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2 Effect of a Child's Death on Birth Spacing: A Cross-National Analysis
Pages 39-73

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From page 39...
... The analysis uses data from phases 1 and 2 of the Demographic and Health Surveys (DHS) , which collect an extensive set of fertility-related variables for women of reproductive age and for live births that occurred in the 5 years before the date of interview.
From page 40...
... We investigated the effect of the premature truncation of breastfeeding on the interval from return of menses and resumption of sexual relations to a subsequent pregnancy. The DHS do not collect information on pregnancies that do not result in a live birth (i.e., spontaneous abortions and stillbirths)
From page 41...
... INTERVENING VARIABLES It is well documented that the length of the birth interval affects child mortality and that shorter previous intervals are associated with higher infant and child mortality rates (Sullivan et al., 1994~. Some of the association between a child's death and a short subsequent birth interval could therefore be confounded by the association between short previous intervals and a subsequent child death.
From page 42...
... The continued presence of a male partner in the household certainly affects the probability of closing the birth interval, but also influences socioeconomic well-being of the household and allocation of resources within the household. Other characteristics that affect birth intervals but that are not necessarily correlated with child mortality, such as the woman's underlying fecundability, can bias estimation of the parameter estimates as well (Heckman and Singer, 1982, 1984~.
From page 43...
... Our analysis is restricted to births in the previous 5 years because a major aim is to examine the mechanisms through which the death of a child affects the subsequent birth interval, specifically the premature truncation of breastfeeding leading to earlier return of menses and resumption of sexual activity. Countries included in the analysis are listed in Table 2-1 and the number of births for each country is shown.
From page 44...
... 44 BIRTH SPACING: A CROSS-NATIONAL ANALYSIS TABLE 2-1 Sample Sizes and Years of Surveys Included in Analysis Region Number of Births and Country Survey Year in Previous 5 Years Africa Botswana DHS1 1988 3,086 Burkina Faso DHS2 1992 5,828 Burundi DHS1 1987 3,811 Cameroon DHS2 1991 3,350 Egypt DHS1 1988 8,647 Ghana DHS1 1988 4,136 Kenya DHS1 1988-1989 6,980 Liberia DHS 1 1986 5,299 Madagascar DHS2 1992 5,273 Malawi DHS2 1992 4,495 Mali DHS1 1987 3,358 Morocco DHS1 1987 6,102 Morocco DHS2 1992 5,197 Namibia DHS2 1992 3,916 Niger DHS2 1992 6,899 Nigeria DHS2 1990 7,902 Ondo State, Nigeria DHS1 1986-1987 3,280 Rwanda DHS2 1992 5,510 Senegal DHS 1 1986 4,287 Senegal DHS2 1992- 1993 5,645 Sudan DHS1 1989-1990 6,644 Togo DHS1 1988 3,134 Tunisia DHS1 1988 4,477 Uganda DHS1 1988-1989 4,959 Zambia DHS2 1992 6,299 Zimbabwe DHS1 1988-1989 3,358 Asia Indonesia DHS1 1987 8,140 Indonesia DHS2 1991 15,708 Pakistan DHS2 1990- 1991 6,428 Sri Lanka DHS1 1987 4,010 Thailand DHS 1 1987 3,627 Latin America Bolivia DHS1 1989 5,814 Brazil DHS1 1986 3,573 Brazil DHS2 1991 3,159 Colombia DHS 1 1986 2,715 Colombia DHS2 1990 3,751 Dominican Republic DHS1 1986 4,767 Dominican Republic DHS2 1991 4,164 Ecuador DHS 1 1987 3,051 E1 Salvador DHS1 1985 3,339 Guatemala DHS2 1987 4,627 Mexico DHS1 1987 5,327 Paraguay DHS2 1990 4,246 Peru DHS1 1986 3,131 Peru DHS2 1991-1992 9,362 Trinidad and Tobago DHS1 1987 1,946
From page 45...
... Although a woman can continue breastfeeding during pregnancy, we focused only on breastfeeding before the time of conception to avoid any possibility of reverse causality that occurs if a woman stops breastfeeding because she is pregnant. The addition of a breastfeeding dummy variable to the model along with child death had the effect of creating three possible statuses of the index child 10 months earlier:
From page 46...
... Because we expected that a major mechanism for the association between death of the index child and a shorter subsequent birth interval was the premature truncation of breastfeeding, we anticipated a large reduction in the effect of a child's death. In fact, if breastfeeding were the only mechanism for the prolongation of the birth interval, as might be the case in countries where contraceptives are seldom used, then we would expect that the effect of child death might be reduced to zero.
From page 47...
... The baseline hazard was estimated in the same way, and the same set of models was estimated. Whereas postpartum amenorrhea is related to breastfeeding through biological mechanisms, postpartum abstinence is related to breastfeeding only through social norms and cultural taboos.
From page 48...
... Table 2-2 gives the ratio of the estimated median interval for subsequent births of children who survive to the median interval for births of children who die. This ratio varies between 1.21 and 3.15, indicating that the increase in birth interval associated with eliminating an early infant death is 21 to 215 percent.
From page 49...
... Postpartum Amenorrhea 0-' 16-~tu 12 E 10 <: 8 ~ 4 :~:;~~~~~~~~~ ~ :` O 2 - A- -4 I 1- 'Africa ~ ~ ~ ~ ~ t- tam ~~-~~-l i iis''a-'~l I I I I I " ILat~n America _ - - - -~- - - ~ c. Postpartum Abstinence ~ .
From page 50...
... 1.50 1.50 Average 1.79 2.35 1.54 Latin America Bolivia DHS 1 1.55 2.68 1.59 Brazil DHS 1 1.87 2.97 1.85 Brazil DHS2 1.83 2.84 1.80 Colombia DHS 1 1.54 2.78 1.05 Colombia DHS2 2.52 1.96 1.13 Dominican Republic DHS1 1.60 2.21 1.86 Dominican Republic DHS2 1.74 2.86 1.63 Ecuador DHS 1 1.62 1.80 1.97
From page 51...
... In Table 2-3, we examine the degree to which the effect of child death is "explained" by each model. In the table, we compute the percentage of reduction in excess risk associated with death of a child, where excess risk is the estimated relative risk minus 1.
From page 52...
... In some cases the percentage of the reduction was negative, indicating that the set of confounding variables as a whole was masking an association between child death and the birth interval. Model 3, labeled "with breastfeeding" in Figure 2-2, introduces an additional variable to model 2.
From page 53...
... In 14 of the 25 surveys analyzed for 22 African countries, controlling for breastfeeding status explains 65 percent or more of the excess risk of child death seen in the initial crude model. The same is true for 4 of the 5 surveys analyzed for 4 countries in Asia and for 8 of the 14 surveys analyzed in 11 countries in Latin America.
From page 55...
... ~ ~ ~ ~ ~ ~ oo ~o ~ ~ ~ oo M ~ ~ ~ oo cM cM M M ~ ~ ~ ~ ~ o ~ ~ ~ oo ~ ~ ~ ~ ~ ~ ~ ~ o ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - ~ cM ~ ~ ~ ~ ~ ~ ~ ~ ~ cM ~ ~ cM o oo ~ ~ o ~ ~ ~ ~ ~ .
From page 56...
... To address whether the observed effects are stronger if a child is older or younger when it dies, we used the same five African countries to estimate models in which the DIED variable was allowed to have time-varying effects. For the full birth interval, effects of a child death are strongest for closing the birth interval within 24 months (Figure 2-4~.
From page 57...
... Interval from Birth to Menses The major physiological pathway through which the death of a child is hypothesized to shorten the subsequent birth interval is by hastening the return of menses and ovulation because the mother is not breastfeeding. In Figure 2-lb, the predicted duration of postpartum amenorrhea after the birth of a child who survives until menses returns is compared with the duration after the death of a neonate for the full set of countries in the DHS.
From page 58...
... Africa stands out as having considerably longer median durations of postpartum amenorrhea, both when the index child who started the interval dies and when the child survives until return of menses (Figure 2-lb)
From page 59...
... -a ~ f ~ ~ ~ -me t; -0.2 ~1; ~1111 I ' it"` its.,` no, :~ '~ In' lye '.~ 1-1 -- -~1 1 1 ~1 1 ~ ~ -- ~ Africa ~ 4.0 . Asia Latin America 2~0 1.0 · - Crude ~ W/Confounders ~ W/Breastteeding FIGURE 2-5 Effect of child death on rate of resuming menses postpartum.
From page 61...
... 61 ~ ~ o ~ ~ oo ~ ~ ~ ~ oo ~ *
From page 62...
... vary considerably across the countries, most likely because of the small amount of exposure in this group. Interval from Birth to Sexual Relations A behavioral pathway through which a child's death may shorten the subsequent birth interval is by shortening the period of postpartum abstinence.
From page 63...
... The relative effect of a child's death is not as great as that for postpartum amenorrhea or for the overall birth interval. On average, across the 46 surveys, child survival increased the birth interval by 60 percent, postpartum amenorrhea by 178 percent, and postpartum abstinence by 47 percent.
From page 64...
... We conclude that the effect of a child's death on increasing the risk of resuming sexual relations is direct and does not appear to operate through breastfeeding. However, there does appear to be a group of Afncan countries for which an addition of the breastfeeding status variable actually increases the effect of DIED over that in the initial crude model.
From page 65...
... This generally had little effect on the coefficients for the effect of DIED in Africa and Asia, but did substantially reduce the effect in most Latin American countries. In Table 2-6, the addition of the confounding variables in Latin America generally explained 30-60 percent of the excess risk of conception resulting in a live birth, which is associated with death of a child in the first model.
From page 66...
... 66 O ca Cq X o .~ ·_4 be 3 o o Cq o .~ a' x VO be Cq o a' o a' · _4 o C)
From page 68...
... . FIGURE 2-9 Effect of child death on rate of closing the birth interval after menses and sexual relations have resumed.
From page 69...
... Third, our predicted birth intervals are based on creating a survival function in which the child's status is dead or living for all durations. Thus, the 60 percent estimate presented here is the reduction associated with elimination of all child death, not just infant death.
From page 72...
... It is not clear whether direct physiological mechanisms are at work here (such as anovulatory cycles after return of menses or reduced fecundity) or whether indirect effects of the breastfeeding experience are more important (such as fatigue and nighttime feedings which reduce coital frequency)
From page 73...
... McDonald, and S.O. Rutstein 1985 Demographic determinants of infant and early child mortality: A comparative analysis.


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