Healthy Timing and Spacing of Pregnancies: Promise or Pretext?

By Rebecca Oas, Ph.D. | May 10, 2018

As discussed in last week’s Friday Fax, “healthy timing and spacing of pregnancies” (HTSP) has become accepted as both the most acceptable rationale for the promotion of family planning by faith-based organizations like World Vision, and also the most likely to be accepted by recipients of assistance in developing countries. In the words of demography professor John F. May:

Within family planning programs, in the experience of this author, “birth spacing” (associated with health) has become virtually the only accepted rationale in [sub-Saharan Africa], while “birth limitation” (associated with control) is being perceived as imperialistic and tainted by Western values.”

So what is a healthy spacing of pregnancies? The Mayo clinic suggests waiting 18-24 months after giving birth before getting pregnant again. So, adding the 9 months of gestation, we’re looking at a range of about 27-33 months between births.

In 2013, demographers John Bongaarts and John Casterline compared birth intervals in three developing regions: sub-Saharan Africa, Latin America, and Asia/North Africa. I quote:

Most of the median intervals in the [sub-Saharan] African countries range between 30 and 40 months, centered around 35 months (almost three years), whereas the median intervals in the other two regions range from 20 to 30 months and are centered around 25–26 months (a bit over two years). Thus, birth intervals in Africa tend to be roughly one year longer than in other regions at this level of fertility.”

Similarly, in 2016, Casterline and Odden noted that this is not a new observation:

Inter-birth intervals are longer in sub-Saharan Africa than in the other three major regions, consistent with the common assumption among demographers since at least the 1980s.”

At the Wilson Center event on HTSP, every example from the field presented by the panel was from sub-Saharan Africa. Yet, if the leading demographers are to be believed, the couples of sub-Saharan Africa have long mastered the art of HTSP and could teach the rest of the world a thing or two. Of course, they still want large families—and that’s the real problem for the family planning movement writ large.

Returning to John F. May, he characterizes the progress of family planning in sub-Saharan Africa as “modest” and lays out his vision for the future, quite independent of the preferences of African women and couples:

Improving access to, and quality of, family planning services and increasing the demand for contraception in [sub-Saharan Africa] will require large programmatic investments, genuine commitment from African leaders, and support from the donor community.”

So much for HTSP, so much for “satisfying demand,” it’s back to fertility reduction—and did we really ever leave that behind?

In other, possibly related, news, UNICEF just published a report on breastfeeding around the world calling for a reduction in the breastfeeding gap between rich and poor. In marked contrast to many of the gaps between rich and poor that need narrowing, when it comes to breastfeeding, it’s the poor women who are doing better: in every global region, the poorest quintile are more likely to be breastfeeding their children at two years. Rich and poor women alike in the most developed regions rank below developing regions when it comes to sustained breastfeeding: one of the main messages of the report is that babies in high-income countries are five times less likely to be breastfed than those in lower-income countries.

The link between HTSP and breastfeeding is well known (although curiously not mentioned in the UNICEF report), and the combination of the two benefits mothers and children alike. Unfortunately, of all the messaging emanating from UN agencies toward the developing world, this report on breastfeeding will likely be lost in the deluge of other reports proclaiming how family planning will usher in a “demographic dividend” and the importance of getting women out of “unpaid care work” and into the paid workforce—because caring for children is apparently only decent work if the children are not your own.

As for the side benefit of breastfeeding on birth spacing, not to worry, the family planning experts have a new High Impact Practice (HIP) brief for that:

Offering modern contraception services as part of care provided during childbirth increases postpartum contraceptive use and is likely to reduce both unintended pregnancies and pregnancies that are too closely spaced.”

No, there’s nothing at all disturbing about the notion that contraceptive use is increased when it’s being offered to the captive audience of a woman in the midst or aftermath of labor, no doubt in the context of counseling involving a barrage of scientific evidence specially packaged for “high impact.”

But it’s all about healthy spacing, really. Just keep telling yourself that.