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.     

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.     

A biocultural investigation of the weanling's dilemma in Kathmandu, Nepal: do universal recommendations for weaning practices make sense?

The primary objective of this report is to use data from a study of infant growth and weaning practices in Kathmandu, Nepal, to investigate universal recommendations about exclusive breast-feeding up to 6 months postpartum. A secondary objective is to demonstrate the complexity of the biocultural nature of infant feeding practices. A sample of 283 children under 5 years of age and their 228 mothers living in a peri-urban district of Kathmandu participated in this study. The children's height/length and weight were measured three times over 9 months. At each session, a demographic, child health and infant feeding survey was administered; between sessions, in-depth interviews were conducted with mothers regarding infant feeding practices. While a few of the infants under 2 months were receiving non-breast milk foods, at 3 months of age half of the sample had been introduced to non-breast milk foods and by 7 months all infants were eating non-breast milk foods. A comparison of growth indices and velocities between exclusively and partially breast-fed infants from birth to 7 months of age shows no evidence for a difference in nutritional status between the two groups. Although there are cultural rules about breast-feeding that vary by ethnic group, all mothers followed a feeding method that depended on their assessment of whether the child was getting enough breast milk. The conclusion is that exclusive breast-feeding up to 6 months may not be appropriate for all infants. In this sample, breast-feeding duration is not shortened by the early introduction of non-breast milk foods, as the median age of breast-feeding cessation is 36 months. One of the main reasons for severance was the onset of another pregnancy. Investigation of infant feeding practices must be contextualized in the local ecology of the population. While cultural beliefs about breast-feeding are relevant, mothers' individual assessments of their children's nutritional needs and demographic events in parents' lives must also be considered.     

Breast-feeding and post-partum amenorrhoea in Indonesia

The association between breast-feeding patterns and resumption of menses post-partum was examined in a prospective study in Indonesia. In order to examine these relationships directly in a longitudinal study, it was first necessary to distinguish among women who experienced infant mortality before menses resumed, women who weaned before menses resumed, and women who had return to menses while breast-feeding. Information on suckling patterns and menstrual status was collected by recall for 444 women at monthly visits for 2 years. Three main breast-feeding variables, minutes per episode, number of episodes per day, number of episodes per night, and other breast-feeding variables were derived for each woman, to give the average nursing pattern up to menses or the end of the study, which-ever came first. While high levels of nursing for each of these three main variables were found to be significantly related to delay in return of menses post-partum, the interactions between more minutes per episode, and more frequent day- and night-time feeds, were found to be the most important factors in the delay in onset of post-partum menstruation in those women whose menses resumed while still nursing or who remained amenorrhoeic and nursing at the end of the study.     

Racial differences in the relationship between infant mortality and socioeconomic status

This study presents an ecological analysis of the relationship between infant mortality and economic status by race in metropolitan Ohio, using census data on mother's residence and economic status determined by the percentage of low-income families living in each area. The analysis updates previous studies as white-non-white comparisons for total infant mortality are examined for the US censuses of 1960, 1970, 1980, 1990 and 2000; and more detailed period- and broad cause-specific rates are presented for 2000. A pronounced inverse association is consistently found between income status and infant mortality for whites, while for non-whites this pattern first emerges in 1979-81, disappears during the 1980s and then returns more strongly during the 1990s. Similarly, the 2000 data reveal a consistent inverse pattern between income status and infant mortality for white and non-white neonatal and postneonatal death rates, as well as exogenous cause-specific death rates. It is concluded that low-income whites and non-whites have infant mortality rates substantially higher than the overall rate for the population. Policy implications are discussed.     

Neonatal hypernatremic dehydration associated with breast-feeding malnutrition: a retrospective survey

BACKGROUND: Hypernatremic dehydration in neonates is a potentially devastating condition. Recent reports have identified breast-feeding malnutrition as a key factor in its pathophysiology. METHODS: Using a theoretical framework for breast-feeding kinetics, a retrospective chart review of all neonates less than 28 days of age who were seen at either British Columbia''s Children''s Hospital or the Vancouver Breastfeeding Centre between 1991-1994 was conducted to identify and classify possible causes of breast-feeding malnutrition among neonates who developed hypernatremic dehydration. RESULTS: Twenty-one cases hypernatremic dehydration were identified. Infant weight loss ranged from 8% to 30% of birth weight, and serum sodium levels ranged from 146 mmol/L to 207 mmol/L. In each case, maternal or infant factors (e.g., poor breast-feeding technique, lactation failure following postpartum hemorrhage and infant suckling disorders associated with cleft palate or ankyloglossia) that could interfere with either lactation or breast-feeding dynamics and account for insufficient breast milk intake were identified. INTERPRETATION: Prenatal and in-hospital screening for maternal and infant risk factors for breast-feeding malnutrition combined with early postpartum follow-up to detect excessive infant weight loss are important for the prevention of neonatal hypernatremic dehydration.     

Underlying and proximate determinants of diarrhoea-specific infant mortality rates among municipalities in the state of Céara, north-east Brazil: an ecological study

This ecological study examines the variations in diarrhoea-specific infant mortality rates among municipalities in the State of Ceará, north-east Brazil, using data from a community health workers' programme. Diarrhoea is the main cause of postneonatal deaths in Ceará, and diarrhoea mortality rates vary substantially among municipalities, from 7 to 50 per thousand live births. To determine the inter-relationships between potential predictors of diarrhoea-specific infant mortality, eleven variables were classified into proximate determinants (i.e. adequate weight gain and exclusive breast-feeding in first 4 months) and underlying determinants (i.e. health services and socioeconomic variables). The health services variables included percentage with prenatal care up-to-date, participation in growth monitoring and immunization up-to-date, while the socioeconomic factors included female illiteracy rate, per capita gross municipality product and percentage of households with low income, percentage of households with inadequate water supply and inadequate sanitation, and urbanization. Using linear regression analysis variables were included from each group to build regression models. The significant determinants of variability in diarrhoea-specific infant mortality between municipalities were prevalence of infants exclusively breast-feeding, percentage of infants with adequate weight gain, percentage of pregnant women with prenatal care up-to-date, female illiteracy rate and inadequate water supply. These findings suggest that community-based promotion of exclusive breast-feeding in the first 4 months and care-giving behaviours that prevent weight faltering, including weaning practices and feeding during and following diarrhoea episodes, may further reduce municipality-level diarrhoea-specific mortality. Primary heath care strategies addressing these two proximate determinants provide only a partial solution to reducing diarrhoeal disease mortality. Improvements in municipal health services (prenatal care) and socioeconomic status variables, including water supply and maternal education, can also contribute to reduction of infant mortality due to diarrhoea. These results may be used by government health officials to set priorities by considering not only the strength of the association between selected risk factors and diarrhoea mortality rates, but also the prevalence of the risk factors being considered at the municipality level. Finally, the methods used are applicable to other settings with community-based primary health care decentralized to the state or municipal level.     

Determinants of waiting time to third pregnancy using censored linear regression

The intervals between pregnancies have important effects on fertility and maternal and infant health outcomes. This study uses linear regression with censored observation to assess the determinants of the waiting time to third pregnancy. The analysis is applied to data from the Second Malaysian Family Life Survey consisting of 1172 women who had their second delivery ending in a live birth. Contraceptive use, age of the woman, duration of breast-feeding, length of previous pregnancy interval and education of the woman all affect the waiting time to third pregnancy significantly.     

An evaluation of a national breast-feeding promotion programme in Honduras

A significant increase occurred in the initiation and duration of breast-feeding among Honduran women between 1981 and 1987. Changes in population characteristics (e.g. level of education of women) would be expected to lead to a decrease in breast-feeding at each infant age, but these were offset by behavioural changes that led to an increase in the likelihood of initiation and continuation of breast-feeding. An exploration of relevant factors suggests that the PROALMA breast-feeding promotion programme has had a profound effect on the breast-feeding behaviour of Honduran mothers.     

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.     

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.     

Determinants of breast-feeding and post-partum amenorrhoea in Orissa

A life table analysis is made of the duration of breast-feeding and post-partum amenorrhoea in Orissa, India, taking one variable at a time using data from a baseline survey of fertility and mortality (BSFM) conducted on the lines of the World Fertility Survey. Then a multivariate (proportional hazard) analysis showed that socioeconomic factors including residence, caste status and education influence the breast-feeding and post-partum amenorrhoea periods. There was no effect of maternal age on the length of breast-feeding, but mean length of post-partum amenorrhoea varied with age. The durations of breast-feeding and post-partum amenorrhoea are strongly related.     

The relationship between socioeconomic status and infant mortality in metropolitan Ohio, 1999-2001

Empirical evidence has consistently documented the direct relationship between infant mortality and socioeconomic inequality in the United States and numerous other countries. While the majority of these studies reveal an inverse relationship between socioeconomic level and infant mortality, not even this finding is free from disagreement. Furthermore, the specific nature and magnitude of this relationship has varied over time. This study will examine the relationship between socioeconomic status and infant mortality in metropolitan Ohio by using birth and infant death data centered on the 2000 Census. The analyses presented herein will describe and analyze the relationship between infant mortality and socioeconomic status in metropolitan Ohio in the year 2000. The key finding is that in spite of remarkable declines in infant mortality during the past several decades, most notably in neonatal mortality, there continues to be a pronounced inverse association between the infant death rate and the economic status of a population.     

Socioeconomic status and infant mortality among Hispanics in a southwestern city

Recent investigations of infant mortality in the Southwest part of the US have shown that Spanish surname infant death rates are lower than might be expected from the relatively low socioeconomic standing of the Spanish surname population, a phenomenon that appears to be confined to the neonatal componont of the infant mortality rate. The relationship between socioeconomic status (ses) and infant mortality is examined overall and separately within the Anglo and Spanish surname populations of Corpus Christ, Texas. The investigation utilizes data from the 36 Nueces County census tracts. Most recent data on infant, neonatal, and postneonatal mortality was provided by the local health department. Subjects were limited to Anglos and those whites with at least 1 Spanish surname parent. The 1979-1983 cohort is analyzed. Information from the 1980 US census was utilized to divide the 36 census tracts into 3 SES groups: high, medium and low. The most immediately striking aspect of the findings is the significant inverse gradient in Anglos between SES and both the total infant mortality rate (IMR) and the neonatal mortality (NMR), a gradient which is nonexistent in the Spanish surname population as well as overall. In addition, Anglos and Spanish persons differ significantly with respect to all IMRs and NMRs. In the high and medium SES groups and overall, all Anglo rates are lower, while in the low SES group, Spanish surname rates are lower. These findings suggest that, among Anglos, SES is a crucial factor in infant deaths, whereas, among the Spanish surname population, having a medium or high SES does not offer any additional protection against mortality. Alternatively, lower SES does not translate into significantly lower infant mortality among Spanish persons. These findings provide support for the study's hypotheses that the SES-infant mortality association is weaker among Spanish persons than among Anglos. The analysis also shows the importance of analyzing the SES-infant mortality association separately by ethnicity. Studies in larger cities and also studies utilizing matched birth and death records are needed to further elaborate these findings.     

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.     

Determinants of intrauterine growth retardation: evidence against maternal depletion

This analysis examines the relationship between length of preceding birth interval and risk of intrauterine growth retardation using data on Swedish infants from the 1973 World Health Organization study of perinatal mortality. Results of a multivariate logit analysis demonstrate that the lower than average mean birth weight of infants born after short birth intervals cannot be completely attributed to their shorter mean gestation length. Infants born after birth intervals of 12 months or less are 30% more likely to be small for gestational age (SGA) than infants born 18-59 months after the previous birth, even when the effects of maternal age and parity are controlled. The results obtained here do not support maternal depletion as an explanation for the association between short birth intervals and elevated risk of SGA, since there is no evidence of an attenuation of the risk of SGA with increasing length of interval in the under 18 month birth interval range.     

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.     

Socioeconomic, demographic and environmental determinants of infant mortality in Nepal

The Nepal Fertility and Family Planning Survey of 1986 demonstrated that demographic variables, previous birth interval and survival of preceding child, still predominated as determinants of infant mortality, particularly in rural areas of Nepal. However, in urban Nepal, where the level of socioeconomic development is higher, an environmental variable, along with previous birth interval and survival of preceding child emerges as important in determining infant mortality. Separate policy measures for child survival prospects in rural and urban Nepal are suggested.     

Community-level determinants of infant mortality in Mexico

Data from pregnancy histories collected by the 1976-77 Mexican Fertility Survey show wide variations in infant mortality among a sample of 125 communities. For example, in regard to community population, localities of 2500 or less averaged 104/1000 live births which was almost 2 times the rate of 56/1000 experienced by cities with 100,000 or more people. While the rates for Mexico's 3 largest cities (Guadalajara, Monterrey, and Mexico City) were slightly higher, this trend was due to the large slum populations. Overall, there were large and statistically significant infant mortality differentials by community population, proportion of the labor force in agriculture, mean wage, access to the nearest urban center, communication means, proportion of households with electricity, piped water and sewers, and distance to the closest 2ndary and preparatory school and university. Considering health care variables, there was an expected relationship between distance to the nearest health care facility and mortality levels. These community-level factors, which have been litte used in previous studies, are highly correlated and do not appear to affect infant survival independently of population size. Community size serves as a summary measure of a locality's overall level of development and comparative risk of early death for its children.     

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.