Healthy Timing and Spacing of Pregnancy (HTSP):
Moving Research into Best Practices and Programs
Maureen Norton, PhD
USAID
Reconvening Bangkok: 2007 to 2010—Progress
Made and Lessons Learned in Scaling-Up
FP/MNCH Best Practices in Asia and Middle
East (AME) Regions
Bangkok, Thailand
March 6-11, 2010
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.
Recommendations of 30 Technical Experts to WHO after
Reviewing Pregnancy Spacing Studies*
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.
Key Findings: Too Short Pregnancy Intervals are
Associated with Multiple Adverse Outcomes
Perinatal/Infant Outcomes:
Maternal Outcomes:
•Pre-term birth
•Maternal mortality
•Low birth weight
•Induced abortion
•Small size for gestational
age
•Stillbirth
•Newborn/infant mortality
•Miscarriage
HEALTHY TIMING AND SPACING BEHAVIORS
Timing
• Pregnancies delayed until 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-tobirth interval)
• Pregnancies spaced to occur 6
months after miscarriage or
induced abortion
Illustrative HTSP Target Audiences
• Adolescents
• Newlyweds
• Postpartum Women
• Women age 30 and older
Evidence-Based Messages for ANC and Postpartum Women
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
Key Elements of HTSP
HTSP – an approach to family planning service delivery that:
•
Conveys evidence-based messages to target audiences--relevant for
their ages and status in life-cycle--on benefits and risks of pregnancy
timing and spacing
•
Helps target audiences make an informed decision about the timing
and spacing of their pregnancies to ensure the healthiest outcomes
•
Provides contraceptive methods to carry out a couple’s decision to
achieve their timing and spacing preferences
No or modest change in birth intervals in 20 years
despite increased CPR in all AME countries
Percent of married women whose preceding birth interval was
less than 36 months among women aged 15-29
Bangladesh
Pakistan
10 20 30 40 50 60 70 80 90
Percent
10 20 30 40 50 60 70 80 90
Percent
100
Cambodia, Indonesia, Philippines
100
Bangladesh, Pakistan, Nepal
Cambodia
Indonesia
0
Philippines
0
Nepal
1990
1995
2000
Year
2005
2010
1990
1995
2000
Year
10 20 30 40 50 60 70 80 90
Percent
100
Egypt, Jordan
Egypt
0
Jordan
1990
1995
2000
Year
2005
2010
Source: All available Demographic and Health Surveys. Note: India (UP) was not included due to definitional changes over trend period.
2005
2010
Very high percentages of too closely spaced
births in AME region
Percent of married women whose preceding birth interval was less than 36 months among
women aged 15-29
100
90
80
Percent
70
60
50
40
77.2
77.0
68.9
72.1
63.4
30
61.1
58.6
42.3
20
40.9
10
Source: Most recent Demographic and Health Surveys for given years.
B
20
07
In
do
ne
s
ia
20
07
an
gl
ad
es
h
Eg
yp
t2
00
8
20
05
am
bo
di
a
C
N
ep
al
20
06
20
08
Ph
il i
pp
in
es
In
di
a
(U
P)
20
05
20
06
Pa
ki
st
an
Jo
rd
an
20
07
0
Significant percentages of young women gave birth before
age 18 in AME region
Percent of currently married women aged 18-24 who had a birth before age 18
100
Total
90
Poorest 2 Quintiles
80
70
59.5
Percent
60
50
40
48.0
39.3
30.5
30
28.1
30.2
30.1
23.3
24.2
18.0
20
23.8
17.0
19.5
16.9 18.3
13.9
10
0
Bangladesh India (UP) Nepal 2006
2007
2005
Source: Most recent Demographic and Health Surveys for given years.
Pakistan
2006
Indonesia
2007
Philippines Cambodia
2008
2005
Egypt 2008
Significant percentage of women older than age 34 with
unmet need for family planning in AME Region
Percent of currently married women aged 35 to 49
with an unmet need for family planning
40
Total
Lowest 2 Quintiles
35
29.9
28.7
30
25.2
Percent
25.1
25
22.4
23.3
20.2
20
16.7
15.4
13.1
15
15.1
11.6
10
5
10.7
8.6
8.6
10
1.1 1.9
Source: Most recent Demographic and Health Surveys for given years.
Eg
yp
t2
00
8
In
do
ne
si
a
20
B
07
an
gl
ad
es
h
20
07
00
5
In
di
a
(U
P)
2
20
07
Jo
rd
an
20
06
ep
al
N
20
06
Ph
il i
pp
in
es
20
08
Pa
ki
st
an
C
am
bo
di
a
20
05
0
HTSP Design and Implementation Best Practices
• Identify target audiences
• Select evidence-based messages
• Prepare provider-client family
education materials
• Select proven HTSP training
materials
• Train providers to counsel and
leaders to speak-out
• Use e-Learning tools for
continuous learning
• Provide FP services
Pathfinder India, PRACHAR Program
Reconvening Bangkok Best Practices Meeting
March 6 -11, 2010
Dr. Rema Nanda
Country Representative, India Office
RH/FP Challenges in Bihar
Median age of marriage for women: 15.9 years
Fertility in women under 25 years : 55%
Current use of contraceptive by couples : 0 parity- 1.4%, 1 parity – 6.0%
Median age of women at first birth: 18.8 years
Death due to pregnancy related complication: Girls below 15- 5 times and
girls aged 15-19 – twice at risk as compared to women in their twenties
Total fertility: 4
NFHS 3, 2005-2006
Design, audience, and messages
• Design: The model uses intensive BCC and IEC to reach an
audience segmented by age, life cycle stage and sex, to promote
delaying age of marriage, delaying fist child and spacing the
second.
 Target audience: Adolescent boys and girls aged 15-19;
Newlyweds; Couples with one child; Parents of adolescents;
Young couples with wife below 30 years of age; Community
influencers
Key Messages
•
Couple communication & negotiation for joint decision making & informed
choice
•
Risks of early marriage and early birth
•
Socio economic befits of delay and space
•
Continuous, consistent, & correct use of contraceptives and early adoption
through actual demonstration of common methods
•
Counseling on care during pregnancy, birth preparedness and new born care
•
Delay marriage and in the case of child marriage delay consummation
•
Delay first birth and space the second: reduces risk to mother and child
and other messages as mentioned above
Marriage & Childbearing Delayed
Nonintervention
Intervention
Difference
Men
21.3
22.3
1 year
Women
19.4
20.9
1.5 years
21.5
23.6
2 years
Indicator
Median age at marriage
Median age at first birth
Education and adoption of D&S
Use of contraception, by women's education and
by survey time: Non intervention areas
75
Use of contraception, by women's education,
and by survey time: Intervention areas
75
58.9
50
50
Baseline
Percent use
Baseline
Percent use
21.2
25
18.9
6.3
4.4 4
32.9
29
Follow-up
24.9
25
11.8
9
4.7
0
0
None
1-9 years 10+ years
Years of schooling
None
1-9 years 10+ years
Years of schooling
Follow-up
Impact of joint decision making on D&S
To delay 1st child
(n=7693)
100
90
80
70
60
50
40
30
20
10
0
To space 2nd child
(n=7614)
33.4
26.3
10.3
Neither exposed
16.6
Only wife
exposed
Only husband
exposed
p<0.001
Both partner
exposed
100
90
80
70
60
50
40
30
20
10
0
59.4
47.8
35.8
21.8
Neither exposed
Only wife
exposed
Only husband
exposed
p<0.001
Both partner
exposed
TIMOR-LESTE
A Country’s Agonizing Birth
Timor-Leste
Independent since 2002
Beth Elson
March 8, 2010
Local context & Challenges: TFR 7.8 (DHS 2003)
• Post-conflict:
– Population replenishment
– Most health staff left the country
– Most health facilities destroyed (WB 70%)
• Pro-natalist: ideology promoting child-bearing
– Catholic country (95% reported)
– Opposition to programs that limit family
size
– Traditional beliefs and gender roles
• MOH capacity & Logistics
Intervention and Approach: BCC
•
Innovative films with Child
Spacing (CS) messages
•
Engaging religious and
traditional leaders
•
Birth Friendly Facilities
•
FP photocards for CHWs to
use in home visits
Intervention and Approach: Service Quality
• Supportive Supervision
of midwives
• Monthly community
outreach clinics
Contraceptive Knowledge and Prevalence Rates
Obrigada!
www.healthallianceinternational.org
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!
HTSP Activities in AME Region 2005
HTSP Activities in AME Region 2010
Source: A. Conde Aqudelo
et al., 2003.
Source: S. Rutstein, 2008.
Source: A. Conde
Aqudelo, RosasBermudez, 2005.
Source: A. Conde
Aqudelo, J. Belizan,
2000.
HTSP Design and Implementation Best Practices
•
•
•
•
Identify target audiences
Select evidence-based messages
Prepare provider-client family education materials
Select proven HTSP training materials
http://www.ibpinitiative.org/knowledge_gateway.php
• Train providers to educate and leaders to speak-out
www.esdproj.org
• Use e-Learning tools for continuous learning
http://www.globalhealthlearning.org/login.cf
• Provide FP services