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									Healthy Timing and Spacing
of Pregnancy (HTSP)
Time it Right: You can choose the
time that’s best for you and your baby
Milka Dinev
Project Director
Extending Service Delivery (ESD) Project
Washington DC, USA
Presentation objectives
 Provide overview of key findings from six USAID-
  sponsored studies
 Share recommendations from WHO technical
  consultation
 Present key components of ESD’s HTSP program
  approach
Purpose
 To mobilize you to join our community of
  practice and add HTSP interventions to your
  programs and practices to achieve:
   Delay of first pregnancy in adolescents
   Spacing of subsequent pregnancies after a live birth
    or a miscarriage or abortion
   Improved health outcomes for mothers and
    newborns
Background
 USAID sponsored six studies on pregnancy spacing
  and health outcomes
    One SLR & meta analysis: maternal and perinatal outcomes
    One study: miscarriage/abortion & next pregnancy outcomes
    One SLR : maternal and child nutrition outcomes
    One 17-country analysis of DHS findings: neonatal, infant
     and under-five mortality
    One country study (Matlab, Bangladesh):maternal, infant and
     child outcomes
    One SLR AND meta-analysis: infant and child outcomes

 In June 2005, USAID supported a WHO technical
  consultation and submitted the six studies for review of
  the evidence
Key Findings: Maternal Outcomes
After a live birth
 Short birth to pregnancy (BTP) intervals < 6
  months were associated with:
    increased risk of maternal mortality
    increased risk of induced abortion
    increased risk of stillbirths, and miscarriages

 Long BTP intervals of > 59 months were
  associated with:
    increased risk of pre-eclampsia
Key Findings: Maternal Outcomes
After a miscarriage
  or abortion
 Short BTP intervals of
  < six months were
  associated with:
    Increased risk of
     premature rupture of
     membranes
    Increased risk of
     maternal anemia
Key Findings: Perinatal Outcomes
After a live birth
 Short birth to pregnancy (BTP) intervals < 18
  months as well as long BTP intervals of > 59
  months were associated with:
    Increased risk of pre-term live birth
    Increased risk of small size for gestational age
    Increased risk low birth weight
Key Findings: Perinatal Outcomes
After a miscarriage or abortion:
 Short BTP intervals of < six months were
  associated with:
    Increased risk of pre-term births
    Increased risk of low birth weight
Key Findings: Neonatal Outcomes

 Short BTP intervals of < 18 months were
  associated with the highest risk of neonatal
  mortality

 Longer BTP intervals of at least 27 months were
  associated with the lowest risk
Key Findings
Post-neonatal Outcomes
 Short BTP intervals < 15 months were associated
  with:
    Increased risk of post-neonatal mortality
    Increased risk of infant mortality

 Post-neonatal survival may be improved with BTP intervals
  of 27 months or greater.

Childhood Outcomes
 Meeting participants did not come to a consensus
Result of the Technical Consultation

 A policy brief which included two
  recommendations-one related to “spacing after a
  live birth” and the other related to “spacing after a
  miscarriage or an induced abortion” to be read in
  conjunction with a preamble
WHO Supported Recommendations
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.
  *Some participants felt it was important to note that, for BTP intervals of five years or more, there is evidence of, an incr eased risk of pre-
  eclampsia, and adverse perinatal outcomes, namely pre-term birth, low birth weight and small infant size for gestational age.




After a miscarriage or induced abortion:
     The recommended minimum interval to next pregnancy,
      should be at least six months, in order to reduce risks of
      adverse maternal and perinatal outcomes.
  Source: World Health Organization, 2006 Report of a WHO Technical Consultation on Birth Spacing
Operationalizing the WHO
Supported Recommendations
ESD and Healthy Timing and Spacing of Pregnancy
 Spearheading an activity to take the findings from
  research to the field
 Operationalizing the recommendations from the WHO
  technical consultation
 Developing a program approach focusing on three take-
  home messages on HTSP to be discussed in the context
  of personal RH goals and fertility intention:
    Two messages based on the two WHO supported
     recommendations
    A third message related to timing of first pregnancies in
     adolescents.
Take Home HTSP Messages
After a live birth:
    For the health of the mother and the baby, wait at least 2 years,
     but not more than 5 years, before trying to become pregnant
     again
    Use a family planning method of your choice during that time
After a miscarriage or abortion:
    For the health of the mother and the baby, wait at least six
     months before trying to become pregnant again
    Use a family planning method of your choice during that time
For adolescents:
    For your health and your baby’s, wait until age18, before trying
     to become pregnant
    Use a family planning method of your choice until you reach 18
     years of age
Haven’t we been doing birth
     spacing all along?
Demand for Spacing
          Portion of Total Demand for Spacing
        Among MWRA ≤ 29 Years Who Wanted FP

    100%
     90%
     80%
     70%
                                         Demand for
     60%
     50%                                 Spacing
     40%
     30%
     20%
     10%
      0%


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Unmet Need for Spacing
 Considerable unmet need for FP/Spacing
   95-98% of postpartum women do not want
    another child within 2 years, but only 40%
    using FP
   Supported by Qualitative Studies conducted by
    USAID



  Source: Contraceptive Use, Intention to Use And Unmet Need During the Extended Postpartum Period, John A. Ross and
  William L. Winfrey, International Family Planning Perspectives, Vol. 27, Number 1, March, 2001.
What is HTSP?

 Women and couples want to know the safest time to
  become pregnant.
 Birth spacing refers only to the interval after a live
  birth, and when to give birth.
 HTSP captures all pregnancy intervals in a woman’s
  life – and when to become pregnant - the healthiest
  time to become pregnant – after a live birth, still birth,
  miscarriage or abortion
 HTSP also addresses the timing of first pregnancies in
  adolescents
What are HTSP interventions?
 FP has made progress in helping women avoid
  unintended pregnancies. Focus has been on lowered
  fertility.
 FP has not been associated with healthy fertility. It has
  not regarded as an “intervention” to prevent adverse
  outcomes for mother and baby.
 HTSP interventions are those activities that help
  women and families delay or space their pregnancies to
  achieve the healthiest outcomes for women, newborns,
  infants, and children, within the context of free and
  informed choice
Free and Informed Choice
 Free and informed choice means
   The client chooses to space or to limit
   The client chooses a method voluntarily, and without
    pressure or coercion
   The choice is based on a clear understanding of the
    benefits and limitations of the available methods
   The client may also choose not to use a FP method. Use
    of a method is completely voluntary
   All choices are made in the context of personal RH
    goals and fertility intention
ESD’s HTSP Strategy

 Key HTSP Interventions
   Advocacy
   Education/counseling &
    linkage to FP services
   M&E
Advocacy
 Bring evidence and WHO recommendations to
  policy makers
 Reach decision makers with DHS data on:
    Country-level burden of disease
    Mortality/morbidity risks of not timing and spacing
     pregnancies
 Support policy dialogue efforts to:
    Ensure recognition of the role of FP/HTSP as an
     intervention
       To prevent adverse outcomes
       To help address the country’s burden of disease
Service Delivery
 Educate/counsel women and couples about HTSP – provide information
  on pregnancy spacing and improved health outcomes
       Add HTSP information to
         Pre-service, in-service training curricula & service delivery
          protocols
         Counseling and BCC tools
       Increase the knowledge of service providers
         FP plays a vital role not only in RH but also in maternal, newborn
          and child health
       Add/integrate HTSP messages in
           Maternal, newborn, child health activities
           Post abortion care activities
           PMTCT/HIV activities
           Youth activities
 Link women to FP services to help women achieve their fertility
  intentions and spacing preferences
Monitoring & Evaluation
 Encourage programs to regularly use birth interval
  data as a measure of program success
    % of births spaced by birth interval, disaggregated by
     age (15-19 and 20-29 will be especially important)
    Neonatal, infant and child mortality rates by birth
     interval

 Add birth-to pregnancy intervals to list of existing
  indicators

 Add “age at first birth” to 15-19 age cohort
Tracking HTSP
 Policies/Frameworks
    HTSP incorporated into maternal, newborn, child, primary
     health, RH/FP policies and national frameworks

 Curricula, Guidelines and Tools
    HTSP integrated into:
      Training curricula (pre-service/in-service/continuing)
      Service delivery protocols and technical guidelines for
       service delivery
      Quality of care standards, performance improvement
       protocols
      Counseling, BCC, communication tools and materials
Tracking
 Health
Public sector (MCH, PPC, PAC, PMTCT, IMCI or
   other health initiatives)
    HTSP included in training of public sector providers
    HTSP counseling/education provided in public sector
     sites

Private sector (e.g. pharmacists, community-based
   distributors, commercial sector initiatives, etc.)
    HTSP included in training of private sector providers
    HTSP counseling/education in private sector sites
Tracking
 Non-Health (youth, GBV, faith-based, agriculture,
  literacy, micro-credit)
    HTSP included in training of non-health groups
    HTSP counseling provided through non-health group(s)
    Community mobilization activities carried out to raise
     awareness of HTSP

 Advocacy/Data for Decision makers
    HTSP Studies conducted to generate data for decision
     making
HTSP Champions Network

 16 US-based HTSP core group members
  working in 27 countries

 HTSP Champions Network consists of more
  than 160 members, representing over 50
  projects and organizations from 23 countries
Current Status & Next Steps
 Continue analysis of existing and additional data to
  build a stronger case for HTSP

 With USAID support ESD is funding:
    A harmonization paper using the BTP interval as a standard
    A causality paper

 Submission of new analyses for WHO review
Annual Global Burden of Disease
 >500,000 maternal deaths (70,000 abortion-related;
  60,000 eclampsia related)

 8 million women suffer complications

 14 million adolescent pregnancies

 4 million newborn deaths (28% linked to pre-term
  births)

 18 million LBW infants (98% in developing
  countries)
  Conclusion
 HTSP is associated with reduced
  risk of multiple adverse outcomes
 The MDGs call for reduction of
  under-5 mortality rates by two-
  thirds and MMRatio by three-
  quarters by 2015
 To save lives and help countries
  reach MDGs, we need to use all
  our interventions and HTSP is one
  of them
 What will YOU do in your country
  to include HTSP and its benefits in
  your programs and practices?
Contact us at info@esdproj.org

								
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