Pregnancy rates and pregnancy loss in Eastern Ethiopia

AOGS MAIN RESEARCH ARTICLE

Pregnancy rates and pregnancy loss in Eastern EthiopiaNEGA ASSEFA1, YEMANE BERHANE2 & ALEMAYEHU WORKU2,3

1College of Health Science, Haramaya University, Harar, 2Epidemiology and Public Health, Addis Continental Institute of

Public Health, Addis Ababa, and 3Biostatistics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

Key words

Ethiopia, fertility, incidence of pregnancy,

pregnancy, pregnancy loss, prevalence of

pregnancy

Correspondence

Nega Assefa, College of Health and Medical

Sciences, Haramaya University, Botie Street,

P. O. Box 1494, Harar Town, Ethiopia. E-mail:

[email protected]

Conflict of interest

The authors have stated explicitly that there

are no conflicts of interest in connection with

this article.

Please cite this article as: Assefa N, Berhane

Y, Worku A. Pregnancy rates and pregnancy

loss in Eastern Ethiopia. Acta Obstet Gynecol

Scand 2013; 92:642–647.

Received: 11 April 2012

Accepted: 8 January 2013

DOI: 10.1111/aogs.12097

Abstract

Objective. To determine pregnancy, pregnancy loss and fertility rates in a rural

community of Ethiopia. Design. A prospective population-based pregnancy

surveillance. Setting. Kersa Demographic Surveillance and Health Research

Center, a demographic surveillance site in Eastern Ethiopia. Population. For

pregnancy rates, the study included 7738 women of reproductive age perma-

nently residing in the field research site. For pregnancy loss, 2072 pregnant

women were included. Method. Pregnancy screening was done every third

month from 1 December 2009 to 30 November 2010 using a questionnaire and

a urine pregnancy test. Descriptive analysis was done to calculate the pregnancy

rate and pregnancy loss. Outcome measures. Pregnancy rate and pregnancy loss.

Result. The pregnancy rate was 227/year/1000 women of reproductive age.

During the study period, 1438 pregnancies ended, with 1295 live births and

143 pregnancies that did not yield a live birth (116 due to bleeding and 27

stillbirths). The incidence of pregnancy loss was 220/year/1000 pregnancies.

Based on the one-year data, the total fertility rate was found to be 5.52. The

overall pregnancy loss and stillbirth ratio were 11 and 2.1/100 live births,

respectively. Conclusions. The study identified a high fertility rate that is proba-

bly accentuated by a high proportion of pregnancy loss in the study popula-

tion. Improving access to family planning service to limit the number of

pregnancies and access to antenatal care (to identify higher risk women) is

essential.

Introduction

Pregnancy occurrence and outcomes of pregnancy at pop-

ulation level are not widely studied in low-income coun-

tries, including Ethiopia. This has forced policy makers to

rely on estimates and projections based on cross-sectional

surveys or clinical records (1–3). In these countries, the

majority of women are unlikely to receive contraceptive

services or antenatal care. Institutional delivery and abor-

tion services are either of low quality or not accessible for

the majority of the women (4–7). In such a situation,

identifying pregnant women from the very start is impos-

sible. Therefore, those pregnancies lost during the early

pregnancy period could not be detected. Records from

health facilities can provide information on women who

at least come to visit such facilities once. In most

instances, even a third of all the pregnant women cannot

be reached (1,3,8,9). As a result, the available information

is liable to underestimate the occurrence of adverse preg-

nancy outcomes.

Provision of sufficient information on the occurrence

of pregnancy and its outcome is essential for devising

programs that address the needs of the women and

their babies. Such reproductive health programs may

rescue them from preventable morbidity and mortality.

The objective of this study was to generate community-

based information on pregnancy, fertility and pregnancy

Key Message

One in four women of reproductive age became preg-

nant during 1 year in a rural and low income Ethio-

pian area. One in four pregnancies were lost.

ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 642–647642

A C TA Obstetricia et Gynecologica

loss patterns among married women of reproductive

age.

Material and methods

Pregnancy surveillance was initiated in Kersa Demo-

graphic and Health Surveillance Center site in Kersa dis-

trict, Eastern Hararge zone of Oromia region, Ethiopia.

The study was conducted from December 2009 to

November 2010. The Kersa Demographic Surveillance

and Health Research Center generates population-based

data on health and health-related events through quar-

terly household visits. In addition, special studies like this

one are incorporated into the system to generate specific

information for public health. A census in 2007 showed

that the total population under surveillance was 53 463

with an average household size of 5.2, and women of

child-bearing age accounting for 26% of the general

population.

In general the study area is rural, but 12.2% of the

population lives in a semi-urban area in two small towns

called Kersa and Weter. While the rural population makes

their living by subsistence agriculture, the urban dwellers

live on petty trade or work for the government, receiving

a monthly salary. All of the study site has road access

during the dry season. According to the 2010/2011 dis-

trict health office report, the district had six health cen-

ters and 28 health posts. The health posts are staffed by

at least one health extension worker. In the same year,

the health service coverage of the district was 80%.

The pregnancy surveillance for this study was con-

ducted among currently married women of reproductive

age (15–49 years) permanently living in the Kersa Demo-

graphic Surveillance and Health Research Center field

sites. Ethical clearance was obtained from the national

ethical clearance committee. After explaining the purpose

and procedures of the study, informed consent was

obtained from each study participant. As a majority of

the study participants were illiterate, the data collectors

read out the contents of the informed consent. The study

women were also informed about their right not to par-

ticipate in the study if they were not interested or to

decline after enrollment, if they did not want to continue

in the study.

A pregnancy test was done for every study woman at

the beginning of the surveillance and then every third

month for those who were not pregnant at the initial and

subsequent tests. Once pregnancy was detected, the

women were followed until the end of their pregnancies.

Identifying pregnant women was a two-step process. First,

all women were screened using pregnancy screening ques-

tions adapted from the Kenya family planning enrollment

questionnaire as published in the Lancet (10) (Table 1).

If the answer to at least one of the six pregnancy

screening questions was ‘yes’, pregnancy was ruled out.

Women who responded in a way that suggested the pos-

sibility of being pregnant were asked to provide a urine

sample for a pregnancy test, which was done using a dip-

stick in the respondent’s home (instant human chorionic

gonadotropin, Tina; The Tulip Group, Goa, India). Dur-

ing the pilot study on 120 women in one of the sur-

rounding districts, the sensitivity (the ability of the

questionnaire to pick up women who were pregnant) and

specificity (the ability of the questionnaire to rule out

those not pregnant) of the screening questions were

found to be 100 and 67.7%, respectively.

Women confirmed pregnant were followed every

month at home to record the status of their pregnancy

until its end. If a woman reported bleeding between the

follow-up visits, the event was recorded as a suspected

incident of ended pregnancy and a urine test was done to

confirm the incident in the subsequent follow-up visit.

Those who tested positive were followed until delivery to

determine the pregnancy outcome for both the mother

and the fetus.

Data were collected by trained 10th grade students.

They were supervised by trained nurses. The completeness

and consistency of the questionnaires were checked by

field supervisors and the principal investigator in the

field. Data entry was done using EPI-DATA STATISTI-

CAL APPLICATION 3.1 software (EpiData Association,

Odense, Denmark) and data analysis was performed using

the STATA v.11 Statistical Software (StataCorp., College

Station, TX, USA).

Pregnancy rates were determined by dividing the num-

ber of women positive for pregnancy by the number of

women at risk of pregnancy per year. The number of

women at risk of pregnancy per year were identified by

Table 1. Pregnancy screening questions adapted from Kenya family

planning screening questions, Kersa, Ethiopia, 2010 (10).

S/No Items No Yes

1 Have you given birth in the past 4 weeks?

2 Are you less than 6 months postpartum or

fully breastfeeding and free from menstrual

bleeding since you had your child?

3 Did your last menstrual period start with in

the past 7 days

4 Have you had a miscarriage or an abortion

in the past 7 days?

5 Have you abstained from sexual intercourse

since your last menses?

6 Have you been using a reliable contraceptive

(pills, injectable, and Norplant) method

consistently and correctly?

ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 642–647 643

N. Assefa et al. Pregnancy rates and pregnancy loss

adding all months produced by women of reproductive

age at risk of pregnancy and dividing by 12. In the same

fashion, pregnancy loss rates were calculated using the

number of lost pregnancies (pregnancies that do not

result in a live birth) by number of pregnancies in a year.

The number or pregnancies in a year was obtained by

adding all pregnancy months and dividing by 12. The age

of the women was categorized in 5-year intervals.

Results

A total of 10 198 women were interviewed at the begin-

ning of the surveillance, of whom 7738 women of repro-

ductive age had pregnancy screening. The remaining 2460

women were not screened because of age (post-reproduc-

tive age). The mean age of the study participants was

28.4 years �7.03 SD.

A total of 2072 (26.8%) pregnant women were identi-

fied during the study period. At the initial screening

12.9% (n = 999) were pregnant. In the subsequent three

rounds, 1073 more recently pregnant women were identi-

Table 2. Pregnancy and fertility pattern among married women,

Kersa, Ethiopia, 2010.

Age

(years)

Total women

(n = 7 738)

Pregnant

(n = 2 072)

Live birth

(n = 1 295)

Pregnancy loss

(n = 143)

15–19 471 159 87 12

20–24 1134 345 234 11

25–29 1585 543 339 34

30–34 2056 553 353 50

35–39 1135 241 154 18

40–44 658 195 95 15

45–49 699 36 33 3

Follow up (56706 personmonths)

Round I = 999

Round II = 539

Round III = 237

Round IV = 297Pregnant (2072)

Post reproductive age/menopause (2460)

Women of Reproductive age (7738)

Not pregnant (5666)

Lost to follow-up (150)Pregnancy concluded (1438)Still pregnant (484)

Stillbirth (27) Live birth (1295) Pregnancy ended to bleeding (116)

All Women (10 198)

Verbal report aboutage and menopause

Pregnancy screening

Follow-up(7802 personmonths)

Figure 1. Identification of study women in Kersa, Ethiopia, 2010.


Pregnancy rates and pregnancy loss N. Assefa et al.

fied: 539 in round two, 237 in round three and 297 in

round four (Figure 1). During the study period, 1438

pregnancies ended: 1295 were live births and the remain-

ing 143 pregnancies were lost due to early miscarriage

(n = 116) or stillbirth (n = 27) (Figure 1). The number

of live births and pregnancy loss followed similar patterns

with respect to the total number of women in each age

category (Table 2).

(a)

1000

1500

2000

2500

200

250

300

350

400

Pregnancy per 1000 women Number of women

(b)

0

500

1000

0

50

100

150

15–19 20–24 25–29 30–34 35–39 40–44 45–49

15–19 20–24 25–29 30–34 35–39 40–44 45–49

15–19 20–24 25–29 30–34 35–39 40–44 45–49

15–19 20–24 25–29 30–34 35–39 40–44 45–49

1500

2000

2500

150

200

250

Age specific fertility rate (per 1000 women) Number of women

(c)

0

500

1000

0

50

100

50

708090100

200

300

350

400

Pregnancy per 1000 women Loss per 1000 pregnant women

(d)

010203040506070

0

50

100

150

200

250

Loss ratio per 1000 live births Loss per 1000 pregnant women

0102030405060708090100

0

20

40

60

80

100

120

140

160

180

Figure 2. (a) Pregnancy, (b) age-specific fertility rate, (c) pregnancy loss and (d) pregnancy loss ratio across the age groups, Kersa, Ethiopia,

2010. Total women, n = 7738.



The rate of pregnancy peaked for the age group 15–29 years with a minor indentation in between. The age-

specific fertility rate was high among the age group 15–29and dropped thereafter. The total fertility rate was 5.52.

Pregnancy loss per 1000 pregnant women was highest

among the age group 15–19 and 30–49 years of age (Fig-

ure 2a–d).Women who were not pregnant during the initial

screening (n = 6739) were followed for possible occur-

rence of pregnancy. These women were at risk of preg-

nancy any time during the follow-up period. Therefore,

their contribution until they became pregnant was calcu-

lated in person-months and person-years. These women

collectively produced 56 706 person-months or 4725 per-

son-years of follow-up (Figure 1). Thus, the incidence of

pregnancy was 18.9/month per 1000 women of reproduc-

tive age, or 227.1/year/1000 women of reproductive age.

The pregnant women for whom complete follow-up

was obtained, produced a total of 7802 pregnant-person

months, or 650.2 pregnant person-years of follow-up.

Thus, the incidence of pregnancy loss was 18.3/month, or

220/year/1000 pregnancies and the incidence of stillbirth

was 3.5/month or 41.5/year/1000 pregnant women

(Figure 1). The overall pregnancy loss ratio was 11/100

live births (143/1295). The stillbirth ratio was 2.1/100 live

births.

Discussion

During the study period, one of four women of repro-

ductive age became pregnant, and one of the four regis-

tered pregnancies did not end in a live birth. The total

fertility rate was found to be 5.52. Although the preg-

nancy rate was high in the age group 15–29 years, the

pregnancy loss rate was high in the age groups 15–19 and

30–49 years. The pregnancy loss ratio was 11/100 live

births. This study is the first of its kind in Ethiopia that

actively followed and generated person time indicators for

pregnancy loss. In many low-income countries such accu-

rate information is not available (1–3) and at best is

reported based on estimations (2).

A limitation of the study was that some pregnancies

might have occurred and ended between intervals of

screening. As most losses occur during early pregnancy

(8,11,12), the loss rates reported in this study could be

slightly lower than some previous studies (13–15). An

easy way to avoid such bias is to carry out the pregnancy

screening at shorter intervals, but this would have huge

cost implications and lead to community fatigue.

We lost 7.2% (150) of the pregnant women during the

follow-up. Twelve of them were permanent migrants and

the remaining 138 moved temporarily out from the study

site to their parents’ home in preparation for delivery. It

is a common phenomenon in Ethiopia to return to the

parents’ home for delivery. These losses appeared to have

been at random (12,16,17).

In this study both pregnancy and pregnancy loss rates

were high. This is in line with a study based on estimates

from a healthcare setting (18) and the Ethiopian Demo-

graphic and Health Survey 2011 that reported on the rural

population (6). Pregnancy loss can be also compounded

by poor maternal nutritional status (19,20), a heavy work-

load (21), a high disease burden due to malaria and other

febrile illnesses (22), and intimate partner violence (23). A

high pregnancy loss probably fuels the high fertility

because of the demand for as many live births as possible

to ensure that the desired number of children grow into

adulthood and provide support during old age (24,25).

Pregnancy loss per 1000 pregnant women was also high

in the earlier and later age categories. This could be

attributable to induced abortion and spontaneous abor-

tion for the earlier and later reproductive ages (4,5).

Nonetheless, the small stillbirth rates have a large

reproductive health implication, as most stillbirths in

low-income countries occur because of asphyxia, Gram-

negative and syphilitic infections (26). This unnecessary

loss could have been prevented at least in part by proper

antenatal and delivery health care (6,7). A high pregnancy

rate was probably fueled by the high proportion of

pregnancy loss in rural Ethiopia, creating a vicious cycle

compromising the health of women and their babies.

Strengthening and expanding appropriate family planning

and antenatal care programs is necessary to ensure a safer

pregnancy and childbirth for all women in this region.

Acknowledgments

The authors would like to thank Haramaya University

and local leaders for facilitating this study.

Funding

The study was funded by Haramaya University, Ethiopia,

as part of the graduate teaching.

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Pregnancy rates and pregnancy loss in Eastern Ethiopia