Healthy Timing and Spacing of Pregnancy

A Prevention Strategy to Enhance the Health of Women, Infants, and Newborns

Objectives

• Bring to your attention the linkage between pregnancy timing and spacing & maternal, newborn and child health outcomes

• Share key findings that support the linkage• Present key components of operationalizing

HTSP

Healthy timing & spacing of pregnancy (HTSP)

• Previous birth spacing recommendations refer to when to give birth.

• HTSP is about pregnancy spacing: when to become pregnant – rather than when to give birth.

• HTSP recommendations help women and couples make informed decision about delay and timing and spacing of pregnanciesfor the healthiest outcomes.

• Recommendations are evidence-based.

The Evidence

• USAID sponsored a total of six studies: five meta analyses and SLRs, and one 17-country analysis– > 190 studies; – 20-30 years of data

• Objective: to assess the effects of pregnancy spacing on maternal and child health outcomes

• Evidence review by a panel of 35 WHO experts.

o One SLR & meta analysis: maternal and perinatal outcomes (77 studies; covering 30 years of data from 1966-2004)

o One study: miscarriage/abortion & next pregnancy outcomes (18 countries; >250,000 women whose previous pregnancy resulted in abortion)

o One SLR : maternal and child nutrition outcomes (33 studies; prospective, cross sectional, case control)

o One study in Matlab, Bangladesh: maternal, infant and child outcomes (outcomes of >150,000 pregnancies; covering 20 years of data from 1982-2002)

o One SLR and meta-analysis: infant and child outcomes (65 studies)

o One 17-country analysis of DHS findings: neonatal, infant and under-five mortality

The Studies

Birth-to-Birth and Birth-to-Pregnancy Intervals

(24 months) (9 months)

Birth Next pregnancy

Birth

Birth-to-Pregnancy IntervalTime period between live birth

and next pregnancy

Birth-to-Birth IntervalTime period between two live births

DEFINITIONS: INTERVALS

A 24 month birth-to-pregnancy interval is the approximate equivalent of a 33 month birth-to-birth interval.

0

0.4

0.8

1.2

1.6

2

2.4

2.8

3.2

3.6

<6 6 to 11 12 to 17 18 to 23 24 to 29 30 to 35 36 to 47 48 to 59

Risk (odds ratio)

Birth-to-Pregnancy Interval (months)

MiscarriageLow Birth WeightMaternal DeathPre-term Birth

Pregnancy Spacing: BTP Intervals and Relative Risk of Adverse Maternal and Perinatal Outcomes

Sources: Conde-Agudelo, 2000, 2005; and DaVanzo et al, 2007

0

0.5

1

1.5

2

2.5

3

3.5

4

<6 6 to 11 12 to 17 18 to 23 24 to 29 30 to 35 36 to 47 48 to 59

Mortality Risk

Birth-to-Pregnancy Interval (months)

InfantNeonatalEarly Neonatal

Pregnancy Spacing: BTP Intervals and Relative Risk of Neonatal and Infant Mortality

Source: Rutstein, 2008

Pregnancy Spacing: BTP Intervals and Relative Risk of Under Five and Child

Mortality 2.94

2.2

1.51

Source: Rutstein, 2008

Key Finding: Too Short Pregnancy Intervals are Associated with Multiple Adverse Outcomes

Perinatal/Infant Outcomes:• Pre-term birth• Low birth weight• Small size for

gestational age• Newborn/infant

mortality

Maternal Outcomes:• Maternal mortality• Induced abortion• Miscarriage

The technical experts concluded:

That after a live birth, women and couples should wait at least 24 months before trying to become pregnant again.

That after a miscarriage or induced abortion, women and couples should wait at least 6 months before trying to become pregnant again

Pregnancy Timing: Early Age Pregnancy

Source: A. Conde Agudelo et al., 2003.

20-24

Recommendations from WHO, UNICEF and UNFPA on early age pregnancy

• Delay first pregnancy until at least 18 years of age.

Kenyan mother, 2006 Mike Wang, Courtesy of Photoshare

Source: UNICEF, Facts for Life 3rd edition, New York, United nations Children’s Fund , 2002; WHO/UNFPA Pregnant Adolescents: Delivering on Global Promises of Hope, WHO, 2006

Source: Stover J, J Ross 2009

Pregnancy Timing: Late Age Pregnancy & the Risk of Mortality Compared to Pregnancy at ages 20-24

8

7

6

5

4

3

2

1

15 -19 20 - 24 25-29 30-34 35-39 40-49

HTSP Concept

HTSP • Helps women

– space pregnancies – better time pregnancies

• so they are becoming pregnant and giving birth when it is healthiest and safest for mother and child.

Rationale for HTSP

• FP has made progress in helping women avoid unintended pregnancies. But, focus has been on lowered fertility (limiting and smaller family size)

• HTSP emphasizes FP’s role in achieving healthy fertility – and healthy outcomes for mother and baby

• The focus on healthy fertility encourages couples to use FP - to time and space pregnancies

• Effective entry point to revitalize FP in sensitive settings, due to its focus on improved mother/child health

Family Planning : Critical for HTSP

Improved access to family planning is essential for HTSP.

HTSP’s “healthy fertility” emphasis may make FP more acceptable.

HTSP helps to better link FP and other services such as MNCH, ANC, PPC, PAC and Youth Friendly Services

Operationalizing HTSP

• HTSP should be integrated at multiple levels:–National–Facility–Community

To ensure that women and couples can effectively practice HTSP.

At the National level

Include HTSP in FP, RH, MCH, PAC and HIV/AIDS guidelines and protocols

Integrate into pre- and in-service training for health workers. Produce range of IEC materials on HTSP for client and

community education Select, integrate and monitor HTSP indicators for HMIS. Promote improved collaboration among FP, MCH, nutrition,

HIV/AIDS and other services for women and children in promoting HTSP,

Ensure ongoing and adequate supplies of FP commodities.

At the Health Facility Level Expand the number of

service delivery points that provide HTSP information and FP

Promote HTSP client education by including it in any facility-based health education or counseling as appropriate

Strengthen referrals between relevant services

At the Community Level Raise awareness and gain support of community

leaders for HTSP and FP

Engage the community in discussions and provide information through the media, meetings, schools, churches/mosques, the workplace, markets and other venues.

Involve community health workers, CBD agents, peer educators, and other community level workers (agriculture, micro-enterprise, water and sanitation, malaria, etc)

Annual Global Burden of Disease

• >500,000 maternal deaths (70,000 abortion-related; 60,000 eclampsia related)

• 8 million women suffer complications

• 14 million adolescent pregnancies

• 4 million newborn deaths (28% linked to pre-term births)

• 18 million LBW infants (98% in developing countries)

HTSP: A Small Change that Produces Big Results

• Reducing closely spaced pregnancies.

• Timing pregnancies at the best age possible.

• Contributing to the healthiest outcomes for mothers, babies, families and communities.

Where we stand:Maternal and Child Health in (Your Country)

This is an optional slide for advocacy purpose.

What can we do?Implementing HTSP in (Your Country)

• What opportunities and mechanisms exist for implementing this simple, yet life-saving approach?

CONCLUSION: International Support for Improved MNCH

Endorsed by 180 nations, ICPD called for the following by 2015:• A 75% reduction in maternal mortality by 2015 (compared to 1990 levels) • Infant and under five mortality should decline to below 35 per 1,000 and 45 per 1,000 respectively

The U N Millennium Declaration, commits nations to reduce extreme poverty and achieve specific goals by 2015:• MDG Goal 4 is to reduce child mortality, specifically reduce by two thirds, the under-five mortality rate• MDG Goal 5 is to improve maternal health, specifically by reducing the maternal mortality ratio by 75% and achieving

universal access to reproductive health care.

The US Global Health Initiative (GHI) will invest $63 billion to improve the health of women, newborns and children. The GHI aims to:

• Reduce maternal mortality by 30% in assisted countries thus saving the lives of 360,000 women• Reduce under 5 mortality by 35% in assisted countries, saving the lives of 3 million children. including 1.5 million

newborns, • Improve access to family planning and reproductive health to:

– increase contraceptive prevalence to 35%;– prevent 54 million unintended pregnancies;– reduce to 20 percent the number of first births by women under 18.

Next StepsWe know what works to meet

these goals.

We know family planning saves women’s and children’s lives.

We must muster the political will to do so.

Acknowledgements

We would like to acknowledge • The Extending Service Delivery Project/Pathfinder

International• Fill in your acknowledgements

Thank you!!!

from the children of the world