Journal Reading

The Value of a Registry Negative Urine Pregnancy

Test for The Prediction of a Future Unintended
Pregnancy Among Young Women

Misgav Rottenstreicha,b , Sorina Grisaru-Granovskyb and Amihai Rottenstreicha,c

aMedical Corps, Israel Defense Forces, Israel; bDepartment of Obstetrics and Gynaecology,
Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine,
Jerusalem, Israel; cDepartment of Obstetrics and Gynecology, Hadassah-Hebrew University
Medical Center, Jerusalem, Israel
Introduction

 Unintended pregnancy among adolescents represents a major

public health problem which carries a high social and economic
burden  its prevention a key step in promoting women’s health
 In Israel, young women who are unmarried and with no children,
are mandated by law to serve in the Israel Defense Forces (IDF).
They clearly play an important role in military readiness and unit
cohesion. Hence, unintended pregnancy is an important issue
Introduction
 Young women with a negative pregnancy test result were shown
to have personality characteristics associated with increased risk
for unintended pregnancy
 The aim of the study was to evaluate whether young unmarried
active-duty women soldiers in whom a negative urine pregnancy
test was registered would be at increased risk of a future
unintended pregnancy.
Materials and Methods
In 2012, the IDF established the Military Pregnancy Center
(MPC) – a dedicated centre aiming to assist active-duty women
with unintended pregnancies, providing them with medical and
psychological support throughout the pregnancy.

Every diagnosed pregnancy among active-duty women soldiers

encountered during mandatory service must be brought to the
attention of the MPC.

Data regarding all unintended pregnancies are prospectively

collected and maintained in an electronic database
Materials and Methods
Following approval by the Israel Defense Forces’ ( IDF ) Institutional Review
Board  we linked data from the MPC to data from the Army’s Draft Board
which records data on all unmarried, drafted women between January 2013
and December 2015.

The draft board maintains an electronic database of the medical and

psychiatric evaluations and intellectual abilities exams performed at the ages
of 16–17 among all potential recruiters to assess their eligibility for military
service

The data collected included patient demographics (age, immigration status),

medical status, educational status, socioeconomic status and intellectual
assessment (measured as IQ).
Materials and Methods
 Data regarding unintended pregnancies were retrieved from the MPC
registry.
 Women’s pregnancy intentions were assessed at the time of creation of an
MPC record with a direct question (‘is this pregnancy intended?’)

 Allowing pregnancies to be categorised as intended or unintended.

 Women reporting an intended pregnancy and women reporting that their
pregnancy resulted from sexual assault were excluded from further
analysis
Materials and Methods
The study cohort consisted of
women soldiers in whom a urine The remaining women
pregnancy test was carried out. soldiers in whom any no
prior history of urine
pregnancy testing was
present provided the
The first urine pregnancy The first urine pregnancy control group
test (+) test (-)
excluded

Interval of less than

42 days  having (+) Experienced an
pregnancy test result unintended pregnancy
excluded
Materials and Methods
Data analyses  The population characteristic were performed by descriptive statistics

The rates of unintended pregnancies and the population characteristics were compared
between the study and control groups.

Differences between the study and control groups were assessed with univariate
analysis by the Fisher’s exact test for categorical variables and the Mann–Whitney U-
test for continuous variables

A two-sided p< .05 indicated statistical significance. The data were

analysed using Software Package for Statistics and Simulation (IBM SPSS
version 23 ; IBM Corp, Armonk, NY, USA).
Results Urine pregnancy testing
was carried out in 2968
women soldiers.
129,638 unmarried women
soldiers 2774 (93.5%) soldiers
tested (-) and were
defined as the study
group.
Urine pregnancy test (+); The first urine
194 women soldiers (0.2%) pregnancy test (-)
excluded The remaining 126,659
women, in whom urine
 5 women who declared
pregnancy test was not
that their pregnancy was
carried out, provided the
intended excluded The final study cohort
 6 women who declared control group
included 129,433 women
that the pregnancy was the soldiers
result of sexual assault
Results

Women soldiers with prior

negative urine pregnancy test
result were more likely to
have lower educational level,
IQ grade and socioeconomic
status higher non-native
Israeli status and immigrant
parents compared to the
control group
Results
During study period, we identified
2147 (1.7%) active duty women that
experienced a subsequent unintended
pregnancy. The risk of unintended
pregnancy was significantly higher in
patients with prior negative urine
pregnancy test result compared to the
control group [4.3% (n=118) vs. 1.6%
(n=2028), OR=2.7, p< .0001].

In multivariable analysis, a negative urine pregnancy test was found to be

an independent predictor of a subsequent unintended pregnancy (OR,
2.03; 95% CI, 1.63–2.52; p< .0001) (Table 2).
Results
Among the 118 patients with negative pregnancy test
results who experienced a subsequent unintended
pregnancy, the median time lapse from the negative
b-HCG test to the diagnosis of the unintended
pregnancy was 201 (41–673) days
Discussion
Findings and interpretation
 In the present study, women enrolled in the Israeli military service who
had a negative pregnancy test result were at higher risk of future
unintended pregnancy.
 The future pregnancy may occur at any time during the military service,
and not necessarily close to the test event.
 It was shown that patients in whom urine b-HCG testing was performed
represent a distinct group with different baseline demographic, ethnic,
intellectual and socioeconomic characteristics.
Discussion
Findings and interpretation
 The rate of unintended pregnancies among adolescents far exceeds the
rate seen among the general population. There is a clear justification for
reducing the rate of unintended pregnancies, as these pregnancies are
often characterised by poor prenatal care and unfavourable maternal and
perinatal outcomes
 We postulate that once a test to confirm pregnancy is performed in this
population, it may reflect woman’s concern of unplanned pregnancy or an
inadequate use of contraception.
Discussion
Findings and interpretation

 Therefore, the of a urine pregnancy test in this population should serve as a

sentinel event for the treating physician which introduces a series of
interventions aimed at preventing future unintended pregnancies. These
preventive measures might include sexual health and contraceptive
education and possible social care interventions
Discussion
Strengths and weaknesses of the study
The retrospective design raises the possibility of biases inherent in such data
collection. Specifically, data regarding gynaecologic history prior to service were
lacking.

Tthe major strengths of this study include its large cohort of patients,
meticulous data collection and the relatively long follow-up period. In addition,
as all females in Israel are mandated by law to serve in the IDF, this cohort is
representative of the general population which contributes to the
generalizability of the study findings
Discussion
Differences in results and conclusion in relation to other studies

 It has been shown previously that adolescents with negative pregnancy test
results are similar socio-demographically compared to adolescents who
experienced an unintended pregnancy in terms of age of first intercourse,
sexual habits, contraceptive use, educational and demographic features.
Others have reported a relatively high rate of prior negative pregnancy testing
in those who had unintended pregnancy.
Discussion
Differences in results and conclusion in relation to other studies

Our findings are consistent with previous publications.

Zabin et al. have followed 100 In a study of 129 young women with
adolescents in whom pregnancy testing negative pregnancy testing, above one-third
was carried out and tested negative. This of patients conceived during a follow-up
group of patients was found to have a period of 18 months.
higher risk (55.9%) of unintended
pregnancy compared to women who had
positive pregnancy test result and either
carried the pregnancy to term or chose
an induced abortio
Conclusions

We have shown significantly higher rates of unintended pregnancies among

young women soldiers in whom urine b-HCG testing was carried out and found
to be negative.
Identification of this subset of young women should promote directed efforts to
prevent the occurrence of a subsequent unintended pregnancy and its
consequences. Future prospective studies are warranted to better delineate the
best interventional approach for this subset of patients.
FLOW CHART
 Young unmarried active-duty women soldiers between January The remaining women
2013 and December 2015 soldiers in whom any no
prior history of urine
The first urine pregnancy testing was
pregnancy test (+) present provided the
excluded control group
The first urine pregnancy
test (-)
Interval of less
• Women who declared that their
than 42 days 
pregnancy was intended
having (+)
• women who declared that the
pregnancy test
pregnancy was the result of
result
sexual assault
excluded excluded
Experienced an
unintended pregnancy
The final study cohort members

Data analysis
CRITICAL APPRAISAL
P (POPULATION or PATIENT or PROBLEM)

The study was about the value of a registry negative

urine pregnancy test for the prediction of a future
unintended pregnancy among young women

The aim of the study was to evaluate whether young unmarried active-
duty women soldiers in whom a negative urine pregnancy test was
registered would be at increased risk of a future unintended pregnancy

Population
Young unmarried active-duty women soldiers between Januari
2013 and December 2015 with minimal duration of one year of
followup
INTERVENTION The remaining women
soldiers in whom any no
The study cohort consisted of women prior history of urine
soldiers in whom a urine pregnancy test pregnancy testing was
was carried out. present provided the
control group

• The first urine

Young unmarried pregnancy test
active-duty (+)
women soldiers
between January • The first urine Experienced an
2013 and pregnancy test
(-)
unintended pregnancy
December 2015
Minimal duration
of one year of
followup
COMPARISON
 Compared: shown some study about adolescents in whom
pregnancy testing was carried out and tested negative.

OUTCOME
 Women soldiers with prior negative urine pregnancy test
result were more likely to have lower educational level, IQ
grade and socioeconomic status higher non-native Israeli
status and immigrant parents compared to the control group
OUTCOME
 The risk of unintended pregnancy was significantly higher in
patients with prior negative urine pregnancy test result compared
to the control group
 A negative urine pregnancy test was found to be an independent
predictor of a subsequent unintended pregnancy

Urine pregnancy testing in this population could function as a

sentinel event for the treating physician who introduces a series of
interventions aimed at preventing future unwanted pregnancies.
Critical appraisal
 Is the aim clearly stated?

The aim of the study was to evaluate whether

young unmarried active-duty women soldiers in
Yes, It is whom a negative urine pregnancy test was
registered would be at increased risk of a future
unintended pregnancy
 Were the basic data adequately described?
Data regarding all unintended pregnancies are prospectively collected and
Yes maintained in an electronic database

Following approval by the Israel Defense Forces’ ( IDF ) Institutional Review

Board  we linked data from the MPC to data from the Army’s Draft Board
which records data on all unmarried, drafted women between January 2013
and December 2015.

The draft board maintains an electronic database of the medical and

psychiatric evaluations and intellectual abilities exams performed at the ages
of 16–17 among all potential recruiters to assess their eligibility for military
service
 Was the sample size justified?
As all females in Israel are mandated by law to
serve in the IDF, this cohort is representative
of the general population which contributes to
Yes, it was
the generalizability of the study findings.
So it was known the existing sample was
sufficient to represent the study population.
 Was the statistical methods described?
Yes, it was
 The population characteristic data analyses were performed by descriptive
statistics.
 Differences between the study and control groups were assessed with
univariate analysis by the Fisher’s exact test for categorical variables and the
Mann–Whitney U-test for continuous variables.
 A univariate linear regression model and a multivariable stepwise regression
analysis was performed to assess factors independently associated with an
unintended pregnancy occurrence using significant factors from the univariate
analysis
 A two-sided p< .05 indicated statistical significance
 The data were analysed using Software Package for Statistics and Simulation
(IBM SPSS version 23 ; IBM Corp, Armonk, NY, USA).
 Was the statistical significance assessed?

No, it didn’t There was no explanation about it

 Where are the biases?
The retrospective design raises the possibility of
biases inherent in such data collection. Specificially,
data regarding gynaecologic history prior to service
were lacking. it is possible that patients among the
control group, which was socioeconomically more
privileged, may have been offered pregnancy testing
and terminations outside the service
 Did untoward events occur during the
study?

The author of this article didn’t tell about

No, it didn’t
untoward events that occuring in this
study.
How do the results compare with previous reports?
The study findings are consistent with previous publications.

Zabin et al. have followed 100

adolescents in whom pregnancy testing
In a study of 129 young women with
was carried out and tested negative. This
negative pregnancy testing, above one-third
group of patients was found to have a
of patients conceived during a follow-up
higher risk (55.9%) of unintended
period of 18 months.
pregnancy compared to women who had
positive pregnancy test result
 What implications does the study have for your
practice?
 This study provides evidence that significantly higher rates of
unintended pregnancies among young women soldiers in
whom urine b-HCG testing was carried out and found to be
negative
 The of a urine pregnancy test in this study should serve as a
sentinel event for the treating physician which introduces a
series of interventions aimed at preventing future unintended
pregnancies.
THANK YOU