Healthy Timing and Spacing of Pregnancy (HTSP):
Moving Research into Best Practices and Programs
Maureen Norton, PhD
USAID
Extending Service Delivery Project
(ESD) End-of-Project and Knowledge
Exchange meeting
May 12, 2010
Nairobi, Kenya
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
Easy to Understand Evidence-Based HTSP Messages
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 breastfeeding
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
Percent of Births in Less Than 36 Months Since the Preceding
Birth, by Residence
On average, rural women appear to be slightly more likely to space their births less than 36 months apart.
Rural
Urban
100
90
80
Percent
70
60
50
40
30
20
10
20
Et
07
hi
op
ia
20
05
G
ui
ne
a
20
05
K
en
ya
M
ad
20
ag
03
as
ca
r2
00
4
M
al
aw
i2
00
N
4
ig
er
ia
20
R
08
w
an
da
20
Ta
07
nz
an
ia
20
08
U
ga
nd
a
20
06
Za
m
bi
a
20
07
DR
o
on
g
C
A
ng
o
la
20
07
0
Source: Demographic and Health Survey Statcompiler data for given years, including Angola MIS 2007. Rwanda Interim DHS 2007 and Tanzania AIS 2008 data are from
reports. Note: Data are not available in Kenya 2008 and Madagascar 2008 Preliminary Reports.
Trends in the Percent of Births in Less Than 36 Months Since the
Preceding Birth, 2005–2025
100
80
60
Percent
40
60
40
Ethiopia
Malawi
Kenya
20
Madagascar
Rwanda
Zambia
Uganda
0
Tanzania
0
20
Percent
80
100
Trends are generally declining, with greatest declines in Guinea, Madagascar, Malawi, and Kenya.
2005
2010
2015
2020
2025
2005
2010
2015
2020
2025
Year
60
40
20
Guinea
Nigeria
0
Percent
80
100
Year
2005
2010
2015
Year
2020
2025
Source: Demographic and Health Survey Statcompiler data for given
years. Rwanda Interim DHS 2007 and Tanzania AIS 2008 data are
from reports. Note: Nigeria 1999 data were not included due to data
irregularities. Insufficient data points to allow for trends to be
constructed for Angola and Democratic Republic of Congo.
Percent of Women Ages 20–24 Who Gave Birth
by Age 15 and by Age 18
The percent of women who are mothers by 18 is much higher compared with those 15 and under.
60
50
Percent
40
35.2
34.1
33.6
31.3
29.1
30
28.4
27.7
23.3
22.7
20
10
6.4
4.6
4.4
4.0
6.5
5.4
2.7
6.7
4.0
3.4
1.1
20
07
03
Source: Demographic and Health Survey report data for given years.
Note: Data are not available in Angola MIS 2007, Tanzania 2008 AIS, or Kenya 2008 and Madagascar 2008 Preliminary Reports.
w
an
R
en
y
K
By age 18
da
a
20
20
0
R
D
o
C
on
g
ig
er
ia
N
7
20
08
05
20
Et
hi
op
ni
a
nz
a
Ta
By age 15
ia
20
20
M
ad
ag
as
c
ar
m
bi
a
Za
04
04
7
20
0
00
4
aw
i2
M
al
U
ga
n
da
20
06
0
Percent of Unmet Need for Family Planning Among Women Ages
35-49, By Residence
Unmet need among rural women is substantially higher than among urban women, with the exception of
DR Congo and Nigeria.
60.0
50.0
46.4
Percent
40.0
32.5
30.1
27.7
30.0
22.5
20.0
18.1
17.6
20.0
20.0
20.7
25.1
20.5
19.819.9
22.5
30.0
24.7
15.6
12.9
11.4
10.0
20
03
ad
ag
as
ca
r2
00
4
M
al
aw
i2
00
4
N
ig
er
ia
20
08
Ta
nz
an
ia
20
04
U
ga
nd
a
20
06
Za
m
bi
a
20
07
K
en
ya
20
05
Et
h
io
pi
a
20
05
ui
ne
a
G
M
D
R
C
on
g
o
20
07
0.0
Urban
Rural
Source: Calculated from Demographic and Health Survey datasets for given years. Note: Angola MIS 2007, Rwanda Interim DHS 2007, and Tanzania AIS 2008 data
are not available. Data not available in Kenya 2008 and Madagascar 2008 Preliminary Reports.
HTSP Design and Implementation of 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
Caroline S. Crosbie, Senior Vice President
Pathfinder International
Extending Service Delivery Project (ESD) End-of-Project and
Knowledge Exchange meeting
May 12, 2010
Nairobi, Kenya
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 Delaying & Spacing
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
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
Impact of joint decision making on Delaying & Spacing
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
A Country’s Agonizing Birth
Timor-Leste
Independent since 2002
www.healthallianceinternational.org
Chelsea Smart, USAID
Extending Service Delivery Project (ESD) End-of-Project and Knowledge
Exchange meeting
May 12, 2010
Nairobi, Kenya
TIMOR-LESTE
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
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 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