Report of a WHO technical consultation on birth spacing: Geneva, Switzerland 13-15 June 2005

Publication date: 2005

Report of a WHO Technical Consultation on Birth Spacing Geneva, Switzerland 13–15 June 2005 Department of Reproductive Health and Research (RHR) Department of Making Pregnancy Safer (MPS) WHO/RHR/07.1 Report of a WHO Technical Consultation on Birth Spacing Geneva, Switzerland, 13–15 June 2005 © World Health Organization, 2007 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in This document reflects the available evidence up until 2005. New research has emerged and may be applicable to the inter-pregnancy interval after miscarriage or induced abortion. This report of a World Health Organization (WHO) “Technical Consultation and Scientific Review of Birth Spacing”, held in Geneva, Switzerland, from 13 to 15 June 2005, was written by Cicely Marston. The report also draws on findings from systematic reviews and research presented by Agustín Conde-Agudelo, Julie DaVanzo, Kathryn Dewey, Shea Rutstein, and Bao-Ping Zhu. We thank the meeting participants for the time they spent reviewing documents and participating in discussions, the 30 reviewers from interna- tional organizations and from 13 countries who provided comments on the background documents for the meeting, and to Barbara Hulka for chairing the meeting. We gratefully acknowledge the United States Agency for International Development for all of their support and efforts, particularly Maureen Norton and Jim Shelton, as well as Taroub Harb Faramand and other CATALYST staff. The technical review, meeting and report were co-ordinated by Annie Portela, Iqbal Shah, Jelka Zupan and Claire Tierney of WHO. Paul Van Look and Monir Islam provided critical advice, suggestions and support. Cover and layout design, Janet Petitpierre. ACKNOWLEDGEMENTS CONTENTS 1. EXECUTIVE SUMMARY 1 1.1 RECOMMENDATIONS 2 1.2 SUGGESTED AREAS FOR FUTURE RESEARCH 3 2. INTRODUCTION 5 2.1 SPACING TERMINOLOGY 6 2.2 OUTCOMES MEASURED 7 3. MAIN FINDINGS FOR EACH GROUP OF OUTCOMES 9 3.1 MATERNAL OUTCOMES 9 3.2 PERINATAL OUTCOMES 9 3.3 NEONATAL MORTALITY (DEATHS UNDER AGE 28 DAYS) 10 3.4 POST-NEONATAL OUTCOMES 12 3.5 CHILDHOOD OUTCOMES 13 3.6 POST-ABORTION SPACING 14 4. CONCLUSIONS AND RECOMMENDATIONS 17 4.1 STRENGTHS AND LIMITATIONS OF THE EVIDENCE 17 4.2 RECOMMENDATIONS 17 4.3 SUGGESTED AREAS FOR FUTURE RESEARCH 19 TABLES 20 ANNEX 1. PAPERS REVIEWED AT THE MEETING 29 ANNEX 2. MEETING AGENDA 30 ANNEX 3. LIST OF PARTICIPANTS 34 1 1. EXECUTIVE SUMMARY Recommendations for birth spacing made by inter- national organizations are based on information that was available several years ago. While publi- cations by the World Health Organization (WHO) and other international organizations recommend waiting at least 2–3 years between pregnancies to reduce infant and child mortality, and also to benefit maternal health, recent studies supported by the United States Agency for International Development (USAID) have suggested that longer birth spacing, 3–5 years, might be more advantageous. Country and regional programmes have requested that WHO clarify the significance of the USAID-supported studies. With support from USAID, WHO undertook a review of the evidence. From 13 to 15 June 2005, 37 international experts, including the authors of the background papers and WHO and United Nations Children’s Fund (UNICEF) staff, participated in a WHO technical consultation held at WHO Headquarters in Geneva. The objective of the meeting was to review evidence on the relationship between differ- ent birth-spacing intervals and maternal, infant and child health outcomes and to provide advice about a recommended interval. Six background papers were considered, along with one supplementary paper. Prior to the meeting, the six main papers were sent to experts for review. Thirty reviews were received: 10 from staff in inter- national organizations and 20 from experts from 13 countries. The reviews were compiled and cir- culated to all meeting participants. At the meeting, the authors of the background papers presented their work, and selected discussants presented the consolidated set of comments, including their own observations. Together, the draft papers and the vari- ous commentaries formed the basis for the discus- sions of the evidence and for the recommendations made by the group at the meeting for spacing after a live birth and after an abortion. The background papers contained evidence from studies that used a variety of research designs and analytical techniques. All the papers submitted were drafts, subject to revision based on the discussions. One study used longitudinal data from Matlab, Bangladesh (DaVanzo et al., draft, no date); one con- tained an analysis of cross-sectional Demographic and Health Surveys (DHS) data from 17 countries (Rutstein, draft, no date). Three of the main back- ground papers were reviews: two provided data from systematic reviews and meta-analysis (Conde- Agudelo, draft 2004; Rutstein et al., draft 2004), and one reviewed literature pertaining specifically to maternal and child nutrition (Dewey and Cohen, draft 2004). The supplementary paper reviewed three studies that used birth records from Michigan and Utah, USA (Zhu, draft 2004). One other back- ground paper specifically looked at post-abortion (miscarriage and induced abortion) inter-pregnancy intervals in Latin America, using hospital records (Conde-Agudelo et al., draft 2004). A list of the papers discussed, the meeting agenda, and the list of participants is given in Annexes 1–3. Together, the set of papers provided an extensive collection of information on the relationship between birth-spac- ing intervals and maternal, infant and child health outcomes. The meeting participants noted that the length of intervals analysed and terminology used in the stud- ies varied, making it difficult to compare results. It was therefore agreed that birth-to-pregnancy inter- val would be used as standard for presenting rec- ommendations. This measure refers to the interval between the date of a live birth and the start of the subsequent pregnancy. The group discussed the strengths and limitations of the studies presented and of the results. Additional analyses and issues to be addressed in the research reviewed were identified, as were gaps in the body of research. The authors are currently undertaking additional analyses to respond to questions raised at the meeting. These analyses and the final papers will be reviewed when they are available. A supplemen- tary report will be issued at that time. Report of a WHO Technical Consultation on Birth Spacing 2 Report of a WHO Technical Consultation on Birth Spacing 1.1 Recommendations The background papers, the expert reviews, and the discussions at the meeting comprised a timely anal- ysis of the latest available evidence on the effects of birth spacing on maternal and child health. The group came to separate conclusions for the different outcomes considered, which were encompassed in two overall recommendations; one on birth spacing after a live birth and one on birth spacing after an abortion. The particulars of the recommendations and the necessary caveats are noted in detail in the body of the report. The group emphasized that the recommendations must be read in conjunction with the preamble below. Preamble Individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health services, child-rearing support, social and economic circumstances, and personal preferences in making choices for the timing of the next preg- nancy. Recommendation for spacing after a live birth After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, peri- natal and infant outcomes. 1 Rationale for the recommendation The studies presented at the meeting considered various maternal, infant and child health outcomes. For each outcome, different birth-to-pregnancy intervals were associated with highest and lowest risks. To summarize, birth-to-pregnancy intervals of six months or shorter are associated with elevated risk of maternal mortality. Birth-to-pregnancy inter- vals of around 18 months or shorter are associated with elevated risk of infant, neonatal and perinatal mortality, low birth weight, small size for gestational age, and pre-term delivery. Some “residual” elevated risk might be associated with the interval 18–27 months, but interpretation of the degree of this risk depended on the specific analytical techniques used in a meta-analysis. Otherwise, the evidence to dis- criminate within the interval of 18–27 months was limited. Further analysis was requested to clarify this point. As mentioned, this additional work is being completed and will be considered at a future date. Evidence about relationships between birth spacing and child mortality was presented but the partici- pants did not reach agreement on its interpretation. On the basis of the evidence available at the time, the participants fell into two groups: those who con- sidered that the evidence indicated that the most suitable recommended interval was 18 months, and those who considered that the evidence supported a recommended interval of 27 months. Participants were, however, unanimous in agreeing that birth-to- pregnancy intervals shorter than 18 months should be avoided. At the meeting, a compromise was reached between the two groups, who agreed that the rec- ommendation for the minimum interval between a live birth and attempting next pregnancy should be 24 months. The basis for the recommendation is that waiting 24 months before trying to become pregnant after a live birth will help avoid the range of birth-to- pregnancy intervals associated with the highest risk of poor maternal, perinatal, neonatal, and infant health outcomes. In addition, this recommended interval was considered consistent with the WHO/ UNICEF recommendation of breastfeeding for at 1 Some participants felt that it was important to note in the report that, in the case of birth-to-pregnancy intervals of five years or more, there is evidence of an increased risk of pre-eclampsia, and of some adverse perinatal outcomes, namely pre-term birth, low birth weight and small infant size for gestational age. 3 Report of a WHO Technical Consultation on Birth Spacing least two years, and was also considered easy to use in programmes: “two years” may be clearer than “18 months” or “27 months”. Recommendation for spacing after an abortion After a miscarriage or induced abortion, the recom- mended minimum interval to next pregnancy is at least six months in order to reduce risks of adverse maternal and perinatal outcomes. Caveat This recommendation for post-abortion pregnancy intervals is based on one study in Latin America, using hospital records for 258,108 women delivering singleton infants whose previous pregnancy ended in abortion. Because this study was the only one available on this scale, it was considered important to use these data, with some qualifications. Abortion events in the study included a mixture of three types – safe abortion, unsafe abortion and spontaneous pregnancy loss (miscarriage), and the relative pro- portions of each of these types were unknown. The sample was from public hospitals in Latin America only, with much of the data coming from two coun- tries (Argentina and Uruguay). Thus, the results may be neither generalizable within the region nor to other regions, which have different legal and service contexts and conditions. Additional research is rec- ommended to clarify these findings. 1.2 Suggested areas for future research • Development of coherent theoretical frameworks explaining and analysing the possible causal mechanisms of birth spacing on outcomes, par- ticularly child mortality, was identified as impor- tant for future research. • Analyses of relationships between birth spacing and maternal morbidity would be useful to add to the few existing studies. For instance, exami- nation of the effects of multiple short birth-to- pregnancy intervals would be useful, as would be more detailed data on the effects of very long intervals. Further analysis of the relationship between birth spacing and maternal mortality would help confirm or refute existing findings, although it is acknowledged that this may often be unfeasible as it may require a very large num- ber of cases. • There is a need to investigate the relationship between birth spacing and outcomes other than mortality, for instance, maternal and child nutri- tion outcomes, or impact on child psychological development. Also, it would be helpful to have information on possible benefits, as well as pos- sible risks, of particular spacing intervals. • More studies on the effects of post-abortion pregnancy intervals are needed in different regions. A distinction between induced and spontaneous abortion, and between safe and unsafe induced abortion, would be particularly helpful in future studies. • Good-quality longitudinal studies that take more potential confounding factors into account are needed to: 1. clarify the observed associations between birth-to-pregnancy intervals and maternal, infant and child outcomes; 2. estimate the potential level of bias in the use of different measures of intervals (birth-to-birth vs. inter-pregnancy interval, for instance); 3. clarify the potentially confounding effect of short intervals following a child death, both because of shortened breastfeeding and because parents may seek to replace the dead child. • Finally, there is a need to develop an evidence base for effective interventions to put birth-spac- ing recommendations into practice. 5Recommendations for birth spacing made by inter- national organizations are based on information that was available several years ago. While publi- cations by the World Health Organization (WHO) and other international organizations recommend waiting at least 2–3 years between pregnancies to reduce infant and child mortality, and also to benefit maternal health, recent studies supported by the United States Agency for International Development (USAID) have suggested that longer birth spacing, 3–5 years, might be more advantageous. Country and regional programmes have requested that WHO clarify the significance of the USAID-supported stud- ies. With support from USAID, WHO undertook a review of the evidence. From 13 to 15 June 2005, 30 international experts, including the authors of the background papers and WHO and United Nations Children’s Fund (UNICEF) staff, participated in a WHO technical consultation held at WHO Headquarters in Geneva. The objective of the meeting was to review evidence on the relationship between differ- ent birth-spacing intervals and maternal, infant and child health outcomes and to provide advice about a recommended interval. Six background papers were considered, along with one supplementary paper. All the papers submitted were drafts, subject to revision based on the discus- sions. (See Annex 1 for a list of the papers reviewed at the meeting.) Prior to the meeting, the six main papers were sent to experts for review. Thirty reviews were received: 10 from staff in international organizations and 20 from experts from 13 countries. The reviews were compiled and circulated to all meeting participants. At the meeting, the authors of the background papers presented their work, and selected discus- sants presented the consolidated set of comments, including their own observations. Together, the draft papers and the various commentaries formed the 2. INTRODUCTION basis for the discussions of the evidence and for the recommendations made by the group at the meet- ing for spacing after a live birth and after an abor- tion. The background papers contained evidence from studies that used a variety of research designs and analytical techniques. One study used cohort data from Matlab, Bangladesh (3) one contained an analysis of cross-sectional Demographic and Health Surveys (DHS) data from 17 countries (5). Three of the main background papers were reviews: two provided data from systematic reviews and meta- analysis (1, 6), and one reviewed literature pertaining specifically to maternal and child nutrition (4). The supplementary paper reviewed three studies that used birth records from Michigan and Utah, USA (7). One other background paper specifically looked at post-abortion (miscarriage and induced abortion) inter-pregnancy intervals in Latin America, using hospital records (2). Together, the set of papers pro- vided an extensive collection of information on the relationship between birth-spacing intervals and maternal, infant and child health outcomes. This report provides a summary of the technical consultation meeting. The meeting agenda and the list of participants are given in Annexes 2 and 3. The working groups presented their conclusions in a final plenary session, at which the overall recom- mendations were agreed. The final conclusions are presented at the end of this report, along with gaps in research identified at the meeting. During the meeting, additional analyses and clarifications were requested from the authors of the papers. The authors are currently undertaking these analyses, responding to the questions raised at the meeting and drafting final versions of the papers. The addi- tional analyses and the final papers will be reviewed when they are available. A supplementary report will be issued at that time. Report of a WHO Technical Consultation on Birth Spacing 6 Report of a WHO Technical Consultation on Birth Spacing 2.1 Spacing terminology 2 One of the tasks at the meeting was to address the fact that the length of intervals analysed and terminology in the studies varied, making it difficult to compare results. A summary of these measures is given in Table 1. There was a discussion of how to reconcile these different measures in a way that would allow comparison between studies. As a starting point to define terms, the following timeline was presented as an example (See Figure 1. below). Each square on the timeline represents three months. Each pregnancy has an initiation date (P) and an outcome date (O), at which the pregnancy ends with either a birth (O1, O3 and O4 in the figure) or other termination (miscarriage or induced abortion: O2 in the figure). The duration of time from P to O is the gestation period. In practice, reported date of last menstrual period is usually measured, not the initiation of pregnancy itself. To ease comparison of findings across studies, given the wide range of different interval measures used, and in line with the agreed terminology for the recommendations, the main text of this report only uses birth-to-pregnancy (BTP) intervals. Other types of intervals are converted as far as possible to approximate this standard interval. BTP intervals measure the time period between the start of the index pregnancy and the preceding live birth (as opposed to other pregnancy outcomes). The studies principally used four measures of inter- vals preceding the index pregnancy (see “interval types” column of Table 1). Using Figure 1. above, and taking P3 to O3 to represent the index pregnancy for the purposes of this illustration, these can be 2 This discussion was based on the description in DaVanzo et al., draft, no date. described as follows: 1. Birth-to-birth intervals: time between the index live birth (O3 in the figure) and the preceding live birth (O1) – note that this mea- sure does not take into consideration the pregnancy P2 to O2 because it ends in a non-live birth; 2. Inter- outcome intervals: time between the outcome of the index pregnancy (O3) and the outcome of the previous pregnancy (O2) – note that the starting point (as in this case) and/or the end point with this measure can be a non-live birth; 3. Birth-to-concep- tion intervals: time between the conception of the index pregnancy (P3) and the previous live birth (O1) – note that this measure also omits pregnancy P2 to O2 from consideration; 4. Inter-pregnancy intervals: time spent not pregnant prior to the index pregnancy (O2 to P3 in the figure) – again, these intervals can begin with non-live births. Few studies used true inter-pregnancy intervals, although this term was sometimes used as a synonym for birth-to- pregnancy intervals. Studies occasionally examined subsequent birth intervals (e.g. subsequent birth-to- birth interval would be time elapsed from the index birth to the subsequent birth – O3 to O4 in the figure) but these were less common and were not discussed in any detail at the meeting. Figure 1. P1 O1 P2 O2 P3 O3 P4 O4 84726036120 24 48 Birth 2 Birth 3AbortionBirth 1 Time (months) 7 Report of a WHO Technical Consultation on Birth Spacing The four principle measures were converted to birth-to-pregnancy intervals as follows: 1. Birth-to-birth intervals minus nine months = birth-to-pregnancy interval 2. Inter-outcome interval minus nine months = birth-to-pregnancy interval 3. Birth-to-conception interval = birth-to-pregnancy interval 4. Inter-pregnancy interval = birth-to-pregnancy interval. For estimates 1. and 2., in the absence of further information, the conversion assumes full gestation, hence nine months are subtracted to account for the approximate time elapsed from the start of the pregnancy to the end. Measures 3. and 4. already give the interval without the gestation period added, so do not need to be adjusted in this way. For measures 1. and 3. all measured intervals begin with live births. To illustrate the potential variation in estimates obtained using different measures, consider the index outcome O3 in the figure. In this case, the birth-to-birth interval (O1 to O3) in Figure 1. would be converted to a birth-to-pregnancy interval of 39 minus nine months = 30 months. The inter-out- come interval for the same birth (O2 to O3) on the other hand would give a birth-to-pregnancy interval of 15 minus nine = six months. Similarly, from the beginning of the index pregnancy, P3, the birth-to- conception interval (O1 to P3) would be converted directly into birth-to-pregnancy interval but so would inter-pregnancy interval (O2 to P3), giving a birth-to-pregnancy interval of 30 months in the former case, and six months in the latter case, even though the index pregnancy is the same. Where the preceding pregnancy is a live birth, this discrepancy does not arise. On average, however, for the rea- sons described, measures 1. and 3. will tend to yield somewhat longer birth-to-pregnancy intervals than measures 2. and 4. The degree of difference in the measures will depend on the population in question and the accuracy of the data. Because non-live births are often not recorded, researchers may have limited choices about which intervals they examine. Throughout this report, the intervals quoted refer to birth-to-pregnancy (BTP) intervals. Precise conversions from other measures to BTP intervals are not possible, for the reasons given above, and the quoted figures therefore give an approximate value only. 2.2 Outcomes measured The major groups of outcomes measured by the studies reviewed at the meeting were divided into maternal, perinatal, neonatal, post-neonatal, child, and post-abortion outcomes. The different mater- nal outcome measures are listed in Table 2, along with their definitions, as provided in the separate papers. The equivalent information for perinatal and neonatal outcomes is shown in Table 3, and for post- neonatal and child outcomes in Table 4. Definitions of the outcome measures were not always given in the papers and, where given, definitions were not always consistent between studies. Of the 39 differ- ent outcomes measured in the six papers, 18 were included in more than one. 9Working groups examined the evidence pertain- ing to a specific set of outcomes. Their findings are presented below, along with information about the evidence examined and the discussions arising from the evidence. Table 5 shows a simplified summary of the main evidence for maternal, perinatal, infant and child outcomes. 3.1 Maternal outcomes 3.1.1 Summary On the basis of the evidence available, the work- ing group concluded that intervals of less than six months between birth and subsequent pregnancy are associated with maternal morbidity and possibly also maternal mortality. Women with BTP intervals over 59 months have an elevated risk of morbidities including pre-eclampsia. 3.1.2 Evidence: maternal mortality There was some evidence that short BTP spac- ing (<12 months) might increase risk of maternal mortality (1), and although the Matlab data did not reach statistical significance, results were in the same direction (3). Matlab data also showed an increase in mortality when BTP intervals were very long (>75 months) (3). 3.1.3 Evidence: maternal morbidity For maternal morbidity, very long intervals were associated with more adverse effects than very short intervals, although there was no clear cut-off point at which long intervals became risky. For instance, some studies included in the systematic review showed an association between long BTP intervals (of varying lengths, but all were over approximately 60 months) and pre-eclampsia (1). One study also showed an association with intrapartum fever (1). Very short intervals (<six months BTP), on the other hand, were associated with premature rupturing 3. MAIN FINDINGS FOR EACH GROUP OF OUTCOMES of membranes (1), and in single studies only, with anaemia (4) and puerperal endometritis (1). The systematic literature review reported studies sug- gesting that among women with previous low- transverse caesarean section who had undergone a trial of labour, there was also increased risk of uterine rupture with short BTP intervals (<16 months) (1). Data from Matlab showed elevated risk of pre- eclampsia and high blood pressure with very short (<six months) and long (>75 months) BTP intervals, although there was no effect on premature ruptur- ing of membranes, anaemia or bleeding (3). There was no consistent evidence about the rela- tionship between maternal anthropometric status and birth spacing (4). 3.1.4 Discussion points raised • In Matlab, risk of induced abortion was higher after short BTP intervals (3). In countries where access to induced abortion is highly restricted and unsafe abortion is prevalent, induced abor- tion is associated with maternal mortality and morbidity. It was noted that potentially important links between induced abortion, birth spacing and maternal outcomes were not fully addressed in the studies reviewed. • The group noted that there is relatively little evi- dence available about the relationship between maternal mortality and birth-spacing intervals and this should be borne in mind for future research. 3.2 Perinatal outcomes 3.2.1 Summary The working group concluded that risk of prematu- rity, fetal death, low birth weight and small size for gestational age are highest for BTP intervals shorter than 18 months. Intervals of over 59 months are also associated with these adverse outcomes. Report of a WHO Technical Consultation on Birth Spacing 10 Report of a WHO Technical Consultation on Birth Spacing 3.2.2 Evidence: miscarriage, induced abortion, stillbirth In the DaVanzo et al. study, very short BTP intervals (<six months) were associated with higher risk of stillbirths and miscarriages. There were reduced odds of stillbirth if the preceding pregnancy ended in miscarriage, suggesting that women with non- live births may have been taking precautions to pre- vent it happening again (3). The odds of having an induced abortion were 10 times that of having a live birth if the BTP interval was very short (<six months) (3), presumably reflecting the higher proportion of unintended pregnancies occurring at shorter compared with longer intervals. Some but not all studies included in the systematic review showed increased risk of fetal death with short intervals (<15 months), and there was some evidence that long intervals (various but all >35 months BTP) were also associated with some elevation in risk (1). In the meta-analysis, the lowest risk was among the group with 18–36 months BTP intervals, and the highest risk was with very short (<six months), and very long (>71 months) intervals (1). 3.2.3 Evidence: pre-term live birth, small size for gestational age, low birth weight, low Apgar scores at five minutes Several, but not all studies included in the system- atic literature review showed an increased risk of pre-term live birth, small size for gestational age and low birth weight when BTP intervals were shorter than 18 months (1). Some also showed increased risk with long intervals (various but >47 months) (1). In the meta-analysis, the lowest risk was associated with BTP intervals of 18–23 months, with the highest risk for intervals under 18 and over 59 months (1). Data from the USA showed elevated risk of these three outcomes with BTP intervals of <18 months and of >60 months (7). The Matlab data showed that very short (<six months) BTP intervals were associated with shorter gestation times (3). Risk of pre-term live birth was also elevated with short (<six months) post-abortion pregnancy intervals. No association was found between spacing and low Apgar scores at five minutes (1; 2). 3.2.4 Discussion points raised • Definitions of terms and measurement of inter- vals was not consistent across studies, making comparisons difficult. 3.3 Neonatal mortality (deaths under age 28 days 3 ) 3.3.1 Summary Most of the data indicated that risk of neonatal mor- tality was highest for BTP intervals of under approxi- mately 18 months, but some also suggested ele- vated risk at longer intervals (see Table 5 and below). The group concluded that the lowest risk was for BTP intervals of at least 27 months. The group noted certain limitations of the evidence (see 3.3.3 on the following page). 3.3.2 Evidence: neonatal mortality The Matlab data showed a higher risk of neonatal death with very short BTP intervals (<nine months) compared with longer intervals (27–50 months), with risk remaining somewhat elevated for intervals 15–27 months long (3). Some studies included in the Rutstein et al. systematic literature review (6) also indicated that short BTP intervals (<18 months) were associated with higher risk. DHS data from 17 devel- oping countries also showed increased risks of neo- natal mortality with intervals shorter than around 21 months; risks increased as intervals decreased until relative odds of mortality reached a level over twice as high at under nine months compared with the lowest risk category, 27–38 months BTP intervals (5). The Rutstein et al. meta-analysis (6) found that, com- pared with the reference category of BTP intervals of 28 or more months, odds ratios of neonatal mor- tality were: OR=2.3 (1.9–2.9) for <nine months and OR=1.2 (1.1–1.4) for 9–27 months. The meta-regres- sion analysis by the same authors showed similar 3 The Rutstein et al. meta-analysis and the Rutstein DHS analysis define this measure as “death in the first month of life” and “death in the first 30 days of life”, respectively (see Table 4). 11 Report of a WHO Technical Consultation on Birth Spacing results (6). In the Conde-Agudelo meta-analysis, how- ever, excess risk of early neonatal mortality (deaths in the first week of life) was found with BTP intervals of under 18 months, and not with greater intervals. Conde-Agudelo’s meta-regression analysis showed similar results to the meta-analysis he reported in the same paper (1). The Conde-Agudelo review noted some evidence of detrimental effects of long (> approximately 59 months) BTP intervals on early neonatal mortality (1), but such effects were not found in the Matlab study (3) or in the DHS data (5). 3.3.3 Discussion points raised The group noted the following concerns: • Interpretation of the data for this outcome was subject to the specific analytical techniques in one meta-regression analysis. Otherwise the evidence to discriminate within the interval 18–27 months was limited. Further checks were requested from the authors to ensure the conclusions from the meta-regression are robust (see final discussion point in this section). The outcome of this addi- tional work will be considered at a future date. • The Rutstein et al (draft, 2004) (6) meta-analysis evidence was largely influenced by two studies: DaVanzo et al. (draft, no date) (3) and Rutstein (draft 2004) (5), both of which were also consid- ered separately. • Many social factors are likely to be important but data for these were not available, e.g. violence, economic factors, access to medical care. For example, higher income might be associated with ability to achieve longer spacing through greater access to contraception services and also with the ability to afford better nutrition and healthcare, both of which would independently affect the survival of the neonate. Further discussion of the evidence for this outcome included the following observations: • Two analyses found the risk of neonatal death was highest for intervals shorter than 27 months: DaVanzo et al. (draft, no date) (3) and Rutstein et al. meta-analysis (draft 2004) (6). In the DaVanzo et al. analysis, however, the more risky category was 15–27 months, and in Rutstein et al. it was 9–27 months. Neither study therefore was able to distinguish between intervals longer and shorter than 18 months. Thus, it was unclear whether or not the findings simply reflected the excess risk associated with intervals under 18 months found in other studies, rather than indicating excess risk for the entire range of intervals included up to 27 months. Further analysis was requested to clarify this point. • It was noted that the data from cross-sectional surveys (5) showed a higher level of risk than data from the prospective Matlab study (3) (see Table 6). This was surprising because the cross-sectional data could take more potential confounding fac- tors into account, which would be expected to reduce the measured risk, not increase it. Cross- sectional data are more vulnerable to recall bias than prospective data, particularly when women are asked to recall dates of births and deaths from a long time before the survey, as in this case, where all births and deaths included occurred at least five years before the survey. The figures in Table 6 may differ because the cross-sectional data refer to the entire country while the pro- spective data only apply to Matlab. Nevertheless, the figures are very different and some partici- pants were concerned that this difference indi- cated the presence of an important study-design effect. Some participants were therefore reluctant to rely only on cross-sectional data in reaching conclusions and making recommendations. 12 Report of a WHO Technical Consultation on Birth Spacing • In the Rutstein DHS analysis (draft 2004) (5), con- fidence intervals were not adjusted to account for the clustered survey design, and confidence intervals were not provided in tables for each category of birth spacing. The author was asked to adjust the figures, provide the missing con- fidence intervals, and provide data on whether or not there were more missing data for dead than for surviving infants and children. Censored cases were omitted in the analysis and the author was asked to examine whether the observed relationships would hold if censored cases were included using Cox regression. It was also noted that because the analysis included 17 develop- ing countries, and did not use the most recently available data, it would be useful to know if the relationships applied in more recent surveys and in countries with comparatively low mortality. • The meetings’ discussions relied heavily on the findings from meta-regression curves. Some of these meta-regression analyses appeared to double-count data, and some low-quality studies appeared to have been included. There was high heterogeneity reported, and three key limitations were identified: variation in data quality; varia- tion in population type examined (some studies were hospital-based, some population-based); variation in confounding variables included in the different studies. Over and above the limita- tions of the available data, it was also not clear to what extent the results of the meta-regression analyses were sensitive to the specific techniques used to plot them. For instance, figures obtained from cross-sectional studies and those from pro- spective studies were combined, which might not be appropriate, and relevant information about study design was not given. The analyses were heavily weighted towards the large stud- ies included, two of which were already being reviewed separately (3; 5). The researchers also elected to use the mid-point of the intervals in their analyses and used an arbitrary multiplier for the open-ended intervals. These decisions are likely to have affected the overall results but no information was given about the estimated size of these effects or why these techniques were chosen for this dataset. Researchers were asked to conduct further analyses to ensure the find- ings from the meta-analyses were robust. 3.4 Post-neonatal outcomes 3.4.1 Summary Based on available data, the working group con- cluded that post-neonatal survival increases if the BTP interval is at least 15 months. Survival may be improved with BTP intervals of 27 months or greater. 3.4.2 Evidence: post-neonatal mortality (deaths from 28 days up to one year) In Matlab, there was an increased risk of post-neo- natal mortality where BTP intervals were shorter than 15 months. The highest risk of post-neonatal mortality was associated with <six month intervals (relative risk compared with 27–50 months intervals was around 1.8) (3). Some studies in the systematic review showed increased risk with BTP intervals of under 15 months, and some showed the reverse: risk of mortality declined with short (<19 months) inter- vals (6). The meta-analysis, which used data from four studies plus the Rutstein (draft, no date) (5) and DaVanzo et al. (draft, no date) (3) studies included in this review, found that compared with the reference category of 28 or more months from birth-to-preg- nancy, 9–27 months intervals were associated with higher risk OR=1.6 (1.4–1.9), as were <nine months BTP intervals: OR=2.3 (1.9–2.9) (6). 13 Report of a WHO Technical Consultation on Birth Spacing 3.4.3 Evidence: infant mortality (deaths in first year of life) Findings for infant mortality were similar to, but less consistent than, those of post-neonatal mortal- ity. For instance, in the systematic literature review, some but not all studies showed increased risk of infant mortality at intervals under approximately 15 months (6). The meta-analysis indicated that the increased risk occurred with BTP intervals under 27 months, and the meta-regression suggested increased risk with intervals under 29 months (6). The Matlab data show excess risk associated with BTP intervals shorter than nine months but not with longer intervals (3). 3.4.4 Discussion points raised • As in the case of the research on neonatal mor- tality mentioned above, there was a discussion about whether or not intervals longer than 15 months could be considered risky. The studies were often unable to distinguish effects of differ- ent intervals between 15 and 27 months long. Thus, while an effect might be present, it was not clear from the studies where the cut-off for excess risk fell within this range. • The same discussion points about aspects of the meta-analyses and the other studies arose as for neonatal mortality findings (see above), and the point was made again here that reliance on cross-sectional data might unduly influence the findings (see above and Table 6). As mentioned above, clarification of these points was requested from the researchers. 3.5 Childhood outcomes 3.5.1 Summary The studies indicated that longer BTP intervals were associated with lower mortality, even at very long intervals. Nevertheless, some participants pointed out that the evidence concerning birth-spacing inter- val length and childhood deaths (between ages one and five years) was less clear than for infant deaths because of the smaller number of studies, and the fact that the meta-analysis in the Rutstein et al. (draft 2004) (6) paper was dominated by cross-sectional data. Furthermore, the possible causal mechanisms are poorly understood. The anthropometric evidence is inconclusive (4), and the results from Rutstein’s DHS (5) analysis reveal considerable variability between countries and modest averaged effects of short pre- ceding interval length on stunting and underweight. Meeting participants did not come to a consensus about interpretation of the evidence for this out- come. 3.5.2 Evidence: child nutrition The review showed there are inconsistent findings for the relationship between child nutrition outcomes and birth spacing. Some studies showed positive associations, some negative, and some showed no effect at all (4). In the DHS analysis, no significant results were found for wasting (5), although short BTP intervals (exact length not specified) were, in a minority of countries, associated with underweight (two countries) or stunting (two countries) or both (four countries) (5). 3.5.3 Evidence: child mortality (deaths in age group 1–4 years) The Matlab study indicated that there was increased child mortality with BTP intervals of under 26 months. Having little household space and no education, however, had larger effects than did short intervals. 14 Report of a WHO Technical Consultation on Birth Spacing Female children were at higher risk of child mortality than male, despite male children having higher risk of first-week mortality (3). Some studies included in the systematic literature review found increased risk of child mortality with BTP intervals of around <24 months, although three other studies recorded a decrease in mortality risk with shorter intervals (6). The meta-analysis, which included three stud- ies, plus the Rutstein and DaVanzo studies reported here, found that, compared with the reference group of 28 or more months BTP intervals, there was increased risk of child mortality associated with BTP intervals of 9–25 months: OR=1.5 (1.3–1.7), and with intervals of <nine months: OR=1.9 (1.2–2.9) (6). 3.5.4 Evidence: under-5 mortality (all deaths under age 5) The Rutstein (5) and Rutstein et al. (6) studies exam- ined this outcome, and the findings were very simi- lar to those for child mortality, which this measure encompasses. The systematic literature review indi- cated some risk was associated with BTP intervals of under 15 months, and the meta-analysis showed that, compared with the reference category of 28 or more month intervals, 9–27 month intervals were associated with increased risk: OR=1.4 (1.2–1.7), as were intervals of <nine months: compared with a reference category of 27 or more months: OR=2.1 (1.5–3.1); the meta-regression analysis showed declining risks associated with increasing intervals for intervals shorter than 40 months (6). In the DHS analysis, compared with the reference category of 27–32 months BTP intervals, longer intervals were associated with lower mortality (e.g. 51 or more months: OR=0.8). Shorter BTP intervals were associated with increased under-five mortality (e.g. 15–20 months: OR=1.6; <nine months: OR=3.0) (5) (confidence intervals not provided). 3.5.5 Discussion points raised • The effects of birth spacing on child mortality are uncertain because possible causal mechanisms are unclear. It would be expected that any bio- logical effect of spacing would occur near to the time of pregnancy or birth, the reverse of what is observed here. This suggests that child outcomes are more susceptible to environmental factors, some of which might be related to spacing (perhaps via sibling competition) or possibly to long-lasting effects carried through from preg- nancy or birth. Alternatively, other unmeasured environmental factors might be confounding the relationship. • The limitations of cross-sectional data were of particular concern with this outcome, especially in terms of the imputation of missing dates. Researchers were asked to give more information about the procedures used for imputation, level of imputation and the likely impact on the results observed. • Participants also asked for more information about the distribution of causes of death, whether having an older sibling increased risks, and whether this varied by sex. 3.6 Post-abortion spacing 3.6.1 Summary Based on the evidence available, the working group concluded that after a miscarriage or induced abor- tion, intervals of less than six months before the sub- sequent pregnancy are associated with increased risk of adverse maternal and perinatal outcomes. 3.6.2 Evidence: post-abortion spacing One study (2) examined the effects of post-abortion spacing, analysing data from hospital records for women who delivered singleton infants in public hospitals. Data came from 18 Latin American coun- tries but two countries (Argentina and Uruguay) accounted for around 40% of all cases analysed. Intervals of shorter than six months between abor- tion and subsequent pregnancy were associated 15 Report of a WHO Technical Consultation on Birth Spacing with elevated risks of premature rupturing of mem- branes, anaemia and bleeding, pre-term and very pre-term births, and low birth weight, compared with longer intervals. There was no significant effect of post-abortion spacing on pre-eclampsia or on eclampsia, gestational diabetes, third trimester bleeding, post-partum haemorrhage, puerperal endometritis, small size for gestational age, non-live birth, or early neonatal mortality. 3.6.3 Discussion points raised Participants were concerned that there was only one study which provided evidence for post-abortion spacing outcomes. Nevertheless, they recognized that this study provides valuable guidance for post- abortion pregnancy-spacing interval recommenda- tions, being the only large-scale study available. Participants indicated that any recommendation must be considered in the context of the following limitations: • It was not possible to distinguish between spon- taneous and induced abortions. Given that the study was in Latin America, where induced abor- tions are legally restricted and frequently unsafe, this distinction would have been useful in assess- ing generalizability of the findings. • All data came from public hospitals and from one region. The data may therefore not be wholly applicable within the region or generalizable to other regions. • While the study was able to control for many confounding factors, it was not possible to take the following into account: history of previous pre-term delivery, gestational age at time of abor- tion, number of previous abortions, wantedness of pregnancy, sexual violence. 17The conclusions from the separate working groups set out above were presented in a final plenary session, where the strengths and limitations of the available evidence were discussed. Final recommen- dations were then agreed. 4.1 Strengths and limitations of the evidence The background papers, the expert reviews, and the discussions at the meeting comprised a timely anal- ysis of the latest available evidence on the effects of birth spacing on maternal and child health. Many world regions were covered by the studies reviewed, although not all outcomes were exam- ined for all regions. Participants mentioned the following limitations of the evidence available in addition to the technical points mentioned above. Causal mechanisms that might explain the associa- tions between birth spacing and the outcomes examined are not known. Hypotheses point to the possible importance of malnutrition, anaemia, repro- ductive tract infections, sub-fecundity and maternal depletion. Two possible links with infant and child mortality are competition for parental attention/ household resources or cross-infection, although neither explanation can muster decisive empirical support. 4 When causal mechanisms are unknown, “over-controlling” might be a problem. For instance, short spacing might lead to low birth weight which might in turn increase mortality risk. If low birth weight is included as a confounding factor in the analysis, some of the association between spacing and mortality will be masked. 4. CONCLUSIONS AND RECOMMENDATIONS The variety of the types and lengths of spacing used in the studies made them difficult to compare, and estimates of gestational age using self-report of last menstrual period can be inaccurate: few studies use estimates derived from ultrasonography or physical and neurological assessment of the newborn (1). Underreporting of non-live births may have led to inaccurate assessments of spacing. Generalizability of the study findings was discussed. For instance, it may be necessary to distinguish between well-nourished and malnourished mothers in any explanations of maternal and perinatal out- comes. Some women may benefit more than others from longer spacing between births. To what extent is the maternal depletion hypothesis relevant in the context of rising obesity, for example? Do interval lengths have different effects at different maternal ages? Does a good nutritional status ameliorate adverse consequences of short birth intervals? Taking into account these strengths and limitations, the group was split in terms of the recommended optimal interval after a live birth with some favour- ing 18 months and others 27 months. However, it was noted that WHO and UNICEF recommend that breastfeeding continue for up to two years or more and this observation helped the group reach an agreement. Evidence pertaining to the two-year breastfeeding recommendation, however, was not reviewed during the meeting and related factors such as recuperation periods for the woman and the effect of pregnancy on breastfeeding were not assessed. 4.2 Recommendations The particulars of the recommendations and the necessary caveats are noted in detail above. The group stressed that recommendations must be considered in conjunction with the preamble on the following page. 4 E.g. see Setty-Venugopal V, Upadhyay UD. Birth spacing: three to five saves lives. Population Reports, Series L 2002:pp 7-8. Report of a WHO Technical Consultation on Birth Spacing 18 Report of a WHO Technical Consultation on Birth Spacing Preamble Individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health services, child-rearing support, social and economic circumstances, and personal preferences in making choices for the timing of the next preg- nancy. Recommendation for spacing after a live birth After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, peri- natal and infant outcomes. 5 Rationale for the recommendation The studies presented at the meeting considered various maternal, infant and child health outcomes. For each outcome, different BTP intervals were asso- ciated with highest and lowest risks. To summarize, BTP intervals of six months or shorter are associated with elevated risk of maternal mortality. BTP inter- vals of around 18 months or shorter are associated with elevated risk of infant, neonatal and perinatal mortality, low birth weight, small size for gestational age, and pre-term delivery. Some “residual” elevated risk might be associated with the interval 18–27 months, but interpretation of the degree of this risk depended on the specific analytical techniques used in a meta-analysis. Otherwise, the evidence to discriminate within the interval of 18–27 months was limited. Further analysis was requested to clarify this point. This additional work will be considered at a future date. Evidence about relationships between birth spacing and child mortality was presented but the partici- pants did not reach agreement on its interpretation. On the basis of the evidence available at the time, the participants fell into two groups: those who con- sidered that this evidence indicated that the most suitable recommended interval was 18 months, and those who considered that the evidence supported a recommended interval of 27 months. Participants were, however, unanimous in agreeing that BTP intervals shorter than 18 months should be avoided. At the meeting, a compromise was reached between the two groups, who agreed that the rec- ommendation for the minimum interval between a live birth and attempting next pregnancy should be 24 months. The basis for the recommendation is that waiting 24 months before trying to become pregnant after a live birth will help avoid the range of BTP intervals associated with the highest risk of poor maternal, perinatal, neonatal, and infant health outcomes. In addition, this recommended interval was considered consistent with the WHO/UNICEF recommendation of breastfeeding for at least two years, and was also considered easy to use in programmes: “two years” may be clearer than “18 months” or “27 months”. Recommendation for spacing after an abortion After a miscarriage or induced abortion, the recom- mended minimum interval to next pregnancy is at least six months in order to reduce risks of adverse maternal and perinatal outcomes. Caveat This recommendation for post-abortion pregnancy intervals is based on one study in Latin America, using hospital records for 258,108 women delivering singleton infants whose previous pregnancy ended in abortion. Because this study was the only one available on this scale, it was considered important 5 Some participants felt that it was important to note in the report that, in the case of birth-to-pregnancy intervals of five years or more, there is evidence of an increased risk of pre-eclampsia, and of some adverse perinatal outcomes, namely pre-term birth, low birth weight and small infant size for gestational age. 19 Report of a WHO Technical Consultation on Birth Spacing to use these data, with some qualifications. Abortion events in the study included a mixture of three types – safe abortion, unsafe abortion and spontaneous pregnancy loss (miscarriage), and the relative pro- portions of each of these types were unknown. The sample was from public hospitals in Latin America only, with much of the data coming from two coun- tries (Argentina and Uruguay). Thus, the results may not be generalizable within the region nor to other regions, which have different legal and service con- texts and conditions. Additional research is recom- mended to clarify these findings. 4.3 Suggested areas for future research • Development of coherent theoretical frameworks explaining the possible causal mechanisms of birth spacing on outcomes, particularly child mortality, was identified as important for future research. • Analyses of relationships between birth spacing and maternal morbidity would be useful to add to the few existing studies. For instance, examina- tion of the effects of multiple short BTP intervals would be useful, as would be more detailed data on the effects of very long intervals. Further analysis of the relationship between birth spacing and maternal mortality would help confirm or refute existing findings, although it is acknowl- edged that this may often be unfeasible as it may require a very large number of cases. • There is a need to investigate the relationship between birth spacing and outcomes other than mortality, for instance, maternal and child nutri- tion outcomes, or impact on child psychological development. Also, it would be helpful to have information on possible benefits, as well as pos- sible risks, of particular spacing intervals. • More studies on the effects of post-abortion pregnancy intervals are needed in different regions. A distinction between induced and spontaneous abortion, and between safe and unsafe induced abortion, would be particularly helpful in future studies. • Good-quality longitudinal studies that take more potential confounding factors into account are needed to: 1. clarify the observed associations between birth-to-pregnancy intervals and maternal, infant and child outcomes; 2. estimate the potential level of bias in the use of different measures of intervals (birth-to-birth vs. inter-pregnancy interval, for instance); 3. clarify the potentially confounding effect of short intervals following a child death, both because of shortened breastfeeding and because parents may seek to replace the dead child. • Finally, there is a need to develop an evidence base for effective interventions to put birth- spacing recommendations into practice. 20 Ta bl e 1. S tu dy d es ig n, in te rv al ty pe s, in te rv al le ng th s a nd c on tr ol v ar ia bl es p er ta in in g to th e st ud ie s c on si de re d in th e re vi ew P ap er /A ut ho r( s) St ud y de si gn In te rv al ty pe s In te rv al le ng th s Co nt ro l v ar ia bl es Co nd e- A gu de lo (d ra ft , 2 00 4) Sy st em at ic re vi ew in cl ud in g 77 s tu di es : 5 7 co ho rt o r cr os s- se ct io na l a nd 2 0 ca se -c on tr ol s tu di es . 2 6 st ud ie s in U SA , r em ai ni ng 5 1 st ud ie s in L at in A m er ic a (2 2 co un tr ie s) , A si a (2 0 co un tr ie s) , A fr ic a (1 4 co un tr ie s) , E ur op e (s ev en co un tr ie s) , N or th A m er ic a (t w o co un tr ie s) , A us tr al ia . M ET A - A N A LY SI S of th re e ou tc om es u si ng s tu di es th at u se d in te r- pr eg na nc y in te rv al (I PI ), pr ov id ed d at a fo r f ou r o r m or e IP I st ra ta , p ro vi de d en ou gh d at a to c on st ru ct a 2 x2 ta bl e an d ca lc ul at e un ad ju st ed O R an d 95 % C I. O ut co m es a na ly se d: pr e- te rm b ir th (e ig ht s tu di es ); lo w b ir th w ei gh t ( fo ur s tu d- ie s) ; s m al l s iz e fo r g es ta tio na l a ge (s ev en s tu di es ). M ET A - RE G RE SS IO N A N A LY SI S al so in cl ud ed : e xa m in in g pr e- te rm bi rt h (1 5 st ud ie s) ; l ow b ir th w ei gh t ( 10 s tu di es ); sm al l s iz e fo r g es ta tio na l a ge (1 3 st ud ie s) ; f et al d ea th (s ev en s tu di es ); ea rly n eo na ta l d ea th (f ou r s tu di es ) Bi rt h- to -c on ce pt io n in te rv al , bi rt h- to -b ir th in te rv al , o r b ot h. M et a- an al ys is u se d in te r- pr eg - na nc y in te rv al Va rio us . I n m et a- an al ys is th ey u se < 6, 6 –1 1, 1 2– 17 , 18 –2 3, 2 4– 59 , 6 0 or m or e m on th s Va rio us . S tu di es h ad to h av e co nt ro lle d fo r a t l ea st m at er - na l a ge a nd s oc io ec on om ic s ta tu s (t he s oc io ec on om ic st at us v ar ia bl es w er e va ria bl e, b ut in cl ud ed o cc up at io n, w or k st at us , e du ca tio n le ve l, in co m e, h ou si ng “o r o th er va ria bl es ”) Co nd e- A gu de lo et a l. (p os t- ab or - tio n) (d ra ft , 20 04 ) Co ho rt s tu dy , r et ro sp ec tiv e, w om en d el iv er in g si ng le to n in fa nt s in p ub lic h os pi ta ls a nd w ho se p re vi ou s pr eg na nc y w as a bo rt ed Po st -a bo rt io n in te r- pr eg na nc y in te rv al 0– 2, 3 –5 , 6 –1 1, 12 –1 7, 1 8– 23 , 24 –5 9, ≥ 60 m on th s M at er na l a ge , p ar ity , m ot he r’s e du ca tio n, m ar ita l s ta tu s, ci ga re tt e sm ok in g, p re -p re gn an cy b od y m as s in de x (B M I), w ei gh t g ai n du rin g pr eg na nc y, h is to ry o f l ow b ir th w ei gh t (L BW ), pe rin at al d ea th , c hr on ic h yp er te ns io n, g es ta tio na l ag e at fi rs t a tt en da nc e fo r a nt en at al c ar e, n um be r o f an te na ta l v is its , g eo gr ap hi c ar ea , h os pi ta l t yp e, y ea r o f de liv er y. T w o ou tc om e m ea su re s: e ar ly n eo na ta l d ea th an d lo w A pg ar s co re , w er e al so a dj us te d fo r b ir th w ei gh t an d ge st at io na l a ge D aV an zo e t a l. (d ra ft , n o da te ) Lo ng itu di na l, D em og ra ph ic S ur ve ill an ce S ys te m (D SS ) M at la b, B an gl ad es h In te r- ou tc om e an d in te r- bi rt h in te rv al s In te r- ou tc om e in te rv al s of < 15 , 15 –1 7, 1 8– 23 , 24 –3 5, 3 6– 59 , 60 –8 3, 8 4 or m or e m on th s Va rio us , d ep en di ng o n an al ys is . C H IL D A N D P ER IN AT A L: m at er na l a ge , p ar ity , m on th o f b ir th , w an te dn es s of p re g- na nc y, re si de nc e in tr ea tm en t a re a, m at er na l e du ca tio n, pa te rn al e du ca tio n, re lig io n, h ou se ho ld s pa ce , o ut co m e of p re ce di ng p re gn an cy , i nt er ac tio ns b et w ee n sh or te st in te rv al a nd o ut co m e of p re ce di ng p re gn an cy , c al en da r ye ar , s ub se qu en t p re gn an cy a nd b ir th . A ls o br ea st fe ed in g an d im m un iz at io n fo r t he w om en in th e tr ea tm en t a re a. M AT ER N A L M O RT A LI TY : a ge , g ra vi di ty , p rio r e xp er ie nc es of c hi ld d ea th a nd p re gn an cy lo ss , e du ca tio n, h ou se ho ld sp ac e, a nd fo ur ti m e pe rio ds (1 98 2– 20 02 ). M AT ER N A L M O RB ID IT Y: a s fo r m or ta lit y, b ut n ot ti m e pe rio ds , a nd in cl ud in g re lig io n. N B th e m or bi di ty s ec tio n on ly in cl ud es w om en w ho a tt en d an te na ta l c ar e in th e tr ea tm en t a re a Report of a WHO Technical Consultation on Birth Spacing 21 P ap er /A ut ho r( s) St ud y de si gn In te rv al ty pe s In te rv al le ng th s Co nt ro l v ar ia bl es D ew ey & C oh en (d ra ft , 2 00 4) Re vi ew o f 2 7 pa pe rs re pr es en tin g 33 s tu di es : fi ve p ro - sp ec tiv e co ho rt s tu di es , 2 7 cr os s- se ct io na l s tu di es , t hr ee ca se -c on tr ol s tu di es (t w o co nt ai ne d bo th c oh or t a nd c as e- co nt ro l s tu di es ) In te r- pr eg na nc y in te rv al (t w o st ud ie s) , i nt er -b ir th in te rv al , re cu pe ra tiv e in te rv al (d ur at io n of th e no n- pr eg na nt , n on -la c- ta tin g in te rv al ) Va rio us in th e di f - fe re nt s tu di es Va rio us a nd n ot c on si st en t b ut in cl ud in g ch ild a ge , s ex , m at er na l a ge , p ar ity , m at er na l e du ca tio n. O nl y si x co n- tr ol le d fo r b re as tf ee di ng , t hr ee fo r m at er na l h ei gh t Ru ts te in (D H S) (d ra ft , n o da te ) Cr os s- se ct io na l D em og ra ph ic a nd H ea lth S ur ve ys , n at io n- al ly re pr es en ta tiv e, 1 7 co un tr ie s: B an gl ad es h, B ol iv ia , C ot e d’ Iv oi re , E gy pt , G ha na , G ua te m al a, In di a, In do ne si a, K en ya , M or oc co , N ep al , N ig er ia , P er u, P hi lip pi ne s, T an za ni a, U ga nd a, Z am bi a Bi rt h- to -b ir th in te rv al s < 18 , 1 8– 23 , 24 –2 9, 3 0– 35 , 3 6– 41 , 4 2– 47 , 4 8– 53 , 54 –5 9, 6 0 or m or e m on th s U N D ER -F IV E M O RT A LI TY : S ex o f c hi ld , b ir th o rd er , m ul ti - pl ic ity o f b ir th , m ot he r’s a ge a t b ir th , s ur vi va l o f p re ce di ng ch ild b y da te o f c on ce pt io n, p re na ta l c ar e pr ov id er , t im - in g of fi rs t A N C v is it (if a ny ), nu m be r o f p re na ta l t et an us to xo id v ac ci na tio ns , d el iv er y at te nd an t, ur ba n- ru ra l r es i- de nc e, m ot he r’s e du ca tio n, in de x of h ou se ho ld w ea lth . N EO N AT A L A N D IN FA N T M O RT A LI TY : A s fo r u nd er -fi ve p lu s w an te dn es s of c hi ld , w he th er b ir th re su lt of c on tr ac ep tiv e fa ilu re . S TU N TI N G a nd U N D ER W EI G H T: A s fo r u nd er -fi ve bu t n ot m ul tip lic ity o f b ir th , a nd a dd in g ty pe o f i nf an t fe ed in g, d rin ki ng w at er s up pl y, ty pe o f t oi le t, w he th er ho us eh ol d ha s re fr ig er at or Ru ts te in e t a l. (d ra ft , 2 00 4) Sy st em at ic re vi ew a nd m et a- an al ys is o f 6 5 st ud ie s. T he re vi ew fo cu se d on c oh or t, cr os s- se ct io na l, or c as e- co nt ro l st ud ie s. In cl ud es 2 9 st ud ie s fr om A si a (n in e of w hi ch w er e fr om M at la b, B an gl ad es h) , 1 5 fr om s ub -S ah ar an A fr ic a, 1 1 fr om L at in A m er ic a an d th e Ca rib be an , t w o fr om M id dl e Ea st , t hr ee fr om E ur op e (t w o of w hi ch w er e hi st or ic al co ho rt s) , fi ve m ul ti- re gi on al . I nc lu de s M ET A -A N A LY SI S of fiv e m or ta lit y ou tc om es : n eo na ta l ( si x st ud ie s) , p os t- ne o- na ta l ( si x st ud ie s) , i nf an t ( fiv e st ud ie s) , c hi ld (t hr ee s tu di es ) an d un de r- fiv e (t hr ee s tu di es ) m or ta lit y. A ls o, M ET A - RE G RE SS IO N A N A LY SI S of s am e ou tc om es , u si ng 2 8 st ud - ie s (n um be r o f s tu di es p er o ut co m e no t s pe ci fie d) 50 u se d pr ec ed in g bi rt h in te rv al , n in e pr ec ed in g in te r- pr eg na nc y in te rv al , e ig ht s uc - ce ed in g bi rt h in te rv al , t hr ee su cc ee di ng b ir th -t o- co nc ep - tio n in te rv al , th re e w he th er or n ot th er e w as s uc ce ed in g co nc ep tio n in th e m or ta lit y ra ng e (n um be rs e xc ee d to ta l nu m be r o f s tu di es ; t he re as on fo r t hi s is n ot s ta te d in th e te xt , bu t i t i s po ss ib le th at m ul tip le m ea su re s m ay h av e be en u se d in in di vi du al s tu di es ) Va rio us . I n m et a- an al ys is th ey u se 18 m on th s an d 37 m on th s as th e cu t- off b et w ee n th e th re e ca te go - rie s: < 18 m on th s, 18 –3 6 m on th s, an d ≥ 3 7 m on th s bi rt h- to -b ir th in te rv al s Va rio us . S tu di es h ad to h av e co nt ro lle d fo r a t l ea st m at er - na l a ge a nd s oc io ec on om ic s ta tu s (o ne s tu dy u se d bi rt h or de r r at he r t ha n m at er na l a ge a nd th e so ci oe co no m ic st at us v ar ia bl es w er e di ve rs e) Report of a WHO Technical Consultation on Birth Spacing Ta bl e 1. c on tin ue d 22 Report of a WHO Technical Consultation on Birth Spacing P ap er /A ut ho r( s) St ud y de si gn In te rv al ty pe s In te rv al le ng th s Co nt ro l v ar ia bl es Zh u (d ra ft , 2 00 4) Tw o cr os s- se ct io na l s tu di es (C S) in U ta h an d M ic hi ga n, o ne re tr os pe ct iv e co ho rt (R C ) s tu dy in M ic hi ga n, a ll us in g bi rt h re co rd s In te r- pr eg na nc y in te rv al 0– 5, 6 –1 1, 1 2– 17 , 18 –2 3, 2 4– 59 , 60 –1 19 , 1 20 o r m or e m on th s (M ic hi ga n C S st ud y us ed 60 –9 5, 9 6– 13 6 m on th s fo r t he up pe r i nt er va ls ) U TA H C S: m at er na l a ge a t d el iv er y, o ut co m e of m os t r ec en t re co gn iz ed p re gn an cy , n um be r p re vi ou s liv e- bo rn in fa nt s st ill a liv e, n um be r p re vi ou s liv e- bo rn in fa nt s w ho h ad di ed , n um be r p re vi ou s sp on ta ne ou s or in du ce d ab or tio ns , he ig ht , p re -p re gn an cy w ei gh t, w ei gh t g ai n du rin g pr eg - na nc y, tr im es te r a t w hi ch p re na ta l c ar e st ar te d, n um be r of p re na ta l c ar e vi si ts , m ar ita l s ta tu s, e du ca tio n, ra ce /e th - ni c gr ou p, re si de nc e (r ur al /u rb an ), to ba cc o us e du rin g pr eg na nc y, a lc oh ol u se d ur in g pr eg na nc y M IC H IG A N C S: (N B po pu la tio n di vi de d in to w hi te a nd A fr ic an -A m er ic an gr ou ps ) a ge a t d el iv er y, m ar ita l s ta tu s, e du ca tio n, a de - qu ac y of p re na ta l c ar e, o ut co m e of p re ce di ng p re gn an cy (i. e. li ve b ir th o r s til lb ir th ), to ta l n um be r o f p re vi ou s pr eg - na nc ie s, to ba cc o us e du rin g pr eg na nc y, a lc oh ol u se d ur in g pr eg na nc y M IC H IG A N R C : p re ce di ng in fa nt ’s bi rt h w ei gh t, pa te rn al a ck no w le dg m en t o n bi rt h ce rt ifi ca te , m ot he r’s ag e at d el iv er y, ra ce , e du ca tio n, a de qu ac y of p re na ta l c ar e ut ili za tio n, o ut co m e of p re ce di ng p re gn an cy (l iv e bi rt h, st ill bi rt h) , t ob ac co a nd a lc oh ol u se d ur in g pr eg na nc y Report of a WHO Technical Consultation on Birth Spacing Ta bl e 1. c on tin ue d 23 Ta bl e 2. D efi ni tio ns o f m at er na l o ut co m es u se d in th e st ud ie s ( bl an k ce ll in di ca te s o ut co m e no t c on si de re d by st ud y) M at er na l o ut co m es P ap er /A ut ho r( s) M at er na l an th ro po - m et ri c st at us Pr e- ec la m ps ia H ig h bl oo d pr es su re Pr em at ur e ru pt ur in g of m em br an es Pr ot ei nu ri a Ed em a A na em ia Ec la m ps ia Po st pa rt um ha em or - rh ag e U te ri ne ru pt ur e Pl ac en ta ac cr et a Co nd e- A gu de lo (d ra ft , 20 04 ) no d efi ni tio n no d efi ni tio n no d efi ni tio n no d efi ni tio n no d efi ni tio n ut er in e ru pt ur e in w om en w ith p re vi - ou s lo w -t ra ns ve rs e C -s ec tio n w ho h ad un de rg on e a tr ia l of la bo ur no d efi ni tio n Co nd e- A gu de lo e t a l. (p os t- ab or tio n) (d ra ft , 2 00 4) IC D -1 0 co de 01 4 IC D -1 0 co de 04 2 IC D -1 0 co de 09 9. 0 IC D -1 0 co de 01 5 IC D -1 0 co de 07 2 D aV an zo e t a l. (d ra ft , n o da te ) an y tw o of th e co nd iti on s of e de m a, pr ot ei nu ria , or h ig h bl oo d pr es su re di as to lic 90 m m H g or gr ea te r cl in ic al cl in ic al cl in ic al cl in ic al D ew ey & Co he n (d ra ft , 20 04 ) de fin iti on s va rie d on e st ud y: ha em og lo bi n < 11 0g /L a t an y tim e du rin g pr eg - na nc y; o th er s m ea su re d di ffe re nt tim es Ru ts te in (D H S) (d ra ft , n o da te ) Ru ts te in e t a l. (d ra ft , 2 00 4) Zh u (d ra ft , 20 04 ) Report of a WHO Technical Consultation on Birth Spacing 24 M at er na l o ut co m es (c on ti nu ed ) Pa pe r/ A ut ho r( s) M at er na l in fe ct io n Pu er pe ra l en do m et ri ti s G es ta ti on al di ab et es Bl ee di ng du ri ng p re g- na nc y In tr ap ar tu m fe ve r M at er na l m or ta lit y Co nd e- A gu de lo (d ra ft , 20 04 ) no d efi ni tio n no d efi ni tio n no d efi ni tio n th ird tr im es - te r b le ed in g no d efi ni tio n no d efi ni tio n Co nd e- A gu de lo e t a l. (p os t- ab or tio n) (d ra ft , 2 00 4) IC D -1 0 co de 08 5 IC D -1 0 co de 02 4. 4 IC D -1 0 co de s 04 4. 1 an d 04 5 D aV an zo e t a l. (d ra ft , n o da te ) no d efi ni tio n de at h du rin g pr eg na nc y or in th e 42 d ay s fo l - lo w in g pr eg na nc y fr om pr eg na nc y- re la te d or bi rt h- re la te d ca us es D ew ey & Co he n (d ra ft , 20 04 ) Ru ts te in (D H S) (d ra ft , n o da te ) Ru ts te in e t a l. (d ra ft , 2 00 4) Zh u (d ra ft , 20 04 ) Report of a WHO Technical Consultation on Birth Spacing Ta bl e 2. c on tin ue d 25 Ta bl e 3. D efi ni tio ns o f p er in at al a nd n eo na ta l o ut co m es u se d in th e st ud ie s ( bl an k ce ll in di ca te s o ut co m e no t c on si de re d by st ud y) Pe ri na ta l o ut co m es Pa pe r/ A ut ho r( s) A bo rt io n N on -li ve bi rt h M is ca rr ia ge St ill bi rt h Pr e- te rm li ve bi rt h Sm al l f or ge st at io na l ag e Lo w b ir th w ei gh t Lo w A pg ar sc or es a t fi ve m in Ea rl y ne on a- ta l m or ta lit y La te n eo - na ta l m or - ta lit y N eo na ta l m or ta lit y Pe ri na ta l de at h Co nd e- A gu de lo (d ra ft , 2 00 4) “f et al de at h” (n o de fin iti on ) no d efi ni tio n no d efi ni tio n no d efi ni tio n sc or e of un de r s ev en no d efi ni tio n no d efi ni - tio n Co nd e- A gu de lo et a l. (p os t- ab or tio n) (d ra ft , 2 00 4) de liv er y of d ea d ba by a t or b ef or e 20 -w ee k ge st at io n de liv er y at < 37 w ee ks ge st at io n; 32 w ee ks fo r “v er y pr e- te rm ” < 10 th p er - ce nt ile fo r ge st at io na l ag e an d ge nd er us in g W il- lia m s et a l. re fe re nc e cu rv e liv e ba by < 25 00 g at bi rt h sc or e of un de r s ev en de at hs in fir st s ev en da ys o f l ife D aV an zo e t al . ( dr af t, no da te ) in du ce d ab or tio n no d efi ni tio n no d efi ni tio n no d efi ni tio n de at hs in fir st w ee k of lif e de at hs in w ee ks 2 –4 of li fe o f th os e su r- vi vi ng fi rs t w ee k D ew ey & C oh en (d ra ft , 2 00 4) Ru ts te in (D H S) (d ra ft , no d at e) de at hs in fi rs t 3 0 da ys o f lif e Ru ts te in e t al . ( dr af t, 20 04 ) de at hs in da ys 0 –6 de at hs in fi rs t m on th o f lif e Zh u (d ra ft , 20 04 ) ge st at io na l ag e < 37 w ee ks < 10 th p er - ce nt ile in U ta h (U ta h C S st ud y) or in U SA (M ic hi ga n C S st ud y) < 25 00 g Report of a WHO Technical Consultation on Birth Spacing 26 Ta bl e 4 . D efi ni tio ns o f p os t- ne on at al a nd c hi ld o ut co m es u se d in th e st ud ie s ( bl an k ce ll in di ca te s o ut co m e no t c on si de re d by st ud y) Po st -n eo na ta l / ch ild o ut co m es Pa pe r/ A ut ho r( s) Po st -n eo na ta l m or ta lit y In fa nt m or ta lit y To dd le r m or ta lit y U nd er -2 m or ta lit y Ch ild nu tr it io n W as ti ng U nd er w ei gh t/ st un ti ng Ch ild m or ta lit y U nd er -5 m or ta lit y M or ta lit y at no n- st an da rd ag es Co nd e- A gu de lo (d ra ft , 2 00 4) Co nd e- A gu de lo e t a l. (p os t- ab or - tio n) (d ra ft , 20 04 ) D aV an zo e t al . ( dr af t, no da te ) de at hs in 5t h– 52 nd w ee k of li fe de at hs a m on g 1– 4 ye ar -o ld s of th os e su r- vi vi ng to a ge on e D ew ey & Co he n (d ra ft , 20 04 ) in cl ud es st un tin g, un de rw ei gh t Ru ts te in (D H S) (d ra ft , n o da te ) de at hs a t a ge 0– 11 m on th s z- sc or e le ss th an − 2 S. D . fo r w ei gh t- fo r- he ig ht st un tin g: he ig ht -f or - ag e z- sc or e < 2 S. D . b el ow th e m ea n; un de rw ei gh t: z- sc or e < − 2 S. D . f or w ei gh t- fo r- ag e de at hs to a ny ch ild re n ag e un de r 5 Ru ts te in e t a l. (d ra ft , 2 00 4 de at hs a t a ge 1– 11 m on th s Co nfl ic tin g de fin iti on : de at hs u nd er 12 m on th s vs . d ea th s at 0– 12 m on th s Co nfl ic tin g de fin iti on s: de at hs a t a ge 13 –2 3 m on th s vs . 1 2– 23 m on th s de at hs b ef or e 24 m on th s Co nfl ic tin g de fin iti on s: de at hs a t a ge 13 –5 9 m on th s vs .1 2– 59 m on th s D ea th s at a ge < 60 m on th s va rio us Zh u (d ra ft , 20 04 ) Report of a WHO Technical Consultation on Birth Spacing 27 Table 5. Simplified summary of the data presented at the June 2005 meeting, by author and by outcome. The numbers given are the upper and lower cut-offs (in months) for birth-to-pregnancy intervals (estimated from the intervals used in the separate studies) at which adverse outcomes were measured in each study. Where studies reported more than one finding, the most conservative estimates have been presented, i.e. the highest figures for the lower cut-off points, and the lowest figures for the upper cut-off points. Conde-Agudelo DaVanzo et al. Rutstein DHS Rutstein et al. review Zhu Maternal mortality SLR <6 >75 - - - Pre-eclampsia* SLR <4, >48 <6, >75 - - - Miscarriage - <6 - - - Fetal death SLR <15, >x Rgrsn <20, >66 - - - - Stillbirth - <6 - - - Pre-term birth SLR <15, >x Meta <18, >59 Rgrsn <15, >60 - - - <12, >120 Small size for gestational age SLR <18, >59 Rgrsn <15, >47 - - - <12, >24 Low birth weight SLR <12, >59 Rgrsn <20, >55 - - - <12, >59 Perinatal death SLR <23, >x - - - - Overall neonatal mortality - <9 <21 SLR <18, Meta <27** Rgrsn <28, >62 - Early neonatal mortality SLR <24, >59 Meta <17, >71 Rgrsn <18, >56 <17 - - - Late neonatal mortality - <27** - - - Post-neonatal mortality - <15 - SLR <15, Meta <27** Rgrsn <33, >75 - Infant mortality - <9 <27 SLR <15, Meta <27** Rgrsn <29 - Child mortality - <51 or <14 (2 different graphs) - SLR <15 Meta <27** Rgrsn <47 - Under-five mortality - - <60 SLR <15 Meta <27** Rgrsn <40 - SLR = figures from cases included in the systematic literature review, Meta = figures from the meta-analysis, Rgrsn = figures from the meta-regression analysis (by eye, where line indicates natural log of relative risk is 0.05 above lowest point), >x = evidence of risk at longer intervals but hard to summarize; - = not included in the study. * Very little information on maternal morbidities available. Other outcomes examined in single studies only. ** In the Rutstein et al. meta-analysis, the calculation for this figure included all intervals from 9–27 months. In the DaVanzo et al. study, it included all intervals 15–27 months. No analysis was available for more discrete categories. Report of a WHO Technical Consultation on Birth Spacing 28 Table 6. Relationship between birth-to-birth interval length and infant and child mortality, comparing data from Matlab DSS (DaVanzo et al., no date) and Bangladesh DHS (Rutstein, no date). Adjusted odds ratios with 36–41 months as reference group. Interval length Matlab DHS <18 months Neonatal 2.0 1.9 Infant 2.0 2.6 Under-five 1.8 2.7 18–23 months Neonatal (1.2) 1.5 Infant (1.2) 1.5 Under-five 1.4 1.8 24–29 months Neonatal (1.0) 1.4 Infant (1.0) 1.6 Under-five (1.1) 1.3 30–35 months Neonatal (0.9) 1.0 Infant (0.9) 1.0 Under-five (1.0) 1.1 Note: Matlab estimates are derived visually from DaVanzo et al., no date (Appen- dix Figure 1). Non-significant results are shown in brackets. Report of a WHO Technical Consultation on Birth Spacing 29 Report of a WHO Technical Consultation on Birth Spacing 1. Conde-Agudelo A (draft, 2004). Effect of birth spac- ing on maternal and perinatal health: a systematic review and meta-analysis. Report prepared for The Academy for Educational Development and The CATALYST Consortium. An amended and abridged version of this report (not reviewed by the WHO consultation) has now been published as follows: Conde-Agudelo A, Rosas-Bermúdez A, Kafury- Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA, 2006, 295:1809–1823. 2. Conde-Agudelo A, Belizán, JM, Breman R, Brock- man SC, Rosas-Bermudez A (draft, 2004). Effect of the interpregnancy interval after an abortion on maternal and perinatal health in Latin America. This paper has now been published as follows: Conde-Agudelo A, Belizán, JM, Breman R, Brock- man SC, Rosas-Bermudez A. Effect of the inter- pregnancy interval after an abortion on maternal and perinatal health in Latin America. Interna- tional Journal of Gynaecology and Obstetrics, 2005, 89:S34–S40 (supplement). 3. DaVanzo J, Razzaque A, Rahman M, Hale L, Ahmed K, Khan MA, Mustafa AG, Gausia K (draft, no date). The effects of birth spacing on infant and child mortality, pregnancy outcomes and maternal morbidity and mortality in Matlab, Bangladesh. 4. Dewey KG, Cohen RJ (draft, 2004). Birth-spacing literature: maternal and child nutrition outcomes. Report prepared for The Academy for Educational Development and The CATALYST Consortium. ANNEX 1. PAPERS REVIEWED AT THE MEETING 5. Rutstein SO (draft, no date). Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in develop- ing countries: evidence from the Demographic and Health Surveys. This paper has now been published as follows: Rutstein SO. Effects of preceding birth intervals on neonatal, infant and under-five years mortal- ity and nutritional status in developing countries: evidence from the Demographic and Health Surveys. International Journal of Gynaecology and Obstetrics, 2005, 89:S7–S24 (supplement). 6. Rutstein SO, Johnson K, Conde-Agudelo A (draft, 2004). Systematic literature review and meta-analy- sis of the relationship between interpregnancy or interbirth intervals and infant and child mortality. Report prepared for The CATALYST Consortium. Supplementary paper 7. Zhu BP (draft, 2004). Effect of interpregnancy inter- val on birth outcomes: findings from three recent US studies. This paper has now been published as follows: Zhu BP. Effect of interpregnancy interval on birth outcomes: findings from three recent US studies. International Journal of Gynaecology and Obstet- rics, 2005, 89:S25–S33 (supplement). 30 Report of a WHO Technical Consultation on Birth Spacing ANNEX 2. MEETING AGENDA Monday, 13 June 2005 Agenda item Presenter 09:00 – 09:30 Opening • Welcome remarks • Presentation of the Chair, Rapporteurs and participants • Background, objectives and expected outcomes of the meeting • Overview of the agenda Paul Van Look, Department of Reproduc- tive Health and Research, WHO Monir Islam, Department of Making Preg- nancy Safer, WHO Barbara Hulka, Chair 09:30 –10:00 The Birth Spacing Initiative • Presentation of the initiative • Introduction to the research Jim Shelton, Office of Population and Reproductive Health, USAID Agustín Conde-Agudelo, Principal Investi- gator 10:00 –12:45 Birth spacing and maternal and peri- natal health • Presentation Zhu BP. Effect of interpregnancy interval on birth outcomes: findings from three recent US studies • Presentation Conde-Agudelo A et al. The effect of the interpregnancy interval after an abortion: implications for maternal and perinatal health in Latin America • Commentary • Questions for clarification Bao-Ping Zhu Agustín Conde-Agudelo Anibal Faundes Technical Consultation: Review of Scientific Evidence for Birth Spacing 13–15 June 2005, WHO, Geneva Salle A, Main Building 31 Report of a WHO Technical Consultation on Birth Spacing Monday, 13 June 2005 – continued Agenda item Presenter Birth spacing and maternal and peri- natal health – continued • Presentation DaVanzo J et al. The effects of birth spacing on infant and child mortality, pregnancy outcomes, and maternal morbidity and mortality in Matlab, Ban- gladesh • Commentary • Questions for clarification • Presentation Dewey KG and Cohen RJ. Birth spac- ing literature review: maternal and child nutrition outcomes • Commentary • Questions for clarification Julie DaVanzo John Cleland Katherine Dewey Inge Hutter 14:00 –15:30 16:00 –17:45 • Presentation Conde-Agudelo A. Effect of birth spac- ing on maternal and perinatal health: a systematic review and meta-analysis. • Commentary • Questions for clarification • Bringing the evidence together • Discussion in plenary • Group work Agustín Conde-Agudelo Jacqui Bell Cicely Marston 32 Report of a WHO Technical Consultation on Birth Spacing Tuesday, 14 June 2005 Agenda item Presenter 08:30 –10:00 Birth spacing and maternal and perina- tal health – continued • Discussion in plenary and recommenda- tions 10:00 –10:30 11:00 –12:45 Birth spacing and child health • Presentation DaVanzo J et al. The effects of birth spacing on infant and child mortality,pregnancy outcomes, and maternal morbidity and mortality in Matlab, Bangladesh • Commentary • Questions for clarification • Presentation Katherine Dewey Dewey KG and Cohen RJ. Birth spacing lit- erature review: maternal and child nutrition outcomes • Commentary • Questions for clarification • Presentation Rutstein S and Johnson K with sections written by Conde-Agudelo A. Systematic review and meta-analysis of the relationship between inter-pregnancy or inter-birth inter- vals and infant and child mortality Rutstein S. Effects of preceding birth inter- vals on young childhood mortality and nutritional status in developing countries: evidence from the Demographic and Health Surveys • Commentary • Questions for clarification Julie DaVanzo John Cleland Katherine Dewey Inge Hutter Shea Rutstein Wong Yut-Lin and Zeba Sathar 33 Report of a WHO Technical Consultation on Birth Spacing Tuesday, 14 June 2005 – continued Agenda item Presenter 14:00 –18:00 Birth spacing and child health – continued • Bringing the evidence together • Discussion in plenary • Group work Cicely Marston Chair Wednesday, 15 June 2005 Agenda item Presenter 08:30 09:00 15:00 Birth spacing and child health – continued • Discussion in plenary Conclusions and recommendations of the meeting • Review of conclusions of working groups • Final statements and recommendations - for birth-spacing intervals - on terminology - on identified gaps in research - on next steps Closure of the meeting 34 Report of a WHO Technical Consultation on Birth Spacing ANNEX 3. LIST OF PARTICIPANTS WHO Temporary Advisers Jacqueline Bell IMMPACT Dugald Baird Centre for Research on Women’s Health Department of Obstetrics and Gynaecology Aberdeen Maternity Hospital Cornhill Road Aberdeen AB25 2ZL UNITED KINGDOM Telephone No: +44 1224 553429 Fax No: +44 1224 404925 Email: ogy185@abdn.ac.uk John Cleland Centre for Population Studies London School of Hygiene and Tropical Medicine 49-51 Bedford Square London, WC1B 3DP UNITED KINGDOM Telephone No: +44 207 2994614 Fax No: +44 207 2994637 Email: john.cleland@lshtm.ac.uk Anibal Faundes CEMICAMP Rua Vital Brasil, 200 - Cidade Universitária 13.081-970 - Campinas, SP BRAZIL Telephone No: +55 19 3289 2856 Fax No: +55 19 3239 2440 Email: afaundes@uol.com.br Mario R. Festin Deputy Director for Health Operations Philippine General Hospital University of the Philippines Manila PHILIPPINES Telephone No: +632 523 4246 Fax No: +632 526 2021 Email: mfestin@msn.com Inge Hutter Professor of Demography Faculty of Spatial Sciences University of Groningen Landleven 5 9747 AD Groningen NETHERLANDS Telephone No: +31 50 363 6910 Fax No: +31 50 363 3901 Email: i.hutter@rug.nl Barbara Hulka (Chair) Kenan Professor Emerita University of North Carolina at Chapel Hill McGarvan-Greenberg Hall Chapel Hill, NC 27599-7400 UNITED STATES OF AMERICA Telephone No: +1 919 933 2243 Fax No: +1 919 933 2243 Email: barbara_hulk@unc.edu Cicely Marston Department of Primary Care and Social Medicine Imperial College London Reynolds Building, Charing Cross Campus St. Dunstan’s Road London W6 8RP UNITED KINGDOM Telephone No: +44 20 7594 0786 Fax No: +44 20 7594 0866 Email: c.marston@imperial.ac.uk Technical Consultation: Review of Scientific Evidence for Birth Spacing Salle A, World Health Organization, Geneva, Switzerland, 13 - 15 June 2005 35 Report of a WHO Technical Consultation on Birth Spacing Zeba A. Sathar Population Council Pakistan # 7, St. 62 F-6/3, Islamabad PAKISTAN Telephone No: +9251 22 77439 Fax No: +9251 2821401 Email: zsathar@pcpak.org Susheela Singh Vice President for Research The Guttmacher Institute 120 Wall Street New York, NY 10005 UNITED STATES OF AMERICA Telephone No: +1 212 248 1111 Fax No: +1 212 248 1951 Email : ssingh@guttmacher.org Wong Yut-Lin Associate Professor Health Research Development Unit Faculty of Medicine University of Malaya 50603 Kuala Lumpur MALAYSIA Telephone No: + 603 7967 5728/5739 Fax No: + 603 7967 5769 Email: wongyl@um.edu.my UN Agencies Naomi Cassirer Senior Specialist Work and Family Sub-programme Conditions of Work and Employment Programme International Labour Office Route des Morillons 4 1211 Geneva SWITZERLAND Telephone No: +41 22 799 6717 Fax No: +41 22 798 8685 Email: cassirer@ilo.org Wilma Doedens Technical Officer Technical Support Division United Nations Population Fund 11 Chemin des Anémones 1219 Châtelaine SWITZERLAND Telephone No: +41 22 917 8315 Fax No: +41 22 917 8016 Email: doedens@unfpa.org Miriam Labbok Senior Advisor Infant & Young Child Feeding and Care/PD/Nutrition United Nations Children’s Fund UNICEF House, Room 756 3 UN Plaza East 44th Street New York, NY 10017 UNITED STATES OF AMERICA Telephone No: +1 212 326 7368 Fax No: +1 212 326 7129 Email: mlabbok@unicef.org USAID Team and Investigators (Authors) José Belizán Department of Mother & Child Health Research Institute for Clinical Effectiveness and Health Policy (IECS) School of Public Health, School of Medicine University of Buenos Aires Marcelo T de Alvear 222, 1er Piso (C1122AAJ) Buenos Aires ARGENTINA Telephone No: +54 11 49 66 00 82 Fax No: +54 11 49 66 00 82 Email: belizanj@allstat.org 36 Report of a WHO Technical Consultation on Birth Spacing Agustín Conde-Agudelo Medical Officer Carlos H. Trujillo Hospital Calle 58 # 26 60 Palmira-Valle COLOMBIA Telephone No: +57 2 275 4547 Fax No: +57 2 2754521 Email: condeagu@uniweb.net.co Julie DaVanzo Principal Investigator RAND 1776 Main Street, P.O. Box 2138 Santa Monica, CA 90407-2137 UNITED STATES OF AMERICA Telephone No: +1 310 393 0411 Fax No: +1 310 260 8158 Email: julie@rand.org Kathryn Dewey Department of Nutrition University of California One Shields Avenue Davis, CA 95616 UNITED STATES OF AMERICA Telephone No: +1 530 752 0851 Fax No: +1 530 752 3406 Email: kgdewey@ucdavis.edu Taroub Faramand Project Director The CATALYST Consortium 1201 Connecticut Avenue, NW, Suite 500 Washington, DC 20036 UNITED STATES OF AMERICA Telephone No: +1 202 775 1977 Fax No: +1 202 775 1988 Email: TFaramand@rhcatalyst.org Bill Jansen Maternal and Child Health Adviser Ronald Reagan Building 1300 Pennsylvania Avenue NW US Agency for International Development Washington, DC 205203-3600 UNITED STATES OF AMERICA Telephone No: +1 202 712 0707 Email: wjansen@usaid.gov Maureen H. Norton Senior Technical Adviser Office of Population and Reproductive Health Bureau for Global Health US Agency for International Development 3.06-041U, 3rd floor Ronald Reagan Building 1300 Pennsylvania Avenue NW Washington, DC 20523-3600 UNITED STATES OF AMERICA Telephone No: +1 202 712 1334 Email: mnorton@usaid.gov Shea Oscar Rutstein Technical Director ORC Macro International 11785 Beltsville Drive Calverton, MD 20705 UNITED STATES OF AMERICA Telephone No: +1 301 572 0950 Fax No: +1 301 572 0999 Email: shea.o.rutstein@orcmacro.com James Shelton Senior Medical Scientist Office of Population and Reproductive Health Bureau for Global Health US Agency for International Development 3.06-041U, 3rd floor Ronald Reagan Building 1300 Pennsylvania Avenue NW Washington, DC 20523-3600 UNITED STATES OF AMERICA Telephone No: +1 202 712 0869 Email: jshelton@usaid.gov 37 Report of a WHO Technical Consultation on Birth Spacing Bao-Ping Zhu State Epidemiologist and Director Office of Epidemiology Missouri Department of Health 920 Wildwood Drive Jefferson City, MO 65102 UNITED STATES OF AMERICA Telephone No: +1 573 751 6128 Fax No: +1 573 522 6003 Email: bpzhu@yahoo.com WHO Secretariat Department of Reproductive Health and Research Paul F.A. Van Look Director Telephone No: +41 22 791 3380/3372 Email : vanlookp@who.int Catherine D’Arcangues Coordinator Telephone No: +41 22 791 4132/3222 Email: darcanguesc@who.int Iqbal Hussain Shah Coordinator Telephone No: +41 22 791 3332/3375 Email: shahi@who.int Mohamed Mahmoud Ali Statistician Telephone No: +41 22 791 1489 Email: alim@who.int Jane Cottingham Girardin Technical Officer Telephone No: +41 22 791 4213/4139 Email: cottinghamj@who.int Nuriye Ortayli Medical Officer Telephone No: +41 22 791 3313 Email: ortaylin@who.int Claire Tierney Administrative Support Telephone No: +41 22 791 3222 Email: tierneyc@who.int Mirriah Vitale Intern Email : vitalem@who.int Department of Making Pregnancy Safer Quazi Monirul Islam Director Telephone No: +41 22 791 5509/3966 Email: islamm@who.int Jelka Zupan Medical Officer Telephone No: +41 22 791 4221/3978 Email: zupanj@who.int Annie Portela Technical Officer Telephone No: +41 22 791 2914/13222 Email: portelaa@who.int Eva Tekavec Intern Email: tekaveke@who.int Department of Child and Adolescent Health Rajiv Bahl Medical Officer Telephone No: +41 22 791 3766 Email: bahlr@who.int Department of Nutrition for Health and Development Sultana Khanum Medical Officer Telephone No: +41 22 791 2624 Email: khanums@who.int

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