Factors Associated with Rapid Repeat Pregnancies in Women at High Risk for Adverse Birth Outcomes

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Litzelman, Qing Tang, Angela M. Diaz, Melissa R. Thomas This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8833935/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Rapid repeat pregnancy (RRP), defined as a live birth within 27 months of a prior delivery, is associated with adverse maternal and infant outcomes and reflects underlying social inequities. Our objective is to identify factors associated with RRP among women participating in a community health worker (CHW)-led maternal health intervention. Methods We conducted a longitudinal prospective cohort evaluation of pregnant or postpartum women enrolled in the WeCare CHW program at seventeen federally qualified health centers in central Indiana. CHWs delivered individualized health coaching, care coordination, and referrals addressing social determinants of health. Maternal and infant health indicators were assessed using validated and internally developed screening instruments, and RRP was ascertained during program enrollment. Multivariable logistic regression model estimated odds ratios and their 95% confidence intervals for factors associated with RRP, adjusting for covariates. Results Overall, 26% (232/894) of participants experienced RRP. In adjusted analyses, younger age at first birth was associated with higher risk of RRP (adjusted OR = 0.95 with one-year increase in age; 95% CI = 0.92–0.98, p < 0.001). Screening positive for anxiety on one occasion (aOR = 1.90; 95% CI = 1.09 to 3.33, p = 0.024), experiencing food insecurity on two or more occasions (aOR = 1.99; 95% CI = 1.23 to 3.24, p = 0.005), and having a history of miscarriage (aOR = 2.80; 95% CI = 1.07 to 7.34, p = 0.036) were independently associated with RRP. Hispanic ethnicity was associated with lower odds of RRP (aOR = 0.57; 95% CI = 0.34 to 0.97, p = 0.037), whereas married participants had higher odds of RRP than unmarried participants (aOR 1.74, 95% CI = 1.08 to 2.80; p = 0.022). Conclusions Among women engaged in a CHW-led intervention, anxiety, chronic food insecurity, and prior pregnancy loss were key factors associated with RRP. These findings highlight the need for preventive strategies that address both psychosocial and structural factors of reproductive health. pregnancy outcomes birth intervals community health workers social determinants of health Background In the United States, nearly one-third of live births occur following interpregnancy intervals of less than 18 months, with the burden disproportionately higher among young (< 20 years) and non-Hispanic Black women [ 1 , 2 ]. Short interpregnancy intervals—the interval between pregnancies of less than 18 months― or rapid repeat pregnancies (RRP)―the interval between the birth dates of two biological children less than 27 months― are associated with adverse maternal and perinatal outcomes, including preterm birth, small for gestational age, low birthweight, congenital abnormalities, neonatal intensive care unit admission, premature rupture of membranes, and perinatal mortality [ 3 – 17 ]. For women, RRP has been associated with higher rates of cesarean delivery and postpartum hemorrhage [ 18 ]. For these reasons, preventing RRP is a significant public health priority. Social determinants of health play a central role in RRP, underscoring the importance of addressing sociodemographic and structural factors in prevention efforts. Lower educational attainment, low socioeconomic status, housing instability, and lack of health insurance can limit access to reproductive healthcare and resources, thereby increasing the risk of RRP [ 19 – 23 ].Age ( 35 years), minority race or ethnicity, unmarried status, substance use, and maternal health conditions are additional risk factors [ 20 , 21 , 24 – 34 ], demonstrating underlying social inequities in addressing RRP. These barriers result in fewer interactions with the healthcare system and limited structural efforts to prevent RRP, including family planning counseling, contraceptive access, and continuity of care following a prior birth. Still, preventive efforts should focus on enhancing routine prenatal care and promoting attendance at postpartum visits, as these represent critical opportunities for counseling on optimal birth spacing, assessment of psychosocial needs, and initiation or continuation of effective contraception [ 20 , 35 – 37 ]. Women at risk for RRP are often affected by a complex interplay of multiple determinants. Those experiencing intimate partner violence are more likely to delay prenatal care due to structural and contextual barriers, including transportation limitations, competing work demands, lack of childcare, and concerns about disclosing a pregnancy [ 21 , 33 , 34 , 38 – 41 ]. Similarly, adolescents and low-income populations with unintended pregnancies experience higher rates of psychosocial stress, including anxiety and depression, and face additional challenges in accessing timely prenatal and postpartum care [ 25 , 42 , 43 ]. Notably, psychosocial stressors may persist even among women with access to support programs. For example, a study among Black pregnant women with short interpregnancy intervals found that, despite social support and access to the Women, Infants, and Children program, persistent negative feelings toward the pregnancy were associated with late entry into prenatal care and increased risk of RRP [ 44 ]. These findings suggest that psychosocial and structural barriers can limit the effectiveness of existing support programs, underscoring the need for interventions that address determinants of health across multiple levels. Effective prevention therefore requires coordinated, multisystem approaches integrating clinical care with social, behavioral, and structural support. Community health workers (CHWs) are uniquely positioned to address this need. By providing culturally tailored education, facilitating access to resources ranging from reproductive healthcare to housing and food support, and offering consistent, trusted engagement, CHWs can address the overlapping social and structural determinants that place women at risk for RRP. WeCare Indiana is a community-based, CHW-led intervention developed to address these interrelated determinants in Marion County, Indiana, a region disproportionately burdened by some of the state’s highest infant mortality rates [ 45 ]. The program provides women with individualized support, connecting participants to resources such as the Women, Infants, and Children program, food assistance, and reproductive health services, while offering education on topics including optimal birthing spacing. Prior program evaluations have demonstrated measurable improvements in depression, anxiety, social determinants of health, and program engagement among women enrolled in WeCare [ 46 ]. However, the extent to which psychosocial and behavioral risk factors, such as food and housing insecurity, mental health, substance use, and miscarriage, contribute to RRP within this population remains unclear. The objective of this prospective cohort evaluation is to assess the impact of a CHW-led intervention, the WeCare program, on high-priority maternal and infant health risk factors associated with RRP. Methods Program Development WeCare was developed through a community–academic partnership involving multiple academic institutions in the state of Indiana [ 46 ]. Academic partners provided evidence-based protocols, educational tools, and data analysis. A human-centered design approach, engaging women of childbearing age, clinicians, educators, and community stakeholders was used to review and refine recruitment strategies, study design, and educational materials. All materials were culturally appropriate, grounded in best practices, and written at an eighth-grade literacy level. Setting and Partnerships The program was implemented at seventeen federally qualified health centers (FQHCs) affiliated with four healthcare systems in Marion County, Indiana. These clinics served women from the thirteen ZIP codes with the highest infant mortality risk and were selected based on their strong community integration. WeCare also partnered with community-based organizations addressing food insecurity, maternal and child health, housing instability, behavioral health, and substance use. Community Health Workers and Training Twenty CHWs were recruited from the target communities based on prior community engagement experience, cultural competence, interpersonal skills, and commitment to serving underserved populations. CHWs completed approximately 30 hours of in-person training covering infant mortality risk factors, motivational interviewing, communication, care coordination, and documentation. Competency-based certification was required prior to service delivery. Ongoing training and supervision were provided through weekly case conferences and regular supervisory meetings. Participants and Recruitment The study was approved by Indian University’s institutional review board and was conducted in accordance with Indiana University’s research guidelines (Protocol #: 1510442771 approved on 1/11/16). Participants were recruited from obstetric and pediatric clinics at participating FQHCs and through referrals from community partners. Eligible participants were pregnant or caring for an infant under one year of age. All enrolled participants were followed an average of 32 months, had at least one delivery after the enrollment, or were postpartum at the time of enrollment. CHWs obtained verbal informed consent using a standardized study information sheet. Intervention CHWs delivered individualized health coaching through in-person, telephone, or text-based interactions. Initial contact occurred within one week of enrollment, with follow-up visits conducted monthly or as needed based on participant priorities. CHWs collaborated with clinical team members to address identified risks and updated participant risk profiles over time. Participants received need-based incentives and support, including transportation assistance, breastfeeding supplies, smoking cessation aids, safe sleep equipment, and food resources. CHWs also facilitated referrals to community services and could provide limited emergency assistance when other resources were unavailable. Data Collection Primary outcomes included maternal mental health (depression, anxiety, substance misuse), food insecurity, tobacco use, safe sleep practices, and breastfeeding. Infant outcomes included birth weight and infant mortality rates, which were compared with county-level data. CHWs administered validated screening instruments, including the Patient Health Questionnaire, Generalized Anxiety Disorder scale [ 47 ], National Institute on Drug Abuse screening questions, and the Global Adult Tobacco Survey. Internally developed surveys assessed food insecurity, safe sleep practices, and breastfeeding [ 46 ]. Data were collected at enrollment and at monthly follow-up visits and entered into a secure REDCap database to support longitudinal analyses [ 48 ]. Participants were asked about the birth date of each child born prior to or during their period of enrollment in WeCare, as well as the expected date of delivery (EDD) and/or birth date of any subsequent pregnancies. The definition of RRP in our study is birth within 27 months from last delivery or time from last delivery to current EDD < 27 months. The RRP interval of 27 months was calculated based on the American College of Obstetrics and Gynecology Interpregnancy Care Consensus guidelines that recommend safely conceiving 18 months after a previous birth [ 49 ], plus nine months of gestation for the subsequent pregnancy. Participants defined as non-RRP had no current EDD, birth from last delivery was ≥ 27 months, and were followed at least 18 months after the last delivery. Participants with current EDD who were considered non-RRP had a birth from last delivery ≥ 27 months and time from last delivery to current EDD ≥ 27 months. Statistical Methods Participant demographic characteristics and follow-up screening results were summarized separately for those with and without RRP. Continuous variables (e.g., age at first birth and duration of program enrollment) were summarized using means and standard deviations and compared between groups using Student’s t tests. Categorical variables (e.g., race/ethnicity, relationship with the father of the baby, depression, anxiety, substance use, food insecurity, transportation insecurity, and childcare insecurity) were summarized as frequencies and percentages and compared using chi-square tests or Fisher’s exact tests, as appropriate. Multivariable logistic regression analysis was used to estimate the association between participant characteristics, follow-up screening results, and the odds of RRP. Covariates included age at first birth, race/ethnicity, duration of program enrollment, depression, anxiety, substance use, food insecurity, transportation insecurity, childcare insecurity, housing insecurity during the study period, and history of miscarriage. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC). Statistical significance was defined as a two-sided p value < 0.05. Results A total of 894 participants were included in the analysis. The mean age at first birth was 26.4 ± 6.2 years. Most participants identified as Black or African American (52.6%), followed by Hispanic (26.5%) and White or other race/ethnicity (20.9%). The majority were unmarried (82.3%). The mean duration of program enrollment was 31.7 ± 14.9 months. Overall, 232 participants (26.0%) experienced RRP, while 662 (74.0%) did not. Participants with RRP were younger at first birth than those without RRP (25.3 ± 5.4 vs. 26.8 ± 6.4 years; p < 0.001). RRP was more common among participants identifying as Black or African American or White and less common among those identifying as Hispanic (56.1%, 23.9%, and 20.0%, respectively, vs. 51.4%, 19.8%, and 28.8%; p = 0.030). Participants with RRP also had a longer mean duration of program enrollment compared with those without RRP (34.1 ± 17.6 vs. 30.8 ± 13.7 months; p = 0.003) (Table 1 ). Table 1 Demographic characteristics comparison between participants with and without RRP Characteristic Overall N = 894 With RRP N = 232 Without RRP N = 662 P-value* Age when gave birth to the first baby (years), mean (± SD) 26.4 ± 6.2 25.3 ± 5.4 26.8 ± 6.4 < .001 Race, n (%) 468 (52.6%) 339 (51.4%) 0.030 Black or African American 129 (56.1%) White or Others 186 (20.9%) 55 (23.9%) 131 (19.8%) Hispanic 236 (26.5%) 46 (20.0%) 190 (28.8%) Relationship with father (at enrollment), n (%) 146 (17.7%) 103 (16.9%) 0.327 Married 43 (19.9%) Others 678 (82.3%) 173 (80.1%) 505 (83.1%) Duration of time enrolled/active in WeCare (months), mean ( ± SD) 31.7 ± 14.9 34.1 ± 17.6 30.8 ± 13.7 0.003 * Bolded value indicates statistical significance With respect to psychosocial and material hardship indicators, participants with RRP were more likely than those without RRP to screen positive for anxiety on one occasion (16.8% vs. 10.1%; p = 0.025), experience food insecurity on two or more occasions (27.2% vs. 17.7%; p = 0.008), and report a history of miscarriage (5.6% vs. 1.7%; p = 0.001) (Table 2 ). Table 2 Follow up visit comparison between participants with and without RRP Characteristic Overall N = 894 N (%) With RRP N = 232 N (%) Without RRP N = 662 N (%) P-value Depression 0.467 Never/no 779 (87.1%) 197 (84.9%) 582 (87.9%) Positive on one occasion 93 (10.4%) 29 (12.5%) 64 (9.7%) Positive on two or more occasions 22 (2.5%) 6 (2.6%) 16 (2.4%) Anxiety 0.025 Never/no 734 (82.1%) 180 (77.6%) 554 (83.7%) Positive on one occasion 106 (11.9%) 39 (16.8%) 67 (10.1%) Positive on two or more occasions 54 (6.0%) 13 (5.6%) 41 (6.2%) Substances 0.466 Never/no 651 (73.0%) 171 (73.7%) 480 (72.7%) Positive on one occasion 180 (20.2%) 42 (18.1%) 138 (20.9%) Positive on two or more occasions 61 (6.8%) 19 (8.2%) 42 (6.4%) Partner or interpersonal violence 0.789 No 817 (91.4%) 213 (91.8%) 604 (91.2%) Yes 77 (8.6%) 19 (8.2%) 58 (8.8%) Food insecurity 0.008 Never/no 464 (52.0%) 113 (48.7%) 351 (53.2%) Positive on one occasion 248 (27.8%) 56 (24.1%) 192 (29.1%) Positive on two or more occasions 180 (20.2%) 63 (27.2%) 117 (17.7%) Transportation insecurity 0.391 Never/no 631 (70.9%) 155 (67.4%) 476 (72.1%) Positive on one occasion 202 (22.7%) 58 (25.2%) 144 (21.8%) Positive on two or more occasions 57 (6.4%) 17 (7.4%) 40 (6.1%) Childcare insecurity 0.309 Never/no 581 (73.3%) 160 (74.4%) 421 (72.8%) Positive on one occasion 162 (20.4%) 38 (17.7%) 124 (21.5%) Positive on two or more occasions 50 (6.3%) 17 (7.9%) 33 (5.7%) House insecurity 0.185 Never/no 654 (73.4%) 171 (73.7%) 483 (73.3%) Positive on one occasion 155 (17.4%) 34 (14.7%) 121 (18.4%) Positive on two or more occasions 82 (9.2%) 27 (11.6%) 55 (8.3%) Discussion of birth spacing 0.250 No 4 (25.0%) 3 (20.0%) 1 (100.0%) Yes 12 (75.0%) 12 (80.0%) History of miscarriage 0.001 No 870 (97.3%) 219 (94.4%) 651 (98.3%) Yes 24 (2.7%) 13 (5.6%) 11 (1.7%) * Bolded value indicates statistical significance Table 2 . Follow up visit comparison between participants with and without RRP In multivariable logistic regression analysis, younger age at first birth was associated with higher risk of RRP (adjusted OR 0.95 with one-year increase in age, 95% CI 0.92–0.98; p < 0.001). Screening positive for anxiety on one occasion was associated with increased odds of RRP (adjusted OR 1.90, 95% CI 1.09–3.33; p = 0.024), as was experiencing food insecurity on two or more occasions (adjusted OR 1.99, 95% CI 1.23–3.24; p = 0.005). A history of miscarriage was also associated with higher odds of RRP (adjusted OR 2.80, 95% CI 1.07–7.34; p = 0.036). Married participants had higher adjusted odds of RRP compared with unmarried participants (adjusted OR 1.74, 95% CI 1.08–2.80; p = 0.022). Hispanic ethnicity was associated with lower odds of RRP compared with White or other race/ethnicity (adjusted OR 0.57, 95% CI 0.34–0.97; p = 0.037) (Table 3 ). Table 3 Multivariable logistic regression analysis estimates probability of RRP (Total N = 750, without RRP: n = 548, with RRP: n = 202) Effect Odd ratio (95%CI) P-value Age at first birth (with one-year increase in age) 0.95 (0.92, 0.98) < .001 Race: Black or African American vs White or Others 0.92 (0.59, 1.43) 0.696 Race: Hispanic vs White or Others 0.57 (0.34, 0.97) 0.037 Married vs Others 1.74 (1.08, 2.80) 0.022 Duration of time enrolled/active in WeCare 1.01 (1.00, 1.02) 0.224 Depression: Positive on one occasion vs Never/no 1.03 (0.55, 1.93) 0.923 Depression: Positive on two or more occasion vs Never/no 0.86 (0.22, 3.35) 0.824 Anxiety: Positive on one occasion vs Never/no 1.90 (1.09, 3.33) 0.024 Anxiety: Positive on two or more occasion vs Never/no 0.58 (0.23, 1.47) 0.250 Substance use: Positive on one occasion vs Never/no 0.72 (0.45, 1.15) 0.165 Substance use: Positive on two or more occasion vs Never/no 0.95 (0.47, 1.93) 0.893 Violence: Yes vs No 0.75 (0.40, 1.44) 0.391 Food insecurity: Positive on one occasion vs Never/no 0.93 (0.61, 1.43) 0.756 Food insecurity: Positive on two or more occasion vs Never/no 1.99 (1.23, 3.24) 0.005 Transportation insecurity: Positive on one occasion vs Never/no 1.33 (0.87, 2.03) 0.188 Transportation insecurity: Positive on two or more occasion vs Never/no 0.91 (0.44, 1.91) 0.809 Childcare insecurity: Positive on one occasion vs Never/no 0.76 (0.48, 1.20) 0.237 Childcare insecurity: Positive on two or more occasion vs Never/no 1.39 (0.67, 2.88) 0.370 House insecurity: Positive on one occasion vs Never/no 0.71 (0.43, 1.16) 0.175 House insecurity: Positive on two or more occasion vs Never/no 0.88 (0.45, 1.72) 0.716 Miscarriage: Yes vs No 2.80 (1.07, 7.34) 0.036 * Bolded value indicates statistical significance Table 3 . Multivariable logistic regression analysis estimates probability of RRP (Total N = 750, without RRP: n = 548, with RRP: n = 202) Discussion Preventing RRPs improves health outcomes for both mothers and infants by reducing the risk of adverse births through integrated social support and CHW-led interventions that address multiple social determinants of health. In this prospective cohort of women at high risk for adverse birth outcomes participating in a CHW-led intervention, risk factors such as younger age at first birth, anxiety, repeated food insecurity, and a history of miscarriage were associated with increased risk of RRP, whereas Hispanic ethnicity was associated with lower risk. Younger age at first birth as a risk factor for RRP is consistent with prior population-based and cohort studies [ 2 , 20 , 21 , 24 – 26 ], suggesting that younger women are more likely to encounter gaps in postpartum care and contraceptive counseling following the early postpartum period [ 35 – 37 ]. Our additional findings demonstrate the multifactorial influences of RRP and the importance of addressing psychosocial stressors and structural barriers within a community-based support model. While the existing literature focuses on depression as a risk factor for RRP [ 23 , 26 , 30 ], our findings also suggest that anxiety may play a significant role, especially in young adults. Anxiety may impair risk perception, decision-making, and the ability to plan or consistently use contraception, particularly in the context of navigating multiple social and economic stressors. From a social-ecological perspective, anxiety may disrupt protective mechanisms across individual, interpersonal, and structural domains, including relationship stability and engagement with healthcare systems [ 50 ]. There is also emerging evidence linking socioeconomic deprivation and perinatal anxiety [ 27 ], as well as an increased risk of RRP among women with serious mental health conditions [ 28 , 29 ]. Our findings highlight the need for targeted interventions that extend beyond the immediate postpartum window with timely referral and treatments among CHW-led maternal health programs. Repeated food insecurity is another salient factor associated with RRP in our study, with women screening positive on two or more occasions experiencing nearly twice the odds of an RRP. Food insecurity often co-occurs with broader economic instability, housing insecurity, and limited access to healthcare, which can impact a woman’s ability to prioritize family planning or maintain consistent contraceptive use [ 19 , 20 , 44 ]. The ‘scarcity mindset’ framework, whereby persistent resource insecurity shifts cognitive and emotional focus toward meeting immediate survival needs, may be one potential mechanism underlying this association, in which women experiencing persistent food insecurity may have less capacity for longer-term decision-making, including reproductive planning. Evidence from a qualitative study in Malawi examining reproductive decision-making demonstrates that women experiencing chronic scarcity were more likely to engage in short-term coping behaviors that increased their risk of unintended, short interpregnancy intervals [ 51 ]. Despite differences in sociocultural context, this framework may help explain our findings in a US-based high-risk population. Notably, persistent food insecurity remained a risk factor despite participation in a thoughtfully designed CHW-led program connecting women with social resources. This finding suggests that existing safety-net services may be insufficient to fully mitigate the effects of food insecurity and hardships faced by mothers in historically disadvantaged groups. These structural determinants are demonstrated to contribute to interpregnancy intervals, and our findings support the need for sustained investments in economic and food security when addressing RRP prevention [ 21 , 44 ]. Finally, a history of miscarriage being associated with RRP reflects complex emotional and psychological responses to pregnancy loss, most notably the desire to conceive again. Prior studies have demonstrated increased risk of pre-term birth, cesarean delivery, and post-partum hemorrhage following shorter pregnancy intervals due to missed miscarriage [ 18 ]. Interestingly, Hispanic participants in this cohort had a lower risk of RRP compared with White or other racial groups, consistent with prior literature [ 13 , 42 ]. Longer pregnancy intervals in Hispanic families may reflect cultural norms, stronger family and social support networks, and differences in fertility intentions or contraceptive behaviors. Future research is needed to better understand how trauma-informed and culturally grounded approaches may improve interventions aimed at reducing RRP in unique populations, such as women experiencing pregnancy loss and immigrant families. We found an association between being married and higher odds of RRP, which contrasts with some prior studies [ 24 , 31 ]. However, this finding may reflect higher pregnancy intention among married women, even when pregnancies occur within shorter intervals. Understanding the distinction between intended and unintended RRP is important in prevention efforts, as both have different health implications and require tailored intervention strategies. Intention to become pregnant was not directly measured in this study, highlighting an important area for future research. Although all participants in this study cohort were followed long enough to have experienced a RRP, participants who experienced RRP remained enrolled in the program longer than those who did not. This finding suggests that engagement alone may be insufficient to prevent RRP among women facing psychosocial and structural barriers. Prior work demonstrates that access to care, while necessary, is not always sufficient to overcome entrenched social determinants of health [ 19 , 44 ]. CHWs are uniquely positioned to address these challenges through sustained relationships, integration of mental health support, facilitation of access to food and economic resources, and reinforcement of reproductive life planning over time. However, our results suggest that CHW-led interventions must be complemented with system-level supports, such as guaranteed access to postpartum contraception, expanded Medicaid benefits, and strengthened social safety-net programs, to achieve meaningful reductions in RRP [ 35 – 38 ]. Several limitations should be considered when interpreting these findings. Information on contraceptive use, pregnancy intention, and partner characteristics was not available, limiting our ability to fully contextualize RRP risk. Screening measures captured the presence of psychosocial and material hardships but may not fully reflect their severity or duration. Finally, this study was conducted within a single urban county among women engaged in a CHW-led intervention, which may limit generalizability to other populations and settings. Conclusion Despite these limitations, this study contributes important evidence on factors associated with RRP among women at high risk for adverse birth outcomes. Anxiety, persistent food insecurity, and prior pregnancy loss emerged as key, potentially modifiable risk factors that warrant attention in RRP prevention efforts. CHW-led models offer a promising platform for addressing these risks, but their impact will depend on sustained policy and funding support that addresses the structural conditions underlying RRP. Future research should examine whether integrating enhanced mental health services, economic support, and family planning into CHW programs can further reduce RRP and improve maternal and infant health outcomes. Declarations Ethics approval and consent to participate: The study was approved by the Indiana University institutional review board and was conducted in accordance with Indiana University’s research guidelines (Protocol #: 1510442771) and the Helsinki Declaration. CHWs obtained verbal informed consent using a standardized study information sheet. Consent for publication: Not applicable. Competing interest: The authors have no conflicts of interest to declare. Funding: This research was funded from a grant from the Indiana State Department of Health (Account Number: 4781008). Author Contribution The individual contributions of authors are as follows: conceptualization, DKL; methodology, DKL, QT; formal analysis, QT and DKL; investigation, DKL; data curation, DKL and QT; writing—original draft preparation, DKL, QT, and AD; writing—review and editing, DKL, QT, AD, MT; visualization, DKL and QT; supervision, DKL; funding acquisition, DKL. All authors have read and agreed to the published version of the manuscript. Acknowledgement The authors wish to acknowledge all members of the WeCare team including the leadership/management team members, the WeCare Community Health Worker’s supervisors, and the WeCare Community Health Workers. Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. References Admon LK, MacCallum-Bridges C, Daw JR. Trends in Short Interpregnancy Interval Births in the United States, 2016–2022. 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Prevalence and correlates of very rapid repeat pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 2009–2020. Paediatr Perinat Epidemiol Jan. 2024;38(1):56–65. 10.1111/ppe.13014 . Dunne J, Foo D, Jancey J et al. Determinants of short interpregnancy intervals in high-income countries: a systematic review. Sex Reprod Health Matters Sep 1 2025:1–31. 10.1080/26410397.2025.2545699 Zhang Y, Quist A, Enquobahrie D. Short birth-to-pregnancy intervals among African-born black women in Washington State. J Matern Fetal Neonatal Med. Mar 2019;32(6):947–53. 10.1080/14767058.2017.1395850 . Bennett IM, Culhane JF, McCollum KF, Elo IT. Unintended rapid repeat pregnancy and low education status: any role for depression and contraceptive use? Am J Obstet Gynecol Mar. 2006;194(3):749–54. 10.1016/j.ajog.2005.10.193 . Cheslack Postava K, Winter AS. Short and long interpregnancy intervals: correlates and variations by pregnancy timing among U.S. women. Perspect Sex Reprod Health Mar. 2015;47(1):19–26. 10.1363/47e2615 . Gemmill A, Lindberg LD. Short interpregnancy intervals in the United States. Obstet Gynecol Jul. 2013;122(1):64–71. 10.1097/AOG.0b013e3182955e58 . Backley S, Knee A, Pekow P, et al. Prenatal Depression and Risk of Short Interpregnancy Interval in a Predominantly Puerto Rican Population. J Womens Health (Larchmt) Nov. 2020;29(11):1410–8. 10.1089/jwh.2019.8201 . Best C, Ayers S, Sinesi A, et al. Socioeconomic deprivation and perinatal anxiety: an observational cohort study. BMC Public Health Nov. 2024;15(1):3183. 10.1186/s12889-024-20608-4 . Brown HK, Ray JG, Liu N, Lunsky Y, Vigod SN. Rapid repeat pregnancy among women with intellectual and developmental disabilities: a population-based cohort study. CMAJ . Aug 13. 2018;190(32):E949-E956. 10.1503/cmaj.170932 Gupta R, Brown HK, Barker LC, Dennis CL, Vigod SN. Rapid repeat pregnancy in women with schizophrenia. Schizophr Res Oct. 2019;212:86–91. 10.1016/j.schres.2019.08.007 . Patchen L, Lanzi RG. Maternal depression and rapid subsequent pregnancy among first time mothers. MCN Am J Matern Child Nurs Jul-Aug. 2013;38(4):215–20. 10.1097/NMC.0b013e3182861572 . Brunner Huber LR, Smith K, Sha W, Zhao L, Vick T. Factors associated with pregnancy intention among women who have experienced a short birth interval: findings from the 2009 to 2011 Mississippi and 2009 Tennessee Pregnancy Risk Assessment Monitoring System. Ann Epidemiol Jun. 2018;28(6):372–6. 10.1016/j.annepidem.2018.03.012 . Loree AM, Gariepy A, Ruger JP, Yonkers KA. Postpartum Contraceptive use and Rapid Repeat Pregnancy Among Women who use Substances. Subst Use Misuse Jan. 2018;2(1):162–9. 10.1080/10826084.2017.1327976 . Scribano PV, Stevens J, Kaizar E, Team N-IR. The effects of intimate partner violence before, during, and after pregnancy in nurse visited first time mothers. Matern Child Health J Feb. 2013;17(2):307–18. 10.1007/s10995-012-0986-y . Rozario SS, Gondwe T, Masho SW. Pre-Pregnancy Intimate Partner Violence and Short Interbirth Interval: The Role of Insurance Status. J Interpers Violence Dec. 2021;36(23–24):11260–80. 10.1177/0886260519897325 . White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol Jun. 2015;125(6):1471–7. 10.1097/AOG.0000000000000841 . Wu M, Eisenberg R, Negassa A, Levi E. Associations between immediate postpartum long-acting reversible contraception and short interpregnancy intervals. Contraception Dec. 2020;102(6):409–13. 10.1016/j.contraception.2020.08.016 . Gifford K, McDuffie MJ, Rashid H, et al. Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population. Contraception Sep. 2021;104(3):284–8. 10.1016/j.contraception.2021.05.006 . Liu A, Hernandez V, Stulberg D, et al. Short-Interval Pregnancy Following Delivery in Catholic-Affiliated Versus Non-Catholic-Affiliated Hospitals Among Patients Insured Through the Medicaid Program. Perspect Sex Reprod Health Sep. 2025;57(3):321–8. 10.1111/psrh.70021 . Liu A, Hernandez V, Dude A, et al. Racial and ethnic disparities in short interval pregnancy following delivery in Catholic vs non-Catholic hospitals among California Medicaid enrollees. Contraception Mar. 2024;131:110308. 10.1016/j.contraception.2023.110308 . Caldwell A, Schumm P, Murugesan M, Stulberg D. Short-interval pregnancy in the Illinois Medicaid population following delivery in Catholic vs non-Catholic hospitals. Contraception Aug. 2022;112:105–10. 10.1016/j.contraception.2022.02.009 . Testa A, Lee J, Semenza DC, Jackson DB, Ganson KT, Nagata JM. Intimate partner violence and barriers to prenatal care. Soc Sci Med Mar. 2023;320:115700. 10.1016/j.socscimed.2023.115700 . Kim TY, Dagher RK, Chen J. Racial/Ethnic Differences in Unintended Pregnancy: Evidence From a National Sample of U.S. Women. Am J Prev Med Apr. 2016;50(4):427–35. 10.1016/j.amepre.2015.09.027 . Cruz-Bendezu AM, Lovell GV, Roche B, et al. Psychosocial status and prenatal care of unintended pregnancies among low-income women. BMC Pregnancy Childbirth Oct. 2020;12(1):615. 10.1186/s12884-020-03302-2 . McFarland KV, Hefelfinger LM, Mendez CV, DeFranco EA, Kelly E. Social determinants among Black people during pregnancy following a short interpregnancy interval. AJOG Glob Rep Nov. 2023;3(4):100279. 10.1016/j.xagr.2023.100279 . Family Health Data and Fatality Prevention Division. Indiana Infant Mortality and Birth Outcomes, 2023. 2025. https://www.in.gov/health/mch/files/2023-Infant-Mortality-Morbidity.pdf Litzelman DK, Umoren RA, Inui TS, et al. Evaluation of a Program to Reduce Infant Mortality Risk Factors in Central Indiana. J Health Care Poor Underserved. 2022;33(3):1461–77. 10.1353/hpu.2022.0124 . Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-7. 10.1001/archinte.166.10.1092 . PMID: 16717171. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform Apr. 2009;42(2):377–81. 10.1016/j.jbi.2008.08.010 . Obstetric Care Consensus No. 8: Interpregnancy Care. Obstet Gynecol. 2019;133(1). Raneri LG, Wiemann CM. Social Ecological Predictors of Repeat Adolescent Pregnancy. Perspectives on Sexual and Reproductive Health . 2007/03/01 2007;39(1):39–47. https://doi.org/10.1363/3903907 Norris AH, Rao N, Huber-Krum S, Garver S, Chemey E, Norris Turner A. Scarcity mindset in reproductive health decision making: a qualitative study from rural Malawi. Cult Health Sex Dec. 2019;21(12):1333–48. 10.1080/13691058.2018.1562092 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers invited by journal 11 Mar, 2026 Editor assigned by journal 18 Feb, 2026 Submission checks completed at journal 16 Feb, 2026 First submitted to journal 16 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Litzelman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYDCCM8wNB4CUDD8ziMdGlBbGhgNAPTySzaRoYQBpMThArBa+MwcbD3/4Y8NjfJzHgOFD2WHCWiTPNgIdxpPGY3aYx4BxxjkitBicB/lF4jBYCzNvG9FaDP7zGDcDtfwlSgvYYQkHgOqBiJEYLZJnDjYcOHMgmUfiMFvBwZ5z6YS18J1JPvyh4o+dHH//4Y0PfpRZE9aCAg6QqH4UjIJRMApGAS4AALaDP6Qie8SiAAAAAElFTkSuQmCC","orcid":"","institution":"Indiana University","correspondingAuthor":true,"prefix":"","firstName":"Debra","middleName":"K.","lastName":"Litzelman","suffix":""},{"id":605252614,"identity":"974b7583-2775-4925-8540-c01c2ac87559","order_by":1,"name":"Qing Tang","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Tang","suffix":""},{"id":605252615,"identity":"a094c955-00cf-472b-b5e6-8dce539b3e02","order_by":2,"name":"Angela M. Diaz","email":"","orcid":"","institution":"Indiana University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"M.","lastName":"Diaz","suffix":""},{"id":605252616,"identity":"51a3426e-4b69-4b3b-9dd7-93a85585029c","order_by":3,"name":"Melissa R. Thomas","email":"","orcid":"","institution":"Regenstrief Institute","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"R.","lastName":"Thomas","suffix":""}],"badges":[],"createdAt":"2026-02-09 19:39:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8833935/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8833935/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104781836,"identity":"5a291798-8c6a-4731-8269-4ae903bef9f4","added_by":"auto","created_at":"2026-03-17 07:56:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":980679,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8833935/v1/ed1d571a-b692-458b-83e5-5bd30f9e7bf4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Associated with Rapid Repeat Pregnancies in Women at High Risk for Adverse Birth Outcomes","fulltext":[{"header":"Background","content":"\u003cp\u003eIn the United States, nearly one-third of live births occur following interpregnancy intervals of less than 18 months, with the burden disproportionately higher among young (\u0026lt;\u0026thinsp;20 years) and non-Hispanic Black women [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Short interpregnancy intervals\u0026mdash;the interval between pregnancies of less than 18 months― or rapid repeat pregnancies (RRP)―the interval between the birth dates of two biological children less than 27 months― are associated with adverse maternal and perinatal outcomes, including preterm birth, small for gestational age, low birthweight, congenital abnormalities, neonatal intensive care unit admission, premature rupture of membranes, and perinatal mortality [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For women, RRP has been associated with higher rates of cesarean delivery and postpartum hemorrhage [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. For these reasons, preventing RRP is a significant public health priority.\u003c/p\u003e \u003cp\u003eSocial determinants of health play a central role in RRP, underscoring the importance of addressing sociodemographic and structural factors in prevention efforts. Lower educational attainment, low socioeconomic status, housing instability, and lack of health insurance can limit access to reproductive healthcare and resources, thereby increasing the risk of RRP [\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].Age (\u0026lt;\u0026thinsp;20 or \u0026gt;\u0026thinsp;35 years), minority race or ethnicity, unmarried status, substance use, and maternal health conditions are additional risk factors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], demonstrating underlying social inequities in addressing RRP. These barriers result in fewer interactions with the healthcare system and limited structural efforts to prevent RRP, including family planning counseling, contraceptive access, and continuity of care following a prior birth. Still, preventive efforts should focus on enhancing routine prenatal care and promoting attendance at postpartum visits, as these represent critical opportunities for counseling on optimal birth spacing, assessment of psychosocial needs, and initiation or continuation of effective contraception [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWomen at risk for RRP are often affected by a complex interplay of multiple determinants. Those experiencing intimate partner violence are more likely to delay prenatal care due to structural and contextual barriers, including transportation limitations, competing work demands, lack of childcare, and concerns about disclosing a pregnancy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Similarly, adolescents and low-income populations with unintended pregnancies experience higher rates of psychosocial stress, including anxiety and depression, and face additional challenges in accessing timely prenatal and postpartum care [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Notably, psychosocial stressors may persist even among women with access to support programs. For example, a study among Black pregnant women with short interpregnancy intervals found that, despite social support and access to the Women, Infants, and Children program, persistent negative feelings toward the pregnancy were associated with late entry into prenatal care and increased risk of RRP [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. These findings suggest that psychosocial and structural barriers can limit the effectiveness of existing support programs, underscoring the need for interventions that address determinants of health across multiple levels.\u003c/p\u003e \u003cp\u003eEffective prevention therefore requires coordinated, multisystem approaches integrating clinical care with social, behavioral, and structural support. Community health workers (CHWs) are uniquely positioned to address this need. By providing culturally tailored education, facilitating access to resources ranging from reproductive healthcare to housing and food support, and offering consistent, trusted engagement, CHWs can address the overlapping social and structural determinants that place women at risk for RRP. WeCare Indiana is a community-based, CHW-led intervention developed to address these interrelated determinants in Marion County, Indiana, a region disproportionately burdened by some of the state\u0026rsquo;s highest infant mortality rates [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The program provides women with individualized support, connecting participants to resources such as the Women, Infants, and Children program, food assistance, and reproductive health services, while offering education on topics including optimal birthing spacing. Prior program evaluations have demonstrated measurable improvements in depression, anxiety, social determinants of health, and program engagement among women enrolled in WeCare [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, the extent to which psychosocial and behavioral risk factors, such as food and housing insecurity, mental health, substance use, and miscarriage, contribute to RRP within this population remains unclear.\u003c/p\u003e \u003cp\u003eThe objective of this prospective cohort evaluation is to assess the impact of a CHW-led intervention, the WeCare program, on high-priority maternal and infant health risk factors associated with RRP.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProgram Development\u003c/h2\u003e \u003cp\u003eWeCare was developed through a community\u0026ndash;academic partnership involving multiple academic institutions in the state of Indiana [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Academic partners provided evidence-based protocols, educational tools, and data analysis. A human-centered design approach, engaging women of childbearing age, clinicians, educators, and community stakeholders was used to review and refine recruitment strategies, study design, and educational materials. All materials were culturally appropriate, grounded in best practices, and written at an eighth-grade literacy level.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and Partnerships\u003c/h3\u003e\n\u003cp\u003eThe program was implemented at seventeen federally qualified health centers (FQHCs) affiliated with four healthcare systems in Marion County, Indiana. These clinics served women from the thirteen ZIP codes with the highest infant mortality risk and were selected based on their strong community integration. WeCare also partnered with community-based organizations addressing food insecurity, maternal and child health, housing instability, behavioral health, and substance use.\u003c/p\u003e\n\u003ch3\u003eCommunity Health Workers and Training\u003c/h3\u003e\n\u003cp\u003eTwenty CHWs were recruited from the target communities based on prior community engagement experience, cultural competence, interpersonal skills, and commitment to serving underserved populations. CHWs completed approximately 30 hours of in-person training covering infant mortality risk factors, motivational interviewing, communication, care coordination, and documentation. Competency-based certification was required prior to service delivery. Ongoing training and supervision were provided through weekly case conferences and regular supervisory meetings.\u003c/p\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003e The study was approved by Indian University\u0026rsquo;s institutional review board and was conducted in accordance with Indiana University\u0026rsquo;s research guidelines (Protocol #: 1510442771 approved on 1/11/16). Participants were recruited from obstetric and pediatric clinics at participating FQHCs and through referrals from community partners. Eligible participants were pregnant or caring for an infant under one year of age. All enrolled participants were followed an average of 32 months, had at least one delivery after the enrollment, or were postpartum at the time of enrollment. CHWs obtained verbal informed consent using a standardized study information sheet.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eCHWs delivered individualized health coaching through in-person, telephone, or text-based interactions. Initial contact occurred within one week of enrollment, with follow-up visits conducted monthly or as needed based on participant priorities. CHWs collaborated with clinical team members to address identified risks and updated participant risk profiles over time. Participants received need-based incentives and support, including transportation assistance, breastfeeding supplies, smoking cessation aids, safe sleep equipment, and food resources. CHWs also facilitated referrals to community services and could provide limited emergency assistance when other resources were unavailable.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003ePrimary outcomes included maternal mental health (depression, anxiety, substance misuse), food insecurity, tobacco use, safe sleep practices, and breastfeeding. Infant outcomes included birth weight and infant mortality rates, which were compared with county-level data. CHWs administered validated screening instruments, including the Patient Health Questionnaire, Generalized Anxiety Disorder scale [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], National Institute on Drug Abuse screening questions, and the Global Adult Tobacco Survey. Internally developed surveys assessed food insecurity, safe sleep practices, and breastfeeding [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData were collected at enrollment and at monthly follow-up visits and entered into a secure REDCap database to support longitudinal analyses [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Participants were asked about the birth date of each child born prior to or during their period of enrollment in WeCare, as well as the expected date of delivery (EDD) and/or birth date of any subsequent pregnancies. The definition of RRP in our study is birth within 27 months from last delivery or time from last delivery to current EDD\u0026thinsp;\u0026lt;\u0026thinsp;27 months. The RRP interval of 27 months was calculated based on the American College of Obstetrics and Gynecology Interpregnancy Care Consensus guidelines that recommend safely conceiving 18 months after a previous birth [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], plus nine months of gestation for the subsequent pregnancy. Participants defined as non-RRP had no current EDD, birth from last delivery was \u0026ge;\u0026thinsp;27 months, and were followed at least 18 months after the last delivery. Participants with current EDD who were considered non-RRP had a birth from last delivery\u0026thinsp;\u0026ge;\u0026thinsp;27 months and time from last delivery to current EDD\u0026thinsp;\u0026ge;\u0026thinsp;27 months.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical Methods\u003c/h3\u003e\n\u003cp\u003eParticipant demographic characteristics and follow-up screening results were summarized separately for those with and without RRP. Continuous variables (e.g., age at first birth and duration of program enrollment) were summarized using means and standard deviations and compared between groups using Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e tests. Categorical variables (e.g., race/ethnicity, relationship with the father of the baby, depression, anxiety, substance use, food insecurity, transportation insecurity, and childcare insecurity) were summarized as frequencies and percentages and compared using chi-square tests or Fisher\u0026rsquo;s exact tests, as appropriate.\u003c/p\u003e \u003cp\u003eMultivariable logistic regression analysis was used to estimate the association between participant characteristics, follow-up screening results, and the odds of RRP. Covariates included age at first birth, race/ethnicity, duration of program enrollment, depression, anxiety, substance use, food insecurity, transportation insecurity, childcare insecurity, housing insecurity during the study period, and history of miscarriage. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC). Statistical significance was defined as a two-sided \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 894 participants were included in the analysis. The mean age at first birth was 26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 years. Most participants identified as Black or African American (52.6%), followed by Hispanic (26.5%) and White or other race/ethnicity (20.9%). The majority were unmarried (82.3%). The mean duration of program enrollment was 31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9 months. Overall, 232 participants (26.0%) experienced RRP, while 662 (74.0%) did not.\u003c/p\u003e \u003cp\u003eParticipants with RRP were younger at first birth than those without RRP (25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 vs. 26.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 years; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). RRP was more common among participants identifying as Black or African American or White and less common among those identifying as Hispanic (56.1%, 23.9%, and 20.0%, respectively, vs. 51.4%, 19.8%, and 28.8%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030). Participants with RRP also had a longer mean duration of program enrollment compared with those without RRP (34.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.6 vs. 30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7 months; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics comparison between participants with and without RRP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;894\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWith RRP\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;232\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWithout RRP\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;662\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge when gave birth to the first baby (years), mean (\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e468 (52.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e339 (51.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 (56.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite or Others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (20.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (23.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e190 (28.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship with father (at enrollment), n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e146 (17.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e103 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (19.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e678 (82.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e173 (80.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e505 (83.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of time enrolled/active in WeCare (months), mean (\u003c/b\u003e\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Bolded value indicates statistical significance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith respect to psychosocial and material hardship indicators, participants with RRP were more likely than those without RRP to screen positive for anxiety on one occasion (16.8% vs. 10.1%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025), experience food insecurity on two or more occasions (27.2% vs. 17.7%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008), and report a history of miscarriage (5.6% vs. 1.7%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFollow up visit comparison between participants with and without RRP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;894\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWith RRP\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;232\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWithout RRP\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;662\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e779 (87.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e197 (84.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e582 (87.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e734 (82.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180 (77.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e554 (83.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106 (11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67 (10.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubstances\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e651 (73.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171 (73.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e480 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e180 (20.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e138 (20.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePartner or interpersonal violence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e817 (91.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e213 (91.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e604 (91.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFood insecurity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e464 (52.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (48.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e351 (53.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e248 (27.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e192 (29.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e180 (20.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63 (27.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e117 (17.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTransportation insecurity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e631 (70.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e155 (67.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e476 (72.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e202 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144 (21.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildcare insecurity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e581 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e160 (74.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e421 (72.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e162 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (17.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e124 (21.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (5.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHouse insecurity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.185\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e654 (73.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171 (73.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e483 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on one occasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e155 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e121 (18.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive on two or more occasions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiscussion of birth spacing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of miscarriage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e870 (97.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e219 (94.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e651 (98.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Bolded value indicates statistical significance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Follow up visit comparison between participants with and without RRP\u003c/p\u003e \u003cp\u003eIn multivariable logistic regression analysis, younger age at first birth was associated with higher risk of RRP (adjusted OR 0.95 with one-year increase in age, 95% CI 0.92\u0026ndash;0.98; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Screening positive for anxiety on one occasion was associated with increased odds of RRP (adjusted OR 1.90, 95% CI 1.09\u0026ndash;3.33; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024), as was experiencing food insecurity on two or more occasions (adjusted OR 1.99, 95% CI 1.23\u0026ndash;3.24; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). A history of miscarriage was also associated with higher odds of RRP (adjusted OR 2.80, 95% CI 1.07\u0026ndash;7.34; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036).\u003c/p\u003e \u003cp\u003eMarried participants had higher adjusted odds of RRP compared with unmarried participants (adjusted OR 1.74, 95% CI 1.08\u0026ndash;2.80; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022). Hispanic ethnicity was associated with lower odds of RRP compared with White or other race/ethnicity (adjusted OR 0.57, 95% CI 0.34\u0026ndash;0.97; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression analysis estimates probability of RRP (Total N\u0026thinsp;=\u0026thinsp;750, without RRP: n\u0026thinsp;=\u0026thinsp;548, with RRP: n\u0026thinsp;=\u0026thinsp;202)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdd ratio (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at first birth (with one-year increase in age)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.92, 0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace: Black or African American vs White or Others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.92 (0.59, 1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace: Hispanic vs White or Others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.57 (0.34, 0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried vs Others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.74 (1.08, 2.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of time enrolled/active in WeCare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.01 (1.00, 1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03 (0.55, 1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.86 (0.22, 3.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.90 (1.09, 3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.58 (0.23, 1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance use: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.45, 1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance use: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.47, 1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViolence: Yes vs No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.75 (0.40, 1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood insecurity: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.93 (0.61, 1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood insecurity: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.99 (1.23, 3.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransportation insecurity: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.33 (0.87, 2.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransportation insecurity: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.91 (0.44, 1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildcare insecurity: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.76 (0.48, 1.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildcare insecurity: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.39 (0.67, 2.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHouse insecurity: Positive on one occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.71 (0.43, 1.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHouse insecurity: Positive on two or more occasion vs Never/no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.88 (0.45, 1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiscarriage: Yes vs No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.80 (1.07, 7.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.036\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Bolded value indicates statistical significance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Multivariable logistic regression analysis estimates probability of RRP (Total N\u0026thinsp;=\u0026thinsp;750, without RRP: n\u0026thinsp;=\u0026thinsp;548, with RRP: n\u0026thinsp;=\u0026thinsp;202)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePreventing RRPs improves health outcomes for both mothers and infants by reducing the risk of adverse births through integrated social support and CHW-led interventions that address multiple social determinants of health. In this prospective cohort of women at high risk for adverse birth outcomes participating in a CHW-led intervention, risk factors such as younger age at first birth, anxiety, repeated food insecurity, and a history of miscarriage were associated with increased risk of RRP, whereas Hispanic ethnicity was associated with lower risk. Younger age at first birth as a risk factor for RRP is consistent with prior population-based and cohort studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], suggesting that younger women are more likely to encounter gaps in postpartum care and contraceptive counseling following the early postpartum period [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Our additional findings demonstrate the multifactorial influences of RRP and the importance of addressing psychosocial stressors and structural barriers within a community-based support model.\u003c/p\u003e \u003cp\u003eWhile the existing literature focuses on depression as a risk factor for RRP [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], our findings also suggest that anxiety may play a significant role, especially in young adults. Anxiety may impair risk perception, decision-making, and the ability to plan or consistently use contraception, particularly in the context of navigating multiple social and economic stressors. From a social-ecological perspective, anxiety may disrupt protective mechanisms across individual, interpersonal, and structural domains, including relationship stability and engagement with healthcare systems [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. There is also emerging evidence linking socioeconomic deprivation and perinatal anxiety [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], as well as an increased risk of RRP among women with serious mental health conditions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our findings highlight the need for targeted interventions that extend beyond the immediate postpartum window with timely referral and treatments among CHW-led maternal health programs.\u003c/p\u003e \u003cp\u003eRepeated food insecurity is another salient factor associated with RRP in our study, with women screening positive on two or more occasions experiencing nearly twice the odds of an RRP. Food insecurity often co-occurs with broader economic instability, housing insecurity, and limited access to healthcare, which can impact a woman\u0026rsquo;s ability to prioritize family planning or maintain consistent contraceptive use [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The \u0026lsquo;scarcity mindset\u0026rsquo; framework, whereby persistent resource insecurity shifts cognitive and emotional focus toward meeting immediate survival needs, may be one potential mechanism underlying this association, in which women experiencing persistent food insecurity may have less capacity for longer-term decision-making, including reproductive planning. Evidence from a qualitative study in Malawi examining reproductive decision-making demonstrates that women experiencing chronic scarcity were more likely to engage in short-term coping behaviors that increased their risk of unintended, short interpregnancy intervals [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite differences in sociocultural context, this framework may help explain our findings in a US-based high-risk population. Notably, persistent food insecurity remained a risk factor despite participation in a thoughtfully designed CHW-led program connecting women with social resources. This finding suggests that existing safety-net services may be insufficient to fully mitigate the effects of food insecurity and hardships faced by mothers in historically disadvantaged groups. These structural determinants are demonstrated to contribute to interpregnancy intervals, and our findings support the need for sustained investments in economic and food security when addressing RRP prevention [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, a history of miscarriage being associated with RRP reflects complex emotional and psychological responses to pregnancy loss, most notably the desire to conceive again. Prior studies have demonstrated increased risk of pre-term birth, cesarean delivery, and post-partum hemorrhage following shorter pregnancy intervals due to missed miscarriage [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Interestingly, Hispanic participants in this cohort had a lower risk of RRP compared with White or other racial groups, consistent with prior literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Longer pregnancy intervals in Hispanic families may reflect cultural norms, stronger family and social support networks, and differences in fertility intentions or contraceptive behaviors. Future research is needed to better understand how trauma-informed and culturally grounded approaches may improve interventions aimed at reducing RRP in unique populations, such as women experiencing pregnancy loss and immigrant families.\u003c/p\u003e \u003cp\u003eWe found an association between being married and higher odds of RRP, which contrasts with some prior studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, this finding may reflect higher pregnancy intention among married women, even when pregnancies occur within shorter intervals. Understanding the distinction between intended and unintended RRP is important in prevention efforts, as both have different health implications and require tailored intervention strategies. Intention to become pregnant was not directly measured in this study, highlighting an important area for future research.\u003c/p\u003e \u003cp\u003eAlthough all participants in this study cohort were followed long enough to have experienced a RRP, participants who experienced RRP remained enrolled in the program longer than those who did not. This finding suggests that engagement alone may be insufficient to prevent RRP among women facing psychosocial and structural barriers. Prior work demonstrates that access to care, while necessary, is not always sufficient to overcome entrenched social determinants of health [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. CHWs are uniquely positioned to address these challenges through sustained relationships, integration of mental health support, facilitation of access to food and economic resources, and reinforcement of reproductive life planning over time. However, our results suggest that CHW-led interventions must be complemented with system-level supports, such as guaranteed access to postpartum contraception, expanded Medicaid benefits, and strengthened social safety-net programs, to achieve meaningful reductions in RRP [\u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral limitations should be considered when interpreting these findings. Information on contraceptive use, pregnancy intention, and partner characteristics was not available, limiting our ability to fully contextualize RRP risk. Screening measures captured the presence of psychosocial and material hardships but may not fully reflect their severity or duration. Finally, this study was conducted within a single urban county among women engaged in a CHW-led intervention, which may limit generalizability to other populations and settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite these limitations, this study contributes important evidence on factors associated with RRP among women at high risk for adverse birth outcomes. Anxiety, persistent food insecurity, and prior pregnancy loss emerged as key, potentially modifiable risk factors that warrant attention in RRP prevention efforts. CHW-led models offer a promising platform for addressing these risks, but their impact will depend on sustained policy and funding support that addresses the structural conditions underlying RRP. Future research should examine whether integrating enhanced mental health services, economic support, and family planning into CHW programs can further reduce RRP and improve maternal and infant health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e The study was approved by the Indiana University institutional review board and was conducted in accordance with Indiana University\u0026rsquo;s research guidelines (Protocol #: 1510442771) and the Helsinki Declaration. CHWs obtained verbal informed consent using a standardized study information sheet.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interest:\u003c/h2\u003e \u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was funded from a grant from the Indiana State Department of Health (Account Number: 4781008).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe individual contributions of authors are as follows: conceptualization, DKL; methodology, DKL, QT; formal analysis, QT and DKL; investigation, DKL; data curation, DKL and QT; writing\u0026mdash;original draft preparation, DKL, QT, and AD; writing\u0026mdash;review and editing, DKL, QT, AD, MT; visualization, DKL and QT; supervision, DKL; funding acquisition, DKL. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to acknowledge all members of the WeCare team including the leadership/management team members, the WeCare Community Health Worker\u0026rsquo;s supervisors, and the WeCare Community Health Workers.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdmon LK, MacCallum-Bridges C, Daw JR. Trends in Short Interpregnancy Interval Births in the United States, 2016\u0026ndash;2022. 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Cult Health Sex Dec. 2019;21(12):1333\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13691058.2018.1562092\u003c/span\u003e\u003cspan address=\"10.1080/13691058.2018.1562092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pregnancy outcomes, birth intervals, community health workers, social determinants of health","lastPublishedDoi":"10.21203/rs.3.rs-8833935/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8833935/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRapid repeat pregnancy (RRP), defined as a live birth within 27 months of a prior delivery, is associated with adverse maternal and infant outcomes and reflects underlying social inequities. Our objective is to identify factors associated with RRP among women participating in a community health worker (CHW)-led maternal health intervention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a longitudinal prospective cohort evaluation of pregnant or postpartum women enrolled in the WeCare CHW program at seventeen federally qualified health centers in central Indiana. CHWs delivered individualized health coaching, care coordination, and referrals addressing social determinants of health. Maternal and infant health indicators were assessed using validated and internally developed screening instruments, and RRP was ascertained during program enrollment. Multivariable logistic regression model estimated odds ratios and their 95% confidence intervals for factors associated with RRP, adjusting for covariates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 26% (232/894) of participants experienced RRP. In adjusted analyses, younger age at first birth was associated with higher risk of RRP (adjusted OR\u0026thinsp;=\u0026thinsp;0.95 with one-year increase in age; 95% CI\u0026thinsp;=\u0026thinsp;0.92\u0026ndash;0.98, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Screening positive for anxiety on one occasion (aOR\u0026thinsp;=\u0026thinsp;1.90; 95% CI\u0026thinsp;=\u0026thinsp;1.09 to 3.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024), experiencing food insecurity on two or more occasions (aOR\u0026thinsp;=\u0026thinsp;1.99; 95% CI\u0026thinsp;=\u0026thinsp;1.23 to 3.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005), and having a history of miscarriage (aOR\u0026thinsp;=\u0026thinsp;2.80; 95% CI\u0026thinsp;=\u0026thinsp;1.07 to 7.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) were independently associated with RRP. Hispanic ethnicity was associated with lower odds of RRP (aOR\u0026thinsp;=\u0026thinsp;0.57; 95% CI\u0026thinsp;=\u0026thinsp;0.34 to 0.97, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037), whereas married participants had higher odds of RRP than unmarried participants (aOR 1.74, 95% CI\u0026thinsp;=\u0026thinsp;1.08 to 2.80; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAmong women engaged in a CHW-led intervention, anxiety, chronic food insecurity, and prior pregnancy loss were key factors associated with RRP. These findings highlight the need for preventive strategies that address both psychosocial and structural factors of reproductive health.\u003c/p\u003e","manuscriptTitle":"Factors Associated with Rapid Repeat Pregnancies in Women at High Risk for Adverse Birth Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 21:18:17","doi":"10.21203/rs.3.rs-8833935/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T14:49:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297299036026987775513319912869721272551","date":"2026-05-08T20:24:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T17:06:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22673938299755142725399060059131441352","date":"2026-03-13T15:18:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241301777648673694232175129556494744719","date":"2026-03-12T18:11:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-11T14:59:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-18T07:32:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-16T14:44:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-16T14:39:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dcb15dd1-f849-4e67-872b-63826a142bb5","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T14:49:30+00:00","index":47,"fulltext":""},{"type":"reviewerAgreed","content":"297299036026987775513319912869721272551","date":"2026-05-08T20:24:18+00:00","index":43,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T21:18:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 21:18:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8833935","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8833935","identity":"rs-8833935","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}