The use of contraceptive methods can reduce the unplanned pregnancies in BD. Its use during childbearing age is associated with high level of education and capacity to planned pregnancy and avoid unplanned pregnancy in BD women. Therefore, it is important to find out which variables are associated with a less adherence to contraceptive methods. Interestingly, the present study found out that the strongest predictive effect are the sociodemographic factors rather than the clinical or treatment characteristics.
The analyzed sample displayed a 61.2% rate of BD women of childbearing age that use contraception. According to the French Health Report in 2016, the use of a contraceptive method in general population in France is around 70% in women of childbearing age (Rahib, et al., 2016). Previous literature with BD women were similar to the present study. They reported rates of contraception use in BD women of 52.1% (Posada-Correa, et al., 2020), 59% (Magalhães, et al., 2009) and 73% (Dinc, et al., 2019), being systematically slightly lower in the group of BD patients in comparison to general population. This could be at least partially explained by variables related to education level, economic status, social barriers and some attitudes of professionals in which the sexuality of people with mental health disorders is not always considered (Santé publique France, 2013). A systematic review of pregnancy in BD described that adverse pregnancy outcomes such as gestational hypertension and antepartum haemorrhage, induction of labor and caesarean section occur more frequently in BD women. BD Women also have an increased risk of relapse in the postnatal period and are more likely to have babies that are severely small for gestational age (Rusner et al., 2016).
In relation to the demographic characteristics associate to contraception use in BD, the present study found that the age, level of education, active working situation, not living alone are positively associated to higher rates of use of contraception. This is consistent with the only study that described demographic variables related to the use of contraception in BD. They displayed that being married, pertaining to the older age group and having had one or two pregnancies and more than two were associated with using contraception (Magalhães, 2019). Similar results with an association with low level of education and no working were found in a study among immigrant and second-generation immigrant women (Poncet et al 2013). It might suggest that the increase age and level of education can be associated to a higher understanding of contraception and sexual education.
Interestingly, in light of the present results and the ones published previously (Magalhães, 2019) there are other demographic variables that do not seem to be related to the use of contraceptive methods, such as income or having a care giver.
Regarding the clinical characteristics, no differences were found in BD type, hospitalization rates, history of suicide attempts or presence of rapid cycling between the groups of women with and without use of contraception. These findings were again consistent with previous research which found no association between use of contraception and symptoms or illness severity (Magalhães, 2019). Data nevertheless highlighted that women using contraception displayed a significantly shorter duration of the illness than the women without use of contraception.
In relation to comorbid disorders, it is interesting to report that, although no differences were found between subjects with and without contraception, half of the patients had an anxiety disorder and more that 15% a substance use disorder. These high rates of comorbidities have been previously described in BD (Icick, et al., 2017).
Considering the level of functioning of the participants, the already described functional impairment of BD patients (Burdick, et al., 2022) was observed in the present study. Over 25% of the analyzed sample displayed a lack of autonomy in the illness management and over 10% a lack of autonomy in their treatment management. Moreover, the percentage of autonomous women using contraception was significantly higher than the percentage of autonomous women not using contraception both for the illness management and the treatment management. This novel finding can suggest that the use of contraception in BD is related to the level of autonomy of the patient and the ability to cope and manage their illness.
Regarding the pharmacological treatment, around 28% of the women received treatment with high or intermediate risk for teratogenic effect. A previous study found that the use of lithium and anticonvulsant mood stabilizers was unrelated to use of contraception (Magalhães, et al., 2019). In the present study, although no differences were found between the women using and not using contraception, only 3% of the women were taking valproate medication. This highlights the avoidance of pharmacological treatment with high risk of teratogenic effect in BD women of childbearing age.
In summary, the present study found out that the most important variables associated with the use of contraception were age, level of education, working and living conditions. These demographic variables are similar to the ones influencing the contraception use in general population (Bentley et al., 2009; Oddens, 1997). However, as BD has an increased risk of unplanned pregnancies, intervention protocols might take this into consideration. Therefore, a collaboration between the psychiatric and gynecologic specialties could be implemented in the protocol assistance for adolescent girls with BD, with a focus on the plan of pregnancy and contraceptive methods, so as to reduce the risk of unplanned pregnancy. A study reported that 32.2% of women with mental health illness had never received information on sexual education and family planning. Authors indicated that evaluation and education on the topic in psychiatry consultations is limited, due to factors such as: lack of knowledge of the psychiatrist on the use of contraceptives, the perception that this evaluation does not correspond to the mental health consultation, avoidance of the topic (Posada-correa et al., 2020).
Our findings need to be appraised in the context of limitations. Firstly, the present study did not use standardized scales with an adequate methodological validation. However, the recruitment of participants followed a systematic procedure and the high level of raters was guaranteed by the involvement of active clinician psychiatrists. Moreover, longitudinal data were not analyzed. Large cohort studies with follow up visits are needed to better identify risk associated to treatment discontinuation or treatment exposure. Furthermore, the data presented was collected ten years ago and therefore the results should be interpreted cautiously taking into consideration potential variations. Finally, in this study, women until 50 years old, who may already be in menopause, were included.
In conclusion, our findings confirm previous evidence of the similar rates of contraception use in BD women of childbearing age. We add to previous studies that it was mainly sociodemographic variables that were associated with contraception use among BD women. As preventive measures for risk of relapse in BD, contraceptive counseling, including reduction of the risk of unwanted pregnancies, should be systematically ensured.