Pregnancy loss and neonatal mortality in Rwanda: The differential role of inter-pregnancy intervals

Abstract

Rwanda has so far paid little attention to 'healthy' intervals between pregnancies awareness programs on family planning and maternal and child health. Results of this thesis shed some light on the contribution of IPI and the type of previous pregnancy outcome on fetal survival, neonatal mortality and maternal morbidity in Rwanda. By using the combined effect of IPI and the type of previous pregnancy outcome instead of Inter-Birth Interval (IBI), it became clear that analysis using IBI leave behind possible fetal deaths that are more likely to happen in between births and that do play a role in affecting the reproductive health of the mother. We posit that women will improve their reproductive health status and avoid the risk of a fetal death trap if they wait at least two years after the previous fetal death. This finding relates to the findings from other developing countries such as Bangladesh (in opposite to findings from developed countries), and might be related to the absence of post-abortion care. Results from other studies give no assurance about what exactly is a healthy interval. In a bid to avoid methodological flaw, studies on infant mortality should avoid selectivity bias by concomitantly considering fetal survival. Yet, we found little evidence for simultaneous effects of short IPI’s fetal and neonatal mortality. The causes for neonatal mortality are not moderated by the inter-pregnancy interval while those for fetal loss are. Short IPIs are not associated with maternal morbidity, yet primigravida and women with long IPIs showed increased risks of third trimester bleeding, premature rupture of membrane and lower limb edema. Primigravida showed adverse outcomes throughout this study, implying that programs geared to reduce maternal death and neonatal mortality should consider primigravida with particular attention. After a pregnancy loss, a pregnancy interval longer than six months must be observed to prevent recurrence. Also women with very long IPI (<=5 years) have consistently shown increased risks of fetal loss, neonatal death and maternal morbidity. Our findings contribute to the debate whether older age of the mother might be hiding behind the effect of very long interval length. We found no negative effects of older age, and a remaining strong effect of long inter-pregnancy interval, which again supports the physiological regression hypothesis. Policy wise, avoiding short IPIs can be achieved through the use of post-partum contraception while long IPIs remain problematic to avoid, given that a desired pregnancy may be precluded by sub-fertility, availability of a partner, economic issues or illness. In the context of poor countries like Rwanda, a full reproductive health package is necessary and pregnancy management strategies should be encouraged through family planning for spacing pregnancies, and the promotion of health seeking behavior in the form ante- and post-natal care. Hospital staff should encourage post-abortion medication, and health centers in remote areas of the country should be less reluctant in transferring pregnant women and not wait until their situation becomes critical, rather they should provide a timely benefit of emergency obstetrical care.