doi: 10.1111/ppe.
12447
Commentary
Optimal Birth Spacing: What Can We Measure and What Do We
Want to Know?
Katherine A. Ahrens,a
a
Office of Population Affairs, Office of the Assistant Secretary for Health, US Department of Health and Human Services, Rockville, MD
b
Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
The optimal spacing between births has long been a
topic of interest to epidemiologists and demogra-
phers. In recent decades, numerous studies on the
association between birth spacing and adverse
perinatal outcomes have been published from both
high- and low-resource countries.1,2 Despite this
extensive body of work, there remains a profound dis-
connect between what these studies typically examine
and the questions that we would like to answer. We
study the observed optimal association between birth
spacing and infant health outcomes, but what we
want to know is if modifying when parous women
start trying to conceive again leads to better outcomes
for the mother and child. The goal of future birth
spacing research should be to bring these 2 lines of
research into closer alignment.
One reason for this disconnect is data availability.
The timing of last livebirth or last pregnancy outcome
is part of routinely collected hospital or birth records
in many countries.3 In the United States, for example,
this information was added to the US national birth
certificate in 1968.4 However, the interpregnancy
interval itself (the time between delivery and the
beginning of a subsequent pregnancy) is not an
actionable intervention. Rather, it is the endpoint of
numerous physiologic changes and behaviours after
giving birth: women’s return to fecundability and
ovulation, pregnancy intentions, contraception use,
and sexual activity. Information on these factors is not
routinely collected. As a result, there is a paucity of
research examining how changes in factors that are
more directly modifiable, and thus more relevant to
counselling and informed decision making, affect
birth outcomes.
Correspondence:
Katherine Ahrens, Office of Population Affairs, Office of the
Assistant Secretary for Health, U.S. Department of Health and
Human Services, Rockville, MD, USA.
E-mail: kate.ahrens@hhs.gov
© 2018 John Wiley & Sons Ltd
Paediatric and Perinatal Epidemiology, 2018, , –
1
Jennifer A. Hutcheonb
The ready-availability of interpregnancy interval on
US birth certificate records has also influenced the
types of health outcomes studied. A large body of the
research to date has focused on only a few neonatal
health outcomes: preterm birth, low birthweight, and
small-for-gestational-age birth.1 There are large gaps
in our knowledge of how birth spacing affects many
other important outcomes, such as maternal post-
partum weight loss, and the risk of obesity and associ-
ated conditions like gestational diabetes at the time of
the subsequent pregnancy; infant and child develop-
ment; and non-health outcomes such as maternal
employment and lifetime earnings.
The dissonance between what we study and
what we would like to know becomes most appar-
ent when associations between interpregnancy
interval and adverse birth outcomes are interpreted
as causal effects. Many authors suggest that their
findings should be used by health care providers
to counsel post-partum women on the optimal
spacing before the next pregnancy or to calculate
the number of adverse health events that could be
prevented by reducing the prevalence of short
interpregnancy intervals in a population.5,6 These
types of leaps may be inappropriate because of the
complexity in using observational data to disentan-
gle the causal effect of interpregnancy interval
from other closely intertwined determinants of
adverse birth outcomes, particularly, low socio-
economic status, and unintended pregnancy. Disen-
tangling these factors is particularly challenging
when using administrative or vital records, which
often lack detailed information on socio-economic
and life style factors. The extent to which unmea-
sured or uncontrolled confounding contributes to
the observed associations is not known, but adjust-
ment for maternal demographics nearly always
attenuates estimates, supporting an important role
for these other factors.
2 K. A. Ahrens and J. A. Hutcheon
The manuscripts by Zhang and colleagues7 and
Conzuelo Rodriguez and Naimi8 in this issue of
Paediatric and Perinatal Epidemiology have furthered
the conversation on this topic. Zhang and colleagues
investigated the association between interpregnancy
interval following livebirth on the risks of preterm
birth and small- and large-for-gestational-age birth
among a cohort of women in Guangzhou, China,
2000–2015. The study is timely, as guidance on birth
spacing for Chinese women is needed given a new
universal 2-child policy issued in China in January
2016. The methodological study by Conzuelo
Rodriguez and Naimi examined changes in the mag-
nitude of associations between short interpregnancy
interval and preterm birth (as well as other factors)
based on what types of pregnancy outcomes (live-
births, miscarriages, stillbirths, induced abortions)
defined the interpregnancy interval. They argue that
previously reported associations between interpreg-
nancy interval and birth outcomes may be biased
because interpregnancy interval has usually been
calculated as the time between the delivery of one
livebirth and the conception of the pregnancy
leading to the next live birth, ignoring intervening
pregnancies that did not result in a livebirth. These
authors use data from the National Survey of Family
Growth, a nationally representative sample of repro-
ductive-aged women in the United States that
includes complete pregnancy history. Although
these 2 manuscripts examine interpregnancy interval
in very different contexts and from different per-
spectives, both help align what we can measure with
what we would like to know.
The study by Zhang and colleagues reports a
J-shaped relationship for interpregnancy interval and
preterm birth similar to that observed in the United
States and other settings. They conclude that recom-
mendations to wait at least 18 months, but not longer
than 60 months may be appropriate. However, as with
administrative data studies from other settings, the
extent to which these findings reflect causal associations
—and thus the extent to which they should be used to
develop recommendations in China—is unclear. Their
use of e-values to estimate the amount of unmeasured
or uncontrolled confounding that would be needed to
explain the observed associations is useful in explor-
ing these concerns, but with results including mini-
mum unmeasured or uncontrolled confounding RRs
<1.50 for some interpregnancy intervals, questions
remain. Perhaps the most valuable contribution of the
study is the findings on long interpregnancy interval
in women whose second child was born in 2016. The
change from a 1-child to 2-child policy provides a
unique natural experiment on long interpregnancy
intervals, as the long interpregnancy intervals associ-
ated with 2016 births may be less likely to be corre-
lated with socio-economic and life style factors than
similar intervals in other countries. The finding that
interpregnancy interval ≥60 months is still associated
with higher risk of preterm birth (but not small- or
large for gestational age birth) is therefore a novel
contribution to the field—although it requires confir-
mation from analyses restricted to 2016 births con-
ceived post policy change. Further exploiting this
policy change to understand the consequences of long
interpregnancy interval on other pregnancy outcomes,
such as preeclampsia or labour abnormalities, pro-
vides a valuable opportunity for reducing the discon-
nect between what is usually studied, and what we
want to know.
The work of Conzeulo Rodriguez and Naimi found
that the link between short interpregnancy interval
(<18 months) and preterm birth was reasonably con-
sistent across different definitions of interpregnancy
interval. These findings provide reassurance for pol-
icy-makers seeking to interpret previous studies
based only on interpregnancy intervals between suc-
cessive livebirths. Nevertheless, this work could be
refined to better answer the questions we most want
to have answered. Combining livebirths with still-
births, miscarriages, and induced abortions for
women’s previous pregnancies is less useful because
these are distinct clinical groups for whom separate
spacing recommendations are likely needed. The evi-
dence for 18 months of recovery time needed for
women following miscarriages and induced abor-
tions, which are most likely to occur in the first trime-
ster of pregnancy, is not compelling. Indeed, the only
recommendation for spacing following miscarriage or
induced abortion is the World Health Organization
recommendation to wait 6 months before attempting
the next pregnancy.3 This may itself be too long for
the United States given a recent cohort study reported
no increased risk of miscarriage/stillbirth, preterm
birth, gestational diabetes, or preeclampsia for cou-
ples who began trying to conceive within 3 months of
a pregnancy loss (although the study was not
designed to detect differences in these outcomes).9
Providing the same guidance on birth spacing to
women whose first birth resulted in a miscarriage or
© 2018 John Wiley & Sons Ltd
Paediatric and Perinatal Epidemiology, 2018, , –

induced abortion as that given to women with a live-
birth could potentially cause psychological harm. An
implicit risk in this scenario is the advancing maternal
age at next pregnancy attempt, which in itself confers
increased risk of adverse outcomes. It is even possible
that risks of adverse outcomes in subsequent preg-
nancy may differ in women with multiple previous
surgical (but not medical)-induced abortions.10 Thus,
separating these groups would best inform guideline
creation.
Even before the availability of modern contracep-
tives, couples controlled their fertility by increasing
spacing between births, presumably reflecting eco-
nomic concerns about increasing family size.11 Quali-
tative work has shown that women’s birth spacing
attitudes are complex, taking into account social and
financial resources, family composition, and partner’s
role, with less emphasis on the health effects associ-
ated with birth spacing.12 An improved understand-
ing of the complex decision making around having
additional children can help women and couples
achieve their desired reproductive goals, including
how birth spacing can lead to better outcomes for the
mother and child.
Acknowledgement
The work performed by Katherine Ahrens was as an
employee of the US federal government. The findings
and conclusions in this article are those of the authors
and do not necessarily represent the official position
of the Office of Population Affairs, Office of the Assis-
tant Secretary for Health, Department of Health and
Human Services.
About the authors
Katherine Ahrens is a health scientist at the Office of
Population Affairs (OPA), Office of the Assistant Sec-
retary for Health, US Department of Health and
Human Services. In this role, she conducts analyses
and provides programme guidance related to family
planning and reproductive health services provided
in the United States, including services provided
through the Title X Family Planning Program. She
and Dr. Hutcheon recently served as co-chairs at an
expert work group meeting convened by OPA to
address the methodological aspects of existing litera-
ture on short interpregnancy intervals and adverse
pregnancy outcomes.
© 2018 John Wiley & Sons Ltd
Paediatric and Perinatal Epidemiology, 2018, , –
Commentary 3
Jennifer Hutcheon is a perinatal epidemiologist and
Associate Professor in the Department of Obstetrics
and Gynaecology at the University of British
Columbia in Vancouver, Canada. Her research uses
population databases and registries to improve our
understanding of maternal and infant health. She
holds a Canadian Institutes of Health Research New
Investigator award and a Career Scholar award from
the Michael Smith Foundation for Health Research.
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