Determinants of fertility in Nepal: applications of an aggregate model

Bongaarts aggregate model of the proximate determinants of fertility is applied to data from the 1976 National Fertility Survey in Nepal. Breastfeeding is shown to be the most important limiting factor, resulting in a reduction of about 6 children per woman. Decline in the duration of breastfeeding by 1/4 would increase fertility by 1 additional child per woman. The temporary separation of spouses due to migration is conjectured to be the 2nd most important fertility inhibiting factor, not explicitly accounted for in the standard model. Results are presented for the 3 major ecological regions, urban-rural residence and educational attainment of women. High nuptiality and virtually no contraceptive use in Nepal produce age-specific fertility rates very close to a natural fertility pattern. Total average interval between births is 36 months; about 18 months are solely due to breastfeeding, the remaining months to combined effects of gestation, waiting time to conception, intrauterine mortality and post-partum infecundability. As urbanization increases and pace of modernization becomes more pronounced, the duration of breastfeeding is susceptible to decline.     

Reproductive change in Zimbabwe and Kenya: the role of the proximate determinants in recent fertility trends

This study examines trends in proximate determinants of fertility in Zimbabwe and Kenya. Findings from the four Demographic and Health Surveys conducted in these countries show that the dramatic fall in fertility in these countries is consistent with the underlying trends in the most important proximate determinants of fertility. In Zimbabwe, contraceptive use far exceeds other proximate determinants in influencing fertility levels and trends. The results show that the fertility inhibiting effects of contraception are more important than the effects of postpartum infecundability, marriage patterns, or sterility. The results also show that contraceptive use has its greatest suppressing effects in the middle and younger age groups. However, in Kenya, the dominant fertility inhibiting effect is postpartum infecundability, with contraception coming in second.     

Breast-feeding in Bangladesh

In this paper the duration of breastfeeding is examined in relation to demographic and socioeconomic characteristics of women and households. 98% of Bangladesh mothers breastfeed their children from birth. In data from the Bangladesh Fertility Survey conducted in 1975-1976 on 4998 live births, the mean duration of breastfeeding was 27.3 months. Duration of breastfeeding was positively related with the age of women. Female children were breastfed for periods about 5 months shorter than male children. Children born to urban mothers were breastfed for shorter durations than children born to rural mothers of all age groups. The duration of breastfeeding decreased with the increase of education of the mother. Promotion of breastfeeding should be a primary responsibility of family planning clinics. Further decline in the duration of breastfeeding would increase levels of fertility and infant and child mortality.     

Correlates and implications of breast-feeding practices in Bas Zaire

A sample of 1871 women having a child under 3 years old in Bas Zaire was studied to determine the correlates of breastfeeding practices and to examine the interrelationships among breastfeeding, contraceptive practices and desire for pregnancy. The methods of analysis applied were life table analysis and its multivariate extensions. Most of the findings in this analysis are consistent with current literature on the correlates of the duration of breastfeeding. Maternal education, economic status, age, parity, urban residence, pregnancy, and sex of the index child were significantly related to the length of breastfeeding. Among non-pregnant women, current desire for pregnancy was also related to breastfeeding status when the length of time since birth of the last child was taken into consideration. Rural women were reportedly ready for another pregnancy sooner after the birth of their last child than were urban women. Breastfeeding appears to be the most important means of contraceptive protection in the study population. The effective traditional method of extended postpartum abstinence is not widely prevalent, particularly among the urban sample, and indeed seems to be on the decline. The data presented here also suggest that breastfeeding pratices are changing in this area of Africa where little economic development has occurred in the past 20 years. This research suggests that if current trends continue, fertility levels are likely to increase significantly. The findings also indicate that Bas Zairian mothers want to space their births and for this reason may be receptive to family planning programs that use appropriate strategies.     

Contraceptive practices and fertility among Southeast Asian, black, and white mothers attending a maternal infant care program

The purpose of this analysis was to determine if there were differences in selected fertility characteristics including parity, pregnancy spacing, age at 1st pregnancy, age of menarche, breastfeeding postpartum, and contraceptive practices among white, black, Hmong, and other Southeast Asian mothers attending a maternal infant care program in Minneapolis, Minnesota, during 1980-1982. White and black mothers were younger than the Hmong and other Asian mothers. The lowest mean age of 1st pregnancy was among blacks. Ages of 1st pregnancy were similar for whites, Hmong, and other Asians, although the mean age of menarche was approximately 2 years later for Hmong and other Southeast Asian mothers compared to the white and black mothers. Based on self reports at the 1st postpartum visit 1 month after delivery, 39% of the whites and 25% of the blacks were breastfeeding. In comparison 8.7% of the Hmong and 17% of the other southeast Asian mothers were breastfeeding. Maternal aged age at 1st pregnancy were significant predictors of parity for whites, blacks, Hmong, and other Southeast Asians. Ever-use of contraception was significant predictor of parity only for Hmong. The highest proportion of ever-users of contraception was among the white mothers (80%) followed by the blacks (69.3%) and other Asian mothers (34.85). Hmong mothers had the lowest proportion having used contraception (17.1%).     

Contraceptive practices and fertility among Southeast Asian,black, and white mothers attending a maternal infant care program

Abstract

The purpose of this analysis was to determine if there were differences in selected fertility characteristics including parity, pregnancy spacing, age at first pregnancy, age of menarche, breastfeeding postpartum, and contraceptive practices among white, black, Hmong, and other Southeast Asian mothers attending a maternal infant care program in Minneapolis, Minnesota, during 1980–82.

White and black mothers were younger than the Hmong and other Asian mothers. The lowest mean age of first pregnancy was among blacks. Ages of first pregnancy were similar for whites, Hmong, and other Asians, although the mean age of menarche was approximately two years later for Hmong and other Southeast Asian mothers compared to the white and black mothers.

Based on self reports at the first postpartum visit one month after delivery, 39 per cent of the whites and 25 per cent of the blacks were breastfeeding. In comparison 8.7 per cent of the Hmong and 17 per cent of the other southeast Asian mothers were breastfeeding.

Maternal age and age at first pregnancy were significant predictors of parity for whites, blacks, Hmong, and the other Southeast Asians. Ever‐use of contraception was a significant predictor of parity only for Hmong.

The highest proportion of ever‐users of contraception was among the white mothers (80 per cent) followed by the blacks (69.3 per cent) and other Asian mothers (34.8 per cent). Hmong mothers had the lowest proportion having used contraception (17.1 per cent).     

Breastfeeding in the United States

The breastfeeding of US infants born in 1974-76 is analyzed using data form the 1976 National Survey of Family Growth. Life table estimates of the proportion of children breastfed by duration since birth and mean breastfeeding durations are presented. The life tables reported are constructed by standard cohort table methods. To compare life tables for children of mothers in various attribute categories, generalised Wilcoxon tests are used, together with multiple classification analysis for continuation at select durations. Variables considered include mother's age at the birth, ethnicity, educational level, education by ethnicity, region of residence and the child's birth order. Findings are restricted to infants remaining with their mothers for at least 2 months following delivery and surviving as of the survey date in January-September 1976. It is found that the proportion of infants breastfed was increasing rapidly, with the highest rates found among white (39%), college-educated (56%), western (56%) mothers and lowest rates among black mothers (17%) mothers with less than a high school education (19%) and mothers living in the south (24%). By age, the highest proportions are mothers at ages 25-29 (44%), followed closely by the mothers under 25 (29%). The proportions breastfeeding were also found to be higher in urban than in rural areas (38% vs. 28%) and higher at parities 1-2 (29%). A multiple classification analysis of the factors most strongly influencing breastfeeding in 1975 shows educational level to be the strongest single predictor of breastfeeding, followed by western residence and white ethnicity. Age effects were found to correlate strongly with education. Reviewing 1971-1981 changes, the proportion of mothers with less than a college education who breastfed their children increased from 19% to 51% over the decade, while the proportion among college-educated mothers rose from 42% to 74%. For children who were breastfed, the median duration was about 4.5 months. The mean was 5.5 months, with a range from about 3.0 months among black mothers with less than a high school education, to 6.0 months among college-educated white women. The nationwide changes in breastfeeding patterns and duration may confer modest health benefits on current generations of youngsters, although not benefits that are easily measured, since human milk substitutes are routinely subjected to rigourous testing for nutritional adequacy.     

Preference for children and subsequent fertility in Matlab: does wife-husband agreement matter?

This study examines wife-husband preference for children and subsequent fertility for a period of 5 years in the treatment and comparison areas of Matlab, Bangladesh. The two data sets used were: the In-depth Survey (1984) and the Demographic Surveillance System (1984-89). In the case of wives' preferences for children, subsequent childbearing was 13.8% higher than desired in the treatment area and 44.7% higher than desired in the comparison area. After controlling for all variables in the model, the likelihood of giving birth was 1.78 times higher for wives who wanted no more children, but whose husbands did want more, compared with couples where neither husband nor wife wanted more children. For couples where the wife wanted more, but the husband did not want more children, the likelihood of giving birth was 0.63 times that of couples where both the husband and wife wanted more children. This finding suggests that to enhance the decline in fertility in these two areas of Matlab, it will be necessary to motivate both wives and husbands to cease childbearing.     

Postpartum lactational amenorrhoea as a means of family planning in the Sudan: a study of 500 cases

The lactational histories of 500 Sudanese women were studied retrospectively to examine postpartum lactational amenorrhea as a method of family planning. Particular attention was given to the factors affecting postpartum lactational amenorrhea, including supplementary feeding and the use of modern contraceptive methods. Breast-feeding was overwhelmingly practised (90%) among this sample, which was roughly representative of the Sudanese population as a whole. The prevalence of amenorrhea among this group of lactating women was quite high (73%). Duration of lactational amenorrhea ranged from 2 to 36 months with a median of 12 months. Introduction of supplementary feeding had little effect on lactational amenorrhea up to the 9th month of breastfeeding. Beyond the 12th month of breastfeeding, lactational amenorrhea was significantly prolonged by postponing the introduction of supplementary feeding until the 4th month or later. Ovulation, and hence conception, during lactational amenorrhea was unpredictable. It occurred as early as the 3rd or as late as the 36th month postpartum. Conceptions interrupting lactational amenorrhea soon after delivery (3-9 months) were more frequent among primiparous women. The failure rate of lactational amenorrhea as a contraceptive was 8.4%. Though extremely high compared to that of the pill, lactational amenorrhea was more useful as a fertility control mechanism because, in this study, a high proportion of women initiated pill use, but soon discontinued it because of side effects. Modern contraceptive practice was not prevalent. Amenorrheic mothers accepted the pill after the 6th month postpartum (41%, compared to lactating mothers whose menses had returned who started much earlier. 49% of the women studied relied completely on the protection of lactational amenorrhea. 57% of all lactating women who used the combined pill reported a reduction in milk production. Knowledge of modern contraception was poor and incorrect in many cases, leading to several policy implications, including usage of sterilization.     

Contraceptive use patterns in Matlab, Bangladesh: insights from a 1984 survey

An experimental maternal and child health and family planning programme has been in existence in Matlab for almost 10 years. During this time the project has achieved remarkable success in the area of family planning. Based upon a 1984 survey, this study examines the pattern of contraceptive use in the Matlab treatment area, and contrasts it with the regular government programme in the neighbouring comparison area. Important differences between the two areas are observed, with the treatment area characterized by substantially higher levels of current contraceptive use, greater reliance upon temporary methods for birth spacing and, among acceptors of sterilization, more prior experimentation with other methods. In the comparison area lower rates of contraceptive use are observed, with heavy reliance upon tubectomy for limiting family size. The findings suggest that an intensive and innovative family planning programme in rural Bangladesh can achieve success not only in terms of contraceptive prevalence, but can also attract users interested in child spacing and others wanting to limit their family size, by offering the widest range of contraceptive methods.     

Contraception with progestogens and progesterone during lactation

The growth and development of breastfed infants whose mothers used the contraceptive implants Norplant® containing levonorgestrel and the injectable containing norethisterone enanthate were studied. Each group comprised of 120 women who initiated the use during the 5th to 7th week postpartum and were compared with a similar number of IUD using mothers. The breastfeeding performance did not differ between groups. The infants of the three groups performed similarly as regards their physical growth and health as well as the time of acquisition of the various milestones of psychomental development. A vaginal ring releasing 10 mg of the “natural” progesterone per 24 h was tested in breastfeeding mothers. The continuous use of the ring produced a serum level of progesterone around 4 ng/ml. This was effective in augmenting lactational infertility even through the later phases of breastfeeding when such an effect starts to wane off. The use of the ring proved to be acceptable and had no ill-effect on breastfeeding or infant growth or health. Using the natural progesterone as a contraceptive adds a new measure of safety, since the amount of the steroid secreted in the mother's milk will not be effectively absorbed from the infant's gut. These studies suggest the possibility of using two new methods for breastfeeding mothers; Norplant and the progesterone vaginal contraceptive ring. These can be initiated early postpartum, whenever this is considered needed.     

Proximate determinants of fertility in the Kathmandu Valley, Nepal: an anthropological case study

The analytical model of Bongaarts and Potter is employed to compare the proximate determinants of fertility among 3 populations in Nepal's Kathmandu valley. 3 sub-groups are studied: high caste (Brahmin and Chetri) urban residents, high caste urban fringe residents, and low caste untouchables (Sarki). Both survey and anthropological methods are employed. According to the analytical model, the transition in fertility follows 4 phases. The changes in fertility levels from Phase 1 to Phase 4 generally indicate that the transition from natural to controlled fertility is characterized by declines in the proportions of women married and the duration of postpartum infecundability, and a substantial increase in the prevalence and effectiveness of contraceptive practices. The results of this study show that Nepal as a whole is entrenched in Phase 1 of the fertility transition. However, data from the 3 populations reported here clearly indicate that each has begun to experience a demographic transition to different degrees. The Sarkis in this study fall between Phases 2 and 3, as indicated by the total fertility rate (TFR). The rural high castes most closely approximate a population in Phase 3, while urban high castes included in this study are approaching Phase 4. Each of the 3 populations is characterized by a decline in the proportion of women married when compared to all of Nepal. It is also apparent that the relative use-effectiveness of contraceptive methods currently employed is high. Gains in the reduction of fertility, then, will have to be made from increasing and retaining the number of acceptors and in reducing the desired family size of those at reproductive risk.     

Kin influences on fertility in Thailand: Effects and mechanisms

It has been suggested that human mothers are cooperative breeders, as they need help from others to successfully raise offspring. Studies working under this framework have found correlations between the presence of kin and both child survival and female fertility rates. This study seeks to understand the proximate mechanisms by which kin influence fertility using data from the 1987 Thailand Demographic and Health Survey (DHS), a nationally representative sample of 6775 women. Kin influence is measured by the length of time couples live with the husband's or wife's parents after marriage. Event history analysis, multilevel modeling and structural equation modeling are used to investigate both fertility outcomes and potential pathways through which postnuptial residence may influence fertility outcomes, including employment status, maternal and child outcomes, contraceptive use, breastfeeding duration, and age at marriage. We show that living virilocally (with husband's kin after marriage) increases total fertility by shortening time from marriage to first birth, and increasing the likelihood of progression to each subsequent birth. These effects are mediated through correlations between virilocal residence and earlier age at marriage as well as delayed initiation of contraceptive use. We find no influence of husband's kin on maternal or child outcomes. Living uxorilocally (with wife's kin after marriage) also reduces age at marriage, shortens time from marriage to first birth and (marginally) improves child survivorship, but has no effect on other child and maternal outcomes or progression to subsequent births and results in a similar number of living children as women living neolocally.     

Poor Adherence to National and International Breastfeeding Duration Targets in an Australian Longitudinal Cohort

Objectives

To report on the proportion and characteristics of Australian infants who are fed, and mothers who feed, in accordance with the national and international breastfeeding duration targets of six, 12 and 24 months. Furthermore, to examine the longitudinal breastfeeding duration patterns for women with more than one child.

Methods

Breastfeeding duration data for 9773 children have been self-reported by a national sample of 5091 mothers aged 30–36 years in 2009, participating in the Australian Longitudinal Study on Women’s Health.

Results

Only 60% of infants received the minimum recommended 6 months of breast milk, irrespective of breastfeeding exclusivity. Less than 30% of infants received any breast milk at 12 months, and less than 3% were breastfed to the international target of 24 months. Young, less educated, unmarried or low-income women were at an increased risk of premature breastfeeding cessation. For women with three or more children, nearly 75% of women who breastfed their first child for at least six months reached this breastfeeding duration target for their next two children.

Conclusion

While national breastfeeding rates are typically evaluated in relation to the infant, a novel component of our study is that we have assessed maternal adherence to breastfeeding duration targets and the longitudinal feeding practices of women with more than one child. Separate evaluations of maternal and infant breastfeeding rates are important as they differ in their implications for public health policy and practice.     

Assessing the reproductive behavior of on- and off-reservation American Indian females: characteristics of two groups in Montana

Only limited fertility and general reproductive health data exist on American Indians. Using data from the 1987 Montana American Indian Health Risk Assessment, we found that the fertility of American Indians in Great Falls and on the Blackfeet Reservation was similar to blacks in the U.S. and relatively high when compared with fertility of whites in the United States. The influence of the direct determinants of fertility (nuptiality, contraceptive use, and lactation) was very different for the populations examined in this study. Great Falls American Indians and the U.S. black population were similar regarding age at first sexual intercourse (very young), breastfeeding (low prevalence and short duration), planning status of pregnancies (high unplanned), and contraceptive use (only moderate use). In contrast, Blackfeet women on the reservation and the U.S. white population married relatively late, had very high contraceptive use, used effective methods of contraception, and had moderately high levels of breastfeeding. However, Blackfeet fertility was much higher than that of whites. Three interrelated reasons are suggested as possible explanations. Blackfeet couples either wanted high fertility, were relatively poor users of family planning methods, or used less effective methods until they had exceeded their desired family size after which time they turned to sterilization. These finds raise numerous questions concerning the social and economic factors that may account for these group similarities and differences. Further studies with much larger data sets are needed to address these issues adequately.     

Changes in contraceptive use and fertility: Panama, 1976 to 1984

Abstract

From 1976 to 1984 important demographic changes occurred in Panama. The total fertility rate declined from 4.5 to 3.7, and contraceptive use amongmarried women 20–44 years of age increased from 55 per cent to 63 per cent. However, using data from three national level reproductive health surveys which were conducted in Panama in 1976, 1979, and 1984, we found that most of the changes took place between 1976 and 1979. Since 1979, overall contraceptive use and fertility have remained virtually unchanged, although there has been an important method‐mix shift toward an increase in the use of contraceptive sterilization and IUD's, with an accompanying decline in the use of oral contraceptives. Although the singulate mean age at marriage remained relatively constant, the average duration of breastfeeding rose 23 per cent during the period. Further gains in contraceptive prevalence and reduction in unplanned fertility in Panama will largely depend on enhanced program efforts first begun in the early 1970's by the Panama Ministry of Health. Future program efforts especially should be directed toward encouraging young couples to space their children more effectively by using temporary methods of contraception.     

Breast-feeding pattern in an urban Nigerian community

This paper examines the pattern of breastfeeding among women still in their prime childbearing ages (15-35 years) in Ilorin, the capital city of Kwara state in Nigeria. While breastfeeding is still a common practice among urban women, there is wide variation in the duration of breastfeeding depending on the socioeconomic characteristics of the mothers. Mother's education and father's education have very strong negative associations with duration of breastfeeding. Use of contraception also has a significant independent but negative effect on breastfeeding duration. Christians continue breastfeeding for shorter periods than Muslims. The introduction of supplementary feedings to the infant occurs in this population much earlier than is recommended by various authorities. Decline in breastfeeding practice may have deleterious effects on the health and survival of children in developing countries and may also lead to higher fertility and more rapid population growth. The high morbidity and mortality among artificially fed infants in many developing countries can be attributed to improper preparation as well as contamination of infant formula and other foods.     

Son preference and its effects on Korean lactation practices

Using retrospective data from Korea, multivariate log-linear analyses were used to determine if the sex of a child influences the probability of it being breastfed, or if it influences the number of months he/she was breastfed. In Korea the likelihood of a woman not breastfeeding a child is very small. The fact that a woman is without living sons increased the average odds of not breastfeeding by 1.55 times. The absence of living sons has the strongest effect of any of the predictor variables used. The highest predicted conditional odds of not breastfeeding are for women with female infants, who live in rural areas, have less than 3 children of which none are boys, and who do not use oral contraceptives. The lowest predicted conditional odds of a woman not breastfeeding are for a city dweller, with 3 or more children of which at least 1 is a boy, who uses the pill, and whose infant is a boy. Although oral contraceptive use is significant for deciding how long to breastfeed, the direction of its effect is not what was expected had it affected lactation physiologically. Apparently, social factors are operative which make pill users more likely to breast feed than non-users. 1 possible explanation for this is that Korean women are aware of the fertility-suppressing effects of lactation and are using breastfeeding as a deliberate form of birth control. The fact that the effect of pill use becomes progressively stronger the longer that women breastfeed lends further support to this explanation. The effect of sex of child is not significant in determining the duration he/she will be breastfed. This study indicates support for the contention that Korean women are aware of the contraceptive effects of lactation, and that their decisions of breastfeed are affected by their preference for sons.     

Postpartum amenorrhoea in Ethiopia: The role of weaning,child death,and socioeconomic factors

Abstract

Using data from the 1990 National Family and Fertility Survey (NFFS) and employing discrete‐time hazards models, we examine the effect of weaning, child death, and socioeconomic factors on postpartum amenorrhoea in Ethiopia. The results show that 91 in every 100 mothers breastfed their child for at least 6 months. The median duration of breastfeeding stands at 18 months, and amenorrhoea lasts for a median duration of 12 months. Significant variations in breastfeeding and amenorrhoea duration are also observed among the different categories of breastfeeding women. The median duration of breastfeeding for lactating women is 24 months, 6 months for those who weaned, and 2 months for those whose child died. The median duration of postpartum amenorrhoea is 14 months for breastfeeding women, 12 months for those who weaned, and 6 months for those whose child died. Discrete‐time hazard models reveal that child death has the strongest effect on the resumption of menses. Net of other factors, the risk of returning to menses increased 3 times for mothers whose child died. The effect of child death, however, decreases over time. Weaning also has a significant positive effect; and, like child death, its effect diminishes as time passes. The study further shows significant differences in the risk of returning to postpartum menses by socioeconomic characteristics of the women, even though they are breastfeeding.     

Reasons given by mothers for discontinuing breastfeeding in Iran

Background

We have previously shown that in Iran, only 28% of infants were exclusively breastfed at six months, despite a high prevalence of breastfeeding at two years of age. The primary aim of this study was to investigate the reasons women discontinued exclusive breastfeeding.

Method

This retrospective study was based on questionnaires and interviews with 63,071 mothers of infants up to 24?months of age, divided into two populations: infants younger than six months and six months or older. The data were collected in 2005?C2006 from all 30 provinces of Iran.

Results

Only 5.3% of infants less than six months of age stopped breastfeeding (mean age of 3.2?months); more commonly in urban than rural areas. The most frequently cited reasons mothers gave for discontinuing exclusive breastfeeding were physicians?? recommendation (54%) and insufficient breast milk (self-perceived or true, 28%). Breastfeeding was common after six months of age: only 11% of infants discontinued breastfeeding, at a mean of 13.8?months. The most common reason for discontinuation at this age was insufficient breast milk (self-perceived or true, 45%). Maternal illness or medication (10%), infant illness (6%), and return to work (3%) were uncommon causes. Use of a pacifier was correlated with breastfeeding discontinuation. Maternal age and education was not associated with duration of breastfeeding. Multivariate analysis showed that using a pacifier and formula or other bottle feeding increased the risk of early cessation of breastfeeding.

Conclusions

Physicians and other health professionals have an important role to play in encouraging and supporting mothers to maintain breastfeeding.