Healthy Timing and Spacing of Pregnancy

 

Welcome to the programmatic area on healthy timing and spacing of pregnancy (HTSP) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. HTSP is one of the subareas found in the family planning (FP) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. HTSP is an intervention to help women and couples make an informed decision about the delay of first pregnancy and the spacing or limiting of subsequent pregnancies to achieve the healthiest outcomes for women, newborns, infants and children. HTSP provides an opportunity to highlight FP as a preventive intervention using the framework of healthy mothers, healthy babies, healthy families, and healthy communities.  The HTSP indicators found in this database can be incorporated into key HTSP interventions including advocacy at the policy level, education, and counseling of women and families, and linking of FP services at the service delivery level. Key indicators to monitor and evaluate HTSP can be found in the links at left.    Full Text Healthy timing and spacing of pregnancy (HTSP) is an intervention to help women and families make an informed decision about the delay of first pregnancy and the spacing or limiting of subsequent pregnancies to achieve the healthiest outcomes for women, newborns, infants and children.  HTSP messages operate within the context of free and informed contraceptive choice, taking into account fertility intentions and desired family size, as well as the social and cultural contexts. Qualitative studies conducted by USAID in Pakistan, India, Bolivia, and Peru show that women and couples are interested in the healthiest time to become pregnant versus when to give birth. In this way, HTSP differs from previous birth spacing approaches that refer only to the interval after a live birth and when to give birth. HTSP also provides guidance on the healthiest age for the first pregnancy. Thus, HTSP encompasses a broader concept of the reproductive cycle – starting from healthiest age for the first pregnancy in adolescents, to spacing subsequent pregnancies following a live birth, still birth, miscarriage or abortion – capturing all pregnancy-related intervals in a woman’s reproductive life. The Rationale USAID is working in collaboration with WHO and other organizations to integrate HTSP into health and non-health programs. For countries to reduce their burden of disease and reach their Millennium Development Goals, adding HTSP interventions to their strategies and programs should be considered a priority because of significant, multiple health benefits for women and babies.  For instance: Multiple studies have shown that adverse maternal and perinatal outcomes are related to closely spaced pregnancies. The risks are particularly high for women who become pregnant very soon after a previous pregnancy, miscarriage, or abortion. Thus, through the promotion of HTSP, there is the potential to significantly reduce risks to both mothers and children. HTSP offers: Reduced risks after a live birth Reduced risks after a miscarriage or postabortion Reduced risks for adolescents  Considerable unmet need and demand for spacing still exist in the younger 15-29 age cohorts as well as in postpartum women. Spacing is the main reason for family planning (FP) demand among women in younger age groups (15-29). Data from developing countries also show that younger, lower parity women have the highest demand and need for spacing births.  Unmet need for spacing among postpartum women is very high. Among postpartum women who want to space their pregnancy, 60% have an unmet need. HTSP is an aspect of FP which is associated with healthy fertility and helping women and families make informed decisions about pregnancy spacing and timing to achieve healthy pregnancy outcomes. FP has made great progress in helping women avoid unintended pregnancies. To date, the focus of FP has mostly been on lowered fertility, rather than healthy fertility. Findings from the WHO technical panel support the role of FP in achieving healthy fertility and healthy pregnancy outcomes.  HTSP is an effective entry point to strengthen and revitalize FP in sensitive settings because it focuses on the mother/child dyad and improved health outcomes for mother and baby. HTSP provides an opportunity to highlight FP as a preventive intervention using the framework of healthy mothers, healthy babies, healthy families and healthy communities.  HTSP Messages To achieve HTSP outcomes, three take-home messages have been developed – all to be discussed in a framework of informed FP choice, personal reproductive health goals and fertility intention. For couples who desire a next pregnancy after a live birth, the messages are: For the health of the mother and baby, wait at least 24 months before trying to become pregnant again. Consider using an FP method of your choice without interruption during that time. For couples who decide to have a child after a miscarriage or abortion, the messages are: For the health of the mother and baby, wait at least six months before trying to become pregnant again. Consider using an FP method of your choice without interruption during that time. For adolescents, the messages are: For yours and your baby’s health, wait until you are at least 18 years of age, before trying to become pregnant. Consider using an FP method of your choice without interruption until you are 18 years old. These messages should be incorporated into key HTSP interventions including advocacy at the policy level; education and counseling of women and families, and links to FP services at the service delivery level; and monitoring and evaluation. ____________ References: Post M. Extending Service Delivery Project. HTSP 101: Everything You Want to Know about Healthy Timing and Spacing of Pregnancy. USAID, 2009.  Available at: http://www.esdproj.org/site/DocServer/HTSP_101_Brief_Final_corrected_8.18.09.pdf?docID=2821

Number of national, provincial, or district level policies, frameworks or guidelines, that include HTSP recommendations

Definition:

Policies, frameworks or guidelines may include reproductive health policies, family planning strategies including counseling recommendations, pre-service and in-service curricula for health providers, etc.  The healthy timing and spacing of pregnancy (HTSP) recommendations must be accurate and up-to-date to be included. 

According to a WHO technical consultation on birth spacing and USAID, the three recommendations that make up the basis of the key HTSP messages are:

  1. After a live birth, the recommended interval before attempting the next pregnancy should be at least 24 months (this is equivalent to a 33 month birth-to-birth interval);
  2. After a miscarriage or induced abortion, the recommended minimum interval to next pregnancy should be at least six months; and
  3.  To delay first pregnancy until at least 18 years of age.

As a proportion, this indicator is calculated as:

(Number of health and non-health workers trained in HTSP who can correctly state the three HTSP recommendations / total number of health and non-health workers trained in HTSP) x 100

Data Requirements:

Number of persons trained (based on an actual list of names for potential verification purposes), their professional positions or community affiliation (e.g. nurse-midwife, religious leader, youth group member), and verification that the trainee correctly identified the three HTSP recommendations

Data Sources:

Training record that evaluates knowledge retained, such as a post-test

Purpose:

This indicator goes one step further than strictly recording number of people trained; it helps project implementers evaluate the effectiveness of an HTSP training by asking training participants to identify the three key recommendations that form the basis of all HTSP messages.  Having this information is useful for assessing effectiveness of and knowledge gaps in HTSP trainings.

Issue(s):

The indicator, as stated, is not sensitive enough to identify how many or which recommendation(s) a trainee did not identify correctly.  Also, it does not indicate if the trainee understands the rationale for the three recommendations. Evaluators can improve this indicator by making it the aggregate of three separate indicators measuring the number/percent of trainees who stated the first recommendation correctly, the second recommendation correctly, and the third recommendation correctly. 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project

Number/percent of health and non-health workers trained in HTSP who can state the three HTSP recommendations, by type of trainee

Definition:

“Type of trainee” refers to the different categories of participants (e.g. doctors, nurses, community health workers, community leaders, traditional birth attendants).  The three healthy timing and spacing of pregnancy (HTSP) recommendations that must be stated correctly are:

  1. After a live birth, the recommended interval before attempting the next pregnancy should be at least 24 months (this is equivalent to a 33 month birth-to-birth interval);
  2. After a miscarriage or induced abortion, the recommended minimum interval to next pregnancy should be at least six months; and
  3. To delay first pregnancy until at least 18 years of age.

 As a proportion, this indicator is calculated as:

(Number of health and non-health workers trained in HTSP who can correctly state the three HTSP recommendations / total number of health and non-health workers trained in HTSP) x 100

Data Requirements:

Number of persons trained (based on an actual list of names for potential verification purposes), their professional positions or community affiliation (e.g. nurse-midwife, religious leader, youth group member), and verification that the trainee correctly identified the three HTSP recommendations.

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Data Sources:

Training record that evaluates knowledge retained, such as a post-test

Purpose:

This indicator goes one step further than strictly recording number of people trained; it helps project implementers evaluate the effectiveness of an HTSP training by asking training participants to identify the three key recommendations that form the basis of all HTSP messages.  Having this information is useful for assessing effectiveness of and knowledge gaps in HTSP trainings.

Issue(s):

The indicator, as stated, is not sensitive enough to identify how many or which recommendation(s) a trainee did not identify correctly.  Also, it does not indicate if the trainee understands the rationale for the three recommendations. Evaluators can improve this indicator by making it the aggregate of three separate indicators measuring the number/percent of trainees who stated the first recommendation correctly, the second recommendation correctly, and the third recommendation correctly. 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project

Number/percent of target population who can state at least one benefit of delaying first pregnancy until after 18 years old

Definition:

“Target population” describes a group intended to benefit from healthy timing and spacing of pregnancy (HTSP) messaging.  These are individuals in the identified project catchment area.  For instance, a target population may be:

  1. An identifiable subgroup in a population
  2. Mothers-in-law in a physical area
  3. The district population of men and/or women of reproductive age

Several benefits of delaying first pregnancy until after 18 years of age may be mentioned, but only one stated health benefit to young woman and/or child is needed to be captured in this indicator. 

As a proportion, this indicator is calculated as:

(Number of individuals in target population surveyed/interviewed who can state at least one health benefit of delaying first pregnancy until after 18 years old / total number of individuals in target population surveyed/interviewed) x 100

Data Requirements:

Number of persons in the target population surveyed and verification that the respondent correctly stated one health benefit of delaying first pregnancy until after 18 years of age

Data Sources:

Population-based survey (such as a Knowledge, Attitudes and Practices survey); interviews

Purpose:

When first pregnancies occur in adolescents less than 18 years old, the mothers and their newborns face increased risks of health complications compared to women 20-24 years old. Adolescents are at a higher risk of developing pregnancy-induced hypertension, anemia, and prolonged or obstructed labor.  Controlling for all other factors, compared to women aged 20-24, a 16-17 year old is 1.25 times more likely to hemorrhage or experience very pre-term delivery and an adolescent under 15 is four times more likely to die giving birth and 1.5 times more likely to hemorrhage or experience very pre-term delivery. Newborns may die, be born too soon, too small, or with a low birth weight.  The younger a female is when she first gives birth, the longer her total child-bearing period and the more children she is likely to have, which increases the risks to the life and health of both mothers and children.

This indicator is useful for assessing level of knowledge in a target audience about the benefits of delaying first pregnancy, which is important for family planning counseling, advocating for raising the minimum age of marriage to 18 (if the target population is policy makers), and promoting healthy social norms. It is also useful for establishing formative evidence or evaluating changes in knowledge before and after an intervention.

Issue(s):

This indicator primarily addresses improved health outcomes of delaying first pregnancy until after 18 years of age, although there are other benefits to the practice such as the positive impact it has on women’s status and empowerment.  Also, this indicator alone does not provide a measure of how well the information was understood by the audience or of the audience’s attitude or practices.  For instance, a respondent may be able to state several benefits to delaying first pregnancy until after 18 years of age, but still subscribe to the personal belief that his 17 year old married daughter should begin child bearing immediately.

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project.

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project.

Number/percent of target population who can state at least one health benefit of waiting at least two years after last live birth before attempting the next pregnancy

Definition:

“Target population” describes a group intended to benefit from healthy timing and spacing of pregnancy (HTSP) messaging.  These are individuals in the identified project catchment area.  For instance, a target population may be:

 Although the intention of this indicator is to evaluate knowledge of health benefits of child spacing, depending on the program design, stated benefits to child spacing can include health or social benefits afforded to men, women, children, or communities.

 As a proportion, this indicator is calculated as:

(Number of individuals in target population surveyed/interviewed who can state at least one health benefit of waiting at least two years after last live birth before attempting the next pregnancy / total number of individuals in target population surveyed/interviewed) x 100

Data Requirements:

Number of persons in the target population sampled and verification that the respondent correctly stated one health benefit of waiting at least two years after last live birth before attempting the next pregnancy.  Evaluators may wish to disaggregate data by demographic characteristics (e.g. age, sex, marital status, parity).

Data Sources:

Population-based survey (such as a Knowledge, Attitudes and Practices survey); interviews

Purpose:

According to a WHO technical consultation on birth spacing, after a live birth women should wait at least 24 months before trying to get pregnant again.  Doing so reduces the likelihood the woman will die in childbirth, will have a miscarriage or induced abortion, or that the newborn will die, be underweight or be born prematurely, or that the child will not grow well or die before the age of five.

This indicator is useful for evaluating how knowledgeable a target audience is about the benefits of birth spacing, which is important for family planning counseling on the part of health providers and understanding demand on the part of clients.

Issue(s):

This indicator alone does not provide a measure of how well the information was understood by the audience or of the audience’s attitude or practices. 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project.

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project.

WHO. 2005.  Report of a WHO Technical Consultation on Birth Spacing.  Geneva: Switzerland.

Percent of target population who can state at least one benefit of waiting 6 months after a miscarriage or abortion before attempting the next pregnancy

Definition:

“Target population” describes a group intended to benefit from healthy timing and spacing of pregnancy (HTSP) messaging.  These are individuals in the identified project catchment area.  For instance, a target population may be:

  1. An identifiable subgroup in a population
  2. Mothers-in-law in a physical area
  3. The district population of men or women of reproductive age

Although the intention of this indicator is to evaluate knowledge of health benefits afforded to either the mother or her future child of adequate spacing after a miscarriage or abortion, depending on the program design and what the training or outreach focuses on, health or welfare benefits could be included.

As a proportion, this indicator is calculated as:

(Number of individuals in target population surveyed/interviewed who can state at least one health benefit of waiting at least six months after  a miscarriage or abortion before attempting the next pregnancy / total number of individuals in target population surveyed/interviewed ) x 100

Data Requirements:

Number of persons in the target population surveyed and verification that the respondent correctly stated one health benefit of waiting at least six months after a miscarriage or abortion before attempting the next pregnancy.  Evaluators may wish to disaggregate data by demographic characteristics (e.g. age, sex, marital status, parity).

Data Sources:

Population-based survey (such as a Knowledge, Attitudes and Practices survey); interviews

Purpose:

When pregnancies occur too soon after a miscarriage or abortion (less than six months), women are at higher risk of developing anemia or premature rupture of membranes. Newborns can be born too early or with a low birth weight.

This indicator is useful for evaluating how knowledgeable a target audience is about the benefits of birth spacing after a miscarriage or abortion, which is important for family planning counseling on the part of health providers and understanding demand on the part of clients.

Issue(s):

This indicator alone does not provide a measure of how well the information was understood by the audience or of the audience’s attitude or practices. 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project

WHO. 2005.  Report of a WHO Technical Consultation on Birth Spacing.  Geneva: Switzerland.

Number/percent of married women under age 18 exposed to HTSP counseling/education who subsequently adopted a family planning method to delay first pregnancy

Definition:

Number/percent of married women ≤17 years of age who have never been pregnant; who have seen, heard, or read healthy timing and spacing of pregnancy (HTSP) messages that have been promoted either through an information, education, or communication (IEC) campaign, interpersonal communication or community outreach; and who subsequently adopted a family planning (FP) method to delay first pregnancy.

To calculate this indicator, the women surveyed/interviewed must answer affirmatively to both questions:

As a proportion, this indicator is calculated as:

(Number of married women under age 18 exposed to HTSP counseling/education surveyed/interviewed who subsequently adopted an FP method to delay first pregnancy / total number of married women under age 18 exposed to HTSP counseling/education surveyed/interviewed) x 100

Data Requirements:

Marital status, gravida, age of woman, confirmation of exposure to HTSP counseling/education, verification that respondent adopted an FP method post-exposure to HTSP counseling/education

Some may wish to collect additional information and disaggregate data by age of respondent, site, underserved population, vulnerable group, FP method adopted, or type of counseling/education.

Data Sources:

Program records; special survey; interviews

Purpose:

When first pregnancies occur to adolescents less than 18 years old, the mothers and their newborns face increased risks of health complications compared to women 20-24 years old. Adolescents are at a higher risk of developing pregnancy-induced hypertension, anemia, and prolonged or obstructed labor.  Controlling for all other factors, compared to women aged 20-24, a 16-17 year old is 1.25 times more likely to hemorrhage or experience very pre-term delivery and an adolescent under 15 is four times more likely to die giving birth and 1.5 times more likely to hemorrhage or experience very pre-term delivery. Newborns may die, be born too soon, too small, or with a low birth weight.  The younger a woman is when she first gives birth, the longer her total child-bearing period and the more children she is likely to have which increases the risks to the life and health of both mothers and children.

In populations where communication programs related to HTSP are implemented using IEC techniques, interpersonal communication channels and community outreach workers, program managers and evaluators may want to know the extent to which the intended audience adopts the HTSP recommendations.  This outcome indicator measures the extent to which a specific population targeted by HTSP messages becomes knowledgeable about the implications of early childbearing and actively takes steps to delay first pregnancy.

Issue(s):

The adoption of an FP method by a married woman under age 18 who has been exposed to HTSP messages may imply, but not prove that the decision to use FP was a result of the HTSP counseling/education. 

The indicator does not specify if the adopted FP method is modern or traditional, nor does it capture information about the chosen method being practiced correctly and consistently. 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project

Percent of children aged 0-23 months who were born (to mothers who have received HTSP counseling/education) at least 33 months after the previous surviving child

Definition:

Among women who have received healthy timing and spacing of pregnancy (HTSP) counseling/education and who have had more than one child, with the youngest being <2 years old, the proportion of those children whose previous sibling (who survived childbirth) is/was at least 33 months older

As a proportion, this indicator is calculated as:

(Number of children aged 0-23 months [born to mothers who had received HTSP counseling/education] who are at least 33 months younger than the previous surviving sibling / total number of children aged 0-23 months with a next older sibling [born to mothers who had received HTSP counseling/education]) x 100

Data Requirements:

Parity, exact age of the two children, verification of exposure to HTSP counseling/education

Some may wish to collect additional information and disaggregate data by age of woman, site, family planning method practiced, underserved population, or vulnerable group.

Data Sources:

Program records; special survey; exit interviews

Purpose:

Based on the recommendations from the WHO technical consultation on birth spacing, women should wait at least 24 months after a live birth before attempting the next pregnancy.  A 33 month minimum birth-to-birth interval helps achieve the healthiest outcomes for women, newborns, and infants. This outcome indicator assists in capturing how well the optimal birth spacing recommendation is being practiced.

Issue(s):

The indicator does not capture if the birth spacing of a child who was born at least 33 months after a previous surviving child was due to adopting an effective family planning method or if it was because of other factors (e.g. secondary infertility). 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project.

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project.

WHO. 2005.  Report of a WHO Technical Consultation on Birth Spacing.  Geneva: Switzerland.

Number/percent of women who received family planning information for pregnancy spacing during a postpartum/postabortion visit, by type of visit

Definition:

The family planning (FP) information received, which includes healthy timing and spacing of pregnancy (HTSP) messages, may be in the form of counseling and/or printed materials.  Only postpartum and postabortion care visits are included.  HTSP information includes risks, benefits and messages.

As a proportion, this indicator is calculated as:

(Number of women presenting for postpartum or postabortion care who received FP information that included HTSP messages / total number of women attending for postpartum or postabortion care) x 100

Data Requirements:

Type of visit (postabortion or postpartum), verification that the client received HTSP information

Some may wish to collect additional information and disaggregate data by age of woman, parity, site, underserved population, or vulnerable group.

The indicator should disaggregate by what form the information was received (counseling and/or printed materials).

Data Sources:

Program records; health information systems; special survey; exit interviews

Purpose:

Based on the recommendations from the WHO technical consultation on birth spacing, women should wait at least 24 months after a live birth before attempting the next pregnancy and at least six months after a spontaneous or induced abortion.  Practicing HTSP helps achieve the healthiest outcomes for women, newborns, infants, and children.

Receiving timely information about FP is a critical step in ensuring optimal birth spacing.  It is the role of the health care provider to inform, educate and counsel women and couples on the best options that are available to them in the context of free choice. Counseling on FP and HTSP should consider and respond to the particular needs and intentions of women given her age, marital status, parity and stage of life.

Issue(s):

The indicator does not capture if an FP method was accepted, but only if FP information for pregnancy spacing was provided.

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project.

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project.

WHO. 2005.  Report of a WHO Technical Consultation on Birth Spacing.  Geneva: Switzerland.

Number/percent of women, with a child under age two, exposed to HTSP counseling/education, who subsequently adopted a family planning method in order to space their next pregnancy

Definition:

Number/percent of women with a child age 23 months or younger; who have seen, heard, or read healthy timing and spacing of pregnancy (HTSP) messages that have been promoted either through an information, education, or communication (IEC) campaign, interpersonal communication or community outreach; and who subsequently practiced a family planning (FP) method to delay their next pregnancy.

To calculate this indicator, the women surveyed/interviewed must answer affirmatively to both questions:

As a proportion, this indicator is calculated as:

(Number of women (with a child <2 years old) exposed to HTSP counseling/education surveyed/interviewed who subsequently adopted an FP method to space their next pregnancy / total number of women (with a child <2 years old) exposed to HTSP counseling/education surveyed/interviewed) x 100

Data Requirements:

Confirmation that woman has a child <2 years old, confirmation of exposure to HTSP counseling/education, verification that respondent adopted an FP method post-exposure to HTSP counseling/education

Some may wish to collect additional information and disaggregate data by age of respondent, site, parity, underserved population, vulnerable group, FP method adopted, or type of counseling/education received.

Data Sources:

Program records; health information systems; special survey; interviews

Purpose:

Based on the recommendations from the WHO technical consultation on birth spacing, after a live birth a woman should wait at least 24 months before attempting the next pregnancy.  Doing so increases the likelihood the woman and newborn will be healthier and her next child will be less likely to be pre-term, small for gestational age and have low birth weight.  The mother will also be less likely to experience maternal mortality and miscarriage.

In populations where communication programs related to HTSP are implemented using IEC techniques, interpersonal communication channels and community outreach workers, program managers and evaluators may want to know the extent to which the intended audience adopts the HTSP recommendations.  This outcome indicator measures the extent to which a specific population targeted by HTSP messages – women with a baby under the age of two – becomes knowledgeable about timing and spacing of pregnancies and actively takes steps to space their next pregnancy.

Issue(s):

The adoption of an FP method by a woman who has been exposed to HTSP messages may imply, but not prove that the decision to practice FP was a result of the HTSP counseling/education. 

The indicator does not specify if the adopted method of FP is modern or traditional, nor does it capture information about the chosen method being practiced correctly and consistently. 

References:

“Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide”, 2008.  USAID and ESD Project.

“Healthy Timing and Spacing of Pregnancies: A Pocket Guide for Health Practitioners, Program Managers, and Community Leaders”, 2006.  USAID and ESD Project.

WHO. 2005.  Report of a WHO Technical Consultation on Birth Spacing.  Geneva: Switzerland.