Short interpregnancy interval associated with preterm birth in U S adolescents

Diving into CDC pregnancy data in the United States: longitudinal study and interactive application

Objective

Preterm birth (PTB) is a major determinant of neonatal mortality, morbidity, and childhood disability. In this article, we present a longitudinal analysis of the risk factors associated with PTB and how they have varied over the years: starting from 1968 when the CDC first started, reporting the natality data, up until 2021. Along with this article, we are also releasing an RShiny web application that will allow for easy consumption of this voluminous dataset by the research community. Further, we hope this tool can aid clinicians in the understanding and prevention of PTB.

Materials and Methods

This study used the CDC Natality data from 1968 to 2021 to analyze trends in PTB outcomes across the lens of various features, including race, maternal age, education, and interval length between pregnancies. Our interactive RShiny web application, CDC NatView, allows users to explore interactions between maternal risk factors and maternal morbidity conditions and the aforementioned features.

Results

Our study demonstrates how CDC data can be leveraged to conduct a longitudinal analysis of natality trends in the United States. Our key findings reveal an upward trend in late PTBs, which is concerning. Moreover, a significant disparity exists between African American and White populations in terms of PTB. These disparities persist in other areas, such as education, body-mass index, and access to prenatal care later in pregnancy.

Discussion

Another notable finding is the increase in maternal age over time. Additionally, we confirm that short interpregnancy intervals (IPIs) are a risk factor for PTBs. To facilitate the exploration of pregnancy risk factors, infections, and maternal morbidity, we developed an open-source RShiny tool called CDC NatView. This software offers a user-friendly interface to interact with and visualize the CDC natality data, which constitutes an invaluable resource.

Conclusion

In conclusion, our study has shed light on the rise of late PTBs and the persistent disparities in PTB rates between African American and White populations in the US. The increase in maternal age and the confirmation of a short IPI as a risk factor for PTB are noteworthy findings. Our open-source tool, CDC NatView, can be a valuable resource for further exploration of the CDC natality data to enhance our understanding of pregnancy risk factors and the interaction of PTB outcomes and maternal morbidities.

Efficacy of Behavioral Economic Nudges to Assist Teen Mothers: the Healthy Adolescent Transitions Randomized Controlled Trial

Communities may often lack the resources to deliver intensive programs to assist teen mothers, and many eligible adolescents may decline participation in lengthy interventions. Therefore, alternative approaches involving less resource and time may be needed. Behavioral economics (BE) can inform the development of such novel interventions. BE often feature low-intensity approaches designed to "nudge" people to help them reach their long-term goals. Nudges can include giving reminders, making the desired behavior more convenient, and optimizing the verbal presentation of recommended options. Three hundred thirty-one American adolescents (ages 14 to 19) who were 22 to 35 weeks pregnant were enrolled in the present trial. One hundred sixty-six participants were randomly assigned to the intervention condition featuring a three-month BE intervention delivered by a registered nurse and social worker. The remaining 165 youths were assigned usual care. Surveys were completed at baseline, 3 months, 12 months, and 18 months. Data collection occurred from 2017 to 2021. Qualitative feedback indicated that the BE intervention was well-received by adolescents. However, there were no significant differences between the intervention and control groups at any time point regarding repeat pregnancy, contraceptive usage, financial literacy, school completion, job attainment, HPV vaccinations, nicotine usage, perception of having a medical home, urgent care/ED usage, and nutritional intake (all p > .05). Our findings suggest that a BE-based intervention may not be sufficient to facilitate change for teen mothers. Future programs should consider lasting longer, featuring a higher dose, and/or incorporating systems-level changes. This trial was prospectively registered (NCT03194672 clinicaltrials.gov).

Birth spacing and risk of adverse pregnancy and birth outcomes: A systematic review and dose-response meta-analysis

INTRODUCTION

The association between extreme birth spacing and adverse outcomes is controversial, and available evidence is fragmented into different classifications of birth spacing.

MATERIAL AND METHODS

We conducted a systematic review of observational studies to evaluate the association between birth spacing (i.e., interpregnancy interval and interoutcome interval) and adverse outcomes (i.e., pregnancy complications, adverse birth outcomes). Pooled odds ratios (ORs) with 95% confidence intervals (CI) were calculated using a random-effects model, and the dose-response relationships were evaluated using generalized least squares trend estimation.

RESULTS

A total of 129 studies involving 46 874 843 pregnancies were included. In the general population, compared with an interpregnancy interval of 18-23 months, extreme intervals (<6 months and ≥ 60 months) were associated with an increased risk of adverse outcomes, including preterm birth, small for gestational age, low birthweight, fetal death, birth defects, early neonatal death, and premature rupture of fetal membranes (pooled OR range: 1.08-1.56; p < 0.05). The dose-response analyses further confirmed these J-shaped relationships (pnon-linear  < 0.001-0.009). Long interpregnancy interval was only associated with an increased risk of preeclampsia and gestational diabetes (pnon-linear  < 0.005 and pnon-linear  < 0.001, respectively). Similar associations were observed between interoutcome interval and risk of low birthweight and preterm birth (pnon-linear  < 0.001). Moreover, interoutcome interval of ≥60 months was associated with an increased risk of cesarean delivery (pooled OR 1.72, 95% CI 1.04-2.83). For pregnancies following preterm births, an interpregnancy interval of 9 months was not associated with an increased risk of preterm birth, according to dose-response analyses (pnon-linear  = 0.008). Based on limited evidence, we did not observe significant associations between interpregnancy interval or interoutcome interval after pregnancy losses and risk of small for gestational age, fetal death, miscarriage, or preeclampsia (pooled OR range: 0.76-1.21; p > 0.05).

CONCLUSIONS

Extreme birth spacing has extensive adverse effects on maternal and infant health. In the general population, interpregnancy interval of 18-23 months may be associated with potential benefits for both mothers and infants. For women with previous preterm birth, the optimal birth spacing may be 9 months.

Prevalence and predictors of spontaneous preterm births in Nepal: findings from a prospective, population-based pregnancy cohort in rural Nepal-a secondary data analysis

OBJECTIVE

Preterm birth can have short-term and long-term complications for a child. Socioeconomic factors and pregnancy-related morbidities may be important to predict and prevent preterm births in low-resource settings. The objective of our study was to find prevalence and predictors of spontaneous preterm birth in rural Nepal.

DESIGN

This is a secondary observational analysis of trial data (registration number NCT01177111).

SETTING

Rural Sarlahi district, Nepal.

PARTICIPANTS

40 119 pregnant women enrolled from 9 September 2010 to 16 January 2017.

OUTCOME MEASURES

The outcome variable is spontaneous preterm birth. Generalized Estimating Equations Poisson regression with robust variance was fitted to present effect estimates as risk ratios.

RESULT

The prevalence of spontaneous preterm birth was 14.5% (0.5% non-spontaneous). Characteristics not varying in pregnancy associated with increased risk of preterm birth were maternal age less than 18 years (adjusted risk ratio=1.13, 95% CI: 1.02 to 1.26); being Muslim (1.53, 1.16 to 2.01); first pregnancy (1.15, 1.04 to 1.28); multiple births (4.91, 4.20 to 5.75) and male child (1.10, 1.02 to 1.17). Those associated with decreased risk were maternal education >5 years (0.81, 0.73 to 0.90); maternal height ≥150 cm (0.89, 0.81 to 0.98) and being from wealthier families (0.83, 0.74 to 0.93). Pregnancy-related morbidities associated with increased risk of preterm birth were vaginal bleeding (1.53, 1.08 to 2.18); swelling (1.37, 1.17 to 1.60); high systolic blood pressure (BP) (1.47, 1.08 to 2.01) and high diastolic BP (1.41, 1.17 to 1.70) in the third trimester. Those associated with decreased risk were respiratory problem in the third trimester (0.86, 0.79 to 0.94); having poor appetite, nausea and vomiting in the second trimester (0.86, 0.80 to 0.92) and third trimester (0.86, 0.79 to 0.94); and higher weight gain from second to third trimester (0.89, 0.87 to 0.90).

CONCLUSION

The prevalence of preterm birth is high in rural Nepal. Interventions that increase maternal education may play a role. Monitoring morbidities during antenatal care to intervene to reduce them through an effective health system may help reduce preterm birth.

Short interpregnancy interval can lead to adverse pregnancy outcomes: A meta-analysis

BACKGROUND

The evidence of some previous papers was insufficient in studying the causal association between interpregnancy interval (IPI) and adverse pregnancy outcomes. In addition, more literature have been updated worldwide during the last 10 years.

METHODS

English and Chinese articles published from January 1980 to August 2021 in the databases of PubMed, Cochrane Library, Ovid, Embase, China Biology Medicine disc (CBM), and China National Knowledge Infrastructure (CNKI) were searched. Then following the inclusion and exclusion criteria, we screened the articles. Utilizing the Newcastle-Ottawa Scale (NOS), we evaluated the quality of the included articles. The literature information extraction table was set up in Excel, and the meta-analysis was performed with Stata 16.0 software (Texas, USA).

RESULTS

A total of 41 articles were included in the meta-analysis, and NOS scores were four to eight. The short IPI after delivery was the risk factor of preterm birth (pooled odds ratio 1.49, 95% confidence interval 1.42-1.57), very preterm birth (pooled OR: 1.82, 95% CI: 1.55-2.14), low birth weight (pooled OR: 1.33, 95% CI: 1.24-1.43), and small for gestational age (pooled OR: 1.14, 95% CI: 1.07-1.21), offspring death (pooled OR: 1.60, 95% CI: 1.51-1.69), NICU (pooled OR: 1.26, 95% CI: 1.01-1.57), and congenital abnormality (pooled OR: 1.10, 95% CI: 1.05-1.16), while was not the risk factor of gestational hypertension (pooled OR: 0.95, 95% CI: 0.93-0.98) or gestational diabetes (pooled OR: 1.06, 95% CI: 0.93-1.20).

CONCLUSION

Short IPI (IPI < 6 months) can lead to adverse perinatal outcomes, while it is not a risk factor for gestational diabetes and gestational hypertension. Therefore, more high-quality studies covering more comprehensive indicators of maternal and perinatal pregnancy outcomes are needed to ameliorate the pregnancy policy for women of childbearing age.

Using probabilistic record linkage and propensity-score matching to identify a community-based comparison population

In retrospective cohort studies of interventions disseminated to communities, it is challenging to find comparison groups with high-quality data for evaluation. We present one methodological approach as part of our study of birth outcomes of second-born children in a home visiting (HV) program targeting first-time mothers. We used probabilistic record linkage to link Connecticut's Nurturing Families Network (NFN) HV program and birth-certificate data for children born from 2005 to 2015. We identified two potential comparison groups: a propensity-score-matched group from the remaining birth certificate sample and eligible-but-unenrolled families. An analysis of interpregnancy interval (IPI) is presented to exemplify the approach. We identified the birth certificates of 4822 NFN families. The propensity-score-matched group had 14,219 families (3-to-1 matching) and we identified 1101 eligible-but-unenrolled families. Covariates were well balanced for the propensity-score-matched group, but poorly balanced for the eligible-but-unenrolled group. No program effect on IPI was found. By combining propensity-score matching and probabilistic record linkage, we were able to retrospectively identify relatively large comparison groups for quasi-experimental research. Using birth certificate data, we accessed outcomes for all of these individuals from a single data source. Multiple comparison groups allow us to confirm findings when each method has some limitations. Other researchers seeking community-based comparison groups could consider a similar approach.

The Effectiveness of Postpartum IUD Compared to Interval IUD in ‘Aisyiyah Hospital Klaten

BACKGROUND: Postpartum IUD (PPIUD) insertion is performed 10 min after the placenta is born until 48 h postpartum, interval method is installed after 4 weeks postpartum. The use of this contraception will provide a distance between pregnancies not to be too close. AIM: To assess the effectiveness of PPIUD and the interval on complaints and complications in acceptors. METHODOLOGY: This study used a cross-sectional design. The subjects were women who gave birth vaginally and cesarean section at the ‘Aisyiyah Hospital Klaten with PPIUD and interval acceptors installed. Complaint data obtained through history taking, complications obtained from ultrasound, inspeculo examination, and vaginal swab. Data were analyzed by univariate, bivariate, and multivariate analysis. RESULTS: One hundred and twenty-nine subjects consisted of 82 (63.6%) PPIUD and 47 (36.4%) interval. On ultrasound examination, 126 (97.7%) subjects had no abnormalities, two (1.6%) had abnormalities, and one (0.8%) found ovarian cysts. On inspeculo examination, 89 (69.0%) subjects found no erotion, and 40 (31.0%) did not find abnormalities. Vaginal swab examination showed that 119 (92.2%) subjects had pathogenic bacteria, ten (7.8%) were normal. The fungus was positive in 75 (58.1%) subjects, and no fungus was in 54 (41.9%), while in NGO, positive was 18 (14.0%) subjects, and negative was 111 (86.0%). There was a significant relationship that the type of IUD insertion had husband’s complaints (p = 0.021), the erosion incidence (p = 0.011), the presence/absence of threads (p = 0.01), and the presence of fungus (0.00). PPIUD is more effective than interval IUD. CONCLUSION: PPIUD is more effective in terms of the lack of complaints from the husband, the incidence of erosion, the presence or absence of threads, and found of fungus on the vaginal swab than interval IUD.

Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population

OBJECTIVE

To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type.

STUDY DESIGN

We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status.

RESULTS

Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI.

CONCLUSIONS

In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth.

IMPLICATIONS

Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.

Pregnant again? Perspectives of adolescent and young mothers who and do not experience a repeat pregnancy in adolescence

Introduction: Teen pregnancy remains a major social and public health issue in developing countries. Each additional child compromises the development of both the mother and children. Scarce studies have been performed in Latin America.

Purpose: This study explores and analyzes individual and family factors associated with repeat pregnancies during adolescence to better elucidate the phenomenon.

Methods: Qualitative-descriptive study. Thirty semi-structured interviews were conducted with mothers 20 years of age or younger from urban areas of Santiago, Chile. Participants were divided into Repeat Pregnancy (RP) and No Repeat Pregnancy (NRP) groups. Qualitative data analysis was based on elements of grounded theory.

Results: The RP group generally related life stories reflecting greater psychosocial vulnerability. Most of the RP group dropped out of school after their first pregnancy to focus on parenting and had a passive attitude towards contraception. In contrast, members of the NRP group actively sought long-term contraceptive methods, motivated largely by the desire to continue their education to improve their living conditions and achieve greater personal fulfilment. They tended to have family support networks that facilitated school retention.

Conclusion: Key differences between groups included use of contraception, focus on life projects, and motivation to finish school. Prevention strategies should promote long-term contraceptive methods, offer strategies to help young mothers continue their education, facilitate achievement of personal projects, and provide support for parenting.

Short birth spacing and its association with maternal educational status, contraceptive use, and duration of breastfeeding in Ethiopia. A systematic review and meta-analysis

Background

Closely spaced birth increases the risk of adverse maternal and child health outcomes. In Ethiopia, the prevalence of short birth spacing was highly variable across studies. Besides, contraceptive use, educational status, and duration of breastfeeding were frequently mentioned factors affecting short birth spacing. Therefore, this meta-analysis aimed to estimate the pooled prevalence of short birth spacing and its association with contraceptive use, educational status, and duration of breastfeeding among reproductive-age women in Ethiopia.

Methods

International databases: Google Scholar, PubMed, CINAHL, Cochrane library, HINARI, and Global Health were searched systematically to identify articles reporting the prevalence of short birth spacing and its association with contraceptive use, educational status, and duration of breastfeeding among reproductive-age women in Ethiopia. The data were analyzed by STATA/SE version-14 statistical software. The random-effect model was used to estimate the pooled prevalence of short birth spacing and the log odds ratio was used to determine the association. Moreover, egger’s test and I-squared statistics were used to assess publication bias and heterogeneity respectively.

Results

After reviewing 511 research articles, a total of nine articles with 5,682 study participants were included in this meta-analysis. The pooled prevalence of short birth spacing in Ethiopia was 46.9% [95% CI: (34.7, 59.1)]. Significant heterogeneity was observed between studies (I² = 98.4, p <0.001). Not using contraceptives [OR = 3.87, 95% CI: (2.29, 6.53)] and duration of breastfeeding < 24 months [OR = 16.9, 95%CI: (2.69, 106.47)] had a significant association with short birth spacing.

Conclusions

Although a minimum inter-pregnancy interval of two years was recommended by the World Health Organization (WHO), significant numbers of women still practiced short birth spacing in Ethiopia. Duration of breastfeeding and non-use of contraceptives were factors significantly associated with short birth spacing. So, efforts should be made to improve breastfeeding practice and contraceptive utilization among women in Ethiopia.

Determinants of preterm birth among women delivered in public hospitals of Western Ethiopia, 2020: Unmatched case-control study

BACKGROUND

Worldwide, preterm birth accounts for 1 million deaths of infants each year and 60% of these deaths occur in developing countries. In addition to the significant health consequences on the infant, preterm birth can lead to economic costs. There was a lack of study in western Ethiopia, and most of those studies conducted in other parts of a country were based on card review with a cross-sectional study design. The risk factors of preterm birth may vary from region to region within the same country due to variation in socioeconomic status and health care service coverage. Therefore, this study aimed to identify determinants of preterm birth in western Ethiopia.

METHODS

An institutional-based case-control study was conducted from February 15 to April 15, 2020, in western Ethiopia. The eligible 188 cases and 377 controls were randomly selected for this study. Cases were women who gave birth after 28 weeks and before 37 completed weeks of gestation, and controls were women who gave birth at and after 37 weeks of gestation from the first day of the last normal menstrual period. Data were collected by a structured interviewer-administered questionnaire. The collected data were entered into Epi info version 7 and exported to SPSS version 21 for analysis. Multivariable logistic regression was used to identify determinants of preterm birth at P-value <0.05.

RESULTS

From a total of 565 eligible participants, 516 (172 cases and 344 controls) participated in this study with a response rate of 91.3%. The result of the multivariable analysis shows that mothers who developed pregnancy-induced hypertension (AOR = 3.13, 95% CI; 1.78, 5.50), only one time ANC visits (AOR = 5.99, 95% CI; 2.65, 13.53), experienced premature rupture of membrane (AOR = 3.57, 95% CI; 1.79, 7.13), birth interval less than two years (AOR = 2.96, 95% CI; 1.76, 4.98), developed anemia during the current pregnancy (AOR = 4.20, 95% CI; 2.13, 8.28) and didn't get dietary supplementation during the current pregnancy (AOR = 2.43, 95% CI; 1.51, 3.91) had statistically significant association with experiencing preterm birth.

CONCLUSION

Antenatal care service providers should focus on mothers with pregnancy-induced hypertension, premature rupture of membrane, and anemia during pregnancy, and refer to the senior experts for early management to reduce the risk of preterm delivery. Antenatal care services such as counseling the mother on the benefit of dietary supplementation during pregnancy, antenatal care follow up, and lengthening birth interval should be integrated into the existing health extension packages. New and inclusive strategies such as the establishment of comprehensive mobile clinic services should also be designed to reduce the burden of preterm birth among women living in the rural community. Lastly, we recommend future researchers to conduct longitudinal and community-based studies supplemented with qualitative methods.

Trends in Adolescent Rapid Repeat Pregnancy in Canada

OBJECTIVE

Rapid repeat pregnancy (RRP), a birth occurring within 33 months of a previous birth, is associated with adverse neonatal outcomes. RRP occurs among 25%-35% of adolescents who become pregnant. The current study examines trends in and outcomes of adolescent RRP in the Canadian context.

METHODS

Using population-based data from the Discharge Abstract Database, we linked maternal and newborn records from labour and delivery hospitalizations across Canada (excluding Québec) from fiscal years 2004/2005 to 2014/2015. Women were included if they were aged younger than 20 years at the index birth event and delivered an infant during the study period. We assessed absolute rates of RRP and differences between groups using χ² tests. Linear tests for trend assessed change over time. Conditional logistic regression models assessed odds of adverse maternal and neonatal outcomes in RRPs compared with first pregnancies.

RESULTS

Overall, we captured 67 957 adolescent pregnancies during the study period. Of these, 32.9% (95% CI 32.5%-33.2%) had an RRP. Rates of RRP were higher among 18- to 19-year-olds (34.1%; 95% CI 33.6%-34.5%) than 15- to 17-year-olds (30.4%; 95% CI 29.7%-31.0%). There was substantial variation in RRP rates across provinces and territories, from 24.5% (95% CI 23.6%-35.6%) in British Columbia to 47.3% (95% CI 46.1%-48.4%) in Manitoba. Generally, the odds of maternal or neonatal morbidity were similar in second pregnancies. However, adolescents had decreased odds of having a small-for-gestational-age infant in their second pregnancy (P < 0.001), affecting 0.4% (95% CI 0.3%-0.7%) of second pregnancies.

CONCLUSIONS

Adolescents who experience a pregnancy are at high risk of experiencing an RRP; however, odds of maternal and neonatal morbidity were similar in second and first pregnancies.

Lactational amenorrhoea among adolescent girls in low-income and middle-income countries: a systematic scoping review

Introduction

Fertility levels among adolescents remain high in many settings. The objective of this paper was to review the available literature about postpartum and lactational amenorrhoea among adolescents in low-income and middle-income countries (LMICs).

Methods

We searched Medline, Embase, Global Health and CINAHL Plus databases using terms capturing adolescence and lactational or postpartum amenorrhoea. Inclusion criteria included publication date since 1990, data from LMICs, and topic related to lactational amenorrhoea as a postpartum family planning method or as an effect of (exclusive) breast feeding among adolescents. Thematic analysis and narrative synthesis were applied to summarise and interpret the findings.

Results

We screened 982 titles and abstracts, reviewed 75 full-text articles and included nine. Eight studies assessed data from a single country (three from India, two from Bangladesh, two from Turkey, one from Nigeria). One study using Demographic and Health Survey data included 37 different LMICs. The five studies measuring duration of postpartum or lactational amenorrhoea reported a wide range of durations across the contexts examined. Four studies (from Bangladesh, Nigeria and Turkey) examined outcomes related to the use of lactational amenorrhoea as a family planning method among adolescents. We did not find any studies assessing adolescents’ knowledge of lactational amenorrhoea as a postpartum family planning method. Likewise, little is known about the effectiveness of lactational amenorrhoea method among adolescents using sufficiently large samples and follow-up time.

Conclusion

The available evidence on lactational amenorrhoea among adolescents in LMICs is scarce. Given the potential contribution of lactational amenorrhoea to prevention of short interpregnancy intervals among adolescents and young women, there is a need for a better understanding of the duration of lactational amenorrhoea, and the knowledge and effective use of lactational amenorrhoea method for family planning among adolescents in a wider range of LMIC settings.

A Systematic Review of Programs to Promote Aspects of Teen Parents' Self-sufficiency: Supporting Educational Outcomes and Healthy Birth Spacing

INTRODUCTION

Expectant and parenting teens experience many challenges to achieving self-sufficiency and promoting their children's healthy development. Teen parents need support to help them address these challenges, and many different types of programs aim to support them. In this systematic review, we examine the research about programs that aim to support aspects of teen parents' self-sufficiency by promoting their educational outcomes and healthy birth spacing.

METHODS

We conducted a comprehensive literature search of published and unpublished literature to identify studies of programs to support teen parents that met this review's eligibility criteria. The quality and execution of the eligible study research designs were assessed to determine whether studies' findings were at risk of bias. We then extracted information about study characteristics, outcomes, and program characteristics for studies considered to provide rigorous evidence.

RESULTS

We identified 58 eligible studies. Twenty-three studies were considered to provide rigorous evidence about either education, contraceptive use, or repeat pregnancy or birth. Seventeen of these studies showed at least one favorable effect on an outcome in one of these domains, whereas the other six did not show any significant or substantial effects in these domains. These 17 studies represent 14 effective programs.

DISCUSSION

Effective programs to support expectant and parenting teens have diverse characteristics, indicating there is no single approach for promoting teens' education and healthy birth spacing. More rigorous studies of programs to support teen parents are needed to understand more about how to support teen fathers and the program characteristics associated with effectiveness.

Interpregnancy interval and risk of stillbirth: a population-based case control study

PURPOSE

We examined the association between interpregnancy intervals (IPIs) and stillbirth (defined as fetal death ≥20 weeks), as both short and long IPIs have been associated with adverse perinatal outcomes. Prior pregnancy loss is also a known risk factor for stillbirth, and women who suffer a prior loss often have shorter IPIs. For these reasons, we also sought to quantify the proportion of the association between prior pregnancy loss and subsequent stillbirth risk that may be attributed to a short IPI.

METHODS

We used data from the Stillbirth Collaborative Research Network, a multisite case-control study conducted in 2006-2008, restricted to singleton pregnancies among multiparous or multigravid women (985 controls and 291 cases). We accounted for complex sample design and nonparticipation with weighted multivariable logistic regression.

RESULTS

In the adjusted models, IPIs <6 months, as compared with a reference of 18-23 months, were associated with increased odds of stillbirth (aOR 1.6, 95% CI: 0.8, 3.4). Long IPIs (60-100 months) were also associated with an increased odds of stillbirth (aOR 2.4, 95% CI: 1.2, 4.5). After control for covariates, about one-fifth (21.2%) of the association of prior pregnancy loss (stillbirth, ectopic pregnancy, molar pregnancy, or spontaneous abortion) and stillbirth may be attributable to a short IPI.

CONCLUSIONS

Our results suggest that women who experience a prior pregnancy loss may benefit from additional counseling on adequate birth spacing to reduce subsequent stillbirth risk.

Birth outcomes of second children after community-based home visiting: A research protocol

Birth-related outcomes, such as birth weight, have lifelong impacts on health. Home visiting (HV) is an established approach to improve the health of children and families, parenting practices, and connections to social and health services. Many HV programs target first-time mothers, in part because HV activities related to a first-birth may improve birth outcomes for subsequent children, but few researchers have examined these effects. We will link data from a statewide HV program (Nurturing Families Network [NFN]) to birth certificate data to create comparison groups and measure outcomes in this observational study. Specifically, we will compare birth outcomes for NFN second-children (n = 3000) to those for: (a) first-child older siblings whose birth/gestation led to NFN enrollment (n = 3000); (b) second children of families who were screened as eligible for NFN, but not offered the program due to home visitor availability and other logistical reasons (n = 650); and (c) non-NFN second children in a propensity-score-matched group created using the likelihood of enrollment in NFN based on maternal health, demographics, and neighborhood characteristics (n = 6000). The outcomes we will examine are birth spacing, prenatal care received, cesarean section rate, gestational age, and birth weight in second-children. We will also examine the associations between program attendance (i.e., missed visits, dropout) and birth outcomes, that will generate evidence that may be used in programmatic decisions regarding continued funding and/or modification of NFN, prioritization of specific retention efforts, and targeting of first-time mothers. Use of this evidence should improve outcomes for future NFN families and may inform similar programs.

Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: An updated systematic review

BACKGROUND

This systematic review summarises association between short interpregnancy intervals and adverse perinatal health outcomes in high-resource settings to inform recommendations for healthy birth spacing for the United States.

METHODS

Five databases and a previous systematic review were searched for relevant articles published between 1966 and 1 May 2017. We included studies meeting the following criteria: (a) reporting of perinatal health outcomes after a short interpregnancy interval since last livebirth; (b) conducted within a high-resource setting; and (c) estimates were adjusted for maternal age and at least one socio-economic factor.

RESULTS

Nine good-quality and 18 fair-quality studies were identified. Interpregnancy intervals <6 months were associated with a clinically and statistically significant increased risk of adverse outcomes in studies of preterm birth (eg, aOR ≥ 1.20 in 10 of 14 studies); spontaneous preterm birth (eg, aOR ≥ 1.20 in one of two studies); small-for-gestational age (eg, aOR ≥ 1.20 in 5 of 11 studies); and infant mortality (eg, aOR ≥ 1.20 in four of four studies), while four studies of perinatal death showed no association. Interpregnancy intervals of 6-11 and 12-17 months generally had smaller point estimates and confidence intervals that included the null. Most studies were population-based and few included adjustment for detailed measures of key confounders.

CONCLUSIONS

In high-resource settings, there is some evidence showing interpregnancy intervals <6 months since last livebirth are associated with increased risks for preterm birth, small-for-gestational age and infant death; however, results were inconsistent. Additional research controlling for confounding would further inform recommendations for healthy birth spacing for the United States.

Maternal Knowledge, Attitudes, and Practices Concerning Interpregnancy Interval

INTRODUCTION

Few studies have examined maternal intentions and practices related to interpregnancy interval (IPI). IPI less than 18 months has been linked to increased preterm birth and infant mortality. This manuscript reports on a cross-sectional survey of mothers conducted to understand maternal knowledge, attitudes, and practice of IPI in Sedgwick County, Kansas.

METHODS

New and expectant mothers and mothers of neonatal infant care unit (NICU) graduates (n = 125) were surveyed regarding the issues surrounding IPI. Front desk staff handed out self-administered surveys, which were returned to a nurse upon completion. NICU participants were emailed a link to the survey hosted on SurveyMonkey^®.

RESULTS

Fewer than 30% of mothers reported previously receiving information about IPI from any source. When asked about risks associated with IPI, women frequently (n = 58, 45%) identified increased risk for birth outcomes with no known association with short IPI. Findings regarding maternal attitudes surrounding optimal IPI were mixed with many mothers defining ideal IPI as less than 18 months (n = 52, 42%), while broadly reporting they believed that a woman's body needs time to heal between pregnancies. Respondents from the NICU sample generally reported shorter optimal IPI values than the other participants. When IPI was estimated from participants' past pregnancies, half of IPIs were less than 18 months. Mothers reported they favored healthcare providers as a source for IPI education. Face-to-face discussions or printed materials were the preferred modes of education.

CONCLUSIONS

Women were aware of the need for spacing between pregnancies, however, that knowledge was unassociated with past behavior. These findings should be taken into consideration when formulating future interventions.

Public Health Implications of Very Preterm Birth

With advanced perinatal care and technology, survival among infants born very preterm (<32 weeks gestation) has improved dramatically over the last several decades. However, adverse medical and neurodevelopmental outcomes for those born very preterm remains high, particularly at the lowest gestational ages. Public health plays a critical role in providing data to assess population-based risks associated with very preterm birth, addressing disparities, and identifying opportunities for prevention, including improving the health of reproductive-age women, before, during, and after pregnancy.

Adolescent Contraception Use after Pregnancy, an Opportunity for Improvement

STUDY OBJECTIVE

To describe contraceptive method use by adolescent women in the 6 months after any pregnancy.

DESIGN

We conducted a secondary analysis of the 2011-2013 and 2013-2015 cycles of the National Survey of Family Growth.

SETTING

This survey is a nationally-representative population-based survey of reproductive aged women in the United States.

PARTICIPANTS

The sample included respondents who had at least 1 pregnancy that ended within the contraceptive calendar period as well as before the month of the respondent's 20th birthday. Women were included even if they did not have a full 6 months' worth of data.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We examined contraception method use at 1, 2, 4, and 6 months post pregnancy regardless of pregnancy outcome (live birth, induced abortion, or miscarriage).

RESULTS

Our sample consisted of 337 women with a mean age of 18.5 years. Almost half (N = 158, weighted percentage = 43.5%) of adolescents were using no method of contraception at 1 month post pregnancy. By 6 months post pregnancy, only 143 of 287 women with data through 6 months (weighted percentage = 49.7%) were using more effective methods of contraception (long-acting reversible contraception or hormonal methods), and 83 of these 287 were using no method (weighted percentage = 29.2%), including 61 of 261 women who reported that their last pregnancy was unwanted. Women from racial and ethnic minorities were less likely to use the most effective contraceptive methods. Rapid repeat pregnancy occurred among 44 of 209 women in the subsample with 18 months' follow-up data (weighted percentage = 16.9%). Only 56 of 337 adolescents (weighted percentage = 19.0%) used long-acting reversible contraceptive methods at any time post pregnancy regardless of pregnancy outcome.

CONCLUSION

Contraceptive use, especially of the most effective methods, remains low for adolescent women by 6 months post pregnancy.

Short interpregnancy interval and adverse birth outcomes in women of advanced age: a population-based study

PURPOSE

Short interpregnancy interval (IPI) has been linked with adverse birth outcomes. However, the association in advanced age women needs further investigation. This study aims to examine the association between short IPI and adverse birth outcomes including preterm birth, post-term birth, low birth weight, and macrosomia, in a population of advanced age U.S. women.

METHODS

The 2016 U.S. public-use natality data was analyzed. Analysis was restricted to women with second-order singleton live births who were ≥35 years at first live birth (n = 46,684). Multinomial logistic regression analysis was used to examine the association between short IPI and adverse birth outcomes.

RESULTS

Short IPI in advanced age women was significantly associated with higher odds of extremely preterm birth (0-5 months IPI: adjusted odds ratio [AOR] = 2.43, 95% confidence interval [CI] = 1.07-5.52; 6-11 months IPI: AOR = 2.17, 95% CI = 1.09-4.31), very preterm birth (0-5 months IPI: AOR = 1.63, 95% CI = 1.04-2.56), and extremely low birth weight (0-5 months IPI: AOR = 2.43, 95% CI = 1.28-4.60) in the second delivery. An inverse relationship between short IPI and post-term birth was observed and no significant association between short IPI and macrosomia was found.

CONCLUSIONS

Short IPI in advanced age women increases the odds of adverse birth outcomes in the second delivery.

Nulliparous teenagers and preterm birth in California

BACKGROUND

Young maternal age is one of the numerous risk factors for delivery before 37 weeks of gestation, yet the mechanisms are unclear. The purpose of the current study was to investigate the association between teenagers and the risk of preterm birth (PTB) in a large and recent cohort study.

METHODS

We conducted a population-based retrospective cohort study using 2007-2011 California birth certificate records linked with hospital discharge indices and United States census data for nulliparous 13-20 year olds who gave birth to singletons. Maternal age was examined categorically at 1 year intervals. PTB was defined as delivery at <37 weeks of gestation with further distinction between <32 and 32-36 weeks, and between spontaneous and medically indicated deliveries. Adjusted multivariable logistic regression was used to estimate odds ratios (OR) for PTB.

RESULTS

The prevalence of PTB was highest among the youngest (13 year olds, 14.5%) and lowest among the oldest (20 year olds, 6.7%). After adjusting for maternal and paternal race/ethnicity, paternal age, initiation of prenatal care, source of payment, pre-pregnancy body-mass-index (BMI), height, smoking, and poverty; young mothers of ages 13, 14, 15, and 16 years had increased odds for spontaneous PTB at <32 weeks [OR (CI): 3.76 (1.83-7.75), 1.65 (1.10-2.48), 1.55 (1.24-1.93), 1.19 (1.00-1.42), respectively] compared to 20 year olds. All teenagers, excluding 19 year olds, had elevated odds of spontaneous PTB at 32-36 weeks.

CONCLUSIONS

Nulliparous teenagers were at increased risk for spontaneous PTB, especially those 16 years or younger. Medically indicated PTB was not associated with young age.

Pregnancy recurrence in adolescents in Southern Brazil

OBJECTIVE

To determine the pregnancy recurrence among adolescents and young people in a city located in the extreme south of Brazil and to identify associated factors.

METHOD

One hundred and twelve (112) women participated, having delivered their children in 2010, while adolescents. The sample was stratified in two stages, being the first a census of the whole population of the city and the second a convenience sample. For statistical analysis, Pearson Chi-square test was used, with a significance level of 5%.

RESULTS

The recurrence rate was 53.6%, with an average of 28.6 months. At the time of delivery, in 2010, recurrence was significantly associated with level of education (p=0.044) as well as not being in school (p=0.036). In 2014, the factors associated were level of education (p<0.001), transcript of grades (p=0.030) and income (p=0.030).

CONCLUSION

Recurrence of teenage pregnancy represents a lack of importance given to formal education, a fact that mitigates the opportunities and hinders insertion in the labor market, creating a cycle of social inequality. Multidisciplinary efforts involving schools, health services and the youth in educational activities are thus vital, aiming at critical thinking to transform reality.

Inter-pregnancy interval and adverse outcomes: Evidence for an additional risk in health disparate populations

OBJECTIVE

Short interpregnancy interval (IPI), <18 months between pregnancies, is a potential cause of adverse delivery and birth outcomes, and may be a particular issue among those with other risks. Our goal was to examine IPI and delivery/infant complications in Tennessee.

METHODS

Birth certificate/vital records data included 101,912 women with a previous delivery. IPI groups (<6, 6-12, 12-18, 18-60 months) were compared on outcomes.

RESULTS

Thirty-nine percent of the deliveries had IPI <18 months, 9% were <6 months, rates 11% and 27% higher than nationally. Women with IPI <18 months were younger, lower educated with lower income, had higher BMIs, and were more likely to be unmarried, smokers, and have begun prenatal care later (p < .001). In adjusted analyses, IPI <18 months predicted elevated risk for precipitous labor, low-birth weight, preterm delivery, NICU admission, and infant mortality, with effects strongest for IPI <6 months. Finally, risks related to IPI <6 months were substantially higher for the lowest income women.

CONCLUSIONS

Rates of less than optimal IPI were high in this population already experiencing significant maternal-child health disparities, with short IPI a particular risk factor for poor outcomes for the most disadvantaged women, suggesting yet another precursor for adverse birth outcomes in those already most at risk.

Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature

Adolescent pregnancy, particularly unintended pregnancy, can have lasting social, economic, and health outcomes. The objective of this review is to identify high-quality interventions and evaluations to decrease unintended and repeat pregnancy among young people in low- and middle-income countries. PubMed, Embase, PsycInfo, Cinahl Plus, Popline, and the Cochrane Databases were searched for all languages for articles published through November 2015. Gray literature was searched by hand. Reference tracing was utilized, as well as unpacking systematic reviews. Selected articles were those that were evaluated as having high-quality interventions and evaluations using standardized scoring. Twenty-one high-quality interventions and evaluations were abstracted. Nine reported statistically significant declines in pregnancy rates (five cash transfer programs, one education curriculum, two life-skills curricula, and a provision of contraception intervention), seven reported increases in contraceptive use (three provision of contraception interventions, two life-skills curricula, a peer education program, and a mass media campaign), two reported decreases in sexual activity (a cash transfer program and an education and life-skills curriculum), and two reported an increase in age of sexual debut (both cash transfer programs). The selected high quality, effective interventions included in this review can inform researchers, donors, and policy makers about where to make strategic investments to decrease unintended pregnancy during young adulthood. Additionally, this review can assist with avoiding investments in interventions that failed to produce significant impact on the intended outcomes. The diversity of successful high-quality interventions, implemented in a range of venues, with a diversity of young people, suggests that there are multiple strategies that can work to prevent unintended pregnancy.

Rapid Repeat Pregnancy in Brazilian Adolescents: Interaction between Maternal Schooling and Age

STUDY OBJECTIVE

An association between rapid repeat pregnancy (RRP; occurring within a birth interval of up to 24 months) and undesirable obstetric and perinatal outcomes has been shown, especially among adolescents and women without adequate schooling. The objective of this study was to evaluate the effect of the interaction between maternal schooling and age on the incidence of RRP. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A nonconcurrent cohort study was carried out using probabilistic record linkage techniques. The 59,400 linked records of singleton live-born infants delivered in 2002 whose mothers were up to 29 years old and lived in Rio de Janeiro City were evaluated.

RESULTS

Compared with young adults with adequate schooling, the adjusted risk ratio for RRP for adolescents with inadequate schooling was 2.1 (95% confidence interval, 1.8-2.4). The attributable proportion was 0.16 (95% confidence interval, 0.02-0.29).

CONCLUSION

Young maternal age and inadequate schooling interact, increasing RRP.

Interpregnancy interval after live birth or pregnancy termination and estimated risk of preterm birth: a retrospective cohort study

OBJECTIVES

We assessed whether interpregnancy interval (IPI) length after live birth and after pregnancy termination was associated with preterm birth (PTB).

DESIGN

Multiyear birth cohort.

SETTINGS

Fetal death, birth and infant death certificates in California merged with Office of Statewide Health Planning and Development.

POPULATION

One million California live births (2007-10) after live birth and after pregnancy termination.

METHODS

Logistic regression was used to estimate odds ratios (ORs) of PTB of 20-36 weeks of gestation and its subcategories for IPIs after a live birth and after a pregnancy termination. We used conditional logistic regression (two IPIs/mother) to investigate associations within mothers.

MAIN OUTCOME MEASURE

PTB relative to gestations of ≥ 37 weeks.

RESULTS

Analyses included 971 211 women with IPI after live birth, and 138 405 women with IPI after pregnancy termination with 30.6% and 74.6% having intervals of <18 months, respectively. IPIs of <6 months or 6-11 months after live birth showed increased odds of PTB adjusted ORs for PTB of 1.71 (95% CI 1.65-1.78) and 1.20 (95% CI 1.16-1.24), respectively compared with intervals of 18-23 months. An IPI >36 months (versus 18-23 months) was associated with increased odds for PTB. Short IPI after pregnancy termination showed a decreased OR of 0.87 (95% CI 0.81-0.94). The within-mother analysis showed the association of increased odds of PTB for short IPI, but not for long IPI.

CONCLUSIONS

Women with IPI <1 or >3 years after a live birth were at increased odds of PTB-an important group for intervention to reduce PTB. Short IPI after pregnancy termination was associated with reduced odds for PTB and needs to be further explored.

TWEETABLE ABSTRACT

Short and long IPI after live birth, but not after pregnancy termination, showed increased odds for PTB.

Prenatal contraceptive counseling and method provision after childbirth

Postpartum contraception is undergoing major changes, not only in timing, but also in content. Failure to provide immediate postpartum contraception contributes to the problems of unintended pregnancies and rapid repeat pregnancy because often the highest-risk women do not return for postpartum care. If they do attend that visit, they have often lost the insurance coverage that would enable them to use the most effective forms of birth control. Most of the issues surrounding early initiation of progestin-only methods and breastfeeding have been favorably resolved. In some cases, insurance coverage for delivery has been expanded to cover the costs of providing intrauterine devices and implants before the woman is discharged home. All of these new opportunities shift the burden of counseling about postpartum contraception onto the shoulders of the prenatal care provider. This article provides information about the advantages and disadvantages of providing immediate postpartum contraception with each of the eligible methods so clinicians can provide the needed counseling both during pregnancy and during hospitalization for delivery. It also provides guidance for initiation of bridging contraception, if needed, to initiate a method for a woman later in the postpartum period.