Optimizing Interpregnancy

IntervalsThe Case for “Birth Spacing” (while respecting individual

desires)

Merry-K. Moos, RN, (FNP), MPH, FAAN

Retired Professor, Medicine, Nursing, Public Health at UNC-Chapel Hill

Lead Nurse Planner, National March of DimesPresident, MKMoos, Inc.

Consultant, EPIC Training Center

mkmoos@med.unc.edu

Objectives

• Discuss foundational concepts around interpregnancyintervals

• Summarize the relationship between interpregnancy birth intervals and risks for prematurity

• Discuss approaches for impacting interpregnancy intervals

My Challenge to YouWhat 3 specific actions can you personally and/or collectively take in the next 8 weeks to impact interpregnancy intervals in your community and your state?

Disclosures

• Ms. Moos had not had a financial relationships with any commercial interest related to this topic in the last twelve months.

Foundational Concepts for Making a Difference in IPIs• Interconception Period

• Unintended Pregnancy

• Interpregnancy Intervals

• Reproductive Life Planning

How Is the “Interconception” Period Defined?

• It has taken awhile for a consistent definition to prevail

• It is properly defined as the period between pregnancies

• It begins at the end of one pregnancy

• It ends with the conception of the next pregnancy

• It can only be defined retrospectively which presents a problem in identifying the target population

The Conundrum: Which of These Women Will Become Pregnant Again—That is: Which Are in the InterconceptionPhase of their Reproductive Lives?

Unintended Pregnancies

• Unintended pregnancies include pregnancies that occurred sooner than the woman desired (mistimed) or occurred when the woman wanted no more pregnancies (unwanted) .

• Unintendedness is measured by asking women, at some point up to 5 years following the pregnancy, if they wanted to become pregnant at anytime or at a time different than when they did.

Some Data • The latest data indicates that

• In the US, 45% of pregnancies unintended (2011)

• In Tennessee, 56% of pregnancies are unintended (2010)*

• 63% of these pregnancies result in birth,

• 22% in abortion

• the remainder in miscarriages (2010)(Guttmacher.org/fact-sheet-state-facts about unintended-pregnancy-Tennessee, and United States)

• Unintended pregnancies are generally mistimed (wanted to become pregnant at sometime but not now) not unwanted (did not want to ever have a[nother] pregnancy).

Reports indicate that as many as 48% of unintended pregnancies occur in a month in which the woman used contraception.

HOW CAN THIS BE?

Who Has Unintended Pregnancies?The short answer is: everyone who has sexual intercourse because there is NO perfect contraceptive (including sterilization and LARC)

Proportion of women who became pregnant while using contraception (represents actual, not perfect, use):

• Female sterilization .05%

• Implanon (rods) .05%

• Male sterilization .15%

• IUDs (Mirena) .2%

• IUD (ParaGard) .8%

• Injectables 3.0%

• Combination Pills 9.0%

• Condoms 18.0%

• Withdrawal 22.0%

Are Some People at Greater Risk?

• While teens ages 15-19 report 82% of their pregnancies as unintended, they contribute only 12% to the total number of unintended pregnancies in this country (ergo: they are NOT “the” problem!).

• The rate of unintended pregnancy in 2011 was substantially above average for:

• Women ages 20-24 (26% of the total number of unintended pregnancies)

• Unmarried, particularly co-habitating women

• Low-income women

• Women who had not completed high school

• Minority women

What We Know about Altering the Unintendedness Rate Is NOT Great

• Two different analyses (of all available research) could find no studies that demonstrated strategies that work! (Moos, 2003; Grimes 2006). A third analysis also reveals little to guide clinicians.

Possible reasons:

• Poor studies

• Ineffective strategies

• Clinical interventions are inadequate to impact patient knowledge, attitudes and behaviors around contraception

• Clinicians are often more comfortable “doing at” rather than “doing with”

Exception: Contraceptive CHOICE Project

• More than 9,000 women included in study

• Women counseled on all contraceptive methods

– Women provided desired method free of charge

– 75% of women chose a LARC method

• At 12 months, 86% of LARC users still udingmethod vs 55% of women who inicitated a short-acting method

Reasons for Using Contraception

• Survey of 2,094 women ages 21-29 attending publically funded family planning clinics.

• Contraceptive use allowed subjects to:• Take better care of self/families (63%)

• Support themselves financially (56%)

• Complete their education (51%)

• Keep or get a job (50%)

• Young women, unmarried women and those without children had more reasons.• “. . .feeling that having a baby would interrupt their goals

and wanting to maintain control in their lives were the most commonly reported ‘very important reasons’ for using BC”

Frost and Lindberg, Contraception 87(4), 2013

Understanding Short InterpregnancyIntervals: “IPIs”Definition of IPI and interconception period are the same: From the end of one pregnancy to the conception of the next

Survey Question

The ideal IPI is:

1. At least 6 months

2. 9-12 months

3. 18-60 months

4. Any time beyond 18 months

Focus Group Findings from AZ Indicate Missed Opportunities to Make a Difference (and practice

evidence-based care)

• Two mixed groups of clinicians (Ob/Gyns, FM, NPs, Midwives)

• When asked what advice they give women about interpregnancy intervals, all but one indicated some variation of: “When you want to get pregnant go ahead and try”.

The Best IPIs are Neither Too Long or Too Short

Conde-Aqudelo JAMA 2006 296(15) 1809-23.

• For each month that IPI was less than 18 months,

• Preterm births increased 1.9%

• Low birthweightincreased 3.3%

• Poor intrauterine growth increased 1.5%

• . . .BUT too long has problems as well: For each month that IPI more than 59 months,• Preterm birth increased

0.6%

• Low birthweightincreased 0.9%

• Poor intrauterine growth increased 0.8%

Why Interpregnancy Intervals Are Part of the Prematurity Prevention Strategies

• Women with IPIs of less than 18 months are 14-47 percent more likely to have premature infants.

• The incidence of short IPIs varies by study and variable definitions:

• In one study (NSFG, 2005) approximately 14% of all US women reported having given birth within 24 months of a previous birth.

• In another study (NSFG, 2013) 35% of pregnancies were conceived less than 18 months of a previous birth.

More on What We Know about Interpregnancy Intervals• Controlling for socioeconomic status, use of

health care services, tobacco, alcohol and other exposures does not alter the finding that interpregnancy intervals exercise an independent influence on poor pregnancy outcomes. (Conde-Aguidelo et al., JAMA, 2006)

• Some hypothesize that increased risks for women with short interconceptional lengths relate to maternal nutrition depletion and/or inadequate maternal folate levels.

Most Important Take-Aways:

• We have evidence to guide our counseling

• I8 months is not the only choice—pushing such a choice could prove objectionable for:

• Couples who purposefully desire children close together

• Women who are in their mid-thirties and beyond

• Couples who have experienced a recent loss

• Couples who may have a prolonged deployment in their futures

• Etc.

• Changes in IPIs have incremental impact.

• Therefore, the woman/couple who desires a subsequent pregnancy within 6 months of giving birth will decrease the likelihood of a preterm infant (and other poor outcomes) by waiting 1, 3, 6 extra months before conceiving;

• Irrespective of their desires, every woman/couple deserves non-judgmental education that the ideal IPI is 18-59 months so they can make a fully informed decision.

Who Is At Greatest Risk?

• Short IPIs are higher among African-American, Latina, and poor women.

Chandra A. et al. “Fertility, Family Planning and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health Statistics. 23(25). 2005; Gemell & Lindberg. Short

Interpregnancy intervals in the US Obstet Gynecol 122 (1) 64-71, 2013.

• BUT. . .beware of stereotypes:• In NSFG study (2013), women significantly more likely to

have a short IPI if:• 15-19 years old• Married• Initiated childbearing after age 30• Reported pregnancy as unintendedGemell & Lindberg. Short Interpregnancy intervals in the US Obstet Gynecol 122 (1) 64-71, 2013.

Unintendedness and Short IPIs Overlap but They Are Not the Same

Some pregnancies with short IPIs could be very intended.

What Are Some Reasons?

Unintended Pregnancies and IPIs

• Examples of situations which could result in intended short IPIs. Here are some reasons:

– Last pregnancy ended with a tragic or poor outcome such as fetal death, infant death, malformations, prematurity.

– Cultural/social/familial expectations about how close in age children should be.

– Advancing maternal age.

– Lack of awareness of the risks (this is a preventable cause and one we can address).

Intended Short IPIs

• Short IPIs more likely to be reported as intended among women who are:

• Married

• Non-Hispanic white

• College-educated

• Non-Medicaid delivery

Gemmill & Lindberg. Short Interpregnancy intervals in the US Obstet Gynecol 122 (1) 64-71, 2013.

Strategies to Impact IPIs

Highlights of the ACOG CO#670as It Relates to IPIs

• The IUD and contraceptive implant, together known as LARC, are safe for most females, including adolescents.

• Inserting LARC immediately after deliver (“postplacental placement”) has the potential to decrease subsequent unintended conceptions and short IPIs

Advantages of PostplacentalInsertions to Reduce IPIs

• Between 40-57% of women report having unprotected intercourse before the routine 6 week postpartum visit.

• Mean ovulation occurs at 39 days pp in non-lactating women

• Between 10-40% of women do not attend their postpartum visit

• 40-75% of women who planned to have an IUD placed in the postpartum period do not obtain it– Possible barriers for those who attend their pp visit

include: inability to afford (e.g. Medicaid window has closed), clinicians/clinics do not offer, need for an additional visit for placement.

Comparison of Immediate vs Routine Postpartum Insertion

• Randomized study

– At 6 months, 83% of the immediate insertion group (IG) vs 64% of the traditional insertion group (TG) still using IUD

– In the TG, 39% did not obtain the previously desired IUD:

• 25% did not return for the pp visit and

• 14% either declined the IUD or had an unsuccessful insertion.

Risks and Benefits

• Medical Eligibility Criteria (MEC) identifies Cu-IUD as a category 1 (no restriction) with postplacental placement at less than 10 minutes

• The LNG-IUD is categorized as category 2 (advantages generally outweigh theoretical or proven risks)

• The implant is a category 1 for placement between 10 minutes after delivery to less than 4 weeks after delivery.

Risks and Benefits, Continued

• Immediate postpartum IUD placement is contraindicated if:– Intrauterine infection at delivery

– Postpartum hemorrhage

– Puerperal sepsis

• There are no such contraindications for the implant

• Impact of early insertions of Cu-IUD and implant on breastfeeding indicate no differences in successful lactation; studies on the impact of LNG-IUD are too limited for interpretation, thus it is a Category 2 MEC choice.

Risks and Benefits, Continued

• The range of expulsion rates for immediate postpartum IUD insertions (10-27%) are higher than for routine postpartum and post abortion insertions.

• ACOG concludes that despite higher expulsion rate, evidence “strongly suggests superiority of immediate placement in reduction of unintended pregnancy, especially for those at greatest risk of not having recommended postpartum follow-up”.

So, Why Isn’t Immediate Postpartum Insertion More Wide-spread?

• Providers unaware of safety

• Women not offered the option in a timely way

• Women feel coerced because they believe they are being singled out for LARC– Perceived or real inequality in emphasis on

choosing LARC between demographic groups

– Counseling starts with directing women to a specific method rather than understanding her specific desires/plans

• Individual providers lack training for IUD post placental placement (ideally within 10 minutes of placental delivery for both vaginal and cesarean births)

• Institutional processes not supportive• LARC devices are not stocked on the labor and

delivery/postpartum units• Reimbursement barriers exist against immediate

placement– Medicaid policies do not reimburse for LARC beyond

global fee– Nearly 2 dozen states have or are in process of

adopting policies to reimburse beyond global fee.

Immediate Postpartum LARC Medicaid Reimbursement (October, 2016)

Ideas for Increasing IPIs in Tennessee

• ACOG recommends prenatal counseling regarding the option of immediate postpartum LARC but offers no structure

• To be patient-centered, I think we need to introduce a conversation that is broader than the method:

THE REPRODUCTIVE LIFE PLAN

My Current Recommendations for Assessing an Individual’s Reproductive Life

Plan (RLP)• Do you hope to have any (or any more) children?

• If no, what are you planning to do to prevent becoming pregnant (again)

• If yes, ask:

• How many (more) children do you hope to have?• How long would you like to wait until you become

pregnant (again)?• Is your partner on board with your plan?• What do you plan to do to prevent getting pregnant

until then?• What can I do to help you achieve your plan?

Adopted from Moos, MCN, 2003, subsequently adopted by CDC. Available at: http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf. Since revised by Moos.

RLP Needs to be Informed by an Overall Life Plan

RLP

Education

Vocation

Health

Other Pieces

in the Life Plan:•Relationships

•Economic status

•Spiritual connections,

•Social outlets, etc.

As such, time is needed by many to formulate a plan—handouts, worksheets, discussions are needed for women/couples to determine what would be “ideal” for them.

Where Does Thinking About One’s Reproductive Life Plan Start?

Relationships/Community

Clinical Settings

Tools to Impact IPIs• Do you have a brochure or some other vehicle that can be given to

every woman in 2nd trimester about:– Imagining how many children they want and how far apart they

want them to be– Education on ideal IPI– Structure to help them consider what they want to achieve

before becoming pregnant again– Contraceptive methods, pros and cons (refer to Bedsider.org for

more detailed information)– Personal RLP– Importance of the postpartum exam

• If not, develop a multi-disciplinary task force and create one (I do not know of an existing vehicle to recommend)

• If you do have a vehicle, use it with EVERY woman/couple to start and continue a conversation to find best contraceptive for woman/couple’s desires

www.bedsider.org

Features of www.bedsider.org

Who Should Be on The Team to Impact IPIs?

• ALL clinic personnel (clinicians, nurses, social workers, etc.)

• Outreach and home visiting personnel

• Childbirth educators

• ALL labor and delivery and postpartum personnel (clinicians, nurses, social workers, lactation consultants, nursery staff, etc.)

• Postpartum programs and providers

• OTHERS???

Develop Strategies to Overcome Access Barriers to Access to Method of Choice

• Address:– Medicaid policies (to assure coverage for hospital

insertions of LARC beyond global fee)– Hospital policies (to assure that necessary methods

are on hand in L and D and on clinic floor)– Clinician barriers (training to do post placental

insertions of LARC and to provide appropriate counseling and follow-up of all methods)

• Develop:– Strategies to investigate and address the no-show

rates for post partum visits.

Addressing IPIs is a CQI Project Waiting for Uptake

Will Tennessee Become the Leader for this Work?

Perhaps, Now Is the Time to Be

“Bold, Smart and Respectfully Impatient”

San Joaquin Valley Health Fund