Substance use disorder: contraceptive options counseling

What’s New in Contraception?

Contraceptive Technology Conference!

Biologic sexism of STIs

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding


Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm


Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception New and Improved

Do Women Really Need to Wait That Long?
June 2017


In the past, women who suffered spontaneous abortions were advised to wait at least 3 months and often 6, before attempting future pregnancies. The reasoning? “To give their bodies time to heal.” The World Health Organization has recommended delaying pregnancy for 6 months after a miscarriage to achieve optimal outcomes in the next pregnancy. The professional justification was that the time was needed for the woman (and her partner) to grieve. Does delaying a pregnancy after miscarriage really help? And come to think of it, how about delaying pregnancy after an abortion? These questions beg the further question: what is the current thinking on interpregnancy intervals in general?

Today it is quite clear that routine delays are not needed. A large systematic review and meta-analysis of 16 studies involving 1,043,840 women showed that a short interpregnancy interval following miscarriage actually was associated with a slightly reduced risk of future miscarriage and preterm labor and no increase in stillbirth, low birthweight, or pre-eclampsia.[1]  Occasionally, a woman who miscarries may need an opportunity to optimize her health: to achieve good glucose control, to switch medications, to update her vaccinations, or to have 1-3 months of taking folic acid. She will need time to deal with those issues before the next pregnancy. But for a healthy woman desiring pregnancy, who has been evaluated and found to have no remaining needs, advise her to continue taking her prenatal vitamins and to avoid coitus just until her bleeding stops. Ovulation detection kits may help the couple more effectively achieve their reproductive goals.

A variation on the question would be: What is the optimal interval following pregnancy termination? Männistö, et al., looked at this question, using an older cross-sectional study design. They studied 19,894 women who underwent pregnancy termination between 2000 and 2009 and whose subsequent pregnancy ended in a live singleton delivery.[2]  They reported that even after adjusting for nine background factors, an interpregnancy interval of less than 6 months was associated with a slightly increased risk of preterm birth OR = 1.35 (95% CI 1.02-1.77), but no other neonatal or maternal adverse events were found.

What about the timing after a delivery? In the past, the World Health Organization recommended that a woman wait 2 years from the delivery of one pregnancy to the conception of a subsequent one. Earlier studies had demonstrated that shorter intervals (>18 months) and longer ones (> 59 months) were associated with increased risks of preterm birth, low birth weight, small for gestational age birth, and neonatal intensive care admissions.[3],[4],[5],[6],[7] Longer inter-pregnancy intervals also have been associated with increased risk of pre-eclampsia.[8] These findings were based on cross-sectional studies in which the outcomes of mothers with short interpregnancy intervals were compared with the outcomes of pregnancies in women who had the so-called optimal interpregnancy intervals.

Now, however, researchers have taken a fresh look at how to study the issue in a way that could give a more true answer. Instead of taking the approach of cross-sectional studies that look at different women who had different interpregnancy intervals, researchers are looking at how individual women’s multiple pregnancies may be affected by their own different interpregnancy intervals. Three large studies have studied large cohorts of women who themselves had three or more deliveries and could provide two interpregnancy intervals.[9],[10],[11]  Most recently, Hanley, et al., compared the outcomes of pregnancies that occurred at shorter time intervals (0-5, 6-11, and 12-17 months) after the prior pregnancy to the outcomes of pregnancies that occurred following the presumed optimal period (18-24 months). Similarly, they compared the outcomes of pregnancies after optimal intervals (18-23 months) to those after longer intervals (24-59 and > 60 months). They studied both adverse neonatal outcomes (birth < 37 weeks’ gestational age, birth weight < 10th percentile for < 2500 g, NICU use) and adverse maternal outcomes (gestational diabetes, BMI ? 30 kg/m2 pre-pregnancy weight, and preeclampsia.)

First, they undertook the traditional analysis (in which outcomes of women with different interpregnancy intervals were compared to each others’ rather than to their own). Using that traditional approach, they found what has been reported in earlier work—that the risk of prematurity was increased in short-interval pregnancies. But when they used the new approach (where the outcomes of women were compared to their own earlier outcomes), they reach a very different result: all the neonatal risks from short-interval pregnancies disappeared. However, some of the maternal risks continued; women with very short interpregnancy intervals (less than 12 months) had higher rates of beginning the next pregnancy with a BMI ? 30 kg/m2 and of developing gestational diabetes during that pregnancy.

While these studies are very reassuring about the neonatal outcomes after close pregnancy spacing, these studies do not measure the impact of a short interpregnancy interval on the health and well-being of the infant born from the preceding pregnancy. With a short interval, will breastfeeding of that first infant have to be stopped early? Will that infant have adequate exposure to parental attention before a sibling diverts that attention to himself?

Even in the face of these potential adverse impacts on the first infant, these studies are very germane for an increasingly large segment of reproductive-age women—older women who have delayed their childbearing. To ask a 41-year-old woman to wait another 18-24 months before she starts another pregnancy may be very difficult, especially if her fertility is dropping precipitously. Her chance of conceiving and carrying a healthy pregnancy after waiting 2 years diminishes dramatically. For women who step out of the work force to have their children, more prolonged delays may diminish their ability to return to work or to achieve their ultimate professional goals. With these new insights, women who have only short time periods to start their families—for any reason—may be reassured that they will not face higher risks with interpregnancy intervals that are shorter than those that have traditionally been advocated. As Klebanoff concluded in a recent editorial:

“Women whose pregnancies were uncomplicated and who are in good health can be advised that their decisions regarding timing of subsequent pregnancies should be based primarily on personal desire regarding child spacing and ultimate family size and only secondarily on obsolete concerns.”[12]

How can we spread this good news?

Submitted by: Anita Nelson, MD, professor emeritus of obstetrics and gynecology at the David Geffen School of Medicine at the University of California-Los Angeles and clinical professor at the University of Southern California

[1] Kangatharan C, Labram S, Bhattacharya S. Interpregnancy interval following miscarriage and adverse pregnancy outcomes: systematic review and meta-analysis. Hum Reprod Update. 2017;23(2):221-231.

[2] Männistö J, Bloigu A, Mentula M, Gissler M, Heikinheimo O, Niinimäki M. Interpregnancy interval after termination of pregnancy and the risks of adverse outcomes in subsequent birth. Obstet Gynecol. 2017;129(2):347-354.

[3] Chen I, Jhangri GS, Chandra S. Relationship between interpregnancy interval and congenital anomalies. Am J Obstet Gynecol. 2014;210(6):564.e1-8.

[4] Stephansson O, Dickman PW, Cnattingius S. The influence of interpregnancy interval on the subsequent risk of stillbirth and early neonatal death. Obstet Gynecol. 2003;102(1):101-8.

[5] Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295(15):1809-23.

[6] Fuentes-Afflick E, Hessol NA. Interpregnancy interval and the risk of premature infants. Obstet Gynecol. 2000;95(3):383-90.

[7] King JC. The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies. J Nutr. 2003;133(5 Suppl 2):1732S-1736S.

[8] Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol. 2007;196(4):297-308.

[9] Erickson JD, Bjerkedal T. Interpregnancy interval. Association with birth weight, stillbirth, and neonatal death. J Epidemiol Community Health. 1978;32(2):124-30.

[10] Hanley GE, Hutcheon JA, Kinniburgh BA, Lee L. Interpregnancy interval and adverse pregnancy outcomes: an analysis of successive pregnancies. Obstet Gynecol. 2017;129(3):408-415.

[11] Ball SJ, Pereira G, Jacoby P, de Klerk N, Stanley FJ. Re-evaluation of link between interpregnancy interval and adverse birth outcomes: retrospective cohort study matching two intervals per mother. BMJ. 2014;349:g4333.

[12] Klebanoff MA. Interpregnancy interval and pregnancy outcomes: causal or not? Obstet Gynecol. 2017;129(3):405-407.