Effect of birth spacing on infant and child mortality in rural Nepal

This examination of the effect of birth spacing on infant and child mortality in rural Nepal is based on data from the Nepal Fertility Survey 1976 carried out by the Nepal Family Planning and Maternal Child Health Project in collaboration with the World Fertility Survey. The study confirms that the higher risk of infant death to 1st born children is mainly due to the higher proportion of younger women having 1st births, rather than due to their being 1st order births per se. The effect of maternal age on infant and child mortality is largely associated with birth interval. Previous birth interval, therefore, stands out as the most important factor affecting infant mortality; the next most important factor is the survival of the preceding child. A child born after an interval of less than 18 months since the previous live birth has a 31% higher risk of dying during infancy than 1 born after an interval of 1 1/2 to 2 years. The risk of the index child's dying is only 50% of that when its preceding sibling is dead. Neither education of mother nor education of father has a significant effect on infant mortality in rural Nepal.     

Relationships between pregnancy spacing,sex of infants,maternal age,and birth order,and neonatal and post‐neonatal mortality in Bangladesh

Abstract

The relationships between length of the interpregnancy interval, outcome of the pregnancy preceding the interval, sex of the infants, pregnancy order, maternal age, and maternal history of previous child deaths and neonatal and postneonatal mortality were explored in a rural Bangladeshi population using a multiple regression analysis. Specific interactions between the interpregnancy interval, outcome of the pregnancy preceding the interval, sex of the infants, and history of previous child deaths were examined. An inverse relationship was observed between postneonatal mortality and the length of the interpregnancy interval when the pregnancy preceding the interval was a surviving infant. No such trend was observed for neonatal mortality. Post‐neonatal mortality rates among children whose mothers had experienced two or more previous child deaths were essentially the same as that for infants whose mothers had experienced 0–1 child deaths when the interpregnancy intervals were more than 24 months. Although female infants have a lower neonatal mortality than male infants, the neonatal mortality rate for female infants conceived less than twelve months following a male infant birth was higher than for a male infant conceived less than twelve months following another male infant birth. Post‐neonatal mortality is consistently higher for female compared to male infants in all interval categories.     

Maternal factors and infant and child mortality in Bangladesh

Using data from The World Fertility Survey, this study shows that the length of the preceding birth interval was the most important maternal factor influencing infant and child mortality risks in Bangladesh. This was such a crucial factor that its effects remain unaltered whether or not the influences of mother's age at birth and birth order are controlled. Infant and child mortality in Bangladesh can be expected to decline considerably if successive births can be spaced by an interval of at least 1.5 years. Child spacing seems to be the major factor requiring program attention. The effects of mother's education and place of residence on infant and child mortality are independent of the effects of maternal age at birth, birth order, and the preceding birth interval. The higher survival chances of children of educated mothers resulted neither through the age at which childbearing started nor through birth spacing but are likely to be related to their smaller family size and to other non-maternal proximate determinants of early mortality.     

Factors affecting infant and child mortality

This paper examines the determinants of infant and child mortality variations in Jordan, Yemen, Egypt, and Tunisia using data from WFS surveys. The analysis considers biological correlates of mortality--mother's age, birth order, birth interval, and previous infant loss--and several social factors--mother's and father's education, mother's residence, father's occupation, and mother's work experience since marriage. The estimates for the 4 countries show large variations in the mortality rates and an expected pattern of declining infant and child mortality during the period of 20 years prior to the survey. Further, the proportionate decline in child mortality in each country was generally greater than the proportionate decline in infant mortality. A persistent pattern of higher child mortality for females than for males is found, suggesting preferential care and treatment of male offspring. The higher mortality risk is found for infants born to very young and very old mothers, with short previous birth intervals, of higher birth orders, and where the previous infant had died. Among the socioeconomic characteristics, the education of the mother and rural-urban residence are found to affect infant survival. In childhood, among the demographic factors, only birth interval shows a significant effect on mortality. The risk of child mortality decreases considerably with the increase in the birth interval. The analysis of the effect of breastfeeding on mortality, although based on limited information, clearly shows the beneficial effect of breastfeeding on the infant's survival, especially during the early months of life. For all countries, the mortality rate for the non-breastfeeders is substantially higher than for the breastfeeders even when the effect of the other covariates is controlled.     

Infant and child mortality in Pakistan--some trends and differentials

Data from reproductive histories collected in the Population, Labor Force and Migration Survey (PLM) of 1979 are used to analyze trends and differentials in infant and child mortality in Pakistan. Comparisons with the Pakistan Fertility Survey (PFS) findings are also presented. The main concern is to provide from the latest national data, the PLM, direct measures of infant and child mortality and to demonstrate the relatively static and low chances of survival for children in Pakistan. The apparent trends from the PLM and the PFS are similar and seem to confirm that infant and childhood mortality has ceased to decline, at least rapidly, since 1965-69. Neonatal mortality is higher at levels of 70-85 deaths/1000 compared to postneonatal mortality of 40-60 deaths/1000. Improvements in neonatal rates from 1950 until 1975 are only approximately 1/2 of those for postneonatal rates for that period. The relationship between maternal age and mortality in the PLM data confirms that children of youngest mothers experienced the highest rates of infant mortality; mortality is again higher for children of oldest mothers aged 35 and above. The pattern of mortality in the 2 surveys is similar except that in the PFS there was little variation among births higher than 5th order. Sex differentials in mortality are very clear in both surveys. Boys have higher chances of dying in the 1st month of life but then the probability of their surviving from age 1 to 5 years is higher, reflecting the behavioral preference for the male sex in this society. The data also demonstrate an almost monotonic decline in infant and child mortality associated with longer birth intervals. Childhood mortality shows a less clear association with preceding birth interval than does infant mortality. While neonatal mortality is much higher in rural than in urban areas, there are negligible differences in the postneonatal rate. The urban-rural differential continues into childhood, reflecting lower health care and nutrition of children in rural areas. The data confirm the importance of parental education, particularly that of mothers, as a contributor to the health and mortality of infants. Mortality between age 1 and 5 years for children of the rural educated group is lower than that for the urban uneducated indicating the strong influence that education of mothers can have in preventing child loss. The combined evidence from the PFS and PLM data stresses the importance of improving health facilities in the rural areas, in aneffort to reduce the differences in mortality by area of residence. The data from both surveys also suggest the need to restrict motherhood to between the ages of 20 and 34, when obstetrical and health risks are minimal, and indicate the definite advantages of increasing the spacing between children.     

Changing determinants of infant and child mortality: on the basis of the Korean experience, 1955-73

Data from the 1974 Korean National Fertility Survey were analyzed to learn more about the main determinants of infant and child mortality in the course of mortality decline and how they change. In the Korean survey, about 5000 eligible women were selected for the individual survey and the sample design aimed at a self-weighting nationally representative and probability sample. Preliminary analysis showed clear mortality differentials between different socioeconomic levels and between demographic subgroups in infant and child mortality during the period 1955-73 in Korea. To examine the net effect of each variable on mortality, the logit-linear model was used. A table shows the probability level of 4 variables -- maternal age, birth order, mother's education, and number of rooms used by household -- in Korea, when the effects of others were controlled. In the urban areas, only the socioeconomic factors were the main determinants of infant mortality on all the birth cohorts. Mother's education and number of rooms used strongly affected infant mortality in the 1955-59 and 1960-64 birth cohorts, but the effects became weaker in the 1965-69 and 1970-73 birth cohorts, and their statistical significance was reduced. In the rural areas, the effects of 3 variables -- the exception being number of rooms used -- on infant mortality were statistically significant. It is concluded that the main determinants of infant mortality in urban areas were socioeconomic factors. The main determinants of infant mortality in the rural areas were demographic in the earlier birth cohorts, but in the recent birth cohorts mother's education, a socioeconomic factor, became the main determinant while the effects of demographic variables became weaker and finally disappeared. The change in the determinants of child mortality appears to be the reverse of that for infant mortality. Prior to the introduction of the national development program, in the rural areas mother's education was the main determinant of child mortality (rural 1955-59 cohort), but with the socioeconomic development the determinants changed to give dominance to demographic factors (urban 1955-59) cohort and, in the recent period, even the effects of demographic factors on child mortality became weaker (urban 1960-69 cohort). When the differences in living status by maternal age were weaker and the competition among siblings less because of small family size, only the socioeconomic variables remained as main determinants affecting child mortality.     

Biological influence of infant death on fertility

This study examines the biological influence of infant death on subsequent fertility in three Asian countries--Indonesia, Nepal and Sri Lanka, comparing the birth interval between two consecutive births up to the sixth birth by survival status of the preceding infant among breast-feeding women not using contraception. There is consistent evidence of biological influence in each of the three countries. Infant death shortens birth intervals by up to 30%, though its influence varies between the countries.     

Neonatal mortality and maternal health care in Nepal: searching for patterns of association

This study explores the factors associated with neonatal mortality and maternal health care in Nepal. The subjects were 4375 births reported in the 1996 Nepal Family Health Survey. Maternal and child health care was found to have a significant association with neonatal mortality, although preceding birth interval and sex of child had stronger effects. Four aspects of maternal care were found to be highly associated with region, household ownership of assets, mother's education and father's education. This indicates that accessibility, affordability and availability of maternal health care are important factors to consider in future research on neonatal mortality.     

Multivariate analysis of infant and child mortality in Java and Bali

The data used in this analysis come from the 1976 Indonesian Fertility Survey, part of the World Fertility Survey. The data are examined 3 times, fitting them to models which include different combinations of independent variables. The dependent variables are: 1) the proportion of children born between 5 and 15 years before the survey who died before their 1st birthday, for infant mortality; and 2) among those alive on their 1st birthday, the proportions who died before reaching their 5th birthday, for child mortality. The figures indicate that the chance of dying for children who were 1st born, born shortly after a previous child, whose previous sibling had died, who lived in rural areas, or had parents who were young and with little education, was greater than for children without these characteristics. In all 3 models used, the greatest net effects are attributed to the survival of a preceding sibling or the length of the preceding interval. Birth order does not have a significant gross effect on infant mortality, but the net effects are significant because of the control on maternal age. Education of both parents has significant effects, but these are overshadowed in magnitude by the demographic variables. Maternal education has a greater influence in determining differences in child mortality than was found for infant mortality. Father's education also has a significant independent effect, but mainly for 1st births. It is uncertain whether these variables are measuring the effect of schooling as such, or other characteristics such as economic status or various social roles adopted by people with different levels of education. The variables distinguishing urban from rural status shows significant gross effects which are greatly reduced when controls for other variables are introduced in the model which includes all births. That is to say, the difference in the survival chances of a child in the city is more a function of the education of its parents, and the associated demographic variables than city residence as such. Access to medical services is quite probably the main element in these differences. The findings are weakened to some extent by the lack of satisfactory data on household economic status which might have provided a better base for indirectly discerning the effects of nutrition and sanitation on mortality at young ages.     

Sibling mortality correlation in Kenya

This paper examines whether infant and child mortality risks among successive siblings are closely correlated, and if so, whether the survival status of the preceding child is an important factor affecting infant and child mortality in Kenya. The data were drawn from the 1988/89 Kenya Demographic and Health Survey. Logistic regression was used as the major method of data analysis. The results show that both infant and child mortality rates are significantly higher among subsequent children whose preceding siblings had died in infancy than for those whose preceding sibling had survived through infancy. The effect of the survival status of the preceding child on infant mortality was statistically strong, even after a large number of control variables were taken into account. However, its effect on child mortality appears to be spurious since it was rendered statistically insignificant when just a few control variables were introduced into the analysis. The results provide empirical evidence that infant and child mortality risks among successive siblings are closely correlated in Kenyan families, and that the effect of the survival status of the preceding child is important in determining infant mortality but not child mortality.     

Effect of education and household characteristics on infant and child mortality in urban Nepal

Infant and child mortality differentials are analysed by education of parents and other family members, access to toilet, electricity and source of drinking water in urban Nepal, using data from the Nepal Fertility and Family Planning Survey, 1986. The analyses showed significant effects of education, access to toilet and electricity in lowering infant and child mortality. Access to toilet and electricity are proxies for household socioeconomic status which suggests that education and household resources are complementary in lowering the infant and child mortality.     

Breast-feeding, birth interval and child mortality in Bangladesh

The 1975-76 Bangladesh Fertility Survey data show little evidence that breast-feeding is the intermediate factor through which birth intervals influence child survival in Bangladesh. Preceding birth interval, subsequent pregnancy and breast-feeding duration each have an independent influence on early mortality risk. Within a specific interval the risk of dying decreases with increase in duration of breast-feeding, and also with an increase in the time between the index birth and the next pregnancy. The death of the immediately preceding child in infancy has a significant negative effect on the survival chance of the index child at ages 1-5 months. However, death of the preceding child appears to have a significantly positive effect on the survival chance of the index child between ages 9 months and 5 years; this may be related to competition between siblings.     

Child survival and its effect on mortality of siblings in Bangladesh

This study of the relationship between mortality risks of siblings born to the same mother shows that, in Bangladesh, the death of the immediately preceding sibling in its infancy has a negative influence on the survival chance of the child in question in its infancy; however, death of the preceding sibling appears to have a positive influence on the index child's survival at ages 1-5 years. Similar results are found for the survival status of the two preceding siblings. Preceding birth interval length and survival status and sex of the immediately preceding sibling are also significant predictors of child mortality between ages 1 and 5 years. Possible explanations may be that the index child faces stronger competition from its immediately preceding brother than from its immediately preceding sister, or that the index child is likely to be looked after more by its preceding sister than by its preceding brother.     

Ethnic differentials in early childhood mortality in Nepal

This paper investigates the association of early childhood mortality (between birth and second birthday) with ethnicity in Nepal, based on data from the 1976 Nepal Fertility Survey, which was part of the World Fertility Survey. The approach is through a series of hazard models, which incorporate ethnicity, year of birth, mother's illiteracy, father's illiteracy, rural-urban residence, region, sex, maternal age, survival of previous birth, previous birth interval, and breast-feeding as covariates. Ethnic differentials in early childhood mortality are not explained by the other socioeconomic and demographic covariates, except for a modest effect of illiteracy, but the remaining covariates explain a great deal of variability in early childhood mortality itself. Analysis using an improved specification of breast-feeding as an age-varying covariate indicates, on average, that breast-feeding, relative to not breast-feeding, reduces age-specific mortality risks during the first 2 years of life by 76%, a very large effect.     

Demographic and socioeconomic factors affecting infant mortality in Egypt

This paper analyses the relative importance of demographic and socioeconomic factors with respect to their role in reducing infant mortality in Egypt. Logit analyses of data from a nationally representative sample of Egyptian households, and for urban and rural households separately, indicate that demographic factors have more effect on infant mortality than socioeconomic factors. The results also show the need to improve housing in urban areas and sewerage systems in rural areas in order to reduce infant mortality. One of the most important policy conclusions, however, concerns the importance of providing a vigorous educational campaign to enlighten mothers and prospective mothers in both rural and urban areas on the positive effects of breast-feeding, longer birth intervals, and fewer children on the survival of infants.     

Housing quality and child mortality in the rural Philippines

Factors influencing child survival to age 5 are investigated for a rural sample in lloilo Province, Philippines. Considered are construction materials in walls, doors, windows, and floors and the typpes of toilet facilities. 707 women were asked how many children they had borne alive; the sexes and dates of each live birth; whether each child was still living; and if not at what age the child had died. This study focused retrospectively on mortality among 2359 children born between 1960 and 1973. About 4.9% had died before age 5. This is 1/2 of what was observed nationally for rural children in the 1978 fertility survey. Health conditions in rural Iloilo Province may have been more favorable than in other rural parts of the nation. Income generated from shipping, lumbering, and fish culture may have also contributed to the lower rate of child mortality observed in this sample. The sex ratio of the children was 102, well within the range regarded as typical. A logit regression was employed. Of the 207 girls with low demographic risk and worse quality housing, 249 were estimated to survive to age 5 and 18 to die before age 5. Sex was not an important factor in child mortality. Boys and girls had about equal chances of surviving. A social-demographic risk factor commonly linked with infant mortality is breast feeding. Breastfed infants from a number of developing countries have had lower rates of infant mortality. A slightly larger % of nonbreastfed children (96.9%) survived to age 5 than did breastfed children. Living in a poorly constructed dwelling reduced the odds of a child's survival. Estimates from the Brass method showed that the expected probability of children dying before age 5 was .073 and .035, representing life expectancies at birth of 63.4 and 69.9 years.     

Place of Residence Moderates the Risk of Infant Death in Kenya: Evidence from the Most Recent Census 2009

Background

Substantial progress has been made in reducing childhood mortality worldwide from 1990–2015 (Millennium Development Goal, target 4). Achieving target goals on this however remains a challenge in Sub-Saharan Africa. Kenya’s infant mortality rates are higher than the global average and are more pronounced in urban areas as compared to rural areas. Only limited knowledge exists about the differences in individual level risk factors for infant death among rural, non-slum urban, and slum areas in Kenya. Therefore, this paper aims at 1) assess individual and socio-ecological risk factors for infant death in Kenya, and at 2) identify whether living in rural, non-slum urban, or slum areas moderated individual or socio-ecological risk factors for infant death in Kenya.

Methodology

We used a cross-sectional study design based on the most recent Kenya Population and Housing Census of 2009 and extracted the records of all females who had their last child born in 12 months preceding the survey (N = 1,120,960). Multivariable regression analyses were used to identify risk factors that accounted for the risk of dying before the age of one at the individual level in Kenya. Place of residence (rural, non-slum urban, slum) was used as an interaction term to account for moderating effects in individual and socio-ecological risk factors.

Results

Individual characteristics of mothers and children (older age, less previously born children that died, better education, girl infants) and household contexts (better structural quality of housing, improved water and sanitation, married household head) were associated with lower risk for infant death in Kenya. Living in non-slum urban areas was associated with significantly lower infant death as compared to living in rural or slum areas, when all predictors were held at their reference levels. Moreover, place of residence was significantly moderating individual level predictors: As compared to rural areas, living in urban areas was a protective factor for mothers who had previous born children who died, and who were better educated. However, living in urban areas also reduced the health promoting effects of better structural quality of housing (i.e. poor or good versus non-durable). Furthermore, durable housing quality in urban areas turned out to be a risk factor for infant death as compared to rural areas. Living in slum areas was also a protective factor for mothers with previous child death, however it also reduced the promoting effects of older ages in mothers.

Conclusions

While urbanization and slum development continues in Kenya, public health interventions should invest in healthy environments that ideally would include improvements to access to safe water and sanitation, better structural quality of housing, and to access to education, health care, and family planning services, especially in urban slums and rural areas. In non-slum urban areas however, health education programs that target healthy diets and promote physical exercise may be an important adjunct to these structural interventions.     

Effect of infant mortality on subsequent fertility in Pakistan and Sri Lanka

This study used data from the 1975 World Fertility Surveys in Pakistan and Sri Lanka to examine the association between fertility and infant mortality. A positive association between the mean number of children ever born and the number of child deaths was found in both rural and urban areas of each country. In Pakistan, women with no child loss had 3.3 children ever born while those who lost 1 child had 4.7 children; in Sri Lanka the figures were 3.5 and 5.4 children, respectively. However, child replacement was much less marked when controls were introduced for demographic and socioeconomic factors. When deaths at specific parities were examined, and age and time since previous birth were controlled, child replacement at the 1st parity was reduced to .3 in Pakistan and .2 in Sri Lanka. Further control for a series of socioeconomic factors (e.g. husband's level of education, husband's occupation, household structure, religion, standard of living) reduced the child replacement ratio to .2 children in Pakistan and zero in Sri Lanka. Replacement was slightly more pronounced when there were fewer surviving male children. This analysis suggests that the relationship between infant mortality and fertility is complex. A possibility that could not be explored in this study is that variation in fertilitty may itself be responsible for some of the variation in infant mortality.     

Birth spacing and infant mortality: evidence for eighteenth and nineteenth century German villages

Data from an historical population in which fertility control was minimal and modern health services were mostly unavailable are used to show that there appears to have been a strong association between previous birth interval length and infant mortality, especially when the previous child survived. Although only imperfect proxies for breast-feeding practices and other potentially confounding factors are available for this population, the results suggest that the association between previous interval length and infant mortality in this population is not solely, or primarily, a function of differences in breast-feeding behaviour or socioeconomic status. Other factors, e.g. maternal depletion or sibling competition, are more likely to explain the observed association.     

Women's status and infant mortality in rural Colombia

This paper investigates the effects of maternal demographic characteristics and social and economic statuses on infant mortality in rural Colombia. Demographic characteristics include the age of the mother, parity and length of preceding interbirth interval, and sex of infant. Measures of women's status at the time of birth include education, wage labor and occupation, economic stratum, place of residence, and whether the mother is living with a husband. The life history data for the study (involving 4,928 births) were collected in 1986 from a representative sample of two cohorts of women resident in rural central Colombia. Overall differentials in infant mortality by measures of women's status are small and are in good part associated with the differing reproductive behaviors of the women and variations in breastfeeding practices. The sharp declines in infant mortality recorded in rural Colombia in recent years appear less related to improved status of women than to reductions in fertility that enhance infant survivorship and to public health interventions shared by all segments of the population.