Healthy Timing and Spacing of Pregnancies: A Family Planning Investment Strategy for Accelerating the Pace of Improvements in Child Survival

Healthy timing and spacing of pregnancies helps Figure 1: Under-5 Mortality Risk by Birth-to-Pregnancy women bear children at healthy times in their lives. Intervals from 52 Demographic and Health Surveys 3.5 Mothers and infants are then more likely to survive 2.97 and stay healthy. A U.S. Agency for International 3.0 Development (USAID) analysis found that if all birth- 2.5 2.22 to-pregnancy intervals were increased to 3 years, 2.0 1.81 1.49 1.6 million under-5 deaths could be prevented annu- 1.5 1.22 1.14 1.00 0.96 0.92 1.05 ally. This brief recommends three key programmatic 1.0 actions to strengthen family planning as an essential Risk Adjusted Relative 0.5 intervention for child survival. 0 <6 6–11 12–17 18–23 24–29 30–35 36–47* 45–59 60–95 96+ 1. Educate families on family planning’s role in Birth-to-Pregnancy Intervals Source: Rutstein, 2008 ensuring pregnancies occur at the healthiest *Ref Group times in a woman’s life. This helps avoid Figure 2: Child Undernutrition Risk by Birth-to-Pregnancy Intervals high-risk pregnancies. 1.4 1.30 1.25 1.12 1.16 Healthy times for a pregnancy are: 1.2 1.29 1.11 1.22 1.07 1.19 1.13 1.00 • At least 24 months after a live birth* – this 1.0 1.11 0.90 0.95 1.06 0.82 interval is consistent with the WHO/UNICEF 1.00 0.8 0.90 0.89 recommendation of breastfeeding for 2 years 0.82 • Between ages 18 and 34 0.6 • At least 6 months after a miscarriage 0.4 Adjusted Relative Risk Adjusted Relative 0.2 Stunted Underweight Multiple studies show that when families recognize 0 <6 6–11 12–17 18–23 24–29 30–35 36–47* 45–59 60–95 96+ that family planning supports maternal, newborn, Birth-to-Pregnancy Intervals and child health, family planning use increases Source: Rutstein, 2008 *Ref Group signifi cantly. Behavior change communication activities can help families understand that newborns Figure 3: Perinatal Mortality by Age of Mother and children are healthier with longer intervals Perinatal Mortality by Mother’s Age at Birth,Adolescent vs.Women 20–29 between births. A key message is “after a live birth, Bangladesh 2004 wait at least 24 months before attempting a preg- India 2005/2006 nancy”* (see Figures 1 and 2). Programs can also help families understand the risks for newborns when Ethiopia 2005 pregnancy occurs before age 18 (see Figure 3).** Mozambique 2003

*Report of a WHO Technical Consultation on Birth Spacing, Geneva, Switzerland, Senegal 2005 13-15 June, 2005, available at http://www.who.int/maternal_child_adolescent/ Age 20–29 documents/birth_spacing05/en/index.html Tanzania 2004 Age < 20 **WHO is reviewing evidence on pregnancy spacing and health outcomes. The Child Health Epidemiological Reference Group is reviewing evidence on fertility- 02 04 0 608 0100 related, high-risk pregnancies (high/low maternal age, closely spaced, high parity) Perinatal Mortality Rate and health outcomes. Findings will be disseminated when they become available. Source:WHO, Making Pregnancy Safer,Adolescent Notes, October, 2008. 2. Expand the mix of available contraceptives, Figure 4: Percentage of Children Alive and Not Undernourished including long-acting, reversible methods, by Duration of Preceding Birth-to-Conception Intervals to help couples effectively delay, time, 80% Alive and not undernourished 75% 71% space, and limit pregnancies to achieve 70% 63% 63% their fertility intentions. 60% 59% 52% 55% 48% 50% 43% 45% As child survival improves, parents recognize they 40% do not need 5–6 children to ensure that 2–3 survive 30% to adulthood; they often increase their use of family 20% planning to achieve their fertility intentions. 10% 0% <6 6–11 12–17 18–23 24–29 30–35 36–47* 48–59 60–95 96+ As a result, couples are also more likely to invest Birth-to-Pregnancy Intervals in the health and well-being of each child, and Source: Rutstein, 2008 *Ref Group more children survive and thrive (see Figure 4). As this behavior becomes the norm, birth rates further decline. Figure 5: Kenya Today and Tomorrow: 3. Enact policies to reap the benefits Double the Population but Not Many More Children 90.0 of the demographic dividend. Total 80.0 Population The demographic dividend is defi ned as the 70.0 60.0 Working Ages opportunity for rapid economic growth that is 15–64 associated with a change in age structure (the 50.0 increase in the working age population, the relative 40.0 decline in dependents – children or the elderly), 30.0 0–14 when coupled with economic policies that promote in Millions Population 20.0 Older 65+ job growth. This window of opportunity begins to 10.0 0.0 open when people start to live longer and have 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 fewer children than previous generations, and jobs Source: Making the Most of Kenya’s Demographic Change and Rapid Urbanization,World Bank, 2011. 2011 World are available for the increasing number of workers. Bank calculations based on United Nations, 2009,World Population Prospects

For example, in Kenya, the total fertility rate has fallen from 8.1 children in 1978 to 4.6 children in 2008. By 2030, the total number of children age 0–14 will only increase from 18 million to 25 million due to fertility decline, but the total population will double, and the working age population will more than double due to past decades’ high population growth rates (see Figure 5). Investments made now in key child survival interventions, including family planning, will yield immediate health benefi ts. By coupling these investments with policies supporting girls’ education and job creation, especially for women, countries like Kenya can be positioned to realize substantial economic growth. The demographic dividend yields benefi ts that can then be further invested in children’s health and well-being.

To learn more and view studies referenced in this document, visit http://transition.usaid.gov/our_work/global_health/pop/techareas/htsp/index.html.

Prepared by U.S. Agency for International Development (USAID), Bureau for Global Health, Offi ce of Population and Reproductive Health, Washington, DC 20523-3600. May 2012. (www.usaid.gov)