Editorial
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Pregnancy following miscarriage: what is
the optimum interpregnancy interval?
“Each case should be assessed individually and advice regarding birth
spacing should be tailored, taking into consideration maternal age, fertility
behavior, socioeconomic status and comorbidities.”
Miscarriage, or the spontaneous loss of preg-
nancy at a relatively early stage of development,
affects one in 20 pregnancies. For couples hop-
ing to start a family, loss of a first pregnancy can
be a devastating experience. Trying to come to
terms with their grief, and to compensate for
their loss, one of the questions foremost in their
mind is ‘how long should we wait before trying
for another pregnancy?’
“This study, although with several
limitations, formed the sole basis of
the WHO consultative group’s
recommendation of delaying
pregnancy for at least 6 months
following a miscarriage.”
In 2005, the WHO published a report of a
technical consultation on birth spacing that
reviewed the evidence surrounding the ideal
birth interval following different types of preg-
nancy outcomes [101] . Although there was ample
evidence from different populations to suggest
that having a short birth interval following a live
birth was detrimental for the next pregnancy,
the evidence was scant regarding birth spacing
after a miscarriage. Based on a single large-scale
study conducted in Latin America, the consulta-
tive group recommended that couples wait for
at least 6 months before trying to conceive after
a miscarriage and called for more research in
diverse populations. The evidence is still thin
on the ground 5 years after the publication of
the report.
Review of the evidence
An updated search of the literature using the
search terms ‘miscarriage’, ‘birth spacing’ and
‘interpregnancy interval’ individually and in
combination yielded six relevant published
reports, including the Latin American study
by Conde-Agudelo et  al. used by the WHO
technical consultative group [1] . However, there
10.2217/WHE.11.2 © 2011 Future Medicine Ltd
was good evidence to support delaying preg-
nancy after a term or preterm live or stillbirth. Sohinee
Conde-Agudelo’s meta-ana­lysis of 67  studies
Bhattacharya
demonstrated that birth intervals of less than
18 months or greater than 59 months follow-
ing live birth were associated with adverse
maternal and perinatal outcomes in the next
pregnancy  [2] . With regard to pregnancies fol-
lowing miscarriage, the results from the few
published studies give conflicting evidence. The Author for correspondence:
oldest published article in this subject area was University of Aberdeen, Aberdeen, UK
by Wyss et al., who did not find any statisti-
sohinee.bhattacharya@abdn.ac.uk
cally significant difference in the occurrence of Norman
preterm deliveries following miscarriage with Smith
birth intervals of less than 90 days in compari-
son with intervals greater than 90 days [3] . Basso
et al. reported that the risk of adverse pregnancy
outcomes such as preterm delivery, low birth-
weight and growth restriction actually increased
with increasing interpregnancy intervals follow-
Aberdeen Maternity Hospital,
ing miscarriage [4] . This was a population-based Aberdeen, UK
study using the Danish birth registry of 45,449
records of women who had had a previous mis-
carriage. Another study by Goldstein et al. from
the USA did not find any association between
birth intervals of less than 100  days follow-
ing miscarriage and adverse outcomes such
as preterm birth, low birthweight or perinatal
deaths in the next pregnancy [5] . The large-scale
Latin American study by Conde-Agudelo et al.
referred to earlier used data collected from hos-
pital admissions in the Perinatal Information
System Database located in Uruguay [1] . They
found that compared with interpregnancy inter-
vals of 18–23  months, intervals of less than Keywords
6 months following abortions (both spontane-
• birth spacing • interpregnancy
ous and induced) were associated with adverse
interval • miscarriage
maternal and perinatal outcomes in the next • spontaneous abortion
pregnancy. This study, although with several • subsequent pregnancy
limitations, formed the sole basis of the WHO
consultative group’s recommendation of delay-
ing pregnancy for at least 6 months following part of
a miscarriage. By the authors’ own admission,
this study had several limitations. Perhaps the
Women's Health (2011) 7(2), 139–141 ISSN 1745-5057 139
Editorial – Bhattacharya & Smith
most important of these was its inability to dis-
tinguish between spontaneous miscarriage and
induced abortion. The authors hypothesized
that the possible explanation of their findings
could lie in the increased rates of infection fol-
lowing induced abortion. Moreover, the data
analyzed were from hospital admissions where
diagnoses were not standardized or validated
and the results were neither population based
nor generalizable to a wider group. Around the
same time, DaVanzo et al. published a report
looking at the effects of interpregnancy inter-
vals using data from a demographic surveillance
system in Matlab, Bangladesh [6] . They found
that interpregnancy intervals of 15–75 months
were associated with a reduced chance of fetal
loss in the next pregnancy independent of how
the previous pregnancy ended. This also meant
that if the previous pregnancy ended in a mis-
carriage, there was a higher risk of the subse-
quent pregnancy ending in another miscarriage,
irrespective of the interpregnancy interval.
This study had several strengths: large-scale
population-based prospectively collected data,
standardized diagnoses and coding criteria as
well as controlling for several potential con-
founding factors. However, the findings were
difficult to interpret as the reference group used
in calculating the odds ratio was women who
had a previous live birth and an interpregnancy
interval of 27–50 months – and women who
had a previous live birth are known to be at a
lower risk of subsequent pregnancy loss than
those whose previous pregnancy ended in mis-
carriage. Love et al. addressed this shortcoming
by assessing second pregnancy outcomes in all
Scottish women recorded to have had an initial
miscarriage and found that best outcomes in the
second pregnancy were associated with inter-
pregnancy intervals of less than 6 months  [7] .
However, this report did not include miscar-
riages that did not warrant hospital admissions
and could not distinguish between voluntary
contraceptive use and involuntary subfertility
when assessing the interpregnancy interval.
“…there remains little doubt that
delaying pregnancy after a
miscarriage is of little benefit and
may indeed be detrimental to the
health of the subsequent child.”
If we now look at the evidence presented
objectively, there remains little doubt that
delaying pregnancy after a miscarriage is of
140 www.futuremedicine.com
little benefit and may indeed be detrimental to
the health of the subsequent child. In fact, this
was evident at the time of writing of the report
by the WHO consultative group on birth spac-
ing. Only one study disputed this [1] ; but the
WHO consultative group felt that despite its
limitations, the findings from such a large-scale
study could not be ignored. There were also, one
suspects, policy constraints underlying the rec-
ommendation. There is huge political pressure
in developing countries such as India and China
to streamline family size and increasing inter-
pregnancy intervals by using modern contracep-
tive methods can only benefit family planning.
There is also the problem of distinguishing
between late miscarriage and preterm births in
countries where gestational age is determined by
maternal recall of her last menstrual period in
the absence of routine ultrasound dating scans.
Furthermore, the effect of maternal nutritional
status and access to healthcare are quite dif-
ferent in the rest of the world compared with
the west. Therefore, one can see the rationale
behind the WHO’s recommendation to delay
the next pregnancy by at least 6 months follow-
ing a miscarriage. From the point of view of the
couple trying to conceive after a miscarriage,
irrespective of the part of the world they live
in, the WHO recommendations mean little or
nothing – there is no ‘one-size-fits-all’ solution.
Each case should be assessed individually and
advice regarding birth spacing should be tai-
lored, taking into consideration maternal age,
fertility behavior, socioeconomic status and
comorbidities. In fact, as many practitioners
already advise, there is no evidence to suggest
that delaying pregnancy following an uncom-
plicated miscarriage is beneficial for the next
pregnancy. Couples should try for another preg-
nancy once they feel physically and mentally
ready for it.
Acknowledgements
The authors would like to thank Eleanor Love for carrying
out the initial literature search for this article.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
­pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.
future science group
 Pregnancy following miscarriage: what is the optimum interpregnancy interval? –
Bibliography
1. Conde-Agudelo A, Belizan JM, Breman R,
Brockman SC, Rosas-Bermudez A: Effect of
interpregnancy interval after an abortion on
maternal and perinatal health in Latin
America. Int. J. Gynaecol. Obstet.
89(Suppl. 1), S34–S40 (2005).
2. Conde-Agudelo A, Rosas-Bermudez A,
Kafury-Goeta AC: Birth spacing and risk of
adverse perinatal outcomes – a meta-ana­lysis.
JAMA 295, 1809–1823 (2006).
3. Wyss P, Biedermann K, Huch A: Relevance of
miscarriage – new pregnancy interval.
J. Perinat. Med. 22, 235–241 (1994).
4. Basso O, Olsen J, Christensen K: Risk of
preterm delivery, low birthweight and
growth retardation following spontaneous
future science group
abortion: a registry based study in
Denmark. Int. J. Epidemiol. 27, 642–646
(1998).
5. Goldstein RR, Croughan MS, Robertson PA:
Neonatal outcomes in immediate versus
delayed conceptions after spontaneous
abortion: a retrospective case series.
Am. J. Obstet. Gynecol. 186, 1230–1236
(2002).
6. DaVanzo J, Hale L, Razzaque A, Rehman M:
Effects of interpregnancy interval and the
outcome of the preceding pregnancy on
pregnancy outcomes in Matlab, Bangladesh.
BJOG 114, 1079–1087 (2007).
7. Love E, Bhattacharya S, Smith NC,
Bhattacharya S: Effect of interpregnancy
interval on outcomes of pregnancy after
Women's Health (2011) 7(2)
Editorial
miscarriage: retrospective ana­lysis of hospital
episode statistics in Scotland. BMJ 341, c3967
(2010).
Website
101. Marston C: Report of a WHO Technical
Consultation on Birth Spacing Geneva,
Switzerland 13–15 June 2005. Department of
Making Pregnancy Safer and Department of
Reproductive Health and Research, WHO,
Geneva, Switzerland (2005)
www.who.int/reproductivehealth/
publications/family_planning/WHO_
RHR_07_1/en/index.html
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