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SPACING BIRTHS, SAVING LIVES Ways to Turn the Latest Birth Spacing Recommendation Into Results by Donna Espeut, Ph.D., M.H.S

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SPACING BIRTHS, SAVING LIVES Ways to Turn the Latest Birth Spacing Recommendation Into Results by Donna Espeut, Ph.D., M.H.S SPACING BIRTHS, SAVING LIVES Ways to Turn the Latest Birth Spacing Recommendation into Results By Donna Espeut, Ph.D., M.H.S. Reproductive Health and HIV/AIDS Specialist THE NEW BIRTH SPACING RECOMMENDATION Development (USAID) recommends birth intervals of three years or longer and recently For many years, family planning experts believed published Birth Spacing: A Call to Action that a 24-month birth interval (the amount of (available at http://www.usaid.gov/pop_health/ time between the birth date of one child and pop/publications/docs/birthspacing.pdf). The the birth date of the next child) was adequate to document summarizes research by Rutstein and ensure healthy mothers and healthy children. others, and discusses important considerations However, recent findings by Shea Rutstein, for action. UNICEF also Ph.D.1 indicate that spacing New Recommendation recognizes the need to promote births at least 36 months (three longer birth intervals. As part of years) apart is even more Births should be spaced at its Integrated Early Childhood 2 beneficial. least 36 months (three Development initiative (which In his analysis, Rutstein years) apart to achieve focuses on the first three years examined the association greater improvements in of life), UNICEF plans to work between birth intervals and child survival (see footnote with USAID and other partners various child health and number 2). to develop an action framework nutrition outcomes, including that promotes birth intervals of perinatal, infant, and under-five mortality.3 The at least three years for optimal health and analysis was conducted using MEASURE nutrition outcomes in children. DHS+ data from 17 less-developed countries. This paper highlights some of Rutstein’s As a result of Rutstein’s study, international findings on birth intervals and discusses specific experts now recognize the need to promote steps that can be taken by PVOs and NGOs to birth intervals that are at least three years long. address this critical determinant of maternal and The United States Agency for International child health (MCH) and survival. 1 Dr. Shea Rutstein works for the MEASURE DHS+ Project at ORC Macro. MEASURE DHS+ assists developing countries in the collection and use of data to plan, monitor, and evaluate population, health, and nutrition programs. For more information about MEASURE DHS+, go to http://www.measuredhs.com. 2 There is some evidence (Conde-Agudelo & Belizan, 2000; Rutstein, 2000) that birth intervals longer than 5 years are associated with adverse maternal and child outcomes. International experts are currently debating whether the recommendation should be "at least 3 years" or "3-5 years". 3 Rutstein explored the effect of birth intervals while taking the following factors into account: sex of the child, birth order, mother's age at birth, survival of the preceding child, type of prenatal care provider, timing of prenatal care, number of prenatal tetanus vaccinations, urban/rural residence, mother's education, index of household wealth, type of person attending the delivery, wantedness of the child, and whether the birth resulted from contraceptive failure. Spacing Births, Saving Lives Figure 1: Under-Five Mortality According to Length of Preceding Birth Interval 3.0 2.5 2.0 1.5 1.0 Adjusted Relative Odds Ratio Relative Adjusted 0.5 0.0 < 18 18 - 23 24 - 29 30 - 35 36 - 41 42 - 47 48 - 53 54 - 59 60 + Duration of Preceding Birth Interval (in months) Adapted from Rutstein (2000) RECENT FINDINGS THAT HAVE more young children in the household IMPLICATIONS FOR CHILD HEALTH means more mouths to feed. Through birth spacing, families can reduce the PROGRAMMING number of young children in the Malnutrition is an underlying factor in household, resulting in less competition for more than half of all under-five deaths. food and other resources, and more care Rutstein found that the risk of chronic or and attention from the mother and other long-term malnutrition (also known as caregivers. stunting) decreases with longer birth Rutstein also observed a direct intervals. There are many possible association between birth intervals and explanations for this association. First, the risk of under-five mortality (see short birth intervals are associated with low Figure 1). Children who are born less than birth weight, which places the child at risk 24 months after the previous birth are for poor health and nutrition outcomes. almost two-and-a-half times more likely to Second, when children are born closely die by the age of five than children who together, older children usually end up are born 36–47 months after the previous getting weaned from breastmilk too early, birth. It is important to note that a which has negative consequences for their minimum birth interval of 24 months is nutrition and health. In general terms, not enough. According to Rutstein’s 2 Spacing Births, Saving Lives analysis, children born 24–35 months after spacing also has positive effects on the previous birth are still 41 percent more maternal health and survival. Adequate likely to die than children born 36–47 months birth spacing allows women to recover after the previous birth. Therefore, from the physical demands of pregnancy. extending the minimum recommended In doing so, it reduces the risk of poor birth interval from two years to three maternal and infant outcomes in future years really makes a difference in terms pregnancies. of child survival. The findings are also convincing for survival during the first year of life. Birth TRANSLATING THE NEW intervals of 36–47 months are associated RECOMMENDATION INTO RESULTS with the lowest risks of neonatal and infant Birth spacing falls within the broader issue mortality. Thus, in terms of maximizing of family planning. Family planning neonatal and infant survival, it appears that programs strive to provide women/couples a birth interval of 36–47 months is not too with the means to a) space their births or long, and it’s not too short. It’s just right. b) limit fertility (i.e., avoid having any more children). Both can lead to a reduction in NOT ONLY ARE LONGER BIRTH the average number of children per woman. INTERVALS OPTIMAL FOR THE CHILD, BUT MOST WOMEN HOW TO GOFROMRECOMMENDATIONS TO RESULTS WANT LONGER BIRTH INTERVALS. • Engage women, men, families, providers, and community leaders in dialogue. Educate them on the benefits of Rutstein found that the majority three-year birth spacing and the great risks of rapid of mothers in African countries childbearing, as well as on ways to access want birth intervals that are at information/services (on breastfeeding/LAM, abstinence, least 36 months long. In India, natural family planning, and other methods). where almost two out of three • Work with health planners and providers to ensure that women have births that are services are client-centered and of high quality. spaced less than 36 months • Educate policymakers and planners about the potential apart, almost one-half of for MCH and nutritional impact if more families chose to women prefer an interval longer space births three years apart. than that. Despite women’s preferences for longer birth intervals, the majority of births worldwide occur less There are many birth spacing program than 36 months after the previous birth. options. Regardless of the strategy, the Thus, there is a need to address factors that emphasis should be on empowering create the gap between women’s desire and women and their partners to make reality. informed choices about a temporary Rutstein’s study focused on child outcomes, contraceptive method (or combination of but other research has indicated that birth methods) that allows them to get the 3 Spacing Births, Saving Lives number of children they want, but in a way • Who makes the decisions regarding that is safest for both the mother and her sexual matters (such as family planning children (by spacing births at least 36 use) or the number and timing of months apart). This section presents five children? guiding principles to consider when • Is there an unmet need for family developing birth spacing strategies. They planning?4 If so, what is the unmet need are as follows: for spacing births versus limiting fertility? 1. Understand the context of fertility Are there variations by women’s age or behavior and sexual decisionmaking. other socio-demographic characteristics? 2. Involve household and community • What are the characteristics of women “power brokers” and decisionmakers. who use family planning? 3. Close the gap between the desire to • What role, if any, does child gender space and reality by addressing the preference play in a couple’s decision to precursors to change. use contraception? 4. Integrate birth spacing with other • What are women/couples doing (either activities. openly or secretly) to prevent pregnancy? (This should include an investigation into 5. Measure what is being done, and use traditional methods or practices intended the information to improve to prevent pregnancy.) programming. • What are the barriers that prevent women from spacing their births? 1. UNDERSTAND THE CONTEXT OF (Consider both individual-level factors FERTILITY BEHAVIOR AND SEXUAL such as the lack of sexual negotiation skills and higher-level factors such as the DECISIONMAKING quality of family planning services.) Access to and the availability of birth As an example, if you discover that men spacing methods are important issues to want more children than women do, the address, but they are not the only factors next steps would be to better understand that affect whether a woman spaces her why men want more children, then births. The following are examples of incorporate this information into birth issues to explore: spacing messages, strategies, and activities • What are the religious or cultural that specifically target men. beliefs/myths related to childbearing or There are a number of quantitative and sexually transmitted infections? qualitative tools available.
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