1. Optimal Birth Spacing: Improving Maternal and Child Health Outcomes Dr. Taroub Harb Faramand-CATALYST Consortium Dr. Issakha Diallo, Advance Africa State-of-the-Art Family Planning & Reproductive Health Services MAQ Mini-University USAID-Washington DC May 12, 2003

2. Session Objectives 1. Present the latest quantitative and qualitative research findings on the impact of Optimal Birth Spacing on maternal and child health outcomes 2. Present CATALYST’s approach to integrating birth spacing messages into health and non- health programs 3. Share with the participants Advance Africa’s approach of using health benefits of Optimal Birth Spacing to revitalizing FP programs in Sub-Saharan Africa 4. Discuss and share experiences on program integration of Optimal Birth Spacing messages

3. Stunting and Underweight for Young Children Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Macro International

4. Risk of Infant and Child Mortality by Birth Intervals Source: Rutstein, Shea, Effects of Birth Interval on Mortality and Health: Multivariate Cross- Country Analysis, Macro International.

5. Adjusted Odds Ratio of Low Birth Weight by Interpregnancy Interval Source: Zhu et al, Effect of Interval Between Pregnancies on Perinatal Outcomes, The New England Journal of Medicine, 25 February 1999 Source: Conde-Agudelo, Agustine “Second Champions Meeting on Birth Spacing” The CATALYST Consortium May 2002

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

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

8. Risk of Maternal Morbidity by Interpregnancy Interval (cont’d) Source: Conde-Agudelo, 2 nd Champions Meeting on Birth Spacing, CATALYST Consortium, Washington DC, May 2, 2002

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

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

11. The Potential Impact of OBS

12. If Women Spaced Births for 3 Years… INDIA  Infant mortality would drop 29%  Under age five mortality would drop 35%  Deaths to children under age five would fall by 1,434,000 annually EGYPT  Infant mortality would drop 35%  Under age Five mortality would drop 45%  Deaths to children under age five would fall by 109,000 annually  Fertility rate would potentially drop by 8%

13. Non-Health Benefits of Family Planning**  Provides economic and health benefits  Can improve sexual life (satisfaction), partner relations, and family well-being  Family planning users are more likely to take advantage of job opportunities  Family planning helps women meet practical needs and is necessary to help meet strategic need (gender equity) ** Synthesis of finding from the Women’s Studies Project, FHI 1998

14. Results from Focus Group Discussion on Optimal Birth Spacing Overview of the Focus Groups  Conducted in 4 countries—India, Pakistan, Peru, and Bolivia  Egypt—on-going  Close to 1000 participants in 122 focus group discussions  Audience: ▸ Spacers and non-spacers, ages 15-19, 20-30 yrs ▸ Male partners, ages 15-19, 20-30 yrs ▸ Health providers ▸ Mothers-in-law (India, Pakistan, Egypt)

15. FGD Common Findings Reasons for Spacing 1. Economic Consideration—relief from financial burdens surfaced as a driving force for spacing births 2. 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

16. FGD Common Findings Reasons for NOT Spacing (Barriers) 1. Inaccurate information and/or misconceptions about contraceptives 2. Gender Inequity ▸ Women lack power in making decisions concerning their reproductive choices ▸ Husbands having the final say in spacing of children 3. Mothers-in-laws influence (India and Pakistan) ▸ Exert strong influence in the couple’s reproductive behavior

17. 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

18. Programmatic Response: Integration with Health Programs RH/FP IMCI/MCH Neonatal Health HIV/AIDS/Infectious Diseases PAC BCC Female Health Volunteers Peer Educators Community-Based Distributors (CBDs) Health Programs Clinical Programs Non-clinical Programs

19. Programmatic Response: Integration with Non-Health Programs  Literacy  Democracy & Governance  Microcredit/microenterprises  Woman’s empowerment programs  Male involvement programs

20. When Women have Ongoing Social Support, They are More Apt to Continue Family Planning Use: Change in Contraceptive Status 1994-1996 Source: Johns Hopkins University 2000

21. Implementing Best Practice Findings  Birth spacing for 3 years of longer provides substantially more health and non-health benefits than the previously recommended 2 year interval.  Intervals of 3 years or longer result in: ▸ Better infant / child outcomes ▸ Lower perinatal, neonatal, infant, and child mortality ▸ Lower stunting and low birth weights ▸ Lower maternal morbidities ▸ 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 couples and saves lives.

22. Advance Africa Program Strategy Family Planning as a Health Intervention Client (Government, NGO, Private Sector) High QualityFP/RH Service Delivery Repositioning Inputs Policy, Partnering, Advocacy & Demonstration Projects (MTCT,VCT, FAWE,Partage, Zimbabwe) Service Delivery T.A. Inputs The ACCOMPLISH Model (Mozambique, Congo, Senegal, Angola, Zimbabwe)

23. Median lengths of actual and preferred Birth Intervals in Sub-Saharan Africa Source: Population Reports, Volume XXX, Number 3, Summer 2002 (11)

24. African Birth Interval Preferences  Mothers in Sub-Saharan African countries would prefer longer birth intervals.  Few African mothers prefer birth intervals shorter than 36 months.  Preferred birth intervals are usually longer in East and Southern Africa than in West and Middle Africa. Source: Shea Rutstein, PhD, Measure/DHS+,Macro International, Inc.

25. Change in Total Fertility Rate with Minimum Birth Interval of 36 Months

26.  Analysis of DHS data from 1990 to 1997 in 27 countries has demonstrated a threshold effect in the relation between temporary method use length of birth interval.  Enabling women to realize their birth interval preferences would result in substantial decreases in both infant and child mortality and fertility. Summary OBI research results(1) Source: Population Reports, Volume XXX, Number 3, Summer 2002 (11)

27.  Avoiding short birth intervals would lower both fertility and infant and child mortality by additional substantial amounts.  When children are weaned too soon, their growth suffers, they are more likely to suffer from diarrheal disease, and skins infections, and they are thus greater risk of dying Source: Shea Rutstein, PhD, Measure/DHS+,Macro International, Inc. Summary OBI research results(2)

28. Suggested Strategies to help couples space Births  Increase access to good-quality contraceptive services and full range of methods,  Encourage community campaigns that speak about needs of younger couples – and cultural norms and tradition beliefs,  Use prenatal and post natal periods as crucial times for information and counseling about birth spacing,  Discuss with mothers during well-baby and immunization visits the benefits of maintaining 3-5 years for the next child,  Support initiative that strengthen the women decision-making power in the household. Source: Population Reports, Volume XXX, Number 3, Summer 2002 (11)