Effect of Birth Intervals on Mortality and Health

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Effect of Birth Intervals on Mortality and Health

• Multivariate Cross-Country Analyses
• Shea Rutstein, PhD.
• Measure/DHS
• Macro International, Inc.

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Purpose of Analyses

• To analyze the effects of birth spacing on
  perinatal, infant and child mortality, on
  morbidity and on nutritional status, controlling
  for the effects of potentially confounding
  variables.

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Analyses

• Health and Nutrition
• Small size at birth
• Low birth weight
• Stunted
• Underweight
• Wasted
• Diarrhea
• ARI

• Mortality
• Early neonatal
• Perinatal
• Neonatal
• Post neonatal
• Infant
• Child
• Under five

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Overall Conclusions

• Mothers are having many births too soon after
  another.
• Too rapid childbearing poses substantial
  mortality and nutritional risks for children.
• Birth intervals of three years or longer
  substantially decrease the risks compared to
  those of both two years and less than two years.

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Overall Conclusions

• Many mothers desire to have longer birth
  intervals. Others need to be informed of the
  advantages of longer intervals.
• Fertility would substantially decline if mothers
  could have the birth intervals with the lowest
  mortality, up to 1 child lower.

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Data

• Latest Demographic and Health Surveys
• 17 countries
• Bangladesh, Bolivia, Egypt, Ghana, Guatemala,
  India, Indonesia, Cote dIvoire, Kenya, Morocco,
  Nepal, Nigeria, Peru, Philippines, Tanzania,
  Uganda, and Zambia.
• All USAID joint programming countries plus two
  others

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Independent variables

• Length of preceding birth interval (if not first
  born)
• Sex of child
• Birth order
• Mothers age at birth
• Survival of the preceding child by conception of
  index child (if not first born)
• Type of provider of prenatal care
• Timing of prenatal care, if any
• Number of prenatal tetanus vaccinations

• Urban/rural residence
• Mothers education
• Index of household wealth
• Type of person attending the delivery
• Wantedness of the child (wanted at conception,
  wanted later, did not want more children)
• Whether birth resulted from contraceptive failure

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Infant and Child Mortality
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Neonatal Mortality Results

• Duration of the preceding birth interval is
  strongly associated with neonatal mortality, even
  after controlling for a host of potentially
  confounding factors
• Significant results in 14 of 17 countries for
  neonatal

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Neonatal Mortality Results

• Risk of neonatal mortality compared with 36-47
  month birth interval
• Births less than 24 months 219
• Births 24-35 months 120
• Births 36-47 months 100
• Births 48 months 107
• First births 196
• Lowest neonatal mortality at 48-59 month birth
  intervals

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Infant Mortality Results

• Duration of the preceding birth interval is
  strongly associated with infant mortality, even
  after controlling for a host of potentially
  confounding factors
• Significant results in all 17 countries for
  infant mortality

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Infant Mortality Results

• Risk of infant mortality compared with 36-47
  month birth interval
• Births less than 24 months 237
• Births 24-35 months 131
• Births 36-47 months 100
• Births 48 months 107
• First births 282
• Lowest infant mortality at 48-53 month birth
  intervals but almost as low from 36-53 months

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Under Five Mortality Results

• Duration of the preceding birth interval is
  strongly associated with under five mortality,
  even after controlling for a host of potentially
  confounding factors
• Significant results in all 17 countries under
  five mortality

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Under Five Mortality Results

• Risk of under five mortality compared with 36-47
  month birth interval
• Births less than 24 months 244
• Births 24-35 months 141
• Births 36-47 months 100
• Births 48 months 84
• First births 135
• Lowest under five mortality at 48 month or
  greater birth intervals

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Special Analyses

• Impact of Breastfeeding
• on
• Post Neonatal and Toddler Mortality

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Breastfeeding and Mortality

• Special analyses were undertaken to reveal the
  potential effects of breastfeeding of the index
  child on mortality. Breastfeeding of the
  preceding child is indirectly taken into account
  using the survival of the preceding child.
• Mortality was examined at ages 2-3, 4-6, 9-12 and
  13-24 months after birth by whether or not the
  child had stopped breastfeeding before those
  ages.
• For these analyses, data from the several
  countries were pooled together.

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Breastfeeding Results

• Stopping breastfeeding is very strongly
  associated with increased mortality in the first
  year of life and still associated with increased
  mortality in the second year of life.
• Excess mortality of up to 403 of stopping
  compared with continuing breastfeeding
• The effect of stopping declines with increasing
  age.

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Effect on Mortality of Stopping Breastfeeding
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Effect on Birth Interval-Mortality Relationship

• The relationship between mortality and birth
  interval is not affected by whether or not the
  child had stopped breastfeeding (negligible
  change in coefficients for birth interval).

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Birth Size and Weight
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Birth Size and Weight Results

• The shortest duration of preceding birth interval
  is associated with small or very birth size and
  low birth weight, even after controlling for a
  host of potentially confounding factors
• Not much effect for intervals 18 to 53 months
• Significant results in 11 of 14 countries for
  birth size, 7 of 14 countries for birth weight
  (not asked in 3 countries).

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Perinatal Mortality

• Relationships between pregnancy intervals and
  perinatal mortality

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Perinatal Mortality Results

• Risk of perinatal mortality compared with 27-38
  month pregnancy interval
• Less than 15 months 137
• 15-26 months 105
• 27-38 months 100
• 39 months 140
• First pregnancy 142
• Lowest perinatal mortality at 27-38 month
  pregnancy intervals (36-47 birth interval)

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Nutritional Status
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Morbidity Status

• Diarrhea
• ARI
• Fever

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Morbidity Results

• Generally not significant for all three
  morbidities with respect to duration of preceding
  birth interval
• Significant results for area, wealth, mothers
  education

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Conclusions

• Birth (and pregnancy) intervals have important
  effects for the mortality of children and birth
  outcomes
• Birth intervals of 36-47 months are preferable to
  those of 24-35 months in almost all cases
• Chronic nutritional status is affected by birth
  interval but not acute status
• Morbidity status is not affected by birth
  intervals

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Conclusions

• Breastfeeding is important for child survival
• The effects of birth intervals do not appear to
  be the result of confounding with breastfeeding.
• The social and behavioral effects of short birth
  intervals are at least as strong as the maternal
  depletion effects.

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Actual and Desired Birth Intervals
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Actual Length of Birth Intervals

• Most birth intervals in Egypt and India are too
  short
• In both countries about 60 percent of intervals
  are shorter than 36 months
• Over a quarter of intervals are shorter than 24
  months
• Egypt and India are not alone in having too many
  short intervals

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African Birth Interval Preferences

• Mothers in Sub-Saharan African countries would
  prefer longer birth intervals.
• Few African mothers prefer birth intervals
  shorter than 36 months.
• Preferred birth intervals are usually longer in
  East and Southern Africa than in West and Middle
  Africa.

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Median Duration of Actual and Preferred Birth
Interval
Source Hantamalala Rafalimanana and Charles F.
Westoff, Highlights of Preferred Birth
Intervals in Sub-Saharan Africa
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Percent of Birth Intervals Less than 24 Months,
Actual and Preferred
Source Hantamalala Rafalimanana and Charles F.
Westoff, Highlights of Preferred Birth
Intervals in Sub-Saharan Africa
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Indian Birth Interval Preferences

• In spite of having too many short intervals, most
  Indian women would prefer longer intervals.
• For India as a whole, birth intervals would be
  four months longer on average if women had their
  preferences.

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Median Duration of Actual and Preferred Birth
IntervalIndia by Geographic Regions, 1992-3
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Birth Interval Preferences, Egypt

• In contrast to India, women in Egypt mostly have
  the birth intervals that they prefer.

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Median Duration of Actual and Preferred Birth
IntervalEgypt by Geographic Regions, 1992-3
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Indian Preferences for Short Birth Intervals

• In all states of India but Andhra Pradesh,
  Gujarat and Punjab, far fewer women prefer birth
  intervals of less than 36 months than actually
  occur.
• For India as a whole, while 62 percent of women
  have intervals shorter than 36 months, only 51
  percent prefer an interval that short.

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Percent of Birth Intervals Less than 24 Months,
Actual and Preferred
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Percent of Birth Intervals Less than 36 Months,
Actual and Preferred
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Egyptian Preferences for Short Birth Intervals

• In Egypt many women prefer short birth intervals.
• For Egypt as a whole, 27 percent of women have
  intervals shorter than 24 months, the same
  percent that occurs.
• 62 percent of Egyptian women have intervals
  shorter than 36 months and 60 percent prefer an
  such intervals.

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Percent of Birth Intervals Less than 24 Months,
Actual and Preferred
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Percent of Birth Intervals Less than 36 Months,
Actual and Preferred
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Effect of Avoiding Short Birth Intervals

• Enabling women to realize their birth interval
  preferences would result in substantial decreases
  in both infant and child mortality and fertility.
  
• Avoiding short birth intervals would lower both
  fertility and infant and child mortality by
  additional substantial amounts

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• In India, if no births occurred before 36 months
  of a preceding birth
• Infant Mortality Rate would drop 29
• Under Five Mortality Rate would drop 35
• Deaths to children under five years of age would
  fall by 1,434,000 annually
• Fertility would drop 9

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• In Egypt, if no births occurred before 36 months
  of a preceding birth
• Infant Mortality Rate would drop 35
• Under Five Mortality Rate would drop 45
• Deaths to children under five years of age would
  fall by 109,000 annually
• Fertility Rate would drop 8

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Overall Conclusions

• Mothers are having many births too soon after
  another.
• Too rapid childbearing poses substantial
  mortality and nutritional risks for children.
• Birth intervals of three years or longer
  substantially decrease the risks compared to
  those of both two years and less than two years.

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Overall Conclusions

• Many mothers desire to have longer birth
  intervals. Others need to be informed of the
  advantages of longer intervals.
• Fertility would substantially decline if mothers
  could have the birth intervals with the lowest
  mortality, up to 1 child lower.