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@<<<4��$!*�$!*?<4?<<.>V>!*���� Ӡ�^��$:�F>�>#@0S@N>�E�;@�EV>�E�$V>�44<44444,?,?<444S@4444���������������������������������������������������������������������E444444444@	I#:	The spectrum of maternal and perinatal outcomes among parturient women with preceding short and normal inter-pregnancy interval at Bugando Medical Centre, Tanzania.
Athanase Lilungulu1, Dismas Matovelo1*, Albert Kihunrwa1, 2, Balthazar Gumodoka1, 2
1Department of Obstetrics & Gynecology, Catholic University of Health & Allied sciences P.O.BOX 1464 Mwanza, Tanzania.
2Department of Obstetrics & Gynecology, Bugando Medical Centre P.O.BOX 1370 Mwanza, Tanzania.
*Corresponding author- Dismas Matovelo: HYPERLINK "mailto:magonza77@yahoo.co.uk"magonza77@yahoo.co.uk
E-mail addresses: 	AL: HYPERLINK "mailto:athalilungulu@yahoo.com"athalilungulu@yahoo.com
			AK: HYPERLINK "mailto:alkihunrwa@yahoo.com"alkihunrwa@yahoo.com
			BG: balthgumo@yahoo.com









Abstract
Background
The burden of shortened inter-pregnancy period results in poor maternal nutrient status and an increased risk of adverse pregnancy outcomes. This study compares maternal and perinatal outcomes among parturient women with shorten and normal inter-pregnancy intervals at Bugando Medical Centre (BMC).
Methods
This was a prospective cohort study conducted from November 2012 to April 2013. Multiple matching design approach was used to adjust for age variables. Every woman identified with a short inter-pregnancy interval (SIPI) was matched with two normal inter-pregnancy interval (NIPI) women until a sufficient sample size was met.
Results
A total of 450 pregnant women were enrolled in which 150 were characterized by SIPI as the exposed group and 300 had NIPI as the unexposed group. Premature rupture of membrane (PROM) was higher [RR=13.6; 95% CI 7.2"25.6] among SIPI women than was observed in NIPI women [RR=0.57; 95% CI 0.49 0.7]. The risk of anemia was 3.4 higher among SIPI women compared to women of NIPI [RR=3.4; 95% CI 2.8"4.1 versus RR=0.08; 95% CI 0.04 0.2]. SIPI women had a risk of failure of trial of vaginal birth after caesarean section (VBAC) that was 14.7 higher when compared to the NIPI group [RR=14.7; 95% CI 6.4"33.6 versus RR=0.72; 95% CI 0.65 0.8]. The risk of postpartum hemorrhage (PPH) was 5.8 higher among SIPI women compared to women of NIPI [RR=5.8; 95% CI 2.9"11.6 versus RR=0.83; 95% CI 0.7 0.9]. Women with SIPI had a higher risk of delivering small for gestation age (SGA) babies compared to women in NIPI [RR=7.7; 3.8 15.7 versus RR=0.79; 95% CI 0.7  0.8]. The risk of low birth weight was 6.7 among SIPI women compared to women of NIPI [RR=6.7; 95% CI 3.6 12.3 versus RR=0.76; 95% CI O.7-0.8]. Women with SIPI had an increased risk of delivering preterm infants compared to women in NIPI [RR=9.78; 95% CI 4.9�19.5 versus RR=0.72; 95% CI 0.6-0.8]. The low score was 6.9 among SIPI women compared to women of NIPI [RR=6.9; 95% CI 3.6 � 13.1 versus RR=0.77; 95% CI 0.7-0.8].
Conclusion
Appropriate intervention measures, including the use of modern family planning, provision of folate supplementation, and education of the risks of SIPI should be done at the family level with skilled healthcare personnel to help avoid adverse pregnancy outcomes.
Keywords: short inter-pregnancy interval, maternal outcome, perinatal outcome

















Introduction
Shortened inter-pregnancy intervals, which result in insufficient maternal nutrient stores and compromise the outcomes of subsequent pregnancies, has  become a major cause of the obstetric complications and fetal morbidity and mortality in developing countries  ADDIN EN.CITE <EndNote><Cite><Author>Grisaru-Granovsky</Author><Year>2009</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grisaru-Granovsky, Sorina</author><author>Gordon, Ethel-Sherry</author><author>Haklai, Ziona</author><author>Samueloff, Arnon</author><author>Schimmel, Michael M.</author></authors></contributors><titles><title>Effect of interpregnancy interval on adverse perinatal outcomes��  a national study</title><secondary-title>Contraception</secondary-title></titles><periodical><full-title>Contraception</full-title></periodical><pages>512-518</pages><volume>80</volume><number>6</number><dates><year>2009</year></dates><isbn>0010-7824</isbn><urls></urls></record></Cite></EndNote>[1]. Approximately 4 million fetal deaths occur each year, 98% of which occur in developing countries. The major causes of these fetal deaths are preventable, however there is debate surrounding the best ways to address the challenges of maternal complications and fetal deaths  ADDIN EN.CITE <EndNote><Cite><Author>Who</Author><Year>2007</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Who, Unicef</author></authors></contributors><titles><title>UNFPA, World Bank. Maternal mortality in 2005: estimates developed by WHO, UNICEF</title><secondary-title>UNFPA, The World Bank. ISBN</secondary-title></titles><periodical><full-title>UNFPA, The World Bank. ISBN</full-title></periodical><pages>4</pages><volume>978</volume><number>92</number><dates><year>2007</year></dates><urls></urls></record></Cite></EndNote>[2].
Birth interval is an important determinant of the rate of population growth and socio economic status of a community. Intervening in short inter-birth intervals offers great potential in protecting the health status of the mothers, and improving outcomes of subsequent pregnancies  ADDIN EN.CITE <EndNote><Cite><Author>Isiugo-Abanihe</Author><Year>2008</Year><RecNum>3</RecNum><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Isiugo-Abanihe, Uche C.</author><author>Nwokocha, Ezebunwa E.</author></authors></contributors><titles><title>Prevalence and consequences of ewu-ukwu custom in Mbaise, Imo State, Nigeria</title><secondary-title>The Nigerian Journal of Sociology and Anthropology Vol</secondary-title></titles><periodical><full-title>The Nigerian Journal of Sociology and Anthropology Vol</full-title></periodical><pages>54</pages><volume>6</volume><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[3]. An inter-pregnancy interval of less than 18 months (SIPI) among the women in developing countries is still common place and remains the leading cause of increased risk for maternal and neonatal mortality  ADDIN EN.CITE <EndNote><Cite><Author>Smits</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">34</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smits, Luc J. M.</author><author>Essed, Gerard G. M.</author></authors></contributors><titles><title>Short interpregnancy intervals and unfavourable pregnancy outcome: role of folate depletion</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>2074-2077</pages><volume>358</volume><number>9298</number><dates><year>2001</year></dates><isbn>0140-6736</isbn><urls></urls></record></Cite></EndNote>[4]. A normal inter-pregnancy interval (NIPI) is the period between delivery of the previous infant and conception of the current pregnancy of 18 to 24 months.  A long inter-pregnancy interval (LIPI) is the period between delivery of the previous infant and conception of the current pregnancy at the interval of 36 to 60 months or more. While NIPI can be achieved through education and contraceptive use, LIPI may be problematic since a desired pregnancy may be precluded by sub fertility, the availability of a partner, economic issues, or illness  ADDIN EN.CITE <EndNote><Cite><Author>Yohannes</Author><RecNum>4</RecNum><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yohannes, Samuel</author><author>Wondafrash, Mekitie</author><author>Abera, Mulumebet</author><author>Girma, Eshetu</author></authors></contributors><titles><title>Duration and determinants of birth interval among women of child bearing age in Southern Ethiopia</title><secondary-title>BMC pregnancy and childbirth</secondary-title></titles><periodical><full-title>BMC pregnancy and childbirth</full-title></periodical><pages>38</pages><volume>11</volume><number>1</number><dates></dates><isbn>1471-2393</isbn><urls></urls></record></Cite></EndNote>[5]. Despite increased education and facilitation of perinatal care among pregnant women, the maternal and fetal outcomes are reported to be poor in pregnant women with short inter pregnant interval  ADDIN EN.CITE <EndNote><Cite><Author>Kaharuza</Author><Year>2001</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">14</key></foreign-keys><ref-type name="Thesis">32</ref-type><contributors><authors><author>Kaharuza, F.</author></authors></contributors><titles><title>Short interpregnancy intervals and child survival</title></titles><dates><year>2001</year></dates><publisher>Ph. D. Thesis. Faculty of Health Sciences, University of Aarhus</publisher><urls></urls></record></Cite></EndNote>[6]. The impact of a short inter-pregnancy interval is greater in very young women because an adolescent who is still developing herself, may compete with the fetus for nutrients  ADDIN EN.CITE <EndNote><Cite><Author>Ekow</Author><Year>1998</Year><RecNum>6</RecNum><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ekow, Edem E.</author><author>Moawad, Atef</author></authors></contributors><titles><title>The relationship of interpregnancy interval to the risk of preterm births to black and white women</title><secondary-title>International journal of epidemiology</secondary-title></titles><periodical><full-title>International journal of epidemiology</full-title></periodical><pages>68-73</pages><volume>27</volume><number>1</number><dates><year>1998</year></dates><isbn>0300-5771</isbn><urls></urls></record></Cite></EndNote>[7]. Pregnant women with shorten birth interval have an increased risk of uterine rupture or scar dehiscence, failure of trial of vaginal birth after caesarean section (VBAC), placenta abruption, placenta previa, antenatal and perinatal infections  ADDIN EN.CITE <EndNote><Cite><Author>Shipp</Author><Year>2001</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shipp, Thomas D.</author><author>Zelop, Carolyn M.</author><author>Repke, John T.</author><author>Cohen, Amy</author><author>Lieberman, Ellice</author></authors></contributors><titles><title>Interdelivery interval and risk of symptomatic uterine rupture</title><secondary-title>Obstetrics &amp; Gynecology</secondary-title></titles><periodical><full-title>Obstetrics &amp; Gynecology</full-title></periodical><pages>175-177</pages><volume>97</volume><number>2</number><dates><year>2001</year></dates><isbn>0029-7844</isbn><urls></urls></record></Cite></EndNote>[8]. Studies have shown higher burden of maternal and child mortality in Tanzania and other developing countries. There is limited information regarding the direct effect of short pregnancy interval on maternal and fetal adverse outcomes  ADDIN EN.CITE <EndNote><Cite><Author>Exavery</Author><RecNum>8</RecNum><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Exavery, A.</author><author>Mrema, S.</author><author>Shamte, A.</author><author>Bietsch, K.</author><author>Mosha, D.</author><author>Masanja, H.</author></authors></contributors><titles><title>Non-adherence of WHO recommended birth intervals in Rufiji, Tanzania</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[9]. Maternal mortality in Tanzania is 454 deaths per 100000 live births with neonatal mortality of 26 deaths per 1000 live birth  ADDIN EN.CITE <EndNote><Cite><Author>Health</Author><Year>2010</Year><RecNum>9</RecNum><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ministry of Health</author></authors></contributors><titles><title>Health Sector performance profile report 2010 update</title></titles><pages>1-58</pages><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>[10].
The maternal and fetal outcomes among parturient women with short inter pregnancy intervals compared with those with normal birth intervals in our setting was previously not known. It is important to determine the maternal and fetal adverse outcomes as a result of short birth intervals in Tanzania in order to continue progress on achieving the Millennium Development Goals  ADDIN EN.CITE <EndNote><Cite><Author>Tanzania</Author><Year>2008</Year><RecNum>10</RecNum><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>United Republic of Tanzania</author></authors></contributors><titles><title>Millennium Development Goals Report. MID-WAY EVALUATION 2000-2008</title></titles><pages>1-56</pages><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[11]. Results from this prospective cohort study will be helpful to clinicians and policy makers when determining the proper management of adverse maternal and fetal outcomes. Therefore, the purpose of this study is to determine the scope and magnitude of maternal and fetal outcomes among pregnant women with short inter-pregnancy intervals compared to those with normal birth intervals attending Bugando Medical Centre (BMC). 
Methods
Study design
The study is a prospective cohort study conducted in order to determine the difference in outcomes among SIPI and NIPI women delivering in the labor ward of BMC over a six month period from November 2012 to April 2013. The trial's technique of implementing randomization as well as a matching design was used in order to adjust for age and education levels among participants during the entire period of the study.
Study area
Bugando Medical Centre (BMC) is one of the four largest referral hospitals in the country and it is located in the city of Mwanza in the northwestern Tanzania. BMC labor ward has average of 600 deliveries per month and provides services for both low risk and high risk pregnancies referred from peripheral hospitals. The hospital has the capacity of delivering 7200 pregnant women annually.
Study population
Those women aged 20 to 25 years, not in the final stages of labor, with short and normal inter-pregnancy intervals at the time of their admission to BMC labor ward were offered enrollment to participate in this study. All pregnant women in the SIPI and NIPI groups admitted to BMC labor ward during the study period who voluntarily consented to participate in the study were included in the results. Women with multiple or post-term pregnancies and those admitted with other risk factors such as past history of uterus rupture, classical or inverted T uterus scar, myomectomy, mentally disability, or the presence of an associated medical disease e.g. diabetic mellitus, HIV, severe malaria, sickle cell anemia or chronic hypertension were excluded. 
Sampling technique
 All eligible SIPI and NIPI laboring pregnant women between the ages of 20 to 25 years were selected to participate. These patients were recruited into exposed (SIPI) and unexposed (NIPI) groups of the same age until the desired number of exposed individuals was reached. The method for adjusting age in years among the study groups was used as the ratio of exposed versus unexposed of 1:2 and adjusted by �1 year.  For example, we recruited one 20 year old exposed patient and then two controls either of the same age, 19 or 21 years old. 
Short inter-pregnancy interval (SIPI) was defined as the period between delivery of the previous infant and conception of the current pregnancy of less than 18 months. Long inter-pregnancy interval (LIPI) was defined as the interval between delivery of the previous infant and conception of the current pregnancy at the interval of 36 to 60 months or more, while normal inter-pregnancy interval (NIPI) was defined as the period between delivery of the previous infant and conception of the current pregnancy of 18 to 24 months.
Data collection procedure
All women with short and normal inter-pregnancy intervals whom met the inclusion criteria and consented to participate were included in the study. Information collected included socio-demographic characteristics; obstetric history such as gravidity, parity and gestational age; mode of delivery, maternal and neonatal adverse outcomes including birth weight, Apgar score, SGA and admission to neonatal intensive care unit (NICU). The matched design was done upon the time of admission at the labor ward and this was followed by the explanation of the study objectives, and a signed consent form and then the assignment of a case record number and demographic information collected by questionnaire. 
Follow up:
The women were followed up for adverse outcomes and detailed information of fetal outcomes was recorded. Fetal outcomes included Apgar scores at the 5th minute of life, requirement for neonatal resuscitation, admission to the neonatal intensive care unit, admission to the prematurity unit and presence of perinatal death. Birth asphyxia was diagnosed when the infant did not take spontaneous respirations at birth and Apgar scores were less than seven after 5 minutes of life. All delivered infants were followed up for 7 days post delivery. All infants with adverse outcomes were either admitted in NICU or prematurity/postnatal units. Those without adverse birth outcomes stayed with their mothers for breast feeding and observed for 24 hours. After discharge they were followed up by mobile phone for 7 days. Mothers with adverse outcomes were admitted and managed based on hospital protocol. Those without adverse outcomes were discharged home after 24 hours, and followed up by mobile phone for 7 days. Those infants born with abnormalities and intrauterine fetal death were recorded but not included in the study. The reasons of termination during the entire period of the study were due to maternal death, withdrawal from the study and loss to follow up.
Data Analysis
Data was analyzed using SPSS software version 17.0 (SPSS, Chicago IL, USA). Results were summarized in the form of proportions for categorical variables. Means, standard deviations at 95%, confidence level and median were used to summarize continuous variables. Chi-square test was used to test for significance of associations between the predictor and outcome variables in the categorical variables. Relative risk was calculated to test for strength of association between variables. A p-value of less than 0.05 at 95% confidence interval was defined as significant.
Results
Study population characteristics: 
The study was conducted between November 2012 and April 2013 on the BMC labor ward. During the study period 450 pregnant women participated.  Of those who participated 150 were in the exposed group characterized by SIPI and 300 pregnant with NIPI were defined as the unexposed group. Women were recruited in the matched group study design if they were between the ages of 20 to 25 years, �1 year, on the same day as their admission. 
The mean age of the participants was 23.4 � 1.7. In the SIPI and NIPI groups, 446 (99.1%) completed Primary school education.  Secondary school education among both SIPI and NIPI groups was 4 (0.9%).  Among the 450 participants, 449 (99.8%) were married (Table 1).
Obstetric outcomes in SIPI and NIPI women: 
The majority of patients in the SIPI group were anemic 141(94.0%) as compared to only 83(27.3%) of the NIPI group. The observed difference was statistically significant p<0.01. Among the SIPI patients 44(29.3%) had failure of trial of scar as compared to 6 (2.0%) of the NIPI.  The observed difference was statistically significant p<0.01. Postpartum hemorrhage occurred in 29(19.3%) of SIPI as compared to 10(3.3%) of the NIPI. The observed difference was statistically significant. Most of the SIPI had premature rupture of membrane 68(45.3%) as compared to 10(3.3%) of NIPI.  The observed difference was statistically significant with p<0.01. In 27(18.0%) of SIPI patients there was a diagnosis of preeclampsia as compared to 8(2.7%) of NIPI group. The observed difference was statistically significant p<0.01 (Table 2).  
Perinatal outcomes in SIPI and NIPI women: 
The majority of the infants born to the SIPI mothers were low birth weight 40(94.0%) as compared to only 83(27.3%) of the NIPI group. The observed difference was statistically significant p<0.01. Of the SIPI group 44(29.3%) infants were born premature as compared to 6(2.0%) of the NIPI patients. The observed difference was statistically significant, p<0.01.  It was noted that 46(68%) of the SIPI infants were categorized as SGA as compared to 10(12%) of the NIPI and the observed difference was statistically significant p<0.01. Most of the SIPI babies had low APGAR scores 56(68%) as compared to only 16(9%) of the NIPI. The observed difference was statistically significant p<0.01. Most of the babies of SIPI women had prolonged hospital length of stay 123(82%) as compared to babies of the NIPI women.  The observed difference was statistically significant p<0.01 (Table 3). 
The relative risk of maternal and fetal adverse outcome among SIPI and NIPI women:
 Women with SIPI have a higher risk of PROM compared to those in the NIPI group [RR, 13.6; 95% CI 7.2 "25.64]. SIPI women were found to have a lower hemoglobin level compared to NIPI women [RR=3.4; 95% CI 2.8"4.1]. Failures of VBAC were found to be higher among SIPI women compared to NIPI women [RR=14.7; 95% CI 6.4"33.6]. The risk of preeclampsia was 6.8 higher among SIPI women compared to women of the NIPI group [RR=6.8; 95% CI 3.1"14.5]. Short inter-pregnancy interval women had an increased risk of postpartum hemorrhage compared to women of NIPI [RR=5.8; 95% CI 2.9"11.6]. Regarding adverse fetal outcomes, it was found that women in SIPI group had an increased risk of preterm delivery compared to NIPI women [RR=9.8; 95% CI 4.9-19.5]. There was an increased risk for low Apgar score among infants born to SIPI women compared to NIPI women [RR=6.9; 95% CI 3.6"13.1]. The SIPI women had an increased risk of low birth weight compared to NIPI women [RR= 6.7; 95% CI 3.6"12.3]. Women with SIPI had higher risk of giving birth to an SGA infant compared to women in the NIPI category [RR=7.7; 3.8�15.7] (Table 4).
Discussion
Our study found that there was a failure of vaginal birth after cesarean section (VBAC) in 29.3% of the women in the SIPI group compared to NIPI women. This finding is similar to results from studies done in Florida, USA and in Uganda where SIPI women had a significantly greater risk of failure of trial of VBAC compared to NIPI women  ADDIN EN.CITE <EndNote><Cite><Author>Kaharuza</Author><Year>2001</Year><RecNum>5</RecNum><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kaharuza, Frank M.</author><author>Sabroe, Svend</author><author>Basso, Olga</author></authors></contributors><titles><title>Choice and chance: determinants of short interpregnancy intervals in Denmark</title><secondary-title>Acta obstetricia et gynecologica Scandinavica</secondary-title></titles><periodical><full-title>Acta obstetricia et gynecologica Scandinavica</full-title></periodical><pages>532-538</pages><volume>80</volume><number>6</number><dates><year>2001</year></dates><isbn>1600-0412</isbn><urls></urls></record></Cite><Cite><Author>Esposito</Author><Year>2000</Year><RecNum>20</RecNum><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">20</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Esposito, Matthew A.</author><author>Menihan, Cydney A.</author><author>Malee, Maureen P.</author></authors></contributors><titles><title>Association of interpregnancy interval with uterine scar failure in labor: a case-control study</title><secondary-title>American journal of obstetrics and gynecology</secondary-title></titles><periodical><full-title>American journal of obstetrics and gynecology</full-title></periodical><pages>1180-1183</pages><volume>183</volume><number>5</number><dates><year>2000</year></dates><isbn>0002-9378</isbn><urls></urls></record></Cite></EndNote>[12, 13]. The reasons for this may be due to a prior history of caesarean section and requirement of increased monitoring in those patients attempting a trial of VBAC. Histological studies of human myometrial healing post caesarian section have shown that the healing granulation tissue at the site of incised myometrium is weak.  Animal studies have shown well formed fibroblastic tissue along the site of myometrium incision scar, but there is unclear evidence to support if this site of myometrium scar is, in fact, the most likely site of rupture during a VBAC. In our study there was association between SIPI and failure of trial of VBAC.  The clinical significance of this is not clear, and further study is needed to evaluating the rate of failure of VBAC in SIPI women. However, this failure of trial of VBAC in SIPI women, as observed in our study, suggests a possible increased risk of uterine rupture, post operative complications such as wound sepsis, subtotal hysterectomy to total hysterectomy if the trial labor was in prolonged and without proper monitoring. 
The study found that postpartum hemorrhage was present in 19.3% of SIPI as compared to NIPI women. This finding is similar to other studies which also reported an increased risk of PPH in SIPI compared to NIPI women  ADDIN EN.CITE [14-16]. One reason why SIPI women have postpartum hemorrhage was postulated to be that with short inter birth intervals there is interference in the normal process of remodeling of the endometrial blood vessels after delivery. This may result in subsequent poor uteroplacental perfusion. Furthermore, it has been observed that short inter-pregnancy intervals increase the risk for developing PPH due to inadequate time for reproductive organs to have sufficient rest before undergoing another set of pregnancy related physiological changes  ADDIN EN.CITE <EndNote><Cite><Author>Conde-Agudelo</Author><Year>2000</Year><RecNum>26</RecNum><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde-Agudelo, Agustin</author><author>Belizán, José M.</author></authors></contributors><titles><title>Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study</title><secondary-title>Bmj</secondary-title></titles><periodical><full-title>Bmj</full-title></periodical><pages>1255-1259</pages><volume>321</volume><number>7271</number><dates><year>2000</year></dates><isbn>0959-8138</isbn><urls></urls></record></Cite><Cite><Author>Uthman</Author><RecNum>33</RecNum><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Uthman, Sadiq G.</author><author>Garba, Mairiga A.</author><author>Danazumi, Ado G.</author><author>Mandara, Mairo U.</author></authors></contributors><titles><title>How Birth Interval and Antenatal Care Affects Postpartum Haemorrhage Prevention in Maiduguri, Nigeria</title><secondary-title>Journal of Applied Pharmaceutical Science</secondary-title></titles><periodical><full-title>Journal of Applied Pharmaceutical Science</full-title></periodical><volume>3</volume><number>3</number><dates></dates><isbn>2231-3354</isbn><urls></urls></record></Cite></EndNote>[17, 18]. The importance of this finding is that with the availability of high quality emergency obstetrics care and antenatal services may help prevent adverse pregnancy outcomes including anemia and maternal deaths in those women with SIPI.
Anemia was found in 94.0% of SIPI patients in our study, these results were consistent with a study done in Iraq. Women with SIPI (28 .3%) were more likely to have anemia during the course of their pregnancy when compared to NIPI women. A study done in Nigeria showed similar results  ADDIN EN.CITE <EndNote><Cite><Author>Nwizu</Author><RecNum>25</RecNum><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">25</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nwizu, E. N.</author><author>Iliyasu, Z.</author><author>Ibrahim, S. A.</author><author>Galadanci, H. S.</author></authors></contributors><titles><title>Socio-demographic and maternal factors in anaemia in pregnancy at booking in Kano, northern Nigeria</title><secondary-title>African journal of reproductive health</secondary-title></titles><periodical><full-title>African journal of reproductive health</full-title></periodical><pages>33-41</pages><volume>15</volume><number>4</number><dates></dates><isbn>1118-4841</isbn><urls></urls></record></Cite></EndNote>[19]. The reason for anemia in SIPI pregnant women was postulated to be due to poor iron stores secondary to short inter-pregnancy intervals leading to total body iron depletion  ADDIN EN.CITE <EndNote><Cite><Author>Conde-Agudelo</Author><Year>2000</Year><RecNum>26</RecNum><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde-Agudelo, Agustin</author><author>Belizán, José M.</author></authors></contributors><titles><title>Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study</title><secondary-title>Bmj</secondary-title></titles><periodical><full-title>Bmj</full-title></periodical><pages>1255-1259</pages><volume>321</volume><number>7271</number><dates><year>2000</year></dates><isbn>0959-8138</isbn><urls></urls></record></Cite></EndNote>[17].
The study found that women with premature ruptured of membranes in SIPI women was found to be 45.3%, leading to an increased risk of post delivery infections. To avoid such a burden of increased risk of infection, providers will need to complete early blood work investigations and immediately provide proper antibiotics. However, this may lead to an increased cost of care. These findings are similar to those found in a systemic review done in 2012 by Conde agunelo et al which revealed that premature rupture of membranes occurred in 60% of the SIPI women. This study also observed that women in the SIPI category may continue to carry the infectious organisms for several weeks to months post delivery. Thus, possibly resulting in unrecognized preconceptional maternal infection leading to increased risk of chorioamnionitis as well as premature rupture of membranes  ADDIN EN.CITE <EndNote><Cite><Author>Conde�� �Agudelo</Author><Year>2012</Year><RecNum>31</RecNum><record><rec-number>31</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">31</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde�� �Agudelo, Agust�n</author><author>Rosas�� �Bermudez, Anyeli</author><author>Casta��o, Fabio</author><author>Norton, Maureen H.</author></authors></contributors><titles><title>Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms</title><secondary-title>Studies in family planning</secondary-title></titles><periodical><full-title>Studies in family planning</full-title></periodical><pages>93-114</pages><volume>43</volume><number>2</number><dates><year>2012</year></dates><isbn>1728-4465</isbn><urls></urls></record></Cite></EndNote>[20]. 
Preeclampsia was found in 18.0% of SIPI women in this study. This finding was similar to the systemic review done in 2006 by Conde Agudelo et al in which it was found that SIPI women of less than 6 or 13 month birth intervals were at increased risk of preeclampsia. Short birth intervals increase the risk of preeclampsia by up 10% to 12% each year from the time of the first delivery  ADDIN EN.CITE <EndNote><Cite><Author>Conde-Agudelo</Author><Year>2007</Year><RecNum>27</RecNum><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">27</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde-Agudelo, Agustin</author><author>Rosas-Bermúdez, Anyeli</author><author>Kafury-Goeta, Ana C.</author></authors></contributors><titles><title>Effects of birth spacing on maternal health: a systematic review</title><secondary-title>American journal of obstetrics and gynecology</secondary-title></titles><periodical><full-title>American journal of obstetrics and gynecology</full-title></periodical><pages>297-308</pages><volume>196</volume><number>4</number><dates><year>2007</year></dates><isbn>0002-9378</isbn><urls></urls></record></Cite><Cite><Author>DaVanzo</Author><Year>2004</Year><RecNum>28</RecNum><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">28</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>DaVanzo, Julie</author><author>Razzaque, Abdur</author><author>Rahman, Mizanur</author><author>Hale, Lauren</author><author>Ahmed, Kapil</author><author>Khan, Mehrab Ali</author><author>Mustafa, Golam</author><author>Gauzia, K.</author></authors></contributors><titles><title>The effects of birth spacing on infant and child mortality, pregnancy outcomes, and maternal morbidity and mortality in Matlab, Bangladesh</title><secondary-title>Technical Consultation and Review of the Scientific Evidence for Birth Spacing</secondary-title></titles><periodical><full-title>Technical Consultation and Review of the Scientific Evidence for Birth Spacing</full-title></periodical><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[21, 22]. This suggests that all SIPI women admitted for delivery need close monitoring during their labor to recognize undiagnosed preeclampsia and eclampsia, and to help prevent possible death of the mother as a complication of hypertension.
 Birth weights of infants were compared in both groups. Our study found that 26.7% of infants delivered in the SIPI grow had birth weights birth below 2500g. This result was found in other studies done in England, Sudan and Tanzania  ADDIN EN.CITE [23-26]. Low birth weight in SIPI women may be the result of poor maternal nutritional status due to the very short birth intervals and poor maternal weight gain  ADDIN EN.CITE <EndNote><Cite><Author>Winkvist</Author><Year>1992</Year><RecNum>12</RecNum><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkvist, Anna</author><author>Rasmussen, Kathleen M.</author><author>Habicht, Jean-Pierre</author></authors></contributors><titles><title>A new definition of maternal depletion syndrome</title><secondary-title>American journal of public health</secondary-title></titles><periodical><full-title>American journal of public health</full-title></periodical><pages>691-694</pages><volume>82</volume><number>5</number><dates><year>1992</year></dates><isbn>0090-0036</isbn><urls></urls></record></Cite><Cite><Author>King</Author><Year>2003</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">15</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>King, Janet C.</author></authors></contributors><titles><title>The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies</title><secondary-title>The Journal of nutrition</secondary-title></titles><periodical><full-title>The Journal of nutrition</full-title></periodical><pages>1732S-1736S</pages><volume>133</volume><number>5</number><dates><year>2003</year></dates><isbn>0022-3166</isbn><urls></urls></record></Cite></EndNote>[27, 28]. This can also be secondary to depleted iron and folate stores which increase the women's susceptibility to anemia and compromise their overall nutritional status. This study showed that preterm delivery was seen in 29.3% of SIPI women. This finding is similar to other studies which also revealed an increased incidence of prematurity in SIPI pregnant women  ADDIN EN.CITE <EndNote><Cite><Author>DeFranco</Author><Year>2007</Year><RecNum>24</RecNum><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>DeFranco, Emily A.</author><author>Stamilio, David M.</author><author>Boslaugh, Sarah E.</author><author>Gross, Gilad A.</author><author>Muglia, Louis J.</author></authors></contributors><titles><title>A short interpregnancy interval is a risk factor for preterm birth and its recurrence</title><secondary-title>American journal of obstetrics and gynecology</secondary-title></titles><periodical><full-title>American journal of obstetrics and gynecology</full-title></periodical><pages>264. e1-264. e6</pages><volume>197</volume><number>3</number><dates><year>2007</year></dates><isbn>0002-9378</isbn><urls></urls></record></Cite><Cite><Author>Conde-Agudelo</Author><Year>2006</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde-Agudelo, Agustin</author><author>Rosas-Bermúdez, Anyeli</author><author>Kafury-Goeta, Ana Cecilia</author></authors></contributors><titles><title>Birth spacing and risk of adverse perinatal outcomes: a meta-analysis</title><secondary-title>Jama</secondary-title></titles><periodical><full-title>Jama</full-title></periodical><pages>1809-1823</pages><volume>295</volume><number>15</number><dates><year>2006</year></dates><isbn>0098-7484</isbn><urls></urls></record></Cite></EndNote>[29, 30]. One hypothesis of a possible biologic mechanism to explain SIPI related prematurity is the iron storage capacity and pregnancy related anemia, facilitating immunosuppression leading to an increased risk of infection. This also increases the risk of chorioamnionitis which leads to prematurity and fetal death. Also histological chorioamnionitis  itself appears to be an independent risk factor for prematurity  ADDIN EN.CITE <EndNote><Cite><Author>Conde-Agudelo</Author><Year>2000</Year><RecNum>26</RecNum><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde-Agudelo, Agustin</author><author>Belizán, José M.</author></authors></contributors><titles><title>Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study</title><secondary-title>Bmj</secondary-title></titles><periodical><full-title>Bmj</full-title></periodical><pages>1255-1259</pages><volume>321</volume><number>7271</number><dates><year>2000</year></dates><isbn>0959-8138</isbn><urls></urls></record></Cite></EndNote>[17]. This also suggests that that in order to overcome the burden of preterm delivery there is a need for a well organized perinatal intensive care unit which will be able to provide all necessary health care services to preterm babies.
 The study revealed that SGA was seen in 23.3% of SIPI rather than NIPI women. This finding was similar to other studies that showed SIPI women have increased tendency to deliver small for gestation age babies. According to the study done at Israel Zedek Medical Centre (IZMC) there was increased risk of SGA (8.5% vs. 7.6%) among SIPI women  ADDIN EN.CITE <EndNote><Cite><Author>Grisaru-Granovsky</Author><Year>2009</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grisaru-Granovsky, Sorina</author><author>Gordon, Ethel-Sherry</author><author>Haklai, Ziona</author><author>Samueloff, Arnon</author><author>Schimmel, Michael M.</author></authors></contributors><titles><title>Effect of interpregnancy interval on adverse perinatal outcomes��  a national study</title><secondary-title>Contraception</secondary-title></titles><periodical><full-title>Contraception</full-title></periodical><pages>512-518</pages><volume>80</volume><number>6</number><dates><year>2009</year></dates><isbn>0010-7824</isbn><urls></urls></record></Cite></EndNote>[1]. Similarly, another study found that SIPI women have higher chances of delivering infants with SGA (22.8%) vs. (11.5%) in NIPI women. The hypothetical explanation for SGA in SIPI pregnant women is due to poor maternal nutritional status and pregnancy folate storage capacity depletion syndrome resulting from the previous pregnancy  ADDIN EN.CITE <EndNote><Cite><Author>Van Eijsden</Author><Year>2008</Year><RecNum>13</RecNum><record><rec-number>13</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">13</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Van Eijsden, Manon</author><author>Smits, Luc J. M.</author><author>Van der Wal, Marcel F.</author><author>Bonsel, Gouke J.</author></authors></contributors><titles><title>Association between short interpregnancy intervals and term birth weight: the role of folate depletion</title><secondary-title>The American journal of clinical nutrition</secondary-title></titles><periodical><full-title>The American journal of clinical nutrition</full-title></periodical><pages>147-153</pages><volume>88</volume><number>1</number><dates><year>2008</year></dates><isbn>0002-9165</isbn><urls></urls></record></Cite></EndNote>[31].
This study showed that a low Apgar score was seen in 25.6% of SIPI women compared to NIPI women.  This indicates that the hospital will need postnatal observation, assessment, management and care in accordance with the postnatal condition.  Infants with a low Apgar scores may therefore incur more cost to their family immediately post delivery as well as during follow up if the infant has delayed milestones or a long-term complication such as cerebral palsy.  A study done in Morogoro Tanzania showed that there is increasing chance of low Apgar score when there was inter-pregnancy interval of less than 6 months to 12 months  ADDIN EN.CITE <EndNote><Cite><Author>Mosha</Author><RecNum>16</RecNum><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mosha, Theobald C. E.</author><author>Philemon, Napendaeli</author></authors></contributors><titles><title>Factors influencing pregnancy outcomes in Morogoro Municipality, Tanzania</title><secondary-title>Tanzania journal of health research</secondary-title></titles><periodical><full-title>Tanzania journal of health research</full-title></periodical><volume>12</volume><number>4</number><dates></dates><isbn>1821-6404</isbn><urls></urls></record></Cite></EndNote>[25]. The reason for low Apgar score in infants born to SIPI pregnant women is due to low birth weights and premature birth which is more commonly found among SIPI pregnant women. Premature and low birth weight babies are prone to fetal distress during labor and resultant low Apgar scores. In our study two babies were found to have congenital anomalies which are not commonly predicted for women with SIPI. Neither of these congenital anomalies were found in the control group, but the result was not statistically significant  ADDIN EN.CITE <EndNote><Cite><Author>Braekke</Author><Year>2003</Year><RecNum>29</RecNum><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Braekke, Kristin</author><author>Staff, Anne Cathrine</author></authors></contributors><titles><title>Periconceptional use of folic acid supplements in Oslo</title><secondary-title>Acta obstetricia et gynecologica Scandinavica</secondary-title></titles><periodical><full-title>Acta obstetricia et gynecologica Scandinavica</full-title></periodical><pages>620-627</pages><volume>82</volume><number>7</number><dates><year>2003</year></dates><isbn>1600-0412</isbn><urls></urls></record></Cite></EndNote>[32]. The possible etiology for congenital malformation could be due to neural tube defects (NTD) possibly secondary to folate depletion in women with SIPI. These defects usually occur before the embryogenesis has taken place, so there is a high chance of NTD anomalies among the infants born to women with very short inter-pregnancy intervals.
The study findings reveal that infants with prolonged length of hospital stay were more likely to be in the SIPI group, 82.0%. Similar findings of increased risk of antenatal and postnatal morbidity was seen in infants born to mothers with short birth intervals, less than 18 months (71.4%), compared to women with birth intervals of more than 18 months (28.6%) were seen in a study done in Cairo. This indicates that these infants need special attention regarding their observation, assessment, care, blood work investigations and management during their entire length of stay in the hospital. Hence, this increases the cost of care for the infant may lead to an increased psychological and financial burden on the mother and other family, as well as possible poor perinatal surveillance. Reasons for admission among those babies in the SIPI group include premature delivery, low Apgar score, small for gestation age, and low birth weight as well as delivery by caesarian section or other obstetric complications  ADDIN EN.CITE <EndNote><Cite><Author>El-Hamid</Author><RecNum>30</RecNum><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>El-Hamid, Azza Ali Abd</author><author>Gaafar, Hassan Mostafa</author></authors></contributors><titles><title>Adverse Effects of Interpregnancy Interval on Maternal Health Among Pregnant Women Attending Delivery at El-Manial University Hospital-Cairo University</title><secondary-title>medical journal of Cairo University</secondary-title></titles><periodical><full-title>medical journal of Cairo University</full-title></periodical><volume>79</volume><number>2</number><dates></dates><urls></urls></record></Cite><Cite><Author>Conde�� �Agudelo</Author><Year>2012</Year><RecNum>31</RecNum><record><rec-number>31</rec-number><foreign-keys><key app="EN" db-id="d2ws2tvtdra9ebeffem5vsebweap95ppt2v5">31</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Conde�� �Agudelo, Agust�n</author><author>Rosas�� �Bermudez, Anyeli</author><author>Casta��o, Fabio</author><author>Norton, Maureen H.</author></authors></contributors><titles><title>Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms</title><secondary-title>Studies in family planning</secondary-title></titles><periodical><full-title>Studies in family planning</full-title></periodical><pages>93-114</pages><volume>43</volume><number>2</number><dates><year>2012</year></dates><isbn>1728-4465</isbn><urls></urls></record></Cite></EndNote>[20, 33].
The limitation of this study is worth to be mentioned; the study was conducted for 6 months and thus does not provide information for the entire year. Not all women were able to undergo fetal ultrasound for fetal age; instead we relied on maternal report of their last normal menstrual flow to obtain fetal age at labor onset. During the entire period of follow up by mobile phone it was difficult to obtain information from the patients due to the unavailability of mobile phone network systems. Therefore this might have resulted in the under-estimation of the relative risk of the adverse outcomes.
CONCLUSION
Anemia, premature ruptured of membranes, failure of trial of VBAC, PPH, preeclampsia, as well as low birth weight; low Apgar score, preterm delivery and small for gestation age are the major adverse outcomes in SIPI women when compared to NIPI women in the obstetrics set-up of the BMC labor ward. Women should be educated about importance of sufficiently spacing their pregnancies, and understand the major risks and complications of short birth intervals.
Ethical approval
Ethical approval to conduct the study was obtained from the joint Catholic University of Health & Allied Health Sciences and Bugando Medical Centre Research Ethics Committee. Patients' refusal to consent or to withdraw from the study did not alter or jeopardize their access to medical care. 
Consent
All participants were provided with a consent information sheet and forms to read in order to consent for participation in the study. For non literate women, the consent sheet was read aloud in Kiswahili by the recruiter who was not part of the health care provision team. After agreeing to participate, the patient's thumbprint was stamped on the consent form to signify her consent.
Competing interests
The authors declare no competing interests
Author�s contributions
AL: Main author of the study, involved in writing the proposal, data collection and analysis. DM: Involved in design, development of proposal, data collection, analysis and preparation of the manuscript. AK: Involved in developing the proposal, data collection, analysis and preparation of the manuscript. BG: Involved in developing the proposal, data collection and analysis.
All authors read and approved the final manuscript.
Acknowledgements
Our gratitude goes to Ms Eveline Konje stastician at Catholic University of Health & Allied Health sciences (CUHAS) for her technical support during data analysis.


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28.	King J.C. The risk of maternal nutritional depletion and poor outcomes incrlm������������o	p	q	�	�	�	�	�	
 
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��Y�a�����������������������������������������������������������������������忷���hV2�h�:khV2�6�h�:kh�T26�h�T2h�:kh�RE5�^J
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h�RE^Jh�REh�:khQ^<6�	hQ^<6�h�:khQ^<5�hQ^<h'b		hQ^<5�C���0�9�:�M�N���������������������)�*�+�N�P�R�W�[�b�f�g�{�|������������,�5�9�@�C�D�s�t�u����������������� , - . F N Q U b p r � � � � � !!!!.!N!Q!U!a!d!e!�!��������������������������������������������������������������������������Uh�~�hemh�:khQ^<6�	hQ^<6�h�:khQ^<5�hQ^<h�T2	hQ^<5�Seases in early or closely spaced pregnancies. The Journal of nutrition, 2003. 133(5):1732S-1736S.
29.	DeFranco E, Stamilio D, Boslaugh S. A short interpregnancy interval is a risk factor for preterm birth and its recurrence. American journal of obstetrics and gynecology, 2007. 197(3):264. e1-264. e6.
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Table 1: Social demographic characteristics of sipi & nipi women 
VariableOverall valueStudy groupsSIPI (n=150)NIPI (n=300)Mean women Age �S.D.*23.4 � 1.723.3 � 1.623.4 � 1.7Education statusPrimary446 (99.1)148 (33.2)298 (66.8)Secondary/Higher Education4 (0.9)2 (50)2 (50)OccupationHousewife447 (99.3)149 (33.3)298 (66.7)Self-employment3 (0.7)1 (33.3)2 (66.7)Marital statusMarried449 (99.8)149 (33.2)300 (66.8)Single1 (0.2)1 (100)-ParityTwo268 (59.5)86 (32.1)182 (67.9)Three138 (30.7)49 (35.5)89 (64.5)More than Four44 (9.8)15 (34)29 (66)*S.D= Standard deviation









Table 2: Maternal adverse outcome among women with short and normal inter-pregnancy interval
    Inter-Pregnant Interval

p-value SIPI (N=150)              NIPI (N=300)
     n(%)                     n(%)    Hemoglobin concentration
<11g/dl
>11g/dl

141(94.0)
9(6.0)  
83(27.7)
217(72.3)
<0.01Failure of trial of VBAC
Present
Absent

44(29.3)
106(70.7)
6(2.0)
294(98.0)
<0.01Preeclampsia
Present
Absent

27(18.0)
123(82.0)
8(2.7)
292(97.3)
<0.01Postpartum hemorrhage
Present
Absent
29(19.3)              
 121(80.7)
10(3.3)
290(96.7)
<0.01PROM
Present
Absent
68(45.3)
82(54.7)
10(3.3)
290(96.7)
<0.01









Table 3: Perinatal adverse outcome among women with short and normal inter-pregnancy interval
Inter- Pregnancy Interval
SIPI (N=150)             NIPI (N=300)n(%)n(%)p-valueBirth weight<2500g40(26.7)12(4.0)< 0.01
>2500g110(77.3)288(96.0)PrematurityPresent44(29.3)9(3.0)< 0.01
Absent
106(70.7)291(97.0)Length of hosp staye" 24 hrs.
123(82)27(9.0)< 0.01
d" 24 hrs.
27(18)273(91)SGAPresent35(23.3)9(3.0)< 0.01
Absent115(76.7)291(97.0)Low Apgar scorePresent38(25.6)11(3.7)< 0.01
Absent112(74.7)289(96.3)






Table 4: Relative risk of maternal and fetal adverse outcome among women with SIPI and NIPI
VariableRelative risk95% CIp-valueMaternal adverse OutcomePROM13.67.2 - 25.64<0.01Anemia status3.42.8 - 4.1<0.01Preeclampsia6.753.14 -14.49<0.01PPH5.82.9 � 11.58<0.01Failure of trial of VBAC14.676.39 � 33.64<0.01Fetal  adverse Outcome�!�!�!�!�!�!�!�!�!M"N"O"y"�"�"�"�"�"�"�"�"�"�"�"####'#5#;#>#?#�#�#�#�#�#�#�#$$$$$Q$R$Z$�������������������������������������ѻ�����~ h��h�iG5�B*OJQJphh�iG5�CJOJQJhQ^<5�CJOJQJh��5�CJOJQJh�*J5�CJOJQJjhQ^<U	h�:k6�h�~�	hQ^<5�hQ^<	hQ^<6�h�:kh�~�5�h�:khQ^<5�h�:kh�~�h�:khQ^<6�h�:khQ^</$$$$	$
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