The effect of inter-pregnancy interval on stillbirth in urban South Ethiopia: a community-based prospective cohort study

Background Stillbirth is an invisible and poorly understood adverse pregnancy outcome that remains a challenge in clinical practice in low-resource settings. It is also a key concern in Ethiopia where more than half of pregnancies occur shortly after preceding childbirth. Whether the interval between pregnancies has an effect on stillbirth or not is unclear. Therefore, we aimed to assess the effect of inter-pregnancy interval on stillbirth in urban South Ethiopia. Methods A community-based prospective cohort study was conducted among 2578 pregnant women and followed until delivery. Baseline data were collected at the household level during registration and enrolment. End-line data were collected from hospitals during delivery. Exposed groups were pregnant women with inter-pregnancy intervals < 18 months and 18–23 months. Unexposed group contains women with inter-pregnancy intervals 24–60 months. A generalized linear model for binary outcome was applied, using R version 4.0.5 software. Relative risk (RR) was used to estimate the effect size with a 95% confidence level. Attributable fraction (AF) and population attributable fraction (PAF) were used to report the public health impact of exposure. Results The overall incidence of stillbirth was 15 per 1000 total births, (95% CI: 11, 20%). However, the incidence was varied across months of inter-pregnancy intervals; 30 (< 18 months), 8 (18–23 months) and 10 (24–60 months) per 1000 total births. The risk of stillbirth was nearly four times (ARR = 3.55, 95%CI: 1.64, 7.68) higher for women with inter-pregnancy interval < 18 months as compared to 24–60 months. This means, about 72% (AF = 72, 95%CI: 39, 87%) of stillbirth among the exposed group (inter-pregnancy interval < 18 months category) and 42% (PAF = 42, 95%CI: 23, 50%) of stillbirth in the study population were attributed to inter-pregnancy interval < 18 months. These could be prevented with an inter-pregnancy interval that is at least 18 months or longer. Conclusions Inter-pregnancy interval under 18 months increases the risk of stillbirth in this population in urban South Ethiopia. Interventions targeting factors contributing to short inter-pregnancy intervals could help in reducing the risk of stillbirth. Improving contraceptive utilization in the community could be one of these interventions.

432Recurrent stillbirth: a population-based study from South Australia

Background In high-income countries, stillbirth is a relatively rare event occurring in &lt; 1% of pregnancies. Recurrent stillbirth is even rarer. Our objective was to explore the prevalence of stillbirth and recurrent stillbirth, factors associated with stillbirth and whether a stillbirth in first pregnancy influences the time to subsequent pregnancy. Methods This population-based study involved routinely-collected administrative data on singleton births in South Australia from 1998 to 2015 (n = 333,785). Stillbirth was defined as pregnancies &gt;20 weeks gestation or weighing &gt;400 grams. Univariable and multivariable logistic regression was used to explore associations between sociodemographic factors and stillbirth. Cox proportional hazard was used to explore time to pregnancy. Results 0.7% of all first pregnancies and 0.6% of all second pregnancies were stillbirths. Of women in their second pregnancy, &lt;10 experienced recurrent stillbirth. In univariable analyses, higher odds of stillbirth in second pregnancies were associated with younger and older maternal age (&lt;20 or ≥ 40 years), being single, unemployed, smoking, shorter inter-pregnancy intervals and numerous medical conditions (e.g. diabetes or hypertension). Multivariable models were unstable due to too few data. The hazard ratio for women who previously experienced a stillbirth compared with livebirth was 1.14 (95%CI 0.39, 3.32). Conclusions Studying recurrent stillbirth is especially difficult due to the rare nature of the problem, limiting progress on developing evidence-based advice for women who experience stillbirth in their first pregnancy. Key messages Recurrent stillbirth is challenging to study due to the rareness of the problem but could be addressed by careful pooling of large administrative datasets.

P–743 The fertility paradox: the need for contraception after in vitro fertilisation

Study question What are a woman’s contraceptive needs after successful in vitro fertilisation (IVF) pregnancy? and how should services respond to help prevent unintended pregnancies? Summary answer Women who have IVF pregnancies require tailored, postnatal contraception counselling. Services must provide evidence-based information about the risks of spontaneous conception to engage them effectively. What is known already Women undergoing IVF are an increasingly heterogeneous group with a wide range of causative subfertility factors. Furthermore, increasingly, women are accessing treatment primarily for reasons other than subfertility. The evidence relating to rates of spontaneous conception post assisted conception varies widely according to population, cause of subfertility, type and outcome of fertility treatment and length of follow-up. A recent large retrospective UK cohort study estimated the treatment-independent live birth rate after IVF live birth over 5 year follow up as 15% [https://doi.org/10.1093/humrep/dez099]. We aim to explore the experiences and views about contraception among this diverse group of women. Study design, size, duration A qualitative study of the views of women who have had spontaneous pregnancies after successful IVF was conducted in September/October 2020. A qualitative approach of in-depth interviews was chosen to allow exploration of individual experiences in an area not much studied previously. The sample consisted of twenty interviewees from around the UK. Participants/materials, setting, methods Purposive and snowballing sampling methods were used with eligible participants recruited from a range of sources including social media and peer networks. The sample included a wide range of spontaneous pregnancy outcomes after successful IVF, including single and multiple livebirths, miscarriage, ectopic pregnancy and termination of pregnancy. The framework method was used for analysis using NVivo12 software. Main results and the role of chance Contraceptive choices were subject to a complex and dynamic interaction of influencing factors including i) beliefs regarding their own subfertility, ii) desire for more children and iii) their views on contraception. After IVF pregnancy, the majority of women (n = 15) used no contraception or ineffective methods (inconsistent condom use or withdrawal) before their next pregnancy with only two women using hormonal methods (progesterone-only pill). Spontaneous pregnancy was not universally welcomed in this group and the inter-pregnancy intervals were often short (n = 15, less than 18 months) or very short (n = 6, less than 12 months). After subsequent spontaneous pregnancy, use of contraception and the most effective (long-acting reversible) methods remained low. Women held persistent beliefs regarding their subfertility despite subsequent spontaneous pregnancy (or pregnancies). Women associated aspects of the IVF process (e.g. need for multiple cycles, low numbers of eggs collected etc.) with a sense of personal failure, despite an ultimately “successful” outcome resulting in livebirth. This may contribute to or reinforce their self-belief in subfertility. Other specific barriers to contraception use, in women having IVF, included lack of knowledge of the likelihood of spontaneous pregnancy, lack of contraceptive experience and inherent incentives towards shorter inter-pregnancy intervals. Limitations, reasons for caution There is potential recall bias with some women recalling experiences associated with IVF treatment more than ten years ago. However our sample included women who were currently pregnant as well as women who were further towards the end of their reproductive life to capture a range of experiences. Wider implications of the findings: The contraceptive needs of women having IVF pregnancies are being overlooked. Fertility services should take responsibility for providing accurate information on the risks of subsequent spontaneous pregnancy in this population. Maternity and community healthcare professionals must address women’s perceptions of their fertility in order to engage them in contraception counselling. Trial registration number N/A

The views of postnatal women and midwives on midwives providing contraceptive advice and methods: a mixed method concurrent study

Background Provision of contraception to women in the immediate postnatal period has been endorsed by professional bodies, to reduce the incidence of short inter-pregnancy intervals. This study examined the views of postnatal women and practising midwives regarding provision of contraceptive advice and contraceptive methods by midwives, in a region of the United Kingdom. Methods A mixed-method approach using qualitative interviews with midwives, and a postnatal survey followed by qualitative interviews with postnatal women, in five hospitals in the East of England. Twenty-one practising midwives and ten women were interviewed. Two hundred and twenty-seven women returned a survey. Survey data was analysed descriptively, augmented by Student’s t-tests and Chi-squared tests to examine associations within the data. Interviews were recorded, transcribed and analysed guided by the phases of thematic analysis. Results Midwives and women supported the concept of increased midwifery provision of contraceptive advice, and provision of contraceptive methods in the postnatal period. Convenience and an established trusting relationship were reasons for preferring midwifery provision over visiting a doctor for contraception. The best time for detailed discussion was reported to be antenatal and community visits. The Progesterone-only-pill (POP) was the method, in which women indicated most interest postnatally. Concerns for midwives included the need for increased education on contraceptive methods and training in supplying these. Structural barriers to such provision were time pressures, low prioritisation of contraceptive training and disputes over funding. Conclusions Women reported interest in midwives supplying contraceptive methods and expressed the view that this would be convenient and highly acceptable. Midwives are supportive of the concept of providing enhanced contraceptive advice and methods to women in their care, and believe that it would be advantageous for women. Institutional support is required to overcome structural barriers such as poor access to continuous professional development, and to allow contraceptive provision to be fully recognised as integral to the midwifery role, rather than a marginalised addition.

The impact of interpregnancy interval on occurance of preterm births in the present pregnancy

Background: The pregnancy outcomes are influenced by the inter pregnancy intervals. Both short and long inter pregnancy intervals are known to adversely affect the mother and the baby. The main aim of birth spacing was to achieve ideal inter pregnancy intervals and thus to decrease maternal, neonatal morbidity and mortality.Methods: It is a prospective observational study. In this study, about 500 gravida 2 women who has delivered vaginally in the index pregnancy, with gestational age more than 28 weeks of gestation and with known interpregnancy interval were included in the study. They followed up to to delivery and occurance of preterm births in relation to maternal characteristics and interpregnancy interval were analysed.Results: Our study showed that Inter pregnancy intervals of 18-24 months were found to have the least number of preterm births when compared to intervals <18 months and >24 months. This association was found to be statistically significant (p value, Pearson chi square 0.0008). This relationship between inter pregnancy intervals and preterm births persisted when stratified according to maternal age, education, residence and BMI.A previous preterm birth was associated with increased risk of recurrent preterm birth (p value -0.034) and was statistically significant. The history of PROM in present pregnancy associated with preterm birth (p value -0.001) and association was statistically significant.Conclusions: From this study it was found that the 18-24 months birth to pregnancy interval is associated with the least incidence of preterm births.

Risk factors and complications of small for gestational age (SGA) in term newborns in first 24 hours after delivery.

Objectives: To determine the frequency of risk factors and acute complications for SGA in term new borns during first 24 hours after delivery. Study Design: Descriptive Case Series. Setting: Department of Pediatric Medicine, Nishter Hospital, Multan. Period: 15 Aug 2014 to 30 Apr 2015. Material & Methods: A total of 157 term babies, delivered in labor room in Nishter hospital Multan were evaluated in 24 hours of birth. Mother of each SGA baby was examined regarding history, clinical examination and nutritional status were noted. SGA babies were completely monitored for 24 hours in the department of pediatric medicine for complications. Results: There were 88 (56.1%) male and 69 (43.9%) female. Mean age and weight of the patients at the time of presentation were 12.73 + 6.65 hours and 2.03 + 0.65 Kg respectively. Among mothers, 61.1% were nulliparous, anemia was found in 47.8%, inter pregnancy intervals of less than or equal to one year in 58.6% and hypertension in 61.8%. Among SGA babies, perinatal asphyxia was found to be present in 63.7%, meconium aspiration in 51%, hypothermia in 37.6%, hypoglycemia in 24.2%, hypocalcaemia in 32.5%, polycythemia in 47.1% and thrombocytopenia in 41.4%. Conclusion: Maternal hypertension, nulliparity, short inter pregnancy interval and anemia were frequently encountered risk factors for SGA babies. The most frequently encountered perinatal complications observed were perinatal asphyxia, meconium aspiration, polycythemia, thrombocytopenia, hypothermia, hypocalcaemia and hypoglycemia in decreasing order of frequency.

Effects of Preconception Care and Periconception Interventions on Maternal Nutritional Status and Birth Outcomes in Low- and Middle-Income Countries: A Systematic Review

Pregnancy in adolescence and malnutrition are common challenges in low- and middle-income countries (LMICs), and are associated with many complications and comorbidities. The preconception period is an ideal period for intervention as a preventative tactic for teenage pregnancy, and to increase micronutrient supplementation prior to conception. Over twenty databases and websites were searched and 45 randomized controlled trials (RCTs) or quasi-experimental interventions with intent to delay the age at first pregnancy (n = 26), to optimize inter-pregnancy intervals (n = 4), and supplementation of folic acid (n = 5) or a combination of iron and folic acid (n = 10) during the periconception period were included. The review found that educational interventions to delay the age at first pregnancy and optimizing inter-pregnancy intervals significantly improved the uptake of contraception use (RR = 1.71, 95% CI = 1.42–2.05; two studies, n = 911; I2 = 0%) and (RR = 2.25, 95% CI = 1.29–3.93; one study, n = 338), respectively. For periconceptional folic acid supplementation, the incidence of neural tube defects were reduced (RR = 0.53; 95% CI = 0.41–0.77; two studies, n = 248,056; I2 = 0%), and iron-folic acid supplementation improved the rates of anemia (RR = 0.66, 95% CI = 0.53–0.81; six studies; n = 3430, I2 = 88%), particularly when supplemented weekly and in a school setting. Notwithstanding the findings, more robust RCTs are required from LMICs to further support the evidence.

Use of contraceptives and uptake of long-acting reversible contraception among postpartum women in rural China

BackgroundPregnancies have been increasing since the universal two-child policy in China was announced and thus the prevention of short inter-pregnancy intervals has become more important. However, little is known about contraceptive use among postpartum women in rural areas of China. This study investigated the current situation and factors associated with contraceptive use, especially long-acting reversible contraception (LARC) practice among postpartum women.Study designA cross-sectional study was conducted with a probability proportionate to size (PPS) sampling method in Shimen County of Hunan province with 423 mothers whose youngest child was aged under 2 years. A questionnaire was used to collect information on participants’ demographics, reproductive history and contraceptive use.ResultsThe rate of using all contraceptive methods was 66.4% in the study group and the rate of using LARC was 9.9%. Statistically significant predictors of contraceptive use were: no breastfeeding, no intention of having another child, and education beyond high school. Statistically significant predictors of LARC utilisation were: vaginal delivery, at least one child before the index delivery, and no breastfeeding.ConclusionsThe utilisation rate of postpartum contraception, especially LARC, was relatively low in rural China. The benefits of LARC have not been realised and breastfeeding is still incorrectly believed to be a definitely reliable method of contraception. Thus, health education and contraceptive knowledge and regulations need to be updated and enhanced based on research evidence, for increased adoption of postpartum contraception in rural China.