Short interpregnancy intervals and adverse maternal outcomes in high‐resource settings: An updated systematic review

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Background Meta‐analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. Methods In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. Results We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio‐economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. Conclusion This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

Section: Introductionmentioning

confidence: 99%

Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes

Hutcheon

Moskosky

Ananth

et al. 2018

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“…The purpose of this systematic review is to summarise research on the associations between short interpregnancy intervals and adverse perinatal outcomes in high‐resource settings. The association between short interpregnancy intervals and adverse maternal outcomes in high‐resource settings is reported separately in this journal supplement . Findings from this review can be used to inform evidence‐based recommendations for healthy birth spacing for the United States .…”

Section: Introductionmentioning

confidence: 99%

“…The association between short interpregnancy intervals and adverse maternal outcomes in high-resource settings is reported separately in this journal supplement. 13 Findings from this review can be used to inform evidence-based recommendations for healthy birth spacing for the United States. 14 At present, although short interpregnancy interval is a recognised risk factor for preterm birth and low birthweight, 15,16 and the American College of Obstetricians and Gynecologists recommends women be advised to avoid interpregnancy intervals shorter than 6 months, 16 there are no federal recommendations on healthy birth spacing for the United States.…”

mentioning

confidence: 99%

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

Ahrens

Nelson

Stidd

et al. 2018

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108

113

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.

“…The new reviews incorporated more narrow inclusion criteria by restricting included studies to those that defined short birth spacing using the interpregnancy interval (with short interpregnancy interval defined as some duration less than 24 months versus a well‐defined longer duration), controlled for at least maternal age (and socio‐economic position, for perinatal outcomes), and were conducted within countries categorised as “very high” on the United Nations Human Development Index . Details on the systematic review methodology, including study quality assessment, and the summary of evidence can be found in other manuscripts in this journal supplement . Studies employing a sibling comparison design, which compared differences in a woman's interpregnancy intervals and birth outcomes using a within‐woman analysis, were considered separately from the studies employing a conventional between‐women analysis.…”

Section: Evidence Presented On Short Interpregnancy Interval and Advementioning

confidence: 99%

“…47 Details on the systematic review methodology, including study quality assessment, and the summary of evidence can be found in other manuscripts in this journal supplement. 48,49 Studies employing a sibling comparison design, which compared differences in a woman's interpregnancy intervals and birth outcomes using a within-woman analysis, were considered separately from the studies employing a conventional between-women analysis.…”

Section: Systematic Reviewsmentioning

confidence: 99%

Report of the Office of Population Affairs’ expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research

Ahrens

Hutcheon

Ananth

et al. 2018

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Background The World Health Organization ( WHO ) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low‐ and middle‐resource countries upon which most of the evidence is based. Methods To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs ( OPA ) convened an expert work group meeting in Washington, DC , on 14‐15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician‐gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health. Results Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. Conclusions This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.