1. How Using Family Planning to Time and Space Pregnancies Reduces Mortality
Adrienne Allison,
December 12, 2012

2. Family Planning to Time and Space Pregnancy
Using family planning to time and space pregnancies is the single most effective way to save lives and improve the health and well-being infants, children and mothers.
UNFPA, 2012

3. Outline of Presentation
1.Impact of FP Use on Infant, Child and Maternal Mortality
2.Impact of FP Use on Child Health
3. Family Planning Methods

4. Impact of Birth Interval on Neonatal Mortality
An infant born less than 18 months after its sibling is almost three more likely to die than an infant born 3 years after the next older sibling.
, actually,most 5 years is the safest birth to birth interval..
A note about the data it is all derived from Demographic and Health Surveys (DHS) and all the analyses control for family income, education of mother, place of birth, and all the other factors that could impact neonatal mortality. This means that even under the very best conditions, a newborn faces a risk of dying that is almost three times greater than the risk faced by an infant born at least three years after the older sibling.
Rutstein 2005 4

5. Impact of Birth-to-Pregnancy Interval on Infant Mortality
The horizontal axis shows the birth-to-next-pregnancy interval.
A birth to pregnancy interval of less than 6 months means that infant is 3.4 times more likely to die than an infant conceived at least 24 months after the next older child.

6. Effect of Birth Interval on Infant Mortality

7. On this slide, look at the bright red line that shows how high maternal mortality is when there is less than 6 months between one birth and the beginning of the next pregnancy. This is why we say “Wait at least 24 months after a birth before trying to become pregnant again.

8. Here we see the mortality risk for girls age 15 to 19, then the “golden ages” of 20 to 24 the optimal ages for child bearing. Maternal mortality starts to rise – slowly to age 25 to 29, faster from ages 30 to 34, and fastest / highest after age 35.
The data are from Bangladesh, Honduras, Guatemala and Burkina Faso, and 3 other countries.
Stover J, J Ross 2009

9. This chart is from the same data base
This chart is from the same data base. This time, Stover and Ross looked at the relationships between Maternal Mortality and the number of births a mother had. The risk of dying rises sharply after the fourth birth. Look at the line for New York State in This shows that even under quite good conditions at that time, the MMR rises after the fourth birth.
Stover J J Ross, 2009

10. Age of Mother Parity Spacing
This compares Infant Mortality Rates. Looking at the age of the mother, parity (her number of births) and spacing between births. Which one has the greatest impact - a mother’s age, the first set of columns, her parity, the second set or spacing? It is clear that spacing, the columns on the right, have the greatest impact on infant deaths. If a mother has only one child, she should be at least 20 years old and likely younger than 30. If she has two children, she should space their births by at least 3 years. (This means that after the birth of her first child, she should wait at least 24 months before trying to become pregnant again.) For healthiest children, use FP to space them at least 3 years apart. Here, we see that the infant mortality rate is about three times as high for births that at less than 24 months apart.
Age of Mother
Parity
Spacing

11. Impact of Short Interpregnancy Intervals
Infants: increased risk of neonatal and perinatal mortality, low birth weight, preterm delivery
Children: mortality for children born 2 to 4 years apart is 75 per 1000 live births; for those born less than 2 years apart, it rises to 134 per 1000
Mothers: higher risk of mortality, pre-eclampsia, ruptured membranes, anemia, high blood pressure
Infants whose mothers die are 3 to 10 times more likely to die before age one, compared to infants whose mothers live Rutstein, DHS, 2005
Adolescent girls: pregnancy– related complications are the leading cause of mortality
Girls age 15 to 19 are twice as likely to die as women age 20 – 24
Girls under 15 are 5 times more likely to die than those
Infants of teenage girls are almost twice as likely to die as those born to women age 20 – SAVE, 2007, Guttmacher 2002

12. Mother’s age as a risk factor for children’s health problems in India
Mother’s age as a risk factor for children’s health problems in India. FP helps mothers delay their first pregnancy until they are old enough to adequately care for themselves and their newborn. 12

13. Longer Birth Intervals Decrease Stunting and Underweight
This is a compilation of three of the first studies on relationships birth intervals and stunting and underweight for children under 5 years old. Children spaced further apart are less likely to be stunted or underweight. This relationship is very important for those populations where undernutrition is serious problem. Undernutrition declines by almost 50%.
Source for figure: Rustein, Shea, Effects of Birth Interval on Mortality and Health: Multivariate Cross-Country Analysis, MACRO International, Presentation at USAID, July 2000; Rutstein 2005; Dewey and Cohen, 2004.

14. The Need for Family Planning
The risk:
Women who do not breastfed may become pregnant again as 25 days after giving birth
Without the protection of FP, 85% of sexually active women will become pregnant within the first year (USAID 2007)

15. Women Do Not Use Family Planning because of:
Lack of knowledge about FP methods
No easy access to health /FP services
Low quality health / FP services
Fears about side effects
Opposition from husbands, mothers-in- law
Cultural values

16. Contraceptive Methods
Most effective: Implants, IUD, Female Sterilization, Vasectomy
More effective: Injectables, LAM, Pills
Less effective: Male Condoms, Female Condoms, Fertility Awareness Methods (FAM)
Least effective: Withdrawal, Spermicides
There are many choices for women and men. Their voluntary choice depends on their fertility intentions. All methods of FP have clear benefits, but also some side effects. No side effect however, is as prolonged and difficult as pregnancy and child birth.

17. Female Sterilization Ideally done within 48 hours after delivery
May be performed immediately following delivery or during C/section
If not performed within 1 week of delivery, delay for 4-6 weeks
Highly effective, 99.5% comparable to vasectomy, implants, IUDs
Follow local protocols for counseling clients and obtaining informed consent in advance
Discuss during prenatal care

18. Male Sterilization: Vasectomy
A safe, convenient, highly effective and simple form of contraception that is provided under local anesthesia in an out-patient setting
Vasectomy is safer, simpler, less expensive and equally effective as female sterilization (tubal ligation)
Highly effective in preventing pregnancy (99.6 to 99.8% effective)
Not effective until after 3 months- requires a back-up contraceptive method during the first 12 weeks after a vasectomy

19. IUDs
Can be inserted postpartum (immediately up to 48 hours after delivery) or after 4 to 6 weeks;
Highly effective
Effective immediately
Long-term method (up to 12 years with Copper T 380A)
Do not interfere with intercourse
Do not affect breastfeeding,
Few side effects
Discussion about the name of sterilet better to call it IUD sterilet may confuse women that they will be sterilized
PPIUCD 19 19

20. Combined Oral Contraception (COC)
Start 3 weeks after delivery if not breastfeeding, 6 months after delivery if breastfeeding
Highly effective when taken daily (0.1 – 0.5 pregnancies per 100 women during the first year of use)
No pelvic exam or lab tests required to initiate use
Can start even if menses has notreturned, but will need to use condoms or abstain for the first week of use
Does not interfere with intercourse
Client can stop use
Can be provided by trained non-medical staff
It is important to note that women in good health do not need to have pelvic examinations and exams and blood work based on medical evidence 20

21. Progestin-only contraceptives (pills, injectables, implants)
No effect on breastfeeding, milk production or infant growth and development after infant is 6 weeks
WHO recommends a delay of 6 weeks after childbirth before starting progestin-only methods to avoid newborn exposure to progestin
If woman is using LAM, progestin-only is a good method to transition to at 6 months or when LAM criteria are no longer met (exclusive breastfeeding and menses not returned 21 21

22. Condoms
When used consistently and correctly, male and female condoms are highly effective against pregnancy (97%) and STIs/HIV
Can be used after childbirth (as soon as intercourse is resumed) 22

23. Lactational Amenorrhea Method (LAM)
Protects from pregnancy if menses have not returned
If Infant is less than six months old
If mother is exclusively breastfeeding on demand (no more than 4 hours between feeds during the day; no more than 6 hours between feeds at night)
Bonus effect - Immediate and exclusive breastfeeding for 6 months can reduce infant mortality by about 50%
At this point participants have heard the 3 criteria. Ask them to tell you 23

24. Emergency Contraception
Provides protection for up to 120 hours after unprotected intercourse, but should be taken immediately as effectiveness declines over 5 days
If a woman is already pregnant, EC does not affect her pregnancy – she will remain pregnant
Levonorgestrel, a progestogen hormone, works by stopping or disrupting ovulation, and may also prevent the egg and sperm from meeting
After EC a mother needs immediate long term protection from pregnancy through a FP method

25. Comparing effectiveness of methods Fertility Awareness-Based Methods
Most effective
How to make your method most effective
Generally 2 or fewer pregnancies per 100 women in one year
Implants
Vasectomy
Female Sterilization
IUD
One-time procedures. Nothing to do or remember.
Need repeat injections every 1 to 3 months
Injectables
Must take a pill each day
Pills
Must follow LAM instructions
LAM
About 15 pregnancies per 100 women in one year
Must use every time you have sex; requires partner’s cooperation.
Male Condoms
Must use every time you have sex
Diaphragm
Must use every time you have sex; requires partner’s cooperation.
Female Condom
Must abstain or use condoms on fertile days; requires partner’s cooperation.
About 30 pregnancies per 100 women in one year
Fertility Awareness-Based Methods
Must use every time you have sex
Least effective
Spermicides

27. Benefits of Using Family Planning
Healthy newborns, infants, children, and women, and happy, stable families and communities.