1. Optimal Birth Spacing: Improving Maternal and Child Health Outcomes International Best Practices Conference Agra, India September 2003 Presenters: Cathy Solter – CATALYST Consortium Bill Jansen – Intrah Rekha Masilamani – Pathfinder India State-of-the-Art Family Planning & Reproductive Health Services

2. Optimal Birth Spacing Session Goals  To present the latest research findings on the benefits of spacing birth for at least 3 years  To discuss CATALYST’s approach to integrating birth spacing messages into health and non-health programs  To present the issue of unmet need for birth spacing  To share the results of the focus group discussions from India on the practice of birth spacing

3. Optimal Birth Spacing: Quantitative Research Findings Cathy Solter CATALYST Consortium State-of-the-Art Family Planning & Reproductive Health Services

4. Research on Optimal Birth Spacing

5. Risk of Neonatal, Infant and Under-five Mortality According to Birth Intervals: 17 DHS Countries Source: Rutstein, Shea, “Effects of Birth Interval on Mortality and Health: Multivariate Cross- Country Analysis, MACRO International, 2002. Birth Interval (months )

6. Stunting and Underweight for Young Children Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to USAID, July 27, 2000.

7. Risk of Maternal Mortality by Interpregnancy Interval Source: Conde-Agudelo, 2 nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

8. Risk of Infant Mortality According to Birth Intervals for Selected Countries in Asia Adjusted odds ratio Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to CATALYST Consortium, October 2002

9. Adverse Perinatal Outcomes by Interpregnancy Interval Source: Conde-Agudelo, 2 nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

10. Risk of Maternal Morbidities by Too Long Interpregnancy Interval Source: Conde-Agudelo, 2 nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

11. In India, if no births occurred before 36 months of a preceding birth:  Infant Mortality Rate would drop 32%  Under Five Mortality Rate would drop 31%  Deaths to children under five years of age would fall by 728,000 annually Source: Rutstein 2002.

12. Infant Mortality Rates with Existing Birth Intervals and Minimum Intervals of 24 and 36 months, India Existing Min. 24 mos. Min. 36 mos.

13. Under Five Mortality Rates with Existing Birth Intervals and Minimum Intervals of 24 and 36 months, India ExistingMin. 24 mos. Min. 36 mos.

14. Implementing Best Practice Findings  Birth spacing for 3 years or longer provides substantially more health and non-health benefits than the previously recommended 2 year interval.  Intervals of 3 years or longer result in: ▸ Best infant / child outcomes ▸ Lower perinatal, neonatal, infant mortality ▸ Lower perinatal stunting / low birth weights ▸ Fewer maternal deaths  There is a need to revisit birth spacing as a central primary health concept.  Taking an integrated approach through health and non-health programs empowers women and saves lives

15. The Underserved Population of Birth-Spacers: Unmet Need for Birth Spacing William H. Jansen, PhD Prime II Project Intrah University of North Carolina Chapel Hill

16. Findings on the Characteristics of Demand for Spacing  Among all MWRA, demand for spacing is substantial : ▸ Ranging from about 1/3 to 3/4 of total FP demand in 14 of 15 countries examined.  Spacing is, by far, the main reason for FP demand among MWRA who are 29 years or younger: ▸ Ranging from about 2/3 to over 9/10 of total FP demand in 12 of 15 countries examined.

17. Portion of Total Demand for FP Due to Spacing Among MWRA < 29 Years

18. Demand for Spacing by Age Cohort and Parity As portion of total FP Demand Uttar Pradesh, India, 1999

19. Portion of total FP demand for spacing by age cohort and parity Uttar Pradesh, India (1999)

20. Frequency at which FP Demand is Met Varies for Spacing and Limiting  In 12 of the 15 countries examined, FP need for limiting is met at a higher rate than the frequency of of the demand for limiting appears within the general MWRA population.  In the same 12 countries, FP need for spacing is met at a lower rate than the frequency of the demand for spacing appears within the MWRA population.

21. Probability Demand for Spacing and Limiting Will Be Met (distance from a value of 1)

22. Summary of Results  Demand for Spacing is substantial  The vast majority of demand for any form of FP services among women < 29 years is due to a demand to space births  There is unmet need for spacing among low-parity, young women (including delaying first birth)  In many countries, the unmet FP need for limiting is satisfied more frequently than that for spacing  The greatest opportunity to increase general FP use in the future lies in meeting the needs of spacers.

23. Optimal Birth Spacing: Focus Group Discussions Findings Rekha Masilamani Pathfinder, India

24. Results from Focus Group Discussion on Optimal Birth Spacing Overview of the Focus Groups  Conducted in 4 countries—India (34), Pakistan (40) Peru (24), and Bolivia (24) and Egypt (51)  A Total of 122, with close to 1000 people participating in these focus group sessions.  Target Audience: ▸ Women who have spaced, ages 15-19, 20-30 yrs ▸ Women who have not spaced, ages 15-19, 20-30 yrs ▸ Male partners, ages 15-19, 20-30 yrs ▸ Health providers ▸ Mothers-in-law- (India, Pakistan, Egypt)

25. Discussions Topics  Individual level: knowledge, beliefs and practices in birth spacing.  Cultural level: beliefs and norms regarding birth spacing.  Women (mothers-in-law included)and men’s perception of the quality of service in birth spacing.  Providers perception of mother’s behaviors and beliefs in birth spacing.  Credible sources of information for men, women and providers regarding B.S.

26. Reasons for Spacing Birth India  Economic: relief from financial burdens surfaced as a driving force for spacing births  Health & well being of the mother and child:The overall physical and mental well- being of the mother, new born, husband and other children living in the household was regarded as a major benefit of birth spacing

27. Key Barriers to Adoption of Birth Spacing, India  Lack of decision-making powers among the women due to the patriarchal structure of the family that gives the man the reins of power  Lack of knowledge of methods available  Inaccurate information and/or misconceptions about contraceptives: negative word of mouth or bad personal experiences

28. Key Barriers to Adoption of Birth Spacing, India  Religious prohibitions dictated by certain scriptures have led to believers not subscribing to spacing  Mothers-in-laws influence: Exert strong influence in the couple’s reproductive behavior  Fear of social disapproval

29. Possible Programmatic Approaches Based on FGD Findings Address Barriers and Strengthen Current Support for OBS  Improve family planning counseling ▸ Provide credible and comprehensive information regarding FP methods Access to information Dispel misconceptions ▸ Involve men in the counseling session  Media Campaign ▸ Disseminate information on the benefits of Birth Spacing ▸ Solicit community support for Birth Spacing  Empowerment of couples to decide on their reproductive choices