Optimal Birth Spacing:Improving Maternal and Child Health

Outcomes

Dr. Taroub Harb Faramand-CATALYST Consortium

Dr. Issakha Diallo, Advance Africa

State-of-the-Art

Family Planning &

Reproductive

Health Services

MAQ Mini-UniversityUSAID-Washington DC

May 12, 2003

Session Objectives

1. Present the latest quantitative and qualitative research findings on the impact of Optimal Birth Spacing on maternal and child health outcomes

2. Present CATALYST’s approach to integrating birth spacing messages into health and non-health programs

3. Share with the participants Advance Africa’s approach of using health benefits of Optimal Birth Spacing to revitalizing FP programs in Sub-Saharan Africa

4. Discuss and share experiences on program integration of Optimal Birth Spacing messages

Stunting and Underweight for Young Children

0.40

0.60

0.80

1.00

1.20

1.40

1.60

<18 18- 23 24- 29 30- 35 36- 41 42- 47 48- 53 54- 59 60+

Duration of Preceding Birth Interval (months)

Ad

j. R

ela

tiv

e O

dd

s R

ati

o

Stunting

Underweight

Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Macro International

Risk of Infant and Child Mortality by Birth Intervals

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

Birth Interval (months)

Rel

ativ

e R

isk

of

Dyi

ng

(a

dju

sted

rat

io)

Neonatal

Infant

Under-five

Source: Rutstein, Shea, Effects of Birth Interval on Mortality and Health: Multivariate Cross-Country Analysis, Macro International.

Adjusted Odds Ratio of Low Birth Weight by Interpregnancy Interval

0

0.5

1

1.5

2

2.5

0-5 6-11 12-17 18-23 24-59 60-119 120+

Interpregnancy Interval (months)

UnitedStates(Zhu)

Source: Zhu et al, Effect of Interval Between Pregnancies on Perinatal Outcomes, The New England Journal of Medicine, 25 February 1999

Source: Conde-Agudelo, Agustine “Second Champions Meeting on Birth Spacing” The CATALYST Consortium May 2002

0

0.5

1

1.5

2

2.5

0-5 6-11 12-17 18-23 24-35 36-47 48-59 60+

Interpregnancy Interval (months)

LatinAmerica(Conde-Agudelo)

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)

Adj

uste

d od

ds r

atio

(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 Morbidity 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+

Inter- pregnancy Interval (months)

Adju

sted o

dds

rati

o

(95%

CI)

AnemiaThird Trimester BleedingPremature Rupture of the MembranesPuerperal Endometritis

Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

Risk of Maternal Morbidity by Interpregnancy Interval (cont’d)

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

sted o

dds

rati

o

(95%

CI)

Pre- eclampsia

Eclampsia

Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

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

sted o

dds

rati

o(9

5%

CI)

MaternalDeath

Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

Risk of Maternal Mortality by Birth Interval

0.5

1

1.5

2

2.5

3

0- 14 15- 20 21- 26 27- 32 33- 44 45- 56 57- 68 69+

Birth Interval (months)

Adju

sted o

dds

rati

o(9

5%

CI)

MaternalDeath

Source: Conde-Agudelo, 2nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

The Potential Impact of OBS

If Women Spaced Births for 3 Years…

INDIA Infant mortality

would drop 29% Under age five

mortality would drop 35%

Deaths to children under age five would fall by

1,434,000 annually

EGYPT Infant mortality

would drop 35% Under age Five

mortality would drop 45%

Deaths to children under age five would fall by 109,000 annually

Fertility rate would potentially drop by 8%

Non-Health Benefits of Family Planning**

Provides economic and health benefits Can improve sexual life (satisfaction),

partner relations, and family well-being Family planning users are more likely to

take advantage of job opportunities Family planning helps women meet

practical needs and is necessary to help meet strategic need (gender equity)

** Synthesis of finding from the Women’s Studies Project, FHI 1998

Results from Focus Group Discussion on Optimal Birth SpacingOverview of the Focus Groups Conducted in 4 countries—India, Pakistan, Peru, and

Bolivia

Egypt—on-going

Close to 1000 participants in 122 focus group discussions

Audience: ▸ Spacers and non-spacers, ages 15-19, 20-30 yrs▸ Male partners, ages 15-19, 20-30 yrs▸ Health providers ▸ Mothers-in-law (India, Pakistan, Egypt)

FGD Common Findings

Reasons for Spacing

1. Economic Consideration—relief from financial burdens surfaced as a driving force for spacing births

2. 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

FGD Common Findings

Reasons for NOT Spacing (Barriers)1. Inaccurate information and/or misconceptions

about contraceptives

2. Gender Inequity▸ Women lack power in making decisions concerning their

reproductive choices▸ Husbands having the final say in spacing of children

3. Mothers-in-laws influence (India and Pakistan) ▸ Exert strong influence in the couple’s reproductive

behavior

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

Programmatic Response: Integration with Health Programs

RH/FP

IMCI/MCH

Neonatal Health

HIV/AIDS/Infectious

Diseases

PAC

BCC

Female Health Volunteers

Peer Educators

Community-Based

Distributors (CBDs)

Hea

lth P

rogr

ams Clinical

Programs

Non-clinical Programs

Programmatic Response: Integration with Non-Health Programs

Literacy Democracy & Governance Microcredit/microenterprises Woman’s empowerment programs Male involvement programs

When Women have Ongoing Social Support, They are More Apt to Continue Family Planning Use: Change in Contraceptive

Status 1994-1996

05

10

15

20

2530

35

40

45

% Change in Contraceptive

USe

InitiatedContraceptive

Use

ContinuedContraceptive

Use

No FPCommunication Home Visit

Social Network

Source: Johns Hopkins University 2000

Implementing Best PracticeFindings

Birth spacing for 3 years of longer provides substantially more health and non-health benefits than the previously recommended 2 year interval.

Intervals of 3 years or longer result in:▸ Better infant / child outcomes▸ Lower perinatal, neonatal, infant, and child mortality▸ Lower stunting and low birth weights▸ Lower maternal morbidities ▸ 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 couples and saves lives.

Advance Africa Program StrategyFamily Planning as a Health Intervention

Client (Government, NGO , Private Sector)High Quality FP /RH Service Delivery

Repositioning Inputs

Policy, Partnering, Advocacy& Demonstration Projects

(MTCT, VCT,FAWE, Partage,

Zimbabwe)

Service Delivery T.A. Inputs

The ACCOMPLISH Model

(Mozambique, Congo,Senegal, Angola,

Zimbabwe)

Median lengths of actual and preferred Birth Intervals in Sub-Saharan Africa

35 36 32 32 31 3239 35 31 33 32 35 31 32 33 34 35 33 32

40

39 40

34 36

4739

52

49

3738 37

36

34 32

4740 39

35 36

53

0

10

20

30

40

50

60

70

80

90

100

Actual BI Preferred BI

Source: Population Reports, Volume XXX, Number 3, Summer 2002 (11)

African Birth Interval Preferences

Mothers in Sub-Saharan African countries would prefer longer birth intervals.

Few African mothers prefer birth intervals shorter than 36 months.

Preferred birth intervals are usually longer in East and Southern Africa than in West and Middle Africa.

Source: Shea Rutstein, PhD, Measure/DHS+,Macro International, Inc.

1.0

0.80.7

0.6

0.5

0.4 0.4

0.4 0.4 0.40.3 0.3

0.3 0.30.3

0.1 0.1

0.5

0.0

0.3

0.5

0.8

1.0

Decre

ase in

Nu

mb

er

of

Ch

ild

ren

Source: Shea Rutstein, PhD, Measure/DHS+,Macro International, Inc.

Change in Total Fertility Rate with Minimum Birth Interval of 36 Months

Analysis of DHS data from 1990 to 1997 in 27 countries has demonstrated a threshold effect in the relation between temporary method use length of birth interval.

Enabling women to realize their birth interval preferences would result in substantial decreases in both infant and child mortality and fertility.

Summary OBI research results(1)

Source: Population Reports, Volume XXX, Number 3, Summer 2002 (11)

Avoiding short birth intervals would lower both fertility and infant and child mortality by additional substantial amounts.

When children are weaned too soon, their growth suffers, they are more likely to suffer from diarrheal disease, and skins infections, and they are thus greater risk of dying

Source: Shea Rutstein, PhD, Measure/DHS+,Macro International, Inc.

Summary OBI research results(2)

Suggested Strategies to help couples space Births

Increase access to good-quality contraceptive services and full range of methods,

Encourage community campaigns that speak about needs of younger couples – and cultural norms and tradition beliefs,

Use prenatal and post natal periods as crucial times for information and counseling about birth spacing,

Discuss with mothers during well-baby and immunization visits the benefits of maintaining 3-5 years for the next child,

Support initiative that strengthen the women decision-making power in the household.

Source: Population Reports, Volume XXX, Number 3, Summer 2002 (11)