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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
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