Women’s health benefits from waiting at least two years after a live birth before the next pregnancy. This is challenging for women who are vulnerable or live in low-income countries to achieve.

The results of a recent study reveal that women are more likely to space out childbearing after participating in a two-year intervention that includes providing women with access to family planning counselors, free transportation to a high-quality family planning clinic, referrals for services, consultations, and financial reimbursement for family planning services.1

“Because of the high demand for spacing, there was a real motivation for this trial, where we’re giving women, who are randomized to the intervention arm, access to family planning and reproductive health services,” says Mahesh Karra, SD, assistant professor of global development policy at Boston University. “Our study is the first randomized, controlled trial to observe a spacing impact, which is what we designed the study around. The women we recruited [from urban Malawi] for the study were, at baseline, either pregnant or immediate postpartum. We were following up with them for at least two years.”

Researchers chose a two-year follow-up based on previous studies. The results of these studies revealed that women who have either very short birth intervals — less than two years between births — or who have more than seven-year intervals are at higher risk of poor morbidity and mortality outcomes, Karra says.

Short birth intervals could result in depletion syndrome, in which women are not nutritionally recovered from the last birth. “If they just had a recent birth, they may be at high risk of anemia. That has implications for their own health,” Karra says. In the case of women with long-spaced births, the risk might be greater because they tend to be older, and maternal age confounds that relationship, he adds.

Researchers enrolled 2,143 married women, ages 18 to 35 years, and randomly assigned them to an intervention arm or the control arm.1

“The women’s likelihood of having a subsequent pregnancy in two years was about 30% to 40% lower in the intervention group vs. those who didn’t get family planning services,” Karra says. “If women are more adequately able to space [their children’s births], they can do more resource allocation to their children and to themselves, over a longer period.”

The intervention included:

• Transportation. Women were given a free ride service from their homes to a family planning clinic.

• Counseling. Women were offered up to six free, private family planning counseling sessions over the two-year period. Trained counselors, who were registered nurses and midwives with previous family planning counseling experience, promoted informed choice by explaining misconceptions about birth spacing.

The counseling sessions covered the advantages of breastfeeding and of birth spacing. Counselors discussed how women could access family planning and reproductive health services to facilitate better timing and spacing of future births, Karra says.

“That information is generalizable to women across different societies and in different contexts,” he adds.

• Financial reimbursement. Women in the intervention arm were reimbursed for any out-of-pocket expenses. These included the costs of family planning medications and contraceptive methods, as well as consultation fees, lab test fees, and exam fees.

In the United States, it is easier for women to think about planning their next birth, but there still are many women who would have preferred to space their next birth differently, Karra notes.

Although the United States overall offers more resources for women than does Malawi, stark disparities result in maternal morbidity and mortality rates in vulnerable American women that are comparable to low- and middle-income nations, Karra says.

“In the U.S., we have health system capacity and access with an asterisk because of disparities. But in theory, we have access to services that minimize a lot of the risks that women in middle- and low-income nations experience,” he explains. “It’s about spacing and having the number of children you want when you want them.”

Family planning services also could address women’s attitudes and cultural perspective on birth spacing. “In general, women who wish to have more than one child and who are thinking about when to have them are making a calculus on two fronts: One, if they just recently had a child, there is a cost to having a subsequent child too soon because they haven’t recovered from pregnancy,” Karra says. “The benefit to having children sooner is they would have children of similar ages, and they may be able to take care of them together.”

The resource cost is that children who are closer in age could cost more in resources than if they were spaced out, allowing the family to take care of one child first and then have another child when more family resources were available to care for a second child, he adds.

“Women bear the biological cost of having children,” Karra says. “During the immediate postpartum period of breastfeeding, women bear a disproportionate burden of cost.”


  1. Karra M, Canning D. The effect of improved access to family planning on postpartum women: Protocol for a randomized controlled trial. JMIR Res Protoc 2020;9:e16697.