captured all general laboratory tests performed across the province and was used to identify women who underwent hemoglobin and β-HCG testing within the index early pregnancy visit to the ED for bleeding. The Alberta Perinatal Data captured information on maternal and perinatal data from the provincial delivery records for all deliveries occurring ≥ 20 weeks of gestation. Pregnancy-related outcomes (e.g., live birth, pregnancy loss, or stillbirth) that occurred within 9 months of the index ED visit were searched. Stillbirths were identified using both follow-up and administrative data. Finally, the Provincial Registry captured Alberta residents covered by the Alberta Health Care Insurance Plan. Alberta residents at the time of the ED visit were identified by records in this dataset during the fiscal year of the ED visit.

Statistical methods

The distributions of continuous and discrete data were tested using the Kolmogorov–Smirnov test. Normally distributed data are reported as means and standard deviations (SDs) while skewed variables are reported as medians and interquartile ranges (IQRs). Categorical variables are reported as frequencies and percentages. To investigate factors associated with a change in management after pelvic examination, we performed univariable binary logistic regression (with the primary outcome being the physician’s perceived change in management following pelvic examination) and reported odds ratios (ORs) and 95% confidence intervals (CIs). For β-HCG level, which had a right-skewed distribution, we selected an approximation of the median (10,404.5 mIU/mL) as the cut-off value. In the multivariable logistic regression analysis, we calculated adjusted ORs (aORs) for variables that showed marginal or significant associations ( p- value < 0.1) in the univariable analyses. These included the color of bleeding (based on the physician’s assessment), presence of abdominal cramping, tachycardia at presentation, right lower quadrant (RLQ) tenderness, and bimanual palpation within the ED. None of the variables included in the logistic regression analyses had more than 10% data missing for the 166 women included. All statistical computations were performed using R version 4.2.2 (The R Development Core Team, Vienna, Austria). Hypothesis tests were two-sided and considered statistically significant at p -value < 0.05.

Patients’ clinical and ED characteristics

Overall, 200 unique patients who presented to one of the study EDs with a complaint consistent with bleeding in early pregnancy were included in the study (Fig.  1 ). Selected patient demographic, clinical, and ED characteristics are shown in Table  1 . The mean age at presentation was 30.7 years (SD: 5.7), with a majority of women between 26 and 35 years of age. Most women (79%) presented with an EGA of ≤ 10 weeks, a median gravidity of 2 (IQR: 1, 3), and a median parity of 1 (IQR: 0, 1). Five (2.5%) women had a history of prior ectopic gestation, 61 (31%) had experienced bleeding in early pregnancy before the index pregnancy, and 55 (28%) had a history of spontaneous miscarriage. Thirteen women (7.8%) had undergone fertility treatment for their current pregnancy.

Flow chart showing variations in the management of 200 women who presented to three Canadian emergency departments with bleeding in early pregnancy

At presentation, the median duration of bleeding was 1 day (IQR: 0.3, 2.0), with a median pain score of 3 on a verbal analog scale of 0 to 10, and 53% had experienced abdominal cramping accompanying the bleeding episode. The median CTAS score was 3 and 21% presented afterhours. During their ED stay, 83% of women underwent at least one β-HCG measurement. On physical examination, 18% presented with either a systolic BP > 140 mmHg or a diastolic BP > 90 mmHg, and 19% were tachycardic (pulse > 100/min) (included in Table  1 ). Eighty-one women (41%) showed normal findings on abdominal examination; nearly equal proportions (~ 12%) showed diffuse tenderness, left lower quadrant tenderness, or RLQ tenderness; and 11 (6%) showed guarding.

Overall, 166 (83%) received a pelvic examination; 123 (62%) women received a speculum examination and 123 (62%) received a bimanual examination. 70% of women subjected to speculum examination in the ED showed bleeding at the cervical os and 14% showed normal findings. Similarly, bimanual palpation revealed normal findings among 31%, adnexal mass/tenderness in 8%, and cervical motion tenderness/uterine tenderness in 7%. At discharge, the median ED LOS was 5 h (IQR: 3, 6). Regarding outcomes, 107/192 (56%) patients with available pregnancy outcome data experienced a miscarriage.

Exploratory analysis of factors associated with a change in management after pelvic examination

The performance of pelvic exam did not significantly differ among facilities with and without ultrasound services (83.2% vs. 81.8%, chi-squared p -value = 0.88). On the other hand, the facility with in-house obstetric services (RAH) performed significantly more pelvic examinations than the other two facilities without (94.7% vs. 76.0%, chi-squared p -value < 0.001). There was no significant difference in the proportions of eventual miscarriage between patients who underwent vs. did not undergo pelvic examination (chi-squared p -value = 0.75). The results of univariate nominal logistic regression analysis seeking factors associated with a change in management after pelvic examination are shown in Table  2 . In the multivariable logistic regression analysis, only brown/dark-red bleeding per vaginam (determined by the examining ED physician) was independently associated with a reduced likelihood of a change in management after pelvic examination in the ED (aOR = 0.37; 95% CI: 0.14–0.98). Controlling for other factors (that showed marginal to significant associations in the univariable analyses: presence of abdominal cramps, tachycardia, RLQ tenderness, bimanual palpation, and color of the blood) failed to identify other factors independently associated with a change in management based on pelvic examination findings.

This prospective observational cohort study identified and characterized the management of 200 women with vaginal bleeding in early pregnancy at three Canadian EDs and further described factors associated with a change in management after pelvic examination. A large majority of included patients were young and had experienced a very short period of bleeding (~ 1 day) in their current pregnancy. Practice was variable among the treating clinicians; however, the majority (83%) performed a vaginal examination, 83% obtained serum β-HCG tests, and nearly all patients were referred for follow-up assessment. The decision to perform a bedside ultrasound was left to the discretion of the treating clinician and was documented in 63 (31.5%) women. These patients experienced prolonged ED stays, with some patients lingering for up to 15 h. Overall, their outcomes were poor (more than 50% experienced a miscarriage); however, it is important to recognize that this population is inherently at higher risk for adverse outcomes, given that a majority of spontaneous miscarriages in early pregnancy occur primarily due to chromosomal abnormalities in the embryo, for which no first trimester treatment exists.

Factors initially identified to be associated with a change in management after pelvic examination were: brown/dark-red bleeding per vaginam, tachycardia, RLQ tenderness, and the performance of bimanual examination in the ED. Among these, only brown/dark-red bleeding per vaginam, was independently associated with a change in management. There was no significant difference in the percentage of women receiving pelvic examinations between facilities with ultrasound services and those without; however, physicians practicing at the facility with in-house obstetric services tended to perform more pelvic examinations than those without. Both facility characteristics (the availability of ultrasound services and in-house obstetrics/gynecology services) were also not associated with a change in management following pelvic examination.

Among the 166 (83%) cases where a pelvic examination was completed, a significant majority of ED physicians reported that pelvic examination changed their approach to management (72.3% vs. 27.7%; difference, 44.6%; 95% CI: 33.4–55.7). While cervical motion tenderness and the presence of adnexal masses are important findings on pelvic examination, they have low sensitivity (45% and 10%, respectively) and their subsequent positive likelihood ratios are unhelpful [ 16 ].

These findings agreed with a recent randomized controlled trial [ 17 ], which failed to meet its goals of enrolling patients with early pregnancy confirmed on ultrasound according to whether pelvic examination was performed during evaluation in the ED. Although the appropriateness of deriving practice-changing conclusions from an underpowered study has been called into question [ 11 ], it is worth noting that the researchers found no statistically significant difference in 30-day morbidity when 202 women underwent pelvic examination in the ED [ 17 ]. Upholding the aforementioned results would likely be based on the fact that ED ultrasound provides much more quantitative and qualitative information than the pelvic examination, particularly in ruling out ectopic gestation. Among such women, a meta-analysis showed that ultrasound performed by ED physicians led to a pooled sensitivity of 99.3%, a negative predictive value of 99.95%, and a negative likelihood ratio of 0.08, without substantial heterogeneity [ 18 ]. Similarly, upon detecting an adnexal mass and no intrauterine pregnancy, the positive likelihood ratio for ectopic gestation exceeded 1.00 while the negative likelihood ratio was 0.12 [ 16 ]. In the presence of ultrasound-confirmed intrauterine gestation, pelvic examination has neither been shown to add information to the management of patients with early pregnancy nor does it affect their disposition, even when the pelvic findings are unexpected [ 19 , 20 ].

For a healthy, hemodynamically stable woman without clinical concern about bleeding in early pregnancy secondary to cervical neoplasia, vaginal trauma, vaginitis, or cervical polyps, some believe conducting a pelvic examination may be invasive, offers little diagnostic benefit, increases health care costs, decreases throughput, and increases the ED LOS [ 17 , 19 , 21 ]. Moreover, from a patient’s perspective, women who did not undergo pelvic examination were half as likely to report a feeling of discomfort, compared to those who did, and when given a choice to participate, many (42%) eligible patients refused study enrollment because they preferred not to undergo pelvic examination [ 17 ]. Further, point-of-care ultrasonography is currently considered a crucial skill for emergency care providers and is recommended in the ED to improve diagnoses and outcomes [ 22 , 23 ]. In another prospective cohort study, pelvic examination led to a change in management in only 6% of cases [ 20 ]. Determining the definitive impact and safety of omitting the ED pelvic examination when there is bedside ultrasound evidence of an intrauterine pregnancy needs to be assessed for equivalence with performing it to evaluate women with abdominal pain and/or bleeding per vaginam in early pregnancy.

Study limitations

Our study had some methodological limitations. First, this study relied on the support of participating ED physicians to identify patients with bleeding in early pregnancy; however, form completion was not universal and often incomplete. While some patients may have been misidentified as having bleeding in pregnancy, a majority of participating ED physicians had many years of clinical experience, so this risk was likely minimal.

We could not complete the analysis of some outcomes as planned due to poor reporting in the patient’s charts or variability in the care provided by clinicians in these three ED settings. A standardized protocol for bleeding in early pregnancy was not in place at any site during this study. The proportion of patients lost to follow-up was high and would have invalidated these findings; however, the use of linked administrative data mitigated this problem (e.g., pregnancy outcomes could be ascertained for 192 of 200 included patients).

ED physicians were not asked to indicate their management approach before and after completing the pelvic examination. Instead, they were asked a general question as to whether the examination changed their management without specifying what changes might have occurred. We also did not record information about how any unexpected findings altered the treatment approach and thus could not ascertain how any such finding would correlate with a change in the management approach.

This study was conducted in Canada, where access to health care is assured by government funding and no co-payments exist for ED care. As a result, ED management and disposition strategies used among such patients may not be representative of outcomes in studies conducted in other countries. Also, some social determinants of health (e.g., supports, race, income, housing, employment), behavioral factors (e.g., alcohol consumption, use of cigarettes/vaping, cannabis use, diet), and comorbidities (e.g., body mass index, diabetes mellitus) that may have affected pregnancy outcomes were also not recorded. Finally, the sample size limited the inclusion of molar pregnancy and other rare presentations.

Notwithstanding these limitations, we believe that our findings raise some important questions and contribute to the discourse regarding the routine performance of pelvic examinations in the ED among women with bleeding in early pregnancy. This is one of the first studies to comprehensively assess the management of patients with early pregnancy loss.

Conclusions

This pilot observational cohort study found that women presenting to the ED with bleeding in early pregnancy (EGA < 20 weeks) who were hemodynamically stable undergo variable assessment and approximately 56% suffer a miscarriage. These presentations appear to be an appropriate target for interventions to standardize care, as well as provide support for patients and their families. Moreover, only brown/dark-red bleeding per vaginam, potentially indicative of bleeding resolution, significantly independently influenced the baseline odds of a change in management after pelvic examination. Although our study primarily explores improving ED efficiency, until the debate regarding the utility of speculum/bimanual examination in the ED is resolved, physician preferences, availability of obstetric services, and shared decision making with patients should guide practice regarding speculum and bimanual pelvic examination for the management of bleeding in early pregnancy.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon request.

Abbreviations

Alberta Health Services

Adjusted Odds Ratio

Confidence Interval

Canadian Triage and Acuity Scale

Emergency Department

Emergency Department Information System

Estimated Gestational Age

Human Chorionic Gonadotropin

Interquartile Range

Left Lower Quadrant

Length of Stay

Northeast Community Health Centre

Royal Alexandra Hospital

Right Lower Quadrant

Standard Deviation

University of Alberta Hospital

Women and Children’s Health Research Institute

Evans CS. Early pregnancy loss in the Emergency Department: lessons learned as a spouse, New Father, and Emergency Medicine Resident. Ann Emerg Med. 2021;77(2):233–6.

Article   PubMed   Google Scholar  

Murtaza UI, Ortmann MJ, Mando-Vandrick J, Lee AS. Management of first-trimester complications in the emergency department. Am J Health Syst Pharm. 2013;70(2):99–111.

Article   PubMed   CAS   Google Scholar  

Miller CA, Roe AH, McAllister A, Meisel ZF, Koelper N, Schreiber CA. Patient experiences with Miscarriage Management in the emergency and ambulatory settings. Obstet Gynecol. 2019;134(6):1285–92.

Article   PubMed   PubMed Central   Google Scholar  

VanArendonk SH, Rockhill K, Stickrath EH, Alston MJ. Evaluation of early pregnancy concerns in an early pregnancy unit compared with an Emergency Department. Obstet Gynecol. 2020;136:995–1000.

MacWilliams K, Hughes J, Aston M, Field S, Moffatt FW. Understanding the experience of miscarriage in the Emergency Department. J Emerg Nurs. 2016;42(6):504–12.

Hahn SA, Lavonas EJ, Mace SE, Napoli AM, Fesmire FM, American College of Emergency Physicians Clinical Policies Subcommittee on Early Pregnancy. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2012;60(3):381–e9028.

Bacidore V, Warren N, Chaput C, Keough VA. A collaborative framework for managing pregnancy loss in the emergency department. J Obstet Gynecol Neonatal Nurs. 2009;38(6):730–8.

Hsu WP, Hsiao PC. Correspondence to pelvic examination is unnecessary in pregnant patients with a normal bedside ultrasound. Am J Emerg Med. 2010;28(4):532. author reply 532 – 3.

McLean ME, Santiago-Rosado L. Plight of the pelvic exam. Emerg Med J. 2019;36(6):383–4.

Radecki R. The End of the Emergency Pelvic Exam – Emergency Medicine Literature of Note. Available online: https://www.emlitofnote.com/?p=4022 (Accessed 26 Apr 2023).

Peyton K, Solnick R. What do we learn from an Equivalence Study without Statistical Power? Ann Emerg Med. 2018;72(2):223–4.

Rosenberg P. Medical myth: the usefulness of pelvic exam. CJEM. 2004;6(1):9–10.

Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42(2):377–81.

Article   Google Scholar  

Ding Y, Park E, Nagarajan M, Grafstein E. Patient prioritization in Emergency Department Triage Systems: an empirical study of the Canadian triage and acuity scale (CTAS). Manuf Serv Oper Manag. 2019;21:723–41.

Murray JM. The Canadian triage and acuity scale: a Canadian perspective on emergency department triage. Emerg Med (Fremantle). 2003;15(1):6–10.

Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA. 2013;309(16):1722–9.

Linden JA, Grimmnitz B, Hagopian L, Breaud AH, Langlois BK, Nelson KP, et al. Is the pelvic examination still crucial in patients presenting to the Emergency Department with vaginal bleeding or Abdominal Pain when an intrauterine pregnancy is identified on Ultrasonography? A Randomized Controlled Trial. Ann Emerg Med. 2017;70(6):825–34.

Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. 2010;56(6):674–83.

Seymour A, Abebe H, Pavlik D, Sacchetti A. Pelvic examination is unnecessary in pregnant patients with a normal bedside ultrasound. Am J Emerg Med. 2010;28(2):213–6.

Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011;12(2):208–12.

PubMed   PubMed Central   Google Scholar  

Aronu ME, Okafor CO, Mbachu II, Iloraah US, Ikeako L, Okafor CI. A review of the correlation between clinical diagnosis and ultrasound diagnosis in first trimester vaginal bleeding. Ann Med Health Sci Res. 2018;8:120–4.

Google Scholar  

Tucker P, Evans DD. Are pelvic exams necessary anymore? Adv Emerg Nurs J. 2019;41:282–9.

Ultrasound Guidelines. Emergency, point-of-care and clinical Ultrasound guidelines in Medicine. Ann Emerg Med. 2017;69(5):e27–54.

Download references

Acknowledgements

We would like to thank all of the emergency physicians who volunteered to participate in the study at the RAH, NECHC, and UAH Emergency Departments. We would also like to thank Ms. Natalie Runham for her support and assistance with the study.

Dr Rowe’s research is supported by a Scientific Director’s Grant (SOP 168483) from the Canadian Institutes of Health Research (CIHR) through the Government of Canada (Ottawa, ON). Dr Fisher’s research was supported by the NECHC Emergency Medicine Special Purposes Fund. The funding organizations were not involved in any aspect of the conduct, analysis, and manuscript preparation of this study; the funders take no responsibility for the conduct or results of this study.

Author information

Authors and affiliations.

Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, 1G1.43 WMC, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada

Steven Fisher, Stephanie Couperthwaite, Esther H. Yang, Nana Owusu Mensah Essel & Brian H. Rowe

SPOR SUPPORT Unit, Alberta Health Services (AHS), Edmonton, AB, Canada

Esther H. Yang

School of Public Health, College of Health Sciences, University of Alberta, Edmonton, AB, Canada

Brian H. Rowe

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualization: S.F. and B.H.R. Data collection: S.F., S.C., E.H.Y., and B.H.R. Data cleaning and formal analysis: N.O.M.E. and E.H.Y. Data interpretation: N.O.M.E., E.H.Y., and B.H.R. Writing-original draft: N.O.M.E., S.F., S.C., E.H.Y., and B.H.R. All the authors have reviewed and approved the manuscript in its current form.

Corresponding author

Correspondence to Brian H. Rowe .

Ethics declarations

Ethics approval and consent to participate.

The study complied with the Declaration of Helsinki (1964) and its later amendments. Written informed consent was obtained from all study participants before enrollment. The study protocol and materials were approved by the Health Research Ethics Board (HREB; reference ID: Pro00047076) at the University of Alberta in Edmonton, Alberta, Canada. Operational and administrative approval was obtained from Alberta Health Services and a data sharing agreement was signed.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Notation of prior abstract publication/presentation

Partial results from this study were presented at the 2023 Annual Meeting of the Canadian Association of Emergency Physicians (CAEP), Toronto, ON, Canada , May 2023.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ .

Reprints and permissions

About this article

Cite this article.

Fisher, S., Couperthwaite, S., Yang, E.H. et al. Utility of pelvic examination in assessing women with bleeding in early pregnancy: a multicenter Canadian emergency department study. Int J Emerg Med 17 , 110 (2024). https://doi.org/10.1186/s12245-024-00686-2

Download citation

Received : 16 May 2024

Accepted : 22 August 2024

Published : 03 September 2024

DOI : https://doi.org/10.1186/s12245-024-00686-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Pelvic examination
• Emergency department
• Miscarriage
• Bleeding in early pregnancy
• Diagnostic utility

International Journal of Emergency Medicine

ISSN: 1865-1380

• General enquiries: [email protected]

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 08 September 2024

Perceived vulnerability to disease in pregnancy and parenthood and its impact on newborn health

• Agnieszka Sorokowska 1 ,
• Aleksandra Pytlinska 1 ,
• Tomasz Frackowiak 1 ,
• Piotr Sorokowski 1 ,
• Anna Oleszkiewicz 1 , 2 ,
• Michal Mikolaj Stefanczyk 1 &
• Marta Rokosz 1  

Scientific Reports volume  14 , Article number:  20907 ( 2024 ) Cite this article

Metrics details

• Health care

Susceptibility to diseases and fear of infections might vary intra-individually, depending on life circumstances. The main aims of the current research were to examine whether perceived vulnerability to disease (PVD) is higher in expectant women and their partners as compared to their non-pregnant peers (Study 1), and to test whether a mother’s disease aversion during pregnancy relates to health of her newborn (Study 2). In Study 1 we collected cross-sectional data from 412 men and women varying in parenthood status. Pregnant female participants were more likely to exhibit higher levels of PVD as compared with childless peers, although mothers also reported relatively high PVD scores. PVD in men, generally lower than that of women, seemed to be rather independent of their parenthood status. In Study 2, a sample of 200 pregnant women completed the PVD scale during the second pregnancy trimester and a follow-up survey after their child was born. We found that PVD in pregnant women was not related to further health outcomes in their newborns. Birth weight, average Apgar score, and general health of a newborn were not associated with the pregnancy-period mother’s PVD score. However, the probability of giving birth to a child with 10 Apgar points was higher in younger mothers and tended to decrease with the increasing number of health issues before pregnancy. Overall, this research contributes to understanding of the health-oriented beliefs of expectant parents and parents of infants, but it also shows that the possible, PVD-related disease avoidance has a relatively little effect on basic markers of a newborn’s health.

Similar content being viewed by others

Factors associated with fear of childbirth among Polish pregnant women

Factor structure of the parental bonding instrument for pregnant japanese women, the association of food insecurity with mental health in preschool-aged children and their parents, introduction.

Susceptibility to diseases and fear of infections might vary intra-individually, depending on life circumstances. For example, pregnancy is a time of particular vulnerability for a woman. The fetus is a half-foreign element of the female body, and to protect it from maternal immune response, the whole immune system slows down, leaving a woman more prone to diseases 1 , 2 , 3 . However, some researchers point out that the mechanism of the mother's immune system is more complex, and that pregnancy is not a period of immune suppression, but of dynamic immunomodulation that both protects against pathogens and prevents fetal rejection by the maternal immune system 4 . Nevertheless, pregnancy is a difficult time for future parents health-wise, as virtually all infections can result in complications in fetal development. Viral infections that cross the placental barrier and reach the fetus can adversely influence a fetus 5 . Viruses such as HIV, hepatitis A-C, or rubella, even influenza or herpes simplex may predispose the pregnancy to spontaneous abortion, preterm labor, and birth defects such as neurological deficits, blindness, hearing loss, or psychiatric disorders 3 , 5 , 6 .

Interestingly, these vulnerable stages of human development are accompanied by some cognitive and behavioral adjustments, potentially decreasing the probability of serious pregnancy complications. Pregnancy relates to increased prophylactic behaviors that can protect women and their children from diseases (e.g., 1 , 7 , 8 , 9 , 10 , 11 ). For example, compared to non-pregnant women, pregnant participants show a stronger preference for faces perceived as healthy 9 . Further, longitudinal studies across pregnancy show that in the first trimester, pregnant women exhibit particularly high disgust sensitivity 10 , 11 . The assumption of increased prophylactic behaviors is also supported by the increased social distance from individuals with symptoms of an infection 12 , or a significant correlation between indicators of immune system activity in pregnant women and their disgust sensitivity 13 . Overall, it can be hypothesized that some female behaviors and preferences are meant to compensate for lower reactivity of the maternal immune system during pregnancy, and to reduce the risk of diseases affecting the unborn child's development. However, it is not entirely clear whether these prophylactic behaviors help reduce a newborn's health risks.

Another critical developmental moment in terms of prophylactic behaviors and disease avoidance is childbirth and young infancy. Parents of small children are expected to be focused on their health and create a protective environment given the high vulnerability of newborns and infants to diseases 14 , 15 . For many infections, such as smallpox, clinical severity is relatively high in infancy, and a peak immune function is reached around 5–14 years of age 16 since a child’s immune system continues to develop 15 . Consequently, it may be assumed that health-oriented behaviors and attitudes would likely be pronounced among parents of young children, but this hypothesis has rarely been tested empirically. There are, however, a few studies concerning disgust-related behaviors of parents which support this notion. Mothers of young children (up to 7 years of age) demonstrate a more marked avoidance of disgust elicitors than parents of older children, suggesting a parent–child transmission of disgust-driven behaviors 17 , in line with a reasoning that proper disgust reactions are obtained through social learning 18 . However, contrary to pregnant women, mothers tend to be less disgust sensitive than childless women 19 . This may result from desensitization, i.e., a gradually acquired indifference to various disgust elicitors commonly encountered during childcare (e.g., diseases, exposure to bodily fluids of the offspring, etc.). This phenomenon may be explained by the source effect, as previous studies showed that familiar disgust elicitors are considered as less disgusting than unfamiliar ones 20 . Given that many essential childcare activities are (and historically predominantly have been) performed rather by mothers than fathers (e.g., 21 ), it could be expected that changes in sensitivity to pathogens during pregnancy and the first years of childrearing should be evident particularly (if not only) among women/mothers, and not men/fathers. There are theoretical works that support this potential discrepancy. For instance, Al-Shawaf et al. 22 state that disease avoidance-related psychological changes apply primarily to women, as “mothers matter more” for an offspring survival. Similarly, considering the childrearing social role of predominantly mothers and offspring’s vulnerability to infections, it is women/mothers who “should be disgusted enough for two” 23 . Consequently, any pregnancy- and childrearing-related changes in vulnerability to disease cues may be found only in women. Notably, a recent study that included also men/fathers showed lowered levels of disgust sensitivity among parents in general 24 , suggesting that parental status may be influential for both women’s and men’s psychology. As such, we expected to see an influence of parental status on perceived vulnerability to disease in mothers, and either a lack of it or a similar effect in men. Additionally, in line with the previous literature (e.g., 25 ), we expected women to declare overall higher levels of vulnerability to disease than men.

Overall, knowledge about health-oriented behaviors and beliefs of people expecting and having children is rather scarce. In the case of parents of small children, studies also tend to focus on beliefs concerning the child, such as parental perception of a child's vulnerability (PPCV; e.g., 26 ), and not on parents’ perception of their own vulnerability to disease. Additionally, previous research mostly fails to examine whether the increased protective behaviors and beliefs that one is vulnerable are observed also among fathers (or partners of pregnant women). Although the magnitude of this effect may be lower than in the case of women, it seems quite logical to expect that it exists; mechanisms promoting disease avoidance could stretch to a man, given that he or his physical/social environment might be a source of potential infections and/or that he needs to take care of his family (i.e., stay healthy). Further, the consequences of disease avoidance during pregnancy have not been examined in the context of further health outcomes in newborn children of mothers varying in PVD levels.

Here, we aimed to examine whether perceived vulnerability to disease is higher in expectant women and their partners as compared to their non-pregnant peers. We hypothesized that the observed effects would be particularly salient among female participants expecting or having a child. Further, in a second study, we explored whether a mother’s disease aversion during pregnancy relates to the health indices of her newborn. Our research included also other variables that seemed potentially important in the context of our predictions. For example, pregnancy and parenthood may generate particularly high stress 27 , which may be even more pronounced in unfavorable socio-economic conditions 28 . Exposure to maternal psychological stress during fetal development has been linked to long-term infant health and development consequences 29 , 30 , including neurodevelopmental and respiratory issues, and preterm birth 30 , 31 . In this context, in addition to our main research questions, we decided to investigate the association of stress with parenthood status, and the predictive value of stress and material situation for pregnancy outcomes.

Materials and methods

Participants.

In Study 1 we collected cross-sectional data from a sample of 412 childless individuals, expectant parents, and parents from Poland. The sample comprised 138 participants who declared they (or their partner) were not pregnant at the time of the study (86 women and 52 men; M age  = 26.8 ± 3.03; M SES  = 4.54 ± 1.20), 117 who expected a child (76 women and 41 men; M age  = 29.4 ± 2.97; M SES  = 4.91 ± 1.06), and 157 who had at least one child under two years of age (94 women and 63 men; M age  = 30.5 ± 3.38; M SES  = 5.08 ± 1.07). All participants declared being involved in a romantic relationship at the time of the study. The participants provided informed written consent to be included in the study.

The participants completed the Perceived Vulnerability to Disease scale (PVD) 25 , the self-assessment Perceived Stress Scale (PSS-10) 32 , and a brief demographic survey that included questions on age, age of the partner, gender, parenthood status, relationship status and duration, hormonal problems, number of years of completed education ( M  = 17.1 ± 2.39 in our sample) and self-assessed socio-economic status (SES; rated from 1 indicating much lower than the average in my country to 7, meaning much higher than the average in my country).

PVD assessment

The 15-item PVD scale 25 comprises two subscales: (1) Germ Aversion, that focuses on emotional discomfort in contexts associated with high pathogen transmission (e.g., I prefer to wash my hands pretty soon after shaking someone’s hand ), and (2) Perceived Infectability which covers one’s beliefs about own susceptibility to infectious diseases (e.g., In general, I am very susceptible to colds, flu and other infectious diseases ). Subscale scores are computed as a total sum or mean score of all items belonging to the subscale. After reverse-scoring of indicated items the higher the score, the higher the perceived vulnerability to disease. The scale shows good convergent and discriminant validity, as the subscales correlate positively with health-related variables such as disgust sensitivity and general hypochondriacal fears and beliefs, but negatively with sociosexual orientation 25 . It also reflects gender, national, and cultural differences that align with existing research on disgust sensitivity, and the geographical differences in prevalence of infectious diseases. Similar to the original study 25 , our data showed an acceptable level of internal consistency for the full scale (Cronbach’s alpha = 0.82 in both our and the original study), the Perceived Infectability subscale, Cronbach’s alpha = 0.90 (0.87 in the original study), and a lower reliability for the Germ Aversion subscale, Cronbach’s alpha = 0.65 (0.74 in the original study). The factors were modestly correlated with each other across the whole sample, r  = 0.32, p  < 0.001.

Stress assessment

The PSS-10 32 is a popular tool for measuring psychological stress (exemplary item: In the last month, how often have you been upset because of something that happened unexpectedly? ). Participants report the frequency of certain psychological and behavioral markers of stress in a past month using a Likert-type 1–5 response format. The scale displays good temporal stability (test–retest correlation 0.85 in the original study), as well as validity, shown by a positive correlation with number and impact of stressful life events 32 . The scale had a satisfactory level of internal consistency (Cronbach’s alpha = 0.88; 0.84-0.86 in the original study).

Participants were invited to complete a short online survey regarding health-oriented behaviors. The invitation to participate in the study was distributed by the experimenters through the institutional website and social media, the authors’ social media, through invitations sent directly to groups of expectant mothers and young parents and by snowball technique (all participants were invited to resend the link to their friends and acquaintances). We noted in the survey inclusion criteria that we only invite people who are childless, expect their first child, or have one child below two years of age to complete the questionnaires. Not meeting any of these criteria (as indicated in the survey) redirected the participants to a screen where they were thanked for their willingness to complete the study. The participants provided their informed consent to be included in the study and the procedure was approved by the Ethical Committee of the Institute of Psychology, University of Wroclaw. All data are available online 33 . The participants received no compensation for their participation in the study.

Data analysis

Statistical analyses were performed with jamovi 2.0 statistical package 34 with the level of significance set to α = 0.05. We computed two separate ANCOVA analyses with Infectability and Germ Aversion PVD subscales as dependent variables, gender (male/female), and parenthood status (no children/pregnant/parent) and their interactions as between-subject factors and age included as a covariate. We also performed two supplementary analyses concerning stress level: an analogous, supplementary ANCOVA with the stress level of our participants as a dependent variable and correlations of perceived vulnerability to disease and stress level (Pearson’s r correlations computed for the entire sample and separately for men and women; see Study 1 Supplementary Materials for the full results).

For Infectability, the interaction effect of gender and parenthood status was non-significant and so was the main parenthood status effect, while the main effect of gender was significant, F (1,405) = 5.16, p  = 0.024, η 2  = 0.01. Women perceived their infectability as slightly higher than men ( M  = 3.24; 95%CI 3.09–3.40 vs. M  = 2.95; 95%CI 2.74–3.15). For Germ Aversion, the overall gender*parenthood status interaction effect was non-significant, but again this PVD subscale score was significantly affected by gender, F (1,405) = 7.95, p  = 0.005, η 2  = 0.02, with women assessing their germ aversion as slightly higher than men ( M  = 3.45; 95%CI 3.38–3.61 vs. M  = 3.22; 95%CI 3.06–3.37). Germ aversion also tended to be affected by parenthood status, F (2,405) = 2.25, p  = 0.107, and provided the focus of this study, we decided to further explore this trend. It appeared to be driven mostly by differences between women varying in parenthood status. Childless women were found to report slightly lower germ aversion than women who expected a child, t  = -2.20, p  = 0.03 and tended to have slightly lower germ aversion scores than women who had a child, t  = -1.97, p  = 0.05 (see Table 1 for all scores). Interestingly, no such differences were observed between groups of men varying in parenthood status. Further, women who had a child reported significantly higher germ aversion than men who had a child, t  = 3.22, p  = 0.001. For full results of the ANCOVA analyses as well as results regarding stress level across pregnancy and parenthood see Study 1 supplementary materials (supplementary Tables S1 – S3 ).

To extend and contextualize the findings of Study 1, we decided to explore whether a mother's perceived vulnerability to disease during pregnancy actually predicts her newborn’s health. A sample of pregnant women completed the PVD scale during the second pregnancy trimester and a follow-up survey on their newborn’s health after birth. We expected that mothers with high PVD could give birth to a healthier newborn, possibly due to an increase in prophylactic behaviors limiting risks and pathogens during pregnancy.

In Study 2, we invited women during the second pregnancy trimester to complete a health-related survey during pregnancy (T1) and after childbirth (T2). The women were recruited for the project by the experimenters through social media (groups for expectant parents and young mothers), leaflets and posters distributed in medical practices (general practitioners and obstetricians), through facilities organizing educational courses for expectant parents, and using a snowball technique (inviting friends and acquaintances of the participants to the project). All women expected singletons. Out of 221 women who expressed initial interest in the study, 200 completed the T1 survey and the follow-up (T2) measurement. The participants were Polish women aged between 19 and 42 ( M  = 28.84, SD  = 3.67). One participant was single and 199 participants declared being in a romantic relationship at the time of the study (150 were married and 49 had a partner they cohabited with). One participant reported that her child was born preterm (30 th week) and that it was a stillbirth. Her data were not included in the final models. All participants received financial compensation for their participation in the study and provided informed written consent prior to inclusion in the project.

During the pregnancy testing session, participants completed the PVD scale 25 , a demographic survey that included questions on age, height, highest completed education level, self-assessed socio-economic status (SES; rated from 1 indicating much lower than the average to 7, meaning much higher than the average), income per household member (presented as 8 numerical categories of income, with 1 further coded as the lowest and 8 – the highest income category). The mothers also reported body mass before and during pregnancy, partner’s age, height and weight, as well as their general health before the current pregnancy (presence of asthma, allergies, epilepsy, heart condition, diabetes, thyroid gland problems, hypertension, coronary heart disease, anaemia, endometriosis, hormonal issues, other diseases) and pregnancy-related health issues (pregnancy diabetes, thyroid gland problems, hypertension, other diseases; for all information see the study data 33 ). Guided by the findings of our Study 1 and the potential impact a mother’s stress has on a child, we also controlled for the mother’s stress at T1 (PSS-10) 32 .

Following childbirth (at T2 meeting), the mothers completed a survey on their newborn using medical records (see Procedure for more details). They reported sex, week of childbirth and several variables related to the newborn’s health, namely birth weight (in grams), lowest body mass after birth, day of the lowest body mass, height, head and chest circumference after birth, Apgar scores (scale 1 to 10) assigned to a child by a medical doctor in the 1 st , 3 rd , 5 th and 10 th minute following birth (these were later averaged to compute a mean Apgar score), and general health assessment right after birth described by 12 different indices of a newborn’s health recorded in the child’s documentation (a medical doctor assessed the condition of a head, neck, skin, genitourinary tract, limbs or pelvis, or in newborn’s breathing, heartbeat frequency and sounds, pulse, and overall muscle tone; the doctor would note “1” in a designated space in the health booklet if no abnormalities in a given index were observed). The 12 health indices were further summarized to obtain a general health score, wherein 0 meant the poorest health and 12 indicated the best health. The mothers also reported whether they experienced any problems during childbirth, and whether a child suffered from jaundice.

The study was part of a larger project on psychological changes experienced by women during pregnancy and after childbirth conducted in 2019. Pregnant mothers completed a survey on several psychological variables (unrelated to the current study). They were invited to contact the experimenter within approximately a month after childbirth to complete a follow-up health-related survey. The majority of the data recorded at the T2 meeting was extracted from the mothers' official medical records and the child's "health booklet." The health booklet is a mandatory instrument in Poland for documenting the health history of pregnant mothers and their children. Parents receive a child's “health booklet” in the hospital where their child is born. It lists information such as the course of pregnancy and birth (including any complications), and the child’s health status after birth (including assessments of 12 aforementioned health indices and the Apgar scores). The mothers brought the medical records and the child's “health booklet” to the T2 meeting and the information were recorded with the assistance of an experimenter. The study was performed in accordance with the Declaration of Helsinki on Biomedical Studies Involving Human Subjects. The procedure was approved by the Ethical Committee of [ University of Wrocław ] and the anonymized data for this study are available on-line 33 .

Statistical analyses were performed with SPSS 28.0.1.0 statistical package (IBM) with the level of significance set to α = 0.05. We intended to estimate the predictive value of variables associated with a mother and her health during pregnancy (age, health problems before pregnancy, health problems related to pregnancy, increase in BMI), material situation (income category), stress and PVD subscales on the health outcomes in newborns. Among material situation indices assessed in this study, we also had data regarding self-assessed SES. However, the reported income category and self-assessed socio-economic status (SES) were significantly and positively correlated ( r  = 0.53, p  < 0.001), and therefore we decided to include just the (more objective) income category to the computed models.

Overall, we computed three separate hierarchical regressions models: (1) Linear regression with a birth weight of a newborn as a dependent variable, (2) Logistic regression with a likelihood to obtain 10 Apgar points (10 Apgar points meaning the best health denoted by 1 vs. any deviations from the score of 10 Apgar points denoted by value 0) as a dependent variable, (3) Logistic regression with likelihood to obtain a maximum value in the newborn general health score as a dependent variable [12-maximum score as indicated by the 12 factors listed above meaning the best health denoted by value 1 vs. any deviations from 12 points score denoted by value 0]. In the two latter cases, we decided to perform a logistic regression analysis predicting any deviations from maximum Apgar or maximum health score, since the data distribution was very skewed both for AGPAR scores and newborn general health scores (skewness of -3.964 and -5.993, respectively).

The first step of each model (Step 1) included the age of a mother, the number of mother’s health problems before pregnancy, the number of mother’s health problems during pregnancy, and the change in the mother’s BMI. The second step of each model (Step 2) involved inclusion of the income category, the subsequent Step 3 additionally comprised stress during pregnancy, while in the fourth step (Step 4) we added perceived infectability and germ aversion PVD scores. The two PVD subscales were positively but weakly correlated with each other, suggesting no multicollinearity problems (which was further confirmed by low values of VIF indices).

Table 2 presents the descriptive statistics for the analyzed variables. Among newborns born to the mothers included in the project, 155 (77.9%) obtained 10 out of 10 possible mean Apgar points and 162 (81.4%) received the maximum, 12-point health assessment.

The full results of the three regression analyses are presented in Study 2 Supplementary Materials (Tables S4 – S6 ). Neither the linear regression analysis focused on a newborn’s birthweight nor the logistic regression analysis focused on newborn’s maximum health score yielded significant outcomes. In the analysis focused on the maximum Apgar score, the Step 1 regression model including the age of a mother, the mother’s health problems before pregnancy, the mother’s health problems during pregnancy, and change in the mother’s BMI showed that only age significantly predicted the probability of obtaining 10 points on Apgar scale. Younger mothers were more likely to give birth to a child with 10 Apgar points (B = − 0.125, p  = 0.01). Further, mothers reporting a higher number of health problems before pregnancy tended to be slightly less likely to give birth to a child with 10 Apgar points (B = − 0.345, p  = 0.085). The logistic regression model was statistically significant, Χ 2 (4, N  = 199) = 12.783, p  = 0.012. The model explained 9.5% (Nagelkerke R 2 ) of the variance in maximum Apgar scores and correctly classified 78.4% of cases. Neither income category, stress nor the PVD subscales were found to significantly predict the dependent variables within the computed model and adding these factors in consecutive Steps 2, 3 and 4 did not improve the models’ fit.

Perceived vulnerability to disease is associated with cognitive and behavioral indices of disgust and prophylactic health protection. Here, we found that pregnant women were more likely to exhibit higher levels of PVD as compared with childless peers, although mothers also reported relatively high PVD scores. PVD in men, generally lower than that of the female participants, seemed to be additionally rather independent of their parenthood status. However, as shown by our second study, regardless of the elevated PVD in pregnancy, neither of the perceived vulnerability to disease subscales had a significant impact on the health outcomes of newborns. Birth weight, average Apgar, and general health of a newborn were not associated with the pregnancy-period mother’s PVD score. However, consistent with previous studies indicating that advanced maternal age is associated with an increased risk of adverse outcomes 35 , 36 , the probability of giving birth to a child with 10 Apgar points was higher in younger mothers. Overall, this research contributes to understanding of the health-oriented beliefs of expecting parents and parents of infants, but it also shows that the possible, PVD-related disease avoidance seems to have a relatively little effect on the basic markers of a newborn’s health.

The results of the first part of our project showed that women, regardless of the parenthood status, perceived their infectability as higher than men, and that the increased female germ aversion tended to interact with the parenthood status. One of the most interesting findings of our study is that slightly elevated germ aversion scores were observed in pregnant women, in line with previous evidence showing an increase of prophylactic behaviors during pregnancy (e.g., 1 , 10 , 11 , 13 ). We may also relate our findings to Behavioral Immune System (BIS) theory, which suggests that human behavior is guided by emotional processes, such as disgust, to avoid pathogen threats, even before they come into contact with the body. These processes result in emotional, behavioral, and cognitive implications, such as sensitivity to disgust and aversion to individuals who pose a risk of pathogen transmission 37 . This relates to a so-called compensatory prophylaxis hypothesis 7 , according to which psychological traits adjust to a current state of immune system, namely that people should be particularly avoidant of pathogen cues when their immune system is compromised. Elevated progesterone level, such as during pregnancy, is related to increased disease avoidance 38 , and our findings show additional support for that assumption. Additionally, general theories of parental investment cost explain that having children is definitely more biologically costly for women than it is for men 39 . This may drive a higher involvement of a mother in prophylactic behaviors and beliefs 22 , although the efficacy of such behaviors may depend on health literacy, an interesting variable that was shown to improve antenatal care and health in pregnancy 40 . Although in Mojoyinola 40 study health literacy was not significant in terms of pregnancy outcomes, it would nonetheless be an interesting variable to include in further research.

The lower levels of perceived vulnerability to disease in men compared to women was expected 25 , 41 , but it still seems worthy of consideration that parenthood status had no significant effect on PVD in the male part of our sample. There are few additional explanations for this phenomenon. Extending the previous reasoning, a mother’s infection might have a greater influence on a fetus or even on a child, since mothers usually display more tactile affection in their care of the child 42 . Men may also perceive their role as a parent in different terms than women. Mothers are usually expected to provide comfort and nurturing to a child, while fathers provide play, adventure, and stimulation 43 . This may explain why avoiding infections might be more important for the mothers than for the fathers. Women are also generally more involved in health-related behaviors, such as consulting their symptoms with a doctor, than men 44 . Finally, in line with the “mothers matter more” argument 22 , and the empirical findings reviewed in Sear and Mace 45 , it is mothers and other female relatives who play major role in keeping offspring alive, and fathers’ unconcerned (and seemingly: not malleable) attitudes to disease cues may be a manifestation of that. On one hand, it is possible that Sear and Mace’s conclusion is due to fathers’ insensitivity to disease, as they do not provide protection from germs to their offspring anyway. On the other hand, perhaps it was not evolutionary necessary for them to adjust their psychological traits to parental status, as an offspring was already sufficiently protected by a mother’s psychological disease-related adjustments. These possible explanations require empirical verification, which could include the mentioned perceived role as a parent, as well as participation in childcare, masculinity and femininity, or sociopolitical worldview on gender roles. It is also possible that men are not completely indifferent to vulnerability to disease, but are more concerned with potential health problems of their partner’s rather than of those of their own.

Despite the parenthood-related differences in PVD that we observed in female participants of the Study 1, newborns’ health indices of our participants in Study 2 were not associated with potential, PVD-driven preventive behaviors of the pregnant mothers. Mother's perceived vulnerability to disease during pregnancy may translate more directly into the health of the mother herself, while the health of the babies may be due to a broader range of factors. Provided the immunoregulatory function of the placenta, the fetus is not completely deprived of protection from infections and other external environmental threats that the mother's preventive behaviors would protect it from 4 . Nevertheless, it could be mentioned here that we observed an interesting trend in our analyses: mothers reporting more health issues before pregnancy were slightly less likely to give birth to a child with 10 Apgar points. Although this slight trend needs to be interpreted with caution, it confirms a logical assumption that maternal health is important in the context of pregnancy outcomes. The impact of maternal perceived vulnerability to disease on health (and disease-preventive behaviors) is, however, still rather poorly investigated. Therefore, it seems crucial to further investigate the meaning of maternal elevated perceived vulnerability to disease during pregnancy, provided the apparent health-related psychological changes associated with motherhood. As mentioned previously, pregnant women typically exhibit higher disgust sensitivity compared to others 10 , 11 . During the COVID-19 pandemic, there was a slight increase in their disgust sensitivity, possibly due to the heightened risk of infection 46 . Additionally, levels of disgust sensitivity appear to fluctuate during pregnancy and post-birth, influenced by women’s illness and even the sex of the fetus 47 . Therefore, these complex interactions and phenomena definitely necessitate further studies.

There are several other health-related behaviors and attitudes which are observed during pregnancy and that influence the infant’s health and pregnancy outcomes, such as prenatal substance use 48 , nutrition 49 or gestational weight gain 50 . Additionally, pregnant women’s mental state has an effect on the pregnancy and adverse birth outcomes, as shown regarding depression and anxiety 51 . Focusing on predictors included in our research, stress during pregnancy is considered an important factor in infant health and development 29 , 30 . Exposure to maternal psychological stress during fetal development has been linked to long-term consequences, including neurodevelopmental and respiratory issues, and preterm labor 30 , 31 . One of the main assumed mechanisms underlying this relationship is the programming effect of prenatal stress on the development of the fetal Hypothalamic—Pituitary—Adrenal axis, leading to alterations in infant stress regulation 52 . However, in our study we observed no apparent parenthood-related stress increase, nor did we find any support for the hypothesis that higher maternal prenatal stress would be associated with adverse neonatal outcomes. A longer longitudinal study could perhaps provide more information on stress effect on the offspring given the solid basis for assuming a significant impact of prenatal maternal stress on later stages of child development 52 beyond the neonatal health indicators we examined. For example, it was found that maternal mental problems in pregnant women, like anxiety or depression, are associated with problematic behaviors in children after birth 53 . Furthermore, maternal prenatal stress has been shown to affect numerous infant and child outcomes, such as temperament, emotional and stress regulation, cognitive skills and child brain development 54 .

Although our study’s longitudinal design is a definitive strength of this project, future research could benefit from extending follow-up testing to include also older children. Some effects of protective health behaviors in pregnancy, or fetal exposure to stress may not become apparent until later in life. To better understand the links between the elevated PVD and child health, future studies should furthermore examine additional health indicators or involve observations aimed at assessing whether PVD actually translates to increased health protection. Researchers should also consider measuring various indicators of stress, as cortisol levels may better predict adverse infant outcomes resulting from prenatal stress than self-reported measures of stress 55 . Further, we did not collect information regarding sexual orientation in our samples. Although, due to legal restrictions, parenthood remains very infrequent in same-sex relationships in Poland, provided the interesting gender differences we observed, it would be worthy to investigate our predictions in same-sex relationships.

Our study had also some other limitations. Unfortunately, we did not conduct an a priori estimation of the required sample sizes. It resulted in our Study 1 being underpowered (the required sample size estimated post-hoc was 432 individuals, not the 412 we recruited).Since we observed some interesting effects and trends despite this issue, we believe that these results may be particularly meaningful and worthy to investigate further. In Study 2, the sample size was mostly dictated by limitations in resources and logistics—all women were to be interviewed personally by the experimenters both at T1 and T2 and the participants were to receive a financial retribution for their efforts. Nonetheless, despite achieving sufficient power to detect even small effects in that study, we still highlight the need for an a priori estimation of a required sample in further research.

One may also consider whether assessing PVD in the second trimester in Study 2 could have affected our findings. We decided to invite women in this trimester to make the study participation as convenient and comfortable for pregnant participants. However, second trimester of the pregnancy is considered less vulnerable health-wise and psychophysiologically demanding than the first one, with is associated with particularly strong hormonal changes and immunomodulation. In the first trimester, women may also have a greater fear of spontaneous abortion, which could be induced by an environmental threat such as infection. Likewise, in the last trimester, women may also fear premature delivery caused by infections. In that context, our null results can be contrasted with previous findings that women in the first trimester are more disease avoidant 7 . A more recent study reported that disgust sensitivity is particularly high during early pregnancy 56 , although the literature is not fully consistent 47 with this regard. Another study showed a negative relationship between disgust sensitivity and immune system activity in the first trimester of pregnancy 13 . Moreover, recently it has been shown that sensitivity to disgust is related to sexual steroids’ levels in opposite directions during the first and the third trimester, suggesting that the second trimester may serve as a plateau period in this regard 57 . Nevertheless, to gain a better insight to the parenthood-related changes in PVD levels and their potential impact (or lack thereof) on newborns’ health outcomes, future longitudinal projects should ideally include PVD measurements across all three pregnancy trimesters.

Data availability

All data for this study are available at https://osf.io/7fjd6/?view_only=860c131dddc74eaa9889d0a0f985e92c .

Fessler, D. M. T. Reproductive immunosuppression and diet: An evolutionary perspective on pregnancy sickness and meat consumption. Curr. Anthropol. 43 , 19–61 (2002).

Article   PubMed   Google Scholar  

Haig, D. Genetic conflicts in human pregnancy. Q. Rev. Biol. 68 , 495–532 (1993).

Article   CAS   PubMed   Google Scholar  

Mor, G., Aldo, P. & Alvero, A. B. The unique immunological and microbial aspects of pregnancy. Nat. Rev. Immunol. 17 , 469–482 (2017).

Racicot, K., Kwon, J.-Y., Aldo, P., Silasi, M. & Mor, G. Understanding the complexity of the immune system during pregnancy. Am. J. Reprod. Immunol. 72 , 107–116 (2014).

Article   PubMed   PubMed Central   Google Scholar  

Racicot, K. & Mor, G. Risks associated with viral infections during pregnancy. J. Clin. Invest. 127 , 1591–1599 (2017).

Silasi, M. et al. Viral infections during pregnancy. Am. J. Reprod. Immunol. 73 , 199–213 (2015).

Fessler, D. M. T., Eng, S. J. & Navarrete, C. D. Elevated disgust sensitivity in the first trimester of pregnancy: Evidence supporting the compensatory prophylaxis hypothesis. Evol. Hum. Behav. 26 , 344–351 (2005).

Article   Google Scholar  

Flaxman, S. M. & Sherman, P. W. Morning sickness: A mechanism for protecting mother and embryo. Q. Rev. Biol. 75 , 113–148 (2000).

Jones, B. C. et al. Menstrual cycle, pregnancy and oral contraceptive use alter attraction to apparent health in faces. Proc. R. Soc. B Biol. Sci. 272 , 347–354 (2005).

Article   CAS   Google Scholar  

Navarrete, C. D., Fessler, D. M. T. & Eng, S. J. Elevated ethnocentrism in the first trimester of pregnancy. Evol. Hum. Behav. 28 , 60–65 (2007).

Żelaźniewicz, A. & Pawłowski, B. Disgust in pregnancy and fetus sex: Longitudinal study. Physiol. Behav. 139 , 177–181 (2015).

Frankowska, N., Szymkow, A., Tolopilo, A. & Galasinska, K. Social distance as a strategy of pathogen avoidance by women in the 1st trimester of pregnancy - mediating role of germ aversion. in (2022).

Kaňková, Š et al. Disgust sensitivity is negatively associated with immune system activity in early pregnancy: Direct support for the Compensatory Prophylaxis Hypothesis. Evol. Hum. Behav. 43 , 234–241 (2022).

Béhar, M. Death and disease in infants and toddlers of preindustrial countries. Am. J. Public Health Nations Health 54 , 1100–1105 (1964).

Simon, A. K., Hollander, G. A. & McMichael, A. Evolution of the immune system in humans from infancy to old age. Proc. R. Soc. B Biol. Sci. 282 , 20143085 (2015).

Glynn, J. R. & Moss, P. A. H. Systematic analysis of infectious disease outcomes by age shows lowest severity in school-age children. Sci. Data 7 , 329 (2020).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Stevenson, R. J., Oaten, M. J., Case, T. I., Repacholi, B. M. & Wagland, P. Children’s response to adult disgust elicitors: Development and acquisition. Dev. Psychol. 46 , 165–177 (2010).

Kavaliers, M., Ossenkopp, K. & Choleris, E. Social neuroscience of disgust. Genes Brain Behav. 18 , e12508 (2019).

Prokop, P. & Fančovičová, J. Mothers are less disgust sensitive than childless females. Personal. Individ. Differ. 96 , 65–69 (2016).

Case, T. I., Repacholi, B. M. & Stevenson, R. J. My baby doesn’t smell as bad as yours: The plasticity of disgust. Evol. Hum. Behav. 27 , 357–365 (2006).

Craig, L. Does father care mean fathers share? A Comparison of how mothers and fathers in intact families spend time with children. Gend. Soc. 20 , 259–281 (2006).

Al-Shawaf, L., Lewis, D. M. G. & Buss, D. M. Sex differences in disgust: Why are women more easily disgusted than men?. Emot. Rev. 10 , 149–160 (2018).

Curtis, V., De Barra, M. & Aunger, R. Disgust as an adaptive system for disease avoidance behaviour. Philos. Trans. R. Soc. B Biol. Sci. 366 , 389–401 (2011).

Stefanczyk, M. M., Rokosz, M. & Białek, M. Changes in perceived vulnerability to disease, resilience, and disgust sensitivity during the pandemic: A longitudinal study. Curr. Psychol. https://doi.org/10.1007/s12144-024-05825-9 (2024).

Duncan, L. A., Schaller, M. & Park, J. H. Perceived vulnerability to disease: Development and validation of a 15-item self-report instrument. Personal. Individ. Differ. 47 , 541–546 (2009).

Tallandini, M. A., Morsan, V., Gronchi, G. & Macagno, F. Systematic and meta-analytic review: Triggering agents of parental perception of child’s vulnerability in instances of preterm birth. J. Pediatr. Psychol. 40 , 545–553 (2015).

Obrochta, C. A., Chambers, C. & Bandoli, G. Psychological distress in pregnancy and postpartum. Women Birth 33 , 583–591 (2020).

Saur, A. M. & Dos Santos, M. A. Risk factors associated with stress symptoms during pregnancy and postpartum: Integrative literature review. Women Health 61 , 651–667 (2021).

DeSocio, J. E. Epigenetics, maternal prenatal psychosocial stress and infant mental health. Arch. Psychiatr. Nurs. 32 , 901–906 (2018).

Vehmeijer, F. O. L., Guxens, M., Duijts, L. & Marroun, H. E. Maternal psychological distress during pregnancy and childhood health outcomes: A narrative review. J. Dev. Orig. Health Dis. 10 , 274–285 (2019).

Shapiro, G. D., Fraser, W. D., Frasch, M. G. & Séguin, J. R. Psychosocial stress in pregnancy and preterm birth: Associations and mechanisms. J. Perinat. Med. 41 , 631–645 (2013).

Cohen, S., Kamarck, T. & Mermelstein, R. A global measure of perceived stress. J. Health Soc. Behav. 24 , 385 (1983).

PVD and parenthood study. Anonymized link: https://osf.io/7fjd6/?view_only=860c131dddc74eaa9889d0a0f985e92c (2023).

The jamovi project. jamovi. (Version 2.0) [Computer Software]. Retrieved from https://www.jamovi.org (2021).

Cleary-Goldman, J. et al. Impact of maternal age on obstetric outcome. Obstet. Gynecol. 105 , 983–990 (2005).

Frick, A. P. Advanced maternal age and adverse pregnancy outcomes. Best Pract. Res. Clin. Obstet. Gynaecol. 70 , 92–100 (2021).

Schaller, M. & Park, J. H. The behavioral immune system (and why it matters). Curr. Dir. Psychol. Sci. 20 , 99–103 (2011).

Fleischman, D. S. & Fessler, D. M. T. Progesterone’s effects on the psychology of disease avoidance: Support for the compensatory behavioral prophylaxis hypothesis. Horm. Behav. 59 , 271–275 (2011).

Trivers, R. L. Parent-offspring conflict. Am. Zool. 14 , 249–264 (1974).

Mojoyinola, J. Influence of maternal health literacy on healthy pregnancy and pregnancy outcomes of women attending public hospitals in Ibadan, Oyo State, Nigeria. Afr. Res. Rev. https://doi.org/10.4314/afrrev.v5i3.67336 (2011).

Díaz, A., Soriano, J. F. & Beleña, Á. Perceived Vulnerability to Disease Questionnaire: Factor structure, psychometric properties and gender differences. Personal. Individ. Differ. 101 , 42–49 (2016).

Feldman, R., Gordon, I., Schneiderman, I., Weisman, O. & Zagoory-Sharon, O. Natural variations in maternal and paternal care are associated with systematic changes in oxytocin following parent–infant contact. Psychoneuroendocrinology 35 , 1133–1141 (2010).

Cabrera, N. J. & Roggman, L. Father play: Is it special?. Infant Ment. Health J. 38 , 706–708 (2017).

Pinkhasov, R. M. et al. Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States. Int. J. Clin. Pract. 64 , 475–487 (2010).

Sear, R. & Mace, R. Who keeps children alive? A review of the effects of kin on child survival. Evol. Hum. Behav. 29 , 1–18 (2008).

Kaňková, Š et al. Disgust sensitivity in early pregnancy as a response to high pathogen risk. Front. Psychol. 14 , 1015927 (2023).

Dlouhá, D., Roberts, S. C., Hlaváčová, J., Nouzová, K. & Kaňková, Š. Longitudinal changes in disgust sensitivity during pregnancy and the early postpartum period, and the role of recent health problems. Sci. Rep. 13 , 4752 (2023).

Article   ADS   PubMed   PubMed Central   Google Scholar  

Ross, E. J., Graham, D. L., Money, K. M. & Stanwood, G. D. Developmental consequences of fetal exposure to drugs: What we know and what we still must learn. Neuropsychopharmacology 40 , 61–87 (2015).

Koletzko, B. et al. Nutrition during pregnancy, lactation and early childhood and its implications for maternal and long-term child health: The early nutrition project recommendations. Ann. Nutr. Metab. 74 , 93–106 (2019).

Rogozińska, E. et al. Gestational weight gain outside the Institute of Medicine recommendations and adverse pregnancy outcomes: Analysis using individual participant data from randomised trials. BMC Pregnancy Childbirth 19 , 322 (2019).

Staneva, A., Bogossian, F., Pritchard, M. & Wittkowski, A. The effects of maternal depression, anxiety, and perceived stress during pregnancy on preterm birth: A systematic review. Women Birth 28 , 179–193 (2015).

Davis, E. P., Glynn, L. M., Waffarn, F. & Sandman, C. A. Prenatal maternal stress programs infant stress regulation. J. Child Psychol. Psychiatry 52 , 119–129 (2011).

Ölmestig, T. K., Siersma, V., Birkmose, A. R., Kragstrup, J. & Ertmann, R. K. Infant crying problems related to maternal depressive and anxiety symptoms during pregnancy: A prospective cohort study. BMC Pregnancy Childbirth 21 , 777 (2021).

Sandman, C. A., Davis, E. P., Buss, C. & Glynn, L. M. Exposure to prenatal psychobiological stress exerts programming influences on the mother and her fetus. Neuroendocrinology 95 , 8–21 (2012).

Caparros-Gonzalez, R. A., Lynn, F., Alderdice, F. & Peralta-Ramirez, M. I. Cortisol levels versus self-report stress measures during pregnancy as predictors of adverse infant outcomes: A systematic review. Stress 25 , 189–212 (2022).

Dlouhá, D. et al. Comparing disgust sensitivity in women in early pregnancy and non-pregnant women in the follicular and luteal phases of the menstrual cycle. Evol. Hum. Behav. 45 , 164–174 (2024).

Kaňková, Š et al. Association between disgust sensitivity during pregnancy and endogenous steroids: A longitudinal study. Int. J. Mol. Sci. 25 , 6857 (2024).

Download references

This study was supported by the National Science Centre research grant Sonata Bis to AS (UMO-2020/38/E/HS6/00289).

Author information

Authors and affiliations.

Institute of Psychology, University of Wroclaw, ul. Dawida 1, 50-527, Wroclaw, Poland

Agnieszka Sorokowska, Aleksandra Pytlinska, Tomasz Frackowiak, Piotr Sorokowski, Anna Oleszkiewicz, Michal Mikolaj Stefanczyk & Marta Rokosz

Smell and Taste Clinic, Dept. of Otorhinolaryngology, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany

Anna Oleszkiewicz

You can also search for this author in PubMed   Google Scholar

Contributions

A.S.—conceptualization, data curation, formal analysis, funding acquisition, methodology, project administration, resources, supervision, writing—original draft, writing—review and editing; A.P.—conceptualization, investigation, writing—original draft, writing—review and editing; T.F.—conceptualization, investigation, methodology, resources, writing—review and editing; P.S.—conceptualization, data curation, investigation, methodology, writing—review and editing; A.O.—conceptualization, data curation, investigation, methodology, writing—review and editing; M.M.S.—conceptualization, investigation, methodology, project administration, writing—review and editing; M.R.—conceptualization, data curation, formal analysis, supervision, writing—original draft, writing—review and editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Marta Rokosz .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary tables., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Sorokowska, A., Pytlinska, A., Frackowiak, T. et al. Perceived vulnerability to disease in pregnancy and parenthood and its impact on newborn health. Sci Rep 14 , 20907 (2024). https://doi.org/10.1038/s41598-024-71870-w

Download citation

Received : 27 September 2023

Accepted : 02 September 2024

Published : 08 September 2024

DOI : https://doi.org/10.1038/s41598-024-71870-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Perceived vulnerability to disease (PVD)

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

• Open access
• Published: 09 September 2024

Determinants of the desire to avoid pregnancy after the disaster of the century in Türkiye

• Zeliha Özşahin   ORCID: orcid.org/0000-0003-1906-9537 1  

BMC Women's Health volume  24 , Article number:  496 ( 2024 ) Cite this article

Metrics details

After natural disasters, the occurrence of mental health problems and adverse effects on reproductive health in women of reproductive age can be attributed to a multitude of factors, including the deterioration of health facilities, a shortage of qualified health professionals, a lack of socio-economic stability, and a paucity of familial and community support.

The descriptive correlational study was conducted through social networks with 405 women who had experienced the disaster of the century 8 months after (between November and December 2023) the earthquake. The snowball sampling method was used to obtain the research data. The questionnaire form, developed for the purpose of data collection, was disseminated to women who consented to participate in the study through social networks. The data were evaluated using a variety of statistical techniques, including number, percentage, mean, standard deviation, independent sample t-test, one-way analysis of variance, and structural equation modeling.

According to the results of linear regression analysis, these were found to be predictors of the desire to avoid pregnancy: having housing problems (β-coefficient 0.173; p  = .008), having a damaged home (β-coefficient. 276; p  = .009), sleep patterns (β-coefficient 0.433; p  = .022), eating habits (β-coefficients 0.248, 0.044), use of psychiatric medication (β-coefficient 0.436, p  = .003), and problems related to the food and water supply (β-coefficient 0.127, p  = .003). In addition, a structural equation model (SEM) was established to examine the relationship between these variables and mental well-being and pregnancy avoidance. Only the model constructed with mental well-being demonstrated significance in the SEM analysis.

Conclusions

This study shows that women’s mental health is negatively affected in unpredictable emergencies such as earthquakes and that poor mental health negatively affects pregnancy planning. The findings of the study may help to guide health professionals working in the field of women’s health to protect women’s mental health in emergency situations, to provide counseling about pregnancy planning, and to provide social and psychological support programs.

Peer Review reports

Earthquakes are a common and destructive phenomenon across the globe. They are among the most frequent natural disasters with the potential to cause significant destruction [ 1 ]. The earthquakes that occurred in Pazarcık and Elbistan, districts of Kahramanmaraş province in Turkey, on February 6, 2023, had a magnitude of 7.8 Mw and 7.5 Mw, respectively, and occurred within an interval of 9 h. These earthquakes were recorded as the most massive earthquake of Turkey with the highest intensity level, XII (cataclysmic), according to the Mercalli scale [ 2 ]. The two major earthquakes that struck Turkey on February 6, 2023, had a significant impact on several provinces, with Kahramanmaraş, Adıyaman, Hatay, and Malatya being among the most severely affected regions. Given the extensive geographical scope of the earthquake-affected region, there were inevitable delays in the provision of essential services, with some locations only accessible after a few days [ 3 ]. Additionally, a considerable number of women were compelled to reside outside of their homes, separated from their spouses and families. Many of these women lost their loved ones or were forced to endure extended periods of uncertainty, awaiting the rescue of their relatives who were trapped beneath the rubble of the earthquake for days on end [ 4 , 5 ]. The region was subjected to considerable damage to its infrastructure. As indicated in the official data, the premises of a total of 42 hospitals affiliated with the Ministry of Health of Turkey (comprising 27 public hospitals, 6 university hospitals, and 9 private hospitals) were severely or moderately damaged by earthquakes. Conversely, 35 field hospitals were established across the region [ 6 ].

The occurrence of natural disasters gives rise to a number of short-term and long-term health issues, with a range of effects on human health. Furthermore, these disasters present a significant threat to public health [ 7 , 8 ]. The World Health Organization (WHO) has indicated that natural disasters, such as earthquakes, have the potential to precipitate mental health issues, with the risk of exacerbation in the future. According to the WHO, one in five individuals who do not receive assistance in the aftermath of such disasters may develop mental health concerns within a decade [ 8 ]. The WHO further notes that poor mental health can give rise to a range of adverse outcomes, including fear, stress, post-traumatic stress disorder (PTSD), and depression [ 9 ].

The hypothesis that preexisting gender and socioeconomic inequalities were deepened even further along with disasters has been put forth by several researchers [ 9 ]. There is a substantial body of evidence indicating that women are affected by natural disasters to a greater extent than men. This evidence suggests that women are more vulnerable to the effects of natural disasters than men [ 10 , 11 , 12 , 13 ]. For example, women are more vulnerable than men in the context of disasters, with increased exposure to violence, sexual harassment, disease, and psychological trauma [ 14 ]. The average lifespan of women is shortened by natural disasters to a greater extent than that of men. Furthermore, the low socioeconomic status of women exacerbates the lethal impact of disasters on women [ 15 ]. It is evident that reproductive-related hormonal developments are adversely impacted during traumatic periods, such as disasters, which can precipitate or exacerbate mental health issues and anxiety disorders [ 16 ]. Some researchers posit that greater attention should be devoted to addressing the reproductive needs of women in the aftermath of natural disasters [ 17 , 18 , 19 ]. The occurrence of disasters can serve to enhance the susceptibility of individuals to unfavorable outcomes with respect to reproductive health. This is due to the fact that such events often result in a reduction of access to reproductive health services, which can be attributed to the damage sustained by health facilities and the subsequent scarcity of available health professionals [ 20 ]. A study conducted in the aftermath of the 2018 Indonesian earthquake revealed that women’s desire for pregnancy was influenced by several factors, including age, the number of previous pregnancies, and the contraceptive method employed [ 20 ]. In the aftermath of the global spread of the COVID-19, the desire of women to avoid pregnancy increased [ 21 ]. The evidence indicates that alterations in brain function resulting from disasters are among the causes of physiological and psychological stress [ 22 ]. Mental health and reproductive health are significant factors that contribute positively to the general well-being of women [ 23 ]. Mental health issues have been linked to a reduction in contraceptive use and an increase in unplanned pregnancies [ 18 , 24 , 25 ]. It has been posited that poor mental health is both a cause and consequence of unwanted pregnancies. It has been asserted that women with poor mental health have been unable to select the appropriate contraceptive method and engage in sound pregnancy planning, resulting in a greater number of unwanted pregnancies [ 26 , 27 ]. To the best of our knowledge, this is the first study to examine women’s desire to avoid pregnancy after the earthquake together with their mental health and the negative conditions caused by the earthquake. Therefore, it is thought that the results of the study will make important contributions to the field.

The objective of this study was to identify the factors that influence the desire for pregnancy among women of reproductive age in Türkiye in the aftermath of the disaster of the century that occurred in the country.

Research questions

Do earthquake-induced adverse events affect the desire to avoid pregnancy?

Does post-earthquake mental well-being affect the desire to avoid pregnancy?

Research design and sample

This correlational survey study was conducted between November and December 2023. The study included women who experienced the Kahramanmaraş earthquakes in Turkey. In the study, the correlational survey model was utilized to analyze the interactions between two or more variable sets in a multifaceted manner including direct and indirect effects [ 28 ]. The study population consisted of women of reproductive age residing in the four provinces most severely impacted by the Kahramanmaraş earthquake, namely Kahramanmaraş, Hatay, Adıyaman, and Malatya. The minimum sample size for the research was calculated with G*Power 3.1.9.2, with the mean Desire to Avoid Pregnancy Scale score in the study by Güney and Okyay serving as the reference point [ 29 ]. In this regard, the minimum sample size was calculated as 358 women in the power analysis with an effect size of 0.26, a margin of error of 5%, a confidence interval of 95%, and a power of 80% to represent the population. In light of the potential for data loss during the research process, the study was conducted with a total of 405 women who consented to participate. Since the study data were collected from the four provinces most severely affected by the earthquake, the data were collected via an online form.

In order to obtain the requisite research data, the snowball sampling method was employed. This method is utilized in instances where it is challenging to gain access to the individuals who constitute the research population, or when data such as the population size are unavailable [ 30 , 31 ]. The advantages of this sampling method include an increase in the amount of data collected and a focus on critical cases [ 32 ]. Upon responding to the research questions, the women who had consented to participate in the study were requested to disseminate the survey link to other women whom they were aware would meet the inclusion criteria for the study. The researcher employed an online survey form created using her personal Google account for the purpose of data collection. The survey link was disseminated to women who had consented to share the survey form with other women through social networks (WhatsApp, Facebook, X, and Instagram). In the initial phase of the study, the researcher sent the survey link to the women she was acquainted with directly or indirectly in the four provinces through the aforementioned social networks. The women who were reached in this manner were then asked to disseminate the survey link to their acquaintances. The women were required to meet several criteria in order to be included in the research. These criteria included being aged 18 years or above, residing in one of the four Turkish provinces that had been most affected by the Kahramanmaraş earthquakes, being sexually active, not pregnant, using a smartphone, having an internet connection, and voluntarily agreeing to participate in the study. In contrast, the research excluded women who were pregnant or sexually inactive.

Data collection tools

The Personal Information Form, the Warwick-Edinburgh Mental Well-Being Scale, and the Desire to Avoid Pregnancy Scale were utilized to collect research data.

Personal information form

In the aftermath of a seismic event, women are confronted with a multitude of challenges, including economic deprivation, difficulties in accessing health facilities, shelter, and hygiene problems, in addition to reproductive health concerns [ 23 , 33 , 34 ]. These issues have the potential to give rise to mental health concerns among women [ 23 ]. In view of this information, the personal data form was developed to include 23 questions based on an analysis of the relevant literature.

Warwick-Edinburgh mental well-being scale [WEMWBS

The WEMWBS comprises 14 items and assesses an individual’s positive mental health by examining psychological and subjective well-being. It is a five-point Likert-type scale [1: strongly disagree – 5: strongly agree], and the scare range of the scale is 14–70 points. In this study, a minimum score of 14 and a maximum score of 70 were obtained. The WEMWBS does not include any inverse items. Gökay Keldal conducted a validity and reliability study to create its Turkish form in 2015 [ 35 ]. In this research, the Cronbach’s alpha coefficient was employed as a measure of internal consistency, with a value of 0.945 obtained for the WEMWBS.

Desire to avoid pregnancy [DAP] scale

Rocca et al. [2019] developed the DAP Scale. Subsequently, Okyay et al. conducted a validity and reliability study to create its Turkish form. It was developed with the objective of prospectively measuring the range of a sexually active woman’s preferences for a likely pregnancy in the future, as well as identifying the woman’s desire to avoid pregnancy. The DAP Scale, comprising 14 items, included five items pertaining to the woman’s feelings and thoughts about conceiving a baby in the next three months and nine items concerning her feelings and thoughts about having a baby in the next year. The minimum score on the scale is 0 and the maximum score is 4. In this study, the minimum score was 0 and the maximum score was 4. A high DAP Scale score indicates that the respondent has a strong desire to avoid pregnancy. The Cronbach’s alpha coefficient, which is a measure of internal consistency, was reported as 0.94 for the Turkish form of the scale [ 36 ]. In this study, the Cronbach’s alpha coefficient was found to be 0.92 for the DAP Scale.

Data collection

The data were gathered via online sources by the researcher between November and December of 2023.

Data evaluation

The research data were analyzed by using the Statistical Package for Social Science (SPSS) 25.0. The Kolmogorov-Smirnov test was utilized to find whether the research data exhibited a normal distribution [ 37 ]. Prior to conducting the multivariate analysis, it was first necessary to ascertain whether the multiple variables in question were normally distributed. The calculated skewness value for the model was 7.124, which was below 8. Consequently, multiple variables were deemed to be normally distributed [ 38 ].

To establish a basis for comparison, a cut-off point of 0.05 was set for statistical significance ( p  < .05). As the variables were normally distributed ( p  > .05), the subsequent analyses were conducted using parametric tests. Descriptive statistics for variables were expressed as numbers, percentages, means, and standard deviations. To ascertain whether there were differences between the groups, an independent samples t-test and one-way analysis of variance were employed. To determine the relationship between mental well-being and the desire to avoid pregnancy, structural equation modeling was utilized. Cronbach’s alpha coefficient was utilized to test the reliability of the scales used in the study. The t-test and one-way analysis of variance (ANOVA) were used as comparative tests. A simple linear regression analysis was used to ascertain whether the variables could predict DAP. Subsequently, a Structural Equation Model (SEM) analysis was performed was conducted using AMOS 24.0.

Ethical considerations

Prior to the commencement of the study, approval for the research project was granted by the Scientific Research and Publications Ethics Committee of Inonu University of Türkiye. Prior to the collection of research data, prospective participants were informed about the study, and subsequently, expressed their informed consent in an online format (Google Forms) to participate in the study. The research was conducted in accordance with the tenets set forth in the Helsinki Declaration.

The mean age of the female participants was determined to be 31.47 ± 7.74 years. Additionally, 61.7% of the female participants had obtained a university degree, while 54.6% were not currently employed. The majority of participants (70.6%) reported a medium-level income, with the majority (71.6%) residing in the provincial center. The majority of participants (74.1%) had at least one child, with 20% having a child below the age of two. It was determined that 51.9% of the subjects exhibited alterations in their menstrual cycles, 53.3% demonstrated prolonged menstrual cycles, 59.3% exhibited an increase in the number of days during which they had menstrual bleeding, 34.6% exhibited intermenstrual bleeding, and 45.2% encountered difficulties in accessing hygienic pads (Table  1 ).

Furthermore, it was determined that 49.4% of individuals residing in the Malatya province of Turkey had experienced earthquakes. As a result of these seismic events, 65.4% of the population had sustained damage to their residences, 35.3% had been compelled to relocate to alternative accommodations, 52.4% encountered challenges related to their housing, and 29.2% were residing in temporary shelters, such as tents or container houses. A total of 5% of the respondents reported difficulties in accessing food and beverages, while 92.3% experienced changes in their sleep patterns. Additionally, 78.8% of the respondents indicated alterations in their dietary habits, 62.5% reported changes in their physical activity levels, and 38.3% lost a relative or relatives. Furthermore, 14.1% of the respondents started using psychiatric medications during the post-earthquake period. The mean DAP Scale scores for women who experienced accommodation problems, women whose houses were damaged by earthquakes, women who experienced changes in sleep patterns, women who experienced changes in dietary habits, women who used psychiatric medications, and women who experienced problems finding food and beverages were all lower than the respective mean scores for other groups of women who did not experience such problems (Table  2 ).

As indicated in Table  3 , there was no correlation between the desire to avoid pregnancy and the province where earthquakes were experienced, the place of residence, the status of experiencing changes in the physical activity level, and the status of experiencing changes in the menstrual cycle. On the other hand, there were correlations between the desire to avoid pregnancy and other variables. Consequently, a linear regression analysis was conducted, based on these correlations, to ascertain the model. Findings demonstrate that, in the post-earthquake period, women who experienced accommodation problems, women whose houses were damaged by earthquakes, women whose sleeping patterns changed, women whose dietary habits changed, women who were using psychiatric medications, and women who experienced problems accessing food and beverages had a lower desire to avoid pregnancy.

Results of the structural equation modeling analysis

The objective of the SEM was to analyze the relationship between the variables and mental well-being and the desire to avoid pregnancy. The results of the SEM analysis indicated that only the model established with mental well-being was significant (Fig.  1 ).

The diagram on the Structural Equation Modeling about the relationship between mental well-being and the desire to avoid pregnancy

In the model, mental well-being is the independent variable, the desire to avoid pregnancy is the dependent variable, and e1 refers to the residual. Table  3 presents the coefficients associated with the model.

A review of the relevant literature revealed that women faced challenges related to accommodation and hygiene in the post-disaster period [ 26 , 39 ]. Additionally, the present study revealed that a considerable proportion of women experienced earthquake-related damage to their residences, necessitating relocation. They encountered challenges in accessing food and beverages, alterations in their sleep patterns and dietary habits, reductions in their physical activity levels, and the loss of family members due to the earthquakes (Table  2 ). Such circumstances have been linked to an increased prevalence of mental health issues, including anxiety and depression, among women who have experienced earthquakes [ 23 ].

In the current research, a significant proportion of the participants exhibited alterations in their menstrual cycles, including prolonged menstrual cycles, an increase in the number of days during which they had menstrual bleeding, and the onset of intermenstrual bleeding (Table  1 ). A study conducted in the aftermath of the Wenchuan earthquake revealed that 30% of the female participants exhibited alterations in their menstrual cycles, with this phenomenon being more prevalent among those who had lost a child [ 40 ]. In a subsequent study conducted in the aftermath of the Wenchuan earthquake, it was observed that the duration of menstrual cycles exhibited a reduction among young women who were concurrently experiencing psychological distress [ 41 ]. It is acknowledged that alterations in the menstrual cycle may be linked to a number of factors, including stress. However, in the context of the present study, it is proposed that the stress induced by earthquakes is influenced by the variables that have been subjected to investigation. In instances of stress, the release of gonadotropins and gonadal steroid hormones is inhibited, which subsequently results in the disruption of the typical menstrual cycle. Prolonged exposure to stress can lead to complete deterioration of reproductive function [ 42 ]. As a matter of fact, natural disasters such as earthquakes, hurricanes, and floods can precipitate the onset of post-traumatic stress disorder [ 43 ]. In this context, it can be stated that the results of the current study are consistent with the results reported in the relevant literature.

Moreover, it was discerned that the mean WEMWBS score obtained by women experiencing the earthquakes in the current study was 10–15 points lower than those obtained in studies conducted in the same region before the earthquakes [ 44 , 45 ]. A meta-analysis study revealed the presence of post-traumatic stress disorder among survivors in the aftermath of the earthquake [ 46 ]. Considering that socioeconomic problems experienced along with changes in reproductive health in the post-earthquake period would lead to the emergence of clinical depression and anxiety [ 25 ], it can be said that the result of the current research is consistent with the relevant literature. Additionally, our findings are corroborated by the fact that 14.1% of the female participants responded affirmatively to the inquiry: “Did you start to use any psychiatric medication in the post-earthquake period?”.

Furthermore, in comparing the mean DAP Scale scores of women in relation to the negative experiences they encountered in the post-earthquake period, it was observed that women who faced challenges in securing accommodation, women whose houses were damaged by earthquakes, and women who experienced changes in their daily routines exhibited lower DAP Scale scores than those who did not experience these problems. Additionally, women who experienced disturbances in their sleep patterns, women who experienced changes in their dietary habits, and women who used psychiatric medications exhibited lower mean DAP Scale scores than those who did not experience such problems. These differences between groups were statistically significant (Table  2 ). The results of the linear regression analysis were also in line with those of this analysis (Table  3 ).

The results of the analysis based on structural equation modeling revealed that mental well-being affected the desire to avoid pregnancy (Fig.  1 ). It is hypothesized that exposure to adverse circumstances may contribute to a decline in the mental well-being of women, which in turn may influence their decision to avoid pregnancy. The current research yielded a noteworthy result: it was hypothesized that women would be unlikely to consider becoming pregnant in the aftermath of such catastrophic earthquakes. Besides, a review of the relevant literature reveals that women with poor mental health are significantly more likely to engage in unsafe sexual practices, avoid using contraceptive methods [ 25 , 46 ], fail to make healthy pregnancy planning, and are at an elevated risk of experiencing an unwanted pregnancy [ 26 ]. The results of the study conducted in the aftermath of the earthquake indicated that there was a correlation between pregnancy desire and several factors, including age, previous pregnancies, and contraceptive history [ 20 ]. A study conducted in Türkiye after the earthquake revealed a decline in contraceptive use among women and a reduction in the frequency of sexual intercourse [ 47 ]. It has been demonstrated that unplanned pregnancies result in a reduction in the level of antenatal care and birth assistance received by the mother, and an increase in the incidence of miscarriage and perinatal mortality [ 25 , 48 ]. In light of the aforementioned findings, it is evident that politicians and service providers must prioritize the needs of women in the context of natural disasters.

Strengths and limitations of the research

Given that the research was conducted by a female academic based in a province that has been most severely affected by earthquakes, it is highly probable that her interpretations of the research results accurately reflect reality. A further strength of this study is that it makes a significant contribution to the development of the relevant literature on pregnancy intentions following earthquakes, a topic that has been under-researched to date. The present study is limited by its reliance on an interview form to examine women’s menstrual cycle characteristics, which has not yet been tested for validity and reliability. Additionally, the inability to generalize the findings to the entire population and the collection of data exclusively online introduce further limitations to the study. The researcher encountered difficulties in accessing the volunteer participants due to the logistical challenges of conducting the research in the region most affected by the earthquake. The aforementioned circumstances precluded the extrapolation of the findings to the entire population. It is therefore imperative to conduct longitudinal studies with a substantial number of participants. Furthermore, it is essential to ascertain the reasons behind women’s decisions to become pregnant or to refrain from doing so through in-depth qualitative research.

The mental health of women of reproductive age is negatively affected by the unfavorable conditions experienced in the post-earthquake period. Poor mental health can lead to unhealthy pregnancy planning. Therefore, health professionals working in the field of women’s health should provide family planning counseling to women who experienced the earthquake. They should also facilitate referrals to specialists for mental health interventions.

Data availability

On request, the author can provide the data if she sees fit.

Erdoğan B. Depremin Sosyolojisi: 6 Şubat Felaketinin Toplumsal ve Kültürel Boyutları. TRT Akademi. 2023;8(18):718–25.

Article   Google Scholar  

AFAD. February 06 2023 Pazarcık (Kahramanmaras) MW 7.7 Elbıstan (Kahramanmaraş) MW 7.6 Earthquakes Prelımınary Evaluatıon Report. https://deprem.afad.gov.tr/assets/pdf/Kahramanmaras%20%20Depremleri_%20On%20Degerlendirme%20Raporu.pdf

Merve Koç, Yalçın S. Afetlerde Krize Müdahale: Kahramanmaraş Depremi’Nde Aile ve Sosyal Hizmetler Bakanlığı’nın Çalışmaları. Uluslararası Sosyal Hizmet Araştırmaları Dergisi. 2023;3(2):93–105.

Topcu EG. Disaster preparedness: the effects of natural disasters on women’s health in Turkey. Int J Gynaecol Obstet. 2023;X10.1002/ijgo.15149.

One month has passed since the earthquakes centered in Kahramanmaraş. What aid has been provided in the region so far and what are the criticisms? https://tr.euronews.com/2023/03/05/kahramanmaras-depremleri-hakkinda-neler-biliniyor

Uzun N. The February 6 Kahramanmaraş Earthquake and Field hospitals. Türk Nöroşir Derg. 2023;33(2):142–3.

Google Scholar  

Kohan S, Yarmohammadian MH, Bahmanjanbeh F, Haghshenas A. Consequences of earthquake (August 2012) on Iranian women’s reproductive health: a qualitative study. Acta Med Mediterranea. 2016;32:1503.

WHO. 2023. Delivering effective and accountable mental health and psychosocial support (MHPSS) during emergencies and beyond. https://www.who.int/news-room/feature-stories/detail/delivering-effective-and-accountable-mental-health-and-psychosocial-support-(mhpss)-during-emergencies-and-beyond

Sohrabizadeh S, Tourani S, Khankeh HR. Women and health consequences of natural disasters: challenge or opportunity? Women Health. 2016;56(8):977–93. https://doi.org/10.1080/03630242.2016.1176101 .

Article   PubMed   Google Scholar  

Behrman JA, Weitzman A. Effects of the 2010 Haiti earthquake on women’s reproductive health. Stud Fam Plann. 2016;47(1):3–17. https://doi.org/10.1111/j.1728-4465.2016.00045.x .

Fatema SR, Islam MS, East L, Usher K. Women’s health-related vulnerabilities in natural disasters: a systematic review protocol. BMJ open. 2019; 9(12).

Murakami K, Ishikuro M, Obara T, et al. Traumatic experiences of the Great East Japan Earthquake and postpartum depressive symptoms: the Tohoku Medical Megabank Project Birth and three-generation cohort study. J Affect Disord. 2023;320:461–7.

Kipay SS. Earthquake reality and its effects on women’s health. İzmir Kâtip Çelebi Üniversitesi Sağlık. Bilimleri Fakültesi Dergisi. 2023;8(2):855–60.

Shooshtari S, Abedi MR, Bahrami M, Samouei R. The mental health needs of women in natural disasters: a qualitative study with a preventive approach. J Family Med Prim Care. 2018;7:678–83.

Article   PubMed   PubMed Central   Google Scholar  

Neumayer E, Plu¨mper T. The Gendered Nature of Natural disasters: the impact of Catastrophic events on the gender gap in Life Expectancy, 1981–2002. Ann Assoc Am Geogr. 2007;97(3):551–66.

Driscoll JW. Recognizing women’s common mental health problems: the earthquake assessment model. J Obstetric Gynecologic Neonatal Nurs. 2005;34(2):246–54. https://doi.org/10.1177/0884217505274701 .

Martine G, Guzmán JM. Populatıon, poverty, and vulnerabılıty: mıtıgatıng the effects. Environ Change Secur Project Rep. 2002; (8), 45.

Nour NN. Maternal health considerations during disaster relief. Reviews in Obstetrics and Gynecology. 2011; 4(1): 22. PMID: 21629495.

Ellington SR, Kourtis AP, Curtis KM, et al. Contraceptive availability during an emergency response in the United States. J Women’s Health. 2013;22(3):189–93. https://doi.org/10.1089/jwh.2012.4178 .

Rahman A, Giyarsih SR, Murti B, Santosa SH. Desire to have children reviewed from reproductive health as the ımpact of natural disasters in Palu, Indonesia. Int J Sustainable Dev Plann, 2023; 18(8).

Druetz T, Cooper S, Bicaba F, Bila A, Shareck M, Milot D-M, et al. Change in childbearing intention, use of contraception, unwanted pregnancies, and related adverse events during the COVID-19 pandemic: results from a panel study in rural Burkina Faso. PLOS Glob Public Health. 2022;2(4):e0000174. https://doi.org/10.1371/journal.pgph.0000174 .

Torche F, Kleinhaus K. Prenatal stress, gestational age and secondary sex ratio: the sex-specific effects of exposure to a natural disaster in early pregnancy. Hum Reprod. 2012;27(2):558–67. https://doi.org/10.1093/humrep/der390 .

Anwar J, Mpofu E, Matthews LR, et al. Reproductive health and access to healthcare facilities: risk factors for depression and anxiety in women with an earthquake experience. BMC Public Health. 2011;11(1):1–13.

Raja M, Azzoni A. Sexual behavior and sexual problems among patients with severe chronic psychoses. Eur Psychiatry. 2003;18(2):70–6.

Marengo E, Martino DJ, Igoa A, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. J Affect Disord. 2015;178:201–5.

Hall KS, Kusunoki Y, Gatny H, Barber J. The risk of unintended pregnancy among young women with mental health symptoms. Soc Sci Med. 2014;100:62–71. https://doi.org/10.1016/j.socscimed.2013.10.037 .

Moreau C, Bonnet C, Beuzelin M, Blondel B. Pregnancy planning and acceptance and maternal psychological distress during pregnancy: results from the National Perinatal Survey, France, 2016. BMC Pregnancy Childbirth. 2022;22(1):1–12.

Kline Rb. Hypothesis testing: principles and practice of structural equation modeling: 3rded. Volume 7. New York: The Guilford Press; 2011. pp. 209–342.

Güney E, Okyay EK. Women vıctıms of vıolence: a comparison of their perceptıons of parentıng and desıre to avoıd pregnancy. İnönü Üniversitesi Sağlık Hizmetleri Meslek Yüksek. Okulu Dergisi. 2023;11(1):1110–21.

Patton MQ. Qualitative research. New York: Wiley, Ltd; 2005.

Baltacı A. Nitel Araştırmalarda Örnekleme Yöntemleri ve Örnek Hacmi Sorunsalı Üzerine Kavramsal Bir İnceleme. BEÜ SBE Derg. 2018;7(1):231–74.

Creswell JW. Research Design: qualitative, quantitative, and mixed methods approaches. New York: Sage; 2013.

Fatema SR, Rice K, Rock A, Islam MS, East L, Usher K. Physical and mental health status of women in disaster-affected areas in Bangladesh. Nat Hazards. 2023;1–19. https://doi.org/10.1007/s11069-023-05964-5 .

Koyama H. (2021). Intersectional Vulnerability in Post Natural Disasters on Women’s Health – Systematic literature review. Oslo Metropolitan University, Faculty of Social Science, Master thesis. https://hdl.handle.net/11250/2983477

Keldal G. Warwick-Edinburgh mental iyi oluş ölçeği’nin Türkçe Formu: Geçerlik ve güvenirlik çalışması. J Happiness Well-Being. 2015;3(1):103–15.

Okyay EK, Güney E, Uçar T. Turkish adaptation of the Desire to avoid pregnancy scale: a validity and reliability study. Ebelik Ve Sağlık. Bilimleri Dergisi. 2023;6(3):128–34.

Alpar R, Spor. Sağlık ve Eğitim Bilimlerinde Örneklerle Uygulamalı İstatistik ve Geçerlik-Güvenirlik. 6 ed. Baskı, Detay Yayıncılık, Ankara; 2020.

Hayes AF. Introduction to mediation, moderation, and conditional process analysis. A regression-based approach. New York, NY: Guilford; 2013.

Azad AK, Hossain KM, Nasreen M. Flood-induced vulnerabilities and problems encountered by women in northern Bangladesh. Int J Disaster risk Sci. 2013;4:190–9.

Liu X, Yang Y, Ping Y, Zhang X, Han Y, Cao Y, Xiong G. A study of the relationship between mental health and menstrual abnormalities in female middle school students from postearthquake Wenchuan. Biosci Trends. 2010;4(1):4–8.

PubMed   Google Scholar  

Li XH, Qin L, Hu H, Luo S, Li L, Fan W, Li SW. Influence of the Wenchuan earthquake on self-reported irregular menstrual cycles in surviving women. Gynecol Endocrinol. 2011;27(9):706–10.

Ranabir S, Reetu K. Stress and hormones. Indian J Endocrinol Metabol. 2011; 15 (1).

Takeda T, Yoshimi K, Kai S, Inoue F. Association between loneliness, premenstrual symptoms, and other factors during the COVID-19 pandemic: a cross-sectional study with Japanese High School Students. Int J Women’s Health. 2023;655–64.

Gökbulut N, Bal Z. The relationship of mental well-being with healthy living awareness Anatolian. J Health Res. 2021;2(2):51–6. https://doi.org/10.29228/anatoljhr.52199 .

Arslandoğan A, Türkmen M, Elif T, Demir B, Hazar S. Covıd-19 Sürecinde Fiziksel Aktivite Düzeyi İle Mental İyi Oluş Arasındaki İlişkinin İncelenmesi. Sivas Cumhuriyet Üniversitesi Spor Bilimleri Dergisi. 2021;2(2):67–75.

Nguyen T, Brooks J, Frayne J, Watt F, Fisher J. The preconception needs of women with severe mental illness: a consecutive clinical case series. J Psychosom Obstet Gynecol. 2015;36(3):87–93.

Keskin Töre F, Ağralı C, Nacar G. Changes in family planning methods and sexual behaviors after Türkiye’s earthquake and the effect of on quality of sexual life. Am J Family Therapy, 2024; 1–15.

Yazdkhasti M, Pourreza A, Pirak A, Fatemeh A. Unintended pregnancy and its adverse social and economic consequences on health system: a narrative review article. Iran J Public Health. 2015;44(1):12.

PubMed   PubMed Central   Google Scholar  

Download references

Acknowledgements

I would like to thank the women who participated in the study and Assoc. Prof. Dr. Feyza İnceoğlu for providing statistical support.

All costs of the study were covered by the researcher.

Author information

Authors and affiliations.

Department of Midwifery, Faculty of Health Sciences, Inonu University, Malatya, Turkey

Zeliha Özşahin

You can also search for this author in PubMed   Google Scholar

Contributions

Z.Ö conducted all stages of the research.

Corresponding author

Correspondence to Zeliha Özşahin .

Ethics declarations

Ethics approval and consent to participate.

Ethical endorsement for the research was obtained from the Scientific Research and Publications Ethics Committee of XXXX University of Türkiye. The data are kept in a way that only the researcher can access.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ .

Reprints and permissions

About this article

Cite this article.

Özşahin, Z. Determinants of the desire to avoid pregnancy after the disaster of the century in Türkiye. BMC Women's Health 24 , 496 (2024). https://doi.org/10.1186/s12905-024-03330-6

Download citation

Received : 22 April 2024

Accepted : 23 August 2024

Published : 09 September 2024

DOI : https://doi.org/10.1186/s12905-024-03330-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Earthquake disaster
• Woman’s health
• Mental well-being
• Desire to avoid pregnancy

BMC Women's Health

ISSN: 1472-6874

• General enquiries: [email protected]