Adverse Neonatal Outcomes and Its Associated Factors Among Mothers with Short and Recommended Interpregnancy Interval, in Awi Zone Public Hospitals, 2020


 Background: Short interpregnancy interval is among modifiable risk factors for maternal and neonatal adverse outcomes for planned pregnancies. It is potentially associated with adverse neonatal outcomes which are known to have considerable public health significance. In Ethiopia neonatal mortality was found to be high according to recent mini Ethiopian Demographic Health Survey Report. More importantly information about adverse neonatal outcomes in relation to interpregnancy interval is poorly described yet in Ethiopia. Methods: Institution based comparative cross-sectional study was conducted in Awi zone public hospitals. A total of 482 mothers (241 with short and 241 with recommended IPI) were selected. The data was collected by using systematic random sampling technique through pretested structured questionnaire and entered in to Epi data version 3.1 then exported to Statistical Package of Social Science version 23.0 for analysis. Chi-square and independent t-test were used to compare means. Bivariable and multivariable logistic regression analyses was employed to estimate the crude and adjusted odds ratio with a confidence interval of 95% and P value of less than 0.05 considered statistically significant.Result: Among a total of selected mothers with short and recommended Interpregnancy interval (IPI) response rate was 237 (98.3%) and 238 (98.7%) respectively. Proportion of adverse neonatal outcomes were higher among short IPI groups (37.1%). Factors like, rural residence [AOR=6.9, 95%CI (3.32, 14.59)], and Cesarean section delivery [AOR=3.4, 95%CI (1.18, 10.09)] were significantly associated with adverse neonatal outcomes in short IPI groups. Factors like rural residence [AOR=6.1, 95%CI (2.11, 17.7)], unintended pregnancy [AOR=5.3, 95%CI (1.11, 25.00)], rupture of membrane [AOR=6.89, 95%CI (2.54, 18.65)] and induction of labor [AOR=13.4, 95%CI (3.17, 21.77)] were significantly associated in recommended IPI groups.Conclusion: Urban residency and vaginal mode of delivery were significantly associated with less risk of adverse neonatal outcomes in both IPI groups. Whereas, intended pregnancy status, spontaneous labor initiation and absence of ROM before labor were protective for adverse neonatal outcomes in recommended IPI mothers. Provision of proper health service coverage at rural area and minimizing C/S rate to reduce adverse neonatal outcome is recommended.


Background
Inter pregnancy period is an opportunity to address complications occurred during pregnancy, to assess a woman's mental and physical wellbeing and to optimize her health along her life time(1). Short Interpregnancy interval (IPI) is among modi able risk factors for adverse neonatal outcomes for planned pregnancies (2). IPI is de ned as the time elapsed between the woman's last delivery and the date of the last menstrual period for the index pregnancy (1,3).
There are existing recommendations that target optimization of women or couples health before conception. The CDC in 2006 and WHO in 2012 had recommended the need to implement highly recommended for good maternal and perinatal outcomes (4). Prevention of short interpregnancy intervals is a public health priority in the United States. Speci cally the American Healthy People objectives call for a 10% reduction of pregnancies that occur within 18 months of a previous birth by 2020 (5).
The health status of the couples, particularly of the woman, prior to pregnancy or conception and during the pregnancy period can adversely affect the outcome of the pregnancy(6). Short interpregnancy interval was found to be potentially associated with adverse neonatal outcomes including stillbirth, early neonatal mortality, preterm birth, Neonatal Intensive Care Unit (NICU) admission, low Apgar score and low birthweight (LBW) which are known to have considerable public health signi cance (7). Globally LBW occurs in > 20 million newborns worldwide, which is a major contributor to perinatal mortality and up to 80% of neonatal mortality (8). Preterm birth complications are also the leading cause of deaths in the neonatal period (9).
Studies from developed countries showed that the risk of developing adverse neonatal outcomes to be higher in pregnancies with short IPI (10)(11)(12). Other reports from developed countries showed an increased risk of developing preterm birth and LBW eventhough they show insigni cant association for other adverse neonatal outcomes (13). Similarly the effect of short IPI on adverse neonatal outcomes among developing countries was also supported by many literatures (14,15).
In Ethiopia the perinatal mortality rate is relatively high among women with a pregnancy interval of less than 15 months (45 deaths per 1,000 pregnancies) (16). Despite; the availability of health facilities and improved health services, recent report from Ethiopian Demographic Health Survey (EDHS) determined that stagnant prevalence in neonatal mortality as compared to the previous 2016 EDHS report (17). Therefore this study aimed to compare pregnancy outcomes between short and recommended IPI and identify associated factors among women delivering at Awi zone public hospitals.

Study area and period
The study was conducted from February 15 to April 15, 2020, at public hospitals in Awi zone, Amhara region, North West Ethiopia, 2020. Awi zone is one of the 15 Zones in Amhara Region of Ethiopia. It is bordered on the west by Benishangul-Gumuz Region, on the north by Semien Gondar Zone and on the east by Mirab Gojjam. The administrative centre of Awi zone is Injibara; other towns include Chagni, and Dangila. Injibara is found 297 Km from Adis ababa, Ethiopia. It has 11 woredas and a total of 5 public hospitals (dangla primary hospital, Injibara general hospital, Jawi primary hospital, and Gmjabet primary hospital and Chagni primary hospitals) and 447 health centers.

Study Design And Population
Institution based comparative cross-sectional study was conducted among all mothers who had at least one previous live birth and who gave their current birth in Awi zone public hospitals during the study period. Mothers whose charts were incomplete and whose current delivery was other than singleton were excluded from the study.

Sample Size Determination
Sample size was calculated using a double population proportion formula; assuming 22.2% proportion (p 1 ) for the exposed and proportion (p 2 ) for un exposed 11.3% based on a previous study which tried to show interpregnancy interval as a risk factor for preterm birth, with 95% level of con dence (z) and power of 80%. By applying 10% of non-response rate the nal sample size became 200.

Data Collection Tools And Procedures
Questionnaire was designed to meet the objective of this study and the study was based on interviewer administered questionnaire and chart review. The questionnaire was pretested on 5% (25) of the calculated sample size in durbete hospital. First, the English version of the questionnaire was prepared.
Then it was translated to Amharic and Awingi version (local languages) and then translated back to English to check its consistency.
The questionnaire has three parts. The rst include socio-demographic information such as age, educational level, and occupation, place of residence (urban and rural), the second part deal with maternal characteristics and the third neonatal outcome. By reviewing their chart sex of their infant, duration of their labor pain, mode of delivery, obstetric U/S estimate of their GA, APGAR score, birth weight of the newborn, were taken from their chart. Then in the postnatal ward just before their discharge mothers were interviewed.

Measurement
The outcome variable was measured as presence or absence of adverse neonatal outcomes.
Adverse neonatal outcome implies the presence of at least one or more of the following conditions in the current pregnancy. These include APGAR score less than 7, still birth, NICU admission, low birth weight, congenital anomaly, and preterm birth.

Data Processing, Analysis And Interpretation
The collected data were entered and cleaned using Epi data version 3.1, then exported to SPSS version 23 for analysis. Descriptive analysis, chi-square and independent t-test were conducted to summarize the data and the nal result of the study was interpreted in the form of text, gures and tables. Binary logistic regression analysis was executed to see the association between independent and dependent variables.
All explanatory variables with p < 0.2 in bivariable logistic regression were entered into multivariable logistic regression analysis and signi cant association was identi ed based on p < 0.05 and odds ratio with 95% CI in multivariable logistic regression. The nal model tness was checked using Hosmer-Lemeshow Goodness of Fit test (p = 0.519). Separate analysis was also done for mothers with both short and recommended IPI.

Ethical Consideration
After approval, ethical clearance was obtained from Institutional Review Board (IRB) of College of Medicine and Health sciences, Bahir Dar University. Then, o cial letter was written from College of Medicine and Health Sciences to each Awi zone public hospitals. The aim of the study was informed for each study participant, and the study participants had a right to refuse or discontinue participating in the research without any restriction. Finally informed written consent was obtained from each participant before data collection and con dentiality was assured.  During their current pregnancy 6(2.5%) mothers with short IPI and 14(5.9%) of those mothers with recommended IPI faced obstetric complication. It was hypertensive disorder which accounts more 5(83.3%) and 12(85.7%) among short and recommended IPI mothers respectively. The overall proportion of ROM was 67(14.1%) and was prolonged in 26(38.8%) of cases. The mean duration of ROM was 7.66 (SD ± 5.09). In 31(6.5%) of cases duration of labor took 12hr and above, while the mean duration of labor was 6.48(SD ± 2.48) ( Table 3). 3.3. Factors associated with adverse neonatal outcomes among mothers with short IPI Three models were tted to assess factors in relation to adverse neonatal outcomes. The rst model was tted to identify factors associated with adverse neonatal outcomes among mothers with short IPI. Variables such as residence, mode of delivery and time of initiation of ANC follow-up were found to have signi cant association with adverse neonatal outcomes. The odds of Mothers from rural area to develop adverse neonatal outcomes were 6.9 times (AOR = 6.9, 95%CI = 3.32, 14.59) higher than those mothers from urban area. Mothers who deliver through C/S were 3.21 times (AOR = 3.21, 95%CI = 1.08, 9.50) more likely to have babies with adverse neonatal outcomes than their counterparts (Table 4). Factors associated with adverse neonatal outcomes among mothers with recommended IPI

Socio-demographic characteristics of participants
The second model was tted to assess factors associated with adverse neonatal outcomes among mothers with recommended IPI. Variables like residence, pregnancy status, presence of ROM before labor and labor status were found to have a signi cant association with adverse neonatal outcomes among mothers with recommended IPI. The odds of delivering babies with adverse neonatal outcome among rural mothers was 6.1 times (AOR = 6.1, 95%CI = 2.11, 17.7) higher than their counterparts. The odds of delivering babies with adverse outcome among mothers whose pregnancy was unintended was found to be 5.3 times (AOR = 5.3, 95%CI = 1.11, 25.00) higher than their counterparts. Similarly mothers who had induction of labor were 13.4 times (AOR = 13.4, 95%CI = 3.17, 21.77) more likely to deliver babies with adverse neonatal outcomes than those whose labor start spontanously. The odds of having babies with Factors associated with adverse neonatal outcomes among mothers with short and recommended IPI A full model was developed to assess factors associated with adverse neonatal outcomes among mothers with short and recommended IPI. In this model variables like residence, IPI, presence of ROM, labor status and mode of delivery were found to be signi cantly associated with adverse neonatal outcomes regardless of the IPI. Mothers with IPI of less than 24 month were 3.39 times (AOR = 3.39, 95%CI = 2.02, 5.7) more likely to develop adverse neonatal outcome than their counter parts. Rural resident mothers were 6.3 times (AOR = 6.3, 95%CI = 3.52) more likely to give birth of newborn with adverse neonatal outcome compared to mothers from the urban residency. Similarly mothers with ROM were also found to be 6.2 times (AOR = 6.2, 95%CI = 3.01, 12.8) more likely to deliver newborn with adverse neonatal outcomes than their counterparts. In this study, Mothers who had induction of labor were 3.88 times (AOR = 3.88, 95%CI = 1.14, 10.71) more likely to deliver newborn with adverse neonatal outcome as compared to their counterparts. Mothers who gave birth through C/S were 2.4 times (AOR = 2.4, 95%CI = 1.17, 5.2) more likely to have adverse neonatal outcomes than those with vaginal deliveries (Table 6).

Discussion
The overall proportion of adverse neonatal outcome in this study was 28.8%. This result was found to be consistent with studies done in East Gojjam (22) and north Wollo(23), 31.7% and 31.8% respectively. Whereas the overall prevalence in this study was found to be higher than a study from Gondar specialized teaching hospital, 23% (24). This might be because the study of Gondar specialized teaching hospital estimate proportions only for stillbirth, preterm birth and LBW, they didn't include other adverse outcomes like APGAR score < 7, NICU admission nor major congenital anomalies.
Waiting at least 24 months before trying to become pregnant after a live birth is highly recommended as it helps to avoid the risk of developing poor neonatal and infant health outcome (25). The nding of this study also supports this recommendation, rates of adverse neonatal outcomes were found to have a signi cant association with short IPI. This result is also supported by a case-control study from northwest Ethiopia (26) and another cohort study from southern Ethiopia (27). It was also consistent with studies from Sudan and Qatar (14,28).
This study also revealed that, unintended pregnancy status was signi cantly associated with adverse neonatal outcomes among mothers with short IPI. This result was consistent with a study done in southern Ethiopia that showed unintended pregnancy status to be associated with risk of adverse neonatal outcomes (29). This is because those mothers with unintended pregnancy status are less likely to seek care from health institutions (30,31) which might alter maternal use of antenatal care services, subsequent poor labor and delivery care and in adequate neonatal care.
Maternal residence was found signi cantly associated with adverse neonatal outcomes. In this study rural residents were found more likely to have adverse neonatal outcome than urban residents. This nding was consistent with a report from Nigst Eleni hospital in hosanna (18), North Wollo (23), Gamo Gofa (20) and Mekelle (32) which also showed rural residents to have signi cantly higher risk of developing adverse neonatal outcomes. This might be due to distance naturally prevents mothers from doing so even if they are knowledgeable of the bene ts of antenatal care services but deprives them the opportunity for early identi cation and management of pregnancy related problems and may further in uence their choice of place of delivery and also lack some health services on time. According to this study, presence of premature ROM was also signi cantly associated with risk of having babies with adverse neonatal outcome. This study was found to be consistent with a study from Gambia, which reported higher risk of developing adverse neonatal outcomes among women who had premature ROM (33) Similarly this result was also consistent with a study from southern Ethiopia, which reported premature ROM to have a signi cant effect on adverse neonatal outcomes (29) This may be because of the risk of developing infection when the duration of rupture prolongs and a subsequent neonatal sepsis that may alter neonates APGAR score and may also need NICU admission.
Induction of labor was found to have a statistically signi cant effect on adverse neonatal outcomes in both short and recommended IPI mothers. This result was consistent with a study from suhul shire (21) This might be due to the risk of subsequent fetal distress after labor establishment through induction.
This study also showed that, C/S delivery was associated with higher risk of having adverse neonatal outcomes than vaginal delivery. This result was consistent with study from low and middle income countries(34) that showed delivery through C/S to be associated with adverse neonatal outcomes. This might be due to the fact that mothers for whom C/S done would have fetal distress during labor as an indication for C/S and this subsequently affects the neonatal condition.

Limitation Of The Study
Cross-sectional nature of this study limits to set a causal-effect relationship between dependent and independent variables. Selection bias might be also the limitation of the study.
Mothers who deliver in health centers in Awi zone were not included, due to the lack of some relevant activities such as obstetric ultrasound, to estimate the GA and absence of NICU.

Conclusion
There was signi cant difference in proportion of adverse neonatal outcomes among short and recommended IPI mothers, 37.1% and 20.6% respectively. Urban residency and vaginal delivery were signi cantly associated with less risk of adverse neonatal outcomes among mothers in the short IPI groups. Whereas urban residency, intended pregnancy status, spontaneous labor initiation and absence of ROM before labor were reported as a protective for adverse neonatal outcomes in recommended IPI mothers. Provision of proper health service coverage at rural area and minimizing C/S rate to reduce adverse neonatal outcome is highly recommended. Formal letter of cooperation was written for public hospitals in Awi Zone, dangla primary hospital, Injibara general hospital, Jawi, Gimjabet and Chagni primary hospitals and permission was obtained.
Written consent was obtained from each study participants. Con dentiality of information and privacy was maintained.

Consent for publication: Not applicable
Availability of data and materials: The datasets used and/or analyzed during the current study is available from the corresponding author on reasonable request.