1. Gadjah Mada University, 2 District Helath Office of Sulawesi Tengah
Short and Prolonged of Interpregnancies Interval as Risk Factors for a Spontaneous Abortion in Purworejo District, Central Java, Indonesia
Siswanto Agus Wilopo1, Emanuel Elisabeth Wantania2, Abdul Wahab 1, Althaf Setiawan1, Agung Nugroho1, and Detty Siti Nurdiati 2
Gadjah Mada University,
Faculty of Medicine,
1The Center for Reproductive Health-Purworejo DSS-Site, Faculty of Medicine, Gadjah Mada Univeristy
2 District Helath Office of Sulawesi Tengah
3Department of Obseteric and Gynacology, Faculty of Medicine, Gadjah Mada Univeristy

2. Background
A spontaneous abortion is a public health problem in Indonesia.
Interpregnancies interval is considered one of many risk factors for spontaneous abortion.
Interpregancies and birth intervals have been used to promote MCH - FP programmes as a key reducing maternal and child mortality

3. Keys to Reducing Maternal and Child Mortality
The Problem—
Births are risky when they are:
“Too many”
“Too close together”
Or when they occur among women who are:
“Too young”
“Too old”
One Solution—Avoid “Too close together” through an Optimal Birth Spacing Interval
Health risks related to maternal and child mortality have been summarized as "the four too's.” Births are risky when they are:
Too many, or
Too close together, or when they occur among women who are
Too young, or
Too old.
It has long been known that avoiding births that are “too close together” is advantageous to maternal and child health. New studies show the importance and significance of the concept of birth spacing.

4. What Is the Policy of Optimal Birth Spacing?
The length of time needed between births to minimize the risks for adverse health outcomes—new research indicates this is “three years or longer.”
But: “How long”?
First, an overview. What is Optimal Birth Spacing?
Over the years, research has shown that when families space the births of their children two years apart, their children are more likely to survive and be healthy. New research has shown that although two-year spacing is good, a longer interval is best.
In this presentation, we will refer to this best interval—when the risks for adverse health outcomes are lowest—as the “optimal” birth spacing interval. Most research indicates that the “optimal” interval for child and maternal survival is three years or longer.
Although birth spacing is a fundamental part of family planning, it is often underemphasized by programs. How do we know this?:
In almost all regions of the world, women report that they want longer birth-spacing intervals than they are achieving;
Few communications campaigns specifically promote the benefits of birth spacing; and
There is great variability in the messages women get from their healthcare providers about the benefits of birth spacing.
International health organizations involved in the Optimal Birth Spacing Initiative have found that birth spacing is a more acceptable way to promote family planning to women and their families, rather than advising them to have fewer children. This is especially true when working with traditional societies and youths. This is because messages about lengthening the time between births do not interfere with cultural norms that dictate the number of children wanted or the desire to prove fertility.

5. Documented Significant Evidences for Health Benefits
For Children
Lower risk for:
Stunted and underweight child
Small for gestational age
Low birth weight
Preterm birth
Child death
Infant death
Neonatal death
Fetal death
ABORTION (?)
For Mothers
Lower risk for:
Malnutrition from overlap of pregnancy and breastfeeding
Puerperal endometritis
Premature rupture of membranes
Anemia
Third trimester bleeding
Maternal death
Here is a summary of the new research on the health benefits of birth spacing. These benefits are seen in children and their mothers. Children are at lower risk for:
Stunting and being underweight,
Being small for gestational age,
Low birth weight,
Preterm birth, and
Death.
This lowered risk includes mortality during childhood and infancy, as well as the neonatal and fetal periods.
Mothers have a lower risk for:
Malnutrition resulting from overlap of pregnancy and breastfeeding,
Puerperal endometritis,
Premature rupture of membranes,
Anemia,
Third trimester bleeding, and
Maternal death.

6. Objective
To assess risk of having short and prolonged interpregnacies intervals on the incidence of spontaneous abortion.

7. Research Methods

8. Fig 1: Map of Purworejo DSS

9. Sources of Data
We used data from longitudinal surveillance at the DSS Purworejo site during the periods of where details of information regarding the spontaneous abortion and pregnancy status were collected.
Details questions on pregnancy status was also confirmed by pregnancy test.
We recorded pregnacies who were ends up with spontaneous abortion or live birth.

10. Sample for Analysis
All Pregnants Women between cycles of Visitation 1-12:
N=2510 Women
Last Menstrual Period:
1/10/ /9/1997
n = 1958
Pregnancies with Complete Data on Abortions Determinants:
n = 1910
First Pregnancies:
n=567
Number of Pregnancies >2 Available for
closed birth interval analysis:
n=1343

11. Statistical Analysis
A logistic regresion was used to estimate risk of interpregnancies interval on the incidence of spontanoues abortion.
Adjustment to other risk factors, such as: age, parity, history of spontaneous abortion, previous used of contraceptives, and others social-economic variables.

12. Results

13. Table 1 Characteristics of Sample Women in Purworejo District
TOTAL PREGNANCY (n=1343)
Age of Mother (year) Mean (SD)
31 (5,4)
MUAC (cm) Mean (SD)
24,6 (2,5)
Parity median (range values)
2 (0-11)
History Having abortion n (%)
43 (3,2)
History Previous Child Death n (%)
66 (4,9)
Contraceptive Used n (%) :
234 (17,4)
Social-Economic Status of the Family n (%):
Poor
Medium
Well off
354 (26,4)
787 (58,6)
202 (15,0)
Education n (%) :
No Education
88 (6,5)
Primary
862 (64,2)
Secondary
195 (14,5)
High School
172 (12,8)
Univeristy
26 (1,9)
Working Status n (%) : Working
660 (79,1)
Inter preganancies Intervals Median (ranges)
Median:48; Ranges 1-229
Pregancies Outcomes: Spontaneus Abortion
92 (6,8)
Induced Abortion
23 (1,7)
Still Birth
29 (2,2)
Live Birth
1199 (89,3)

14. Interpregancies Intervals
Table 2. Frequencies of Spontaneous Abortion According to Interpregancies Interval and It’s RR (95% Confidence Intervals)
Interpregancies Intervals
(Month)
Spontaneous Abortion
n (%)
Live Births n (%)
RR (95%CI)
1-12
9 (9,6)
85 (90,4)
3,3 (1,12-9,43)
13-24
12 (5,9)
190 (94,1)
2,0 (0,73-5,61)
25-33
10 (6,5)
144 (93,5)
2,2 (0,77-6,31)
34-45 (Reff)
5 (2,9)
165 (97,1) 1
46-60
15 (7,3)
191 (92,7)
2,5 (0,92-6,67)
61-84
16 (7,5)
198 (92,5)
2,5 (0,95-6,79)
85-229
25 (9,9)
226 (90,1)
3,4 (1,32-8,67)
R= Refference
RR = Relative Risks
CI = 95% Confidence Interval

15. Table 3 A Multivariable Analysis on RR of Interpregancies Intrval Adjusted for Age, history of abortion and contraceptive use
Variabel
Model 1
OR (95%CI)
Model 2
Model 3
Model 4
Birth Intervaks bulan
3,5 (1,14-10,75)
3,7 (1,20-11,52)
2,4 (0,73-8,08)
2,6 (0,76-8,58)
13-24 bulan
2,1 (0,72-6,04)
2,0 (0,69-5,87)
1,9 (0,66-5,61)
2,0 (0,67-5,81)
25-33 bulan
2,3 (0,76-6,86)
2,3 (0,76-6,87)
2,4 (0,78-7,14)
2,3 (0,77-7,04)
34-45 bulan 1
46-60 bulan
2,6 (0,92-7,98)
2,5 (0,89-7,07)
2,6 (0,92-7,36)
2,6 (0,92-7,37)
61-84 bulan
2,7 (0,96-7,43)
2,6 (0,91-7,15)
2,7 (0,97-7,64)
2,8 (0,99-7,83)
bulan
3,6 (1,37-9,73)
3,1 (1,15-8,46)
3,3 (1,21-8,91)
3,3 (1,21-8,97)
Age of Moher ≤25
26-30
31-35
≥36
1,4 (0,63-3,05)
1,6 (0,72-3,49)
2,0 (0,90-4,67)
1 1,3 (0,58-2,85)
1,5 (0,67-3,25)
1,9 (0,84-4,38)
1,3 (0,59-2,88)
1,5 (0,66-3,21)
1,9 (0,82-4,30)
Previous Abortion : Yes No
3,6 (1,41-9,34)
3,8 (1,47-9,81)
Contraceptive Use : Yes
1,9 (1,18-3,17) N
1291
Devian
653,4984
650,05606
643,77078
p value
0,133
0,328
<0,05
R2 (%)
1,5 2
2,9
3,9

16. Figure Risk of Interpregancies Interval (month) for Speontaneous Abortion ajudted for Age of Mother, Pervious History of Having Abortion and the Use of Any Contraceptive Method

17. Summary of the Findings
Six out of 100 pregnant women experienced spontaneous abortions annually.
Risk of spontanoues abortion among interval of 1-12 months was 2.6 (95% CI: ) higher than months intervals,
Having prolonged interpreganancies interval (85 months or more) was also higher (OR=3,6 with 95% CI: ) compared with months interval.

18. Summary of the Findings
After controling for others risk factors, the prolonged interpregancies interval continued to high risk of spontanoues abortion.
After social-economic variables considered (results is not shown), histories of having previous used of contraceptives and spontanious abortion were also proven as risk factors for a spontaneous abortion.

19. Conclusion and Recommendation
Short and prolonged interpregnancies intervals were risk factors of spontaneous abortion
Policy on the optimal birth spacing needs to consider an upper-limit for birth interval (not just over 3 years).
This study suggests that interpregancies interval more than 4 years is increased risk of spontaneous abortion.

20. Terima Kasih