|Year : 2016 | Volume
| Issue : 4 | Page : 180-184
Determinants of interpregnancy interval among parturient in Port Harcourt, Nigeria
Goddy Bassey, Tamunomie Kennedy Nyengidiki, Numonyo D Dambo
Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Web Publication||21-Dec-2016|
Dr. Goddy Bassey
Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State
Background: Interpregnancy interval (IPI) offers an important period which allows the parturient to recover from the effects of pregnancy and to be in optimum health before the next pregnancy. Short IPI has serious health and economic implications. Objective: To determine the IPI among parturient attending the antenatal clinic of the University of Port Harcourt Teaching Hospital and the factors that determine this interval. Materials and Methods: This was a cross-sectional survey involving 340 eligible women who attended the antenatal clinic. A pretested interviewer-administered questionnaire was used to obtain relevant information from the participants. The Chi-square and Student's t-tests were used to determine association between predictor variables and the IPI with P < 0.05 as level of significance. Results: The mean age of respondents was 28.4 ± 3.9 years. The average IPI was 14.9 ± 8.5 months with a range of 3-28 months. The incidence of women with short IPI was 65.9% (224/340). Contraceptive use, the presence of a male child, perinatal death in the previous confinement, number of living children, previous history of infertility, duration of exclusive breastfeeding, and duration of postpartum amenorrhea showed significant association with the IPI. Conclusion: A significant proportion of our women had short IPI. Lack and failure of contraceptive use, absence of a male child, small family size, and perinatal death were among the factors that were significantly associated with short IPI. Knowledge of the of these factors would be of assistance to family planning counselors to understand the peculiar needs of our women and to offer appropriate contraceptive advice.
Keywords: Interpregnancy interval, parturient, Port Harcourt
|How to cite this article:|
Bassey G, Nyengidiki TK, Dambo ND. Determinants of interpregnancy interval among parturient in Port Harcourt, Nigeria. Sahel Med J 2016;19:180-4
| Introduction|| |
The interval between delivery and conception is determined by the length of postpartum amenorrhea and waiting time to conception.  This time interval has an important bearing on the well-being of the index child and the outcome of the next pregnancy. , At this time, the mother has the opportunity to build up stores of nutrients that may have been depleted in pregnancy and also to ensure the healthy growth of her newborn. The interpregnancy interval (IPI) also has a bearing on the socioeconomic outlook of the family. 
A short IPI has been associated with a host of maternal and fetal problems including spontaneous miscarriages, preterm deliveries, low birth weight infants, anemia in pregnancy, preeclampsia, and maternal mortality. ,
Family planning programs had in the past advocated a 2-year interval between births which translates to a 15-month IPI. , The report of a World Health Organisation (WHO) technical committee on birth spacing recommended a 2-year IPI  and in a study published by the Johns Hopkins School of Public Health, a 3-5 year interval between births was advocated.  The National Demographic Health Survey (NDHS) of 2008 gave an average IPI (extrapolated from the reported inter-birth interval [IBI]) of 22 months.  A similar study in Enugu, Nigeria, reported an average IPI of 12 months.  IPIs from other parts of Africa indicated 19 and 23 months in Mozambique and Ethiopia, respectively. , Factors that are known to affect the IPI are duration of breastfeeding, use of contraception, maternal age, parity, sex distribution of children, death of a child, and socioeconomic class. ,,,
Sociodemographic and economic factors by themselves have been unable to define the variables that determine reproductive intentions in Africa.  This is because sociocultural, religious beliefs, and other poorly defined factors contribute to the decision-making process on reproductive intentions.  Cultural practices such as allocating parcels of land to a newborn male or holding a celebratory festival for a grand multiparous woman are hindrances to innovations that seek to improve the reproductive health of women. It is therefore evident that in Sub-Saharan Africa, a myriad of factors including sociocultural, religious, economic, and educational background have a bearing on decisions regarding reproduction.  A short IPI may adversely affect the socioeconomic situation in the family while socioeconomic status may also be the determining factor in deciding IPI. For instance, couples with low socioeconomic status may decide to defer childbearing until such a time when their economic situation improves while a poor socioeconomic situation may arise due to short IPI as a result of increased economic demand in catering for the pregnancy and child. It is also important to state that factors which influence decisions on childbearing varies between communities and could appear ambivalent. ,
The study aims to determine IPI among parturient attending the antenatal clinic of the University of Port Harcourt Teaching Hospital (UPTH) and to determine the factors that affect the IPI. The IPI is known to vary from place to place with various factors contributing to the variability. Knowledge of IPI in our environment can contribute to improvement in reproductive health practices, family planning programs, and policy making that will be peculiar to this environment and to compare with experiences in other centers. This is especially important since no similar study has been carried out in this center.
| Materials and methods|| |
This cross-sectional survey was carried out using a pretested questionnaire to obtain information from women who met the eligibility criteria. The open-ended questionnaire was administered by the investigators and trained assistants. The questionnaire was devised by the authors based on knowledge of the literature review on the subject and was used to obtain relevant information from the respondents. Information obtained include age, level of education, religion, husband's occupation, IPI, use and type of contraceptive, desired IPI, male child in the family, number of living children, medical history, prior history of infertility, mode of delivery in the last confinement, history of perinatal death, exclusive breastfeeding, duration of breastfeeding, duration of postpartum amenorrhea, and resumption of sexual activity postpartum. Respondents were drawn from the antenatal clinic of the UPTH. The antenatal clinic is run from Monday to Friday each week and the daily average attendance is 180 women. The UPTH is one of the two tertiary health facilities in the state and serves as a referring center for the primary and secondary health facilities as well as neighboring communities of Bayelsa, Abia, Imo, and Akwa Ibom states.
The IPI is defined as the time between the last childbirth and the last menstrual period.  IPI below 24 months was considered short based on the recommendation of the WHO.  The desired IPI is the time interval the woman will want to have before the next pregnancy.
Married women who were booked for antenatal care in the UPTH and consented to take part in the study were certain of their last menstrual period.
Nulliparous women, women whose preceding pregnancy ended in a miscarriage, women whose last menstrual period cannot be determined, women who cannot recall the month and year of their last childbirth, unmarried women, women with a history of sub-fertility prior to their index pregnancy, and women who decline consent.
Using Epi Info™ 7 (Equation N = (1.96 2 × [p (1 − p)] χ e2 )
(p = prevalence, e = error) for the determination of sample size, the estimated sample size is 340 using a short interpregnancy prevalence of 59%  while allowing an attrition rate of 5% and a confidence interval of 95%. Using this as a guide, 340 consecutive women who met the inclusion criteria were interviewed. Data was analyzed using SPSS version 19 software package (IBM, Armonk, NY, USA). Besides descriptive statistics, Chi-square test was used to examine for the relationship between categorical data such as perinatal death, presence of a male child, use of contraceptive, and IPIs. Independent t-test was used to test for the level of association between IPIs and the duration of exclusive breastfeeding, postpartum amenorrhea, and resumption of coitus. The level of significance was set at P < 0.05.
| Results|| |
The mean age of respondents in the study was 28.4 ± 3.9 and it ranged from 22 to 35 years. Two hundred and twenty-eight women out of 340 (67.1%) were aged between 20 and 29 years and to the Ikwerre ethnicity (157/340, 46%). Three hundred and thirty-four (98.2%) of the respondents were Christians, and 6 (1.8%) of the respondents were Muslims. All the respondents attained at least secondary school level of education. Three hundred thirteen (92.1%) out of the 340 respondents were in a monogamous marriage whereas 27 (7.9%) were in a polygamous marriage. Three hundred and twenty-six (95.9%) of the 340 spouses were employed whereas 14 (14/340, 4.1%) were unemployed. Two hundred and fifty women (73.5%) had a living male child whereas 90 (26.5%) had no living male child. Perinatal death in the last confinement was reported by 45 (13.2%) of the respondents. Three hundred and fourteen respondents (92.4%) had vaginal delivery in the last confinement whereas 26 (7.6%) had cesarean section.
Two hundred and twenty-four (65.9%) of the 340 women surveyed had a short IPI using the recommendation of the WHO technical group. The mean IPI was 14.9 ± 8.5 months and it ranged from 3 to 28 months. The mean of the desired IPI was 13.7 ± 9.4 months with a range of 0-30 months. One hundred and thirty women (38.2%) had used a modern method of contraception. The male condom was the most preferred method and accounted for 40% (52) of the contraceptive methods used whereas injectables accounted for 39.2% (51), 14 (10.8%) women used oral pills and 13 (10.0%) women used intrauterine device. The most common reason for discontinuation of contraception was the desire for another pregnancy in 78 (60.0%) of the 130 respondents who had used contraceptives while side effects (25/130, 19.2%) and incidental pregnancy (27/130, 20.8%) were the other reasons for discontinuation. Women with unmet needs for contraception constituted 32.3% (110) of the study population of which 23.8% (81) had an unmet need for spacing, whereas 8.5% (29) had an unmet need for limiting family size. [Table 1] shows the sociodemographic and other indices of the respondents.
The average number of children born to respondents in this study was 2.6 ± 1.0 and ranged from 1 to 5. One hundred and ninety-one (191/340, 56.2%) respondents had 3 or more living children.
Twenty-six (7.6%) of the respondents were managed for infertility before the delivery of their first baby whereas 314 (92.4%) did not have a history of infertility. All the women with history of infertility had short IPI whereas 198 of the 314 women without infertility had short IPI. The difference was statistically significant (P = 0.00).
The average duration of exclusive breastfeeding from this study was 4.1 ± 2.3 months with a range of 0-6 months whereas the mean duration of postpartum amenorrhea was 4.7 ± 1.1 months with a range from 3 to 6 months. The mean period for resumption of coitus was 2.7 ± 0.5 months after delivery and ranged from 2 to 4 months. One hundred and seventy of the respondents (76%) of those with short IPI viewed pregnancy as "a gift from God" and did not plan their pregnancies and would only consider using contraceptives when they had achieved their desired family size. About 54 (24.0%) of the respondents wanted to pursue their academic/career goals and wanted to be done with childbearing as quickly as possible.
Statistical analysis showed that lack of contraceptive use, perinatal death, absence of a male child, number of living children <4, short period of exclusive breastfeeding, and short duration of postpartum amenorrhea were significantly associated with short IPI as shown in [Table 2] and [Table 3].
| Discussion|| |
The mean IPI from this study was 14.9 ± 8.5 months. This is shorter than the 24 months recommended by the WHO technical group.  It is also shorter than the intervals obtained from the NDHS  and other studies from the African continent. , It is however longer than the 12 months obtained from a study in Enugu.  The incidence of women with short IPI in this study was 65.9% and higher than the incidence in Enugu  and the NDHS.  These figures should however be interpreted with caution as those studies focused on IBI, which is longer than the IPI by 9 months (IPI = IBI − 9).  The general agreement among all these studies is that based on the weight of current evidence, many women do not space their pregnancies adequately and are exposed to several morbidities including anemia, spontaneous miscarriages, preterm deliveries, and socioeconomic imbalance. ,,
The mean desired IPI in this study, 13.7 ± 9.4 is shorter than the mean IPI obtained. The reverse is usually the case as seen in other studies. ,, This occurrence may be explained by the fact that in this study, there are a number of women who had an unmet need for limiting their family size as these women had achieved their desired family size. The desired interpregnancy for these women was recorded as zero. This led to an increase in the denominator and a stasis in the numerator and hence this deviation from the findings in other studies.
Lack of contraceptive use, number of living children less than 4, absence of a male child, previous history of infertility, perinatal death in the previous confinement, short or lack of exclusive breastfeeding, and short duration of postpartum amenorrhea all showed significant association with short IPI. This was similar to findings in other studies. ,, Women who did not use contraceptives and who did not have a male child were about 57 times and 3 times, respectively, more likely to have a short IPI. There is an urgent need to sensitize our women during the antenatal period on the importance and health benefits of achieving an adequate IPI, and the important role contraception plays in this regard. Women with previous history of infertility, perinatal death, and who lack a male child should be offered a short-term contraceptive taking into consideration the appropriate IPI. They should not be offered contraceptives that interfere with prompt return of fertility following discontinuation of the contraceptive because of the need to achieve pregnancy as soon as possible.
Several women (20.8%) in this study got pregnant despite using contraceptives. A failed method of contraception was identified in this study as a contributor to short IPI. Women on contraceptives need to receive proper education on how to use contraceptive agents so as to reduce the failure rates. More so, barrier methods were the most commonly used contraceptive agents in this study and are known to have a failure rate of 2 per 100 woman years with perfect use and 15 per 100 woman years with typical use.  These women should be offered more reliable contraceptives with better typical use failure rate.
A lot of women in this study, especially those with short IPIs, believed that children were a divine gift and on that premise, did not take any active measure to control their fertility. This is demonstrated in the high incidence of unmet needs for contraception (28.5%), low incidence of contraceptive use (38.2%), and short duration of exclusive breastfeeding (4.1 months), which is known to protect women from pregnancy by inducing amenorrhea.
The effect of socioeconomic status on IPI could not be assessed in this study. Though the educational achievements of all respondents could be ascertained, there was difficulty in assessing the occupation of their spouses as most women responded that their spouses were businessmen or civil servants but could not and would not give a clear description of the nature of the business. This created a difficulty in classifying couples into social classes as described by Olusanya et al. 
| Conclusion|| |
A significant proportion of our women had short IPI. Lack of contraceptive use, contraceptive failure, absence of a male child, previous perinatal death, prior history of infertility, and small family size were associated with short IPI. Knowledge of the factors that determine IPI as evident from this study can help family planning counselors understand the peculiar needs of our women and to offer appropriate contraceptive advice. Further study to determine obstetric outcome with short IPI among study population is recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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