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Two Years-The Invisible Norm
For many years, family planning experts have generally agreed that a twenty-four month or two-year birth interval is important for infant, child and maternal health. Studies have shown that birth intervals less than two years are associated with adverse perinatal and maternal outcomes. Despite this knowledge, few governments, or international health organizations have birth spacing policies or programs. Although birth spacing is at the heart of reproductive health/family planning, it is rarely addressed directly. In short, the two-year recommendation for birth spacing is an "invisible norm".
A review of over one thousand abstracts from the health and development literature revealed that few programs address birth spacing for its health benefits. As a result, the health benefits of adequately spacing births are often left out from client education materials and provider training manuals. In the few countries that have birth spacing programs the terms "birth spacing" and "family planning" are incorrectly used as synonyms.
New Findings on the Optimal Birth Interval
New research on optimal birth spacing collected and commissioned by CATALYST has confirmed the long-held notion that the highest risks for adverse health outcomes for children and mothers often occur with the shortest birth intervals. In addition, the new research shows that there is substantially more health benefit gained from lengthening the birth interval beyond the previously recommended two years to a three to five year birth interval. The new research shows there is an optimal interval for birth spacing- a period associated with the lowest risks for adverse health outcomes-and that optimal interval is three to five years. Based on these groundbreaking new research findings, CATALYST and the Optimal Birth Spacing Champions has taken the position that the previous two year guidelines need to be revised to be: Three to Five Years for Optimal Birth Spacing.
The new research on optimal birth spacing comes from large retrospective cross sectional analyses that statistically controlled for potentially confounding socio-demographic and biological variables. Shea Rutstein examined the association between birth intervals and neonatal, infant and child health and nutritional outcomes using Demographic and Health Survey (DHS) data from fifteen developing countries in Africa, Latin America and Asia. Agustin Conde-Agudelo examined the association between birth intervals and perinatal, maternal, and adolescent health outcomes, using a database of over two million pregnancies in eighteen countries in Latin America and the Caribbean. Bao Ping Zhu examined the association between birth intervals and perinatal health in two U.S. States and between two racial groups. Their findings indicate that spacing births for three to five years has the greatest positive health impact on perinatal, neonatal, infant, child, maternal, and adolescent maternal health in both developing and developed countries. The findings ( Graphs: 1 & 2 ) indicate that the lowest risks for fetal death, pre-term delivery, small for gestational age, neonatal death, and low birth weight occur when births are spaced from three to five years. The lowest risk for maternal morbidity and mortality also occur at three to five year birth intervals. Additionally, the new research indicates that the risks for both mother and child increase after five years.
CATALYST has crafted the graph Optimal Birth Spacing Interval: Maternal- Perinatal Risks to illustrate the recommended optimal birth spacing interval. Research findings on the association of birth intervals and maternal and perinatal health were plotted on an eighty- month timeline. As Figure 1 shows:
- The current recommendation of two years is too close to the high risk period for both mother and child;
- Most researchers, but not all, identify the period of lowest risk for adverse health outcomes from between 27 to 60 months;
- Risks for the mother starts climbing at 60 months and becomes statistically significant at 69 months.
For the mother-child dyad, the data supporting an optimal birth interval window spans from 27 to 69 months. However, as a public health recommendation, it is safer to create a buffer of nine months at each end of the interval window (27 + 9 = 36 and 69 - 9 = 60). Based on these findings CATALYST, the OBSI Champions and USAID have recommended a 36-60 month or a 3-5 year window as the optimal birth spacing interval.
New Findings on the Determinants of Birth Spacing Behaviors
In order to better understand the larger social, cultural, religious, institutional and structural influences on birth spacing behaviors, CATALYST has gathered qualitative data through focus group discussions in four countries: Peru, Bolivia, India and Pakistan. Over 1,000 respondents participated in the focus groups. In 2003, CATALYST will conduct OBSI focus groups in Egypt. Results from the series will help CATALYST form a more comprehensive research base for new birth spacing programming.
OBSI Reports and Technical Papers
CATALYST has commissioned several studies by Dr. Agustin Conde-Agudelo, Consultant to the World Health Organization, and the Pan American Health Organization. These are presented in Optimal Birth Spacing: New Research from Latin America on the Association of Birth Intervals and Perinatal, Maternal and Adolescent Health (2002). The document is available in English and Spanish.
Other useful reports on optimal birth spacing include:
Birth Spacing: Research Update 2002 USAID.
Birth Spacing: A Call to Action 2002 USAID.
Three to Five Saves Lives, Population Reports, Volume XXX, Number 3, Series L, Number 13 Summer 2002 Population Information Program, Johns Hopkins University
Espeut, Donna Spacing Births, Saving Lives: Ways to Turn the Latest Birth Spacing Recommendation into Results, 2002 ORC Macro, Child Survival Technical Support Project
The following list provides a short bibliography of some of the most recent studies in optimal birth spacing interval:
Conde-Agudelo, A. and J. Belizan. Maternal mortality and morbidity associated with interpregnancy interval: A cross sectional study. British Medical Journal (321): 1255-1259.1998
Conde-Agudelo, A. Analysis of the Association Between Maternal Age and Adverse Pregnancy Outcomes. Unpublished.
Conde-Agudelo, A. Analysis of the Maternal-Perinatal Morbidity and Mortality Associated with Inter-Pregnancy Intervals Following a Miscarriage in Women and Adolescents. Unpublished.
Conde-Agudelo, A. Maternal Sociodemographic and Obstetric Factors Associated with Short Birth Intervals in Women in Adolescents. Unpublished.
Fuentes-Afflick, E., N.A. Hessol. Interpregnancy interval and the risk of premature infants. Obstetrics and Gynecology 95: 383-90.
Rafalimanana, H. and C. Westoff. Potential effects on fertility and child health and survival of birth-spacing preferences in Sub-Saharan Africa. Studies in Family Planning 31 (2): 99-110.
Jansen, W.H. D. Frick, and R. Mason. The "X" factor in birth spacers: age and parity in demand for birth-spacing in 15 developing countries. Paper Presented at the Population Association of America. May, 2002.
Rutstein, S. Effect of birth intervals on mortality and health: multivariate cross-country analyses. Unpublished Data from Measure/DHS+ Macro International, Inc. Calverton Maryland.
Skjaerven, R. et al. The interval between pregnancies and the risk of preeclampsia. New England Journal of Medicine 346 (1): 33-38.
Zhu, B.P. et al. Effect of interval between pregnancies on perinatal outcomes among white and black women. American Journal of Obstetrics and Gynecology (185): 1403-10.
Zhu, B.P. et al. Effect of the interval between pregnancies on perinatal outcomes. The New England Journal of Medicine (340): 589-94.