Healthy Timing and Spacing of Pregnancy: Strengthening Referrals by Helping Providers Educate Clients on Behaviors that Save Lives and Prevent High-Risk

Pregnancies

Maureen Norton Flexible Fund and Advancing

Partners Meeting: Making CBFP Part of the Health System World Vision April 30, 2013 Washington , DC

Healthy Timing and Spacing of Pregnancy

An approach to family planning education, counseling, and services to help women/ families have wanted pregnancies at the

healthiest times of their lives.

Family planning helps prevent fertility-related, high-risk pregnancies.

 

 

 

 

Healthy Pregnancy Timing and Spacing Behaviors

Timing • Pregnancies delayed until at least 18

years of age • Pregnancies occur before age 34

Spacing • Pregnancies spaced to occur at least

24 months after preceding live birth (a 33 month birth-to-birth interval)

• Pregnancies spaced to occur 6 months after miscarriage or induced abortion

The number of children per women isalso important.

Pregnancy Timing: Recommendations from WHO, UNICEF and UNFPA on early age pregnancy

Delay first pregnancy until at least 18 years of age

Source: UNICEF, Facts for Life. 3rd ed. New York: United Nations Children’s Fund (http://www.unicef.org/ffl/text.htm), 2002; WHO/ UNFPA. Pregnant Adolescents: Delivering on Global Promises of Hope. Geneva, World Health Organization, 2006.

Pregnancy Timing: Perinatal Mortality is Lower among Babies Born to

Women Ages 20-29, Compared to Babies Born to Adolescents

 

 

Pregnancy Spacing: Recommendations of 30 Technical Experts to WHO after Evidence Review

Recommendation for spacing after a live birth: • The recommended interval before attempting the next

pregnancy is at least 24 months to reduce the risk of adverse maternal, perinatal and infant outcomes (a birth-to-birth interval of at least 33 months).

Recommendation for spacing after miscarriage or induced abortion:

• The recommended minimum interval to next pregnancy should be at least six months to reduce risks of adverse maternal and perinatal outcomes.

Source: World Health Organization, 2006 Report of a WHO Technical Consultation on Birth Spacing. *WHO is reviewing the technical experts’ recommendations and has requested additional analyses to address

questions that arose at the 2005 meeting. WHO recommendations will be issued when their review has been completed.

 

 

 

 

 

 

 

 

Pregnancy Spacing: Key Findings of WHO Technical Consultation – Short Pregnancy Intervals are Associated with Increased Risk of Multiple Adverse

Outcomes

Perinatal/Infant Outcomes: Maternal Outcomes: •Pre-term birth

•Maternal mortality •Low birth weight

•Induced abortion •Small size for gestational age

•Miscarriage •Stillbirth

•Newborn/infant mortality

Sources: Conde-Agudelo, 2002; 2006; Rutstein, 2008; DaVanzo, 2007.

Pregnancy Spacing: Risk of Under-Five Mortality is Lower When Births are Spaced Approximately Three Years Apart

Source: Rutstein, 2008

*Ref Group/ Birth-to-Pregnancy Intervals are in Months

Pregnancy Timing: Risk of Maternal Death is Higher When

Pregnancies Occur after Age 34

Source: A. Blanc, W. Winfrey and J. Ross, 2012 Forthcoming.

High Fertility: Risk of Maternal Death is Higher after Four

Births

Source: J. Stover and J. Ross, 2010.

 

 

 

 

 

 

Examine Country-Context: Prevalence of Fertility-Related, High-Risk Pregnancies that Contribute to U-5 and Maternal Mortality

• High prevalence of adolescentpregnancies

• High percentage of shortpregnancy intervals

• High number of children per woman

• High percentage of advanced maternal age pregnancies

• Minimal or no change in shortinterval births over past twenty years

• Pregnancy intervals after miscarriage/induced abortion – unknown

 

 

 

 

 

 

 

 

Indentify HTSP Target Audiences

• Adolescents

• Parents of Adolescents

• Newlyweds – Engaged Couples

• First-Time Parents

• Postpartum Women

• Women Age 30 and older

• Men/Boys

• Community and Religious Leaders

   

Develop Evidence-Based HTSP Messages

• Healthy timing and spacing of pregnancy protects you and your baby • Healthy times for a pregnancy are between the ages of 18 and 34 • For healthy spacing after a live birth, use a contraceptive method of your

choice for 24 months before attempting a new pregnancy

If pregnancy occurs less than 24 months after a live birth:

Risks The baby can be born too soon or be of

low birth weight

When pregnancy occurs more than 24 months after a live birth:

Benefits Allows infant to benefit from two full years of breast feeding

Does HTSP information help families adopt healthy behaviors?

Yes. Eight completed studies show that when families are advised of the role of family planning in preventing fertility-related, high-risk pregnancies, family planning use in the intervention area

increases significantly.

 

 

 

 

Summary of Possible Steps to Strengthen Referral Messages

• Assess prevalence of unhealthy pregnancy timing and spacing behaviors at country and community levels

• Share global and country/community HTSP evidence and recommendations with country leaders and program managers

• Identify key target groups, possibly including men, first time parents, postpartum women, mothers-in-law, and grandmothers

• Develop evidence-based messages on healthy behaviors, including risks and benefits

Bangladesh Case Study

Healthy Fertility Study: “Helping Newborns Survive and Thrive”

 

   

 

 

Study Objectives

• To develop and test an integrated FP/MNH service delivery approach in Sylhet Bangladesh

• To assess: o strengths and limitations of integrating FP into an ongoing

community-based MNH care program

o impact of the intervention package on contraceptive knowledge and practices

o impact of the intervention package on pregnancy spacing

Context: Sylhet district compares poorly to Bangladesh as a whole

Unmet FP Need OverallContraceptive Prevalance RateTotal Fertility RateBirth Intervals:

<24 months<36 months

BDHS 2007BGD Syl

17% 26%

56% 31%2.7 3.7

15% 26%37% 57%

 

 

 

 

 

   

 

Design of Healthy Fertility Study

• 10th Grade-educated Community Based Health Workers trained to conduct pregnancy surveillance and deliver key HTSP and newborn/maternal care messages

• Household counseling visits – during pregnancy and postpartum using IEC materials

• Convey key messages: – After a live birth, use a modern contraceptive method for 24 months

before attempting a new pregnancy – After miscarriage, use a modern contraceptive method for six

months – Fertility awareness messages – Educate on LAM/transition

• Dispense condoms, pills, injectables and refer to health-facility for LAPM

Strengthening Referral Messages to Improve FP Use and Newborn and Child Survival

Intervention Potential Impact

Evidence-based HTSP messages conveyed by providers, community mobilizers and NGOs

Improved knowledge of HTSP behaviors - pre-condition for behavior change

Education on LAM and LAM transition at six months to other modern method

Helps prevent pregnancy in the first six months postpartum – pregnancy occurring in the six-month postpartum period is associated with highest risk of newborn mortality and pre-term birth in the next pregnancy

Counseling on and actual use of FP for 24 months after live birth

<24 month birth to pregnancy intervals – associated with reduced risk of stunting and underweight and <-5 mortality

Referral for LAPMs LAPMs and LARCs – highly effective methods for effective spacing and to prevent advanced maternal age and high parity pregnancies – these high-risk pregnancies associated with stillbirth and maternal/newborn mortality

Healthy Fertility Study: Any contraceptive method use at

3, 6, 12, 18, and 24 months postpartum

Thank you!HTSP – an underutilized prevention strategy to achieve healthy pregnancy outcomes, save lives, and help countries achieve Millennium Development Goals.

Please Join our Community of Practice!

Healthy Timing and Spacing of Pregnancies in Asia

November 21, 2011 24

Total Fertility Rate, by Richest and Poorest Wealth Quintiles, Asia

Total fertility rates are significantly higher in the poorest quintiles as compared with the richest quintiles.

TFR

25 Source: Demographic and Health Surveys by given year. Data for Afghanistan and Yemen are unavailable.

Percentage of Married Women Using a Modern Method of Contraception, by Wealth Quintile, Asia

Use among poor women is consistently lower than among rich women in PRH priority countries.

Perc

ent

26 Source: Demographic and Health Surveys for given years. Data for Afghanistan and Yemen are unavailable.

Percentage of Births by Number of Months Since Preceding Birth Asia

27

Source: Demographic and Health Surveys for given years. Pakistan is ever-­‐married only.

Percentage of Women Aged 15–19 Who Are Mothers or Pregnant With Their First Child, by Wealth Quintile

Asia

Adolescent pregnancy is consistently higher among the lowest wealth quin:le than among the highest wealth quin:le in PRHpriority countries in Asia and Hai:.

Source: STATcompiler – most  recent  Demographic and Health Surveys. Informa9on is not  available for India  (UP). 28

Proportion of Births That Are Fifth Order or Higher Asia

The propor:on of births of fi,h order or higher ranges from 10.7 in Bangladesh to 30.8 in Pakistan.

Source: STATcompiler. Informa9on is not  available for India  (UP). 29

Trends in births spaced less than 36 months, Asia