“Whatever you do, don’t do what Jessica Simpson did,” my OB told me with a look of disgust on her face. “And if you wind up with a c-section definitely don’t do what Jessica Simpson did! Her OB has got to be livid with her right now.”

I was 20 weeks into my pregnancy when my OB gave me this lecture. I’d been reading a copy of US Weekly with Simpson on the cover when my doctor walked into the room. “Getting pregnant four months after a c-section, we’re talking double the risk of fetal demise and pre-term birth, and triple the risk of uterine rupture. Promise me you won’t do what Jessica Simpson did.”

I promised, and then didn’t really give her warning another thought until the other day. I heard a story on the radio about a new CDC study that shows 30% of women space their pregnancies too close together. But what does that even mean, why does it matter and does anyone care?

For parents that are able to have kids the traditional way, pregnancy spacing is a very personal issue. Factors such as age, medical history, access to health care, wealth, family histories, partner relationships, and career aspirations all factor into the decision. But what we do know is that spacing pregnancies less than 18 months apart is more likely to lead to lasting negative health impacts for the mother and baby.  In addition to the risks my OB outlined, there are increased risks of anemia, repeated miscarriages, placental abruption, pre-eclampsia, hysterectomies and postpartum depression.

Ask any woman who has been pregnant (except maybe Beyonce, Gwyneth Paltrow and Heidi Klum) and they will tell you that pregnancy is hard. Even the easiest pregnancy puts a lot of strain on the body. A pregnant woman’s blood volume increases by 50%, as does kidney size, the uterus will increase from the size of a lemon to the size of a watermelon, while at the same time the growing fetus is grabbing every spare nutrient your body has to offer. Our bodies need time to recover before becoming pregnant again, similar to the way a marathon runner needs to rest after a big race. If pregnancies are spaced too close together, a mother’s body is too drained to properly support the subsequent pregnancy, leading to complications.

Of the 30% of women that don’t wait the recommended 18-24 months, there tend to be two distinct groups: 1. Teens, aged 15-19; and 2. White college educated married women who began childbearing after age 30 and intentionally space their pregnancies close together. As a woman who falls into the latter category (except for the last variable, my son is two) I can see the motivations for this demographic. Warnings of infertility and complications from ‘advanced maternal age’ loom heavily in the zeitgeist.  For this cohort (speaking as a focus group of one) it can seem as if we’re damned by our OBs if we don’t wait 18-24 months, and we’re damned if we’re 35 and pregnant.

But there’s another factor here that matters: The, shall we say, “surprises.”  In fact, if accidental pregnancies were eliminated, there’d actually be a 12% decrease in the suboptimal interpregnancy interval rate. Jessica Simpson’s second pregnancy falls into this category. In a quick survey of my own friends, this seems to hold true. When asked friends if they planned to conceive less than 18 months after a pregnancy the response was usually along the lines of, “we knew we wanted a second baby, but not that soon.” So it looks like there’s an issue with interpregnancy contraception as well.

Contraception between pregnancies is a bit of a fraught issue in the same way that sex after a baby can be fraught. Some, but not all, IUDs require the presence of a menstrual period before they can be inserted, which if a mother is breastfeeding can mean waiting months. Myths abound about hormonal contraceptives and breastfeeding, but studies have shown that they are safe and don’t impact milk production. There’s also the misconception that you can’t get pregnant while breastfeeding (you can, for the love of  bleep, you can). This means that it’s important for not just patients but for providers to have a frank discussion about birth control at the postpartum checkup.

Update 4.20.15: An earlier version of this post stated that all IUDs need to be inserted during a menstrual period.  Hat tip to Facebook commenter Alice C. who pointed out that many IUDs can be inserted without a period.


 

Resources:

Gemmill, A., & Lindberg, L. D. (2013). Short Interpregnancy Intervals in the United States. Obstetrics and Gynecology, 122(1), 64–71. doi:10.1097/AOG.0b013e3182955e58

Copen, C., Thoma, M. and Kirmeyer, S. Interpregnancy Intervals in the United States: Data from the Birth Certificate and National Survey of Family Growth. National VItal Statistics Report. 64:3. April 2015.

Mike Stobbe. Study: US moms typically space pregnancies 2 1/2 years apart. WTOP.com, April 16, 2015.

Smith, G., Pell, J. and Dobbie, R. Interpregnancy Interval and Risk of Preterm Birth and Neonatal Death: Retrospective Cohort Study. British Medical Journal.doi: http://dx.doi.org/10.1136/bmj.327.7410.313 (Published 07 August 2003)

Howard, E., Harville, E., Kissinger, P. et al. The Association Between Short Interpregnancy Interval and Preterm Birth in Louisiana: A Comparison of Methods. Maternal and Child Health Journal. 17:5.pp 933-939 (2012)

Shachar, B. and Lyell, D. Interpregnancy Interval and Obstetrical Complications. Obstetrical and Gynecological Survey. 67:9 pp 584-596 (2012)

Thiel de Bocanegra, H., Chang, R. Menz, R. et al. Postpartum Contraception in Publicly-Funded Programs and Interpregnancy Intervals. Obstetrics and Gynecology. 122:2:1 pp 296-303.

Bahamondes, L., Bahamondes, M.B., Modesto, W. et al. Effect of hormonal contraceptives during breastfeeding on infant’s milk ingestion and growth. Fertility and Sterility. 100:2 (2013).

WebMD. Breast-Feeding as Birth Control – Topic Overview. Updated May 3, 2012. Retrieved April 19, 2015.

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Categories: Policy, Politics, + Pop Health, Pregnancy, Birth + Family Planning