Contents
Chapters
- Exploring the New Evidence
- Actual Versus Preferred Birth Intervals
- Contraception for Spacing Births
- Who Has Shorter Intervals?
- How Programs Can Help Couples Space Births
Highlights
- 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
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.
Volume XXX, Number 3
Summer 2002
Series L, Number 13
Issues in World Health
Expanding Access and Outlets
Many women will be unable to achieve their preferred birth intervals unless they have better access to family planning supplies and services appropriate for spacing. Some technical assistance organizations are focusing on expanding access to enable people to space their births further.
A major focus of the Catalyst Consortium www.rhcatalyst.org is to increase awareness of 3 to 5 years as the optimal birth interval (177). By offering technical guidance, holding conferences, and publishing research findings, the Consortium increases awareness among public health agencies and supports governments in developing medical guidelines that recommend intervals of 3 to 5 years, based on the new evidence. EngenderHealth www.engenderhealth.org provides technical assistance on birth spacing, particularly in clinic-based settings, so that women have better quality services to achieve their spacing goals. It assists countries in updating their national service delivery guidelines and protocols to incorporate recommendations of intervals of 3 to 5 years (136).
Continuity of care. People who want to space births have special needs that family planning programs often do not meet adequately. The higher levels of unmet need for spacing than for limiting suggest this (see chapter 3_3, Unmet Need for Spacing). Women who want to space their births need continuity of care to continue using contraception and achieve their preferred birth intervals (30, 77, 192), to stop use to become pregnant, and then after delivery to start a method that is appropriate during breastfeeding (82). Many studies have found that such good-quality services enable people to continue using contraception for many years (75, 91).
The PRIME II Project www.prime2.org uses Performance Improvement methods to identify how health care providers can improve the quality of family planning services they offer to women who want to space their births. Service providers may need new client-provider interaction skills to respond better to the birth spacing needs of younger, low-parity women. The PRIME II Project emphasizes self-directed learning and interactive instruction so that service providers do not need to leave the service delivery site to learn new skills (78).
Access to sources of supply. Access to good-quality contraceptive services and a range of methods helps people to space births. Sometimes having a nearby source is key to continuation of contraceptive use. Broadening the types of service delivery can provide more choices closer to home, especially for people whom conventional programs have difficulty serving, such as young women, people with low incomes, and women who cannot easily leave their homes (138). Programs can deliver methods through community-based distribution, private-sector sales including social marketing, and private providers, as well as through family planning clinics and hospitals.
A full range of methods. When more contraceptive methods are available, more couples who want to space births can find a method that suits them. All programs should offer at least several temporary methods, such as condoms, pills, injectables, implants, or IUDs, in addition to permanent ones. The options to switch from one method to another and to choose a different method after giving birth are central to continued satisfactory use of family planning (60). Providers should make clear that all clients have the option to switch methods whenever and as often as needed, and that they should return if they experience any problems (188).
Today, some women cannot always get the contraceptive methods that they prefer (157). In many programs stock-outs and other problems in the supply chain prevent women who want longer birth intervals from obtaining a continuous supply of their preferred method (146, 163, 164). Offering a range of methods also helps ensure that at least some methods will always be available even when some shortages do occur (31). Other women do not want to use a supply method of family planning but do not know that they can control their birth intervals by using the Lactational Amenhorrea Method (LAM) or other fertility awareness-based methods (40). Offering a wide variety of contraceptive methods, along with accurate information about the benefits of spacing, will help women space their births longer.
 PROFAMILIA |
In Nicaragua a pamphlet discusses contraceptives that couples can use after the birth of their child. Both the prenatal and postpartum periods are crucial times to provide information about birth spacing. | |||
Working with communities. Community norms help shape people’s decisions and expectations about their birth intervals (see chapter 4_3, Cultural Norms). Communication campaigns that speak to the needs of younger couples and new parents can help make 3- to 5-year birth intervals a social norm. Learning more about women’s birth spacing practices and their needs can inform effective birth spacing messages. Also, providers can counsel women better if they understand cultural practices and traditional beliefs including taboos on breastfeeding during pregnancy and sexual relations during lactation (187).
The Catalyst Consortium is conducting focus-group discussions in five countries—Bolivia, Egypt, India, Pakistan, and Peru—to learn why women space their births. They hope to understand their ideal interval lengths and, for women who prefer intervals of 3 to 5 years, which benefits motivate them most. The Consortium plans to publish the results in 2002. The results will be used to develop training modules to improve counseling (177).
Prenatal and postpartum care. The prenatal and postpartum periods and up to a year after a woman gives birth are crucial times for information and counseling about birth spacing, since most women see health care providers more often during this period (48). Most of the time these contacts rarely include opportunities for discussion and counseling on birth spacing (157). During a woman’s prenatal period, health care providers can discuss the health benefits of spacing pregnancies and can encourage women to continue receiving reproductive health care between pregnancies (89).
As part of postpartum care, providers can tell women about LAM, explaining that during the baby’s first six months, fully or almost fully breastfeeding can prevent pregnancy, so long as the woman has not menstruated yet (66, 205). Providers can advise women that IUDs, condoms, and vaginal methods are appropriate methods during breastfeeding. Hormonal methods are not the first choice, but progestin-only pills, injectables, and implants can be used after six weeks postpartum (66, 82). Combined hormonal methods—combined oral contraceptives and monthly injectables—should be avoided because they may reduce production of breast milk.
Child health programs. Because birth spacing helps protect child health, the 3-year message complements efforts of child health programs. Well-baby visits and immunization visits provide opportunities for health staff to counsel parents of young children about the benefits of waiting 3 to 5 years for the next child. Of course, spacing births 3 to 5 years in and of itself will not ensure child survival and good health. Parents can help safeguard their baby’s health by ensuring skilled care at delivery, arranging for a clean sterile delivery, keeping the newborn warm, starting exclusive breastfeeding immediately and supplementing with appropriate and nutritious complementary foods after six months, maintaining hygiene during infancy and early childhood, and obtaining all the recommended childhood immunizations (41). Women who are HIV-positive can avoid breastfeeding and use formula instead if they have access to a clean, consistent, and affordable supply (120).
Improving women’s status. Over the long term, improving women’s status can contribute to longer birth intervals. For example, if parents can feel that their well-being is as secure with female children as with male children, they may want to wait longer before having another child (132). When women have more decision-making power in the household, they tend to have longer birth intervals (see chapter 4_2, Women's Characteristics). Women’s status can be improved by raising age at marriage, increasing education, and expanding employment opportunities. Improving opportunities for women will enable them to make the healthiest choices about birth spacing and about childbearing in general.
