Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys.

OBJECTIVE: This paper examines the association between birth intervals and infant and child mortality and nutritional status. METHODS: Repeated analysis of retrospective survey data from the Demographic and Health Surveys (DHS) program from 17 developing countries collected between 1990 and 1997 were used to examine these relationships. The key independent variable is the length of the preceding birth interval measured as the number of months between the birth of the child under study (index child) and the immediately preceding birth to the mother, if any. Both bivariate and multivariate designs were employed. Several child and mother-specific variables were used in the multivariate analyses in order to control for potential bias from confounding factors. Adjusted odds ratios were calculated to estimate relative risk. RESULTS: For neonatal mortality and infant mortality, the risk of dying decreases with increasing birth interval lengths up to 36 months, at which point the risk plateaus. For child mortality, the analysis indicates that the longer the birth interval, the lower the risk, even for intervals of 48 months or more. The relationship between chronic malnutrition and birth spacing is statistically significant in 6 of the 14 surveys with anthropometric data and between general malnutrition and birth spacing in 5 surveys. However, there is a clear pattern of increasing chronic and general undernutrition as the birth interval is shorter, as indicated by the averages of the adjusted odds ratios for all 14 countries. CONCLUSION: Considering both the increased risk of mortality and undernutrition for a birth earlier than 36 months and the great number of births that occur with such short intervals, the author recommends that mothers space births at least 36 months. However, the tendency for increased risk of neonatal mortality for births with intervals of 60 or more months leads the author to conclude that the optimal birth interval is between 36 and 59 months. This information can be used by health care providers to counsel women on the benefits of birth spacing.

Factors associated with trends in infant and child mortality in developing countries during the 1990s.

The 1990s have seen a remarkable decrease in mortality among infants and children in most developing countries. In some countries, particularly in sub-Saharan Africa, these declines in mortality among children have slowed and are now increasing again. Internationally comparable data derived from survey programmes, such as the Demographic and Health Survey (DHS) programme, are available both to document the changes that have occurred in mortality and to provide insight into some of the factors that may explain these trends in mortality. The factors found in repeated DHS programmes that explain these trends fall into five categories: fertility behaviour; nutritional status, breastfeeding, and infant feeding; the use of health services by mothers and for children; environmental health conditions; and socioeconomic status. Both simple analyses and multivariate analyses of changes in these factors between surveys indicate that all factors affected the mortality trends. However, to explain trends in mortality, the variables themselves had to have changed over time. During the 1990s fertility behaviour, breastfeeding, and infant feeding have changed less than other factors and so would seem to have played a smaller role in mortality trends. This study confirms that trends in mortality during the 1990s were related to more than just a handful of variables. It would, therefore, be a mistake to concentrate policy actions on one or a few of these while forsaking others. Countries with the largest decreases in mortality have had substantial improvements in most of the factors that might be used to explain these changes. In some countries mortality has risen. In part these increases can be explained by the factors included in this study, such as deterioration in seeking medical care for children with fever. Other factors that were not measured, such as the increasing resistance of malaria to drug treatment and the increased prevalence of parental HIV/AIDS, may be contributing to the increase noted.

[Data on birthweight in developing countries: are surveys useful?]. / Datos sobre el peso al nacer en países en desarrollo: son útiles las encuestas?

The main source of data on birth weight in developing countries is statistics from health facilities, although most developing countries do not produce annual estimates of the incidence of low birth weight from these data. Such estimates would be subject to selection bias as the data are usually limited to babies born within health facilities, and therefore are representative of a subgroup that is markedly different from the overall population of neonates. Since 1990 the Demographic and Health Surveys programme has included questions on recalled birth weight and relative size at birth in 15 national surveys. In this article, we show that these cross-sectional surveys can provide a useful data source for making national estimates of mean birth weight and the incidence of low birth weight. The extent of misclassification of birth weight is, however, too large to use the data on relative size as birth as an indicator of low birth weight at the individual level.

Datos sobre el peso al nacer en países en desarrollo: son útiles las encuestas? / Data on birth weight in developing countries: can surveys help?

Las estadísticas de centros de atención de salud son la fuente principal de datos sobre el peso al nacer en los países en desarrollo, si bien en la mayor parte de esos países no se producen estimaciones anuales de la incidencia de bajo peso al nacer a partir de esos datos. Si se produjeran, las estimaciones serían propensas al sesgo de selección ya que los datos están limitados en general a los niños nacidos en centros de salud y, por lo tanto, representan un subgrupo decididamente diferente de la población general de neonatos. Desde 1990, el programa de Encuestas Demográficas y de Salud ha realizado 15 encuestas nacionales en las que se incluyeron preguntas sobre el peso y el tamaño relativo al nacer tal como los recordaban las madres. Este artículo muestra que las encuestas transversales pueden constituir una fuente útil de datos para estimar la media nacional de peso al nacer y la incidencia de bajo peso. Sin embargo, la clasificación errónea del peso al nacer es demasiado extensa para emplear los datos de tamaño relativo al nacer como indicador de bajo peso a escala individual

Datos sobre el peso al nacer en países en desarrollo: son útiles las encuestas? / Data on birth weight in developing countries: can surveys help?

Las estadísticas de centros de atención de salud son la fuente principal de datos sobre el peso al nacer en los países en desarrollo, si bien en la mayor parte de esos países no se producen estimaciones anuales de la incidencia de bajo peso al nacer a partir de esos datos. Si se produjeran, las estimaciones serían propensas al sesgo de selección ya que los datos están limitados en general a los niños nacidos en centros de salud y, por lo tanto, representan un subgrupo decididamente diferente de la población general de neonatos. Desde 1990, el programa de Encuestas Demográficas y de Salud ha realizado 15 encuestas nacionales en las que se incluyeron preguntas sobre el peso y el tamaño relativo al nacer tal como los recordaban las madres. Este artículo muestra que las encuestas transversales pueden constituir una fuente útil de datos para estimar la media nacional de peso al nacer y la incidencia de bajo peso. Sin embargo, la clasificación errónea del peso al nacer es demasiado extensa para emplear los datos de tamaño relativo al nacer como indicador de bajo peso a escala individual

The professionals and patients involved in dental examinations are at risk for infection by various disease-causing bacteria, viruses, and fungi, such as those responsible for hepatitis, tuberculosis, herpes, and AIDS. It is known that aerosols and spatter containing pathogenic microorganisms can spread during an examination. Nevertheless, some dental clinics are designed to have multiple examination areas in the same room, with no physical barriers between them. The objective of this study was to verify the reach of spatter resulting from the use of a triple syringe and high-rotation turbine during five simulated exams in a collective clinic, bearing in mind that spattercan contain the patient's saliva and blood. To facilitate tracking of the spatter, aniline dye (pink, blue, yellow, green, and brown) was added to the water in the appropriate receptacle in each of the five units. The room, the equipment, and the patient's and operator's clothing were covered with white paper. A high concentration of spatter was observed on the chair, the operator, and the floor of each unit, and it also appeared on the chairs and trays of the surrounding units. The maximum distance reached by spatter was 1.82 m from a point on the chair corresponding to the position of the patient's mouth. During real simultaneous examinations, the surrounding chairs and their patients and operators, as well as the trays containing sterilized instruments, are within spatter range. Therefore, there is a real possibility of crossinfection, and physical barriers should be placed between the units. This study also confirmed the need for protection of the operator's face, body, hair, and arms, since these regions were heavily affected by spatter.

The use of breast milk substitutes in developing countries: the impact of women's employment.

OBJECTIVES: This study quantified the influence of employment, specifically a mother's employment away from her infant, on the use of breast milk substitutes in developing countries. METHODS: Data from the Demographic and Health Surveys were used to calculate the population attributable risk percentage for use of breast milk substitutes among women employed away from their babies in 15 countries for which suitable data were available. RESULTS: The estimated proportion of breast milk substitute use attributable to employment away from the baby ranged from 0.74% to 20.9% in the various countries. CONCLUSIONS: Employment is not the main determinant of breast milk substitute use. Efforts to improve breast-feeding can be safely targeted at the majority of women who are not employed away from their babies while nevertheless giving appropriate attention to the minority of new mothers who are employed away from their babies.

Contraceptive use during lactational amenorrhea.

OBJECTIVE: The study uses data from nationally representative sample surveys in developing countries to estimate the overlap between lactational amenorrhea and contraceptive use during the first 6 months postpartum. METHOD: Secondary analyses of survey data were used to tabulate the proportion of the population in lactational amenorrhea among contraceptive users for all women, for postpartum women and for the country as a whole. RESULTS: Among postpartum women, the proportion in lactational amenorrhea was particularly high in Africa and the Near East and lower in Latin America and the Caribbean where breast-feeding practices have declined. The median duration of use for oral contraceptives is also presented as an aid to interpreting the significance of the findings. CONCLUSIONS: The significance of the findings is considered in the context of planning reproductive health services in the postpartum period. Decisions about timing of contraceptive use for postpartum women, while arrived at on an individual basis, also result from program strategies that focus counseling immediately postpartum or at a later interval, such as when menses resume. On a national level the impact of postpartum contraception policies on use of commodities may be substantial.

Contraceptive use during lactational amenorrhea

OBJECTIVE: The study uses data from nationally representative sample surveys in developing countries to estimate the overlap between lactational amenorrhea and contraceptive use during the first 6 months postpartum. METHOD: Secondary analyses of survey data were used to tabulate the proportion of the population in lactational amenorrhea among contraceptive users of all women, for postpartum women and for the country as a whole. RESULTS: Among postpartum women, the proportion in lactational amenorrhea was particularly high in Africa and the Near East and lower in Latin America and the Caribbean where breast-feeding practices have declined. The median duration of use for oral contraceptives is also presented as an aid to interpreting the significance of the findings. CONCLUSIONS: The significance of the findings is considered in the context of planning reproductive health services in the postpartum period. Decisions about timing of contraceptive use for postpartum women, while arrived at on an individual basis, also result from program strategies that focus counseling immediately postpartum or at a later interval, such as when menses resume. On a national level the impact of postpartum contraception policies on use of commodities may be substantial.(AU)

Data on birth weight in developing countries: can surveys help?

The main source of data on birth weight in developing countries is statistics from health facilities, although most developing countries do not produce annual estimates of the incidence of low birth weight from these data. Such estimates would be subject to selection bias as the data are usually limited to babies born within health facilities, and therefore are representative of a subgroup that is markedly different from the overall population of neonates. Since 1990 the Demographic and Health Surveys programme has included questions on recalled birth weight and relative size at birth in 15 national surveys. In this article, we show that these cross-sectional surveys can provide a useful data source for making national estimates of mean birth weight and the incidence of low birth weight. The extent of misclassification of birth weight is, however, too large to use the data on relative size at birth as an indicator of low birth weight at the individual level.

PIP: Data from 15 surveys conducted in developing countries that included questions on birth weight were analyzed to determine whether birth weight data from cross-sectional surveys can be used to improve national estimates of mean birth weight and the incidence of low birth weight (LBW). The proportion of children weighed at birth ranged from 9% in Pakistan and Yemen to 91% in the Dominican Republic. Most women could recall the birth weight. Units of measurement to record birth weight included grams in seven surveys, kilograms carried to one decimal place in five surveys, kilograms carried to two decimal places in one survey, pounds and ounces in one survey, and pounds or kilograms in one survey. Among all surveys reporting in kilograms or grams, 33-50% of birth weights were recorded in multiples of 500 g. The sensitivity of the relative-size-at-birth indicator to identify LBW babies was very low in all surveys (mean, 29%), even though the positive predictive value (PPV) was at least 70% in most surveys. Thus, most infants reported as very small were indeed LBW, but only 29% of all LBW infants were identified. When one used both very small and small as indicators of LBW, sensitivity improved greatly (mean, 66%). Yet 45% (mean PPV) of the very small and small infants were of LBW. The incidence of LBW, when considering both numerical weight and size, ranged from 8.7% (Colombia) to 18.8% (Tanzania). Poor data quality probably accounted for the fact that data from Yemen were very different than those from the other surveys. These findings suggest that these surveys can be a useful data source for estimating mean birth weight nationwide and the incidence of LBW. Misclassification of birth weight is too common to use the data on relative size at birth as an indicator of LBW at the individual level.

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.

Comparison of microcomputer programs for making population projections: an update.

"There are many programs for making population projections now available for use with microcomputers. This article reviews six of approximately 15 microcomputer population projection programs. Each program is compared to a standard set of criteria relating to such items as hardware and software requirements, input data requirements and specification of assumptions, methodology and documentation, and summary output indicators. Numerical results from projections of six test data sets reflecting different assumptions about mortality, fertility, and migration are compared. Qualitative comments are included for describing special features and for making an overall assessment of each program." (SUMMARY IN FRE)

Six microcomputer programs for population projection: an evaluation.

PIP: Microcomputer-based population projection software packages were evaluated to determine if all the programs would yield similar results if tested on the same set of data. These included the PROJ5 from Microcomputer Program for Demographic Analysis, converted for microcomputers by Westinghouse; the FIVFIV/SINSIN from The Population Council; the PROJPC-II, developed by Kenneth Hill for the World Bank; and CELADE, developed by Centro Latinamericano de Demographia (CELADE), a Spanish microcomputer version of the population projection program of the United Nations. These were all modified from mainframe programs. The DEMPROJ, developed by the RAPID2 project at the The Futures Group, and ESCAP/POP, developed by the Population Division of the U.N. Economic and Social Commission for Asia and the Pacific (ESCAP) were both specifically developed for microcomputers. A standard set of criteria covering hardware and software and requirements, methodology, projection results, and summary demographic indicators in the output are used in the evaluation. Table 1 gives hardware and software requirements. All the programs can be used on IBM or compatable micros. Table 2 gives data input requirements, which vary widely. All 6 programs use a cohort-component projection, although there is a wide variety in application of methodology. Programs and data sets produced similar results, and choice of a system should based on intended use. Appendices list programs and addresses for obtaining copies as well as other kinds of software available for demogrphic analysis and their sources.^ieng

Mortality trends of young children in developing countries.

PIP: The findings of a World Fertility Survey of infant and early childhood mortality trends in 29 countries in Africa, the Americas, and Asia are reported. The national surveys, carried out in 1974-79, utilized the synthetic cohort method. Analysis of the infant and child mortality 0-4 years before the data of each survey revealed wide variation. A moderate percentage (4-8%) of children died before reaching age 5 in 10 of the 29 countries studied: Costa Rica, Fiji, Guyana, Jamaica, Jordan, Korea, Malaysia, Panama, Trinidad and Tobago, and Venezuela. A moderate to high percentage (8-12%) of infant and child deaths was noted in Colombia, Mexico, Paraguay, Philippines, Sri Lanka, Syria, and Thailand. Mortality in this age group was high (12-15%) in Dominican Republic, Indonesia, Kenya, Peru, and Sudan; very high (16-20%) in Haiti, Lesotho, and Turkey; and extremely high (20% or more) in Bangladesh, Nepal, Pakistan, and Senegal. Even the countries with the lowest mortality levels have more than twice the mortality of developed countries. The neonatal death rate has been the most difficult to control. To determine time trends, children born to women ages 20-29 at time of the survey were further analyzed. Mortality has declined over time in all countries studied. There was an average of 43 fewer deaths under the age of 5 years per 1000 births in the period 0-4 years before the surveys than 15-19 years earlier, for an overall 28% decrease. Per 1000 births, 20 infant, 10 toddler, and 13 preschooler deaths were averted. However, the declines have not been equal or consistent across countries. When the countries were grouped by region, Western Asia recorded the greatest decline, with an average of 93 fewer infant and early childhood deaths in the period 0-4 years before survey than 15-19 years earlier. With 26 fewer deaths per 1000 births, the countries of Africa demonstrated the least fall. Asia (excluding Western Asia) and the Americas showed average declines of 34 and 45 deaths, respectively. There is some indication of a slowdown in the rate of decline of mortality, and 4 countries have shown increases in the recent period. This finding must be interpreted with caution, however, since recently born children may have been better reported.^ieng