# Presentation: 638211

## Short Interpregnancy Spacing in Utah

- Lois Bloebaum MPA,BSN, Manager Reproductive Health Program
- Laurie Baksh MPH, PRAMS Data Manager
- Joanne McGarry BS, PRAMS Operations Manager
- Debby Carapezza MSN, NFP, Nurse Consultant
- Shaheen Hossain PhD, Manager, Data Resources Program Manager
- Nan Streeter MS, RN, Director, Maternal Child Health Bureau
- Utah Department of Health, Community & Family Health Services Division,
- Maternal Child Health Bureau, Reproductive Health Program

## Background

- Research indicates that short interpregnancy intervals (IPIs) are associated with pregnancy outcomes that are less than optimal
- Women with short IPIs  more likely to have a premature infant1

- 1) Fuentes-Afflick, E. and N. A. Hessol (2000). "Interpregnancy Intervals and the Risk of Premature Infants." _Obstetrics and Gynecology_ 95(3): 383-390.

**Notes:**
A large study carried out by Fuentes-Afflick et al found that after adjusting for confounding variables.
 In addition, the study found that there was a gradient of risk for premature outcomes, and women with the shortest intervals had the highest risk. 

## Background

- In bivariate analysis, the percentage of preterm deliveries decreased as the interval lengthened but had no effect on the risk of IUGR2

- 2) Klerman, L. V., S. P. Cliver, et al. (1998). "The Impact of Short Interpregnancy Intervals on Pregnancy Outcomes in a Low-Income Population." _American Journal of Public Health_ **88**(8): 1182-1185.

**Notes:**
 In another study, Klerman et al researched whether the length of the interval between pregnancies was associated with either preterm birth or intrauterine growth restriction (IUGR) 

## Background

- In a large study utilizing Utah data, Zhu et al analyzed data to determine whether the association between a short interval between pregnancies and adverse perinatal outcomes was due to confounding by other risk factors

## Background

- Zhu et al examined three adverse perinatal outcomes: low birth weight (LBW-<2500 gms.), preterm births (< 37 weeks gestation), and small for gestational age (SGA-BW< the 10th percentile for GA)

## Background

- Zhu et al found that after controlling for confounders, the risk of any of the three adverse perinatal outcomes was high if the interpregnancy interval was < 3 months and that the risks declined rapidly as the interpregnancy interval increased 3

- 3) Zhu, B.-P., R. T. Rolfs, et al. (1999). "Effect of the Interval Between Pregnancies on Perinatal Outcomes." _New England Journal of Medicine_ **340**(8): 589-594.

## Purpose 

- Identify characteristics of Utah women who experienced short IPIs
- Highlight increased risk for poor pregnancy outcomes
- Aid us in targeting populations at risk for short pregnancy intervals
- Identify strategies that may help improve their pregnancy outcomes

## Methodology

**Operational Definition:**
- Pregnancy interval was defined as the length of time between the last live birth and the delivery of the current live birth minus the length of gestation of the current pregnancy

## Methodology

- Interpregnancy interval was calculated from data contained on the birth certificate
- PRAMS data from 2000 – 2003 were used
- Chi-square tests were used to determine if differences between groups were statistically significant

## Methodology

- An IPI of 19 – 59 months was used as the comparison group
- Approximately 20% of repeat births in the dataset were missing either the month or year of the last live birth
- Women who delivered twins or triplets were excluded
- ~96,300 births represented with weighted data (unweighted n=3,247)

**Notes:**
This group was chosen for comparison as the authors felt it aligned well with the Healthy People 2010 goal to reduce the proportion of births occurring within 24 months of a previous birth.

In addition, the studies published by Zhu and Fuentes-Afflick indicated that women with long pregnancies intervals also demonstrated less than optimal pregnancies outcomes, hypothesizing that women who have long pregnancy intervals may have confounding health issues that impair fertility and also have a negative impact on pregnancy outcomes. 

## Results

- Almost 5% of Utah women experienced a very short IPI (0-6 months) during the study period
- Almost 40% of live births reporting an interpregnancy interval of _< _18 months

**Notes:**
Although there no national comparison data are available, the study by Fuentes-Afflick et al which was carried on white Hispanic and non-Hispanic women who resided in California, reported a similar percentage (~37%) of women with IPIs< 18 months. 

## Results

- 19-59 mos.

- 7-12 mos.

- 0-6 mos.

- 13-18 mos.

- 59 + mos.

- Interpregnancy Interval
- Utah PRAMS Data 2000 - 2003

**Notes:**
Illustrates the distribution of interpregnancy intervals among the Utah women who were multiparous during the study period.

## Results 

**Women with the shortest IPI (0-6 months) were more likely to:**
- be of a younger age
- be from a non-white racial group
- be unmarried
- report no insurance prior to pregnancy or report Medicaid prior to pregnancy
- report incomes  less than 100% of the federal poverty level
- report being enrolled in WIC during pregnancy

## Results

- Among women with the shortest IPIs, almost 63% reported that their pregnancy was unintended – despite the fact that over 60% of these women reported using some form of birth control at conception.

**Notes:**
-an indication of contraceptive failure/misuse
-questions response choices include all forms of birth control, including some of the less effective methods such as rhythm and withdrawal 

## Reasons for Not Using Birth Control at Time of Conception Among Women Who Reported Their Most Recent Pregnancy Was Unintended, 2000 - 2003 Utah PRAMS Data

-  categories are not mutually exclusive

**Notes:**
This chart denotes the reasons women gave for not using birth control among women who reported an unintended pregnancy by IPI. 
Most frequently cited reason among women with shortest IPIs (~40%) - “Thought I couldn’t get pregnant at that time” (indicating lack of knowledge of return of fertility after birth) , followed by “Didn’t mind if I got pregnant at that time” (indicating ambiguous feelings about conceiving).

## Results 

- Poor pregnancy outcomes among women with short IPIs did not vary significantly from the comparison group
- There were not statistically significant differences in the rate of preterm births or small for gestational age (SGA) infants between study and comparison groups

**Notes:**
-We hypothesize that the reason that there were not statistically significant differences in the rate of preterm births or small for gestational age (SGA) infants between study and comparison groups in our analysis, may be attributed to the comparison group we used in this analysis; most published studies used a shorter interval for comparison.

## Results 

- However, in stratifying the study group by previous preterm birth, women who had _**not**_ delivered a previous preterm infant experienced an increased risk of delivering a _**very**_ preterm infant following the shortest pregnancy intervals

|  | IPI 0-6
 | IPI 19 - 59 |
| --- | --- | --- |
| <32 weeks | 1.8% | 0.9% |
| 33-36 weeks
 | 1.8% | 4.5% |
| 37+ weeks
 | 96.4% | 94.6% |
| P-Value | 0.014 | Ref |

**Notes:**
-This may indicate that history of a previous preterm birth is a confounder and that short interval may contribute to an increased risk for preterm birth among select women. 
Significantly higher percentage of women in the shortest IPI category delivered at <32 weeks gestation than those in the comparison (p-value 0.01). 

## Results 

- A variety of psychosocial stressors were reported at significantly higher rates among women who experienced very short IPIs (0-6 mos).
- Reported higher rates of:
- financial stress
- partner associated stress
- traumatic stress
- abuse before and during pregnancy
- postpartum depression

## Results 

| Indicator | IPI 0 - 6Months | IPI 7 - 12Months | IPI 13 - 18Months | IPI 19 - 59Months |
| --- | --- | --- | --- | --- |
| Severe Postpartum Depression | 16.0% | 10.2% | 6.5% | 6.3% |
| Unintended Pregnancy | 62.8% | 56.4% | 32.6% | 25.9% |
| Financial Stress~ | 64.3% | 55.2% | 51.5% | 49.7% |
| Partner Associated Stress* | 39.1% | 29.1% | 28.5% | 24.5% |
| Traumatic Stress^ | 24.4% | 10.8% | 13.8% | 13.5% |
| Physical Abuse Before Pregnancy | 12.3% | 3.7% | 2.7% | 3.2% |
| Physical Abuse During Pregnancy | 8.2% | 3.9% | 2.0% | 2.7% |
| Hospital Stay of 1 to 7 Days | 18.3% | 13.1% | 11.8% | 9.3% |
| Bed Rest | 46.4% | 29.7% | 27.5% | 31.2% |
| Prenatal care in first trimester | 62.2% | 77.1% | 80.5% | 82.6% |

**Notes:**
Financial stress” includes loss of job for woman or partner, unpaid bills, moving to a new address				
“Partner associated stress” ncludes separation or divorce, arguing with partner, or partner not wanting pregnancy				
“Traumatic stress” includes jail, physical fight, being homeless, or a close person experiencing drug or alcohol use	
19-59 mos. (bolded/italicized numbers in far right column) used as comparison group 
Pink numbers indicate statistically significant difference		

## Discussion 

- The majority of women with very short IPIs reported their pregnancy as unintended despite the fact 60% of these women were using some form of birth control at the time of conception

**Notes:**
Contraceptive misuse/failure in these women is an area of intervention that may help to avert and/or delay pregnancies and improve pregnancy outcomes.

## Discussion	

- Largest reported reason for not using contraception was, “thought I couldn’t get pregnant”
- Many women felt that breastfeeding was an effective birth control method

## Recommendations

- More thorough patient education regarding fertility postpartum may help to alleviate short IPIs
- Discuss birth control options multiple times with postpartum women
- Collaborate with WIC to education women

**Notes:**
Display patient education insert in Spanish and English-downloadable at www.utah.health.gov/rhp

## Recommendations

## Produced in 2005, downloadable at: 

- Produced in 2005, downloadable at:
- http://www.who.int/reproductive-health/family_planning/index.html

**Notes:**
WHO’s Department of Reproductive Health and Research produced tool in 2005, available at www.who.int/reproductive-health/family_planning/index.html

## Public Health Implications

- Underscores need for :
- Public education to improve contraceptive misuse/failure
- More thorough education of women regarding fertility postpartum
- Expansion of Medicaid coverage (including case management) for high risk women during interconception period
- Importance of screening for social-emotional issues in women with short IPIs

**Notes:**
Analysis confirms importance of adequately spacing pregnancies

## Public Health Implications

**Notes:**
Bottom line-healthy babies and families...