Research Article The Effects of Interpregnancy Intervals and ......The Effects of Interpregnancy Intervals and Previous Pregnancy Outcome on Fetal Loss in Rwanda (1996 2010) IgnaceHabimana-Kabano,

Research ArticleThe Effects of Interpregnancy Intervals and Previous PregnancyOutcome on Fetal Loss in Rwanda (1996–2010)

Ignace Habimana-Kabano,1,2 Annelet Broekhuis,2 and Pieter Hooimeijer2

1Demography and Statistics, University of Rwanda, P.O. Box 117, Huye, Rwanda2Utrecht University, P.O. Box 80115, 3508 TC Utrecht, Netherlands

Correspondence should be addressed to Ignace Habimana-Kabano; [email protected]

Received 5 August 2015; Accepted 7 October 2015

Academic Editor: Hind A. Beydoun

Copyright © 2015 Ignace Habimana-Kabano et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

In 2005, a WHO consultation meeting on pregnancy intervals recommended a minimum interval of 6 months after a pregnancydisruption and an interval of two years after a live birth before attempting another pregnancy. Since then, studies have foundcontradictory evidence on the effect of shorter intervals after a pregnancy disruption. A binary regression analysis on 21532 lastpregnancy outcomes from the 2000, 2005, and 2010 Rwanda Demographic and Health Surveys was done to assess the combinedeffects of the preceding pregnancy outcome and the interpregnancy intervals (IPIs) on fetalmortality in Rwanda. Risks of pregnancyloss are higher for primigravida and for mothers who lost the previous pregnancy and conceived again within 24 months. Aftera live birth, interpregnancy intervals less than two years do not increase the risk of a pregnancy loss. This study also confirmshigher risks of fetal death when IPIs are beyond 5 years. An IPI of longer than 12 months after a fetal death is recommended inRwanda. Particular attention needs to be directed to postpregnancy abortion care and family planning programs geared to spacingpregnancies should also include spacing after a fetal death.

1. Introduction

An expert consultation organized by theWorld Health Orga-nization in 2005 made an inventory of available research onbirths spacing.The experts recommended an interpregnancyinterval (IPI) of at least 6 months after a miscarriage beforeattempting a next pregnancy, in order to reduce morbidityand mortality risks for mother, fetus, and newborn. An IPIof at least 24 months was recommended after a live birth,corresponding to a birth interval of at least 33 months. Theconsultation team also concluded that future research isneeded on the mechanisms underlying the relation betweeninterval length and pregnancy outcomes. More studies usingdatasets from both rich and poor countries could contributeto more in-depth knowledge [1]. Contradicting results ofresearch on the effect of short intervals on the risk of adversepregnancy outcomes [1–6] conducted after 2005 confirmedthe relevance of these statements.The few studies on the effectof intervals after a previous pregnancy disruption showa large

variation by country. DaVanzo and colleagues [4] emphasizedthat studies on the effects of interpregnancy intervals shouldtake into account the outcome of the previous pregnancy.

Our study contributes to the debate on pregnancy lossand interpregnancy intervals (IPIs) in line with these rec-ommendations. We focus on the effect of the duration ofthe IPI on pregnancy losses by combining the effect ofthe interval duration and the type of previous pregnancyoutcome (pregnancy loss, live births that survived infancyor died in the first year), and controlling for importantconfounders. In this study, the term pregnancy loss includesall pregnancy outcomes (spontaneous and induced abortion,fetal death, and stillbirth) opposite to a live birth.

Fetal loss has got limited attention [7] compared to otherissues, neither in the field of reproductive health nor indevelopment debates among policy makers, nor in debatesamong scholars in population studies.This lack of attention isregrettable, because for many women the loss of a pregnancyis an emotional experience which affects their subsequent

Hindawi Publishing CorporationInternational Journal of Reproductive MedicineVolume 2015, Article ID 413917, 10 pageshttp://dx.doi.org/10.1155/2015/413917

2 International Journal of Reproductive Medicine

reproductive health and behavior. Fetal loss and stillbirthsconstitute the majority of the world’s perinatal deaths and,yet, the absence of easy accessible and reliable secondary dataon pregnancy loss is mentioned as a reason for neglecting thetopic of fetal deaths by scientists [7, 8].

Reducing adverse pregnancy outcomes contributes to thehealth of the mother. Contrary to the reduction of maternalmorbidity and of infant mortality, reducing pregnancy loss isnot a policy objective but should become so in the future.

The outcome of our analysis will be discussed in theframework of results of a few [1, 4, 7, 9–11] available studiesthat followed the same approach by including the IPI durationand the previous pregnancy outcome to estimate the riskof a pregnancy loss. The majority of these studies focus onthe effect of IPI duration on adverse pregnancy outcomesafter a previous spontaneous or induced abortion while onlya few have a broader perspective and include also otherprior pregnancy outcomes (see Table 4). The studies differon essential points, such as various types of mothers in thesample, nulliparous or multiparous women; various types ofadverse pregnancy outcomes, pregnancy loss, preterm births,and low birth weight; reference group; categories of IPI; datacollection method; and geographical region, which couldcontribute to explain the variety in the findings.

Only two studies, one from the USA and the otherfrom Latin America, did not find significant associationsbetween IPI duration and a fetal or neonatal death after aspontaneous or induced abortion [7, 9]. The other studiesdo find an association between IPI duration and adversematernal and pregnancy outcomes after a previous fetal loss,but the associations between IPI duration and recurrentpregnancy losses are weak or nonexistent for late fetal deaths(stillbirths) [9–11]. Some results from USA and Scotlandare even the opposite of what is expected on the WHOrecommendations after early fetal deaths (miscarriages) [5,6]. They find that, after a previous early fetal loss, shortIPI intervals are associated with a higher likelihood on alive birth compared to longer IPIs. For Bangladesh [4], nodifferences between these likelihoods were found after a fetalloss according to IPI length except after very long IPI (>74months).

However, the studies [10, 11] that focus on the associationbetween IPI duration and the risk of a fetal death (andother adverse pregnancy outcomes) show higher risks of anadverse outcome after a fetal loss and a short IPI relative toa previous live birth combined with a healthy IPI. The meta-analyses [10] includedmany countries from all over the worldand consequently examples with good and poor health caresystems. A study on Sweden [12], a country with an advancedmedical health care system, however, stated that risks are onlyfound for long intervals and that the impact of short intervalsmay have been overestimated in other studies. From all thosestudies, we learn that it is important to include the outcomeof the previous pregnancy in the analysis and to focus onseveral previous pregnancy outcomes when analyzing theeffect of short IPIs on fetal losses. Therefore, we will followthis approach in our analysis about pregnancy loss inRwanda.

Since 2000, Rwanda is experiencing a steady economicgrowth and after 2005 a rapid demographic and health

transition [13, 14] thanks to the extension of access to repro-ductive health facilities [15].Thehealth service infrastructure,which was badly damaged during the civil war of the ninety-nineties, has been rebuilt to a large extent. At local level,community health centers are established and more than45,000 community health care workers, male and female,have been trained to provide basic medical care and drugsand to give information on health matters. A third of thosehealth care workers were trained in midwifery. The numberof qualified medical staffs increased yet is still insufficientaccording to international standards: onemedical doctor andone professional midwife per 16,500 and 23,400 inhabitants,respectively [16].

The government improved access to community healthcare also by introducing a community based insurancesystem. Today, more than 90% of the population participatesin these Mutuelles de Santé “Health Mutualities” whichgive access to community level health services and, withadditional payment, to a package of extra health care atdistrict hospitals. This percentage of more than 90% explainsan impressive increase in access to health care, given the factthat this percentage was only 7% in 2003.The prenatal checksand the costs of a normal delivery assisted by a nurse ormidwife are covered by the basic health insurance schemesbut exclude the 200 RwF per visit to a health center.

Yet, the health-seeking behavior among pregnant womenstill needs improvement although, according to the 2010Demographic and Health Survey (DHS), less than twopercent of the women did not have any antenatal medical testbefore the delivery.However, only 35 percent of themwent forfour antenatal checks, as recommended by the WHO. Mostpregnant women got their first medical examination in thesecond trimester of their pregnancy and some even later [16–19].

2. Material and Method

The Demographic and Health Survey (DHS) is an inter-nationally recognized data collection method that providescurrent and reliable data based on a national representativesample. Data from three successive Rwanda Demographicand Health Surveys (RDHS 2000, RDHS 2005, and RDHS2010) were merged in this study to analyze the last pregnancyoutcome of women within the DHS calendar periods of fiveyears preceding the moment of interview.

Pregnancies and pregnancy outcomes that occurred inthe eight months before the month of the interview were notincluded in our analysis to be sure that all pregnancies in theanalysis had the same probability of ending in a pregnancytermination or a live birth after nine months. To identify themoment of the start of the last pregnancy,we used the detailedrecording in the “calendar” of the DHS, which gives thepregnancy status for each month over a period of 59 monthsbefore the month of the interview. The nature and timing ofthe previous event are then defined. The exact months of allbirths, deaths, and pregnancy terminations are recorded inthe DHS. The duration of the IPI is measured by subtractingthe date of the previous pregnancy outcome from the date ofthe start of the last pregnancy.

International Journal of Reproductive Medicine 3

The month of the previous outcome is registered at anytime before the start of the last pregnancy. In total, 21532women had at least one pregnancy outcome in the threereduced calendar periods before 2000, 2005, and 2010; for3631 women, it was their first pregnancy (primigravida);for the other 17901 women, we calculated the date andtype of the previous pregnancy outcome. In case of a longinterpregnancy interval, this previous pregnancy outcomecould have occurred before the five-year calendar period.

The DHS datasets enable the calculation of the exact date(in terms ofmonth and year) of the events in the reproductivehistory of women in the sample if one combines answers tovarious questions in the questionnaire. We constructed Cen-tury Month Codes (CMC), the number of months elapsedsince January 1900, of the pregnancy outcomes (pregnancyloss, infant death, and live birth) reported by the mothers tocalculate the IPIs. In case of a live birth as last pregnancyoutcome, the pregnancy was supposed to start 9 monthsbefore the CMC of the birth. In case of a fetal loss as lastpregnancy outcome, themother did report the duration of thepregnancy in months. Data from retrospective studies, likethe Demographic and Health Surveys, are biased by errorsdue to memory lapses as the respondents have to report thenumber and date of the events in the past [20]. This is inparticular the case when one asks for matters as pregnancylosses and induced abortions. Early pregnancy lossesmay notbe noted or easily forgotten and induced abortions may notbe reported as these are illegal in many societies. By focusingon the two last pregnancies of which the last one (and inmany cases the previous aswell) occurred during the calendarperiod, we reduced the risk of memory errors.

For our analysis, we calibrated a binary logistic regressionmodel using the statistical package STATA 12.The dependentvariable is the outcome of the last pregnancy (fetal loss codedas 1, live birth coded as 0). We checked whether a distinctionbetween early and late losses gave different results, but thisturned out not to be the case. To construct a more powerfulmodel, we decided to take all fetal deaths together.

We defined the twomain independent variables: length ofthe interpregnancy interval and previous pregnancy outcomeas follows. Interpregnancy intervals (IPI) were calculated asthe time between the outcome of the previous pregnancythat ended either in a pregnancy loss or live birth and thelast conception. Short intervals are defined as shorter than 4months or 4 up to 12 months after a previous pregnancy lossand shorter than 1 year or between 1 and 2 years after a livebirth. A healthy interval after a live birth is an interval of atleast two years and less than 5 years.

We categorized the live births of the previous pregnancyin two groups: infants that survived the first year of theirlife or infants that did not survive. The reason behind thiscategorization relates to the maternal depletion hypothesisand the quick return of the ovulation combined with thereplacement strategy. In regard to the maternal depletion,the idea is to test whether a surviving breastfed infant willincrease the depletion of maternal resources and thereforeaffect the survival of the next pregnancy that is conceived aftera short IPI. Secondly, the death of the previous infant mightbe related to an unhealthy physiological status of the mother

and the wish to quickly replace the infant, thus shortening theIPI.

We did not excludemultiple gestations, butwe consideredthem as one birth. Subsequently, we constructed variablesto represent the interaction between those two main inde-pendent variables in which we used different classificationsfor the IPI duration after the previous pregnancy outcomes.We tested for several confounding factors but, in the finalmodel, included only four control variables that turned out tobe of significance. The first is the inevitable biodemographiccontrol variable age of the mother at conception which isan indicator for her physiological condition at the start ofand during her pregnancy. We specified mother’s age as acategorical variable to allow for nonlinear effects as we willfocus on broad age categories and compare young (below theage of 21) and especially older mothers (over the age of 35)with women of a more optimal reproductive age. Age refersto the reproductive condition that contributes to a healthypregnancy and the birth of a healthy infant. In particular,we want to test if older mothers have higher pregnancyloss risks compared to younger ones. The second controlvariable is the pregnancy wish. Question V228 of the DHSwomen’s questionnaire asks the responding woman whether,at the time she became pregnant for the last pregnancy,she wished to become pregnant, she wished to wait untillater, or she did not want to have any more children atall. Response categories included the following: wantingpregnancy then, wanting pregnancy later, wanting no morechildren, or unknown/vague answer. The latter category isused as a proxy for intended pregnancy losses togetherwith the third included variable: place of residence thatdistinguishes between urban and rural residence.

The available dataset does notmake a distinction betweeninduced and spontaneous pregnancy losses, which is anomission seen in the different relations between the twotypes of abortions at the beginning of the IPI, length ofthe IPI, and pregnancy outcome found in other researches.However, we expect that Rwandan women will not easilyindicate that they had an induced abortion as it is illegal,except when the physical health of the mother is in greatdanger. The study of Basinga and colleagues [21] estimatedthe rate of induced abortion in Rwanda in 2009 between18 and 31 per 1,000 women in the 15–44-year-old group.Their study also revealed that the induced abortion rate wasremarkably higher in the capital city Kigali compared to thesituation in the provinces. In most African rural settings,induced abortion remains a taboo and social control incommunities that watch over virginity as a core value, thereason why in particular rural women support legalizationof abortion less compared to urban women [22]. As faras Rwanda is concerned, May et al. [23] stated that in theearly nineties induced abortion did not occur traditionally inthis country. For that reason, we expected that in case thissituation changed during the last two decades abortions willbe chiefly an urban phenomenon. We tried to control for itby including place of residence (urban versus rural) in theanalysis. The percentages of unknown/vague answers in ourdataset were, respectively, 27.9 and 23.6 for urban and ruralwomen.


Table 1: Descriptive statistics: last pregnancy outcomes in percent-ages and in total numbers (pooled data from DHS 2000, DHS 2005,and DHS 2010).

Variable names

Latest pregnancy outcome(𝑁 = 21532)

Pregnancy loss(%)

Totalnumber

First pregnancy (primigravida) 3.3 3631Previous pregnancy outcome and IPIPregnancy loss

IPI ≤3 months 10.6 161IPI ≥4 months and ≤12 months 7.9 381IPI ≥13 months and ≤24 months 8.0 217IPI ≥25 months 4.7 149

Live birth (child died in infancy)IPI ≤12 months 3.3 662IPI ≥13 months and ≤24 months 2.6 582IPI ≥25 months 5.5 513

Surviving live birthIPI ≤12 months 2.3 1594IPI ≥13 months and ≤24 months 2.7 5580IPI ≥60 months 7.6 1314IPI ≥24 and ≤59 months 3.5 6740

Age of mother at the latest conception20 years and younger 2.7 207536 years and older 6.8 478021 to 35 years 2.7 14677

Pregnancy timingMistimed (later) 1.7 4116Unwanted (no more) 1.4 2786Unknown/vague answer 8.7 5246Wanted (then) 2.2 9368

Type of place of residenceUrban 4.2 4125Rural 3.5 17407

Year of interview2000 4.1 63832005 3.6 68162010 3.3 8333

Total 3.6 21532Sources: RDHS 2000, RDHS 2005, and RDHS 2010.

Finally, we included the year of the interview to check forchanges over time in reproductive health: notably, the extentof the possible reduction of fetal mortality. Table 1 gives thedescriptive statistics of the research population.

3. Results and Discussion

The results presented in Table 1 illustrate that many Rwandanwomen still have to deal with pregnancy losses, the deathof an infant, and unwanted pregnancies: 36 out of 1000 last

pregnancies in our sample population ended in a pregnancyloss. Among the women with at least two pregnancies, 15percent mourned a fatal outcome of the previous pregnancy:five percent had a pregnancy loss and nearly ten percent gota child that died in infancy. The results indicate also that thepercentages of pregnancies ending in a pregnancy loss are thehighest after an IPI shorter than 24 months that started aftera pregnancy loss. Higher percentages of pregnancy loss thanthe mean of 3.6 per cent were found after a live-born infantthat died in its infancy and an IPI of more than two years andafter a surviving live birth and a very long IPI (>60 months).

The descriptive statistics in Table 1 show amodest declineof the rate of fetal losses during the period under study. Forthe three consecutive research periods, the rate of pregnancyloss diminished from 41 out of 1000 pregnancies (1996–2000)to 36 (2001–2005) and finally to 33 in the most recent period2006–2010. It is difficult to assess if the total number ofreported pregnancy losses in the three DHSs used in thisstudy, 36 per 1000 pregnancies, is in line with expectationsor not. It is a result of measurements over a rather diffuseperiod of time. The frequency fits within an indication giveninmedical literature that states that the number of fetal lossesin themonth after conception is high but that after a gestationof 8 weeks the loss is about 3 percent [21]. This could meanthat women in Rwanda did not mention losses that occurredin the first one or two months of a pregnancy, when theywere not fully aware of being pregnant. The early pregnancylosses reported in the DHS are probably underestimated as inpoor countries the number of stillbirths (after a gestation of28 weeks) is higher compared to that of rich countries and thestillbirth rate in countries in the central part of Sub-SaharanAfrica varies between 25 and 40 or more per 1000 births [24].With the number of early miscarriages added, the final ratemust be even higher.

Women who were pregnant for the first time reportedthe highest percentage of wanted pregnancies (nearly 60%,see Table 2). Of all last pregnancies by the other women,only 40 percent were wanted at that time, while more than athird were unwanted or the mother gave an unclear answer(or answer not known). The cross tabulation presented inTable 2 shows that after a pregnancy loss or the loss of aninfant a large portion of the women want to replace this loss.The percentages of wanted pregnancies extend the averageof 40 percent. Very low numbers of wanted pregnancies arefound among women who became pregnant within two yearsafter the birth of the previous child that survived the firstyear of its life. Those two groups of women had liked tobecome pregnant later in time (indicated by 40 and 31%,resp.).

A large portion of the women became pregnant againbefore the recommended time (by WHO) for recovery wasover. From the women whose previous pregnancy endedwith a fetal loss, 43 percent were expecting a child againwithin half a year. For women who had a live-born childthat died afterwards in infancy, 71 percent were pregnantagain within two years after the last delivery, which couldpoint at a replacement effect or at a lack of protection againstpregnancy. For women whose child survived the first year ofits life, this percentage was much lower (47%). This group


Table 2: Wanted the last pregnancy (in %) according to previous pregnancy outcome and IPI duration.

Prev. outc. IPI Vague Unwanted Mistimed Wanted Tot. no.Primigr. — 19.6 8.3 13.4 58.8 100.0 3631

Fetal loss


Table 3: Binary logistic coefficients on the risk of pregnancy loss in Rwanda (pooled data 2000, 2005, and 2010).

Log likelihood = −3038.95LR 𝜒2 (19) 642.2Prob. > 𝜒2 0.000Pseudo 𝑅2 0.096

Variable names 𝑁 = 21532 𝐵 𝑃 > 𝑧 Exp(𝐵)Previous pregnancy outcome and IPI

Previous live birth and IPI ≥25 and ≤59 months (Ref.) 6,740Pregnancy termination

IPI ≥3 months 161 1.303 ∗ ∗ ∗ 3.680IPI ≥4 months and ≤12 months 381 0.974 ∗∗ 2.648IPI ≥13 months and ≤24 months 225 0.663 ∗ 1.940IPI ≥25 months 149 0.102 1.107

Previous infant deathIPI ≤12 months 662 −0.014 0.986IPI ≥13 months and ≤24 months 582 −0.401 0.670IPI ≥25 months 513 0.257 1.292

Previous surviving live birthIPI ≤12 months 1,594 −0.410 ∗ 0.664IPI ≥13 months and ≤24 months 5,580 −0.083 0.920IPI ≥60 months 1,314 0.494 ∗∗ 1.639

Primigravida 3,631 0.400 ∗ 1.492Age of mother at the latest conception

21 to 35 years (ref.) 14,67720 years and younger 2,075 −0.199 0.81936 years and older 4,780 0.843 ∗ ∗ ∗ 2.323

Pregnancy timingWanted (ref.) 9,368Untimed (later) 4,116 −0.108 0.898Unwanted (no more) 2,786 −0.751 ∗ ∗ ∗ 0.472Unknown/vague answer 5,262 1.308 ∗ ∗ ∗ 3.698

Place of residenceRural (ref.) 17,407Urban 4,125 0.217 ∗ 1.243

Year of interview2000 (ref.) 6,3832005 6,816 −0.117 0.8892010 8,333 −0.259 ∗∗ 0.772Constant −4.004 ∗ ∗ ∗ 0.018

Significance: ∗


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than two years after a live birth do not give higher risks of apregnancy loss, but they will affect other pregnancy outcomessuch as pretermbirth, low birthweight, lowApgar scores, anda higher neonatal death.

We found clear indications for negative effects of thereplacement mechanism after the loss of a pregnancy. Thereplacement wish after a fetal death leads to shorter IPIs andtherefore to a higher risk of another pregnancy loss [12].Finally, the results of our study confirm the physiologicalregression hypothesis: a higher risk of a fetal death whenIPIs are longer than 5 years. Also older women have a higherlikelihood of a pregnancy loss compared to younger ones.

Our results are partially in line with the ones fromDaVanzo and colleagues in Bangladesh [1, 11] based also ona general sample of women with all types of prior pregnancyoutcomes. To avoid a higher risk of a next miscarriage orstillbirth also in Bangladesh, women should wait longer thanthe recommended 6 months (up to 15 months) to becomepregnant again after a former pregnancy loss.The researchersfound a significant increased risk of a pregnancy loss after alive birth and an IPI < 6 months. For longer IPI durations upto 74 months after a live birth, no significant higher risks ofa pregnancy loss were found. After a duration of 74 months,the risk was again significantly higher.

Based on the results of this study on Bangladesh and ourson Rwanda, one could conclude that, in societies without anadvanced health care system, the WHO recommendationsconcerning spacing after a fetal loss still count. Workers inthe health care system should advise women, even if they areeager to become pregnant again, to take actions to preventa quick new pregnancy and wait even longer than a year tobecome pregnant again.

The improvements in the Rwandan health care systembetween 2000 and 2010 and in particular the increasedaccess to this system contributed to a lower pregnancy lossfrequency. Probably, the increased antenatal checks duringthe last pregnancy period had an impact, as the significantdecrease in pregnancy losses between 2000 and 2010 resultedin particular in fewer late fetal losses (after a pregnancyduration of 20 weeks). With a policy that recommends towomen an IPI of at least a year to two years after a fetal deathand more early pregnancy visits to the community healthfacility, a decrease in an early fetal death could be achievedas well.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgment

Theauthors thank theWilliam and FloraHewlett FoundationandTheNetherlands Organization for Scientific Research fortheir financial support (Grant no. W07 40 202 00).

References

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Research Article The Effects of Interpregnancy Intervals and ......The Effects of Interpregnancy Intervals and Previous Pregnancy Outcome on Fetal Loss in Rwanda (1996 2010) IgnaceHabimana-Kabano,