Maternal education and child survival: a comparative study of survey data from 17 countries.

A uniform analytical methodology was applied to survey data from 17 developing countries with the aim of addressing a series of questions regarding the positive statistical association between maternal education and the health and survival of children under age two. As has been observed previously, the education advantage in survival was less pronounced during than after the neonatal period. Strong but varying education effects on postneonatal risk, undernutrition during the 3-23 month period, and non-use of health services were shown--although a large part of these associations are the result of education's strong link to household economics. Differential use of basic health services, though closely tied to a mother's educational level, does little to explain the education advantage in child health and survival. However, the issue of the actual quality of services measured in the DHS is raised. Other issues concerning the roles of the pattern of family formation and differential physical access to health services are explored and discussed.

Preceding birth intervals and child survival: searching for pathways of influence.

The importance of the length of preceding birth intervals for the survival chances of young children has been established, but the debate concerning the causal biomedical or behavioral mechanisms continues. This article uses data from 17 Demographic and Health Surveys to investigate the effect of birth intervals on child mortality: Anthropometry of children, recent morbidity of children, and use of health services are examined in addition to child survival data for children born in the five years before the survey. Various methodological approaches are used to investigate the relative importance of the postulated mechanisms linking birth intervals and child survival. Short preceding birth intervals are associated with increased mortality risks in the neonatal period and at 1-6 months of age, and, to a much lesser extent, at 7-23 months of age. The effects of short birth intervals on nutritional status are rather moderate, and there is a weak relationship with lower attendance at prenatal care services. No consistent relationship exists between the length of birth intervals and other health status or health-service utilization variables. The results indicate that prenatal mechanisms are more important than postnatal factors, such as sibling competition, in explaining the causal nature of the birth interval effect.

PIP: Using data on births occurring 5 years prior to the survey and anthropometry from Demographic and Health Surveys (DHS), 1986-89, this study examined how birth intervals (24 months, 24-35 months, 35 months) may affect early childhood mortality. Discussion is provided on some possible mechanisms prenatally and postnatally to link birth intervals to child survival. A short review of relevant evidence from DHS data is given. Dependent variables include mortality (neonatal, 1-6 months, 7-23 months), anthropometry (stunting), morbidity (diarrhea prevalence), prenatal and delivery care, breast feeding, immunization, and medical treatment. Control variables were socioeconomic status (maternal education, urban/rural residence, household assets, and floor material of the house), biodemographic variables (sex, multiple birth status, maternal age, and duration of breast feeding), survival status of preceding birth, and use of maternity services. Statistical significance was determined by the Wald statistic. Results are reported for the pace of childbearing, the overlap of gestation and lactation, age specific patterns of mortality, previous child survivorship, breast-feeding duration, use of health services, and child health status (anthropometry, health service use, and breast-feeding initiation). It is suggested that postnatal factors are less important than prenatal factors. There is little support for a hypothesis about sibling competition and disease transmission, i.e., short birth intervals had only moderate effects on health status. Mothers with no education placed their infants at twice the risk for stunting and being underweight as mothers with at least a secondary education. Short birth intervals had little or no effect on diarrhea prevalence, child immunization, and medical/service use. The overlap of gestation and lactation in 6% of pregnancies occurred almost 2 times more often in birth intervals 24 months. Short birth intervals are associated with a higher risk of not having prenatal care in contrast to high birth intervals. Preceding child survival does not increase the effect of short intervals on mortality. Short birth intervals have a greater effect at 1-6 months than neonatally, and have the least effect at 7-24 months. In-depth country-specific analysis would contribute to a more complete understanding. Attention should also be paid to short intervals and lactation and sociocultural aspects.

Child anthropometry in cross-sectional surveys in developing countries: an assessment of the survivor bias.

In cross-sectional surveys, the sample of children with anthropometric measurements is not representative of all children in a birth cohort, since only children surviving to the survey date are measured. This survivor bias may have implications for studies of trends and differentials in anthropometric indicators. In this paper, the effects of the survivor bias on the estimates of child anthropometric indicators are assessed by 1) reviewing evidence from longitudinal studies on the prevalence of malnutrition among deceased children and among surviving children and by 2) analyzing retrospective data on child mortality and cross-sectional data on child anthropometry in 17 national surveys that are part of the Demographic and Health Surveys Program. It is concluded that comparisons of anthropometric data across geographic units, population subgroups, and calendar time are marginally affected by the survivor bias, unless mortality differences between the birth cohorts are very large (e.g., well over 50 per 1,000 births).

PIP: The effects of survivor bias in cross-sectional surveys of anthropometric measurements of children, that is overestimates due to omission of children that died before the survey date, were estimated by reviewing longitudinal studies for prevalence of malnutrition in deceased and surviving children, and analyzing retrospective data on child mortality and cross-sectional data on child anthropometry. Data were taken from 17 Demographic and Health Surveys, collected from 1986-1989. The odds ratio of the prevalence of malnutrition in deceased to that of living children was computed to assess how much worse the nutritional status of deceased children is to surviving children. In most countries 50% of the dead children were malnourished. The ratios were higher if malnutrition was more severe, specifically if the differences were pronounced for weight for age, and weight for height, or for severe stunting, below -3 SD from the median height for age. The proportion dead among children 3-36 months ranged from 2.5% in Sri Lanka to 15% in Mali, and was higher in older children. The largest bias was seen in weight for age: e.g., in Mali, where mortality is highest, the proportion of underweight increased by 4.6%, and of severely underweight by 2.7%. There was a relationship between level of malnutrition and child mortality at the country level, with considerable variation between countries, and a few outstanding outliers, countries whose malnutrition was much higher than expected from mortality rates. The effects of mother's education and of length of preceding birth interval were computed, and the odds ratio rose only from 1.8 to 2.2. It was concluded that comparisons of anthropometric data across countries and time are only marginally affected by survivor bias, unless the mortality differences between birth cohorts are very large, over 50/1000 births.

Accuracy and completeness of mothers' recall of diarrhoea occurrence in pre-school children in demographic and health surveys.

In the context of the Demographic and Health Surveys program (DHS), data were collected on diarrhoeal diseases in childhood and related treatment patterns. In this paper we assess the accuracy and completeness of mothers' recall of diarrhoea in 19 national DHS surveys and discuss the implications for health interview surveys in developing countries. It is concluded that there is under-reporting of diarrhoea if the recall period is longer than 2-3 days, whereas there may be over-reporting of very recent or current diarrhoea in most DHS surveys. Reporting errors appear to vary considerably between countries, which affects the comparability of survey results. A second and related issue, that is addressed in this paper, is the reporting of treatment practices by duration of diarrhoeal episode. There were no major differences in reported treatment patterns between children with diarrhoea that terminated in the last two weeks and children with current diarrhoea of at least two days' duration. The implications of the findings for retrospective surveys on childhood morbidity and treatment patterns are discussed.

Bottle use for infant feeding in developing countries: data from the demographic and health surveys. Has the bottle battle been lost?

This paper uses data from 22 national surveys in developing countries to estimate the use of bottles for feeding of infants under 6 months of age. These data were collected in the context of the Demographic and Health Surveys programme (DHS) between 1986 and 1989. Bottle use appears to be very common in most countries. Only six of the 22 countries had levels of bottle use of less than 20 per cent, and all these countries are in sub-Saharan Africa. The policy implications are discussed briefly.