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