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.

Postpartum long-acting reversible contraceptive use among active-duty, female US Army soldiers

BACKGROUND

Postpartum use of long-acting reversible contraception has been found to be effective at increasing interpregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military service members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers.

OBJECTIVE

This study aimed to (1) quantify postpartum uptake of long-acting reversible contraception among active-duty female US Army soldiers and (2) identify demographic and military-specific characteristics associated with use.

STUDY DESIGN

This retrospective cohort study used longitudinal data of all digitally recorded health encounters for active-duty US Army soldiers from 2014 to 2017. The servicewomen included in our analysis were aged 18 to 44 years with at least one delivery and a minimum of 4 months of total observed time postdelivery within the study period. We defined postpartum long-acting reversible contraception use as initiation of use within the delivery month or in the 3 calendar months following delivery and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception use with multivariable logistic regression.

RESULTS

The inclusion criteria were met by 15,843 soldiers. Of those, 3162 (19.96%) initiated the use of long-acting reversible contraception in the month of or within the 3 months following delivery. Fewer than 5% of these women used immediate postpartum long-acting reversible contraception. Among women who initiated postpartum long-acting reversible contraceptive use, 1803 (57.0%) received an intrauterine device, 1328 (42.0%) received an etonogestrel implant, and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those who were married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest use rates overall. When compared with these women, the adjusted odds of postpartum use among self-reported Black and Asian or Pacific Islander women were 18% and 30% lower, respectively (both P<.001). There was also a trend of decreasing postpartum use with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential use of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older and among women who identified as Black.

CONCLUSION

Among active-duty US Army servicewomen, 1 in 5 used postpartum long-acting reversible contraception, and fewer than 5% of these women used an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of use and significant differences in the uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

Effects of Short Interpregnancy Intervals on Adverse Pregnancy Outcomes - Haidian District, Beijing Municipality, China, 2017-2019

What is already known about this topic?

Interpregnancy intervals (IPIs) that are either excessively long or short have been linked with an elevated risk of adverse perinatal outcomes. Presently, no pertinent guidelines have been established in China to provide clear direction with regard to optimal IPI.

What is added by this report?

A brief interpregnancy interval may elevate the risk of miscarriage, postpartum hemorrhage, and fetal distress among expectant women.

What are the implications for public health practice?

These results could inform prenatal consultations, guiding pregnant women towards an ideal interpregnancy interval of no less than 24 months.

Efficacy and safety of intrauterine device placement during a planned cesarean section

Objective

Approximately 79% of pregnancies conceived within the first year after delivery are unintended and 50% of the couples report having unprotected intercourse before the first routine postpartum appointment. Unintended pregnancies are associated with unsafe abortions and other poor outcomes. We aimed to determine the efficacy and safety of intrauterine device (IUD) placement during a planned cesarean section (CS) at one year after insertion.

Study Design

A survey-based retrospective cohort study conducted at a university teaching hospital. The study cohort included term pregnant women delivered by a planned CS between December 2016 and July 2020, and data collection and questionnaires were completed in July 2021. In the study group, copper or Levonorgestrel IUDs were placed through the uterine incision after delivery of the fetus and placenta, while women in the control group did not receive an IUD. Other perioperative managements were similar. The primary outcome was unintended pregnancy rate during the first year after delivery.

Results

The study comprised a total of 150 women, with 50 and 100 in the study and control groups, respectively. None of the women in the study group became pregnant, compared with nine (9%) in the controls (p = 0.03), of them eight (88.9%) were unplanned. Perioperative outcome was comparable between groups. The rate of contraceptive use one year after delivery was significantly higher in the study group compared to the control group (86.0% vs. 35.0%, respectively, p < 0.001).

Conclusion

IUD placement during CS is effective in preventing unintended pregnancies within the first year after delivery, with operative outcomes unaffected.

Implications

Intrauterine device (IUD) placement during a planned cesarean section prevented unintended pregnancies within one year after birth. Additionally, the rate of contraceptive use at one year was significantly higher compared to women who elected not to have an IUD inserted during the cesarean. IUD placement did not affect perioperative outcomes.

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.

Interpregnancy Interval and Birth Outcomes: A Propensity Matching Study in the California Population

INTRODUCTION

Previous studies that used traditional multivariable and sibling matched analyses to investigate interpregnancy interval (IPI) and birth outcomes have reached mixed conclusions about a minimum recommended IPI, raising concerns about confounding. Our objective was to isolate the contribution of interpregnancy interval to the risk for adverse birth outcomes using propensity score matching.

METHODS

For this retrospective cohort study, data were drawn from a California Department of Health Care Access and Information database with linked vital records and hospital discharge records (2007-2012). We compared short IPIs of < 6, 6-11, and 12-17 months to a referent IPI of 18-23 months using 1:1 exact propensity score matching on 13 maternal sociodemographic and clinical factors. We used logistic regression to calculate the odds of preterm birth, early-term birth, and small for gestational age (SGA).

RESULTS

Of 144,733 women, 73.6% had IPIs < 18 months, 5.5% delivered preterm, 27.0% delivered early-term, and 6.0% had SGA infants. In the propensity matched sample (n = 83,788), odds of preterm birth were increased among women with IPI < 6 and 6-11 months (OR 1.89, 95% CI 1.71-2.0; OR 1.22, 95% CI 1.13-1.31, respectively) and not with IPI 12-17 months (OR 1.01, 95% CI 0.94-1.09); a similar pattern emerged for early-term birth. The odds of SGA were slightly elevated only for intervals < 6 months (OR 1.10, 95% CI 1.00-1.20, p < .05).

DISCUSSION

This study demonstrates a dose response association between short IPI and adverse birth outcomes, with no increased risk beyond 12 months. Findings suggest that longer IPI recommendations may be overly proscriptive.

Intention of pregnant women for the postpartum use of intrauterine devices in Upper Egypt's rural communities

OBJECTIVES

This study aims to assess pregnant women's intention in rural Upper Egypt to use the copper-bearing intrauterine device (IUD) and to identify the factors influencing their intention to use the method.

METHODS

The study was a household survey of 400 pregnant women in 16 villages in Assiut and Sohag Governorates in Upper Egypt.

RESULTS

Only one third of the study participants (30.8%) had the intention to use IUD. Reasons of not intending to use IUD were; perceived pain during IUD insertion or removal (37.5%), perceived side effects (21.3%) and misconceptions (15.2%), husbands' disapproval for using the method (15.8%) and the desire for future fertility (12.3%). Having a secondary or a higher level of education (OR (95% CI) = 1.726 (1.085-2.746), p = 0.01) and previous use of IUD (OR (95% CI) = 2.277 (1.108-4.678), p = 0.02) were the positive predictors of the intention to use IUD, while perception of husband opposition to IUD use (OR (95% CI) = 0.604 (0.379-0.964), p = 0.03) and perception of IUD related myths (OR (95% CI) = 0.893 (0.836-0.955), p = 0.004) were the negative predictors of the intention to use IUD.

CONCLUSION

The intention to use IUD is relatively low among pregnant women in rural Upper Egypt. Targeting pregnant women and their husbands with proper counselling regarding IUD use during antenatal care visits would greatly impact increasing their use of the method.

Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis

BACKGROUND

Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently.

METHODS

We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling.

RESULTS

The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected.

CONCLUSIONS

High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care.

TRIAL REGISTRATION

CTRI/2015/09/006219. Registered 28 September 2015.

Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women

BACKGROUND

Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period.

OBJECTIVE

This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery.

STUDY DESIGN

We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing, >$0-<$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type.

RESULTS

Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P<.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P<.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point.

CONCLUSION

Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.

<p>Determinants of Sub-Optimal Birth Spacing in Gedeo Zone, South Ethiopia: A Case–Control Study</p>

Background

Birth spacing is key in ensuring the health of mothers and their children as well as determining population growth. Most of the mothers in developing nations including Ethiopia have been practicing short inter-birth intervals. There is a paucity of studies concerned with suboptimal birth spacing among women in reproductive age in the study area.

Purpose

This study aims to identify the determinants of sub-optimal birth spacing among reproductive-age women in Gedeo zone, South Ethiopia.

Materials and Methods

A community-based unmatched case–control study was undertaken among 814 reproductive-age women in Gedeo zone, South Ethiopia from October 1 to November 30, 2018. Cases were women practiced suboptimal/short birth intervals (<33 months), whereas controls were women practiced inter-birth intervals of 33 months and more. A structured interviewer-administered questionnaire was used. A stratified, two-stage cluster sampling technique was used. EpiData version 3.1 and SPSS version 22 were used for data entry and analysis, respectively. Bivariate and multivariable logistic regression analyses were computed. P-value <0.05 was considered as statistically significant. All ethical procedures were considered.

Results

Women’s educational status, AOR (95% CI) =0.6 (0.43, 0.96), age at first marriage, AOR (95% CI) = 0.9 (0.85, 0.99), distance from the nearest health facility, AOR (95% CI) = 1.4 (1.04, 1.94), wealth index, AOR (95% CI) = 4.1 (2.66, 6.19), and postnatal care utilization after the previous birth, AOR (95% CI) = 0.4 (0.25, 0.53) were statistically significant with suboptimal birth spacing.

Conclusion

Women’s educational status age at first marriage, distance from the nearest health facility, wealth index and postnatal care utilization after the previous birth were the determinants of suboptimal birth spacing.

Influence of interpregnancy interval on uterine rupture

OBJECTIVE

This study aims to assess the independent influence of interpregnancy interval (IPI) on uterine rupture using a population-based cohort of all Ohio births, regardless of prior cesarean (PCS) or trial of labor (TOL) status.

STUDY DESIGN

Population-based retrospective cohort study of all live births in Ohio (2006-2012). Frequency of uterine rupture was quantified and stratified by number of prior cesarean deliveries and IPI. The relative and adjusted risk of IPI on uterine rupture was calculated using multivariate logistic regression.

RESULTS

Of 1,034,522 live births recorded during the 7-year study period, 249 cases of uterine rupture were identified for analysis. Two-thirds of uterine rupture cases (n = 158) occurred in women with one or more PCS and one-third (n = 91) had no prior cesarean. IPI 24-59 months had the lowest frequency of uterine rupture and was used as the referent group. IPI 12-23 and IPI ≥ 60 months were not significantly associated with risk of uterine rupture, p = .847, .540 respectively. In women with PCS, IPI < 12 months was associated with greater than two-fold increased risk of uterine rupture (aRR 2.4, CI 1.5-3.8). No association between IPI < 12 months and uterine rupture was observed in women with no PCS, p = .696.

CONCLUSION

IPI < 12 months is independently associated with uterine rupture in women with prior cesarean, but does not appear to influence risk in women with an unscarred uterus.

Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women

BACKGROUND

Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women.

METHODS

Using the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4-60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no).

RESULTS

We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93-5,055.91; inpatient implant: median, $11.91; range, $2.49-650.14; outpatient IUD: median, $25.00; range, $0.01-3,354.80; outpatient implant: median, $27.20; range, $0.18-2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71-0.77).

CONCLUSIONS

Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.

The effect of short pregnancy interval on perinatal outcomes in Turkey: A retrospective study

OBJECTIVE

The aim of the study was to determine the effect of short pregnancy interval on perinatal outcomes.

METHODS

The research was a retrospective study. The material consisted of birth records of a state hospital for the last three years in Manisa in the western region of Turkey (2015-2017) (n:8961). The research population included women whose gestational interval was ≤two years and the gestational week was over 22 weeks (n:2089). Perinatal outcomes were assessed through preterm birth, stillbirth, and low birth weight.

RESULTS

The mean age of women who are in the research group is 26.7 ± 5.32. According to the perinatal results of women with a pregnancy interval of two years and shorter; 8.2% of women had birth before 37 weeks and 0.3% resulted in stillbirth. It was determined that 4.8% of infants were born with low birth weight. There was no difference between the short pregnancy interval and stillbirth or preterm birth. However, a significant difference was found between the low birth weight and short pregnancy interval. (p>0.05).

CONCLUSIONS

Pregnancy interval does not affect preterm birth and stillbirth from perinatal outcomes, but has a significant effect on the birth weight of the newborn.

The effect of sex of last child on short birth interval practice: the case of northern Ethiopian pregnant women

Objective

Improving short birth interval practice is a key strategy to reduce maternal mortality, neonatal mortality, adverse pregnancy outcomes, high fertility rate and undermining economic development efforts. However, there were limited evidences on short birth interval practice and its determinant factors in Ethiopia. This study aimed to determine the prevalence of short birth interval practice and associated factors among pregnant women. Institutional based cross-sectional study was conducted among 418 pregnant mothers using stratified sampling technique. Multivariable logistic regression analysis was performed at the level of significance of P-value < 0.05.

Result

Short birth interval practice was found to be 40.9%. Child death (AOR = 3.60, 95% CI 1.35, 9.59), female child (AOR = 2.03, 95% CI 1.12, 3.67), younger maternal age (AOR = 4.23, 95% CI 1.14, 12.66), contraceptive non-use (AOR = 8.15, 95% CI 4.17, 15.94), increase duration of breastfeeding (AOR = 4.72, 95 CI% 1.10, 20.60) and home delivery (AOR = 4.75, 95 CI% 2.30, 9.79) were found to be significantly associated with short birth interval practice. The prevalence of short birth interval practice is high. Multi disciplinary approach through improving maternal and child health care are recommended to prevent short birth interval practice.

A Comparison of Breastfeeding Exclusivity and Duration Rates Between Immediate Postpartum Levonorgestrel Versus Etonogestrel Implant Users: A Prospective Cohort Study

OBJECTIVE

This study compares breastfeeding outcomes after immediate postpartum initiation of single-rod etonogestrel (ENG) versus two-rod levonorgestrel (LNG) contraceptive implants. Outcomes assessed include the following: (1) breastfeeding continuation through 24 months after delivery and (2) exclusive breastfeeding until 6 months after delivery, at Kasungu District Hospital, Malawi.

METHODS

We used Kaplan-Meier survival analysis to compare breastfeeding continuation through 24 months and exclusive breastfeeding through 6 months after delivery for ENG versus LNG implant users. We described infant feeding practices up to 6 months after delivery.

RESULTS

We analyzed 140 women: 28 (20%) ENG and 112 (80%) LNG impalnt users. Eighty-seven percent (n = 122) of women completed the 24-month study visit. Twenty-four months breastfeeding continuation proportions were 54.2% (95% confidence interval [CI] = 32.7-71.4) and 74.7% (95% CI = 64.9-82.2) for ENG and LNG implant users, respectively (p = 0.10). Breastfeeding continuation was high in both groups at 21 months: 100% and 93.2% (95% CI = 86.2-96.7) for ENG and LNG implant users, respectively (p = 0.18). Seventy-one percent (20/28, 95% CI = 51.0-84.6) of ENG and 72% (78/108, 95% CI = 62.4-79.7) of LNG implant users exclusively breastfed their infants until 6 months postpartum (p = 0.89).

CONCLUSIONS

Continuation of breastfeeding until 24 months and exclusive breastfeeding until 6 months were high among users of both types of progestin implant initiated immediately postpartum and similar to proportions among the general population of postpartum women in the Central region of Malawi.

Postpartum intrauterine devices: clinical and programmatic review

The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long-acting reversible contraception, which includes the insertion of an intrauterine device. The use of the intrauterine device in the postpartum period is a safe practice with few contraindications and many benefits. Although an intrauterine device placed during the postpartum period is more likely to expel compared with one placed at the postpartum visit, women who initiate intrauterine devices at the time of delivery are also more likely to continue to use an intrauterine device compared with women who plan to follow up for an interval intrauterine device insertion. This review will focus on the most recent clinical and programmatic updates on postpartum intrauterine device practice. We discuss postpartum intrauterine device expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum intrauterine devices and encourage those involved in the healthcare system to remove barriers to this worthwhile practice.

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.

Intimate partner violence and pregnancy spacing: results from a meta-analysis of individual participant time-to-event data from 29 low-and-middle-income countries

Introduction

Inadequately spaced pregnancies, defined as pregnancies fewer than 18 months apart, are linked to maternal, infant, and child morbidity and mortality, and adverse social, educational and economic outcomes in later life for women and children. Quantifying the relation between intimate partner violence (IPV) and women’s ability to space and time their pregnancies is an important part of understanding the burden of disease related to IPV.

Methods

We applied Cox proportional hazards models to monthly data from the Demographic and Health Surveys’ Reproductive Health Calendar to compare interpregnancy intervals for women who experienced physical, sexual and/or emotional IPV in 29 countries. We conducted a one-stage meta-analysis to identify the periods when women who experienced IPV were at the highest risk of unintended and incident pregnancy, and a two-stage meta-analysis to explore cross-country variations in the magnitude of the relation between women’s experience of IPV and pregnancy spacing.

Results

For the one-stage analysis, considering 52 959 incident pregnancies from 90 446 women, which represented 232 394 person-years at risk, women’s experience of IPV was associated with a 51% increase in the risk of pregnancy (95% CI 1.38 to 1.66), although this association decreased over time. When limiting our inference to unintended pregnancies that resulted in live births, women’s experience of IPV was associated with a 30% increase in the risk of unintended pregnancy (95% CI 1.25 to 1.34; n=13 541 pregnancies, 92 848 women, 310 319 person-years at risk). In the two-stage meta-analyses, women’s experience of IPV was associated with a 13% increase in the probability of incident pregnancy (95% CI 1.07 to 1.20) and a 28% increase in the likelihood of unintended pregnancy (95% CI 1.19 to 1.38).

Conclusions

Across countries, women’s experience of IPV is associated with a reduction in time between pregnancies and an increase in the risk of unintended pregnancy; the magnitude of this effect varied by country and over time.

Expectant inner-city women: attitudes about contraception given infant feeding choice

PURPOSE

We sought to examine whether low-income inner-city expectant women who intend to breastfeed make different contraceptive choices than those who intend to formula feed.

MATERIALS AND METHODS

This cross-sectional pilot study surveyed expectant women age 14 years and older receiving prenatal care at MacDonald Women's Hospital, Cleveland Ohio (01 November 2016-15 January 2017). Questions assessed knowledge and attitudes regarding infant feeding and contraception options, and postpartum feeding and contraceptive intentions.

RESULTS

We enrolled 223 expectant women, mean age 25.6 years at a median of 30 weeks gestation; 192 (86.5%) were African-American and 171 (75%) were multiparous. Women intending to breastfeed had 0.44 times the odds of intending to use birth control after delivery (95% CI [0.19-1.05], p = .06), while women intending to feed formula had 2.26 times the odds of intending to use birth control after delivery (95% CI [0.95-5.40]). Contraceptive attitudes significantly impacted intent to use contraception (p = .007), with every point higher on the contraception attitudes scale equating to a 7% increase in odds of postpartum contraception use.

CONCLUSIONS

Postpartum contraceptive intentions do not differ significantly between women intending to breastfeed and those intending formula feeding. Contraception attitudes do not significantly change this association, but were significantly related to contraceptive intent. Findings highlight the importance of providing comprehensive birth control education to all expectant mothers, regardless of feeding intention. Our study is unique in addressing interactions between maternal contraceptive and feeding intentions among expectant women at high risk for both not breastfeeding and unintended short interval pregnancy.

Immediate versus delayed postpartum use of levonorgestrel contraceptive implants: a randomized controlled trial in Uganda

BACKGROUND

Use of long-acting, highly effective contraception has the potential to improve women's ability to avoid short interpregnancy intervals, which are associated with an increased risk of maternal morbidity and mortality, and preterm delivery. In Uganda, contraceptive implants are not routinely available during the immediate postpartum period.

OBJECTIVE

The purpose of this study was to compare the proportion of women using levonorgestrel contraceptive implants at 6 months after delivery in women randomized to immediate or delayed insertion.

STUDY DESIGN

This was a randomized controlled trial among women in Kampala, Uganda. Women who desired contraceptive implants were randomly assigned to insertion of a 2-rod contraceptive implant system containing 75 mg of levonorgestrel immediately following delivery (within 5 days of delivery and before discharge from the hospital) or delayed insertion (6 weeks postpartum). The primary outcome was implant utilization at 6 months postpartum.

RESULTS

From June to October 2015, 205 women were randomized, 103 to the immediate group and 102 to the delayed group. Ninety-three percent completed the 6 month follow-up visit. At 6 months, implant use was higher in the immediate group compared with the delayed group (97% vs 68%; P < .001), as was the use of any highly effective contraceptive (98% vs 81%; P = .001). Women in the immediate group were more satisfied with the timing of implant placement. If given the choice, 81% of women in the immediate group and 63% of women in the delayed group would choose the same timing of placement again (P = .01). There were no serious adverse events in either group.

CONCLUSION

Offering women the option of initiating contraceptive implants in the immediate postpartum period has the potential to increase contraceptive utilization, decrease unwanted pregnancies, prevent short interpregnancy intervals, and help women achieve their reproductive goals.

Prevalence and Predictors of Prenatal and Postpartum Contraceptive Counseling in Two Texas Cities

OBJECTIVES

We investigated the prevalence of and sociodemographic associations with receiving prenatal and postpartum contraceptive counseling, including counseling on intrauterine devices (IUDs) and implants.

METHODS

We used data from a prospective cohort study of 803 postpartum women in El Paso and Austin, Texas. We examined the prevalence of prenatal and postpartum counseling, provider discouragement of IUDs and implants, and associated sociodemographic characteristics using χ2 tests and logistic regression.

RESULTS

One-half of participants had received any prenatal contraceptive counseling, and 13% and 37% received counseling on both IUDs and implants prenatally and postpartum, respectively. Women with more children were more likely to receive any contraceptive counseling prenatally (odds ratio [OR], 1.99; p < .01). Privately insured women (OR, 0.53; p < .05) had a lower odds of receiving prenatal counseling on IUDs and implants than publicly insured women. Higher education (OR, 2.16; p < .05) and attending a private practice (OR, 2.16; p < .05) were associated with receiving any postpartum counseling. Older age (OR, 0.61; p < .05) was negatively associated with receiving postpartum counseling about IUDs and implants and a family income of $10,000 to $19,000 (OR, 2.21; p < .01) was positively associated. Approximately 20% of women receiving prenatal counseling and 10% receiving postpartum counseling on IUDs and implants were discouraged from using them. The most common reason providers restricted use of these methods was inaccurate medical advice.

CONCLUSIONS

Prenatal and postpartum counseling, particularly about IUDs and implants, was infrequent and varied by sociodemographics. Providers should implement evidence-based prenatal and postpartum contraceptive counseling to ensure women can make informed choices and access their preferred method of postpartum contraception.

Interpregnancy Interval and Congenital Anomalies: A Record-Linkage Study Using the Manitoba Population Research Data Repository

OBJECTIVE

Congenital anomalies are a serious public health issue, and relatively few modifiable risk factors have been identified. Our objective was to investigate one such potential risk factor, the interpregnancy interval (IPI).

METHODS

We conducted a secondary analysis of data housed at the Manitoba Centre for Health Policy. In-hospital live births and stillbirths of at least 20 weeks' gestation were identified, and consecutive births to the same mother were grouped into sibling pairs to calculate the IPI for the younger siblings of each pair. Logistic regression models were fit to examine the association between the IPI and any congenital anomaly, as well as CNS and chromosomal anomalies, while controlling for potentially confounding sociodemographic and clinical factors.

RESULTS

Among 172 909 live births and stillbirths, the IPI was not significantly associated with congenital anomalies overall or with chromosomal anomalies. Short IPIs were associated with significantly increased odds of CNS anomalies relative to IPIs of 18-23 months (adjusted OR [aOR] for IPIs <6 months 2.15; 95% CI 1.48-3.12), whereas the aOR for IPIs ≥60 months was elevated but not statistically significant (aOR 1.50; 95% CI 0.96-2.34). In a sensitivity analysis in which the cohort was restricted to births from 2003 onwards (which yielded more complete data on health-related behaviours), the observed effect for IPIs shorter than 6 months and CNS anomalies was attenuated and no longer significant, but it remained elevated (aOR 1.65; 95% CI 0.85-3.24).

CONCLUSION

The findings for CNS anomalies warrant further investigation.

The impact of inter-pregnancy interval on subsequent risk of preterm birth

OBJECTIVE

The aim of the study was to assess optimal time to conceive after previous delivery associated with smallest risk of preterm birth.

METHODS

We selected all women (n = 2723) with their first and second singleton delivery between the years 2004 and 2012. Inter-pregnancy interval was defined as that between live birth and subsequent conception. We performed logistic regression analyses to assess the risk of preterm birth adjusted for maternal age and body mass index.

RESULTS

Association between inter-pregnancy interval and the natural logarithm of the adjusted relative risk of preterm birth had a J-shaped curve with lowest risk at 15 months after last birth.

CONCLUSION

The optimal time to conceive after a previous delivery is 15 months, as longer or shorter interval are associated with increased risk of preterm birth. Women with short or long inter-pregnancy intervals were 1.6 times more likely to experience preterm birth.

Interpregnancy Interval and Adverse Perinatal Outcomes: A Record-Linkage Study Using the Manitoba Population Research Data Repository

OBJECTIVE

To examine the association between the interpregnancy interval (IPI) and preterm birth, low birth weight, and SGA birth in a developed country with universal health coverage.

METHODS

We conducted a secondary analysis of data housed at the Manitoba Centre for Health Policy. All live births in Manitoba hospitals over a 29-year period were identified and consecutive births to the same mother were grouped into sibling pairs to calculate the IPI for the younger siblings. Logistic regression models were fit to examine the association between the IPI and adverse perinatal outcomes, adjusted for potentially confounding sociodemographic and clinical factors.

RESULTS

In a cohort of more than 171 000 births and relative to IPIs of 18 to 23 months, IPIs shorter than 12 and longer than 23 months were associated with significantly increased odds of preterm birth overall and both medically indicated and spontaneous preterm births, low birth weight, and SGA birth. The strongest association observed was for intervals shorter than 6 months and spontaneous preterm birth (adjusted OR 1.83, 95% CI 1.65-2.03). When the outcome was modelled as GA categories, the strongest association observed was for intervals shorter than 6 months and early preterm birth (<34 weeks' GA; adjusted OR 2.47, 95% CI 2.07-2.94).

CONCLUSION

If the associations observed between the IPI and adverse perinatal outcomes in this large, population-based cohort are causal, birth spacing could form an important target of public health messaging in Canada.

Postpartum intentions on contraception use and method choice among breastfeeding women attending a university hospital in Ohio: a cross-sectional study

BACKGROUND

Few postpartum women use effective contraception and those who use less effective methods have increased rates of unintended pregnancy. Little is known about postpartum contraception intentions among breastfeeding women. Our objectives were to measure the extent of prenatal contraceptive counseling, to assess contraceptive intentions, and to identify correlates of both among postpartum women who were planning to breastfeed.

METHODS

We conducted a cross-sectional study using a convenience sample of 100 breastfeeding women before their discharge following delivery at a large university hospital in 2015. We used logistic regression to assess three outcomes of interest: not intending to use contraception before 6 months postpartum, reporting receiving counseling on postpartum contraception during prenatal care, and considering the effects of contraception methods on the breastfeeding mother-infant dyad when choosing a postpartum contraception method.

RESULTS

Most women (91%) intended to use contraception. Prior history of no contraception use was the sole factor related to not intending to use contraception. The most commonly cited reason for the intended choice of contraceptive method was convenience (35%). Few women (21%) reported considering the effects of contraception methods on the breastfeeding dyad when choosing a postpartum contraception method. Nearly half of women reported never discussing postpartum contraception options with their healthcare provider during prenatal care. In the multivariate analysis, receiving public assistance was the only factor that remained statistically significantly associated with reporting having received contraception counseling during prenatal care.

CONCLUSIONS

Although most women intended to use contraception, they did not appear to have received adequate prenatal counseling on postpartum contraception.

Achieving higher-value obstetrical care

Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.

Home visiting for first-time mothers and subsequent pregnancy spacing

OBJECTIVE

The objective of the study was to determine the association of home visiting with subsequent pregnancy outcomes.

STUDY DESIGN

Retrospective study of Ohio mothers delivering their first infant from 2007 to 2009. First, we compared mothers enrolled in home visiting with a matched eligible group. Second, we compared outcomes within home visiting based on program participation (low <25% of recommended home visits, moderate 25 to 75%, high 75 to 100% and very high >100%). Time to subsequent pregnancy within 18 months was evaluated using Cox proportional hazards regression; logistic regression tested the likelihood of subsequent preterm birth.

RESULTS

Of 1516 participants, 1460 were matched 1:1 to a comparison mother (n=2920). After multivariable adjustment, enrollment was associated with no difference in pregnancy spacing or subsequent preterm birth. Among those enrolled, moderate vs low participants had reduced risk of repeat pregnancy over 18 months (hazard ratio 0.68, P=0.003).

CONCLUSION

Increased pregnancy spacing is observed among women with at least moderate home visiting participation.

Estimating community-level costs of preterm birth

OBJECTIVES

To develop generalizable methods for estimating the economic impact of preterm birth at the community level on initial hospital expenditures, educational attainment and lost earnings as well as to estimate potential savings associated with reductions in preterm birth.

STUDY DESIGN

The retrospective, population-based analysis used vital statistics and population demographics from Hamilton County, Ohio, USA, in 2012.

METHODS

We adjusted previously reported, mean initial hospital cost estimates (stratified by each week of gestation) to 2012 dollars using national cost-to-charge ratios. Next, we calculated excess costs attributable to prematurity and potential hospital cost savings, which could be realized by prolonging each preterm pregnancy by a single week of gestation. Using reported associations among preterm birth, educational attainment and adult earnings, we developed generalizable formulas to calculate lost academic degrees and lost income estimates attributable to preterm birth. The formulas generated estimates based on local population demographics.

RESULTS

The annual initial hospital cost associated with 1444 preterm infants was estimated at $93 million. In addition, over 9000 fewer college degrees and over $300 million in lost annual earnings were attributed to local adults who were born preterm. Prolonging each preterm birth by 1 week could potentially reduce initial hospital expenditures by over $25 million. Additional potential savings could be realized as healthier infants attain higher levels of education and earnings as adults.

CONCLUSIONS

The generalizable methods developed for estimating the economic impact of preterm birth at the community level can be used by any community in which vital statistics and population demographics are available. Cost estimates can serve to rally support for local stakeholder investment in developing strategies for preterm birth intervention leading to improved pregnancy outcomes.

Incidence and risk factors for recurrent spontaneous preterm birth: A retrospective cohort study in Japan

AIM

The aim of this study was to assess the incidence and risk factors for recurrent spontaneous preterm birth (PTB) in Japan.

MATERIAL AND METHODS

A retrospective cohort study was conducted at five tertiary perinatal centers in Osaka, Japan from 2008 through 2012. Perinatal data were collected from medical records of women with a singleton gestation and a previous spontaneous PTB. Exclusion criteria were first-trimester spontaneous abortion, first antenatal visit beyond 14 weeks of gestation, and previous PTB with medical indications, placenta previa, abruptio placenta, multiple pregnancy, fetal anomaly, and antepartum fetal demise. The associations between recurrent spontaneous PTB and perinatal factors were evaluated by logistic regression analysis.

RESULTS

Of 547 women with a previous spontaneous PTB, 89 (16.3%) suffered a recurrent spontaneous PTB. The risk factors for recurrence included multiple previous spontaneous PTB (adjusted odds ratio [aOR]: 2.26; 95% confidence interval [CI]: 1.19-4.30; P = 0.013), no previous term birth (aOR: 2.08; 95%CI: 1.24-3.49; P = 0.005), and interpregnancy interval < 12 months (aOR: 2.13; 95%CI: 1.17-3.85; P = 0.013).

CONCLUSION

Approximately one in six women with a previous spontaneous PTB suffered a recurrent spontaneous PTB. Multiple previous spontaneous PTB, no previous term birth, and short interpregnancy interval were independent risk factors for recurrence.

Risk Prediction for Adverse Pregnancy Outcomes in a Medicaid Population

BACKGROUND

Despite prior efforts to develop pregnancy risk prediction models, there remains a lack of evidence to guide implementation in clinical practice. The current aim was to develop and validate a risk tool grounded in social determinants theory for use among at-risk Medicaid patients.

METHODS

This was a retrospective cohort study of 409 women across 17 Cincinnati health centers between September 2013 and April 2014. The primary outcomes included preterm birth, low birth weight, intrauterine fetal demise, and neonatal death. After random allocation into derivation and validation samples, a multivariable model was developed, and a risk scoring system was assessed and validated using area under the receiver operating characteristic curve (AUROC) values.

RESULTS

The derived multivariable model (n=263) included: prior preterm birth, interpregnancy interval, late prenatal care, comorbid conditions, history of childhood abuse, substance use, tobacco use, body mass index, race, twin gestation, and short cervical length. Using a weighted risk score, each additional point was associated with an odds ratio of 1.57 for adverse outcomes, p<0.001, AUROC=0.79. In the validation sample (n=146), each additional point conferred an odds ratio of 1.20, p=0.03, AUROC=0.63. Using a cutoff of 20% probability for the outcome, sensitivity was 29%, with specificity 82%. Positive and negative predictive values were 22% and 85%, respectively.

CONCLUSIONS

Risk scoring based on social determinants can discriminate pregnancy risk within a Medicaid population; however, performance is modest and consistent with prior prediction models. Future research is needed to evaluate whether implementation of risk scoring in Medicaid prenatal care programs improves clinical outcomes.

Relationship between interpregnancy interval and cervical length in high-risk women

OBJECTIVE

Our objective was to evaluate the relationship between the interpregnancy interval (IPI) and next-pregnancy mid-trimester cervical length (CL) in women at high risk for recurrent spontaneous preterm birth (SPTB).

METHODS

Retrospective review identified high-risk women, defined as a prior SPTB <36 weeks, who began scheduled serial transvaginal sonographic CL screening at 16-18 weeks gestation between December 2008 and November 2010. All CL assessment ended by 22(6/7) weeks, and weekly 17-α hydroxyprogesterone caproate, 250 mg IM, was recommended to all patients. Details of the prior and current pregnancy were collected, and regression models were used to evaluate the relationship between IPI and CL shortening.

RESULTS

One hundred and eight women with singleton gestations and a qualifying SPTB underwent CL screening. The mean (SD) birth gestational age (GA) of the last pregnancy was 25 (10) weeks, the median IPI was 613 (range 49-6038) days, and the mean (SD) delivery GA in the current pregnancy was 36 (5.3) weeks. Linear regression found no significant relationship between the IPI and the GA of the current birth (p = 0.98). There was a weak significant relationship between IPI and shortest CL (p = 0.04). However, after controlling for the GA of the prior pregnancy, this relationship was non-significant (p = 0.13).

CONCLUSIONS

IPI does not predict next birth outcome or next-pregnancy mid-trimester CL in high-risk women managed with progesterone and ultrasound-indicated cerclage.

Influence of interpregnancy interval on neonatal morbidity

OBJECTIVE

We sought to assess the influence of birth spacing on neonatal morbidity, stratified by gestational age at birth.

STUDY DESIGN

This was a population-based retrospective cohort study using Ohio birth records, 2006 through 2011. We compared various interpregnancy interval (IPI) lengths in multiparous mothers with the rate and risk of adverse newborn outcomes. The frequency of neonatal intensive care unit admission or neonatal transport to a tertiary care facility was calculated for births occurring after IPI lengths: <6, 6 to <12, 12 to <24, 24 to <60, and ≥60 months, and stratified by week of gestational age. Neonatal morbidity risk was calculated for each IPI compared to 12 to <24 months (referent), and adjusted for the concomitant influences gestational age at birth, maternal race, age, and prior preterm birth.

RESULTS

We analyzed 395,146 birth outcomes of singleton nonanomalous neonates born to multiparous mothers. The frequency and adjusted odds of neonatal morbidity were lowest following IPI of 12 to <24 months (4.1%) compared to short IPIs of <6 months (5.7%; adjusted odds ratio [adjOR], 1.40; 95% confidence interval [CI], 1.32-1.49) and 6 to <12 months (4.7%; adjOR, 1.19; 95% CI, 1.13-1.25), and long IPIs 24 to <60 months (4.6%; adjOR, 1.12; 95% CI, 1.08-1.17) and ≥60 months (5.8%; adjOR, 1.34; 95% CI, 1.28-1.40), despite adjustment for important confounding factors including gestational age at birth. The lowest frequency of adverse neonatal outcomes occurred at 40-41 weeks for all IPI groups. The frequency of other individual immediate newborn morbidities were also increased following short and long IPIs compared to birth following a 12- to <24-month IPI.

CONCLUSION

IPI length is a significant contributor to neonatal morbidity, independent of gestational age at birth. Counseling women to plan an optimal amount of time between pregnancies is important for newborn health.

Fighting for the next generation: US Prematurity in 2030

Preterm birth (PTB) is a serious problem, with >450 000 neonates born prematurely in the United States every year. Beginning in 1980, the United States experienced a nearly 3-decade rise in the PTB rate, peaking in 2006 at 12.8%. PTB has declined for 7 consecutive years to 11.4% in 2013, but it still accounts for 1 in 9 neonates born every year. In addition to elevated neonatal and infant mortality among those born preterm, many who survive will have lifelong morbidities and disabilities. Because of the burden of morbidity, disability, and mortality for PTB, as well as its impact more broadly on society, including excess annual costs estimated to be at least $26.2 billion by a committee for the Institute of Medicine, the March of Dimes initiated the Prematurity Campaign in 2003. In 2008 the March of Dimes established a goal of reducing the US PTB rate to 9.6% by 2020. However, the United States ranks extremely poorly for PTB rates among Very High Human Development Index (VHHDI) countries, subjecting untold numbers of neonates to unnecessary morbidity and mortality. Therefore, the March of Dimes proposes an aspirational goal of 5.5% for the 2030 US PTB rate, which would put the United States in the top 4 (10%) of 39 VHHDI countries. This 5.5% PTB rate is being achieved in VHHDI countries and by women from diverse settings receiving optimal care. This goal can be reached and will ensure a better start in life for many more neonates in the next generation.