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Rapid repeat pregnancy among women with intellectual and developmental disabilities: a population-based cohort study

Abstract

BACKGROUND

Rapid repeat pregnancy within 12 months of a live birth is associated with adverse perinatal outcomes. We evaluated the risk for rapid repeat pregnancy among women with intellectual and developmental disabilities, with whom sharing of information about pregnancy planning and contraception may be inadequate.

METHODS

We accessed population-based health administrative data for all women with an index live birth in Ontario, Canada, for the period 2002–2013. We used modified Poisson regression to compare relative risks (RRs) for a rapid repeat pregnancy within 12 months of the index live birth in women with and without intellectual and developmental disabilities, first adjusting for demographic factors and then additionally adjusting for social, health and health care disparities.

RESULTS

We compared 2855 women with intellectual and developmental disabilities and 923 367 women without such disabilities. At the index live birth, women with intellectual and developmental disabilities were more likely to be younger than 25 years of age (46.8% v. 18.2%) and to be disadvantaged on each measure of social, health and health care disparities. These women had a higher rate of rapid repeat pregnancy than those without such disabilities (7.6% v. 3.9%; adjusted RR 1.34, 95% confidence interval [CI] 1.18–1.54, after controlling for demographic factors). This risk was attenuated upon further adjustment for social, health and health care disparities (adjusted RR 1.00, 95% CI 0.87–1.14).

INTERPRETATION

Rapid repeat pregnancy, which was more common among women with intellectual and developmental disabilities, may be explained by social, health and health care disparities. To optimize reproductive health, multifactorial approaches to address the marginalization experienced by this population are likely needed.

Rapid repeat pregnancy within 12 months of a live birth is associated with adverse perinatal outcomes, with previous meta-analyses showing increased risks for stillbirth (adjusted odds ratio [OR] 1.35, 95% confidence interval [CI] 1.07–1.71), fetal growth restriction (adjusted OR 1.26, 95% CI 1.18–1.33), preterm birth (adjusted OR 1.40, 95% CI 1.24–2.58) and early neonatal mortality (adjusted OR 1.29, 95% CI 1.02–1.64).1^,2 There is debate about whether these risks are due to inadequate recovery from the prior pregnancy, including depleted maternal nutrient stores, or confounding by other factors such as socioeconomic status.2 Nevertheless, high rates of rapid repeat pregnancy in North America, as well as research showing that as many as 55% of such pregnancies are unintended,3 make prevention of rapid repeat pregnancy a public health priority. Adolescents and women with low education or income have been shown to be at high risk for rapid repeat pregnancy4^–6 and have been the focus of public health efforts.3 Women with intellectual and developmental disabilities, who exhibit some of the same risk factors for rapid repeat pregnancy, such as suboptimal access to contraception and other family planning services,7 have yet to be studied.

Intellectual and developmental disabilities affect 1 in every 100 adults8 and are characterized by cognitive limitations and difficulties with conceptual, social and practical skills.9 Examples of such disabilities include autism, fetal alcohol spectrum disorder and trisomy 21, but most are nonspecific diagnoses associated with mild intellectual impairment.9 Sterilization and long-term admission to an institution have historically limited child-bearing in this population.10 However, these practices are now uncommon,11 such that young women with and without intellectual and developmental disabilities have similar fertility rates.12^,13 Given stigma and other barriers to education and employment, as well as the financial burden associated with disability, women with intellectual and developmental disabilities are more likely than their peers to live in poverty. Poverty, combined with inadequate access to health care and poor social support, has further downstream effects in this population, including elevated rates of medical and psychiatric comorbidities.14^–17According to these markers of disadvantage, it is plausible that women with intellectual and developmental disabilities may be at increased risk for rapid repeat pregnancy. We compared the risk of rapid repeat pregnancy among women with and without intellectual and developmental disabilities.