OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

BACKGROUND: Several studies have examined the association between IPI and birth outcomes, but few have explored the association between interpregnancy interval (IPI) and postnatal outcomes. OBJECTIVE: We examined the association between IPI and injury-related infant mortality, a leading cause of postneonatal mortality. METHODS: We used 2011-2015 US period-linked birth-infant death vital statistics data to generate a multiyear birth cohort of non-first-born singleton births (N = 9 782 029). IPI was defined as the number of months between a live birth and the start of the pregnancy leading to the next live birth. Causes of death in the first year of life were identified using ICD-10 codes. Hazard ratios (HR) for IPI categories were estimated using Cox proportional hazards models adjusted for birth order, county poverty level, and maternal characteristics (marital status, race/ethnicity, education, age at previous birth). RESULTS: After adjustment, overall infant mortality (48.1 per 10 000 births) was higher for short and long IPIs compared with IPI 18-23 months (reference): <6, aHR 1.61, 95% CI 1.54, 1.68; 6-11, aHR 1.22, 95% CI 1.17, 1.26; and 60+ months, aHR 1.12, 95% CI 1.08, 1.16. In comparison, the risk of injury-related infant mortality (4.4 per 10 000 births) decreased with longer IPIs: <6, aHR 1.77, 95% CI 1.55, 2.01; 6-11, aHR 1.41, 95% CI 1.25, 1.59; 12-17, aHR 1.25, 95% CI 1.10, 1.41; 24-59, aHR 0.78, 95% CI 0.69, 0.87; and 60+ months, aHR 0.55, 95% CI 0.48, 0.62. CONCLUSION: Unlike overall infant mortality, injury-related infant mortality decreased with IPI length. While injury-related deaths are rare, these patterns suggest that the timing between births may be a marker of risk for fatal infant injuries. The first year postpartum may be an ideal time for the delivery of evidence-based injury prevention programmes as well as family planning services.

BACKGROUND: Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. METHODS: In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. RESULTS: We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. CONCLUSION: This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

BACKGROUND: The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based. METHODS: To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health. RESULTS: Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. CONCLUSIONS: This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

BACKGROUND: The relationship between unintended pregnancy and interpregnancy interval (IPI) across maternal age is not clear. METHODS: Using data from the National Survey of Family Growth, we estimated the percentages of pregnancies that were unintended among IPI groups (<6, 6-11, 12-17, 18-23, 24+ months) by maternal age at last live birth (15-19, 20-24, 25-29, 30-44years). RESULTS: Approximately 40% of pregnancies were unintended and 36% followed an IPI<18months. Within each maternal age group, the percentage of pregnancies that were unintended decreased as IPI increased. CONCLUSION: Unintended pregnancies are associated with shorter IPI across the reproductive age spectrum.

Hanley et al1 present a compelling analysis of interpregnancy intervals and adverse pregnancy outcomes using a case-crossover design to analyze data from Canadian women with at least three deliveries between 2000 and 2015. Consistent with a previous analysis,2 the authors found that adverse associations between short interpregnancy interval and neonatal outcomes commonly reported in studies using unmatched analyses were erased (or even reversed) after conducting a case-crossover analysis. Although we agree with Hanley et al that time-invariant confounding is most likely reduced when using a within-woman study design such as case-crossover analysis, it may be at the expense of generalizability. | | As the study authors point out, unmatched designs use information from all women, whereas case-crossover analyses use information only from women with discordant exposures and outcomes.1,3 According to the article’s appendix tables, of the 38,178 women with at least three deliveries included in the unmatched analysis, 14% had discordant preterm birth outcomes (n = 5,195). Because 27% of women overall had discordant interpregnancy intervals (one in the reference group, one not in the reference group), approximately 3.8% (n = 1,457) of the total cohort presumably provided data for the case-crossover analysis on preterm birth. Although the authors note that their results may not generalize to other settings, further work on the generalizability of case-crossover analyses, which by design exclude individuals who have not experienced the outcome under study, to the broader target population would be welcome.4

INTRODUCTION: The purpose of this study was to evaluate the risk of death during the first year of life due to injury, such as unintentional injury and homicide, by birth order in the U.S. METHODS: Using national birth cohort-linked birth-infant death data (births, 2000-2010; deaths, 2000-2011), risks of infant mortality due to injury in second-, third-, fourth-, and fifth or later-born singleton infants were compared with first-born singleton infants. Risk ratios were estimated using log-binomial models adjusted for maternal age, marital status, race/ethnicity, and education. The statistical analyses were conducted in 2016. RESULTS: Approximately 40%, 32%, 16%, 7%, and 4% of singleton live births were first, second, third, fourth, and fifth or later born, respectively. From 2000 to 2011, a total of 15,866 infants died as a result of injury (approximately 1,442 deaths per year). Compared with first-born infants (2.9 deaths per 10,000 live births), second or later-born infants were at increased risk of infant mortality due to injury (second, 3.6 deaths; third, 4.2 deaths; fourth, 4.8 deaths; fifth or later, 6.4 deaths). The corresponding adjusted risk ratios were as follows: second, 1.84 (95% CI=1.76, 1.91); third, 2.42 (95% CI=2.30, 2.54); fourth, 2.96 (95% CI=2.77, 3.16); and fifth or later, 4.26 (95% CI=3.96, 4.57). CONCLUSIONS: Singleton infants born second or later were at increased risk of mortality due to injury during their first year of life in the U.S. This study's findings highlight the importance of investigating underlying mechanisms behind this increased risk.

Risk of death during the first year of life due to external causes, such as unintentional injury and homicide, may be higher among twins and higher-order multiples than among singletons in the United States. We used national birth cohort linked birth-infant death data (2000-2010) to evaluate the risk of infant mortality due to external causes in multiples versus singletons in the United States. Risk of death from external causes during the study period was 3.6 per 10,000 live births in singletons and 5.1 per 10,000 live births in multiples. Using log-binomial regression, the corresponding unadjusted risk ratio was 1.40 (95% confidence interval (CI): 1.30, 1.50). After adjustment for maternal age, marital status, race/ethnicity, and education, the risk ratio was 1.68 (95% CI: 1.56, 1.81). Infant deaths due to external causes were most likely to occur between 2 and 7 months of age. Applying inverse probability weighting and assuming a hypothetical intervention where no infants were low birth weight, the adjusted controlled direct effect of plurality on infant mortality due to external causes was 1.64 (95% CI: 1.39, 1.97). Twins and higher-order multiples were at greater risk of infant mortality due to external causes, particularly between 2 and 7 months of age, and this risk appeared to be mediated largely by factors other than low-birth-weight status.

INFERTILITY AND ITS TREATMENT have implications beyond just pregnancy (or its absence), including financial, psychological, and health consequences.1–5 Ensuring the magnitude of infertility is accurately defined at the national and state levels is essential for understanding population trends, improving prevention programs, and providing access to quality care and services. Currently, states do not collect routine data on infertility. The National Survey of Family Growth (NSFG) publishes estimates of current infertility and impaired fecundity for the United States,6 but these data are not designed to examine state-level differences. A further challenge is the lack of consensus on a standard approach for monitoring infertility.7 In this context, the article by Crawford et al.8 in this edition of the Journal and Women’s Health provides an important contribution to our understanding of state-specific prevalence of lifetime infertility, its treatment, and potential factors to consider for future infertility surveillance efforts. | Measurement of infertility and consensus regarding its definition have been a subject of much ongoing debate. Infertility, whether current or lifetime, has not been defined consistently across studies,7 hindering the ability to understand the magnitude of the problem and make meaningful comparisons across populations. Assumptions regarding the population at risk of infertility (i.e., the denominator) can also impact estimation,7,9,10 even when similar definitions for infertility are applied. This affects population-based surveillance of infertility, which should have consistent definitions with which to compare across geographic regions and over time and reliable survey instruments to capture similar at-risk populations.