Why birth spacing matters for Pakistan’s mothers and children

Pakistan's maternal and child health challenges are usually discussed through the lens of hospitals, emergency care, nutrition programs and vaccination campaigns. Yet one of the most important factors affecting the health of mothers and children often receives much less attention: the time between one pregnancy and the next.

Birth spacing is frequently viewed only as a family planning issue. But experts argue that it should be treated as a broader public health concern because it influences maternal survival, child growth, nutrition and long-term development.

Dr Sidrah Nausheen, assistant professor in the Department of Obstetrics and Gynecology at Aga Khan University Hospital, says poor birth spacing is a major but often overlooked contributor to maternal and child mortality and undernutrition in Pakistan.

Healthy timing and spacing of pregnancies, she says, should not be seen merely as a reproductive health intervention. It is a strategy for improving survival, nutrition and economic well-being across generations.

That message deserves greater attention in a country where millions of children are stunted and preventable maternal and newborn deaths remain among the highest in South Asia.

What constitutes healthy birth spacing?

The World Health Organization recommends waiting at least 24 months after a live birth before attempting the next pregnancy. In practice, this translates into a birth interval of roughly 33 months between two children.

The purpose of that recommendation is straightforward. Pregnancy, childbirth and breastfeeding place tremendous physical and nutritional demands on women. Allowing sufficient time before the next pregnancy helps mothers recover and improves the chances that both mother and child remain healthy.

Pakistan remains some distance away from that benchmark.

According to the Pakistan Demographic and Health Survey 2017-18, the median birth interval was 28.2 months. More concerning, 37% of births occurred within 24 months of the previous birth.

That means more than one in three births happened sooner than the minimum interval recommended by WHO.

Dr Nausheen says many women become pregnant again within two years because of limited access to family planning services, unmet contraceptive needs, social pressure and low decision-making autonomy.

These factors turn birth spacing into much more than a personal choice. They make it a health system issue.

Why short intervals increase risks for mothers

When pregnancies occur too close together, women often do not have enough time to replenish nutritional stores depleted during pregnancy and breastfeeding.

Dr Nausheen says this can result in maternal depletion syndrome, characterized by deficiencies in iron, folate and other essential nutrients.

Anemia, already widespread among Pakistani women, becomes more likely. Closely spaced pregnancies are also associated with postpartum hemorrhage, hypertensive disorders including pre-eclampsia, premature rupture of membranes and delayed recovery after cesarean sections.

These complications increase the risk of severe maternal illness and death.

Pakistan has made progress over the years, but maternal mortality remains high. According to WHO Pakistan, the country's maternal mortality ratio stood at 155 deaths per 100,000 live births in 2024.

Behind every statistic lies a reality faced by thousands of families. The loss of a mother often affects entire households, leaving children vulnerable and worsening cycles of poverty.

The risks for newborns and young children

The consequences of poor birth spacing extend beyond mothers.

Dr Nausheen says closely spaced pregnancies are linked to preterm births, low birth weight, small-for-gestational-age babies, neonatal infections and higher risks of infant and under-five mortality.

Breastfeeding may also be interrupted earlier when a mother becomes pregnant again. Older siblings can lose a major source of nutrition and immune protection at a stage when they still require both.

A 2024 systematic review published in the Journal of Global Health found short birth intervals were associated with preterm birth, stillbirth, neonatal mortality, infant mortality and under-five mortality.

Pakistan's neonatal mortality rate stood at 37.6 deaths per 1,000 live births in 2024, according to WHO Pakistan. Under-five mortality remains among the highest in the region.

Birth spacing is not the only explanation for these outcomes. Poverty, poor sanitation, inadequate healthcare and malnutrition all contribute. But spacing is one of the few risk factors that can be addressed through counseling and better access to contraception.

Why birth spacing matters for stunting

Pakistan's struggle with child malnutrition makes the issue even more urgent.

UNICEF estimates nearly 10 million Pakistani children suffer from stunting, a condition caused by chronic undernutrition that impairs physical and cognitive development.

The first 1,000 days, from conception until a child's second birthday, are considered critical for preventing stunting.

Dr Nausheen says short birth intervals disrupt this period through several pathways.

Mothers who become pregnant too quickly often enter the next pregnancy malnourished or anemic. Families with several closely spaced children may struggle to provide sufficient food and healthcare. Breastfeeding duration can decline, and repeated infections among siblings further impair growth.

Caregivers also have less time to provide responsive feeding and developmental stimulation.

A 2024 meta-analysis published in Maternal & Child Nutrition found short birth intervals significantly increased the risk of stunting and child malnutrition across Asia-Pacific countries.

Birth spacing alone cannot solve Pakistan's nutrition crisis. Access to food, clean water, immunization and healthcare remains essential.

But birth spacing sits alongside all of these factors.

How Pakistan compares with its neighbors

Pakistan's challenges become more apparent when viewed against regional comparisons.

According to UNICEF estimates, Pakistan's under-five mortality rate stands at 56 deaths per 1,000 live births. India records 27 deaths, while Bangladesh records 30.

Neonatal mortality in Pakistan is estimated at 36 deaths per 1,000 live births, compared with 17 in India and 18 in Bangladesh.

Stunting affects about 34% of Pakistani children under five. Bangladesh has reduced the rate to around 25%, while Afghanistan remains worse at 42%.

Dr Nausheen notes that Pakistan also has shorter birth intervals and higher mortality rates than neighboring countries.

The relationship is not coincidental. Countries with longer birth intervals generally experience lower maternal anemia, fewer premature births, improved breastfeeding rates and better child nutrition.

Birth spacing alone does not explain these differences. Women's education, health infrastructure, poverty and immunization all play important roles.

But the comparisons show that Pakistan's outcomes are not inevitable.

Lessons from Bangladesh and Sri Lanka

Bangladesh's achievements are particularly striking.

Despite having fewer resources than many countries, Bangladesh has steadily improved maternal and child health through investments in community health workers and family planning services.

The country integrated reproductive health into primary healthcare and expanded outreach programs that brought services closer to women.

Sri Lanka's experience offers another lesson.

For decades, the country invested in universal maternal and child healthcare, free public health services, strong referral systems and near-universal skilled birth attendance.

High female literacy and effective family planning programs further strengthened those gains.

Today, Sri Lanka enjoys some of the lowest maternal and child mortality rates in South Asia.

The message for Pakistan is clear.

Progress requires sustained investment, political commitment and integration of services rather than isolated programs.

Why postpartum care is a missed opportunity

Perhaps the biggest policy gap in Pakistan lies after childbirth.

Healthcare systems often treat delivery as the end of care rather than the beginning of another critical phase.

Dr Nausheen says postpartum counseling should become a routine component of maternal and child healthcare.

Women should receive information about breastfeeding, recovery and contraceptive options before leaving health facilities. Follow-up discussions should continue during immunization visits and community health encounters.

The postpartum period offers a rare opportunity because women are already interacting with healthcare providers.

Yet counseling often remains inconsistent or absent.

This is particularly important because reproductive decisions are rarely made by women alone.

In many households, husbands and elders influence decisions regarding pregnancies and contraception.

Fear of side effects, myths surrounding contraceptives, social pressures and limited mobility create additional barriers.

A 2024 UNFPA political economy analysis concluded that family planning challenges in Pakistan are rooted not only in awareness but also in social, institutional and governance barriers.

That means birth spacing should not be approached through slogans or isolated campaigns.

It requires broader community engagement involving men, religious leaders and families.

The economic cost of inaction

Poor birth spacing and childhood stunting are not only health issues. They carry long-term economic consequences.

Stunted children often experience impaired cognitive development, poorer educational outcomes and lower productivity later in life.

Countries with high levels of undernutrition face reduced human capital and slower economic growth.

Healthy mothers are more likely to have healthy babies.

Healthy children are more likely to stay in school, learn effectively and participate productively in the workforce.

These benefits accumulate over generations.

Investing in maternal and child health is therefore not simply a social policy. It is an economic strategy.

What Pakistan should prioritize

Dr Nausheen believes reducing stunting and mortality requires coordinated action across health, nutrition, education and social protection.

First, Pakistan must expand access to voluntary family planning and postpartum contraception. Modern contraceptives should be consistently available at primary healthcare facilities, and services should be integrated into antenatal and postnatal care.

Second, maternal nutrition programs need strengthening. Iron and folic acid supplementation, screening for anemia and nutrition counseling should become universal.

Third, quality matters as much as coverage. Every birth should be attended by skilled providers supported by effective referral systems and emergency care.

Fourth, policymakers should prioritize the first 1,000 days by promoting breastfeeding, improving complementary feeding and expanding growth monitoring.

Fifth, investments in water, sanitation and hygiene are essential because repeated infections contribute significantly to stunting.

Girls' education and delayed marriage should also be viewed as health interventions. Educated women are more likely to marry later, access healthcare and have healthier children.

Finally, Pakistan needs better and more recent data.

Current birth spacing estimates rely heavily on the 2017-18 demographic survey. Policymakers need updated information showing where short intervals are most common and which populations face the greatest risks.

Tracking birth spacing, postpartum contraceptive use, breastfeeding and nutrition indicators together would allow resources to be targeted more effectively.

Why the conversation needs to change

One reason birth spacing has not received the attention it deserves is that it is often discussed primarily through the lens of population control.

Dr Nausheen argues that such a narrow approach overlooks the wider health implications. Healthy timing and spacing of pregnancies should be viewed first and foremost as a maternal and child health intervention.

This broader framing matters because family planning decisions in Pakistan are rarely made by women alone. Husbands, mothers-in-law and other family members frequently influence decisions about when to have another child. Misconceptions about contraceptive side effects, concerns rooted in cultural norms and unequal decision-making power can further limit women's ability to access services even when they understand the health benefits.

Birth spacing therefore cannot be treated as a separate issue handled only through awareness campaigns. It needs to be integrated into routine healthcare. Discussions about postpartum recovery, breastfeeding and contraception should begin during pregnancy and continue after childbirth through immunization visits and community health services.

Men and families should be part of these conversations because healthier spacing benefits entire households, not only mothers.

More than family planning

Birth spacing is not a substitute for stronger hospitals, better nutrition programs or poverty reduction.

Nor is it the only reason Pakistan continues to struggle with maternal and child mortality.

But recent evidence consistently shows that short intervals increase risks for mothers and children at nearly every stage of life.

That is why Dr Nausheen argues that healthy timing and spacing of pregnancies should be viewed as a maternal and child health intervention rather than merely a family planning issue.

The period after childbirth should no longer be treated as the end of care.

It should be recognized as one of the most important opportunities to protect mothers, save children and improve Pakistan's future.

Healthy spacing between pregnancies will not solve every challenge facing the country.

But it may be one of the simplest and most cost-effective ways to ensure that more mothers survive, more children thrive and future generations grow up healthier than the last.