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The Effects of Birth Spacing on Infant and Child Mortality, Pregnancy Outcomes, and Maternal Morbidity and Mortality in Matlab, Bangladesh
Abstract and Figures
Using a large, high-quality longitudinal dataset on around 145,000 pregnancy outcomes gathered over a period of more than twenty years from an experimental setting in Matlab, Bangladesh, this paper seeks a better understanding of the effects of the lengths of interbirth intervals on infant and child mortality and on maternal mortality and morbidity.
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... The strenuous processes associated with the physiology of pregnancy, delivery and lactation is nutritionally and mentally demanding on the women [1]. To obtain the needed reserves for quality pregnancy outcome proper spacing of pregnancy is essential. ...
... To obtain the needed reserves for quality pregnancy outcome proper spacing of pregnancy is essential. Adverse obstetric outcomes such as ante-partum anaemia, perinatal and maternal morbidity and mortality have been linked with sub-optimally spaced pregnancies [1,2]. Inter-pregnancy interval is defined as the period between delivery of the previous infant and conception of the current pregnancy [3,4]. ...
... Long interpregnancy interval (LIPI) is IPI of 72 months and above while Short inter-pregnancy interval (SIPI) is IPI of less than 24 months. LIPI has been associated with increased risk of gestational hypertension, premature rupture of membranes (PROM) and difficult labour [1]. Studies have shown that intervals of three to five years are safer for both mother and infant as opposed to two years or less [4,9]. ...
Background: Short inter-pregnancy interval (SIPI) has been linked with low maternal haematological indices and adverse fetal outcome. The World Health Organization (WHO) recommended a minimum of 24 months inter-pregnancy interval to reduce the risk of adverse maternal and fetal outcomes. However, sub-optimal pregnancy spacing is common in many developing countries including Nigeria. Objectives: To determine the impact of inter-pregnancy interval on maternal serum ferritin, haematocrit level and fetal outcome among parturient in University of Ilorin Teaching Hospital, Ilorin, Nigeria. Study Design: A prospective cohort study of parturient less than 20weeks gestation. Those who did not satisfy the WHO recommended inter-pregnancy interval of at least 24months were categorized as group II while gestational age and social status matched parturient who satisfied the WHO recommendation were in group I. Methodology: A total of 316 parturient who satisfied the inclusion criteria were recruited for the study by systematic sampling. These were equal number of 158 participants each as subject and control. Subject and control were matched for gestational age and social status. The serum ferritin and haematocrit levels as well as fetal outcome were evaluated for each participant. The results were analysed using SPSS version 20.0 with appropriate tables and figures generated. Results: There was statistically significance difference in the mean levels of serum ferritin (P<0.001) and haematocrit (P<0.001) at booking for the two groups of participants. There was statistically significant difference in the gestational age at delivery (P<0.001) with higher rate of preterm delivery (22.1% vs. 1.9%; P<0.001) in group II compared to group I. In addition, there were higher percentages of group II babies with 1st (32.5% vs. 9.6%; P<0.001) and 5th minute (18.2% vs. 1.9%; P<0.001) APGAR scores < 7 compared to group I babies (P<0.001). The mean birth weight was lower in group II (2.70±0.35 vs. 3.10±0.31; P<0.001) with higher need for neonatal resuscitation (16.9% vs. 2.6%; P<0.001) and intensive care admission (18.2% vs. 1.3%; P<0.001) among neonates of women in group II. Neonatal anaemia (15.4% vs. 0.0%; P<0.001) occurred only in group II participants’ babies. Neonatal mortality was zero for group I and 18(11.7%) for group II babies. Conclusion: Inter-pregnancy interval below the WHO recommendation is associated with low maternal serum ferritin and haematocrit levels as well as adverse fetal outcome. Recommendations: Adequate child spacing should be emphasized during antenatal visits, postpartum counselling, postnatal clinic visits as well as other contacts with non-pregnant women of reproductive age.
... All these may ultimately contribute to the adverse outcomes in the subsequent pregnancy. Other issues such as competition between short-spaced siblings for parental time, material resources and inadequate parental attention have also been identified as possible causes of child mortality among babies born in SBIs [6,82]. These socio-behavioral issues make infants susceptible to infectious diseases (eg, diarrhea, acute respiratory infection) and child nutritional disorders (stunting, wasting, and underweight) [83][84][85], which, in LMICs, are major causes of child mortality [86]. ...
Methods:
Eight databases, PubMed, CINAHL, Web of Science, Embase, PsycINFO, Cochrane Library, Popline, and Maternity and Infant Care, were searched, covering the period of January 2000 to January 2022. Studies that had examined the association between SBI and any form of child mortality were included. The findings of the included studies were summarized through fixed-effects or random-effects meta-analysis and the model was selected based on the heterogeneity index.
Results:
A total of 51 studies were included. Of them, 19 were conducted in Ethiopia, 10 in Nigeria and 7 in Bangladesh. Significant higher likelihoods of stillbirth (odds ratio (OR) = 2.11; 95% confidence interval (CI) = 1.32-3.38), early neonatal mortality (OR = 1.58; 95% CI = 1.04-2.41), perinatal mortality (OR = 1.71; 95% CI = 1.32-2.21), neonatal mortality (OR = 1.85; 95% CI = 1.68-2.04), post-neonatal mortality (OR = 3.01; 95% CI = 1.43-6.33), infant mortality (OR = 1.92; 95% CI = 1.77-2.07), child mortality (OR = 1.67; 95% CI = 1.27-2.19) and under-five mortality (OR = 1.95; 95% CI = 1.56-2.44) were found among babies born in short birth intervals than those who born in normal intervals.
Conclusions:
SBI significantly increases the risk of child mortality in LMICs. Programmes to reduce pregnancies in short intervals need to be expanded and strengthened. Reproductive health interventions aimed at reducing child mortality should include proper counselling on family planning, distribution of appropriate contraceptives and increased awareness of the adverse effects of SBI on maternal and child health.
... In contrast, behavioural mechanisms between short birth intervals and child outcomes are hypothesised to operate through parental investment and sibling competition for parental resources, care, and attention Miller & Karra, 2020). Prior studies have examined the sibling competition hypothesis through the survival status of the previous sibling DaVanzo et al., 2004). However, to our knowledge, no studies have tested parental investment and sibling competition with regards to other resources, such as food and parental stimulation, as possible mechanisms. ...
There is considerable literature on the associations of short birth intervals with adverse perinatal outcomes. However, less is known about the associations with child growth and development. In this study, we investigated the associations between birth intervals and child growth and development and examined child illness, child diet, and maternal stimulation as potential mechanisms. We pooled Demographic and Health Survey data on 8300 children aged 36–59 months from 13 countries (Benin, Burundi, Cambodia, Cameroon, Chad, Congo, Haiti, Honduras, Rwanda, Senegal, Timor-Leste, Togo, and Uganda). Longer birth interval was defined as a preceding birth interval ≥33 months. Child growth was assessed using height-for-age Z-score (HAZ). Child cognitive and socio-emotional development were measured using the Early Childhood Development Index. Child morbidity was defined as any illness in the past two weeks. Child diet was assessed using dietary diversity score and maternal stimulation by the number of stimulation activities. We used generalised linear models to estimate associations between longer birth intervals and child growth and development. Structural equation modelling was used to assess direct and indirect effects. In our sample, 44% of children had a preceding birth interval ≥33 months, 42% were stunted, 25% were cognitively off-track, and 33% socio-emotionally off-track. Longer birth intervals were associated with higher HAZ (mean difference 0.23 (95% CI 0.14, 0.32)) and socio-emotional development (relative risk (RR) 1.04 (95% CI 1.00, 1.09), but not cognitive development (RR 1.02 (95% CI 0.98, 1.06). We observed no significant indirect effects via child illness, child dietary diversity, or maternal stimulation. Although longer birth intervals were beneficial for child growth and socio-emotional development, we found no empirical support for the biological and behavioural mechanisms we explored. Additional research is needed to investigate alternative mechanisms to elucidate underlying processes and inform future interventions.
... La evaluación de la sintomatología depresiva se realizó con el Inventario de Depresión infantil cdi (Kovacs, 1992). Se aplicó la versión adaptada al español de Davanzo et al. (2004); consta de 27 ítems y tres opciones de respuesta (0, ausencia de síntomas; 1, síntoma moderado, y 2, síntomas severos). Con dos dimensiones: 1) estado de ánimo disfórico, que es una expresión o muestra de tristeza, soledad, desdicha, indefensión o pesimismo, con 17 ítems, y un puntaje máximo de 34. ...
... Indeed, in Karra et al. (2022), we show that pregnant and postpartum women who received our family planning intervention had a significantly lower risk of short pregnancy spacing (having a subsequent pregnancy within 24 months) and giving birth again within three years of their prior birth. Short birth intervals have been associated with an increased risk of neonatal, infant, and child mortality (Rutstein, 2006;Conde-Agudelo et al., 2006, 2012DaVanzo et al., 2004;Molitoris et al., 2019) and have also been linked to higher rates of stunting and wasting in children (Rutstein, 2006;World Health Organization, 2005;Huttly et al., 1992;Miller and Karra, 2020;. In this study, we present results for the pregnancy or birth that determined women's eligibility for recruitment into the study (henceforth referred to as the "index" child). ...
... The sex of a child, birth order, and mother's age at first birth are among the socio-demographic factors that influence child mortality, as pointed out by Mosley and Chen [5]. Other similar studies were carried out by Rutstein [6] and Davanzo et al. [7]. ...
... Child spacing information can significantly reduce maternal morbidity and mortality rate, prevention of high risk and or unwanted pregnancies that can be terminated through risky abortions, increase positive impact on women's overall health, and quality of life (Agudelo, 2004). However, despite all the above mentioned benefits in many developing countries, studies indicated that, low or non-use of child spacing information is the major causes of complication during pregnancy and childbirth (Bawah 2002;Davanzo et, al. 2004;Orji 2006). Complications during pregnancy and childbirth are leading causes of maternal mortality for women in most developing countries including Nigeria (McGinn, 2010). ...
Maternal mortality is a major cause of concern in developing countries. To reduce maternal mortality several public health agencies diffused child spacing information to the public. Howev-er, while most people accept and use child spacing information there remain some individuals that are resistant to it especially in developing countries. Resistance to information about child spacing is a major public health issue in developing countries, particularly in Nigeria. Using Chatman’s (2000) theory of nor-mative behavior as a theoretical framework to guide the investi-gation. This study therefore set out to explore the perception of child-bearing women on child spacing information in polygamous homes in Kusfa Zaria City. A qualitative research methodolo-gy was adopted. Data were collected using in-depth interview with ten child-bearing women. Purposive sampling was used to identify respondents. To be included as respondent the following three criteria must be met: 1) have to be child-bearing women in polygamous homes in Kusfa Area of Zaria city, 2) 20-45 years of age and 3) must have a minimum of four children over the last six years. Data from respondents were analyzed using themat-ic analysis. Findings revealed that, injection, pills, condom, IUD and implant were the type of child spacing information communi-cated to child-bearing women and perceived these type of child spacing information with apprehension and suspicion. This study posit that for a sustained acceptance and use of child spacing information there is the critical need for policy makers and infor-mation professionals to design child spacing information services based on the social and cultural dynamics of the Kusfa commu-nity Zaria city.
The Sustainable Development Goals 3 targets significant reductions in maternal and under-five deaths by 2030. The prevalence of these deaths is significantly associated with short birth intervals (SBI). Identification of factors associated with SBI is pivotal for intervening with appropriate programmes to reduce occurrence of SBI and associated adverse consequences. This study aimed to determine the factors associated with SBI in Bangladesh. A total of 5,941 women included in the 2017/18 Bangladesh Demographic and Health Survey 2017/18 and 1,524 healthcare facilities included in the 2017 Bangladesh Health Facility were linked and analysed. The sample was selected based on the availability of the birth interval data between the two most recent subsequent live birth. SBI was defined as an interval between consecutive births of 33 months or less, as recommended by the World Health Organization and was the outcome variable. Several individual-, households-, and community-level factors were considered as exposure variables. We used descriptive statistics to summarise respondents' characteristics and multilevel Poisson regression to assess the association between the outcome variable with exposure variables. Around 26% of live births occurred in short intervals, with a further higher prevalence among younger, uneducated , or rural women. The likelihoods of SBI were lower among women aged 20-34 years (PR, 0.14; 95% CI, 0.11-0.17) and �35 years (PR, 0.03; 95% CI, 0.02-0.05) as compared to the women aged 19 years or less. Women from households with the richest wealth quin-tile experienced lower odds of SBI (PR, 0.61; 95% CI, 0.45-0.85) compared to those from the poorest wealth quintile. The prevalences of SBI were higher among women whose second most recent child died (PR, 5.23; 95% CI, 4.18-6.55), those who were living in Chatto-gram (PR, 1.52; 95% CI, 1.12-2.07) or Sylhet (PR, 2.83, 95% CI, 2.08-3.86) divisions. Availability of modern contraceptives at the nearest healthcare facilities was 66% protective to the occurrence of SBI (PR, 0.34; 95% CI, 0.22-0.78). Also, the prevalence of SBI increased around 85% (PR, 1.85; 95% CI, 1.33-2.18) for every kilometer increase in the distance of nearby health facilities from women's homes. Targeted and tailored regional PLOS GLOBAL PUBLIC HEALTH PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.
Reproductive Health and family planning policies and programmes recommend a 3-year period for birth spacing between two succeeding births to improve maternal, infant and child health. Inadequate birth spacing between two successive births increases the risk of neonatal death and adverse health outcomes. This paper examines the relationship between length of birth interval from the preceding birth and its association with neonatal death and low birthweight outcomes. This study uses four rounds of NFHS data and applies multivariate econometric methods to comprehend whether inadequate birth spacing (< 24 months) between two succeeding births has significant risk of neonatal deaths and low birthweight. We also find that confounding factors such as maternal education, sex and birth order of the child, and socioeconomic status of the household are associated with neonatal death and low birth weight outcomes. The study concludes that adverse health outcomes among infants can be averted by improving coverage of reproductive health and family planning services in India.
Background
Closely spaced birth increases the risk of adverse maternal and child health outcomes. In Ethiopia, the prevalence of short birth spacing was highly variable across studies. Besides, contraceptive use, educational status, and duration of breastfeeding were frequently mentioned factors affecting short birth spacing. Therefore, this meta-analysis aimed to estimate the pooled prevalence of short birth spacing and its association with contraceptive use, educational status, and duration of breastfeeding among reproductive-age women in Ethiopia.Methods
International databases: Google Scholar, PubMed, CINAHL, Cochrane library, HINARI, and Global Health were searched systematically to identify articles reporting the prevalence of short birth spacing and its association with contraceptive use, educational status, and duration of breastfeeding among reproductive-age women in Ethiopia. The data were analyzed by STATA/SE version-14 statistical software. The random-effect model was used to estimate the pooled prevalence of short birth spacing and the log odds ratio was used to determine the association. Moreover, egger's test and I-squared statistics were used to assess publication bias and heterogeneity respectively.ResultsAfter reviewing 511 research articles, a total of nine articles with 5,682 study participants were included in this meta-analysis. The pooled prevalence of short birth spacing in Ethiopia was 46.9% [95% CI: (34.7, 59.1)]. Significant heterogeneity was observed between studies (I2 = 98.4, p
Data from the World Fertility Survey for selected Latin American countries are used to produce estimates of the simultaneous effects of breastfeeding and pace of childbearing on mortality during infancy and between first and fifth birthday. This is done by postulating models which take into account the reciprocal influences between the dynamics of birth intervals and breastfeeding. We also attempt to show that the effects vary according to several important characteristics of the child, mother, or community of residence. Finally, we investigate possible pitfalls in the inferences drawn by using alternative measurements of the main variables and by applying competing methods for the estimation of their effects. Although the results we obtain are quite robust to the definition of several indices and to the type of estimation method used, they remain partially inconclusive as a result of lack of proper controls for past and current health status of the infant.
In this paper we examine the relative importance of a number of demographic determinants of infant and early child mortality using information from 39 World Fertility Survey countries. We include sex of the child, age of the mother at the time of the birth, birth order, mother's educational level and a number of indicators of spacing of adjacent births among the correlates of chances of survival for children below the age of five years. Mortality of firstborn children and of those born to teenage mothers is shown to be higher than average; that of later children and those of older mothers was not much higher than average, once other factors are controlled. Effects of poor birth-spacing persist even after other factors have been controlled, and are similar where a sib was born during the two years preceding the birth of the child, regardless of the survival status of that sib; however, mortality was higher when that sib had died, due to increased familial risks of mortality. Rapid subsequent births also raise mortality for their earlier sibs. The findings are generally remarkably consistent in a wide range of countries and associated mortality conditions, although attention is drawn to a few interesting geographically clustered exceptions which deserve further investigation. The study leaves little room for doubt that poor child-spacing is clearly linked to decreased survival chances.
Although it is widely accepted that family planning can theoretically reduce infant and child mortality, it is not clear whether the changes in family-formation patterns that typically accompany the adoption of contraception do in fact have a significant favorable effect on infant mortality rates. This note compares the proportions of high-risk pregnancies in groups of developing countries at different stages of the family planning transition. Countries with relatively high levels of contraceptive use have fewer teenage births as well as fewer births of orders over six, when compared with countries in which family planning is minimal. These differentials would by themselves result in lower infant mortality rates in the later phases of the fertility transition. This effect is offset, however, by the fact that countries with higher levels of contraceptive prevalence also tend to have higher proportions of births of order one and higher proportions of births after short birth intervals, both of which are associated with higher than average mortality risks. The net effect of these two compensating sets of factors on infant mortality rates is very small. Thus, changes in the age/order/interval distributions of births do not necessarily improve the chances for survival of infants as a society moves through a fertility transition.
This study uses retrospective data from the 1976–7 Malaysian Family Life Survey to examine the determinants of infant mortality variations in Peninsular Malaysia. It considers proximate biological correlates of mortality as well as family characteristics and behaviour, and inspects the degree to which some of these latter factors exercise their effects indirectly through more proximate factors. It assesses how these influences and interactions change in importance through successive sub-periods of the first year of an infant's life.Biological factors such as low birthweight are more important early in the first year of life, while such behavioural and environmental factors as mother's education, or types of water and sanitation system, are more important later. Breast-feeding significantly reduces mortality, especially during the first half of infancy. Unsupplemented breastfeeding is more beneficial than supplemented breast-feeding.
In this paper results recently published in this journal concerning the influence of birthspacing on child survival are reviewed, and two reasons are suggested why the statistical associations observed in the data collected in the World Fertility Survey may be, at least in part, spurious. Where reporting is poor, it is argued that errors may often be responsible for a substantial portion of the association between interval length and mortality, and also for the apparent influence of the death of one child on the survival prospects of a younger sibling. Where the reported dates of birth and death are reliable but contraceptive prevalence is high, there is the problem that contraceptive practice is apt to be closely associated with other behaviour likely to have a direct effect on mortality.
Background:
Fertility decline is often associated with an increase in contraception and abortion, but the causal relations are difficult to examine with non-experimental data. We aimed to assess the effects of family planning services on abortion rates in two similar areas.
Methods:
We examined trends in overall abortion rates and rates for intended and unintended pregnancies in two similar areas typical of rural Bangladesh. We analysed Matlab Demographic Surveillance System (DSS) data on pregnancy outcomes between 1979 and 1998 in these areas, matching them to survey data on fertility preferences, which enabled us to identify pregnancies as intended or unintended.
Findings:
Abortion rates were significantly lower in the area with better family planning services compared with the comparison area (1984-86, 2.2 vs 5.2; 1996-98, 2.3 vs 6.8). Abortion of unintended pregnancies is similar in both areas, but the higher levels of contraceptive use in the treatment area have led to lower levels of unintended pregnancy and abortion. The likelihood that an unintended pregnancy will be aborted has increased in both areas but the decrease in unintended pregnancies was sufficiently large in the treatment area to offset this increase.
Interpretations:
Abortion may increase during the fertility transition in less-developed countries as the desire to limit family size increases unless there is widespread availability of quality family planning services.
Summary In this study retrospective data from the 1975 Pakistan Fertility Survey are used to examine the effects of birth spacing on infant and child mortality. The length of the preceding interval between live births emerges as a major determinant of mortality. The effect persists for rural and urban families, for children of uneducated and educated mothers, for both boys and girls, and for large and small families. The possibility that this relationship is the spurious consequence of data defects or of a common cause, such as early weaning, is examined but rejected. Once the length of the preceding interval is controlled, the average spacing of earlier births is found to be unrelated to survivorship. However, the length of the succeeding interval is significantly related to survivorship during the second year of life.