Neo-natal mortality in South Asia: The special role of tetanus

First-year mortality in rural Uttar Pradesh is characterized by a predominance (60 per cent) of deaths during the first month of life, of which 66 per cent are reported to be due to tetanus. This pattern is not typical of the historical experience of many developed countries and the current experience of some less developed countries where post-neo-natal mortality predominates. To examine this phenomenon, two causal models of neo-natal mortality (one for tetanus and one for all other diseases) are developed and tested using retrospective survey data from 2000 couples living in rural Uttar Pradesh.

Neo-natal tetanus mortality is found to be primarily a function of opportunities for exposure to the disease (e.g. lack of antiseptic birth practices, ownership of large animals) rather than of socio-economic status or demographic variables. The importance of examining neo-natal mortality by cause, and the shortcomings inherent in making inferences from the historical experiences of Western nations are emphasized.     

Neo-natal mortality in South Asia: The special role of tetanus

Summary First-year mortality in rural Uttar Pradesh is characterized by a predominance (60 per cent) of deaths during the first month of life, of which 66 per cent are reported to be due to tetanus. This pattern is not typical of the historical experience of many developed countries and the current experience of some less developed countries where post-neo-natal mortality predominates. To examine this phenomenon, two causal models of neo-natal mortality (one for tetanus and one for all other diseases) are developed and tested using retrospective survey data from 2000 couples living in rural Uttar Pradesh. Neo-natal tetanus mortality is found to be primarily a function of opportunities for exposure to the disease (e.g. lack of antiseptic birth practices, ownership of large animals) rather than of socio-economic status or demographic variables. The importance of examining neo-natal mortality by cause, and the shortcomings inherent in making inferences from the historical experiences of Western nations are emphasized.     

Some aspects of the relationship between the levels of infant mortality and fertility in the ESCAP region

The death of a child within the first year of life is a crucial factor in fertility decisions in a developing country. The infant mortality rate gives a close, inverse indication of the socioeconomic conditions of a country. This paper presents studies by Brass, Rutherford, Chowdhury, Khan and Chen, Agrawal, Iskander and Jones, in summary/abstract form. It concludes that the probabilities of survival are poorer for births of older women and/or higher parities. Early child deaths may increase the total period of exposure to the risk of conception. A lower infant and child mortality norm calls for fewer births to meet the needs for survivors. Child replacement motivational response seems to be strongest with the birth immediately following a death event. Agrawal analyzed the interval between successive births of 1107 women of Patna, Pakistan, according to the age of mother and sex and fate of the previous child. He observed that if a child died shortly after its birth, often a new pregnancy began within a short interval. The interval between 2 consecutive live births when the previous child was male and alive was greater than when the previous child was female and alive. The interval between 2 births was reduced if the child died in infancy and specially if this was a male child.     

Determinants of Regional Variations in Infant Mortality in Rural India

An analytical framework is specified for understanding the determinants of infant mortality. It distinguishes between factors at three levels – village, household and individual – and arranges them in ascending order with respect to their proximity to infant mortality. Village and household-level factors are assumed to influence infant mortality indirectly by influencing at least one of the six individual-level factors. The present analysis of the data aggregated at the state level clearly demonstrates the importance of both medical and non-medical factors for explaining the observed regional differences in infant mortality in rural India. The percentage of births attended by trained medical personnel and poverty, are the two important determinants of regional variations in neo-natal mortality; and the village-level availability of medical facilities and the extent of triple vaccination are the two important determinants of post-neo-natal mortality. The influence of adult women's literacy on infant mortality is explained by better medical care at birth, and preventive and curative medical care during the post-neo-natal period. Medical factors have been shown to be slightly more important than non-medical factors. This suggests that it might be possible to reduce the high level of infant mortality currently prevalent in many states in India by simple preventive medical interventions.     

The effect of child mortality experience on subsequent fertility: in Pakistan and Bangladesh

Summary This paper presents an empirical analysis of the effects, behavioural and biological, of child mortality experience on subsequent fertility in two South Asian Islamic nations. Data for the investigation came from retrospective pregnancy histories of 2,910 currently married women interviewed in the Pakistan National Impact Survey (1968-69) and from longitudinal vital registration data (1966-2070) of 5,236 women residing in a rural area of Bangladesh collected by the Cholera Research Laboratory. The aim of this study was to assess the importance of the child-replacement motivational response to child death experience after biological effects have been controlled adequately. A common approach employed previously has been to examine cumulative fertility according to child death experience. In Pakistan and Bangladesh, a consistently positive relationship was demonstrated between the number of children ever born and the number of child deaths. This method, however, did not exclude the inverse relationship, the influence of fertility on mortality, nor did it dissect out behavioural from biological effects. Utilizing a measure of subsequent fertility, live-birth-to-live-birth intervals, the study further illustrated another common pitfall. Since the risk of infant death, which leads to shorter birth intervals, is associated with the mother's reproductive history, women with child mortality experience are more likely to experience shorter intervals because of the biological effect of subsequent infant death. Behavioural influences may, therefore, be observed by considering only those birth intervals in which the first-born child survives to the end of the interval. With these limitations controlled, very few, if any, behavioural influences were noted in the Pakistan and Bangladesh data. Median birth intervals in Pakistan varied between 35-43 and 41-42 months, increasing with parity. Within each parity group, no consistent difference was observed between women with and without previous child loss. In Bangladesh, the median birth interval for all women with a surviving infant was 37-2 months. This was shortened to 24-31 months by an infant death. When intervals with infant deaths were excluded, little or no behavioural influence was detected among women of the same parity, but with varying levels of previous child loss. Even without behavioural effects, elimination of infant mortality in Bangladesh would reduce fertility by prolonging the average period of post-partum sterility. In the Bangladesh setting, however, the size of the effect was only about four per cent. This modest effect, more-over, was counterbalanced by an overall increase of net reproduction by seven per cent due to better survivorship of infants.     

High-risk families: the unequal distribution of infant mortality in nineteenth-century Sweden

An analysis of infant mortality (based on 133,448 births) in two regions, Sundsvall and Skellefte?, in north-eastern Sweden during the nineteenth century shows that infant mortality was highly clustered with a relatively small number of families accounting for a large proportion of all infant deaths. Using logistic regression, two important factors were found to be associated with high-risk families: (i) a biological component evidenced by an over-representation of women who had experienced stillbirths, and (ii) a social component indicated by an increased risk among women who had remarried. The results strengthen the argument for using the family rather than the single child as the unit of analysis. The clustering of infant deaths points to the need to re-evaluate our interpretations of the causes of infant mortality in the past.     

Estimating the effect of child mortality on the number of births

This article rigorously derives the properties of the regression of births on child deaths. It is shown how the raw regression coefficient may be corrected for the effects of fertility on mortality so that the rate at which dead children are replaced may be estimated. The method is applied to data from Colombia. It is found that the mortality rate differs across individuals and is correlated with fertility. Such conditions vitiate the use of birth intervals and parity progression ratios yet can be dealt with using the new method. On average each death produces 0.2 new births as a direct result of the death. Fertility hoarding may raise the total fertility response to roughly one-half birth per death.     

Infant mortality,birth order,and sibship size: The role of heterogeneous risk and the previous‐death effect

This paper derives an analytic model to study biases in infant mortality estimates by birth order and sibship size, which occur when the death of an infant tends to shorten the next birth interval and mortality risk varies among families. We find that order‐specific and sibship‐size‐specific estimates are biased by a selection for high‐risk women across birth orders, since women with higher risk will tend to have shorter intervals, and more births, within a given period of time. Sibship‐size‐specific estimates are, in addition, biased by a selection of women who have experienced deaths, even if there is no heterogeneity in risk. Numerical examples based on data from Matlab, Bangladesh, are used to illustrate the possible magnitude of these biases. The results resemble patterns of infant mortality by birth order and sibship size which are often observed empirically.     

Levels and patterns of infant and child mortality in ghana

This paper attempts to measure infant and child mortality levels and also to determine their structure by utilizing the results of the 1968–1969 National Demographic Sample Survey which was conducted under the directorship of the author. Among the major problems encountered in the exercise are the adjustment of the current raw mortality data and the estimation of infant and child mortality from independent source material. The estimated infant mortality rates range from 56 per 1,000 live births in the Accra Capital District to 192 in the Upper Region during the late 1960’s. The urban rate is lower than the rural rate, 98 as against 161 per 1,000 live births. A large proportion of the deaths among children aged 0–4 occur in the second year of life, and deaths in this age group account for the bulk of the deaths within the age group 1–4 years.     

Demographic crisis: The impact of the Bangladesh civil war (1971) on births and deaths in a rural area of Bangladesh

Summary In Matlab Bazaar Thana the Cholera Research Laboratory has registered the births, deaths and migrations in a population of approximately 125,000 since 1966. Although this rural area was not the scene of any significant armed encounters, striking changes in birth and death rates were registered during and after the conflict. Birth rates did not change during the relatively brief period of the civil war, but a small decline was registered for one year after the war. Fertility rates which had been declining slightly and irregularly in the pre-war baseline period may have increased slightly during the war and fell substantially in all age groups in the year following the war. The crude death rate, which rose by 37 per cent during the war, was a very sensitive reflection of the administrative and economic problems. Overall infant mortality rose by only 15 per cent over pre-war levels because all of the increase was observed in the post-neo-natal component, which traditionally accounts for less than one-third of the total infant mortality in Bangladesh. Children and older adults accounted for the majority of excess deaths which were largely attributed to acute diarrhoeas and other gastro-intestinal causes. The death rate at ages 1-4 rose by 43 per cent and at ages 5-9 soared to 208 per cent above pre-war baseline rates. All increases in age-specific mortality rates fell to baseline levels during the year following the war, except the 5-9-year age group, in which rates continued to be high largely because of deaths due to dysentery.     

Changes in fertility patterns can improve child survival in Southeast Asia

This analysis of 1988 Philippine Demographic Survey data provides information on the direct and indirect effects of several major determinants of childhood mortality in the Philippines. Data are compared to rates in Indonesia and Thailand. The odds of infant mortality in the Philippines are reduced by 39% by spacing children more than two years apart. This finding is significant because infant mortality rates have not declined over the past 20 years. Child survival is related to the number of children in the family, the spacing of the children, the mother's age and education, and the risks of malnutrition and infection. Directs effects on child survival are related to infant survival status of the preceding child and the length of the preceding birth interval, while key indirect or background variables are maternal age and education, birth order, and place of residence. The two-stage causation model is tested with data on 13,716 ever married women aged 15-49 years and 20,015 index children born between January 1977 and February 1987. Results in the Philippine confirm that maternal age, birth order, mortality of the previous child, and maternal education are directly related to birth interval, while mortality of the previous child, birth order, and maternal educational status are directly related to infant mortality. Thailand, Indonesia, and the Philippines all show similar explanatory factors that directly influence infant mortality. The survival status of the preceding child is the most important predictor in all three countries and is particularly strong in Thailand. This factor acts through the limited time interval for rejuvenation of mother's body, nutritional deficiencies, and transmission of infectious disease among siblings. The conclusion is that poor environmental conditions increase vulnerability to illness and death. There are 133% greater odds of having a short birth interval among young urban women than among older rural women. There is a 29% increase in odds for second parity births compared to third or higher order parities. Maternal education is a strong predictor of infant survival only in the Philippines and Indonesia. Adolescent pregnancy is a risk only in Indonesia. Socioeconomic factors are not as important as birth interval, birth order, and maternal education in determining survival status.     

Socioeconomic Inequalities in Infant Mortality in Egypt: Analyzing Trends Between 1995 and 2014

This paper analyses the trend of the socioeconomic inequalities in infant mortality rates in Egypt over the period 1995–2014, using repeated cross-sectional data from the National Demographic and Health Survey. A multivariate logistic regression and concentration indices are used to examine the demographic and socioeconomic correlates of infant mortality, and how the degree of socioeconomic disparities in child mortality rates has evolved over time. We find a significant drop in infant mortality rates from 63 deaths per 1000 live births in 1995 to 22 deaths per 1000 live births in 2014. However, analyzing trends over the study period reveals no corresponding progress in narrowing the socioeconomic disparities in childhood mortality. Infant mortality rates remain higher in rural areas and among low-income families than the national average. Results show an inverse association between infant mortality rates and living standard measures, with the poor bearing the largest burden of early child mortality. Though the estimated concentration indices show a decline in the degree of socioeconomic inequality in child mortality rates over time, infant mortality rate among the poor remains twice the rate of the richest wealth quintile. Nonetheless, this decline in the degree of socioeconomic inequality in child mortality is not supported by the results of the multivariate logistic regression model. Results of the logistic model show higher odds of infant mortality among rural households, children who are twins, households with risky birth intervals. We find no statistically significant association between infant mortality and child’s sex, access to safe water, mothers’ work, and mothers’ nutritional status. Infant mortality is negatively associated with household wealth and regular health care during pregnancy. Concerted effort and targeting intervention measures are still needed to reduce the degree of socioeconomic and regional inequalities in child health, including infant mortality, in Egypt.     

Measures and effectiveness in controlling omission of reports on infant deaths in Shanghai metropolitan areas]

The infant mortality rate is a sensitive indicator of a country's or area's economic, cultural, and health care conditions, and in particular, it reflects the quality of health care for women and young children. Since liberation, great progress has been achieved in Shanghai's health and medical care in general as well as in health care for women and young children, and the infant mortality rate has dropped notably. However, the omission of reports on infant deaths is still a very serious problem. In order to control such omissions in reporting, the Shanghai municipal government and Department for Public Health have improved the methods of reporting deaths. Health care units are required to fill out a report on births and deaths, and census registers in the city government are responsible for registering all new births and deaths and preparing complete statistics on new births and deaths. At the end of each year, special investigators are sent to various hospitals to check on omissions of reports on infant deaths and they also help households to report infant deaths to census registers. The new measures have proved to be very effective. According to a new report released in 1980, the omission of reports on infant deaths has been reduced by 94.01% as compared with the 1972 statistics.     

Paradox found (again): Infant mortality among the Mexican-origin population in the united states

Recent research suggests that the favorable mortality outcomes for the Mexican immigrant population in the United States may largely be attributable to selective out-migration among Mexican immigrants, resulting in artificially low recorded death rates for the Mexican-origin population. In this paper we calculate detailed age-specific infant mortality rates by maternal race/ethnicity and nativity for two important reasons: (1) it is extremely unlikely that women of Mexican origin would migrate to Mexico with newborn babies, especially if the infants were only afew hours or afew days old; and (2) more than 50% of all infant deaths in the United States occur during the first week of life, when the chances of out-migration are very small. We use concatenated data from the U.S. linked birth and infant death cohort files from 1995 to 2000, which provides us with over 20 million births and more than 150,000 infant deaths to analyze. Our results clearly show that first-hour, first-day, and first-week mortality rates among infants born in the United States to Mexican immigrant women are about 10% lower than those experienced by infants of non-Hispanic, white U.S.-born women. It is extremely unlikely that such favorable rates are artificially caused by the out-migration of Mexican-origin women and infants, as we demonstrate with a simulation exercise. Further, infants born to U.S.-born Mexican American women exhibit rates of mortality that are statistically equal to those of non-Hispanic white women during the first weeks of life and fare considerably better than infants born to non-Hispanic black women, with whom they share similar socioeconomic profiles. These patterns are all consistent with the definition of the epidemiologic paradox as originally proposed by Markides and Coreil (1986).     

The cocos-keeling islands: A demographic laboratory

The Cocos Islands, which are situated in the Indian Ocean approximately halfway between Colombo and Fremantle, were first peopled early in the nineteenth century and were gradually developed as a very isolated coconut plantation with a labour force consisting partly of persons of Malay stock descended from the original group of settlers and partly of Bantamese contract labourers from Java. As the Cocos-born population increased in size, the dependence on contract labour decreased and, before the end of the century, all immigration ceased. The 1947 Malay population of the islands was about 1,800.

The islands are fascinating from a demographer's point of view because there was a virtually complete registration of live births, deaths and marriages and a partial registration of stillbirths. With these registration records it was possible to construct the life history of every individual from birth, through infancy and childhood to marriage, and thence through fatherhood or motherhood to death.

The picture revealed by an analysis of these records is that of a population with very high fertility and with mortality at a high level before the first World war and at a medium level after that war. Crude birth rates varied between 50 and 60 per thousand population during the period 1888 to 1947. Crude death rates were between 30 and 40 per thousand population until 1912 but under 2.0 per thousand population after 1918.

Most Cocos girls married before reaching the age of 20 and there were an average of between eight and nine live births per woman living through the childbearing period. There was a steady decline in the average number of live births with advancing age at marriage from age 16 onwards. A significantly high proportion of those dying in the middle of the childbearing period had never married, but the fertility of those marrying at an early age (14, 15 and 16) and dying before reaching the age of 36 was slightly higher than that of those who married at a similar age and survived. Women who survived to the age of 55 were of higher fertility than those who died between the ages of 40 and 55. An analysis of birth intervals revealed significant differences (a) between birth intervals after a stillbirth or after a live birth in which the child died in early infancy, and birth intervals after a live birth in which the offspring survived for longer than 0.4 years, and (b) between the interval from first to second birth and the subsequent birth intervals. There was a difference of almost exactly a year between the average birth interval after a stillbirth or live birth ending in a neo-natal death and the average birth interval after the birth of a child surviving to age 2; there was a similar difference of a year between corresponding median birth intervals.

From 1888 to 1912 infant mortality was well above 300 per thousand. After 1918 infant mortality averaged rather under 100 infant deaths per 1,000 live births. The reduction in infant mortality rates was accompanied by an increase in the mortality of children aged 1 to 4, and the heavy incidence of mortality at these ages after 1918 is the most striking feature of the analysis of mortality by age. Whilst mortality in infancy fell much more heavily on males than on females, early childhood mortality was much higher in Cocos for girls than for boys. The life table computed for the period 1918 to 1947 indicated a life expectancy of about 50 years for males and 47 years for females.     

The effects of maternal smoking on infant health

Maternal smoking has serious consequences for the developing fetus and infant, including a higher probability that the infant will be born prematurely and at low birth weight, will require admission to neonatal intensive care, and die during infancy. Data from Alabama birth certificates for births occurring between 1988 and 1991 were analyzed using log linear methods to calculate relative risks of adverse pregnancy outcomes and infant death. Smoking by mothers during pregnancy is associated with an elevated risk of infant death, low birth weight, and prematurity, controlling for mother's educational attainment, age, marital status, race, and trimester prenatal care was initiated. Smoking was also associated with a higher rate of admission to neonatal intensive care and to deaths from SIDS and respiratory causes. Reducing maternal smoking can contribute to a reduction of premature and low weight births and infant deaths. Because of the difficulty of stopping smoking, efforts need to be directed at preventing younger women from beginning to smoke.An earlier version of this paper was presented at the Southern Demographic Association annual meeting in New Orleans in October 1993.     

India's National Family Health Survey provides new information on maternal and child health and AIDS awareness

Teams surveyed a sample of 88,562 households, drawn from 99% of the population of India in 24 states plus the National Capital Territory of Delhi, between April 1992 and September 1993 to collect a basic set of information on all 500,492 household members, with more details on the 89,777 women in the households who had ever been married and were aged 13-49 years. This National Family Health Survey (NFHS) collected information from the women on a range of health topics including child immunization, women's knowledge of AIDS, services and facilities use during pregnancy and childbirth, infant feeding and treatment for diarrhea, and infant, child, and maternal mortality. Levels of infant and child mortality declined in India, but 8% of all children still die before their first birthday and 11% die before reaching age 5. As for maternal mortality, there are an estimated 420 maternal deaths per 100,000 live births annually. That rate implies that at least 100,000 Indian women die each year due to causes related to pregnancy and childbirth. Survey results indicate the need to strengthen vaccination programs and teach women about proper infant feeding practices. They also highlight the need to increase antenatal care and other medical services. In all of these areas, the NFHS results indicate wide variation among India's regions and states. Furthermore, a general lack of AIDS awareness suggests that the government's AIDS awareness campaign, relying primarily upon electronic media, has not yet reached the majority of India's population.     

Mortality in Ghana: Evidence from the cape coast project data

This paper deals with the estimation of mortality for a rural community of about 20,000 persons in the rain-forest area of south-west Ghana. Specifically, infant, child and adult mortality estimates have been obtained by the application of a wide range of direct and indirect methods of measuring mortality from the different statistics collected by a longitudinal mortality and fertility project conducted during 1974–7. It was noted that infant and childhood mortality rates obtained from death registrations were consistent with those rates yielded by pregnancy histories and child survival statistics. However, the adult mortality estimates derived from orphanhood statistics tended to be lower than those suggested by death registrations. The analysis revealed an infant mortality rate of 100 for boys and 84 for girls, equal childhood mortality rates for boys and girls (85–6), a lower expectation of life at birth for men (45.8 years) than for women (52.8), and a much more severe incidence of mortality among men aged over 40 than for women at the corresponding ages.     

Mortality in Ghana: Evidence from the cape coast project data

Abstract This paper deals with the estimation of mortality for a rural community of about 20,000 persons in the rain-forest area of south-west Ghana. Specifically, infant, child and adult mortality estimates have been obtained by the application of a wide range of direct and indirect methods of measuring mortality from the different statistics collected by a longitudinal mortality and fertility project conducted during 1974-7. It was noted that infant and childhood mortality rates obtained from death registrations were consistent with those rates yielded by pregnancy histories and child survival statistics. However, the adult mortality estimates derived from orphanhood statistics tended to be lower than those suggested by death registrations. The analysis revealed an infant mortality rate of 100 for boys and 84 for girls, equal childhood mortality rates for boys and girls (85-6), a lower expectation of life at birth for men (45.8 years) than for women (52.8), and a much more severe incidence of mortality among men aged over 40 than for women at the corresponding ages.