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The risk of perinatal mortality following short inter-pregnancy intervals—insights from 692?402 pregnancies in 113 Demographic and Health Surveys from 46 countries: a population-based analysis
Authors: Mohamed M Ali, Saverio Bellizzi, and Iqbal H Shah
Source: Lancet Global Health , Volume 11, Issue 10; DOI:
Topic(s): Birth interval
Infant mortality
Neonatal mortality
Pregnancy outcomes
Country: More than one region
  Multiple Regions
Published: OCT 2023
Abstract: Background Inter-pregnancy interval has been identified as a potentially modifiable risk factor to improve perinatal outcomes. We examined the WHO recommended interval of at least 24 months after a livebirth to next pregnancy, and its recommendation of waiting for at least 6 months after a pregnancy loss to improve subsequent pregnancy outcomes. We aimed to estimate the association between inter-pregnancy interval and perinatal mortality using the Demographic and Health Survey reproductive and contraceptive calendar. Methods For this population-based analysis, we extracted data for pregnancies with gestational age and pregnancy outcomes from 113 publicly available Demographic and Health Surveys conducted between 2000 and 2022 in 46 countries that included a reproductive or contraceptive calendar module. The primary outcome was perinatal mortality (stillbirth and early neonatal death) while the inter-pregnancy interval was the exposure of interest, grouped into categories of less than 6 months, 6–11 months, 12–17 months, 18–23 months, and 24–59 months. The analysis was stratified by preceding pregnancy outcome (livebirths, stillbirths, or abortions). The Kaplan-Meier method and Cox proportional hazard model were used to calculate the cumulative probability of perinatal mortality and the hazard ratios (HRs). Findings The analysis sample comprised of 692?402 pregnancies contributed by 570?145 women with a mean age of 28·4 years (SD 5·96). The overall HR of perinatal death was 2·72 (95% CI 2·52–2·93) times higher for an inter-pregnancy interval of less than 6 months compared with the WHO recommended optimal waiting time of 18–23 months following a livebirth. Overall HRs followed a context-related pattern, with the highest ratio of 2·95 (95% CI 2·67–3·25) in sub-Saharan Africa and the lowest of 1·98 (1·47–2·66) in north Africa, west Asia, and Europe. Inter-pregnancy intervals of less than 3 months, 6 months, and 12 months following stillbirth or abortion (spontaneous or induced) do not pose a higher risk for perinatal death in subsequent pregnancy. Interpretation Our study reaffirms the WHO recommendation on optimal interval between the last livebirth and the next pregnancy of at least 24 months and avoiding pregnancy before 18 months. However, our analysis does not support the WHO recommendation of delaying the next pregnancy for at least 6 months after a pregnancy loss for improved perinatal survival.