Determinants of infant mortality in Malawi: an analysis to control for death clustering within families

Clustering of child deaths among families in low and middle-income countries: A meta-analysis

Background and Aims

Several studies have examined the phenomenon of "death clustering," in which two or more children born to the same mother or from the same family die at an early age. Therefore, a scientific examination of the results is essential to understand how the survival status of the older siblings affects the survival of the younger siblings. By using meta-analysis, this study aims to provide a quantitative synthesis of the results of studies on "child death clustering" in low- and middle-income countries (LMICs).

Methods

This study followed the PRISMA-P 2015 guidelines. We used four electronic databases-PubMed, Medline, Scopus, and Google Scholar with search and citation analysis capabilities. Initially, 140 studies were identified, but only 27 met the eligibility criteria eventually. These were studies that had used the death of a previous child as a covariate to determine the survival status of the index child. The heterogeneity and the publication bias of the studies were examined using the Cochran test, I ² statistic, and Egger's meta-regression test.

Results

The pooled estimate of 114 study estimates for LMICs contains some bias. India's 37 study estimates were distributed more or less equally along the middle line, indicating no publication bias, while there was a slight bias in the estimates for Africa, Latin America, and Bangladesh. The odds of experiencing the death of the index child in the selected LMICs were 2.3 times higher for mothers who had lost any prior child as compared to those mothers who had not had any prior child loss. For African mothers, the odds were five times higher, whereas for Indian mothers, the odds were 1.66 times higher. Mothers' characteristics, such as education, occupation, health-seeking behavior, and maternal competence, significantly affect the child's survival status.

Conclusion

Achieving the sustainable development goals would not be possible if mothers in countries experiencing high levels of under-five mortality are not provided with better health and nutrition facilities. Mothers who have lost multiple children should be targeted for assistance.

Trends of infant mortality and its determinants in Ethiopia: mixed-effect binary logistic regression and multivariate decomposition analysis

BACKGROUND

Infant mortality remains a serious global public health problem. The global infant mortality rate has decreased significantly over time, but the rate of decline in most African countries, including Ethiopia, is far below the rate expected to meet the SDG targets. Therefore, this study aimed to investigate the trends of infant mortality and its determinants in Ethiopia based on the four consecutive Ethiopian Demographic and Health Surveys (EDHSs).

METHODS

This analysis was based on the data from four EDHSs (EDHS 2000, 2005, 2011, and 2016). A total weighted sample of 46,317 live births was included for the final analysis. The logit-based multivariate decomposition analysis was used to identify significantly contributing factors for the decrease in infant mortality in Ethiopia over the last 16 years. To identify determinants, a mixed-effect logistic regression model was fitted. The Intra-class Correlation Coefficient (ICC) and Likelihood Ratio (LR) test were used to assess the presence of a significant clustering effect. Deviance, Akaike Information Criteria (AIC), and Bayesian Information Criteria (BIC) were used for model comparison. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to identify the statistically significant determinants of infant mortality.

RESULTS

Infant mortality rate has decreased from 96.9 per 1000 births in 2000 to 48 per 1000 births in 2016, with an annual rate of reduction of 4.2%. According to the logit based multivariate decomposition analysis, about 18.1% of the overall decrease in infant mortality was due to the difference in composition of the respondents with respect to residence, maternal age, type of birth, and parity across the surveys, while the remaining 81.9% was due to the difference in the effect of residence, parity, type of birth and parity across the surveys. In the mixed-effect binary logistic regression analysis; preceding interval <  24 months (AOR = 1.79, 95% CI; 1.46, 2.19), small size at birth (AOR = 1.55, 95% CI; 1.25, 1.92), large size at birth (AOR = 1.26, 95% CI; 1.01, 1.57), BMI <  18.5 kg/m² (AOR = 1.22, 95% CI; 1.05, 1.50), and twins (AOR = 4.25, 95% CI; 3.01, 6.01), parity> 6 (1.51, 95% CI; 1.01, 2.26), maternal age and male sex (AOR = 1.50, 95% CI: 1.25, 1.79) were significantly associated with increased odds of infant mortality.

CONCLUSION

This study found that the infant mortality rate has declined over time in Ethiopia since 2000. Preceding birth interval, child-size at birth, BMI, type of birth, parity, maternal age, and sex of child were significant predictors of infant mortality. Public health programs aimed at rural communities, and multiparous mothers through enhancing health facility delivery would help maintain Ethiopia's declining infant mortality rate. Furthermore, improving the use of ANC services and maternal nutrition is crucial to reducing infant mortality and achieving the SDG targets in Ethiopia.

Child Malnutrition and Feeding Practices in Malawi

The 1992 Malawi and Demographic Health Survey data are used to assess the association between breast-feeding practices, socio-economic and morbidity variables, and the nutritional status of children under the age of five years using multilevel models. About 27% of under-five children in Malawi are underweight, and nearly 50% are stunted. The results of this study suggest that socio-economicfactors, morbidity, and inappropriate feeding practices are some of the factors associated with malnutrition in Malawi. High socio-economic status, as measured by urban residence, the presence of modern amenities, and some maternal education, is associated with better nutritional status, whereas morbidity within two weeks before the survey is associated with low weight-for-age Z scores. Breast-feeding is almost universal and is carried on for about 21 months, but the introduction of complementary food starts much too early; only 3% of Malawian children under the age of 4 months are exclusively breastfed. Children aged 12 months or older who were still breastfeeding at the time of the survey were of lower nutritional status than those who had stopped breastfeeding. The analysis also showed a significant intra-family correlation of weight-for-age Z scores of children of the same family of about 39%.

How a Communication Intervention in Zambia Re-Oriented Health Services to the Needs of the Least-Supported

Despite decades of training health workers in communication, complaints from clients and communities about poor health worker attitudes abound. This was found to be so in Zambia where the More Mobilizing Access to Maternal Health Services in Zambia (MORE MAMaZ) program was trying to ensure the inclusion of under-supported women in a community-based maternal and newborn health program in five intervention districts. Under-supported women suffer a disproportionate burden of child mortality and are poor users of health services. An exploratory small-scale qualitative survey involving nurses from training schools and health facilities found that nurses knew how to communicate well, but were selective with whom and in what circumstances they did this. In general, those who received the worst communication were under-supported and had low confidence—the very people who needed the best communication. An experiential training program was started to help health workers reflect on the reasons for their poor communication. The training was evaluated after 14 months using semi-structured interviews and focus group discussions with staff at participating health facilities. The results showed improved inclusion of under-supported women but also increased attendance generally for ante-natal clinics, deliveries and under-five clinics. Another outcome was improved communication between, and a sense of job satisfaction among, the health workers themselves. The program demonstrated an effective way to improve the inclusion and involvement of the least-supported women and girls. There are important lessons for other health programs that aim to operationalize the goals of the Global Strategy for Women’s, Children’s and Adolescent’s Health, which include an emphasis on reaching every woman.

Early-life mortality clustering in families: A literature review

Research on early-life mortality in contemporary and historical populations has shown that infant and child mortality tend to cluster in a limited number of high-mortality families, a phenomenon known as 'mortality clustering'. This paper is the first to review the literature on the role of the family in early-life mortality. Contemporary results, methodological and theoretical shortfalls, recent developments, and opportunities for future research are all discussed in this review. Four methodological approaches are distinguished: those based on sibling deaths, mother heterogeneity, thresholds, and excess deaths in populations. It has become clear from research to date that the death of an older child harms the survival chances of younger children in that family, and that fertility behaviour, earlier stillbirths, remarriages, and socio-economic status all explain mortality clustering to some extent.

A comprehensive analysis on child mortality and its determinants in Bangladesh using frailty models

BACKGROUND

Bangladesh has experienced a significant reduction of child mortality over the past decades which helped achieve the Millennium Development Goal 4 (MDG 4) target. But the mortality among under-5 aged children is still relatively high and it needs a substantial effort to achieve the Sustainable Development Goal (SDG) target and decelerate the current rate of under-5 mortality. At this stage, it is hence important to explore the trend and determinants of under-5 mortality in order to reduce the vulnerability of child's survival. The aim of this study is to explore the trends and identify the factors associated with mortality in children aged less than 5 years in Bangladesh.

METHODS

Data from three repeatedly cross-sectional Bangladesh Demographic and Health Surveys (BDHSs) for the year 2007, 2011 and 2014 were used. A stratified two-stage sampling method was used to collect information on child and maternal health in these surveys. Cox's proportional hazards models with community and mother level random effects (or frailty models) were fitted to identify the associated factors with under-five mortality.

RESULTS

Our study reveals that urban-rural disparity in child mortality has decreased over the time. The frailty models revealed that the combined effect of birth order and preceding birth interval length, sex of the child, maternal age at birth, mother's working status, parental education were the important determinants associated with risk of child mortality. The risk of mortality also varied across divisions with Sylhet division being the most vulnerable one. Moreover, significant and sizable frailty effects were found which indicates that the estimations of the unmeasured and unobserved mother and community level factors on the risk of death were substantively important.

CONCLUSION

Our study suggests that community-based educational programs and public health interventions focused on birth spacing may turn out to be the most effective. Moreover, unobserved community and familial effects need to be considered along with significant programmable determinants while planning for the child survival program.

CASTE DIFFERENTIALS IN DEATH CLUSTERING IN CENTRAL AND EASTERN INDIAN STATES

This study assessed caste differentials in family-level death clustering, linked survival prospects of siblings (scarring) and mother-level unobserved heterogeneity affecting infant mortality risk in the central and eastern Indian states of Jharkhand, Madhya Pradesh, Odisha and Chhattisgarh. Family-level infant death clustering was examined using bivariate analysis, and the linkages between the survival prospects of siblings and mother-specific unobserved heterogeneity were captured by applying a random effects logit model in the selected Indian states using micro-data from the National Family Health Survey-III (2005-06). The raw data clustering analysis showed the existence of clustering in all four states and among all caste groups with the highest clustering found in the Scheduled Castes of Jharkhand. The important factor from the model that increased the risk of infant deaths in all four states was the causal effect of a previous infant death on the risk of infant death of the subsequent sibling, after controlling for mother-level heterogeneity and unobserved factors. The results show that among the Scheduled Castes and Scheduled Tribes, infant death clustering is mainly affected by the scarring factor in Jharkhand and Madhya Pradesh, while mother-level unobserved factors were important in Odisha and both (scarring and mother-level unobserved factors) were key factors in Chhattisgarh. Similarly, the Other Caste Group was mainly influenced by the scarring factor only in Odisha, mother-level unobserved factors in Jharkhand and Chhattisgarh and both (scarring and mother-level unobserved factors) in Madhya Pradesh. From a government policy perspective, these results would help in identifying high-risk clusters of women among all caste groups in the four central and eastern Indian states that should be targeted to address maternal and child health related indicators.

Examining the effect of household wealth and migration status on safe delivery care in urban India, 1992-2006

BACKGROUND

Although the urban health issue has been of long-standing interest to public health researchers, majority of the studies have looked upon the urban poor and migrants as distinct subgroups. Another concern is, whether being poor and at the same time migrant leads to a double disadvantage in the utilization of maternal health services? This study aims to examine the trends and factors that affect safe delivery care utilization among the migrants and the poor in urban India.

METHODOLOGY/PRINCIPAL FINDINGS

Using data from the National Family Health Survey, 1992-93 and 2005-06, this study grouped the household wealth and migration status into four distinct categories poor-migrant, poor-non migrant, non poor-migrant, non poor-non migrant. Both chi-square test and binary logistic regression were performed to examine the influence of household wealth and migration status on safe delivery care utilization among women who had experienced a birth in the four years preceding the survey. Results suggest a decline in safe delivery care among poor-migrant women during 1992-2006. The present study identifies two distinct groups in terms of safe delivery care utilization in urban India--one for poor-migrant and one for non poor-non migrants. While poor-migrant women were most vulnerable, non poor-non migrant women were the highest users of safe delivery care.

CONCLUSION

This study reiterates the inequality that underlies the utilization of maternal healthcare services not only by the urban poor but also by poor-migrant women, who deserve special attention. The ongoing programmatic efforts under the National Urban Health Mission should start focusing on the poorest of the poor groups such as poor-migrant women. Importantly, there should be continuous evaluation to examine the progress among target groups within urban areas.

Clustering of child mortality in a contemporary polygamous population in Africa

Child mortality, defined here as mortality under age five, is not evenly distributed but found in clusters. In a contemporary polygamous population in Ghana with extended families, we separate clustering at the parental and household levels, which are often overlapping and inseparable in other historical studies. For eight years, we followed 28,994 individuals, including 9,288 children under the age of five, in 1,703 households. We identified four determinants that had a significant effect on child mortality: sex of the child, age of the child, drinking source, and socioeconomic status. After correcting for these determinants, we still identified significant clustering of child mortality at the level of the village (covariance [cov] = 0.02, p = .04), household (cov = 0.14, p = .003), father (cov = 0.24, p = .001), and mother (cov = 0.18, p = .05). The present data provide clues regarding the levels at which to look for unidentified determinants of child mortality and suggest that the importance of the father could be larger than previously thought.

Historical trends in the correlation of sibling deaths in infancy in the Netherlands

In this article, we study temporal, regional, and social variation in infant and childhood death clustering in The Netherlands, using data from three provinces. The data relate to children born in 90,000 marriages contracted between the beginning and the last quarter of the nineteenth century. Descriptive indicators show that death clustering was more frequent in the province of Zeeland and more common in the lower classes, and that it increased in two provinces over time. Shared frailty hazard models make it clear that the number of children who died before the birth of an index child had a negative effect on the mortality of index children, whereas earlier stillbirths and the number of children who died when the index child was at a young age had an increasing effect on the mortality of index children.

Infant death clustering in families: magnitude, causes, and the influence of better health services, Bangladesh 1982-2005

This analysis of infant mortality in Bangladesh focuses on explaining death clustering within families, using prospective data from a rural region in Bangladesh, split into areas with and without extensive health services (the area covered by the International Centre for Diarrhoeal Disease Research and the comparison area, respectively). The modelling framework distinguishes between two explanations of death clustering: (observed and unobserved) heterogeneity across families and a causal 'scarring' effect of the death of one infant on the survival chances of the next to be born. Keeping observed and unobserved characteristics constant, we find scarring in the comparison area only. There the likelihood of infant death is about 29 per cent greater if the previous sibling died in infancy than otherwise. This effect mainly works through birth intervals: infant deaths are followed by shorter birth intervals, which increases the risk of infant death for the next child.

Overview of migration, poverty and health dynamics in Nairobi City's slum settlements

The Urbanization, Poverty, and Health Dynamics research program was designed to generate and provide the evidence base that would help governments, development partners, and other stakeholders understand how the urban slum context affects health outcomes in order to stimulate policy and action for uplifting the wellbeing of slum residents. The program was nested into the Nairobi Urban Health and Demographic Surveillance System, a uniquely rich longitudinal research platform, set up in Korogocho and Viwandani slum settlements in Nairobi city, Kenya. Findings provide rich insights on the context in which slum dwellers live and how poverty and migration status interacts with health issues over the life course. Contrary to popular opinions and beliefs that see slums as homogenous residential entities, the findings paint a picture of a highly dynamic and heterogeneous setting. While slum populations are highly mobile, about half of the population comprises relatively well doing long-term dwellers who have lived in slum settlements for over 10 years. The poor health outcomes that slum residents exhibit at all stages of the life course are rooted in three key characteristics of slum settlements: poor environmental conditions and infrastructure; limited access to services due to lack of income to pay for treatment and preventive services; and reliance on poor quality and mostly informal and unregulated health services that are not well suited to meeting the unique realities and health needs of slum dwellers. Consequently, policies and programs aimed at improving the wellbeing of slum dwellers should address comprehensively the underlying structural, economic, behavioral, and service-oriented barriers to good health and productive lives among slum residents.

Intra-urban differentials in the utilization of reproductive healthcare in India, 1992-2006

This paper examines trends in three reproductive healthcare indicators- namely, antenatal care, medical assistance at delivery, and contraceptive use among the urban poor and non-poor in India using data from the National Family Health Surveys, 1992-1993 and 2005-2006. The urban poor and non-poor are derived from composite wealth indices based on a set of economic proxies. Results indicate that the estimates of poor and non-poor are reliable. During the last 14 years, the service coverage in all three indicators has increased in the country, among both the urban poor and non-poor. However, the utilization of reproductive health services is concentrated among the urban non-poor cutting across the states, with the exception of Kerala. While the non-poor/poor gap in antenatal care and medical assistance at delivery remained large over the years, the gap in contraceptive use has narrowed down cutting across states. After adjusting for other confounders, household poverty was found to be a significant barrier in the utilization of reproductive healthcare services across the states. It has been observed that the utilization of reproductive healthcare services followed a continuum of rural total, urban poor, and urban non-poor.

The health and well-being of older people in Nairobi's slums

BACKGROUND

Globally, it is estimated that people aged 60 and over constitute more than 11% of the population, with the corresponding proportion in developing countries being 8%. Rapid urbanisation in sub-Saharan Africa (SSA), fuelled in part by rural-urban migration and a devastating HIV/AIDS epidemic, has altered the status of older people in many SSA societies. Few studies have, however, looked at the health of older people in SSA. This study aims to describe the health and well-being of older people in two Nairobi slums.

METHODS

Data were collected from residents of the areas covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) aged 50 years and over by 1 October 2006. Health status was assessed using the short SAGE (Study on Global AGEing and Adult Health) form. Mean WHO Quality of Life (WHOQoL) and a composite health score were computed and binary variables generated using the median as the cut-off. Logistic regression was used to determine factors associated with poor quality of life (QoL) and poor health status.

RESULTS

Out of 2,696 older people resident in the NUHDSS surveillance area during the study period, data were collected on 2,072. The majority of respondents were male, aged 50-60 years. The mean WHOQoL score was 71.3 (SD 6.7) and mean composite health score was 70.6 (SD 13.9). Males had significantly better QoL and health status than females and older respondents had worse outcomes than younger ones. Sex, age, education level and marital status were significantly associated with QoL, while slum of residence was significantly associated with health status.

CONCLUSION

The study adds to the literature on health and well-being of older people in SSA, especially those in urban informal settlements. Further studies are needed to validate the methods used for assessing health status and to provide comparisons from other settings. Health and Demographic Surveillance Systems have the potential to conduct such studies and to evaluate health and well-being over time.

Inequalities in under-5 mortality in Nigeria: do ethnicity and socioeconomic position matter?

BACKGROUND

Each ethnic group has its own cultural values and practices that widen inequalities in child health and survival among ethnic groups. This study seeks to examine the mediatory effects of ethnicity and socioeconomic position on under-5 mortality in Nigeria.

METHODS

Using multilevel logistic regression analysis of a nationally representative sample drawn from 7620 females age 15 to 49 years in the 2003 Nigeria Demographic and Health Survey, the risk of death in children younger than 5 years (under-5 deaths) was estimated using odds ratios with 95% confidence intervals for 6029 children nested within 2735 mothers who were in turn nested within 365 communities.

RESULTS

The prevalence of under-5 death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The risk of under-5 death was significantly lower among children of mothers from the Igbo and other ethnic groups, as compared with children of Hausa/Fulani/Kanuri mothers, after adjustment for individual- and community-level factors. Much of the disparity in under-5 mortality with respect to maternal ethnicity was explained by differences in physician-provided community prenatal care.

CONCLUSIONS

Ethnic differences in the risk of under-5 death were attributed to differences among ethnic groups in socioeconomic characteristics (maternal education and to differences in the maternal childbearing age and short birth-spacing practices. These findings emphasize the need for community-based initiatives aimed at increasing maternal education and maternal health care services within communities.

Examining the "urban advantage" in maternal health care in developing countries

Andrew Channon and colleagues outline the complexities of urban advantage in maternal health where the urban poor often have worse access to health care than women in rural areas.

Is mortality among under-five children in Nairobi slums seasonal?

OBJECTIVE

To investigate the seasonal pattern of overall mortality among children aged below 5 years living in two informal settlements in Nairobi City.

METHODS

We used data collected from January 2003 to December 2005 in the Nairobi Urban Health and Demographic Surveillance System on demographic events (birth, death, and migration). Analyses of seasonal effects on under-five mortality are based on Poisson regression controlling for sex, age, study site and calendar year.

RESULTS

During the study period, there were 17 878 children below 5 years in the study sites. Overall 436 under-five deaths were recorded. The overall death rate for the under-five children was 19.95 per 1,000 person years. There is a significant seasonal variation of under-five mortality. The mortality risk was significantly higher in the second and third quarters of year than in the fourth quarter (RR = 1.6, CI: 1.3-2.2 and RR = 1.5, CI: 1.1-2.0).

CONCLUSION

This paper demonstrates that overall mortality among under-five children in the urban poor is seasonal. Overall during the second quarter of the year, the death rate increases by nearly twofold. This evidence generated here may help to support well targeted interventions in reducing under-five mortality in the slums.

Marriage, not religion, is associated with HIV infection among women in rural Malawi

Despite the fact that religious affiliation is almost universal in Malawi, and religious denomination could potentially influence HIV-risk behaviors, limited data exist on its role of in HIV infection in this setting. This study was conducted to assess whether religious denominational affiliation, religiosity or place of residence were associated with sexual behaviors and HIV infection among Christian women. A total of 63 of 939 women with HIV test results (6.7%) were HIV infected. There was no association between religion or frequency of church attendance and HIV infection or condom use within the current or most recent marriage. Compared to women who lived in a village which was neither the husband's village nor her own village, women living with spouse in her own village or living in a husband's village were less likely to be HIV infected.

Inequities in under-five mortality in Nigeria: differentials by religious affiliation of the mother

Observations in Nigeria have indicated polio vaccination refusal related to religion that ultimately affected child morbidity and mortality. This study assessed the role of religion in under-five (0-59 months) mortality using a cross-sectional, nationally representative sample of 7,620 women aged 15-49 years from the 2003 Nigeria Demographic and Health Survey and included 6,029 children. Results show that mother's affiliation to Traditional indigenous religion is significantly associated with increased under-five mortality. Multivariable modelling demonstrated that this association is explained by differential use of maternal and child health services, specifically attendance to prenatal care. To reduce child health inequity, these results need to be incorporated in the formulation of child health policies geared towards achieving a high degree of attendance to prenatal care, irrespective of religious affiliation.

The burden of disease profile of residents of Nairobi's slums: results from a demographic surveillance system

BACKGROUND

With increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System.

METHODS

Data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) collected between January 2003 and December 2005 were analysed. Core demographic events in the NUHDSS including deaths are updated three times a year; cause of death is ascertained by verbal autopsy and cause of death is assigned according to the ICD 10 classification. Years of Life Lost due to premature mortality (YLL) were calculated by multiplying deaths in each subcategory of sex, age group and cause of death, by the Global Burden of Disease standard life expectancy at that age.

RESULTS

The overall mortality burden per capita was 205 YLL/1,000 person years. Children under the age of five years had more than four times the mortality burden of the rest of the population, mostly due to pneumonia and diarrhoeal diseases. Among the population aged five years and above, HIV/AIDS and tuberculosis accounted for about 50% of the mortality burden.

CONCLUSION

Slum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.

An investigation of district spatial variations of childhood diarrhoea and fever morbidity in Malawi

Although diarrhoea and malaria are among the leading causes of child mortality and morbidity in Sub-Saharan Africa, few detailed studies have examined the patterns and determinants of these ailments in the most affected communities. In this paper, we investigate the spatial distribution of observed diarrhoea and fever prevalence in Malawi using individual data for 10,185 children from the 2000 Malawi Demographic and Health survey. We highlight inequalities in child health by mapping the residual district spatial effects using a geo-additive probit model that simultaneously controls for spatial dependence in the data and potential nonlinear effects of covariates. The residual spatial effects were modelled via a Bayesian approach. For both ailments, we were able to identify a distinct district pattern of childhood morbidity. In particular, the results suggest that children living in the capital city are less affected by fever, although this is not true for diarrhoea, where some urban agglomerations are associated with a higher childhood morbidity risk. The spatial patterns emphasize the role of remoteness as well as climatic, environmental, and geographic factors on morbidity. The fixed effects show that for diarrhoea, the risk of child morbidity appears to be lower among infants who are exclusively breastfed than among those who are mixed-fed. However, exclusive breastfeeding was not found to have a protective effect on fever. An important socio-economic factor for both diarrhoea and fever morbidity was parental education, especially maternal educational attainment. Diarrhoea and fever were both observed to show an interesting association with child's age. We were able to discern the continuous worsening of the child morbidity up to 8-12 months of age. This deterioration set in right after birth and continues, more or less linearly until 8-12 months, before beginning to decline thereafter. Independent of other factors, a separate spatial process produces district inequalities in child's health.

Contextual influences on the use of health facilities for childbirth in Africa

OBJECTIVES

Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries.

METHODS

Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries.

RESULTS

We found strong community-level influences on a woman's decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified.

CONCLUSIONS

Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a woman's decision to seek care during labor, but significant community variation remains unexplained.

Infant mortality in Zambia: socioeconomic and demographic correlates

Trends in infant mortality in Zambia suggest a reversal of the decline experienced between the 1960s and the late 1970s. From a high of about 140, infant mortality rate declined to about 90 in the late 1970s only to rise again to 100 by 1996. Data on 5,600 births born between 1987 and 1992, and 6,630 births between 1991 and 1996 from the Zambian DHS are analyzed to identify socioeconomic and demographic correlates of infant mortality. Demographic factors such as small size at birth and short birth intervals are associated with higher neonatal mortality. In the post-neonatal period, urban children from poorer households had the highest mortality between 1991-1996. Also, differences in infant mortality rates between provinces narrowed. Children born in the most developed province of Lusaka had as high of risk of dying as those from Luapula, a province with a history of extremely high mortality rates in Zambia.

A tale of two continents: a multilevel comparison of the determinants of child nutritional status from selected African and Indian regions

This paper compares individual and household predictors of underweight among young children in sub-Saharan Africa and India, while also assessing the impact of clustering of weight for age z-scores at the household, community and regional levels. Multilevel statistical models are employed to compare the strength of the correlates of underweight (using weight-for-age z-scores) in six sub-Saharan African countries and four Indian states. The multilevel approach controls for correlation among children resulting from clustering within families, communities, or regions and in addition enables tests for differences in the regional, community and household effects for children from families of different socio-economic characteristics. Findings demonstrate the importance of individual and household level predictors such as age, the size of child at birth, prolonged breast-feeding, recent diarrhoea episodes, and maternal education as predictors of low weight-for-age z-scores across regions. Strong family effects are observed as well as significant community and regional random effects on variation in weight for age z-scores. In some regions, socio-economic characteristics of the household result in significant differences in the household or community level variance in weight for age z-scores, suggesting that the impact of the geographical context varies by socio-economic status of the household.

Gender, family, and the nutritional status of children in three culturally contrasting states of India

This paper has three main aims: to measure the clustering of children with low weight for age z-scores within families, to establish whether significant differences exist by gender in weight for age z-scores, and to demonstrate whether the presence of a mother-in-law in the household has any significant impact on the nutritional status of young children. Regression modelling is used to examine the weight for age z-scores of children under the age of four years in Maharashtra, Tamil Nadu and Uttar Pradesh using the 1992-93 Indian National Family Health Survey data. Random effects models measure the clustering of children with low weight for age z-scores in families, controlling for a number of other family factors. Our findings do not reveal significant gender differences in weight for age z-scores. Although little variation was found between family structures in the nutritional status of children, there were significant differences between families after controlling for family type. This suggests that there are differences between families that cannot be explained by a cross-sectional demographic survey. The evidence from this work suggests that nutrition programs need to adopt community nutrition interventions that aim resources at young children from families where children with low weight for age z-scores are found to cluster. However, there is a need for further inter-disciplinary research to collect data from families on behavioural factors and resource allocation in order that we might better understand why some families are more prone to having children with low weight for age z-scores. The diversity in the significant covariates between the three states in the models has shown the need for Indian nutrition programs to adopt state-specific approaches to tackling malnutrition.

Geography of child mortality clustering within African families

After decades of sustained child mortality reductions, infant and early childhood mortality levels in Africa remain high. This can partly be ascribed to the concentration of child mortality within particular families, communities or geographic localities. Strong mortality clustering is indicative of marked social inequality and of an unequal distribution of health and health-related resources and infrastructures. It also signifies a concentration of nutritional and sanitary behaviors harmful to the good health and longevity of children. Finally, it likely points to the existence of particular genetic problems in certain families, or environmental problems within specific communities. Using nationally representative family level data from all sub-regions of Africa, two important findings emerge from this study. First, levels of mortality have generally declined in all countries over time, and as mortality decreases, mortality clustering tends to follow the same trend. Second, bio-demographic covariates have a more important effect on familial mortality clustering risks than socio-economic ones.

Birth intervals, breastfeeding and determinants of childhood mortality in Malawi

Childhood mortality in Malawi is analyzed by employing proportional hazards models. The analysis uses highly reliable data collected from the 1992 Demographic and Health Survey (DHS) of Malawi. The results show that the substantial birth interval and maternal age effects are largely limited to the infant period. The influence of social and economic variables on the mortality risk and on the relationship between biodemographic variables and mortality risk is much enhanced with increasing age of the child. It has also been found that consideration of breastfeeding status of the child does not significantly alter interpretation of effects of preceding birth interval length on mortality risk, but does partially diminish the succeeding birth interval effect. The results are discussed and then summarized in the context of policy implications for Malawi. The paper addresses a very important issue in Malawi and it adds valuable insights to the base of knowledge in childhood mortality in sub-Sahara Africa.

Rapid risk household screening by neonatal arm circumference: results from a cohort study in rural Burkina Faso

Neonatal arm circumference (NAC) and other attributes of the newborn and its household were analysed as potential predictors of child death in a cohort of 1367 newborn children representing the majority of births in a rural area of Burkina Faso from 1992 to 1994. During 3872 person years observed 264 children died, resulting in an average mortality rate of 6.8% per year. 90 mm was chosen as the best cut-off to differentiate low NAC associated with high mortality from normal NAC. The hazard ratio of children with low NAC (15.7%) compared to others was 1.7 (P < 0.001) in Cox regression. Kaplan-Meier curves of cumulative survival showed that this higher risk lasted throughout the first two years of life. Multivariate Cox regression comparing NAC with other variables known or suspected to influence child survival yielded a model including mother's death, twin birth, affiliation to a particular health centre, home delivery and birth during the rainy or harvest season as other significant risk factors beside NAC. Protective factors were mother's participation in antenatal care despite considerable distance to the health centre, medium household size (5-7 members) and household cash crop production. We propose a simple risk score for rapid household screening in rural Burkina Faso and comparable settings elsewhere for identifying households at risk of experiencing child death. As much of the other variables' contribution to the explanation of survival pattern is absorbed by NAC in more parsimonious models, even simpler screening strategies based on NAC make sense. In the study area risk households will be offered periodical home visits by the local nurse promoting immunization, treatment of illness and strengthening the mothers' competence to recognize and manage frequent health problems of their children as part of a 'Shared Care' concept.

The coevolution of human fertility and wealth inheritance strategies

Life history theory concerns the scheduling of births and the level of parental investment in each offspring. In most human societies the inheritance of wealth is an important part of parental investment. Patterns of wealth inheritance and other reproductive decisions, such as family size, would be expected to influence each other. Here I present an adaptive model of human reproductive decision-making, using a state-dependent dynamic model. Two decisions made by parents are considered: when to have another baby, and thus the pattern of reproduction through life; and how to allocate resources between children at the end of the parents' life. Optimal decision rules are those that maximize the number of grandchildren. Decisions are assumed to depend on the state of the parent, which is described at any time by two variables: number of living sons, and wealth. The dynamics of the model are based on a traditional African pastoralist system, but it is general enough to approximate to any means of subsistence where an increase in the amount of wealth owned increases the capacity for future production of resources. The model is used to show that, in the unpredictable environment of a traditional pastoralist society, high fertility and a biasing of wealth inheritance to a small number of children are frequently optimal. Most such societies are now undergoing a transition to lower fertility, known as the demographic transition. The effects on fertility and wealth inheritance strategies of reducing mortality risks, reducing the unpredictability of the environment and increasing the costs of raising children are explored. Reducing mortality has little effect on completed family sizes of living children or on the wealth they inherit. Increasing the costs of raising children decreases optimal fertility and increases the inheritance left to each child at each level of wealth, and has the potential to reduce fertility to very low levels. The results offer an explanation for why wealthy families are frequently also those with the smallest number of children in heterogeneous, post-transition societies.

Factors affecting the most recent fertility rates in urban-rural Bangladesh

This paper reports on a study which has been undertaken using data from the 1989 Bangladesh Fertility Survey (BFS) to determine the significance of influences on the probability of birth in the year preceding the survey. In the survey a total of 11905 ever-married women of reproductive age were asked a battery of questions relating to fertility aspects of women. Variables selected in this study were grouped into demographic, socio-economic, cultural and decision-making variables. Findings from the study indicate that the mother's age, whether contraception has ever been used, the death of a child at any time, whether the woman has ever worked, religion, region of residence, and female independence are the important covariates for explaining recent fertility in Bangladesh. Models are developed for the probabilities of a woman giving birth in urban and rural areas, dependent on her demographic and socio-economic conditions. Also developed are models for contraceptive use in urban-rural Bangladesh. This modelling contributes to a better understanding of fertility changes in Bangladesh and the differentials between urban and rural fertility. It is indicated that a continued fertility decline is likely.