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Postpartum Family Planning: Healthy Timing and Spacing of Pregnancy   


November 26 – December 14, 2007
http://my.ibpinitiative.org/ppfp

The purpose of this forum is to bring novices and veterans together to share best practices and country-based experiences on healthy timing and spacing of pregnancy (HTSP). 


Discussion Statistics


Number of participants: 315
Number of participants' countries: 52
Number of contributions: 31
% of contributions from developing countries: 65%
Number of countries contributing: 10 countries

Contributing countries: Democratic Republic of Congo, Egypt, India, Jordan, Kenya, Pakistan, Peru, Philippines, Uganda, USA


Purpose and Objectives

Purpose:

The purpose of this forum is to bring novices and veterans together to share best practices and country-based experiences on healthy timing and spacing of pregnancy (HTSP).

Objective: To provide:

  • State-of-the-art information on HTSP
  • An overview of HTSP, highlighting new birth-spacing studies, and focusing on programmatic experiences with HTSP

                                                                                                                                
Week 1 , Day 1 

Summary:

What is HTSP? Healthy Timing and Spacing of Pregnancy (HTSP) is an intervention to help women and families delay or space their pregnancies, and achieve the healthiest outcomes for women, newborns, infants and children, within the context of free and informed reproductive choice. HTSP encompasses a broad concept of the reproductive cycle ─ starting from healthiest age for the first pregnancy in adolescents, to spacing subsequent pregnancies following a live birth, stillbirth, miscarriage or abortion - capturing all pregnancy-related intervals in a woman’s reproductive life.

Full text daily digest
              
Week 1, Day 2 

Summary:

Today, we have a question posed by Dr. Judith Brown about spacing pregnancies according to the weight rather than the age of a woman’s youngest child. Shea Rutstein, PhD, Technical Director, Macro International and Carla Schnell White, Senior Advisor Monitoring and Evaluation, Extending Service Delivery Project responds to this question.

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Week 1, Day 3 

Summary:

Today we have a new question about the mechanism through which long birth spacing (e.g. five years) causes poor health outcomes. Experts respond to this question and other participants share their experiences with HTSP programs in Egypt, Pakistan and Peru. 

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Week 1, Day 4 

Summary:

Today’s digest continues to discuss spacing pregnancies according to the weight (rather than the age) of a woman's youngest child. Maureen Norton, Senior Technical Advisor, USAID provides her thoughts on this topic. 

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Week 1, Day 5 

Summary:

In the past few days, we have read the research and the practical applications of HTSP discussed in the forum. Today, we would like to introduce the Extending Service Delivery (ESD) Project’s role as the Coordination Unit of the HTSP Champions Network and our tools for disseminating information for the HTSP intervention.

ESD implements the following activities to roll out HTSP: Supporting formative research and data analysis which influences the global agenda around HTSP; Spearheading the effort to apply HTSP evidence from research to programs in field through sharing of evidence-based state-of-the-art (SOTA) technical updates and program implementation experiences and tools in publications, on-line and at international meetings and conferences; Increasing global awareness, knowledge and application of HTSP by coordinating the HTSP Champions Network—which has grown from 16 to 160 members—representing over 50 projects and organizations from 23 countries.

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Week 1, Day 6 

Summary:

Have you encountered situations where teamwork failures in your health-care system harmed patients?
What barriers to effective teamwork have encountered in your health-care environment. Do you have any examples of how these can be overcome?

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Week 2 , Day  1: HTSP program in Jordan

Questions:

  1. Are the results of this qualitative study similar or different from the situation in the country where you live or work?
  2. What programmatic approaches can be taken to address barriers to contraceptive use and healthy spacing intervals?

Summary:

: Welcome to Week 2 of the global online forum on Healthy Timing and Spacing of Pregnancy (HTSP). This week’s moderators will be from the Health Communication Partnership (HCP) – based at the Johns Hopkins Center for Communication Programs. The focus of this week’s discussion will be information shared at the “Changing Norms for Healthy Spacing of Pregnancy: New Research and Programs” Videoconference on December 3, 2007 organized by HCP in partnership with ACCESS-FP, ESD Project, INFO Project and USAID. The videoconference linked public health professionals in Baltimore, Jordan, Kenya, Uganda, and Geneva. Today we summarize the results from the qualitative study in Jordan described during the videoconference.

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Week 2, Day 2 

Summary:

Today a contributor asks a question about "late age at marriage" mentioned in yesterday’s posting from Jordan. Linda Qardan from Jordan Health Communication Partnership responds to the question. If anyone has more questions, please do send them in.

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Week 2, Day 3 

Summary:

Today we will be summarizing the results of a qualitative study conducted in Uganda in October 2007 and presented at the December 3 “Changing Norms for the Healthy Spacing of Pregnancy” videoconference.

The overall objective of the study was to explore the attitudes and beliefs of women and men towards birthspacing and further understand the individual and social factors that serve as motivators or barriers. The focus group discussions were carried out in two districts of Kampala in the central region and Iganga in the eastern part of Uganda. The participant selection criteria were the same as for the Jordan study summarized in yesterday’s discussion. Main results of the study can be found by clicking on the full text daily digest link below.

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Week 2, Day 4 : Communication and HTSP

Questions:

  1. What is the role of communication in changing social norms and the symbolic environment?
  2. What has been your experience in communicating birthspacing messages to women and families in your countries and programs?
  3. How have spacing norms changed (or not changed) over time in your country?

Summary:

Today’s posting will summarize the presentation, “More Women Becoming Expert Users of FP: The Rise of the Spacing Norm in Egypt” presented at the December 2, 2007 videoconference on “Changing Norms for Healthy Spacing of Pregnancy: New Research and Programs.”

Over the past 20 years, Egypt’s population program has shifted from addressing the effects of rapid population growth and the benefits of small family size to a program positioning households as producers of health with the “Your Health is Your Wealth” campaign conducted by the Communication for Healthy Living Project (CHL in Egypt). The main messages of the campaign include:
  • Promoting family planning after the first child;
  • 3-5 years spacing between pregnancies; and
  • (Re)initiation of FP within 40 days of delivery.

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Week 2, Day 5

Summary:

: Mary Sebastian from Population Council in India wrote in response to the summary of the qualitative study conducted in Uganda that was posted yesterday. Mary discussed communication in the HTSP program in India..

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Week 2, Day 6 

Summary:

Today, in our posting to the Global Forum on Healthy Timing and Spacing of Pregnancy, we have a summary of the presentation by Sheikh Hussein Mahad, from the Council of Imams and Preachers of Kenya. Sheikh Hussein Mahad presented at the December 3, 2007 videoconference on “Changing Norms for Healthy Spacing of Pregnancy: New Research and Programs.” A full summary of the project can be found by clicking on the full text daily digest below.

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Week 3, Day 1

Summary:

Welcome to the third and final week of the Global Forum on Healthy Timing and Spacing of Pregnancy. This week, we would like to invite everyone to share their experiences with HTSP programs. Our first posting is from Mary Sebastian with Population Council in India. Mary describes a recent study to assess effectiveness of a pregnancy spacing intervention in a rural area of Uttar Pradesh, India.

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Week 3, Day 2 

Summary:

Today, we have a couple of questions regarding Mary Sebastian’s posting yesterday about a recent study to assess effectiveness of a pregnancy spacing intervention in a rural area of Uttar Pradesh, India.

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Week 3, Day 3 

Summary:

Today we will be summarizing the results of a qualitative study conducted in Uganda in October 2007 and presented at the December 3 “Changing Norms for the Healthy Spacing of Pregnancy” videoconference.

The overall objective of the study was to explore the attitudes and beliefs of women and men towards birthspacing and further understand the individual and social factors that serve as motivators or barriers. The focus group discussions were carried out in two districts of Kampala in the central region and Iganga in the eastern part of Uganda. The participant selection criteria were the same as for the Jordan study summarized in yesterday’s discussion. Main results of the study can be found by clicking on the full text daily digest link below.

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Week 3, Day 4 

Questions:

Today, Robin Anthony Kouyate from ACCESS-FP poses an interesting question to the forum regarding strategies to delay unintended pregnancy among young non-married girls.

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Week 3, Day 5A

Summary:

In our first posting today, we have a comment from a colleague in the Philippines who discusses an adolescent reproductive health project in the Philippines and another from a participant in the Democratic Republic of Congo who discusses the importance of reducing illiteracy.

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Week 3, Day 5B 

Summary:

In our second posting today, we have a presentation from Nahla Tawab regarding a Population Council intervention in Egypt: “Helping Egyptian Women Achieve Healthier Birth Spacing Intervals: Testing an Intervention for Low-Parity Women.” Catharine McKaig, from ACCESS-FP also asks for others to share experiences with reaching peri-menopausal women.

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Day 6 

Summary:

Today we have a question and response regarding counseling on spacing after a miscarriage. We will be wrapping up the forum on Healthy Timing and Spacing of Pregnancy today but will still post comments and resources in the community..

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Programmes Examples

Summary:

Jordan. Twelve focus group discussions were conducted in Northern and Southern regions of Jordan, each with 8-9 respondents. In each region 2 focus groups were conducted with currently married women of reproductive age not currently using contraception, 2 focus groups with fathers, and 2 focus groups with “positive deviant” women. Women classified as “positive deviants” were those who expressed interest in birth intervals greater than 2 years and who were currently using contraception. The focus group discussions covered the following areas: fertility aspirations and age of marriage, birth spacing and attitudes towards contraception.

The main findings of the study follow:

Fertility aspirations and age of marriage:
  • There is a trend towards delaying marriage due to the high cost of living and changes in women’s education and career aspirations.
  • Couples feel pressure to conceive and have babies as soon as they are married. This pressure is due to the combination of late age of marriage and the cultural importance placed on fertility.
  • Fertility seems to give women a higher status in society and problems with fertility are considered the woman’s responsibility.
  • In cases where a man has more than one wife, there is competition between the two wives to produce children.
  • There is a growing awareness that couples should “enjoy life” and “each other” before starting a family.
  • Some women expressed the hidden motivation to have more children in order to exert greater control and gain more attention from the husband.
  • There is high social and family pressure to have a male child.

Birth spacing:
  • Most respondents favored the term birth spacing over family planning.
  • Respondents emphasized the challenges to space between the first children.
  • The ideal age between siblings is considered to be 2-3 years.
  • The high cost of living is a main reason for the acceptance longer intervals and smaller families.
  • Main sources of information are friends, relatives and health providers

Attitudes towards contraception:
  • There is no religious taboo to using contraception as long as it is to space, and not limit, births.
  • The majority of respondents had limited knowledge of contraception, were misinformed and afraid.
  • Contraception is considered in the realm of the woman.
  • Barriers against contraceptive use include:
  • Large family norms
  • Family and community pressure
  • Conservative mindset
  • Importance of fertility and desire for male heirs
  • Late marriages
  • Information gap and lack of proper knowledge on contraceptive methods

Uganda. The overall objective of the study was to explore the attitudes and beliefs of women and men towards birthspacing and further understand the individual and social factors that serve as motivators or barriers. The focus group discussions were carried out in two districts of Kampala in the central region and Iganga in the eastern part of Uganda. The participant selection criteria were the same as for the Jordan study summarized in yesterday’s discussion.

The main findings of the study are as follows:
  • Childbearing is the number one expectation from and by couples and is the primary reason for marriage.
  • Fertility is the woman’s responsibility and any delay or failure is blamed on the woman; however fertility decisions such as the number of children are the preserve of the man.
  • Delayed pregnancy can threaten the marriage relationship and can lead to early separation, divorce or extra marital relationships.
  • Urban couples are more likely to achieve their ideal birth intervals due to access to family planning services and methods. Rural women have limited options and the subsequent pregnancies are left to God to determine
  • Late age of marriage and ideal number of children overshadow any aspirations for longer spacing. Urban couples who have a choice calculate their spacing intervals based on the ideal age by which they want to have completed childbearing.
  • Polygamous marriages breed competition among women for a higher number of children and gender mix.
  • There is still a clear preference for males as heirs and propagators of the family name, however most families want a gender mix.
  • The health status of a previous child influences the birth spacing interval.
  • Women are more likely to think about birthspacing then men. Men, on the other hand, consider the required number of children and view birthspacing as an automatic occurrence.
  • Too short and too long intervals are not desirable in the community.
  • While there is universal basic awareness of family planning, there are still widespread myths and biases.
  • One advantage of short birth intervals is the ability to compress childbearing and rearing into a few years and avoid advanced maternal age.
  • Disadvantages of short birth intervals are the financial and time resource stress related to child rearing. Although health risks to the mother and child are acknowledged, there does not seem to be strong conviction among the population.
  • Most participants noted that birthspacing is more appropriate for people living in rural settings where women get married at a younger age and household income is limited.
  • It is interesting to note that there are striking similarities between these results and those from the Jordan qualitative study. Some of these similarities include:
  • Couples want (and are pressured) to have their first child as soon as possible after marriage.
  • Infertility is assumed to be the woman’s fault, one more reason to have the first child early.
  • In case a couple does not have children, pressure is often put on the husband to remarry or have extramarital affairs in order to have children.
  • High fertility increases a woman’s status in her family and the society.
  • There is a preference for male children.
  • Men decide the number of children.
  • The method to space births is a women’s business.
  • Too short or too long birth intervals are not acceptable.
  • Factors of pressure to have children include age of woman at marriage, gender of first child, loss of a pregnancy or child, multiple wives.
  • In polygamous marriages, there is competition between wives to have more (male) children than the other wives. This creates pressure for short birth intervals and large families.
  • Factors to delay childbearing include waiting until the woman finishes school, financial burden / high cost of living, etc.
  • Health of previous child can influence both ways. 1) It can make a couple want to wait longer in fear that the next child will also be unhealthy, or 2) it can pressure them into having another child as soon as possible in hope of a healthy child.
  • There is a poor knowledge of modern contraceptive methods. Rumors and fear of side effects are undermining use.

Kenya. The Council of Imams and Preachers (CIPK) of Kenya is a Garissa-based Islamic organization, which coordinates Mosque activities in the 11 administrative divisions of Garissa District. CIPK’s major mandate is to disseminate Islamic information to the Muslim communities through the Imams. CIPK collaborated with the ESD Project to organize a five day training on Child Spacing and Reproductive Health for 30 Muslim Religious Leaders in Garissa. The training was facilitated by local and other Muslim RH and medical experts. Religious leaders shared knowledge on Reproductive Health with special reference to the Islamic view of healthy timing and spacing of births.

India. Promoting Optimal Inter-pregnancy Intervals in India through Integrated Public Delivery Systems FRONTIERS Program of Population Council is collaborating with the Ministry of Health and Family Welfare, Office of the Integrated Child Development Services (ICDS) scheme, and Lala Lajpat Rai Memorial Medical College (at Meerut, Uttar Pradesh) to conduct a study that assesses the effectiveness of promoting a three-year interval between births among pregnant women with no or one child by increasing postpartum contraception. The key intervention is an educational campaign for pregnant women during antenatal check-ups and house visits. In addition, their husbands, mothers-in-law and community opinion leaders were educated by community level workers trained in counseling young couples on birth spacing and postpartum contraception. Several IEC materials and educational aides (pocket booklet, posters and wall paintings in Hindi) were developed on delaying first birth, need to space births 3-5 years, correct practice of LAM, and other spacing methods.















Post-forum survey results

Number of surveys completed 34

% who have passed content to others 53%

% who have or will use in their work  94%

% very satisfied with forum content 61%

Suggestions for improvement :  

  • The format in which the postings came out was not easy to see who was responding/ posting to whose message.
  • It was unfortunate that there was another online forum going on at the same time and it was a challenge keeping up with all the postings. The information was valuable, but I think the format for the online discussions needs some reconsideration. Posting a series of questions at the beginning of the week and then summarizing contributions at the end of the week, with access to the actual contributions online if desired, would be helpful. Daily postings are too much - our inboxes are too cluttered with things to address this on a daily basis.
  • It would be great to reach out to more people- in addition to the technical experts working on the issue- to participate in the discussions.
  • I do not have good ideas yet on how to achieve this- but it seems like the forum could be enriched by a diversity of people with different viewpoints and programming experiences.
References and resources
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Organizing groups

Health Communication Partnership (HCP) and the INFO Project, based at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (JHU/CCP), ACCESS/FP Project, Extending Service Delivery (ESD) Project, United States Agency for International Development (USAID), World Health Organization Department of Reproductive Health and Research (WHO/RHR)

Contributing experts/facilitators 

Shea Rutstein, PhD, Technical Director, Macro International

Carla Schnell White, Senior Advisor Monitoring and Evaluation, Extending Service Delivery Project

Lina Qardan, MS, Mass. Comm, Senior Technical Advisor, Jordan Health C Lina Qardan, MS, Mass. Comm, Senior Technical Advisor, Jordan Health Communication Partnership Communication Partnership

Maureen Norton, Senior Technical Advisor, USAID

Ricky Lu, JHPIEGO

Maria Ofelia Ocana-Alcantara, MD, MPH, Consultant: Health Sector and Health Finance Health Care Perspective Inc. RH Link Inc

Cate Lane, Senior Youth Advisor, Extending Service Delivery (ESD) Project

Robin Anthony Kouyate from ACCESS-FP

Sheikh Hussein Mahad, Council of Imams and Preachers of Kenya

Mary Sebastien, Population Council, India

Robin Anthony Kouyate, ACCESS-FP

Dr. Judith Brown

Catharine McKaig, ACCESS-FP

Salvador-Davila, MD, CATALYST

Moderators 

Angela Nash-Mercado, ACCESS-FP, Jhpiego