THE EFFECT OF PREGNANCY SPACING ON FETAL SURVIVAL AND NEONATAL MORTALITY IN RWANDA: A HECKMAN SELECTION ANALYSIS.

Most studies on birth intervals and infant mortality ignore pregnancies that do not result in live births. Yet, fetal deaths are important in infant mortality analyses for three reasons: ignoring fetal deaths between two live births lengthens the measured interval between births, implying that short intervals are underestimated; the recommended inter-pregnancy interval (IPI) after a fetal loss is shorter (6 months) than after a live birth (24 months), as the effect of IPI on outcomes might differ according to the previous type of pregnancy outcome; fetal death will selectively reduce the population at risk of neonatal mortality, leading to biased results. This study uses the Heckman selection model to simultaneously estimate the combined effect of IPI duration and the type of pregnancy outcome at the start of the interval on pregnancy survival and neonatal mortality. The analysis is based on retrospective data from the Rwanda Demographic Health Surveys of 2000, 2005 and 2010. The results show a significant selection effect. After controlling for the selection bias, short (60 months) intervals after a fetal death reduce the chances of pregnancy survival, but no longer have an effect on neonatal mortality. For intervals starting with a live birth, the reverse is true. Short intervals (<24 months) do not affect pregnancy survival but increase the odds of neonatal mortality. If the previous child died in infancy, the highest odds are found for neonatal death regardless of the IPI duration.

The Effects of Interpregnancy Intervals and Previous Pregnancy Outcome on Fetal Loss in Rwanda (1996-2010).

In 2005, a WHO consultation meeting on pregnancy intervals recommended a minimum interval of 6 months after a pregnancy disruption and an interval of two years after a live birth before attempting another pregnancy. Since then, studies have found contradictory evidence on the effect of shorter intervals after a pregnancy disruption. A binary regression analysis on 21532 last pregnancy outcomes from the 2000, 2005, and 2010 Rwanda Demographic and Health Surveys was done to assess the combined effects of the preceding pregnancy outcome and the interpregnancy intervals (IPIs) on fetal mortality in Rwanda. Risks of pregnancy loss are higher for primigravida and for mothers who lost the previous pregnancy and conceived again within 24 months. After a live birth, interpregnancy intervals less than two years do not increase the risk of a pregnancy loss. This study also confirms higher risks of fetal death when IPIs are beyond 5 years. An IPI of longer than 12 months after a fetal death is recommended in Rwanda. Particular attention needs to be directed to postpregnancy abortion care and family planning programs geared to spacing pregnancies should also include spacing after a fetal death.

Inter-Pregnancy Intervals and Maternal Morbidity: New Evidence from Rwanda.

The effects of short and long pregnancy intervals on maternal morbidity have hardly been investigated. This research analyses these effects using logistic regression in two steps. First, data from the Rwanda Demographic and Health Survey 2010 are used to study delivery referrals to District hospitals. Second, Kibagabaga District Hospital's maternity records are used to study the effect of inter-pregnancy intervals on maternal morbidity. The results show that both short and long intervals lead to higher odds of being referred because of pregnancy or delivery complications. Once admitted, short intervals were not associated with higher levels of maternal morbidity. Long intervals are associated with higher risks of third trimester bleeding, premature rupture of membrane and lower limb edema, while a higher age at conception is associated with lower risks. Poor women from rural areas and with limited health insurance are less often admitted to a hospital, which might bias the results.

Role of Conflict in Shaping Fertility Preferences in Rwanda

Conflicts affect the social and economic conditions that could account for the stall in fertility decline in Sub-Saharan Africa. For Rwanda; the total fertility rate decreased very rapidly to 6.1 in the eighties but stalled at that level in the nineties. Part of the stall can be attributed to a lack of fertility control; but the question is whether social upheaval also affects fertility preferences. We identify three mechanisms through which the Rwanda conflict have led to a preference for larger families: mortality experience; modernization and the attitudes of third parties. Using data from DHS; we tested the contribution of these mechanisms to the preference for small; medium or large families. With the exception of sibling mortality; there is a strong impact of these mechanisms on the preference for large families; yet they do not fully account for the shifts in preferences over the years

Demand and unmet need for means of family limitation in Rwanda.

CONTEXT: Rwanda is the most densely populated country in Africa, with substantial annual population growth. The current government seeks new policies for family limitation as a way to facilitate more sustainable development. METHODS: Data from the 2005 Rwanda Demographic and Health Survey were used for a two-step analysis; binary logistic regression was used to identify factors associated with desiring to stop childbearing and having unmet need. RESULTS: Eighty-seven percent of women aged 15-49 approve of family planning, but only 64% believe that their partner approves of it. There is a high level of unmet need for family limitation; 58% of women who want to stop childbearing do not use modern contraceptives. Demand was lower among women who did not approve of family planning, those who did not know their partner's attitude toward family planning and those who had discussed family planning with their partner fewer than three times. Unmet need was higher among women who did not approve of family planning, those who believed their partner did not approve of family planning or who did not know his attitude, and those who had never discussed family planning with their partner or had done so only once or twice. CONCLUSIONS: Negative attitudes toward family planning and failing structures of provision are the dominant constraints on the use of modern contraceptives in Rwanda. Community-based family planning services could greatly expand access, especially in underserved provinces.