Interpregnancy interval — You can help women
There is work to do
Reducing the proportion of pregnancies conceived within 18 months of a previous birth is one of the objectives of the U.S. Department of Health and Human Services' Healthy People 2020, the national 10-year plan for health promotion and disease prevention.1 There is work to do.
A 2013 published study indicates that more than one-third (35%) of all repeat pregnancies in the United States are conceived within 18 months of the previous birth.2 Such short interpregnancy intervals are associated with adverse maternal and child health outcomes, such as increased risk of preterm birth and infants with low birth weight.3
New research released online indicates that provision of effective contraception at the time of postpartum follow-up is a key strategy for achieving optimal interpregnancy intervals.4 Results of the study suggest that compared to women using barrier methods, the use of long-acting reversible contraception (LARC) in the postpartum period increases the odds of achieving an optimal interpregnancy interval nearly four times greater than those relying on barrier methods.4
Members of the University of California, San Francisco (UCSF) Family PACT (Planning, Access, Care, and Treatment) evaluation team designed the study with an objective to determine the use of contraceptive methods, defined by effectiveness, length of coverage, and their association with short interpregnancy intervals, controlling for provider type and client demographics. Family PACT is California's Medicaid family planning expansion program; the evaluation team has worked extensively on access to and quality of family planning care for low-income women, men, and adolescents, explains Heike Thiel de Bocanegra, PhD, MPH, evaluation team director in the UCSF Bixby Center for Global Reproductive Health and assistant professor in UCSF's Department of Obstetrics, Gynecology, and Reproductive Sciences.
It is difficult to have objective quality indicators for contraceptive use because birth records and claims data do not capture pregnancy intention or client contraceptive preference, says Thiel de Bocanegra. The Healthy People 2020 objective to avoid pregnancies for 18 months after a birth is one of the few objective recommendations in the field of family planning, she notes.
Researchers identified a cohort of 117,644 women from the 2008 California Birth Statistical Master file with second or higher order birth and at least one Medicaid (Family PACT or Medi-Cal) claim within 18 months after index birth. They looked at the effect of contraceptive method provision on the odds of having an optimal interpregnancy interval, controlling for covariates.
Analysis indicates the average length of contraceptive coverage was 3.81 months, with most women receiving user-dependent hormonal contraceptives as their most effective method (55%, n=65,103) and one-third (33%; n=39,090) with no contraceptive claim. A much smaller percentage used barrier methods (7%, n=8,320), followed by LARC (LARC, n=5,131, 4%).
According to the research, women who used LARC methods had 3.89 times the odds and women who used user-dependent hormonal methods had 1.89 times the odds of achieving an optimal birth interval compared to women who used barrier methods only. Women with no method had 0.66 times the odds. When considering user-dependent methods, for each additional month of contraceptive coverage, the odds of having an optimal birth interval increased by 8% (odds ratio 1.08, confidence interval: 1.08-1.09). Women who were seen by Family PACT or by both Family PACT and Medi-Cal providers had significantly higher odds of optimal birth intervals compared to women served by Medi-Cal only, researchers report.4
Time for a change
"Access to and utilization of family planning services are critical to achieving a longer birth interval," state the UCSF researchers. "The positive association of optimal birth intervals corresponding to the method tier demonstrates the advantage of using methods with longer duration and lower rates of contraceptive failure."
It is time to make structural changes to allow more women to get access to effective, reversible methods as easily as they receive irreversible sterilization during their delivery and hospitalization, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.
"We also need to change the timing of the routine postpartum visit from six to three weeks after delivery, before it's too late," says Nelson. "Unless we show women how important we think contraception is to their children, we will continue to have unintended and short-interval pregnancy."
- U.S. Department of Health and Human Services. Healthy People 2020. Topics and objectives. Family planning. Accessed at http://1.usa.gov/1b0tm4e.
- Gemmill A, Lindberg LD. Short interpregnancy intervals in the United States. Obstet Gynecol 2013; 122(1):64-71.
- Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes; Behrman RE, Butler AS, editors. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies Press (US); 2007.
- Thiel De Bocanegra H, Chang R, Howell M, et al. Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol 2013; doi:10.1016/j.ajog.2013.12.020.