ORIGINAL

Niger J Paed 2013; 40 (3): 264 –269

Onubogu CU

Ugochukwu EF

Inter-pregnancy interval and

pregnancy outcomes among HIV

positive mothers in Nnamdi Azikiwe

University Teaching Hospital,

Nnewi, South-East Nigeria

DOI:http://dx.doi.org/10.4314/njp.v40i3,12

Abstract Background: Both short

and long inter-pregnancy intervals

have been associated with higher

risk of adverse pregnancy

outcomes. More so, short inter-

pregnancy interval among HIV-

positive women implies higher

birth rate and subsequently a

higher number of neonates

exposed to HIV and potentially at

ris k o f mo t her -to -c hi ld

transmission.

Aims: To study the influence of

inter-pregnancy interval on

pregnancy outcomes among

booked HIV-positive mothers

with singleton live-births at

Nauth, Nnewi.

Methods: A cross-sectional study

was carried out with the aid of

structured questionnaires,

maternal clinical records and

relevant anthropometry, between

May and December 2011, among

booked multiparous HIV-positive

mother/singleton newborn pairs at

NAUTH, Nnewi.

Results: More than half (56.5%)

of the 175 multiparous HIV-

positive women studied had short

inter-pregnancy interval (<18

months). Short inter-pregnancy

interval was significantly

associated with adverse maternal

and perinatal outco₂mes like

maternal anaemia (X =14.95,

p=0.021) and low values of

m a t e r n a l o r n e o n a t a l

anthropometric parameters.

However only adverse maternal

outcomes and MAC/OFC ratio of

t h e n e o n a t e s r e m a i n e d

significantly associated with short

Inter-pregnancy interval after

logistic regression analysis. Long

inter-pregnancy interval was

significantly associated with low

values of neonatal anthropometric

parameters and maternal MAC less

Onubogu CU

Ugochukwu EF

(

)

Department of Paediatrics

Nnamdi Azikiwe University

Teaching Hospital

Nnewi, Nigeria

E-mail: luvilyamy@yahoo.co.uk

2

than 25cm (X =15.10, p=0.019) as

well as third trimester weight gain

2

rate less than 250g/week (X

=31.20, p= 0.000). The proportion

of mothers with long inter-

pregnancy that had anaemia or

intra-partum BMI less than 25kg/

2

m differed only slightly from that

of those with inter-pregnancy

interval of 18-59 months.

Conclusion: Inter-pregnancy

interval of 18 to 59 months is

significantly associated with the

lowest risk of both adverse

maternal and fetal outcomes

among HIV-positive women.

Introduction

income countries with effective implementation of anti-

retroviral prophylaxis during pregnancy, caesarean

section delivery and avoidance of breastfeeding. On the

4

HIV/AIDS continues to kill women, infants and young

children especially in Sub-Saharan Africa with

exceptionally high burden of HIV/AIDS. Young

women remain disproportionately affected by HIV/

AIDS and constitute 71% of₂15-24 year olds living with

HIV in Sub-Saharan Africa. Above 90% of infections

in children result from mother-to-child transmission

contrary, MTCT rate is still very high in developing

countries like Nigeria, where prevention of MTCT

(PMTCT) coverage is still very limited and

breastfeeding is essential for child survival. Only about

18% of HIV-positive pregnant women receive effective

1

5

,6

anti-retrovirals for PMTCT in Nigeria. Nigeria’s

MTCT rate is 33% with 75,000 new paediatric

infections attributed to MTCT in 2010, and the country

currently has the highest burden of MTCT as ₂w_,₅ell as

maternal deaths attributed to HIV/AIDS globally.

(

MTCT) and without any intervention, 30-45% of HIV-

positive pregnant women transmit the virus to₃their

infants during pregnancy, delivery or breastfeeding.

MTCT rate has diminished to less than 2% in high

2

65

Both long and short inter-pregnancy intervals have been

associated with increased risk of poor perinatal and

(IHVN).

Approval for the study was obtained from the NAUTH

Ethics Committee and written informed consent was

obtained from all participating mothers. Subjects were

booked, multiparous, HIV-positive mothers that had

singleton live births at NAUTH, Nnewi together with

their newborn infants. Those whose preceeding

pregnancy ended in an abortion were excluded.

maternal_-₁₅outcomes among the general population of

8

women.

Women who become pregnant within 18-59

months after a preceeding delivery a₈r_-₁e₅ least likely to

have adverse pregnancy outcomes. Shorter inter-

pregnancy interval has been associated with low birth

weight, premature delivery, intrauterine fetal ₉d_-e₁₁ath, as

well as higher risk of under-five mortality.

Poor

maternal outcomes like puerperal endometritis, ante-

partum haemorrhage, anaemia, poor nutritional status

and maternal death have als₈_,o₉_,₁b₁_,e₁e₄_,n₁₆associated with short

The mothers were interviewed with a pre-tested,

interviewer-administered, semi-structured questionnaire

to obtain relevant socio-demographic and obstetric

information. A cross-check was made with the mothers’

antenatal clinic record after data collection for further

validation of the data. Mothers’ gestational age (GA)

and weight at booking were obtained from their ante-

natal records. Mothers’ variables were age, educational

status, occupation, last menstrual period (LMP), date of

last confinement, parity, GA at delivery and pregnancy

complications like ante-partum haemorrhage,

hypertensive disorders, pre-term premature rupture of

membranes and gestational diabetes mellitus. The inter-

pregnancy interval in months was obtained by

subtracting the date of previo₈u_-₁s₀confinement from LMP

inter-pregnancy interval.

Likewise, inter-

pregnancy interval above 59 months has been associated

with higher rates of gestational diabetes and

hypertensive di₈s_,₉orders in pregnancy as well as adverse

fetal outcomes.

Addressing inter-pregnancy interval among HIV-

positive mothers is essential to achieving the “Global

Plan” of eliminating MTCT and improving maternal

health by year 2015 in view of the limited PMTCT

coverage in developing countries and benefit₂s_,₅ of optimal

pregnancy spacing on maternal health. Adequate

pregnancy spacing imply lo₇w_-₁e₅r fertility rate and ensures

before the index pregnancy.

Third trimester weight

better pregnancy outcomes.

This can be achieved by

gain and duration of the weight gain was obtained by

subtracting the first documented third trimester weight

and the GA at which it was taken from the intra-partum

weight and GA at delivery, respectively. The rate of

third trimester weight gain in grammes(g) per week was

calculated by dividing weight gained during third

correct and consistent use of effective contraception,

which by extension, reduces the number of babies

exposed to HIV or potentially at risk of MTCT when₇

applied to populations of HIV-positive women.

Unfortunately, this is often neglected in PMTCT

7

18

programmes. The need for contraception is even higher

trimester by the duration of the weight gain. The socio-

among non-breastfeeding HIV-positive mothers as

ovulation may return as early as six weeks post-partum

putting th₇_,e₁₇m at risk of another pregnancy shortly after

delivery.

The current study was set out to examine the inter-

pregnancy intervals of HIV-positive mothers as well as

the relationship between inter-pregnancy interval and

some pregnancy outcomes like low values of maternal

or neonatal anthropometric parameters, low maternal

economic status of the family was assessed based on the

highest educational attainment and t₉he occupation of

1

both parents as described by Oyedeji. Mothers’ weight,

height and mid-arm circumfere₀ nce (MAC) were

2

measured using standard methods. The maternal health

indicators were Body Mass Index (BMI), MAC, third

trimester weight gain rate, CD count, intra-partum

4

packed cell volume(PCV) and pregnancy complications

like ante-partum haemorrhage, hypertensive disorders,

diabetes mellitus and premature rupture of membranes.

For every neonate, GA assessment was carried out

within 24 hours of birth using the Dubowitz GA

assessment chart. This was cross-checked with GA

calculated from mother’s LMP for further validation.

Where discrepancy of more₈ than two weeks occured, the

CD

4

count, maternal anaemia and occurence of

pregnancy complications like hypertensive disorders,

antepartum haemorrhage, premature rupture of

membranes and diabetes mellitus.

1

Dubowitz score was used.

Methods

Anthropometric assessment of the newborn infants was

conducted as soon as pos₂₀s_,i₂b₁le within 24 hours of birth

The infants were weighed

A

cross-sectional questionnaire-based study was

conducted to determine the effect of inter-pregnancy

interval on some pregnancy outcomes among booked

HIV-positive mother/singleton newborn baby pairs at

Nnamdi Azikiwe University Teaching Hospital

using standard methods.

naked using an infant weighing scale (SALTER

MODEL 180) which was checked daily for zero

adjustment. Three measurements were₁obtained and the

2

(

NAUTH), Nnewi, Anambra state, South-Eastern

mean recorded to the nearest 0.05kg. The length was

Nigeria. NAUTH is a tertiary hospital that serves as the

major obstetric referal centre for Anambra state and

environs. The centre offers PMTCT services which is

supported by the U.S. Presidential Emergency

Programme for AIDS Relief (PEPFAR) through the

auspices of the Institute of Human Virology, Nigeria

measured with the infant placed in a supine position on

an infantometer. An assistant, while gently cupping both

ears, held the infant’s head snugly touching the fixed

head-piece so that the inner and outer canthi of the eyes

were in the vertical plane. Using the left hand, the

researcher gently pressed the knees firmly against the

2

66

board and with the right hand, apposed the movable

foot-piece against the infant’s heel which was kept

perpendicular to the board. Three measurements were

obtained and recorded to the nearest 0.1cm. Occipito-

frontal circumference (OFC) and MAC were measured

with a flexible inelastic tape. For OFC, the tape was

applied over the glabella, passed around the head at the

same level on each side and over the occipital

prominence, then pulled firmly to compress the hair.

Three measurements were obtained and the mean

recorded to the nearest 0.1cm. The MAC was measured

at a level that was mid-way between the tip of acromion

and olecranon on the left arm, with the elbow flexed to a

right angle. The tape was wrapped snugly around the

arm without compressing the underlying tissue. Three

measurements were obtained and the mean recorded to

the nearest 0.1cm. The anthropometric parameters of the

neonates were birth weight, weight-for-GA, MAC/OFC

ratio and ponderal index. Ponderal index was calculated

using the formula : 100 x birth weight (in grammes)

anthropometric parameters assessed in the neonates.

There was no significant difference between the

anthropometric parameters of neonates whose mothers

had inter-pregnancy interval of 13 to 17 months and

those whose mothers had inter-pregnancy interval of 18

to 59 months. No pre-term delivery occured in mothers

with inter-pregnancy intervals of 18–59 months

compared to the other inter-pregnancy intervals. There

was, however, no significant association between GA at

delivery and inter-pregnancy interval.

Table 1: Socio-demographic and obstetric characteristics of

the mothers

Maternal Characteristics

Number

(total=175)

Percentage

Inter-pregnancy interval (months)

≤

7

6

– 12

29

36

34

57

19

16.6

20.5

19.4

32.6

10.9

1

3 – 17

18 – 59

59

3

>

divided by cube of birth length (cm ).

Data analysis was done with statistical package for

social sciences (SPSS) software, version 17.

Multinomial logistic regression analysis was used to

determine the Odds Ratio (OR) of adverse pregnancy

outcomes significantly associated with inter-pregnancy

interval in Chi-square test. Probability (p) value of less

than 0.05 was considered statistically significant.

Social-Class

High

Middle

Low

8.6

41.7

49.7

1

5

73

87

Educational status

Tertiary

Secondary

Primary

No formal education

Marital status

Married

Single

Widowed

Divorced

33

18.9

41.7

39.4

0.0

73

69

0

165

0

10

0

94.3

0.0

5.7

0.0

Results

Age (years)

Out of a total of 777 mothers that had live births during

the study period, 240 were HIV-positive. Among the

HIV-positive mothers, 197 were multiparous. Twenty-

two out of 197 mothers were excluded on account of

multiple births, incomplete ante-natal records, history of

abortion in preceeding pregnancy and refusal to give

informed consent. Thus final analyses was done with

data obtained from 175 multiparous HIV-positive

mother/singleton newborn baby pairs.

<

1

>

18

8-35

35

0

141

34

0.0

80.6

19.4

Parity

Multiparous [>1]

Grandmultiparous [ >5]

135

40

77.1

22.9

High social class = Socio-economic classes I and II

Middle social class = Socio-economic class III

Low social class = Socio-economic class IV and V

Some socio-demographic characteristics and obstetric

parameters of the mothers are shown in Table 1. The

mothers were predominantly from low and middle social

classes. All of them were christians, aged 18 years or

more and had at least primary school education. They

were predominantly married women (94.3%). Inter-

pregnancy interval ranged from three to 132 months

with a mean of 21.51 + 18.45 (n=167) months. Inter-

pregnancy interval in 8 extreme cases (outliers) were

deselected while calculating the mean and standard

deviation as they exerted undue leverage upon the

initially obtained values which did not give a true

representation of the mean inter-pregnancy interval for

the studied population. Inter-pregnancy intervals of 18-

Table 3 shows the relationship between inter-pregnancy

interval and some maternal health indicators. Inter-

pregnancy intervals of 12 months or less was

significantly associated with the highest risk of low intra

-partum BMI or MAC, 3rd trimester weight gain less

than 250g per week and maternal anaemia while

intervals of 18-59 months was associated with the

lowest risk. Surprisingly, inter-pregnancy intervals of 12

months or less was associated with the lowest risk of

3

maternal CD

4

count less than 250cells/mm although the

association was not statistically significant. Though inter

-pregnancy interval of 18-59 months had the least risk of

pregnancy complications like hypertensive disorders,

ante-partum haemorrhage, diabetes mellitus and

premature rupture of membranes, the association was

not statistically significant.

5

9 months occured in 32.6% of cases.

Table 2 shows the relationship between inter-pregnancy

interval and some neonatal indices. Inter-pregnancy

intervals of 12 months or less and above 59 months were

2

67

Table 2 : Relationship between inter-pregnancy interval and neonatal indices

Characteristic

Inter-pregnancy interval (months)

2

<12

13-17

18-59

>59

Total (%)

X

P-value

0.000

Birth weight

1

4

7(26.2)

8(73.8)

4(11.8)

30(88.2)

0(0.0)

4(7.0)

47(82.5)

6(10.5)

6(31.6)

9(47.4)

4(21.0)

31(17.7)

134(76.6)

10(5.7)

<

2

>

2.5kg

.5-3.9kg

4kg

27.86

32.70

0

(0.0)

Weight-for-GA

SGA

AGA

1

4

6(24.6)

7(72.3)

2(3.1)

2(5.9)

32((94.1)

0(0.0)

3(5.3)

40(70.2)

14((24.5

4(21.1)

10(52.6)

5(26.3)

25(14.3)

129(73.7)

21(12.0)

0.000

LGA

Ponderal Index

1

6(24.6)

3(8.8)

31(91.2)

0(0.0)

7(12.3)

40(72.0)

10(17.5)

5(26.3)

8(42.1)

6(31.6)

31(17.7)

126(72.0)

18(10.3)

<

2.32

.32-2.85

2.85

MAC/OFC ratio

4

7(72.3)

25.69

13.29

0.000

0.004

2

>

2

(3.1)

26(40%)

5(14.7)

29(85.3)

9(15.8)

48(84.2)

4(21.1)

15(78.9)

44(25.1)

131(74.9)

<

>

0.27

3

9(60%)

GA at birth (weeks)

<

>

37

4

1(93.8)

(6.2)

2(5.9)

32(94.1)

0(0.0)

57(100)

2(10.5)

17(89.5)

8(4.6)

167(95.4)

4.78

0.188

6

Total (%)

65(37.1)

34(19.4)

57(32.6)

19(10.9)

175(100.0)

SGA=small for gestational age, AGA=adequate for gestational age

LGA=large for gestatioal age, GA=gestational age

MAC= mid-arm circumference, OFC=occipito-frontal circumference

Table 3: Effect of inter-pregnancy interval on maternal health

Characteristic

Inter-pregnancy interval(months)

<12 13-17 18-59

2

>59

Total (%)

X

p-value

2

Intrapartum BMI (kg/m )

18.5

<

0(0.0)

0(0.0

0(0.0)

6(10.5)

24(42.1)

27(47.4)

0(0.0)

2(10.5)

8(42.1)

9(47.4)

0(0.0)

35(20.0)

84(48.0)

56(32.0)

1

2

8.5-24.9

5-29.9

21(32.3)

33(50.8)

11(16.9)

6(17.6)

19(55.9)

9(26.5)

20.07 0.003

15.10 0.019

>

30

MAC(cm)

25

5-30

30

rd trimester weight gain

250g/wk

50-500g/wk

500g/wk

<

2

>

3

<

2

>

22(33.9)

29(44.6)

14(21.5)

7(20.6)

18(52.9)

9(26.5)

5(8.8)

32(56.1)

20(35.1)

4(21.1)

6(13.6)

9(47.3)

38(21.7)

85(48.6)

52(29.7)

32(49.2)

27(41.5)

6(9.2)

9(26.5)

25(73.5)

0(0.0)

5(8.8)

42(73.7)

10(17.5)

5(26.3)

13(68.4)

1(5.3)

51(29.1)

107(61.1)

17(9.7)

31.20 0.000

14.95 0.021

Intrapartum PCV(%)

30

0-32

33

CD

250

50-500

500

<

3

>

22(33.8)

26(40.0)

17(26.2)

6(17.6)

19(55.9)

9(26.5)

7(12.3)

24(42.1)

26(45.6)

3(15.8)

6(31.6)

10(52.6)

38(21.7)

75(42.9)

62(35.4)

4

count

<

2

>

4(6.1)

23(35.4)

38(58.5)

4(11.8)

16(47.1)

14(41.1)

5(8.8)

26(45.6)

2(10.5)

9(47.4)

8(42.1)

15(8.6)

74(42.3)

86(49.1)

4.03

1.83

0.671

0.608

Pregnancy Complications

Yes

No

9(13.8)

56(86.2)

4(11.8)

30(88.2)

4(7.0)

53(93.0)

3(15.8)

16(84.2)

20(11.4)

150(85.7)

Total (%)

65(37.1)

34(19.4)

57(32.6)

19(10.9)

175(100.0)

2

68

The result of logistic regression analysis for adverse pregnancy outcomes significantly associated with inter-pregnancy

interval in chi-square test is shown in Table 4. The associations that remained statistically significant after logistic

regression analysis were maternal anaemia and low anthropometric parameters as well as MAC/OFC ratio of the

neonates.

Table 4 : Result of logistic regression analysis for adverse pregnancy outcomes significantly associated with inter-pregnancy

Characteristic

Inter-pregnancy Interval (months)

13-17

<

12

18-59

>60

OR

95% C1

OR

95% CI

OR

95% CI

OR 95% CI

Intra-partum PCV < 30%

MAC< 25cm

3.35*

0.69-16.23 1.51*

0.96-18.99 1.56*

0.22-9.98

0.54

0.48

0.09-3.07

+

4.26*

0.27-8.81

0.09-2.59

0.11-5.71

0.01-1.50

2

Intrapartum BMI< 25kg/m

10.42* 1.53-70.89 2.86*

0.34-23.97 0.78

Third trimester weight gain < 250g/

week

1.59*

0.12-14.46 3.74*

0.58-1.49

0.12

Low Ponderal index

0.63

0.16-2.50

0.06

0.01-0.68

0.31

0.07-1.36

+

Low MAC/OFC

SGA

4.47*

0.85

1.05-19.07 1.00

0.18-5.63

0.25-0.98

1.0

0.19

0.24-5.42

0.36-0.98

+

0.23-3.09

0.25-2.39

0.16

0.29

LBW

0.77

0.07-1.20

0.16

0.04-0.66

+

CI=Confidence interval,

=data insufficient for analysis,

*=Statistically significant,

LBW= Low birth weight,

OR=Odds ratio,

SGA=Small for gestational age,

MAC=Mid-arm circumference,

OFC= Occipito-frontal circumference, BMI=Body mass Index

unfavourable outcome of preceeding pregnancy,

underlying medical disorders, poor socio₉-_-e₁c₁_,o₁₄n_,₁o₆mic

status, poor antenatal care or life-style factors.

Discussion

The effect of short inter-pregnancy interval on birth

weight is believed to result from inadequate time for

replenishment of maternal nutrient stores as well as

recovery from the physiologic stress of pregnancy and

lactation am₁₂_-o₁₄ng women with close succession of

The high prevalence of HIV infection (30.9%) found

among parturients at NAUTH, Nnewi may be explained

by the fact that NAUTH is the only obstetrics tertiary

referal centre in Anambra state and has the largest

PMTCT programme in the state. NAUTH as a centre for

PMTCT caters for a considerable number of HIV-

positive clients. Similar prevalence of 29.6% was

documented in the same centre by a study conducted

pregnancies

Some hypothesis have been proposed to

explain the relationship between long inter-pregnancy

interval and adverse pregnancy outcomes. These include

a

gradual post-partum regression of a woman’s

reproductive c₉a_,₁p₆acity to become similar to that of a

primigravidae. Another possible explanation is that

long interpregnancy interval may be secondary to factors

like chronic maternal diseases and genital tract infection

which are risk factors for b₉o_,₁t₆h secondary infertility and

adverse perinatal outcomes.

2

about 1 year prior to the index study.

Findings of the index study suggest a high rate of short

inter-pregnancy intervals among HIV-positive women

that enrolled for PMTCT at NAUTH, Nnewi as 56.5%

of them had inter-pregnancy intervals less than 18

months. The study, however, was not adequately

powered to draw conclusions due to lack of comparison

with HIV negative controls.

The lack of significant association between short inter-

pregnancy interval and neonatal anthropometric

parameters like low birth weight, low ponderal index

and weight-for-gestational age, after logistic regression

analysis, suggests that short inter-pregnancy interval

may interact with other factors in causing low values of

these parameters. This may be explained by the fact that

the fetus is an “obligate parasite” a₂n₃d may thrive on

The obvious benefits of inter-pregnancy interval of 18-

5

9 months in preventing some adverse maternal and

perinatal outcomes, found in the index study, is

consistent with the report of some studies co_-n₁₄ducted in

6

both developing and developed countries. Most of

limited maternal nutrient stores.

However the

these studies have shown that both short and long inter-

pregnancy intervals are associated with adverse maternal

and perinatal outcomes in all women irrespective of

their HIV-status. Some authors sugested a “J” shaped

relationship between inter-pregnancy interval and

pregnancy outcomes with optimal outcome associated

with an inter-pregnancy interval between 18_,₁-₄23 months

significant relationship between short inter-pregnancy

interval and MAC/OFC ratio suggests a late gestational

weight loss in neonates whose mothe₂₄s had inter-

pregnancy interval of 12 months or less. Low MAC/

OFC ratio has been assoc₂i₄ated with adverse perinatal

outcomes among neonates.

9

after adequately adjusting for confounders. However,

The effects of inter-pregnancy interval on both maternal

and neonatal health, found in this study, should provide

a strong motivating force for PMTCT programmes and

some authors have argued that short or long inter-

pregnancy interval merely depicts women already at

higher reproductive risks due to young age, high parity,

2

69

reproductive clinicians to address pregnancy spacing

among HIV-positive women of child bearing age. All

HIV-positive young women should be educated on the

health and nutritional benefits of avoiding another

pregnancy less than 18 months or above 59 months after

child birth. PMTCT programmes should re-examine the

extent of access to birth spacing services and ensure

consistent and correct use of effective contraceptives by

families who wish to achieve optimal pregnancy

spacing. This will not only improve maternal health and

child survival but will reduce the number of babies

exposed to HIV and thus at risk of MTCT.

Conclusion

Inter-pregnancy interval of 18 to 59 months is

significantly associated with the lowest risk of both

adverse maternal and fetal outcomes among HIV-

positive women.

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