Jhpiego study shows simple, community-based interventions can promote birth spacing
Kaliganj, Bangladesh – A community health worker escorts us into a small, mud brick home on the edge of this village in the northeast part of the country. A young mother is seated on a high bed, the only furniture in the small room, breastfeeding a new baby. Another child, a boy about 16 months old, reaches for his mother – arms outstretched and crying. His mother pushes him away. The child looks miserable, thin and sniffling, and confused about why his mother was pushing him away.
The woman and her husband tell us that the new baby was not planned.
Sylhet District, where this couple lives, has among the worst health indicators for women and children in the country. The maternal mortality ratio is highest in Sylhet (471 deaths per 100,000 live births, compared to the national average of 322), and the infant mortality rate is twice what it is elsewhere in Bangladesh, according to country health data. Women in Sylhet District have about four children, compared to an average of about three in the country’s five other divisions. Only 31 percent of married women of reproductive age use any method of contraception, compared to 56 percent for the country as a whole. Moreover, approximately 26 percent of women in Sylhet give birth to their children with fewer than two years between them, an unhealthy interval that leads to an increased risk of poor health outcomes for mothers and babies alike.
This is tough terrain for the public health specialists who have a plan to increase healthy spacing of births, address the unmet need for family planning during the postpartum period, and reduce maternal and newborn deaths. But community health workers engaged in the Healthy Fertility Study are helping produce groundbreaking information about an integrated community-based service delivery strategy to increase family planning use, a model with the potential to be replicated globally. In a place like Sylhet, women who can space their children within a healthy period of time are better able to care for themselves and their families.
The Healthy Fertility Study is a collaboration of the Bangladesh Ministry of Health and Family Welfare, Jhpiego, two local nongovernmental organizations and the Johns Hopkins Bloomberg School of Public Health. Since 2007, the study, supported by the U.S. Agency for International Development, delivers a package of maternal and newborn health including postpartum family planning through female community health workers. By including simple counseling messages on pregnancy risks during the first year postpartum, the importance of exclusive breastfeeding, and the benefits of healthy pregnancy spacing, together with the provision of pills and condoms, these community health workers have made a big difference in the lives of many women who want to avoid having closely spaced pregnancies.
The one year results from the study demonstrate a 20 percent increase in contraceptive use in the intervention area compared to a neighboring site. In addition, through the promotion of effective use of the lactational amenorrhea method the study showed an additional increase of 10 percent in the practice and duration of exclusive breastfeeding.
Laily Begum, the 24-year-old mother of two daughters, didn’t know when a woman could get pregnant again after giving birth. She also knew little about family planning methods or where to access them. But after a visit by Mousumi Apa, a community mobilizer with the Healthy Fertility Study, Begum and her 26 year-old husband have decided to practice family planning.
“I am also very happy as now I know that, after giving birth to a child, there should be at least three years gap to give birth to another child for better health outcomes for the baby and the mother,” says Begum. “There is only 13 months space between my two girls. That’s why neither of the two children gets proper breast feeding. Even I could not take care of them properly.”
At the 2011 International Family Planning Conference in Dakar, experts from around the world will be discussing innovative and proven ways to prevent unintended pregnancies, reduce maternal deaths, and promote healthy birth spacing. The Healthy Fertility Study, because of its design, provides convincing evidence about the power of family planning integration in community-based maternal and newborn health.
Our experience from the Healthy Fertility Study shows that women and families are eager to learn how to properly plan their families for the benefit of all members of the family. One of the unique aspects of the Sylhet work is the prospect of implementing the project elsewhere around the globe. Consistent evidence from many settings suggests that short birth intervals of two years or fewer are associated with poor neonatal and maternal outcomes. That research suggests that improving birth spacing among women could contribute to the achievement of Millennium Development Goals 4 and 5 and the reduction of maternal and child mortality.
The study is also challenging preconceptions about the potential barriers of providing family planning services and information in culturally and religiously conservative areas such as Sylhet. Experiences with this model have shown that promoting optimal spacing of births to assure the health of the baby is effective in securing support from the families. Women, their husbands, mothers-in-law and village leaders across the district are steadily becoming supporters and acting as conduits for sharing information about healthy spacing and family planning.
Rowshon Ara, a 33-year old mother of five and a participant in the study, says women in her village now know about other family planning methods and are interested in using them to practice healthy birth spacing. “I think this change has taken place in the mentality of the people because of the counseling and meetings of the community health workers and community mobilizers of the Healthy Fertility Project,” says Ara. “I can say I did not know all these things that I know now. Now I know that giving optimum birth-to-pregnancy spacing results in a healthy and strong baby, reduces the chance of a child dying and a mother dying during delivery.”
Dr. Catharine McKaig is the family planning team leader for the Maternal Child Health Integrated Program at Jhpiego. Jaime Mungia is a program officer at Jhpiego.