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

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.

Determinants of short birth interval among ever married reproductive age women living in Jigjiga, Eastern Ethiopia 2020 (unmatched case-control study)

Objectives:

A short birth interval is a universal public health problem resulting in adverse maternal, neonatal, and child outcomes. Therefore, the aim of this study was to identify determinants of short birth interval among ever married reproductive age mothers who live in Jigjiga city administration, Eastern Ethiopia, 2020.

Methods:

A community-based unmatched case–control study was used among 194 cases and 194 controls in Jigjiga city administration from September to December 2020. Cases were women with short birth interval (less than 3 years) and controls were women with optimum birth interval (3–5 years). Simple random sampling technique was employed to select cases and controls. Data were entered into Epi data version 4.2 and analysis with SPSS version 22. Binary logistic regression with 95% confidence interval at p < 0.05 is used to declare significantly associated predictors of short birth interval.

Result:

This study reported that women who have not attended formal education (adjusted odds ratio = 5.28, 95% confidence interval: (2.25–12.36)), attended primary education (adjusted odds ratio = 2.79, 95% confidence interval: (1.46–5.34)), women who married to a polygamous husband (adjusted odds ratio = 3.69, 95% confidence interval: (1.80–7.58)), having a history of neonatal death (adjusted odds ratio = 2.15, 95% confidence interval: (1.07–4.32)), preceding child being female (adjusted odds ratio = 3.69, 95% confidence interval: (2.02–6.72)), and never used contraceptive methods (adjusted odds ratio = 3.69, 95% confidence interval: (2.02–6.72)) were identified as determinants of the short birth interval.

Conclusion:

Short birth intervals were associated with educational level of the women, sex of the baby, husband marriage types, history of neonatal death, and contraceptive utilization. Strategy should be engaged to enhance women education, contraceptive uses, and to decrease neonatal death.

Interpregnancy interval and subsequent perinatal risk of congenital heart disease in Guangzhou, Southern China: a retrospective cohort study, 2014-2019

BACKGROUND

The association between maternal interpregnancy interval (IPI) and congenital heart disease (CHD) in neonates remains inconclusive. This study aimed to examine the effect of maternal IPI on birth risk of CHD.

METHODS

Chinese women with two consecutive singleton deliveries in Guangzhou between January 2014 and December 2019 were selected as participants. Information on IPI and CHD was extracted from the Guangzhou Perinatal Health Care and Delivery Registry and the Guangzhou Birth Defects Surveillance Program. We stratified IPI into four categories: <24 months, 24-35 months, 36-59 months, and ≥60 months. A multivariate logistic regression model was used to examine the association between IPI and CHD. Subgroup analysis was also performed to assess whether the associations differed across top three CHD subtypes.

RESULTS

For 119,510 women enrolled in this study, the mean ages at two consecutive deliveries were 26.2 ± 3.8 and 28.8 ± 4.0 years, which yielded a median IPI of 51.2 (interquartile range, 32.1-77.2) months. Among them, 828 delivered infants with CHD during their second pregnancy. There was a J-shaped curve relationship between IPI and CHD with the lowest birth prevalence (5.33‰) at 24-35-month interval. Compared to women with an IPI of 24-35 months, those with an IPI ≥60 had an increased risk of delivering infants with CHD (adjusted odds ratio (OR), 1.41; 95% confidence interval (CI), 1.19-1.64). However, for those with an IPI <24 months (adjusted OR, 1.24; 95% CI, 0.97-1.51), IPI was statistically insignificant associated with the risk of delivering infants with CHD (p = .12). There were different patterns of associations for different CHD subtypes.

CONCLUSIONS

Longer maternal IPI (≥60 months) was associated with an increased risk of delivering infants with CHD in the Chinese population.

Long and short interpregnancy intervals increase severe maternal morbidity

BACKGROUND

Severe maternal morbidity is a composite variable that includes adverse maternal outcomes during pregnancy that are associated with maternal mortality. Previous literature has shown that interpregnancy interval is associated with preterm birth, fetal growth restriction, and low birthweight, but the association of interpregnancy interval and composite severe maternal morbidity is not well studied.

OBJECTIVE

We sought to determine the relationship between interpregnancy interval (stratified as <6, 6-11, 12-17, 18-23, 24-59, and ≥60 months) and severe maternal morbidity, which we considered both with and without blood transfusion.

STUDY DESIGN

This was a retrospective cohort study of multiparous women 15 to 54 years old with singleton, nonanomalous births between 23 and 42 weeks gestation in California (2007-2012). We defined severe maternal morbidity as the composite score of a published list of the International Classification of Diseases, ninth Revision, diagnoses and procedure codes, provided by the Centers for Disease Control and Prevention. We used chi-square tests for categorical variables, and multivariable logistic regression models were used to determine the association of interpregnancy interval (independent variable) with severe maternal morbidity (dependent variable), adjusted for maternal race and ethnicity, age, education, body mass index, insurance, prenatal care, smoking status, and maternal comorbidity index score.

RESULTS

Here, 1,669,912 women met the inclusion criteria, and of these women, 14,529 (0.87%) had severe maternal morbidity and 4712 (0.28%) had nontransfusion severe maternal morbidity. Multivariable logistic regression models showed that compared with women with 18 to 23 months interpregnancy interval, women with an interpregnancy interval of <6 months (adjusted odds ratio, 1.23; 95% confidence interval, 1.14-1.34) and ≥60 months (adjusted odds ratio, 1.11; 95% confidence interval, 1.04-1.19) had significantly higher adjusted odds of severe maternal morbidity. The odds of nontransfusion severe maternal morbidity is higher in women with long interpregnancy intervals (≥60 months) after controlling for the same potential confounders (adjusted odds ratio, 1.17, 95% confidence interval, 1.04-1.31). In addition, we found significantly higher odds of requiring ventilation (adjusted odds ratio, 1.34; 95% confidence interval, 1.03-1.75) and maternal sepsis (adjusted odds ratio, 2.08; 95% confidence interval, 1.31-3.31) in women with long interpregnancy interval.

CONCLUSION

The risk of severe maternal morbidity was higher in women with short interpregnancy interval (<6 months) and long interpregnancy interval (≥60 months) compared with women with normal interpregnancy interval (18-23 months). The risk of nontransfusion severe maternal morbidity was significantly higher in women with long interpregnancy interval (≥60 months). Interpregnancy interval is a modifiable risk factor, and counseling women to have an adequate gap between pregnancies may be an important strategy to decrease the risk of severe maternal morbidity.

Perceived norms, personal agency, and postpartum family planning intentions among first-time mothers age 15-24 years in Kinshasa: A cross-sectional analysis

Unintended pregnancy is an important global health problem and frequently occurs during the immediate postpartum period. However, few studies have examined postpartum family planning (PPFP) intentions among adolescent girls and young women. This study assessed whether perceived norms and personal agency predicted PPFP intentions among first-time mothers age 15–24 in Kinshasa, the Democratic Republic of Congo. Data were derived from the 2018 Momentum Project baseline survey. Analysis was based on 2,418 nulliparous pregnant women age 15–24 who were approximately six months pregnant with their first child in six health zones of Kinshasa. Overall PPFP intentions were low and ten to thirteen percent of women stated they were very likely to discuss PPFP next month with (a) their husband/male partner and (b) a health worker, and to (c) obtain and (d) use a contraceptive method during the first six weeks following childbirth. The results of multivariable linear regression models indicated that the PPFP intention index was predicted by description norms, perceptions of the larger community’s approval of PPFP, normative expectations, perceived behavioral control, self-efficacy, and autonomy. Rejection of family planning myths and misconceptions was also a significant predictor. Interaction terms suggested that the association of normative expectations with PPFP intentions varied across ethnic groups and that the positive association of injunctive norms with PPFP intentions was significantly increased when the larger community was perceived to disapprove of PPFP use. Normative expectations and PPFP-related self-efficacy accounted for two-thirds of the variance in PPFP intentions. The results suggested that understanding different normative influences may be important to motivate women to use contraception in the immediate postpartum period. In addition to addressing institutional, individual, and social determinants of PPFP, programs should consider integrating norm-based and empowerment strategies.

Association between interpregnancy interval and hypertensive disorders of pregnancy: Effect modification by maternal age

BACKGROUND

Short and long interpregnancy intervals (IPI) are associated with increased risk of hypertensive disorders of pregnancy, yet whether this association is modified by maternal age remains unclear.

OBJECTIVES

To examine if the association between IPI and hypertensive disorders of pregnancy varies by maternal age at birth prior to IPI.

METHODS

We conducted a population-based cohort study of all mothers who had their first two (n = 169 896) consecutive births in Western Australia (WA) between 1980 and 2015. We estimated the risk of preeclampsia and gestational hypertension for 6 to 60 months of IPI according to maternal age at birth prior to IPI (<20 years, 20-24, 25-29, 30-34 and ≥35 years). We modelled IPI using restricted cubic splines and reported adjusted relative risk (RRs) with 95% CI at 6, 12, 24, 36, 48 and 60 months, with 18 months as reference.

RESULTS

The risk of preeclampsia was increased at longer IPIs (60 months) compared to 18 months for mothers 35 years or older (RR 2.19, 95% confidence interval (CI) 1.14, 4.18) and to a lesser extent for mothers 30- to 34 years old (RR 1.43, 95% CI 1.10, 1.84). Compared to 18 months, the risk of preeclampsia was lower at 12 months of IPI for mothers younger than 20 years (RR 0.74, 95% CI 0.57, 0.96), but not for mothers 35 years or older (RR 0.62, 95% CI 0.36, 1.07). There was insufficient evidence for increased risk of hypertensive disorders of pregnancy at shorter IPIs of <18 months for mothers of all ages.

CONCLUSIONS

Our findings challenge the "one size fits all" recommendation for an optimal IPI, and a more tailored approach to family planning counselling may be required to improve health.

Maternal age at first cesarean delivery related to adverse pregnancy outcomes in a second cesarean delivery: a multicenter, historical, cross-sectional cohort study

Background

To determine the effects of maternal age at first cesarean on maternal complications and adverse outcomes of pregnancy with the second cesarean.

Methods

This was a multicenter, historical, cross-sectional cohort study involving singleton pregnancies ≥28 gestational weeks, with a history of 1 cesarean delivery, and who underwent a second cesarean between January and December 2017 at 11 public tertiary hospitals in 7 provinces of China. We analyzed the effects of maternal age at first cesarean on adverse outcomes of pregnancy in the second cesarean using multivariate logistic regression analysis.

Results

The study consisted of 10,206 singleton pregnancies. Women were at first cesarean between 18 and 24, 25–29, 30–34, and ≥ 35 years of age; and numbered 2711, 5524, 1751, and 220 cases, respectively. Maternal age between 18 and 24 years at first cesarean increased the risk of placenta accreta spectrum (aOR, 1.499; 95% CI, 1.12–2.01), placenta previa (aOR, 1.349; 95% CI, 1.07–1.70), intrahepatic cholestasis of pregnancy (aOR, 1.947; 95% CI, 1.24–3.07), postpartum hemorrhage (aOR, 1.505; 95% CI, 1.05–2.16), and blood transfusion (aOR, 1.517; 95% CI, 1.21–1.91) in the second cesarean compared with the reference group (aged 25–29 years). In addition, maternal age ≥ 35 years at first cesarean was a risk factor for premature rupture of membranes (aOR, 1.556; 95% CI, 1.08–2.24), placental abruption (aOR, 6.464, 95% CI, 1.33–31.51), uterine rupture (aOR, 7.952; 95% CI, 1.43–44.10), puerperal infection (aOR, 6.864; 95% CI, 1.95–24.22), neonatal mild asphyxia (aOR, 4.339; 95% CI, 1.53–12.32), severe asphyxia (aOR, 18.439; 95% CI, 1.54–220.95), and admission to a neonatal intensive care unit (aOR, 2.825; 95% CI, 1.54–5.17) compared with the reference group (aged 25–29 years).

Conclusions

Maternal age between 18 and 24 years or advanced maternal age at first cesarean was an independent risk factor for adverse maternal outcomes with the second cesarean. Advanced maternal age at the first cesarean specifically increased adverse neonatal outcomes with the second. Therefore, decisions as to whether to perform a first cesarean at a young or advanced maternal age must be critically evaluated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03608-9.

Folate Levels by Time Since Last Live Birth Among U.S. Women, 2007-2016

Background: Folate depletion in the postpartum period may increase the risk of adverse pregnancy outcomes for women with a short interpregnancy interval following a live birth. We sought to examine folate levels by time since last live birth among U.S. women. Materials and Methods: Data were from 4,809 U.S. women, 20-44 years of age, participating in the National Health and Nutrition Examination Survey, 2007-2016. Red blood cell (RBC) folate was measured using microbiological assay on whole blood samples. Dietary folate intake and folic acid supplementation were measured during a 24-hour dietary recall. Prevalence of supplementation by time since last live birth was estimated from logistic regression models; mean levels of RBC folate and mean intake of dietary folate equivalent were estimated from linear regression models. Models were adjusted for maternal sociodemographic characteristics. Results: In adjusted models, supplementation (±standard error) was highest among women in the first year postpartum (31.7% ± 3.2) compared with nulliparous women (23.7% ± 1.9) and those 2-3 years (15.6% ± 1.9) and ≥3 years (18.4% ± 1.6) after last live birth. Mean RBC folate was highest among women in the first year postpartum, regardless of supplementation, with overall mean levels of 606 ± 15 ng/mL, compared with 484 ± 9, 477 ± 11, and 474 ± 7 among women in the aforementioned groups, respectively. Mean dietary folate intake was also highest among postpartum women: 542 ± 23 mcg/day, compared with 474 ± 12, 486 ± 21, and 467 ± 12. Conclusions: Folate levels are highest in the first year postpartum compared with other time periods within a woman's reproductive lifespan. These findings do not support the idea that postpartum U.S. women are depleted in folate, on average.