• Editors' Summary
• Credits

1. Exploring the New Evidence
2. Actual Versus Preferred Birth Intervals
3. Contraception for Spacing Births
4. Who Has Shorter Intervals?
5. How Programs Can Help Couples Space Births
• Developing an Effective Message
• Expanding Access and Outlets

• Figures
• Tables
• Side-bars
• Bibliography

• Why are longer intervals better?
• Spacing: A matter of choice
• How to measure intervals
• Women want longer intervals
• Demand for spacing is high
• Infant deaths shorten intervals
• Traditional practices can help
• Health programs can spread the message

• POPLINE
• Other reports
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• CCP Home Page

Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

How Programs Can Help Couples Space Births

Although not always addressed specifically, promoting birth spacing has long been a central goal of family planning programs around the world (150). The new evidence for the benefits of spacing births 3 to 5 years apart argues for renewed emphasis on helping couples space births, especially young women who want to postpone their next pregnancy longer. Expanded access to good-quality family planning services through a variety of avenues will help women achieve their preferred intervals.

Program strategies will be different in communities where preferred birth intervals are shorter than 3 years than in those where preferred intervals are longer than 3 years. In the former, programs can focus more on developing messages that explain to all family members the benefits of spacing births by 3 to 5 years. Where women and couples already want longer birth intervals, programmatic efforts can focus on increasing access and successful continued use of contraceptive methods to help people achieve their spacing goals.

The mass media and communication programs could do more to raise awareness of the benefits of birth spacing. A better understanding is needed, however, of what messages elicit the best responses from different audiences. Programs need to test whether people respond to messages that emphasize the health benefits, and also whether they respond to messages that stress the social benefits of longer birth intervals, such as increased savings, time, and attention to the family. In a 1992 survey in Nigeria, for example, at least 85% of women and at least 68% of men agreed with the statements that spacing helps a mother to regain her strength before having her next baby, that child spacing protects the health of mothers, and that child spacing helps the health of children (86). At the same time, in Uganda, interviews in 1992 found that women who viewed birth spacing positively cited other benefits, including having older children to help raise their younger siblings. One woman said that birth spacing helps women look younger. “Delivery every year will make you look unhealthy and ugly,” she told the interviewers (50).

Since most women do not make decisions about family planning by themselves, messages for husbands, mothers-in-law, and other family members also are useful. The benefits of spacing can appeal to all members of the household. For example, in a 1996 study in Jordan, one male respondent summarized the variety of benefits of longer birth intervals, saying that births that are spaced “give each child born his rightful level of caring and attention, and they give your wife the time to rest and regain her health. They give the husband the chance to weigh his financial situation and plan his family’s future” (52).

Another area needing research is which messages are easiest to understand and remember for all women and couples. Birth to pregnancy intervals may be preferable because they explain when a woman can become pregnant again, rather than when she can have another birth. Some have suggested a message that explains that a woman should use contraception until her youngest child is two to four years of age. Remembering this message, a woman would not need to subtract nine months of pregnancy, as she would using a birth to birth interval, to calculate whether she has spaced sufficiently to receive the health benefits (178). The Nepali slogan, “When the first child goes to school, then only a second child,” aired on radio stations across the country, illustrates how long couples should space (104).

Communication campaigns in several countries have already begun using the 3-year message. Posters from the Planned Parenthood Association of Ghana, for example, encourage parents to space their births 2 to 3 years apart (137). Posters from India’s State Innovations in Family Planning Services Agency urge couples to wait at least 3 years (176). Nigeria’s State Ministry of Health encourages birth spacing of 3 to 4 years (122). In Bangladesh posters suggest that couples wait 5 years between births (158) (see photos below). Most of these communication campaigns point to the social and economic benefits of spacing for their audiences rather than to the health benefits.

Nigeria Federal Ministry of Health, Health Education Division

In Nigeria the Ministry of Health encourages families to space their births 3 to 4 years apart. Posters and other media can inform parents that spacing births improves health and can help families provide for their children better.

	State Innovations in Family Planning Services Agency (SIFPSA)
Left: Used in provider training and client educational materials, this Nepali logo illustrates that couples should wait until the older child is in school before having another birth. Right: A poster in India suggests that couples wait 3 years before having a second child.

Changing the message? Communication programs with the new message of 3 to 5 years may need to address the apparent conflict with the 2-year spacing message of the past. The 2-year message has enjoyed widespread recognition. For example, when asked in surveys what is the best number of months between births, most women in most countries respond that an interval of 2 years or more is best (15). In Malawi 95% of women responded to a survey that an interval of 24 months is desirable and, 59% said that waiting 36 months is even more desirable (189).

Because so many people believe that 2 years is the preferred interval between births, moving away from so well-established a message should be handled carefully. If people start to hear that spacing 3 years is better than 2, they may get confused about why the preferred interval has “changed.” The facts themselves have not changed, of course. Messages can communicate that waiting 2 years between births clearly improves child survival, while waiting 3 to 5 years is even better. Above all, messages should convey that the best intervals are those that women choose for themselves based on their individual circumstances.

Finding the right term for birth spacing or longer birth intervals—without confusing the term with family planning in general—is a good starting point for developing messages. In many places where family planning is not yet widely accepted, the phrase “birth spacing” is used as a substitute since it is more acceptable (194). For instance, in Jordan, where many people believe that God alone determines the number and timing of children, a major initiative of the national family planning program was named the Jordan Birth Spacing Project (12, 135, 174). Usually programs with names that include the phrase “birth spacing” focus on increasing contraceptive use rather than specifically on achieving longer birth intervals.

Some languages have no word for birth spacing, and birth spacing advocates may need to develop new terms based on audience research and testing. In Nepal before 1990, the generic Nepali term for family planning, “pariwar niyogen,” was commonly used to mean sterilization. Family planning programs were concerned that villagers would interpret a health worker’s advice to “use a family planning method” as “have a vasectomy or tubal ligation”—advice that would not be attractive to young couples (204).

In the early 1990s World Education, Inc./Nepal, in collaboration with the Ministry of Education and Culture and the Program for Appropriate Technology in Health, first conducted focus-group discussions to learn how villagers talk about birth spacing. Nepali farmers mentioned that they often leave yams, turmeric, ginger, and sugarcane to grow for 3 years before harvesting and therefore, an analogy to these crops would be meaningful in messages promoting 3- to 5-year birth intervals. A contest elicited several potential terms for birth spacing, and field testing determined that one term (“janma antar”—literally “birth gap”) was better understood and more acceptable than other terms among both villagers and family planning administrators. Today, the Ministry of Health, the Nepal Contraceptive Retail Sales Project, and nongovernmental organizations throughout the country use the term “janma antar” in training and client communication materials (168). With more research and use of different birth spacing messages, the best ones will become apparent, making it easier for advocates to raise awareness of the benefits of longer birth intervals.