2. Objectives Bring to your attention the linkage between pregnancy timing and spacing & maternal, newborn and child health outcomes Share key findings that support the linkage Present key components of operationalizing HTSP

3. Healthy timing & spacing of pregnancy (HTSP) Previous birth spacing recommendations refer to when to give birth. HTSP is about pregnancy spacing: when to become pregnant – rather than when to give birth. HTSP recommendations help women and couples make informed decision about delay and timing and spacing of pregnanciesfor the healthiest outcomes. Recommendations are evidence-based.

4. The Evidence USAID sponsored a total of six studies: five meta analyses and SLRs, and one 17-country analysis –> 190 studies; –20-30 years of data Objective: to assess the effects of pregnancy spacing on maternal and child health outcomes Evidence review by a panel of 35 WHO experts.

5. o One SLR & meta analysis: maternal and perinatal outcomes (77 studies; covering 30 years of data from 1966-2004) o One study: miscarriage/abortion & next pregnancy outcomes (18 countries; >250,000 women whose previous pregnancy resulted in abortion) o One SLR : maternal and child nutrition outcomes (33 studies; prospective, cross sectional, case control) o One study in Matlab, Bangladesh: maternal, infant and child outcomes (outcomes of >150,000 pregnancies; covering 20 years of data from 1982-2002) o One SLR and meta-analysis: infant and child outcomes (65 studies) o One 17-country analysis of DHS findings: neonatal, infant and under-five mortality The Studies

6. Birth-to-Birth and Birth-to-Pregnancy Intervals (24 months) (9 months ) Birth Next pregnancy Birth Birth-to-Pregnancy Interval Time period between live birth and next pregnancy Birth-to-Birth Interval Time period between two live births DEFINITIONS: INTERVALS A 24 month birth-to-pregnancy interval is the approximate equivalent of a 33 month birth-to-birth interval.

7. Pregnancy Spacing: BTP Intervals and Relative Risk of Adverse Maternal and Perinatal Outcomes Sources: Conde-Agudelo, 2000, 2005; and DaVanzo et al, 2007

8. Pregnancy Spacing: BTP Intervals and Relative Risk of Neonatal and Infant Mortality Source: Rutstein, 2008

9. Pregnancy Spacing: BTP Intervals and Relative Risk of Under Five and Child Mortality 2.94 2.2 1.51 Source: Rutstein, 2008

10. Key Finding: Too Short Pregnancy Intervals are Associated with Multiple Adverse Outcomes Perinatal/Infant Outcomes: Pre-term birth Low birth weight Small size for gestational age Newborn/infant mortality Maternal Outcomes: Maternal mortality Induced abortion Miscarriage

11. The technical experts concluded: That after a live birth, women and couples should wait at least 24 months before trying to become pregnant again. That after a miscarriage or induced abortion, women and couples should wait at least 6 months before trying to become pregnant again

12. Pregnancy Timing: Early Age Pregnancy Source: A. Conde Agudelo et al., 2003. 20- 24

13. Recommendations from WHO, UNICEF and UNFPA on early age pregnancy Delay first pregnancy until at least 18 years of age. Kenyan mother, 2006 Mike Wang, Courtesy of Photoshare Source: UNICEF, Facts for Life 3 rd edition, New York, United nations Children’s Fund, 2002; WHO/UNFPA Pregnant Adolescents: Delivering on Global Promises of Hope, WHO, 2006

14. Source: Stover J, J Ross 2009 Pregnancy Timing: Late Age Pregnancy & the Risk of Mortality Compared to Pregnancy at ages 20-24 8765432187654321 15 -1920 - 2425-2930-3435-3940-49

15. HTSP Concept HTSP Helps women –space pregnancies –better time pregnancies so they are becoming pregnant and giving birth when it is healthiest and safest for mother and child.

16. Rationale for HTSP FP has made progress in helping women avoid unintended pregnancies. But, focus has been on lowered fertility (limiting and smaller family size) HTSP emphasizes FP’s role in achieving healthy fertility – and healthy outcomes for mother and baby The focus on healthy fertility encourages couples to use FP - to time and space pregnancies Effective entry point to revitalize FP in sensitive settings, due to its focus on improved mother/child health

17. Family Planning : Critical for HTSP Improved access to family planning is essential for HTSP. HTSP’s “healthy fertility” emphasis may make FP more acceptable. HTSP helps to better link FP and other services such as MNCH, ANC, PPC, PAC and Youth Friendly Services

18. Operationalizing HTSP HTSP should be integrated at multiple levels: –National –Facility –Community To ensure that women and couples can effectively practice HTSP.

19. At the National level  Include HTSP in FP, RH, MCH, PAC and HIV/AIDS guidelines and protocols  Integrate into pre- and in-service training for health workers.  Produce range of IEC materials on HTSP for client and community education  Select, integrate and monitor HTSP indicators for HMIS.  Promote improved collaboration among FP, MCH, nutrition, HIV/AIDS and other services for women and children in promoting HTSP,  Ensure ongoing and adequate supplies of FP commodities.

20. At the Health Facility Level  Expand the number of service delivery points that provide HTSP information and FP  Promote HTSP client education by including it in any facility-based health education or counseling as appropriate  Strengthen referrals between relevant services

21. At the Community Level  Raise awareness and gain support of community leaders for HTSP and FP  Engage the community in discussions and provide information through the media, meetings, schools, churches/mosques, the workplace, markets and other venues.  Involve community health workers, CBD agents, peer educators, and other community level workers (agriculture, micro-enterprise, water and sanitation, malaria, etc)

22. 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)

23. HTSP: A Small Change that Produces Big Results Reducing closely spaced pregnancies. Timing pregnancies at the best age possible. Contributing to the healthiest outcomes for mothers, babies, families and communities.

24. Where we stand: Maternal and Child Health in (Your Country) This is an optional slide for advocacy purpose.

25. What can we do? Implementing HTSP in (Your Country) What opportunities and mechanisms exist for implementing this simple, yet life-saving approach?

26. CONCLUSION: International Support for Improved MNCH Endorsed by 180 nations, I CPD called for the following by 2015: A 75% reduction in maternal mortality by 2015 (compared to 1990 levels) Infant and under five mortality should decline to below 35 per 1,000 and 45 per 1,000 respectively The U N Millennium Declaration, commits nations to reduce extreme poverty and achieve specific goals by 2015: MDG Goal 4 is to reduce child mortality, specifically reduce by two thirds, the under-five mortality rate MDG Goal 5 is to improve maternal health, specifically by reducing the maternal mortality ratio by 75% and achieving universal access to reproductive health care. The US Global Health Initiative (GHI) will invest $63 billion to improve the health of women, newborns and children. The GHI aims to: Reduce maternal mortality by 30% in assisted countries thus saving the lives of 360,000 women Reduce under 5 mortality by 35% in assisted countries, saving the lives of 3 million children. including 1.5 million newborns, Improve access to family planning and reproductive health to: –increase contraceptive prevalence to 35%; –prevent 54 million unintended pregnancies; –reduce to 20 percent the number of first births by women under 18.

27. Next Steps We know what works to meet these goals. We know family planning saves women’s and children’s lives. We must muster the political will to do so.

28. We would like to acknowledge The Extending Service Delivery Project/Pathfinder International Fill in your acknowledgements

29. Thank you!!! from the children of the world