Maternal Education, Birth Weight, and Infant Mortality in the United States

This research determines whether the observed decline in infant mortality with socioeconomic level, operationalized as maternal education (dichotomized as college or more, versus high school or less), is due to its “indirect” effect (operating through birth weight) and/or to its “direct” effect (independent of birth weight). The data used are the 2001 U.S. national African American, Mexican American, and European American birth cohorts by sex. The analysis explores the birth outcomes of infants undergoing normal and compromised fetal development separately by using covariate density defined mixture of logistic regressions (CDDmlr). Among normal births, mean birth weight increases significantly (by 27–108 g) with higher maternal education. Mortality declines significantly (by a factor of 0.40–0.96) through the direct effect of education. The indirect effect of education among normal births is small but significant in three cohorts. Furthermore, the indirect effect of maternal education tends to increase mortality despite improved birth weight. Among compromised births, education has small and inconsistent effects on birth weight and infant mortality. Overall, our results are consistent with the view that the decrease in infant death by socioeconomic level is not mediated by improved birth weight. Interventions targeting birth weight may not result in lower infant mortality.     

Revising Infant Mortality Rates for the Early Twentieth Century United States

Accurate vital statistics are required to understand the evolution of racial disparities in infant health and the causes of rapid secular decline in infant mortality during the early twentieth century. Unfortunately, U.S. infant mortality rates prior to 1950 suffer from an upward bias stemming from a severe underregistration of births. At one extreme, African American births in southern states went unregistered at the rate of 15 % to 25 %. In this study, we construct improved estimates of births and infant mortality in the United States for 1915–1940 using recently released complete count decennial census microdata combined with the counts of infant deaths from published sources. We check the veracity of our estimates with a major birth registration study completed in conjunction with the 1940 decennial census and find that the largest adjustments occur in states with less-complete birth registration systems. An additional advantage of our census-based estimation method is the extension backward of the birth and infant mortality series for years prior to published estimates of registered births, enabling previously impossible comparisons and estimations. Finally, we show that underregistration can bias effect estimates even in a panel setting with specifications that include location fixed effects and place-specific linear time trends.     

出生性别比偏高的特征与原因分析——对湖北省麻城、广水、安陆三市的调查

湖北省麻城、广水、安陆三市总出生性别比升高呈现出的特征:一孩出生性别比基本正常或略微高些,但二孩及以上出生性别比超高,而二孩出生性别比超高是总出生性别比升高的主要原因;政策内二孩生育存在严重男孩性别选择行为;贫困农民家庭是选择性男孩生育的主要群体;性别选择最容易在农村流出育龄人群中实现。农村经济社会文化环境、农民家庭多重生育需求、男孩偏好、生育性别选择,这些环环相扣的因果关系变量,以及胎儿性别鉴定与人工终止妊娠易获得性和现行生育政策的“挤压”效应等,是造成调查地出生性别比异常的综合因素。     

Racial differences in infant mortality by cause of death: The impact of birth weight and maternal age

This research examines racial disparities in infant mortality, overall and separately according to cause of death. Using linked birth and death records for the 1975 cohort of live births in Florida, racial differences are initially described and then explained statistically as a product of the distribution of births by birth weight and maternal age. The impact of birth weight is more pronounced than is the effect of maternal age. The analysis suggests the potential utility of examining infant mortality separately by cause of death. Based on the findings, we argue for systematic research focused on factors affecting birth weight.     

Indirect evidence of the contribution of prenatal sex selection practices to the high sex ratio at birth in Vietnam

This paper reports indirect evidence that prenatal sex selection is a contributor to the recent increase in sex ratio at birth in Vietnam. The paper uses birth data from the Population Change Survey 2006 to assess the associations between sex ratio at birth and variables that predict increased opportunities to practise prenatal sex selection, including maternal knowledge of foetal sex before birth, the use of ultrasound for foetal sex determination, the gestation week when foetal sex was disclosed, and access to abortion services. The high sex ratio of most recent births was significantly associated with the use of ultrasound to determine the foetal sex in gestation weeks 12–22 and with access to family planning services that provide abortion. Prenatal sex selection in health facilities are likely to contribute to the recent increase in sex ratio at birth in Vietnam.     

Eastern Europe: pronatalist policies and private behavior

Fertility trends in the 9 Eastern European socialist countries (Albania, Bulgaria, Czechoslovakia, German Democratic Republic, Hungary, Poland, Romania, USSR, Yugoslavia) are reviewed. Official policy in all these countries but Yugoslavia is explicitly pronatalist to varying degrees. Attention is directed to the following areas: similarities and differences; fertility trends (historical trends, post World War 2 trends, and family size); abortion trends (abortion legislation history, current legislation, abortion data, impact on birth rates, abortion seekers, health risks, and psychological aftereffects); contraceptive availability and practice; pronatal economic incentives (impact on fertility); women's position; and marriage, divorce, and sexual attitudes. The fact that fertility was generally higher in the Eastern European socialist countries than in Western Europe in the mid-1970s is credited to pronatalist measures undertaken when fertility fell or threatened to fall below replacement level (2.1 births/woman) after abortion was liberalized in all countries but Albania, following the lead of the USSR in 1955. Fertility increased where access to abortion was again restricted (mildly in Bulgaria, Czechoslovakia, and Hungary at various times, and severely in Romania in 1966) and/or economic incentives such as birth grants, paid maternity leave, family and child care allowances, and low interest loans to newlyweds were substantially increased (Bulgaria, Czechoslovakia, Hungary, and Poland to some extent, in the late 1960s and early 1970s, and the German Democratic Republic in 1976). Subsequent declines in Bulgaria, Czechoslovakia, Hungary, and Romania suggest that policy induced increases in fertility are short-lived. Couples respond to abortion restrictions by practicing more efficient contraception or resorting to illegal abortion. It is evident that the region's low birth rate is realized mainly with abortion, for withdrawal remains the primary contraceptive method in all countries but Hungary and the German Democratic Republic. It seems that cash incentives have advanced the timing of 1st and 2nd births without substantially increasing the 3rd births required to keep national fertility above replacement level. Demographic factors alone will most likely keep birth rates low in several Eastern European countries during the 1980s and the 1990s. Due to the low birth rates in the 1960s, there will be fewer women in the prime childbearing ages of 20-29 in at least Poland, Czechoslovakia, Bulgaria, and Hungary. It becomes clear that policy efforts to influence private reproductive behavior can only be moderately successful if the living conditions are such that women are determined not to have more than 1 or 2 children.     

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.     

Family cap provisions and changes in births and abortions

As part of welfare reform efforts in the 1990s, 23 states implemented family caps, provisions that deny or reduce cash assistance to welfare recipients who have additional births. We use birth and abortion records from 24 states to estimate effects of family caps on birth and abortion rates. We use age, marital status, and completed schooling to identify women at high risk for use of public assistance, and parity (number of previous live births) to identify those most directly affected by the family cap. In family cap states, birth rates fell more and abortion rates rose more among high-risk women with at least one previous live birth compared to similar childless women, consistent with an effect of the family cap. However, this parity-specific pattern of births and abortions also occurred in states that implemented welfare reform with no family cap. Thus, the effects of welfare reform may have differed between mothers and childless women, but there is little evidence of an independent effect of the family cap.     

Family cap provisions and changes in births and abortions

As part of welfare reform efforts in the 1990s, 23 states implemented family caps, provisions that deny or reduce cash assistance to welfare recipients who have additional births. We use birth and abortion records from 24 states to estimate effects of family caps on birth and abortion rates. We use age, marital status, and completed schooling to identify women at high risk for use of public assistance, and parity (number of previous live births) to identify those most directly affected by the family cap. In family cap states, birth rates fell more and abortion rates rose more among high-risk women with at least one previous live birth compared to similar childless women, consistent with an effect of the family cap. However, this parity-specific pattern of births and abortions also occurred in states that implemented welfare reform with no family cap. Thus, the effects of welfare reform may have differed between mothers and childless women, but there is little evidence of an independent effect of the family cap.     

High Sex Ratios at Birth in the Caucasus: Modern Technology to Satisfy Old Desires

During the 1990s, the sex ratio at birth increased considerably and simultaneously in the three independent Caucasian countries, Armenia, Azerbaijan, and Georgia. At the end of the first decade of the twenty‐first century, levels remain abnormally high in Armenia and Azerbaijan (above 114 male births per 100 female births) and show erratic trends in Georgia. Analyzing data from demographic surveys carried out around 2005, we confirm the persistence of high sex ratios in these three countries and document significant differences in fertility intentions and behavior according to the sex of the previous child or children that constitute evidence of the practice of sex‐selective abortion. These countries combine societal features and medical systems that make this phenomenon possible: son preference in a context of low fertility and the possibility of prenatal sex selection given easy access to ultrasound screening and induced abortion. Why high sex ratios are observed only in these three countries of the sub‐region remains, however, an open question.     

An Increase in the Sex Ratio of Births to India‐born Mothers in England and Wales: Evidence for Sex‐Selective Abortion

Male preference in many Asian cultures results in discriminatory practices against females, including neglect and infanticide. This preference, together with the availability of prenatal sex determination and sex‐selective abortion, has led to an increase in sex ratios at birth in China, India, and South Korea. The resulting expected gender imbalances raise ethical, demographic, and social concerns. We analyzed birth statistics to see whether similar trends are apparent among births to foreign‐born mothers in England and Wales. Before 1990, sex ratios at birth were consistently nearly one point lower (104) for the three major Asian groups in Britain compared with mothers born in Western countries. This is inconsistent with previous suggestions that Asian populations have a higher “natural” sex ratio at birth. In the birth statistics since 1990, we find a four‐point increase in the sex ratio at birth for mothers born in India, attributable particularly to an increase at higher birth orders, mirroring findings reported for India. This suggests that sex‐selective abortion is occurring among mothers born in India and living in Britain. By contrast, no significant increase was observed for Pakistan‐born and Bangladesh‐born mothers, among whom male preference also exists. It seems that male preference in different cultures does not necessarily lead to sex‐selective abortion.     

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.     

Parental underinvestment: A link in the fertility-mortality continuum

Selective parental investment in siblings has been used to describe differential mortality rates. Using data from 986 Filipino women who had an average of 4.8 live births, a LISREL and six sets of regression models support the hypothesis that fertility is linked to underinvestment and that mortality, as a consequence, is linked to high birth order. The analysis also identifies intervening factors associated with this relationship. Age of mother at childbirth showed a strong influence on the relationship of birth order and infant and child mortality; correlations are stronger among older than youger mothers. However, even after the effect of age of mother at childbirth was partialled out, the effect of birth order on infant and child mortality remained significant and substantial. The conclusion is that parental underinvestment represents a link between fertility and mortality during infancy and early childhood that has not been described previously. Policy makers appear to have overlooked parental underinvestment in favor of more obvious economic and health mediators.     

Premature birth and the changing composition of newborn infectious disease mortality: Reconsidering “exogenous” mortality

Linked death and birth records from San Antonio, Texas reveal that infectious infant mortality is increasingly a function of premature birth and low birth weight. Between 1935 and 1944, 4% of infectious infant deaths had associated causes involving prematurity and related conditions; by 1980, 25% of infectious infant deaths involved prematurity and more than 40% of those infants weighed less than 2,500 grams. The shift in birth-weight composition results almost entirely from an increase in very low-weight births. Under conditions of advanced perinatal technology, infectious infant mortality should no longer be viewed as wholly exogenous. These findings further undermine the contemporary relevance of the exogenous-endogenous distinction.     

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.     

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.     

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.     

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.     

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.