Impacts of Healthy Birth Spacing in Jordan Photo Credit: © Othman Al Othman © Credit: Photo

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The Impacts of Healthy Birth Spacing in Jordan Photo credit: © Othman Al Othman © credit: Photo

May 2013 - Robina Issa/Studio Higher Population Council

Presentation Outline

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Birth Spacing and the Qur’an WHO Recommendations for Birth Spacing

Recommendation for spacing after a live birth

 After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, perinatal, and infant outcomes. In simple terms, couples are encouraged to wait to attempt a new pregnancy until after the 2nd birthday of their last child.

Recommendation for spacing after a miscarriage

 After a miscarriage, the recommended minimum time to wait to attempt another pregnancy is at least six months in order to reduce the risk of adverse maternal and perinatal outcomes.

World Health Organization (WHO). 2006. Report of a Technical Consultation on Birth Spacing, Geneva June 13–15, 2005. Geneva: WHO, Department of Making Pregnancy Safer and Department of Reproductive Health and Research. Definitions Recommended Birth-to-Birth and Birth-to-Pregnancy Intervals

Birth-to-Birth Interval Period between two live births

Birth-to-Pregnancy Interval Period between a live birth and the next pregnancy

24 months 9 months A 24-month birth-to-pregnancy interval is the approximate equivalent of a 33-month birth-to-birth interval. Presentation Outline

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Why is Birth Spacing Important?

When pregnancies are too close together

 Newborns can be born too soon, too small, or with a low birth weight

 Infants and children may not grow well and are more likely to die before age five years old

 Mothers may die in childbirth

five years years old five

infants under under

Who Benefits from from Benefits Who Healthy Birth Spacing? children Newborns, Newborns, Mothers Men Communities

Photo credit: © Othman Al-Issa/Studio Robina Reduces theriskReduces Watertown,Pathfinder MA: International,Project. ESDUSAID Pocket A Guide for Health Practitioners, Program Managers, andCommunity Leaders ( Extending Service Delivery periods for longer of breastfeeding benefits the substantial health Allows toexperience children young   Under Age Five Age Under Children and Infants, Newborns, to Benefits under under andchildren infants, newborns,for Death conditions underweightor stunting populations, for Pre gestational age, and, in some some in and, age, gestational term births, low birth weight, small size small weight, birth low births, -term age five

ESD) Project. ESD) Project. 2006. of Healthy Timing andSpacing Pregnancies,of

Helps mothers avoid pregnancy-induced high blood pressure and associated complications like preeclampsia, obstructed and prolonged labor, iron-deficiency anemia, and maternal death

Provides mothers with enough time before becoming pregnant again to focus on their newborns, husbands, and other children

Extending Service Delivery (ESD) Project. 2006. Healthy Timing and Spacing of Pregnancies, A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders. Watertown, MA: Pathfinder International, USAID ESD Project. Allows best interests best making from satisfaction Contributes to a chooses couple emotionallyand for their next child, if Delivery ( Extending Service Delivery well Helps Community Leaders Pregnancies, Pocket A Guide for Health Practitioners, ProgramManagers, and Benefits to to Fathers Benefits - being being fathers safeguard fathers safeguard fathers fathers time decisions family’s the decisions in that are . Watertown, MA:Pathfinder International, USAID ESD Project. and their children wives of ESD) Project.ESD) 2006.

to father’s sense of sense father’s supporting his his supporting have one to plan financially plan financially to Healthy Timing andSpacing of the health and health the wife in

the the

Photo credit: Haider Nakkash Benefits to Communities

Benefits communities because it reduces the incidence of death and illness among mothers, newborns, infants, and children

In doing so, it can contribute to poverty reduction and improve a community’s quality of life

- Mohammad credit: Photo

Khawaja Extending Servive Delivery (ESD) Project. 2006. Healthy Timing and Spacing of Pregnancies, A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders. Watertown, MA: Pathfinder International, USAID ESD Project. Presentation Outline

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Under mortalityPostneonatal Neonatal mortality Children’s Lives on Spacing Birth of Unhealthy Impact -five mortality

Photo credit: Jennifer Hayes Impact on Neonatal Mortality

Neonatal Mortality (Weeks 2–4)

3.5 3 2.5 2 1.5 1 0.5 Adjusted Odds Odds Adjusted Ratio 0 <15 15–20 21–26 27–32 33–38 39–44 45–56 57–68 69–104 105+ Interbirth Interval

N = 17 p < .01 Rutstein, S. 2005. “Effects of Preceding Birth Intervals on Neonatal, Infant, and Under-five Years Mortality and Nutritional Status in Developing Countries: Evidence from the Demographic Health Surveys.” International Journal of Gynecology and Obstetrics 89: S7–S24. Impact on Postneonatal Mortality

Postneonatal Mortality (Weeks 5–52)

3.5 3 2.5 2 1.5 1 0.5 Adjusted Odds Odds Adjusted Ratio 0 <15 15–20 21–26 27–32 33–38 39–44 45–56 57–68 69–104 105+ Interbirth Interval

3.5

2.5

1.5

0.5

Adjusted Relative Odds Ratio 0 <18 18–23 24–29 30–35 36–41 42–47 48–53 54–59 60+ Duration of Preceding Birth Interval (Months)

Rutstein, S. 2005. “Effects of Preceding Birth Intervals on Neonatal, Infant, and Under-five Years Mortality and Nutritional Status in Developing Countries: Evidence from the Demographic Health Surveys.” International Journal of Gynecology and Obstetrics 89: S7–S24. Presentation Outline

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Relationship between Birth Intervals and Health Outcomes in Jordan

Neonatal mortality

Photo credit: © Karen Kasmauski/Corbis

Infant mortality

Under-five mortality

Relationship between Birth Spacing and Neonatal Mortality

Mortality Rate by Length of Birth Interval 30 24 25 22

20 16 15 11 9 10 Deaths Deaths 1,000 per 5

0 <24 months 24–35 months 36–47 months 48–60 months >60 months

Birth Interval

Department of Statistics (Jordan) and ICF Macro. 2010. Jordan Population and Family Health Survey 2009. Calverton, MD: Department of Statistics and ICF Macro. Additional analysis provided by Dr. Ali Arbaji, USAID/Amman. Relationship between Birth Spacing and Infant Mortality

Mortality Rate by Length of Birth Interval

40 35 35 000 ,

1 30 28 24 25 19 20

15 11

Deathsper 10 5 0 <24 months 24–35 months 36–47 months 48–60 months >60 months

Birth Interval

Mortality Rate by Length of Birth Interval 45 41 40 35 32 33 30 25 23

20 15 15

Deaths Deaths 1,000 per 10 5 0 <24 months 24–35 months 36–47 months 48–60 months >60 months

Birth Interval

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Trends in Length of Birth Interval

49.8 50 44.3 41.1 41.9 40 37.4 33.5 33.2 32.7 31.3 29.3 29.1 30 26.2 24.9 26.3 20 18.8

10 Percentage of Births 0 < 24 mos. 24–35 mos. 36+ mos. Months Since Preceding Birth 1990 1997 2002 2007 2009

Department of Statistics (Jordan) and ICF Macro. 2010. Jordan Population and Family Health Survey 2009. Calverton, MD: Department of Statistics and ICF Macro. Trends in Median Birth Interval

35 31 31 30 30 26 24

irth 25 B 20

Months Since 10 Preceding

0 1990 1997 2002 2007 2009

Department of Statistics (Jordan) and ICF Macro. 2010. Jordan Population and Family Health Survey 2009. Calverton, MD: Department of Statistics and ICF Macro. Current Birth Intervals

35 33.2

24.9 25 <2 years 20 2–3 years 16.2 15.5 3–4 years 15 4–5 years 10.2 10 5+ years

5 Percentage of Births 0 Years Since Preceding Birth

Department of Statistics (Jordan) and ICF Macro. 2010. Jordan Population and Family Health Survey 2009. Calverton, MD: Department of Statistics and ICF Macro. Median Birth Intervals by Background Characteristic

Characteristic Related to Median Characteristic Not Related to Birth Interval Median Birth Interval Characteristic MBI Characteristic MBI Characteristic MBI Characteristic MBI Age Wealth Quintile Region Education 15–19 18.7 Lowest 28.0 Central 31.5 None 31.6 20–29 24.0 Second 29.4 North 31.0 Elementary 28.4 30–39 35.8 Middle 31.7 South 30.4 Preparatory 33.8 40–49 48.7 Fourth 34.2 Badia Area Secondary 30.7 Birth Order Highest 38.0 Badia 27.9 Higher 32.0 2–3 26.4 Survival of Preceding Other 31.7 Sex of Preceding Child Child 4–6 37.8 Residence Living 31.6 Male 31.7 7+ 38.0 Urban 31.7 Dead 21.7 Female 30.7 Rural 29.6

Department of Statistics (Jordan) and ICF Macro. 2010. Jordan Population and Family Health Survey 2009. Calverton, MD: Department of Statistics and ICF Macro. Presentation Outline

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Impacts of Healthy Birth Spacing

Anticipated Infant Deaths 10,000 9,096 9,000 8,000 7,239 8,284 7,000 6,219

6,000 5,012 6,593 5,000 5,664

4,000 4,564 4,832 3,000 3,846 3,304 2,000 2,663

Number of Deaths 1,000 0 2010 2015 2020 2025 2030 2035 2040 No Change No Births < 2 Years No Births < 3 Years

Projections computed using the DemProj Model of the Spectrum System of Policy Models. Infant Lives Saved through Healthy Birth Spacing

Scenario Total Number of Infant Lives Saved Deaths (2010–2040) (Difference from No Change Scenario) No Change 211,329 0 No Births <2 Years 192,460 18,869 No Births <3 Years 112,266 99,064

Projections computed using the DemProj module of the Spectrum Model, Futures Group. Presentation Outline

 Birth spacing and the Qur’an

 WHO recommendations and definition of intervals

 Benefits of healthy birth spacing

 Consequences of unhealthy birth spacing

 Relationship between birth intervals and health outcomes in Jordan

 Trends in birth spacing in Jordan

 Impacts of increasing birth intervals in Jordan

 Interventions to improve birth spacing in Jordan Interventions

Policy Environment

 Conduct advocacy with decisionmakers to gain their support of related policies and programs. Interventions

Education

 Educate married women about the benefits of waiting at least 24 months before becoming pregnant again after a birth, and the health consequences of short birth intervals.

 Educate engaged and newly married couples about the benefits of healthy birth spacing and use of modern family planning methods.

 Educate all family members (e.g., husbands, mothers, mothers-in-law, children) about the benefits of healthy birth spacing.

 Engage the media and civil society to help raise the awareness of the benefits of birth spacing. Interventions

Service Delivery

 Train healthcare providers on the benefits of healthy birth spacing and encourage them to counsel women of reproductive age on those benefits.

 Counsel women to shift to more effective modern family planning methods to avoid closely spaced births.

 Integrate and provide services to assist mothers in attaining healthy birth spacing.

 Allocate sufficient human and financial resources to ensure that women and men’s contraceptives of choice are available when needed.

Summary

More than one-half of all births in Jordan occur less than three years after the previous birth.

Neonatal, infant, and child mortality in Jordan is closely associated with the length of birth intervals, and extending the length of birth intervals will save the lives of infants and children.

Encouraging women to space births at least three years apart will improve maternal and child health and support healthy childhood development.

Thank You!

Higher Population Council