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Optimal Birth Spacing:Improving Maternal and Child Health
Outcomes International Best Practices Conference
Agra, India
September 2003
Presenters: Cathy Solter – CATALYST Consortium
Bill Jansen – Intrah Rekha Masilamani – Pathfinder India
State-of-the-Art
Family Planning &
Reproductive
Health Services
Optimal Birth Spacing Session Goals
To present the latest research findings on the benefits of spacing birth for at least 3 years
To discuss CATALYST’s approach to integrating birth spacing messages into health and non-health programs
To present the issue of unmet need for birth spacing
To share the results of the focus group discussions from India on the practice of birth spacing
Optimal Birth Spacing:Quantitative Research Findings
Cathy Solter CATALYST Consortium
State-of-the-Art
Family Planning &
Reproductive
Health Services
Previous guideline Proposed guidelines
Conde-Agudelo
Zhu
Conde-Agudelo
Rutstein
Definition of the Optimal Birth Interval: The optimal birth spacing interval has been defined by CATALYST as the period associated w ith the most favorable outcomes for both mothers and children. Based on the new research f indings, CATALYST crafted Figure 1 to illustrate the recommended revision of existing birth spacing guidelines.
Highest perinatal risk
Low est perinatal risk
Highest maternal risk
Low est maternal risk
15 24 27 30 36 53 60 69
Zhu
Zhu
Conde
Conde-Agudelo
Rutstein
Zhu
Conde-Agudelo
48
Fuentes-Afflick Fuentes
Conde-Agudelo
Rutstein
Fuentes-Afflick
Research on Optimal Birth Spacing
Risk of Neonatal, Infant and Under-five Mortality According to Birth Intervals: 17 DHS Countries
0
0.5
1
1.5
2
2.5
3
3.5
<18 18-23 24-29 30-35 36-41 42-47 48-53
Rela
tive R
isk f
or
Dyin
g
(ad
juste
d r
ati
o)
Neonatal
Infant
Under-five
Source: Rutstein, Shea, “Effects of Birth Interval on Mortality and Health: Multivariate Cross-Country Analysis, MACRO International, 2002.
Birth Interval (months)
Stunting and Underweight for Young Children
0.40
0.60
0.80
1.00
1.20
1.40
1.60
<17 18- 23 24- 29 30- 35 36- 41 42- 47 48- 53 54- 59 60+
Duration of Preceding Birth Interval (months)
Ad
j. R
elat
ive
Od
ds
Rat
io
Stunting
Underweight
Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to USAID, July 27, 2000.
Risk of Maternal Mortality by Interpregnancy Interval
0.5
1
1.5
2
2.5
3
0- 5 6- 11 12- 17 18- 23 24- 35 36- 47 48- 59 60+
Interpregnancy Interval (months)
Adju
ste
d o
dds r
ati
o(9
5%
CI)
MaternalDeath
Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002
Risk of Infant Mortality According to Birth
Intervals for Selected Countries in Asia
0
0.5
1
1.5
2
2.5
3
3.5
4
India Pakistan Nepal Indonesia
<24
24-35
36-47
48+
Ad
just
ed o
dd
s ra
tio
Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to CATALYST Consortium, October 2002
Adverse Perinatal Outcomes by Interpregnancy Interval
0
0.5
1
1.5
2
2.5
3
0-5 6-11 12-17 18-23 24-35 36-47 48-59 60+Interpregnancy Interval (months)
Ad
just
ed o
dd
s ra
tio
(9
5% C
I)
Fetal Death
NeonatalDeath
Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002
Risk of Maternal Morbidities by Too Long Interpregnancy Interval
0.5
1
1.5
2
2.5
3
0- 5 6- 11 12- 17 18- 23 24- 35 36- 47 48- 59 60+
Interpregnancy Interval (months)
Adju
ste
d o
dds r
ati
o
(95%
CI)
Pre- eclampsia
Eclampsia
Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002
In India, if no births occurred before 36 months of a preceding birth:
Infant Mortality Rate would drop 32%
Under Five Mortality Rate would drop 31%
Deaths to children under five years of age would fall by 728,000 annually
Source: Rutstein 2002.
Infant Mortality Rates with Existing Birth Intervals and Minimum Intervals of 24 and 36 months, India
0
10
20
30
40
50
60
70
Dea
ths
per
1000
bir
ths
26% of deaths averted
Additional 6% of deaths averted
Existing Min. 24 mos.
Min.36 mos.
Under Five Mortality Rates with Existing Birth Intervals and Minimum Intervals of 24 and 36 months, India
Existing Min. 24 mos.
Min.36 mos.
0
10
20
30
40
50
60
70
80
90
Dea
ths pe
r 10
00 b
irth
s
19% of deaths averted
Additional 12% of deaths averted
Implementing Best PracticeFindings
Birth spacing for 3 years or longer provides substantially more health and non-health benefits than the previously recommended 2 year interval.
Intervals of 3 years or longer result in:▸ Best infant / child outcomes▸ Lower perinatal, neonatal, infant mortality▸ Lower perinatal stunting / low birth weights▸ Fewer maternal deaths
There is a need to revisit birth spacing as a central primary health concept.
Taking an integrated approach through health and non-health programs empowers women and saves lives
The Underserved Population of Birth-Spacers:
Unmet Need for Birth Spacing
William H. Jansen, PhD
Prime II Project
Intrah
University of North Carolina
Chapel Hill
Findings on the Characteristics of Demand for Spacing
Among all MWRA, demand for spacing is substantial:▸ Ranging from about 1/3 to 3/4 of total FP demand in 14
of 15 countries examined.
Spacing is, by far, the main reason for FP demand among MWRA who are 29 years or younger:▸ Ranging from about 2/3 to over 9/10 of total FP
demand in 12 of 15 countries examined.
Portion of Total Demand for FP Due to Spacing Among MWRA < 29 Years
0
50
100
Zimbabwe Tanzania Mali Ghanaspacing
spacing total FP
Demand for Spacing by Age Cohort and Parity As portion of total FP Demand
0
20
40
60
80
100
15-19 20-24 25-29 30-34 35-39
Age group
3 parity2 parity1 parity0 parity
Uttar Pradesh, India, 1999
Portion of total FP demand for spacing by age cohort and parity
0
20
40
60
80
100
Per
cent
15-19 20-24 25-29 30-34 35-39
Age group
3 parity
2 parity
1 parity
0 parity
Uttar Pradesh, India (1999)
Frequency at which FP Demand is Met Varies for Spacing and Limiting
In 12 of the 15 countries examined, FP need for limiting is met at a higher rate than the frequency of of the demand for limiting appears within the general MWRA population.
In the same 12 countries, FP need for spacing is met at a lower rate than the frequency of the demand for spacing appears within the MWRA population.
Probability Demand for Spacing and Limiting Will Be Met
(distance from a value of 1)
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76
Zimbabwe
Yemen
U. P.
Togo
Tanzania
Philippines
Peru
Mali
Kenya
Ghana
Egypt
Bolivia
Benin
Bangladesh
Indonesia
Limiting
Spacing
Summary of Results
Demand for Spacing is substantial The vast majority of demand for any form of FP services
among women < 29 years is due to a demand to space births
There is unmet need for spacing among low-parity, young women (including delaying first birth)
In many countries, the unmet FP need for limiting is satisfied more frequently than that for spacing
The greatest opportunity to increase general FP use in the future lies in meeting the needs of spacers.
Optimal Birth Spacing: Focus Group Discussions
Findings
Rekha Masilamani Pathfinder, India
Results from Focus Group Discussion on Optimal Birth Spacing
Overview of the Focus Groups Conducted in 4 countries—India (34), Pakistan (40) Peru
(24), and Bolivia (24) and Egypt (51)
A Total of 122, with close to 1000 people participating in these focus group sessions.
Target Audience: ▸ Women who have spaced, ages 15-19, 20-30 yrs▸ Women who have not spaced, ages 15-19, 20-30 yrs▸ Male partners, ages 15-19, 20-30 yrs▸ Health providers ▸ Mothers-in-law- (India, Pakistan, Egypt)
Discussions Topics
Individual level: knowledge, beliefs and practices in birth spacing.
Cultural level: beliefs and norms regarding birth spacing. Women (mothers-in-law included)and men’s perception of
the quality of service in birth spacing. Providers perception of mother’s behaviors and beliefs in
birth spacing. Credible sources of information for men, women and
providers regarding B.S.
Reasons for Spacing BirthIndia
Economic: relief from financial burdens surfaced as a driving force for spacing births
Health & well being of the mother and child:The overall physical and mental well-being of the mother, new born, husband and other children living in the household was regarded as a major benefit of birth spacing
Key Barriers to Adoption of Birth Spacing, India
Lack of decision-making powers among the women due to the patriarchal structure of the family that gives the man the reins of power
Lack of knowledge of methods available
Inaccurate information and/or misconceptions about contraceptives: negative word of mouth or bad personal experiences
Key Barriers to Adoption of Birth Spacing, India
Religious prohibitions dictated by certain scriptures have led to believers not subscribing to spacing
Mothers-in-laws influence: Exert strong influence in the couple’s reproductive behavior
Fear of social disapproval
Possible Programmatic Approaches Based on FGD Findings
Address Barriers and Strengthen Current Support for OBS
Improve family planning counseling▸ Provide credible and comprehensive information regarding FP
methods• Access to information• Dispel misconceptions
▸ Involve men in the counseling session Media Campaign
▸ Disseminate information on the benefits of Birth Spacing ▸ Solicit community support for Birth Spacing
Empowerment of couples to decide on their reproductive choices