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.     

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.     

Family planning's benefits include improved child health and nutrition: new data from Bangladesh

2 recent studies from the Matlab in Bangladesh confirm that family planning promotes child survival. The 1st study is a longitudinal analysis of 3370 births in 1985 to women living in 70 villages who were served by the International Centre for Diarrhoeal Disease Research, Bangladesh's Matlab Family Planning and Health Services Project. The 2nd is a study of 12-26 month old children and 24-36 month old children, all of whom were born in the same 70 villages between July 1985 and June 1986. The 1st study demonstrates that family planning improves child survival by lengthening the birth interval. In fact, if women delay a subsequent birth by about 2 years, child survival improves at all ages up to 5 years. Longer birth intervals result in a reduction of very high order births. The same study also reveals that family planning improves child survival indirectly by granting mothers access to integrated maternal and child health services. The 2nd study indicates that a child is 3 times more likely to suffer malnutrition, even at age 3, than a child whose mother gives birth again at an interval greater than 24 months. Specifically, the mother removes the index child from the breast prematurely, thereby adversely affecting the index child's nutrition. The birth interval prior to the index child does not adversely affect the index child's nutritional status, however. The 2nd study's result suggest that birth spacing, as promoted by family planning programs, improves child health and nutrition. The findings from these studies show the importance of continued investments in family planning programs in developing countries.     

The impact of infant and child death on subsequent fertility in Ethiopia

This paper uses hazard regression models to assess the impact of experienced infant and child mortality on the risk of subsequent conceptions in Ethiopia. The purpose of this paper is to test for the presence of a fertility response to an infant or child death, net of the effects of truncated breastfeeding on fecundity. Using retrospective birth history data from a national survey in Ethiopia, we find a significantly higher risk of a conception in the months following the death of an index child, even after controlling for postpartum amenorrhoea and breastfeeding status. The fertility response is strongest after the death of the fourth or fifth child, which is when most women in Ethiopia are at or near their desired family size. However, we find no evidence of a fertility response to the death of a nonindex child. We attribute the higher risk of a conception following an index child’s death to the intentional efforts of couples to reduce the waiting time to a next birth and thereby replace the deceased child. However, absent evidence of replacement fertility in response to the death of older nonindex children, we interpret the response to the death of an index child as an emotional response to child loss rather than a conscious strategy to meet a fertility target.

Childhood Mortality Estimates Using the Preceding Birth Technique: Some Applications and Extensions

The Preceding Birth Technique has proved to be a simple and effective way of estimating mortality during the first two years of life when the question on the survival of the preceding child is asked at the time of a subsequent delivery. This article shows first that earlier worries about significant biases in the estimates are unfounded. Amongst the possible sources of bias considered are: the link between birth-interval length and child survival; the effects of birth intervals differing from 30 months; and the contribution of other systematic biases, such as the omission of all reports on the survival of a woman's last child. Results from a trial in the maternity clinics in Bamako, Mali are presented to illustrate both practical aspects of the method and selection effects by age and parity. A strong association between the survival chances of the succession of children born to one mother emerges. The second part of the article describes how the method can be applied more widely by asking the key questions at times other than a subsequent delivery. Adjustment factors are developed to correct for the biases introduced when the sample includes only mothers whose last-born children are alive at interview.Finally, some examples are given of recent use of the question on the survival of the preceding child in household surveys.     

New evidence about effects of reproductive variables on child mortality in sub-Saharan Africa

There is still considerable uncertainty about how reproductive factors affect child mortality. This study, based on Demographic and Health Survey data from 28 countries in sub-Saharan Africa, shows that mortality is highest for firstborn children with very young mothers. Other children with young mothers, or of high birth order, also experience high mortality. Net of maternal age and birth order, a short preceding birth interval is associated with above average mortality. These patterns change, however, if time-invariant unobserved mother-level characteristics of importance for both mortality and fertility are controlled for in a multilevel–multiprocess model. Most importantly, there are smaller advantages associated with longer birth intervals and being older at first birth. The implications of alternative reproductive ‘strategies’ are discussed, taking into account that if the mother is older at birth, the child will also be born in a later calendar year, when mortality may be lower.     

The effect of female migration on infant and child survival in Uganda

This article uses data from the 1996 Uganda Demographic and Health Survey to examine whether migration of women improves the survival chances of their children to age five. We expand on prior research by testing not only the hypothesized positive effect of rural-urban migration, but also the effects of other migration stream behaviours on child survival. Results show that up to 10% of children die before age five and within-group differences in mortality exist among urban and rural children depending on their mother's migration status. Only urban-urban migration was significantly related to child survival, compared to rural non-migrants, after controlling for other factors, although other streams of migration (rural-urban, urban-rural, rural-rural) were positively related to child survival. Generally, migration explains a small component of the variance in child survival. Several other factors, including parents' education, household size, household headship, mother's age at birth, duration of breastfeeding, and place of delivery have a significant predictive power on child survival.     

The impact of childhood mortality on Fertility in six rural Thanas of Bangladesh

In this article, we examine the relationship between child mortality and subsequent fertility using prospective longitudinal data on births and childhood deaths occurring to nearly 8000 Bangladeshi mothers observed over the 1982-1993 period, a time of rapid fertility decline. Generalized hazard-regression analyses are employed to assess the effect of infant and child mortality on the hazard of conception, with controls for birth order and maternal age and educational attainment. Results show that childhood mortality reduces the time to subsequent conception if the death occurs within a given interval, representing the combined effect of biological and volitional replacement. The time to conception is also reduced if a childhood death occurs during a prior birth interval, a finding that signifies an effect of volitional replacement of the child that died. Moreover, mortality effects in prior birth intervals are consistent with hypothesized insurance (or hoarding) effects. Interaction of replacement with elapsed time suggests that the volitional impact of child mortality increases as the demographic transition progresses. This volitional effect interacts with sex of index child. Investigation of higher-order interactions suggests that this gender-replacement effect has not changed over time.     

Pregnancy outcome and the time required for next conception

Abstract Variations in the time required for next conception by outcome ofthe preceding pregnancy, and the age of woman, are studied for Taiwanese women. Pregnancy interval, defined as the period between the end of one pregnancy and the beginning of the next, is taken as a measure of the time required for the next conception. The averages and variances of pregnancy intervals are estimated from reports of pregnancies occurring in a probability sample of 2,443 married women, aged 20-39, living in Taichung (Taiwan) in 1962. The effects of 'truncation bias' and 'memory bias' on the two moments of pregnancy intervals are estimated indirectly by cross-classifying women according to their ages at interview and their ages at the beginning (or end) of each pregnancy interval. The moments of post-partum amenorrhoea are, then, estimated indirectly from the moments of pregnancy intervals. The effects of truncation bias and memory bias are compensatory in this sample. In the absence of contraception, women, on an average, took longer to conceive following a live birth than following a foetal death. The time taken for next conception increases as women become older irrespective of the outcome of the preceding pregnancy.     

The effects of pregnancy spacing on infant and child mortality in Matlab, Bangladesh: how they vary by the type of pregnancy outcome that began the interval

Using high-quality longitudinal data on 125,720 singleton live births in Matlab, Bangladesh, we assessed the effects of duration of intervals between pregnancy outcomes on infant and child mortality and how these effects vary over subperiods of infancy and childhood and by the type of outcome that began the interval. Controlling for other correlates of infant and child mortality, we find that shorter intervals are associated with higher mortality. Interval effects are greater if the interval began with a live birth than with another pregnancy outcome. In the first week of the child's life, the effects of short intervals are greater if the sibling born at the beginning of the interval died; after the first month, the effects are greater if that sibling was still alive. Many relationships found are consistent with the maternal depletion hypothesis, and some with sibling competition. Some appear to be due to correlated risks among births to the same mother.     

Reproductive patterns and child mortality in guatemala

In this paper, we investigate the association of child mortality with maternal age, parity, birth spacing, and socioeconomic status, in a sample of Guatemalan children who were included in a public health intervention program. Our results indicate that maternal age, birth order, and the length of the previous and following birth intervals all have a significant impact on the risk of child mortality and that these associations cannot be accounted for by differences in breastfeeding, socioeconomic status, or the survival status of the previous child.     

The child survival hypothesis

Summary Because of current interest in the child survival hypothesis, we have reviewed available evidence bearing upon the relationships of infant and child mortality to fertility and contraceptive behaviour. The evidence is drawn from time series data for local and national vital events, from special in-depth studies of the infant mortality-fertility relationships in family formation, and from service statistics from health and family planning programmes. As a result of this review, we suggest five clarifications which should be made in redefining the child survival hypothesis and assessing its potential programme implications. The child survival hypothesis states that improved child survival will contribute to increased family planning motivation and consequent fertility decline. The evidence presented here suggests that the effect is not automatic and probably not a necessary pre-condition for fertility decline. There is certainly not a reflexive one-to-one replacement, but a partial effect may still be important. In the clearly demonstrated reduction in inter-pregnancy intervals after a child death, the major component is undoubtedly the removal of the biological protection of lactational amenorrhoea. A separate but somewhat smaller effect has been demonstrated in situations where lactation did not seem to have been the explanation. It is expected that increased child survival will contribute to fertility decline mainly in countries experiencing rapid mortality decline and population growth. The replacement of children who die is probably not so much 'volitional' as a result of alterations in sub-conscious expectations. It is apparent that in traditional agrarian populations, few direct and manipulable means of influencing motivation for fertility limitation are available, and, therefore, it must be stressed that integrated health and family planning programmes do provide opportunities for immediate programme development. By making parents aware of improved changes of survival through health services in which they develop confidence, the spontaneous linkages between mortality and fertility can presumably be reinforced. Family planning services must be provided as an essential initial step in programme development, but they can be made more effective, as well as politically more acceptable if appropriately integrated with maternal and child health and nutrition services.     

Frontier settlement and child survival in the Brazilian Amazon

This study uses sample data from the 1960, 1970 and 1980 demographic censuses to estimate child survival rates among children born to native and migrant women in the Brazilian Amazon. Estimates show that by 1980 the probability of death among children was quite similar when comparing native and migrant populations in the aggregate. However, after controlling for household economic activity and income, death rates were higher among migrant children. The findings suggests that nonmigrants are better able than recent colonists to mobilize physical and social environments to safeguard the health of their children.     

Pre-term Foetal Life Times in Scotland

A proportional hazards model was used to evaluate the association between ten categorical covariates and the risk of pre-term delivery for women having their first child and women in subsequent pregnancies. An adaptation of the model for use with grouped survival times made it possible to model foetal life times between 28 and 36 completed weeks of gestation for 67,000 Scottish singleton births in 1981. The use of the model was justified by testing time-dependent effects. For both groups of women age, and a history of abortion, were major factors associated with increased hazard. For women experiencing a second or higher-order birth a history of perinatal death was also associated with substantially increased hazard to the pregnancy.     

An alternative sampling strategy for obtaining child health data in a reproductive health survey

Retrospective demographic surveys typically collect substantial information about child health. This information is often collected for all children born during a specified period. For women with several young children, the interview can become quite long. To shorten the interview, some surveys have asked child health questions only for the last child born. However, data on the last birth may be biased because last children have a younger age distribution and have longer subsequent birth intervals than does the average child. In this paper, we propose an alternative approach to collecting child health data - that child health questions be asked only for a child chosen randomly from among the respondent's children younger than age five. This alternative has the advantage of keeping the interview shorter but does not lead to biased information.Abbreviations DHS Demographic and Health Surveys     

Birth spacing and child mortality in bangladesh and the Philippines

This analysis uses data from Bangladesh and the Philippines to demonstrate that children who are born within 15 months of a preceding birth are 60 to 80% more likely than other children to die in the first two years of life, once the confounding effects of prematurity are removed. The risks associated with short conception intervals are confined to children who are also high birth order; they persist in the presence of controls for prior familial child mortality, breast-feeding, mother's age, and socioeconomic status. In Bangladesh but not in the Philippines, these effects are confined to the neonatal period.     

Infant mortality and fertility in three Bavarian villages: An analysis of family histories from the 19th century

Abstract Family history data derived from the records of three parishes in Bavaria provide evidence for several important demographic questions when analysed in conjunction with information concerning the prevalent breast-feeding practices. The results suggest strongly that breast feeding can prolong birth intervals substantially. The evidence concerning the independent influence of infant deaths on subsequent birth intervals is inconclusive. It is clear, however, that even if such an influence did exist it was relatively small, compared to the effect of lactation. In addition the results do not lend support to the hypothesis that couples experiencing low child mortality practised family limitation more than couples experiencing high child mortality. In all three parishes, however, fertility appeared to influence infant mortality. Infants born after short intervals were subject to considerably higher mortality risks than infants following longer intervals.     

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.     

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.