Nepal survey shows that "family planning saves lives"

This article presents the results of the Nepal Family Health Survey (NFHS) conducted from January through June 1996. Data on fertility, family planning, and maternal and child health were collected from 8429 ever-married women aged 15-49 years. These women provided information on 29,156 children. Using the method of regression analysis, findings reveal those factors, such as young mothers, large families, and short birth intervals, substantially increase under-five mortality risks. However, socioeconomic factors have only a limited effect on under-five mortality. Statistics have suggested that much of the urban/rural differences in mortality have been due to factors closely related to residence, mother's level of education and economic status. In addition, although positive effects of interventions (antenatal and postpartum checkups, tetanus immunization and assistance at delivery by a traditional birth attendant) have been documented, statistical results show that few children in Nepal are receiving the benefits of maternal health care. In conclusion, results of the 1996 NFHS show that delaying, spacing, and limiting births can substantially reduce infant and child mortality.     

The unintended effects of cash transfers on fertility: evidence from the Safe Motherhood Scheme in India

India launched the Safe Motherhood Scheme (Janani Suraksha Yojana or JSY) in 2005 in response to persistently high maternal and child mortality rates. JSY provides a cash incentive to socioeconomically disadvantaged women for childbirth at health facilities. This study explores some unintended consequences of JSY. Using data from two large household surveys, we examine a policy variation that exploits the differential incentive structure under JSY across states and population subgroups. We find that JSY may have resulted in a 2.5–3.5 percentage point rise in the probability of childbirth or pregnancy over a 3-year period in states already experiencing high population growth.     

Sex‐Selective Abortions in India

Provisional estimates from the 2001 census of India, which showed unusually high sex ratios for young children, have sparked renewed concern about the growing use of sex‐selective abortions to satisfy parental preferences for sons. According to the 1998–99 National Family Health Survey (NFHS‐2), in recent years the sex ratio at birth in India has been abnormally high (107–121 males per 100 females) in 16 of India's 26 states. Data from NFHS‐2 on abortions, sex ratios at birth, son preference, and the use of ultrasound and amniocentesis during pregnancy present compelling evidence of the extensive use of sex‐selective abortions, particularly in Gujarat, Haryana, and Punjab. The authors estimate that in the late 1990s more than 100,000 sex‐selective abortions of female fetuses were being performed annually in India. Recent efforts to expand and enforce government regulations against this practice may have some effect, but they are not likely to be completely successful without changes in the societal conditions that foster son preference.     

Son preference, use of maternal health care, and infant mortality in rural China, 1989-2000

This study assesses the effects of socio-economic conditions and the interaction between son preference and China's one-child family planning policy on the use of maternal health care services and their effects on infant mortality in rural China, using nationally representative data from the 2001 National Family Planning and Reproductive Health Survey. The results show that while the use of maternal health care services has continued to increase over time, large gaps still exist in the use of these services and in infant survival by mother's education, community income, and parity. Further improvements in the reproductive health of all women and in infant survival will require effective reduction of the obstacles to the use of maternal health care among those women in rural China who are less educated, poor, and of higher parity.     

The Pervasive and Persistent Influence of Caste on Child Mortality in India

This study examines the effect of caste on child mortality and maternal health care utilization in rural India using data from the National Family Health Survey (NFHS-2) carried out during 1998–1999. Results from multilevel discrete-time hazard models indicate that, net of individual-level and community-level controls, children belonging to low castes have higher risks of death and women belonging to low castes have lower rates of antenatal and delivery care utilization than children and women belonging to upper castes. At the same time, the controls account for most of the differences within the low castes. Further analysis shows that the mortality disadvantage of low castes is more pronounced in poorer districts. These results highlight the need to target low caste members in the provision of maternal and child health services.     

Infant and child mortality in India: trends in inequalities across economic groups

This paper examines the trends in economic inequalities with respect to infant and child mortality in India using three rounds of the Indian National Family Health Survey conducted in 1992–1993, 1998–1999, and 2005–2006. The paper uses concentration index, and pooled discrete-time survival regression model to examine the aforementioned trends and regional patterns. The findings suggest a decreasing trend in economic inequality in infant mortality but an upward trend in economic inequality in child mortality in India. Economic inequalities in infant mortality have narrowed in the southern region, whereas they have widened in the western region and risen in the northern region. However, mixed trends in concentration indices were found in the different regions of India in the case of child mortality.     

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.     

Child mortality in rural India

This paper focuses on infant and child mortality in rural areas of India. We construct a flexible duration model, which allows for frailty at multiple levels and interactions between the child’s age and individual, socioeconomic, and environmental characteristics. The model is estimated using the Indian National Family and Health Survey 1998/1999. The estimation results show that socioeconomic and environmental characteristics have significantly different impacts on mortality rates at different ages. These are particularly important immediately after birth. The parameter estimates indicate that child mortality can be reduced substantially, particularly by improving the education of women, providing safe water, and reducing indoor air pollution caused by dirty cooking fuels. Finally, we still found substantial differences in mortality rates between states, which are associated with differences in schooling expenditures, female immunization, and poverty rates.     

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 pregnancy intention on child development

In this paper, we use data from the National Longitudinal Survey of Youth to investigate the empirical link between unintended pregnancy and child health and development. An important contribution of our study is the use of information on siblings to control for unmeasured factors that may confound estimates of the effect of pregnancy intentions on infant and child outcomes. Results from our study indicate that unwanted pregnancy is associated with prenatal and postpartum maternal behaviors that adversely affect infant and child health, but that unwanted pregnancy has little association with birth weight and child cognitive outcomes. Estimates of the association between unwanted pregnancy and maternal behaviors were greatly reduced after controls for unmeasured family background were included in the model. Our results also indicate that there are no significant differences in maternal behaviors or child outcomes between mistimed and wanted pregnancies.     

The First Fifty Years – A Tribute to E. Grebenik

India is a country with a pervasive preference for sons and one of the highest levels of excess child mortality for girls in the world (child mortality for girls exceeds child mortality for boys by 43 per cent). In this article, data from the National Family Health Survey are used to examine the effect of son preference on parity progression and ultimately on child mortality. The demographic effects of family composition are estimated with hazard models. The analysis indicates that son preference fundamentally affects demographic behaviour in India. Family composition affects fertility behaviour in every state examined and son preference is the predominant influence in all but one of these states. The effects of family composition on excess child mortality for girls are more complex, but girls with older sisters are often subject to the highest risk of mortality.     

Effects of education on reproductive behavior: lessons from Pakistan

Evidence from the Pakistan Demographic and Health Survey 1990/91 (PDHS) and a 1987 study by Zeba A. Sathar and Karen Oppenheim on women's fertility in Karachi and the impact of educational status, corroborates the correlation between improved education for women and fertility decline. PDHS revealed that current fertility is 5.4 children/ever married woman by the end of the reproductive period. 12% currently use a contraceptive method compared to 49% in India, 40% in Bangladesh, and 62% in Sri Lanka. The social environment of high illiteracy, low educational attainment, poverty, high infant and child and maternal mortality, son preference, and low status of women leads to high fertility. Fertility rates vary by educational status; i.e., women with no formal education have 2 more children than women with at least some secondary education. Education also affects infant and child mortality and morbidity. Literacy is 31% for women and 43% for men. 30% of all males and 20% of all females have attended primary school. Although most women know at least 1 contraceptive method, it is the urban educated woman who is twice as likely to know a source of supply and 5 times more likely to be a user. The Karachi study found that lower fertility among better educated urban women is an unintended consequence of women's schooling and deliberate effort to limit the number of children they have. Education-related fertility differentials could not be explained by the length of time women are at risk of becoming pregnant (late marriage age). Fertility limitation may be motivated by the predominant involvement in the formal work force and higher income. The policy implications are the increasing female schooling is a good investment in lowering fertility; broader improvements also need to be made in economic opportunities for women, particularly in the formal sector. Other needs are for increasing availability and accessibility of contraceptive and family planning services and increasing availability and accessibility of contraceptive and family planning services and increasing knowledge of contraception. The investment will impact development and demography and is an adjunct to child health an survival.     

Who uses reproductive health services in the Philippines (and who doesn't)?

Data from the 1993 National Demographic Survey and the Safe Motherhood Survey have filled gaps in knowledge about the accessibility and use of reproductive health services in the Philippines. Analysis of the data by the East-West Center's Program on Population has revealed that the number of women using family planning (FP) and maternal health services has risen to 40% in 1993 from 17% in 1973. Modest gains were also seen in the past five years despite disruption to program efforts. Prenatal care showed the greatest maternal care coverage rate increase, but 70% of births occurred at home, with only 51% attended by a trained person, and only 32% of postpartum women received care. Adolescents and women who are over age 40, uneducated, Muslim, and/or live in a rural setting have the most unmet need. In addition, less than half of the women reporting symptoms of a sexually transmitted disease sought treatment from a trained practitioner. Most women use public sector services, including 71% of those using modern contraceptives. While trained midwives provided 58% of prenatal care, traditional birth attendants delivered 52% of all births, and a high incidence of maternal mortality persists (209/100,000). Recommendations arising from this analysis include 1) improving prenatal and delivery care, 2) strengthening postpartum FP services, 3) expanding the program to reach more women, 4) extending the range of reproductive health services offered, 5) integrating traditional practitioners into the reproductive health system, and 6) balancing cost and service variations between the public and private sectors.     

An Index of Maternal and Child Healthcare Status in India: Measuring Inter- and Intra-State Variations from Capability Perspectives

Despite remarkable progress in past few decades India’s current maternal and child mortality levels fall significantly short to attain many of the targets of MDGs. The variation in attainments across and within regions has always been a crucial dimension of Indian concerns. The present paper takes a closer look at the spatial variation of maternal and child healthcare status in India by summarising a set of constituent indicators that are instrumental in nature, and result in debilitating outcomes for women and their newborn. Taking the stock of information generated by the third round of District Level Health and Facility Survey (DLHS-3) this paper adopts the Pena Distance Method to gauge the spatial variations. The states are classified first in terms of their MCH status in 2007–2008. At later stage intrastate disparities are captured by measuring rural–urban inequality, and inter-district disparity within states. Key results indicate that the overall state ranking is, to a significant extent, explained by the intrastate variations. However, the major contribution of this paper lies in quantifying the relative role of constituent indicators that are responsible for the existing disparities across and within state boundaries.     

Political History and Disparities in Safe Motherhood Between Guatemala and Honduras

Each year, worldwide, more than 500,000 women die of complications from childbirth, making this a leading cause of death globally for adult women of reproductive age. Nearly all studies that have sought to explain the persistence of high maternal mortality levels have focused on the supply of and demand for particular health services. We argue that inquiry on health services is useful but insufficient. Robust explanations for safe motherhood outcomes require examination of factors lying deeper in the causal chain. We compare the cases of Guatemala and Honduras to examine historical and structural influences on maternal mortality. Despite being a poorer country than Guatemala, Honduras has a superior safe motherhood record. We argue that four historical and structural factors stand behind this difference: Honduras's relatively stable and Guatemala's turbulent modern political history; the presence of a marginalized indigenous population in Guatemala, but not in Honduras, that the state has had difficulty reaching; a conservative Catholic Church that has played a larger role in Guatemala than Honduras in blocking priority for reproductive health; and more effective advocacy for maternal mortality reduction in Honduras than Guatemala in the face of this opposition.     

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.     

Job continuity among new mothers

In the early 1990s, both state and federal governments enacted maternity-leave legislation. The key provision of that legislation is that after a leave of a limited duration, the recent mother is guaranteed the right to return to her preleave employer at the same or equivalent position. Using data from the National Longitudinal Survey of Youth, we correlate work status after childbirth with work status before pregnancy to estimate the prevalence, before the legislation, of returns to the preleave employer. Among women working full-time before the pregnancy, return to the prepregnancy employer was quite common. Sixty percent of women who worked full-time before the birth of a child continued to work for the same employer after the child was born. Furthermore, the labor market behavior of most of the remaining 40% suggests that maternity-leave legislation is unlikely to have a major effect on job continuity. Compared with all demographically similar women, however, new mothers have an excess probability of leaving their jobs.     

Multi-Dimensional Deprivation in India During and After the Reforms: Do the Household Expenditure and the Family Health Surveys Present Consistent Evidence?

This paper uses the recent approach of multidimensional deprivation measures to provide a comprehensive and wide ranging assessment of changes to living standards in India during the period, 1992/93–2004/5. This covers the reforms and the immediate post reforms time periods. The study is the first to be based on the simultaneous use of two parallel data sets, namely the National Sample Survey (NSS) and National Family Health Survey (NFHS) data sets, covering proximate rounds and near identical time periods. The results allow a check of consistency on the picture of deprivation in India between these two data sets. The study is conducted both at regionally disaggregated levels and by socio economic groups. The deprivation dimensions range widely from the conventional expenditure dimensions to non-expenditure dimensions such as access to drinking water and clean fuel, to health dimensions such as child stunting and the mother’s BMI. The use of decomposable deprivation measures allows the identification of regions, socio economic groups and deprivation dimensions that are contributing more than others to total deprivation.     

Navigating infant feeding supports after migration: Perspectives of Arabic and Chinese mothers and health professionals in Australia

Optimal feeding practices can establish lifelong, transgenerational and global health benefits. Migration and cultural factors impact infant feeding practices and the support mothers receive for optimal infant feeding. This qualitative study explored support for infant feeding among Arabic and Chinese speaking migrant mothers in Australia.Semi-structured focus groups were conducted in language with 24 Arabic and 22 Chinese-Mandarin speaking migrant mothers with children under five years of age. Individual interviews were conducted in English with 20 health professionals working with Arabic or Chinese speaking migrant families. Data were thematically analysed using the framework method.Traditional family networks and trusted bi-cultural doctors were influential infant feeding supports for mothers. Health professionals perceived maternal and child health services to be poorly understood, and some mothers who accessed services felt they were not always culturally sensitive. Mothers sought additional information and support through online sources and peers. Both mothers and health professionals recognised the challenges of managing conflicting infant feeding advice and seeking best-practice support.The findings of this study highlight opportunities for health professionals to better support migrant mothers’ infant feeding practices, for example through engaging families and working with doctors. There is a need for greater cultural sensitivity within maternal and child health services and culturally relevant programs to support healthy infant feeding practices among migrant communities.     

Aids mortality and the mobility of children in Kwazulu Natal,South Africa

This paper examines the effect of parental death on the mobility of 39,163 children aged 0-17 in rural KwaZulu Natal, South Africa, in 2000 and 2001. Parental mortality from all causes prior to and during follow-up increased the risk of a child moving by nearly two times after we controlled for the age and gender of the child and household characteristics. However, in the follow-up period, child mobility following maternal deaths from AIDS was lower than child mobility following maternal deaths from other causes. Younger children, boys, and children whose mothers or fathers were resident members of the children's households were also less likely to move.