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.     

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.     

Birth and death in cities in the developing world

City dwellers in Sub-Saharan Africa have increased roughly 600% in the last 35 years. Throughout the developing world, cities have expanded at a rate that has far outpaced rural population growth. Extensive data document lower fertility and mortality rates in cities than in rural regions. But slums, shantytowns, and squatters' settlements proliferate in many large cities. Martin Brockerhoff studies the reproductive and health consequences of urban growth, with an emphasis on maternal and child health. Brockerhoff reports that child mortality rates in large cities are highest among children born to mothers who recently migrated from rural areas or who live in low-quality housing. Children born in large cities have about a 30% higher risk of dying before they reach the age of 5 than those born in smaller cities. Despite this, children born to migrant mothers who have lived in a city for about a year have much better survival chances than children born in rural areas to nonmigrant mothers and children born to migrant mothers before or shortly after migration. Migration in developing countries as a whole has saved millions of children's lives. The apparent benefits experienced in the 1980s may not occur in the future, as cities continue to grow and municipal governments confront an overwhelming need for housing, jobs, and services. Another benefit is that fertility rates in African cities fell by about 1 birth per woman as a result of female migration from villages to towns in the 1980s and early 1990s. There will be an increasing need for donors and governments to concentrate family planning, reproductive health, child survival, and social services in cities, particularly in Sub-Saharan Africa, because there child mortality decline has been unexpectedly slow, overall fertility decline is not yet apparent in most countries, and levels of migration to cities are anticipated to remain high.     

Single Motherhood and Child Mortality in Sub-Saharan Africa: A Life Course Perspective

Single motherhood in sub-Saharan Africa has received surprisingly little attention, although it is widespread and has critical implications for children’s well-being. Using survival analysis techniques, we estimate the probability of becoming a single mother over women’s life course and investigate the relationship between single motherhood and child mortality in 11 countries in sub-Saharan Africa. Although a mere 5 % of women in Ethiopia have a premarital birth, one in three women in Liberia will become mothers before first marriage. Compared with children whose parents were married, children born to never-married single mothers were significantly more likely to die before age 5 in six countries (odds ratios range from 1.36 in Nigeria to 2.61 in Zimbabwe). In addition, up to 50 % of women will become single mothers as a consequence of divorce or widowhood. In nine countries, having a formerly married mother was associated with a significantly higher risk of dying (odds ratios range from 1.29 in Zambia to 1.75 in Kenya) relative to having married parents. Children of divorced women typically had the poorest outcomes. These results highlight the vulnerability of children with single mothers and suggest that policies aimed at supporting single mothers could help to further reduce child mortality in sub-Saharan Africa.     

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.     

Data on survival of recent births as a source of child mortality estimates in the developing world: An assessment of census data

In many less developed countries, household surveys collect full and summary birth histories to provide estimates of child mortality. However, full birth histories are expensive to collect and cannot provide precise estimates for small areas, and summary birth histories only provide past child mortality trends. A simple method that provides estimates for the most recent past uses questions about the survival of recent births in censuses or large household surveys. This study examines such data collected by 45 censuses and shows that on average they tend to underestimate under-5 mortality in comparison with alternative estimates, albeit with wide variations. In addition, the high non-sampling uncertainty in this approach precludes its use in providing robust estimates of child mortality at the country level. Given these findings, we suggest that questions about the survival of recent births to collect data on child mortality not be included in census questionnaires.     

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.     

Maternal Age and Child Development

Although the consequences of teen births for both mothers and children have been studied for decades, few studies have taken a broader look at the potential payoffs—and drawbacks—of being born to older mothers. A broader examination is important given the growing gap in maternal ages at birth for children born to mothers with low and high socioeconomic status. Drawing data from the Children of the NLSY79, our examination of this topic distinguishes between the value for children of being born to a mother who delayed her first birth and the value of the additional years between her first birth and the birth of the child whose achievements and behaviors at ages 10–13 are under study. We find that each year the mother delays a first birth is associated with a 0.02 to 0.04 standard deviation increase in school achievement and a similar-sized reduction in behavior problems. Coefficients are generally as large for additional years between the first and given birth. Results are fairly robust to the inclusion of cousin and sibling fixed effects, which attempt to address some omitted variable concerns. Our mediational analyses show that the primary pathway by which delaying first births benefits children is by enabling mothers to complete more years of schooling.     

Registration completeness and international comparisons of infant mortality

The physical development of the live born infant is the single most important variable governing its survival: infant mortality among those weighing 2,500 grams (5 1/2 pounds) or less at birth is 17 times the mortality among those weighing more than 2,500 grams at birth. The variation in mortality according to birth weight (or gestation) is greater than for subclasses of color, sex, maternal age, or birth order. Infant mortality in the United States is significantly higher than in a number of other countries e.g., Sweden, Netherlands, Norway. The difference is thought, by some, to be due to underregistration of low birth weight infants in other countries. In this paper, distributions of live births by birth weight for Denmark, England and Wales, New Zealand, and the United States, and infant mortality data for Denmark and the United States are examined. The data do not support a hypothesis of gross underregistration of live born infants in other countries. The results indicate that some index of physical development (birth weight, gestation, or a combination of both) should be included in any appraisal of infant mortality.     

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.     

Organized Violence and Institutional Child Delivery: Micro-Level Evidence From Sub-Saharan Africa, 1989–2014

The conditions under which a mother gives birth greatly affect the health risk of both the mother and the child. This article addresses how local exposure to organized violence affects whether women give birth in a health facility. We combine geocoded data on violent events from the Uppsala Conflict Data Program with georeferenced survey data on the use of maternal health care services from the Demographic and Health Surveys. Our sample covers 569,201 births by 390,574 mothers in 31 countries in sub-Saharan Africa. We use a mother fixed-effects analysis to estimate the effect of recent organized violence events within a radius of 50 km of the home of each mother on the likelihood that her child is born in a health facility. The results indicate that geographical and temporal proximity to organized violence significantly reduces the likelihood of institutional births. Although the level of maternal health care overall is lower in rural areas, the negative effect of violence appears to be stronger in urban areas. The study further underscores the importance of household and individual resilience, indicating that the effect of organized violence on institutional child delivery is greater among poor and less-educated mothers.     

The Effect of birth spacing on childhood mortality in Pakistan

Summary In this study retrospective data from the 1975 Pakistan Fertility Survey are used to examine the effects of birth spacing on infant and child mortality. The length of the preceding interval between live births emerges as a major determinant of mortality. The effect persists for rural and urban families, for children of uneducated and educated mothers, for both boys and girls, and for large and small families. The possibility that this relationship is the spurious consequence of data defects or of a common cause, such as early weaning, is examined but rejected. Once the length of the preceding interval is controlled, the average spacing of earlier births is found to be unrelated to survivorship. However, the length of the succeeding interval is significantly related to survivorship during the second year of life.     

Death Clustering,Mothers' Education and the Determinants of Child Mortality in Rural Punjab,India

In this paper the behavioural factors which make for continuing high levels of child mortality in rural Punjab, despite favourable conditions in terms of nutrition, income, women's literacy and health care facilities are examined. A major factor is that inadequate attention has been paid to improved health care practices within the home. Women's autonomy, social class, and mothers' education significantly influence child survival. One of the pathways by which mothers' education affects child survival is through improved child care. In this society, a woman's autonomy is lowest during that part of her life-cycle which also contains her peak childbearing years: this perverse overlap raises child mortality. The risk of dying is distributed very unevenly amongst children, as the majority of child deaths are clustered amongst a small proportion of the families. The death-clustering variable remained significant even after several possible biological and socio-economic reasons for clustering had been controlled. It is argued that this clustering of deaths is partly due to the poor basic abilities of some mothers and other carers.     

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.     

Child Mortality in Beirut: Six Indirect Estimates Based on Data Collected at the Time of a Birth

Six indirect techniques for estimating child mortality were applied to information on survival status of all children ever born, provided by a sample of 1,252 women delivered at the Maternity Unit of the American University of Beirut Hospital. The results were compared, using as a reference the estimate derived from partial birth histories (ages of surviving children, ages at death of children who have died). Their dispersion is minimal for the probability of dying between birth and fifth birthday, estimated at 48 per thousand. For each mother, the ratio of the observed number of children who have died, to that expected given the lengths of exposure of the children to the risk of mortality, was used as a dependent variable in a multiple regression analysis. Educational level of mothers had a significant effect, but not occupational status of father, religion or consanguinuity.     

Parental investment responses to a low birth weight outcome: who compensates and who reinforces?

This study analyzes how parental investment responds to a low birth weight (LBW) outcome and finds important differences in investment responses by maternal education. High school dropouts reinforce a LBW outcome by providing less investment in the human capital of their LBW children relative to their normal birth weight children whereas higher educated mothers compensate by investing more in their LBW children. In addition, an increase in the number of LBW siblings present in the home raises investment in a child, which is consistent with reinforcement, but this positive effect tends to be concentrated among high school dropouts. These results suggest that studies analyzing the effects of LBW on child outcomes that do not account for heterogeneity in investment responses to a LBW outcome by maternal education may overestimate effects of LBW on child outcomes for those born to low-educated mothers and underestimate such effects for those born to high-educated mothers.     

Rural-to-Urban migration and child survival in Senegal

Analysis of the 1986 Senegal Demographic and Health Survey reveals that mothers may be able to improve their children's survival chances by migrating from the countryside to the city. Children of urban migrants, however, continue to experience a much higher risk of mortality before the age of 5 than children of urban nonmigrants, even after the mother has lived in the city for several years. This migrant mortality disadvantage persists when controlling for numerous socioeconomic and fertility-related factors typically associated with child mortality in developing countries, which also serve as indicators of migrant selection and adaptation.     

Fertility decline in a US population favoring large families: A hazard-model analysis of the effect of sib death on Amish fertility

This paper uses proportional hazards techniques and population data from a directory of the Old Order Amish of the Lancaster, PA settlement. It examines the effect of death of the immediately prior sibling on the risk of childbearing for up to 11 children. Prior research typically has pooled data for maternal cohorts. In contrast, separate models are estimated for each maternal cohort. The results are based on all reported first marriages of Amish women born between 1884–1973 (N = 4066). Hazard models run separately for children of each birth order reveal that net of maternal age and length of the prior birth interval (and other statistical and design controls), the death of the prior sib significantly increases the risk of a subsequent birth for the lower birth orders. Separate models by maternal cohort show that sib death increases the risk primarily for later cohorts. The pattern of effects from child mortality and other variables suggests changes in fertility behavior among the Amish, who have strong, traditional norms opposing contraception and favoring large families.     

Social determinants of low birth weight in a high-risk population

Over ninety low-weight infants were born per thousand live births in South Carolina, based on 96,000 birth records from 1975 and 1979. Higher incidence of low birth weight for black infants cannot be explained away as a result of black/white differences in age or education of mothers, prenatal care, parity or length of birth intervals. Though all these factors are important predictors of birth weight, an increasing propensity to have low-weight babies persists among black mothers even after all these factors are controlled.     

Child mortality in Malaysia: explaining ethnic differences and the recent decline

Infant and child mortality rates have dropped sharply for all ethnic groups in Malaysia between 1950 and 1988, but persistent ethnic differences remain. In this article we assess the contribution of several potential reasons both for the decline and the remaining differences between the Malay and Chinese sub-populations. Increased use of health inputs is found to explain a substantial part of the decline, but increased education of mothers, and income growth are also important. Longer spacing between births, and, higher average age at birth as a result of lower fertility and higher age at marriage provide only a marginal direct contribution to the fall in mortality. We find that lower mortality among the Chinese is accounted for by their higher incomes and greater propensty to purchase medical care. We also control for self-selection among users of medical care, and find that those who use health care in Malaysia tend to be subject to higher-than-average risks.