Abstract
Background:
Adverse birth outcomes are the most common public health problem in both developed and developing countries, including Ethiopia. Short pregnancy interval has an adverse effect on the growth of unborn child and newborn. In our country Ethiopia, studies are limited regarding adverse birth outcomes among mothers with short and recommended pregnancy interval.
Objective:
This study was aimed to assess adverse birth outcomes among mothers with short and recommended pregnancy interval, in east Gojjam public hospitals, northwest Ethiopia, 2021.
Methods:
A facility-based comparative cross-sectional study was conducted from November 1 to December 30, 2021. A total of 456 mothers were included in the study using systematic random sampling technique. The data were collected through face-to-face interviews using structured pretested questionnaires and chart review using a checklist. Bivariable and multivariable logistic regression model was fitted. Adjusted odds ratio with 95% confidence interval at p-value of ≤0.05 was used to declare the level of significance.
Result:
The overall prevalence of adverse birth outcomes was 23.9%. The magnitude of adverse birth outcomes were 29.4% and 18.4% in mothers with short and recommended pregnancy interval, respectively. Having no antenatal care visits, history of intimate partner violence, history of pregnancy-induced hypertension, inability to read and write, instrumental delivery, cesarean section, and long duration of labor were significantly associated with adverse birth outcomes.
Conclusion:
Adverse birth outcomes had a significant association with pregnancy interval. Designing strategies to increase women’s educational status, with emphasis on maternal and child health services, will reduce adverse birth outcomes.
Introduction
Adverse birth outcomes (ABOs) are the most common public health problem in both developed and developing countries. 1 It brings about significant health consequences on infant, children, and mothers’ emotional and economic costs on families, and communities across the world, particularly in resource-limited settings where health systems and access to and utilization of health services are limited.2,3 Short pregnancy interval has been associated with an increased risk of adverse outcomes, which hurt maternal, fetal, neonatal, and child health outcomes, including, low birth weight (LBW), preterm birth (PTB), 4 and stillbirth. 5
LBW infants could suffer for the risk of developing numerous complications including respiratory distress, sleep apnea, heart problems, jaundice, anemia, death, stunting, and developmental difficulties. 6 PTB is a leading cause of newborn deaths, and it is the second leading cause of under-five children death next to pneumonia.7,8 Even if they survive, they may face short-term complications such as acute respiratory, immunological, gastrointestinal, and central nervous system problems and long-term effects including cognitive, visual, hearing, behavioral, and growth problems that may not become apparent for years and may persist throughout their life. 9
Globally, neonatal death accounts 38% of under-five mortality, and two-thirds of the newborns died in the first week of life. 10 Around 20.5 million newborns died due to LBW. 6 Annually, an estimated 2.0 million babies were stillborn at 28 weeks or more of gestation with a global stillbirth rate of 13.9 per 1,000 total births, and more than half of all stillbirths were mostly in developing countries. 11 In addition, 98% of perinatal death occurred in sub-Saharan Africa and South Asian countries. 10 Likewise, in Ethiopia, the overall prevalence of ABOs was 26.88%. Of them, LBW (10.06%) and PTB (8.76%) were the most common ABOs at the national level. 12 According to Ethiopian Health Sector Transformation Plan II, neonatal mortality rate was estimated to be 33 per 1,000 live births and half of neonatal deaths occurred on the first day and three quarters of neonatal deaths occurred in the first week of life. 13
Even though not limited, some of the factors affecting the ABOs are maternal age, 14 number of gravidity, 15 pregnancy-induced hypertension, prolonged duration of labor, and multiple pregnancies.15,16
To reduce the risk of adverse maternal, perinatal, and infant outcomes, the World Health Organization recommended a minimum interpregnancy interval of 24 months after a live birth. 17 Besides, the government of Ethiopia is working by assigning trained health professionals to all districts, giving training and refreshment courses, allocating ambulance services to all districts, and developing organized referral linkages. 18 Even if there are various studies conducted in many developing countries, including Ethiopia, about ABOs and associated factors, there is a scarcity of information regarding the effect of birth interval on ABOs. Therefore, this facility-based comparative cross-sectional study assessed and compared the prevalence of ABOs and associated factors among mothers with short and recommended birth interval in east Gojjam public hospital.
Materials and Methods
Study design, period, and setting
A facility-based comparative cross-sectional study was conducted from November 1 to December 30th, 2021, in public hospitals in east Gojjam zone, northwest Ethiopia. The administrative town, Debre Markos, is located about 300 km northwestern from Addis Ababa (the capital city of Ethiopia) and 265 km from Bahir Dar (the capital city of Amhara regional state). Based on the 2014 Population Projection by the Central Statistical Agency of Ethiopia, the study zone has an estimated population of 2,485,673, of which 1,257,476 are females. 19 East Gojjam has 9 hospitals and 102 health centers.
Study population
All immediate postpartum mothers who gave birth in east Gojjam public hospitals and were available during the data collection period were included.
Sample size determination and sampling procedure
The sample size was determined by using Epi info software. The largest sample size of 456 (228 mothers with short pregnancy interval [SPI] and 228 mothers with recommended pregnancy interval [RPI]) was taken. East Gojjam has one comprehensive and specialized hospital, one general hospital, and seven primary hospitals. Samples were allocated based on annual delivery report of the facility and selected by using systematic random sampling technique. The 2-month delivery report of hospitals (3,074) was calculated from their annual report (18,449). The interval (k) was computed from the 2-month delivery report of hospitals. k = 3,074/456 = 6.7 ≈ 7.
Measurements
Short interpregnancy interval
This is the interval between the delivery date of the preceding birth and the conception date of the index pregnancy <24 months and <6 months after miscarriage or safe termination of pregnancy. 17
Adverse birth outcomes
At least one of undesirable health outcomes comprises stillbirths, LBW, and PTB. 20
Preterm birth
PTB is if a baby is born alive before 37 completed weeks of gestation but after 28 weeks of gestation. 21
Stillbirth
Stillbirth is if a newborn has no signs of life at or after 28 completed weeks of pregnancy. 22
Low birth weight
LBW is considered when weight at birth is <2,500 g. 23
Intimate partner violence
Intimate partner violence is reported when women reported that they experienced any act of physical, sexual, or psychological violence or any combination of the three by an intimate partner during current pregnancy. 24
Immediate postpartum mothers
Immediate postpartum mothers are mothers in the immediate postnatal period or within the first 24 hours after giving birth. 25
Data collection tools, procedures, and quality control
The data collection tool was developed by reviewing related literature.15,26–31 The data were collected through face-to-face interviews using a structured pretested questionnaire and chart review using a checklist. Sociodemographic characteristics, reproductive health and obstetrics-related characteristics, and maternal medical problems were incorporated in the questionnaire. Nine BSc midwives and four BSc midwives were recruited for data collection and supervision, respectively. The questionnaire was first prepared in English and translated to the local language Amharic and back to English to keep its consistency. Before the actual data collection, a pretest was done on 5% (23) of the sample size at Finote Selam general hospitals. One day training was given for data collectors and supervisors to assure language clarity and to give information on interview techniques, how to keep the information, and to have a better understanding of the overall process of data collection. During the actual data collection period, the questionnaire was checked for completeness weekly by supervisors and the principal investigator.
Data processing and analysis
Data were checked, coded, and entered to EPI data version 4.6 and then exported to SPSS version 25 analysis software. Descriptive statistics such as percentage, frequency, means, standard deviation, and tables were used to present the characteristics of the study participants. The binary logistic regression model was fitted to identify the associated factors for ABOs. Initially, bivariable analysis was conducted to identify the eligible independent variables for the multivariable analysis. After that, all explanatory variables having a p-value of ≤0.25 in the bivariable analysis were entered into a multivariable logistic regression analysis to minimize the effect of possible confounding factors and identify independent factors associated with ABOs. Chi-squared test was used to test the relationship of different ABOs with pregnancy interval. Lastly, the level of significance was claimed based on the adjusted odds ratio (AOR) with 95% confidence interval (CI) at a p-value of ≤0.05.
Ethical approval
The ethical approval letter was obtained from the School of Midwifery, on the behalf of institutional review board of University of Gondar. A formal letter of organizational approval was obtained from east Gojjam health bureau. Thereafter, the study participants were informed about the purpose of the study, the importance of their participation, and their rights. Finally, written informed consent was obtained from each participant before the actual data collection.
Results
Sociodemographic-related characteristics
In this study, a total of 456 mothers were included, giving a response rate of 100%. Of which 228 were mothers with SPI and 228 were mothers with RPI. The median age of the participants was 30 years with an interquartile range (IQR) of 28–35 years. More than half (55.3%) of the mothers with SPI and nearly two-thirds (68.9) of the participants with RPI were from rural areas. Regarding their religion, 93.4% and 82.9% of the study participants were orthodox Christian among SPI and RPI, respectively. Regarding their marital status, 98.7% and 94.3% of the study participants were married among mothers with SPI and RPI, respectively. Of them, 46.7% and 27% of their husbands’ occupation were farmer (Table 1).
Sociodemographic-Related Characteristics of Women with Short and Recommended Pregnancy Interval in East Gojjam Public Hospitals, Northwest Ethiopia, 2022
Catholic and protestant.
Single, separated, widowed, and divorced.
RPI, recommended pregnancy interval; SPI, short pregnancy interval.
Reproductive and medical-related characteristics
The median gravidity count was 3 (IQR: 2–5). Two-thirds (67.5%) of mothers with SPI had gravidity of 2–4. Similarly, 78.1% of the study participants with RPI had gravidity of 2–4. From the total participants, 75.9% and 85.1% had antenatal care (ANC) follow-up among women with SPI and RPI, respectively. Nearly three-fourth (77.2%) of mothers with SPI and 84.6% of mothers with RPI had no history of pregnancy-induced hypertension; 95.2% and 98.2% of the study participants had no history of confirmed medical problems among mothers with SPI and RPI, respectively (Table 2).
Reproductive and Medical-Related Characteristics of Mothers with Short and Recommended Pregnancy Interval in East Gojjam Public Hospitals, 2022
ANC, antenatal care; APH, antepartum hemorrhage; C/S, cesarean section; DM, diabetics mellitus; PIH, pregnancy-induced hypertension; ROM, rupture of membrane; SVD, spontaneous vertex delivery.
Adverse birth outcomes
The overall prevalence of ABOs was 23.9% (95% CI: 20.0%−28.0%). The magnitude of ABOs were 29.4% (95% CI: 23.0%–35.0%) and 18.4% (95% CI: 13.0%–23.0%) from mothers with SPI and RPI, respectively. The commonest ABO among mothers with SPI was LBW (13.40%), and PTB (9.60%) and LBW (9.60%) were the commonest among mothers with RPI (Fig. 1).
Adverse birth outcomes among mothers with short and recommended pregnancy interval in east Gojjam public hospitals, northwest Ethiopia, 2022.
Factors associated with ABOs among mothers with SPI and RPI
On multivariable logistic regression, SPI, history of intimate partner violence, and long duration of rupture of membrane were significantly associated with ABOs regardless of pregnancy interval.
The odds of ABOs were 1.95 times more likely among mothers with short interpregnancy interval as compared with mothers with RPI (AOR: 1.95; 95% CI: 1.24–3.08).
Similarly, the odds of ABOs were 1.73 times more likely among mothers who had a history of intimate partner violence during the most recent pregnancy as compared with mothers who had no history intimate partner violence during the most recent pregnancy (AOR: 1.73; 95% CI: 1.07–2.80).
Furthermore, the odds of ABOs were 2.24 times higher among mothers with membrane rupture duration of 8 hours and more as compared with their counterpart (AOR: 2.24; 95% CI: 1.43–3.49) (Table 3).
Logistic Regression on Factors Associated with Adverse Birth Outcomes Among Mothers with Short and Recommended Pregnancy Interval in East Gojjam Public Hospitals, Northwest Ethiopia, 2022
p-Value ≤0.05.
AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio.
Factors associated with ABOs among mothers with SPI
On the multivariable logistic regression analysis, no use of ANC services, having history of intimate partner violence, having pregnancy-induced hypertension during the recent pregnancy, and long duration of labor were significantly associated with ABOs.
In this study, the odds of ABOs were 2.14 times more likely among mothers who hadn’t used ANC services as compared with women who had ANC visits (AOR: 2.14; 95% CI: 1.08–4.22).
Similarly, the odds of ABOs were 2.05 times higher among mothers who had a history of intimate partner violence as compared with mothers who had no history of intimate partner violence (AOR: 2.05; 95% CI: 1.06–3.98).
In addition, the odds of ABOs were 2.65 times higher among mothers who had pregnancy-induced hypertension during the most recent pregnancy as compared with its counterpart (AOR: 2.65; 95% CI: 1.29–5.43).
Lastly, the odds of ABOs were 6 times higher among mothers with labor duration of >18 hours as compared with their counterpart (AOR: 6.00; 95% CI: 2.82–12.63) (Table 4).
Logistic Regression Analysis on Factors Associated with Adverse Birth Outcomes Among Women with Short Pregnancy Interval in East Gojjam Public Hospitals, Northwest Ethiopia, 2022
p-Value ≤0.05.
p-Value ≤0.001.
Factors associated with ABOs among mothers with RPI
On multivariable logistic regression analysis, inability to read and write, having pregnancy-induced hypertension during the most recent pregnancy, instrumental delivery, and cesarean section were significantly associated ABOs among mothers with RPI.
The odds of ABOs were 6.66 times more likely among mothers with educational status of unable to read and write as compared with mothers with educational achievement of college and above (AOR: 6.66; 95% CI: 2.04–21.71).
In addition, the odds of ABOs were 2.54 times more likely among mothers who had pregnancy-induced hypertension during the most recent pregnancy as compared with its counterpart (AOR: 2.54; 95% CI: 1.07–6.00).
The odds of ABOs were 4.49 times higher among mothers who were assisted with instrument during delivery as compared with mothers who gave birth in spontaneous vertex delivery (AOR: 4.49; 95% CI: 1.18–17.17). Similarly, the odds of ABOs were 2.64 times more likely among mothers who gave birth with cesarean section as compared with mothers who gave birth with spontaneous vertex delivery (AOR: 2.64; 95% CI: 1.22–5.71) (Table 5).
Logistic Regression on Factors Associated with Adverse Birth Outcomes Among Mothers with Recommended Pregnancy Interval in East Gojjam Public Hospitals, Northwest Ethiopia, 2022
p-Value ≤0.05.
Discussion
This facility-based comparative cross-sectional study assessed ABOs and associated factors among mothers with SPI and RPI in east Gojjam public hospitals, northwest Ethiopia. Slightly less than one-third of mothers with SPI and nearly one-fifth of mothers with RPI had ABOs.
In this study, the overall prevalence of ABOs was found to be 23.9%. This is in line with the studies done in Negest Elene Mohammed Memorial General Hospital (24.5%), 32 Bale zone hospitals (21%), 16 and Ghana (27.7%). 33 This may be due to the similarity in some of the sociodemographic characteristics of participants including residency. From a study done in Negest Elene Mohammed Memorial General Hospital, 58.7% of participants were urban dweller, 32 which is almost similar to this study finding (61.8%). In addition, study participants had almost similar ANC service utilization, which may create opportunities to discuss with health care providers.
The finding of this study was higher than studies conducted in Butajira (18.2%), 1 Hawassa (18.3%), 34 Canada (16.1%), 35 Italy (11.2%), 36 and China (5.8%). 37 The possible reasons for this variation could be due to differences in maternal and child health service utilization of the participants. Most (90%) of the study participants in Butajira had at least one ANC visit, 16 which may create opportunities to discuss with health care providers about the possible danger signs during pregnancy and about birth preparedness and complication readiness plan. But in the current study, only 80.9% of study participants had at least one ANC visit. In addition, two-thirds (68.4%) of women from Butajira were urban residents, 1 in which access to information and health care service is good compared with the rural dwellers, whereas only 61.8% of mothers in the present study were from the urban area. Furthermore, the habit of seeking health-related information and understanding is better in the urban population.
On the contrary, the prevalence of ABOs was lower than studies done in north Wollo (31.8%), 38 Dessie (32.5%), 39 and Kenya (40.3%). 40 The possible justification for this variation might be due to the time gap. In addition, it might be due to differences in proportion of associated pregnancy-related complications. From a study done in north Wollo, the proportion of antepartum hemorrhage and pregnancy-induced hypertension was 21.7% and 30.1%, respectively. 38 But in the current study, the proportion of antepartum hemorrhage was 5.7% and pregnancy-induced hypertension was19.3%. Evidences show that pregnancy-related complications could upsurge the maternal and neonatal adverse outcomes.1,32,38
This study showed that ABOs were more frequent among mothers with SPI as compared with those with RPI. Proportion of stillbirth was 12.3% and 8.8% in women with SPI and RPI, respectively, and the difference in proportion was statistically significant (p = 0.02). This finding was similar to a study done in south Ethiopia, which revealed that stillbirth was higher (3.8%) in SPI than RPI (1%). 41 The reason might be mothers with short birth spacing are more prone to develop pregnancy-induced hypertension and placental abruption, which could result in fetal demise. 42
LBW was 17.1% in mothers with SPI and 9.6% in mothers with RPI, and the difference in proportion was statistically significant (p = 0.006). This finding was consistent with a study done in Nekemte that affirmed LBW was higher (28.9%) in mothers with SPI as compared with mothers with RPI (9.4%). 31 LBW might be the effect of poor maternal nutritional status due to short birth spacing and the poor maternal weight gain. 43 In addition, this could be secondary to poor iron storage capacity and folate depletion in the body, which increases women’s susceptibility to anemia and compromises their nutritional status. 31 Hence, poor weight gain during pregnancy may have a negative effect on birth weight.
Proportion of PTB was higher among mothers with SPI (13.9%) than the RPI (9.6%), and the difference was significant (p = 0.012). This finding was consistent with a study done in Nigeria. 44 The reason could be mothers with SPI can’t recover from the biological stress imposed by the preceding pregnancy and delivery, resulting in decreasing macronutrient supplementation in maternal body, folate depletion, cervical insufficiency, vertical transmission of infections, incomplete healing of uterine scar, abnormal remodeling of endometrial blood vessels, and anemia and increasing the risks of certain other factors achieving pregnancy outcomes. 45
The current study affirmed that who hadn’t used ANC services was significantly associated with ABOs. Thus, the odds of ABOs were 2.14 times higher among mothers who hadn’t ANC visits as compared with their counterpart among mothers with SPI. This finding was supported by studies done in north Wollo and Negest Elene Mohammed Memorial General Hospital in Hosanna Town. The possible explanation might be that those mothers having no ANC visits lack information and knowledge regarding pregnancy-related danger signs and actions that should be taken if such problems happened. 46
Educational level of mother was another factor that had significant association with ABOs among mothers with RPI. Thus, women who were unable to read and write were 6.66 times more likely to have ABOs as compared with those mothers with educational attainment of college and above. This could be because education is the main track for women’s employment, improved household economic status, and empowerment on decision-making, which, in turn, is associated with the use of maternal and child health services. 47 Women with better educational attainment will have good health literacy, which, in turn, influences them to seek information and care from health personnel. 48 The reverse is true that women with lower educational achievement are more reluctant to move and seek maternity and child health services. In turn, ABOs might be increased.
The present study revealed that history of intimate partner violence during the most recent pregnancy had a significant association with ABOs. The odds of ABOs were 2.14 and 1.73 times higher among mothers who had a history of intimate partner violence during the most recent pregnancy among mothers with SPI and merged one. The possible explanation might be physical and psychological violence could affect the health of both the mother and the unborn baby. Evidences show that intimate partner violence could affect the maternal weight gain and has association with LBW and PTB. 49 Even one form of intimate partner violence could result in abortion, stillbirth, and infantile death. 50
In addition, having a history of pregnancy-induced hypertension was significantly associated with ABOs. The odds of ABOs were 2.65 and 2.54 times higher among mothers who had a history of pregnancy-induced hypertension in the most recent pregnancy among mothers with SPI and RPI, respectively. The possible explanation might be pregnancy-induced hypertension affects the overall physiology of the mother and the fetus. Then, the transfusion of important nutrients through placental circulation could be interrupted, and the intrauterine growth of the fetus will be restricted. In addition, pregnancy might be terminated earlier to manage preeclampsia and eclampsia before the fetus gets matured to survive the extrauterine environment. Evidences shows that pregnancy-induced hypertension had association with higher risks of adverse perinatal outcomes, including LBW, smaller for gestational age, preterm delivery, birth asphyxia, and neonatal death. 51
Similarly, the mode of delivery was significantly associated with ABOs among mothers with RPI. The odds of ABOs were 4.49 and 2.64 times more likely among mothers for whom instrumental delivery and cesarean section was done, respectively, as compared with mothers who gave birth in spontaneous vertex delivery. The possible justification might be mothers for whom instrumental delivery was applied were at higher risk to have birth canal tear and will have postpartum hemorrhage (PPH). Similarly, operative vaginal delivery techniques might traumatize the baby, and they may develop immediate and/or lifelong complications. On the other way, operative deliveries are indicated if there is maternal or fetal abnormality to shorten stages of labor. The adverse finding may not be a result of the procedure done; rather the problem could be from the outset and the operative deliveries might be done to minimize the progressive maternal and fetal health defect. In addition, mothers for whom operative deliveries planned might be stressed for the procedure, and this subsequently affects the respiratory pattern of the unborn baby and again the newborn.
Duration of labor was significantly associated with ABOs among mothers with SPI. The odds of ABOs were 6 times more likely among mothers with labor duration of >18 hours as compared with their counterpart. The possible explanation might be prolongation of labor could affect maternal and fetal physiology and result in umbilical acidosis and might be associated with birth asphyxia. In addition, evidence shows that mothers experiencing prolonged labor were more likely to have PPH, obstetric trauma, infection, or a combination of problems and babies born after a prolonged labor were found to be at a greater risk to have low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score. Low APGAR score has been associated with a low or absent heart rate, difficulty of breathing, and low muscle tone and could have cerebral palsy. 52
Duration of rupture of membrane was another factor associated with ABOs. The odds of ABOs were 2.24 times higher among mothers for whom the duration of rupture of membrane was >8 hours as compared with their counterpart. This might be if rupture of membrane is premature, they may end up with PTB, acute infection, placental abruption, cord prolapse, or refractory labor and the fetus could be at a greater risk for respiratory distress. 53 In addition, mothers may be exposed to frequent pelvic examination and develop infection, which may result in neonatal respiratory problem and may develop early-onset neonatal sepsis.
Limitation of the study
This study may have recall and social desirability bias. To reduce social desirability bias, initially, participants were informed in detail about the purpose of the study and ways of handling the information to keep confidentiality. Probing questions were used to reduce recall bias.
Conclusions
ABO was a common public health problem. The prevalence of ABOs was higher in mothers with SPI than mothers with RPI. Not using ANC services, having a history of intimate partner violence, having pregnancy-induced hypertension during the recent pregnancy, and long duration of labor were significantly associated with ABOs in mothers with SPI. In addition, inability to read and write, having pregnancy-induced hypertension during the most recent pregnancy, instrumental delivery, and cesarean section were significantly associated ABOs among mothers with SPI.
Footnotes
Acknowledgments
The authors would like to acknowledge the University of Gondar, College of Medicine and Health Sciences, School of Midwifery for providing ethical clearance for this research. They would also like to express their deep appreciation to the data collectors, supervisors, and the study participants.
Authors’ Contributions
T.M.T. and T.A.A. were involved in the conception and design of the study, participated in data collection, analyzed the data, drafted the article, and approved the final version of the article. M.A.B. and M.S.M. approved the proposal with some revisions, participated in data analysis, revised subsequent drafts of the article, and approved the last version of the article. All authors have agreed on the journal to which the article has been submitted and agree to be accountable for all aspects of the work.
Data Availability
The datasets for the current study are available from the corresponding author and can be submitted for reasonable requests.
Author Disclosure Statement
The authors declare that they have no conflict of interest for this work.
Funding Information
There was no funder for this study.