Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MORTALITY IN THE REPUBLIC OF THE CONGO Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In the Republic of the Congo, about seven percent of children die before the age of five; for children born of mothers younger than 18, the risk is higher.  Controlling for socio-economic and other characteristics, being born of a mother younger than 18 does not lead to a statistically significant increase in the risk of under-five mortality as compared to otherwise similar children born of older mothers.  Early childbirth is associated with health risks for children, Box 1: Brief and Series Primer including under-five mortality. This could be in part How is early childbirth defined? Early childbirth is defined in because young mothers often come from disadvantaged this brief as a child being born of a mother younger than 18. Early groups. But the age of the mothers may also play a role. childbearing is often related to the practice of child marriage. Children of young mothers are at higher risk of Why a series on child marriage? Child marriage has significant negative impacts – not only for girls, but also for a range of morbidity and under-five mortality. development outcomes. Demonstrating these impacts will assist governments and others to make the case for intervening to Young mothers often come from disadvantaged socio- reduce the practice. economic backgrounds and early childbirths are more common in poor areas where prenatal care is limited and What are the topics discussed in the series? The series looks access to health facilities may be an issue. Girls who have at the impacts of child marriage on health, population, education, children early also tend to be less educated and may suffer employment, agency, and violence, among other outcomes. The from lack of agency within the household, further reducing welfare, budget, and non-monetary costs of child marriage are estimated. Legal/institutional aspects and options to reduce the access to care. In addition, some girls who give birth early practice are also discussed. may not yet be ready physiologically to give birth. The risk of obstetric fistula, for example, is higher for young What is the question asked in this brief? The question is: How mothers. These various factors lead to higher risks of large is the impact of early childbirth on under-five mortality and under-five mortality for children born of young mothers. does it account for a large share of under-five deaths? How large is the impact of early childbirth on under-five mortality? Does early childbirth accounts for a large share How is the question answered? Econometric analysis of of under-five deaths? These are the questions asked in this Demographic and Health Survey data is used to estimate the brief for the Republic of the Congo. impact of early childbirth on under-five mortality. Page 1 HNPGP Knowledge Brief  Statistically, children from young mothers are one controlling for other characteristics. With the baseline percentage point more likely to die before five. specification, tables 2 indicates that deliveries at a young age do not significantly increase the likelihood of under-five The analysis is based on data from the 2011-2012 mortality for the children in comparison to a delivery at 18 Demographic and Health Survey for the Republic of the to 34 years of age (in the Republic of the Congo). The Congo (EDSC-II). According to the survey, the under-five difference in risk of under-five mortality between mothers mortality rate was 68 ‰ with three in forty children dying ages 18-34 and mothers above 35 is also not statistically before the age of five. This indicates a steady and significant. significant progress over time as the under-five mortality rate decreased from 118 ‰ in the 1997-2001 period to 99 In the Republic of the Congo, delivery at a young age does ‰ in the 2002-2006 period. (Centre Nationale de la not increase the likelihood of under-five mortality for the Statistique et des Études Économiques (CNSEE) [Congo] child in comparison to a delivery at 18 to 34 years of age. et ICF International, 2013). Marginal effects do not change much when additional In this brief we focus on whether all children identified in the survey have died or not before reaching five years of controls are used (extended model). There is thus some age, and the factors that affect that outcome. This implies evidence that in the case of the Republic of the Congo, after controlling for a wide range of other variables, early relying on statistics computed in a different way from the childbirth may not contribute to under-five mortality, but official under-five mortality rate, but the idea and orders of prudence remains needed when interpreting the results magnitude are similar (to avoid a risk of confusion, we will given the risk of omitted variable bias (box 2). use below the term “under-five mortality” but not the term “under-five mortality rate”). As shown in table 1, 5.52 Table 2: Impact of Early Childbirth on Under-five percent of children born of mothers younger than 18 die Mortality before reaching five years of age. The proportion, which we Age at first marriage Baseline Extended refer to as under-five mortality, is 4.81 percent for children model model born of mothers 18 to 34 years of age. The difference in Mother younger than 18 0.0164 0.00486 under-five mortality between the two age groups is not Mother in 18-34 age bracket Reference Reference statistically significant. For children of older mothers (35 Mother older than 35 0.0102 -0.00293 and older), the under-five mortality is higher at 6.73 Source: Authors. percent. Levels of statistical significance: *** 1%, ** 5%, * 10%. Table 1: Under-five Mortality by Age of the Mother Box 2: Risk of Omitted Variable Bias Age of the mother Under-five Mortality (‰) In many countries, although not in the Republic of the Congo, Mother younger than 18 5.52 early childbirth appears to be positively correlated with the risk of Mother in 18-34 age bracket 4.81 under-five mortality after controlling for other factors that may also Mother older than 35 6.73 contribute to mortality. This could indicate a causal effect. Source: Authors. However, other variables correlated with both early childbirth and under-five mortality not included in the analysis could be at the Controlling for other factors, early childbirth does not source of the correlation between early childbirth and under-five increase the likelihood of under-five mortality mortality. Because of the risk of omitted variable bias, the results substantially. cannot be considered as fully conclusive regarding a causal effect of early childbirth on under-five mortality. The difference in under-five mortality between children of young and older mothers does not necessarily imply a A number of results from the regression analysis not shown causal effect of the age at delivery, but it does suggest that in table 2 are worth mentioning. The impact of the early childbirth may contribute to under-five mortality. To education of the mother on the likelihood of under-five check whether controlling for other factors early childbirth mortality is not statistically significant. Similarly, the impact is associated at the margin with higher under-five mortality, of wealth on the likelihood of stunting is not statistically regression analysis is used (see the annex for details on significant, at least when measured through wealth the methodology). quintiles. This is a bit surprising, but it could be due to the fact that households in all four bottom quintiles are poor or Table 2 provides key results with baseline and extended near poor in a country like the Republic of the Congo, and models. The interpretation of the coefficients is in terms of whether a household is extremely poor or simply poor may marginal impacts in percentage terms. For example, a not make much of a difference on the likelihood that the statistically significant coefficient of 0.05 for a mother child may die. A few other effects are also statistically younger than 18 would indicate that children of very young significant, as discussed in the more detailed study on mothers have a likelihood of under-five mortality five which the brief is based. percentage points higher than children of older mothers, Page 2 HNPGP Knowledge Brief  While the direct impact of early childbirth on under-five is higher by 0.71 percentage points than the risk for mortality is not statistically significant in the Republic of the children of older mothers. Congo, the inclusion of other independent variables as controls points to the possibility of indirect effects of early Because only a small share of deliveries are by mothers childbirth on under-five mortality. Because early childbirth younger than 18, very few children deaths before five can may have an impact on other variables used as controls in be said to be directly due to early childbirth. the regression, its overall effect on under-five mortality, including indirect effects through these other variables, Controlling for socio-economic and other characteristics, may be larger than the (non-significant) direct effect documented in table 2. For example, for some of the girls being born of a mother younger than 18 does not have a delivering a baby at a young age, early pregnancy may statistically significant effect on under-five mortality as compared to otherwise similar children born of older have a negative effect on education enrollment and mothers. This, together with non-significant indirect effects attainment, which through the impact of education of early childbirth through education and wealth in the attainment on under-five mortality would lead to an indirect Republic of the Congo, suggests that few children die effect of early childbirth on under-five mortality. In addition, early deliveries, by increasing the number of children that directly or indirectly because of an early childbirth, even women have, may also contribute to lower labor force though some may. participation for women and thereby lower household References wealth, and in some countries higher under-five mortality (although for the Republic of the Congo wealth effects are Bicego, G., & Ahmad, O. (1996). Infant and child mortality, again not statistically significant). Demographic and health surveys comparative studies No. 20. Calverton (Maryland): Macro International Inc . Early childbirth may also affect under-five mortality indirectly, for example through lower education attainment Centre Nationale de la Statistique et des Études Économiques for mothers. (CNSEE) [Congo] et ICF International (2013). Enquête Démographique et de Santé du Congo (EDSC-II) 2011-2012. Calverton, Maryland, USA : CNSEE et ICF International. Simulations suggest that few deaths among children under five are directly or indirectly due to early Nasrullah, M., Zakar, R., Zakar, M. Z., & Krämer, A. (2014). Girl- childbirth. child marriage and its association with morbidity and mortality of children under 5 years of age in a nationally-representative The last step in the analysis of the impact of early sample of Pakistan. The Journal of pediatrics,164(3), 639-646. pregnancy and delivery on under-five mortality consists in Prakash, R., Singh, A., Pathak, P. K., & Parasuraman, S. (2011). assessing the potential reduction in under-five mortality Early marriage, poor reproductive health status of mother and that could arise from eliminating early pregnancies and child well-being in India.Journal of family planning and deliveries. This can be done by predicting (i.e. simulating) reproductive health care, jfprhc80. the likelihood that children who were born of mothers younger than 18 would have remained alive if they had Raj, A., Saggurti, N., Winter, M., Labonte, A., Decker, M. R., been born of older mothers. In other words, we are Balaiah, D., & Silverman, J. G. (2010). The effect of maternal child considering the direct effects of the age of the mother on marriage on morbidity and mortality of children under 5 in India: under-five mortality, shifting in the data deliveries by young cross sectional study of a nationally representative mothers to deliveries at a later age, and observing the sample. BMJ, 340. difference that this makes for under-five mortality Raj, A., & Boehmer, U. (2013). Girl child marriage and its nationally. In the case of the Republic of the Congo, association with national rates of HIV, maternal health, and infant because the effect of early childbirth on under-five mortality mortality across 97 countries.Violence against women, 19(4), is not statistically significant, direct effects are not 536-551. (statistically speaking) present. Raj, A., McDougal, L., & Rusch, M. L. (2014). Effects of young Conclusion maternal age and short interpregnancy interval on infant mortality in South Asia. International journal of gynaecology and obstetrics: Early pregnancy and delivery may contribute to the risk of the official organ of the International Federation of Gynaecology and Obstetrics, 124(1), 86. under-five mortality for children, directly, or indirectly. This brief has provided estimates of the direct impact of early childbirth on under-five mortality in the Republic of the Congo using the latest DHS survey. About seven percent of children under the age of five die; but for children born of mothers younger than 18, the risk of under-five mortality Page 3 HNPGP Knowledge Brief  Annex: Methodological Note It is worth noting that the specifications used for modeling the There is an existing literature on the relationship between early correlates of under-five mortality are more parsimonious in terms pregnancy (as well as child marriage) and the risks of infant, child, of the independent variables included than the specifications used and under-five mortality. Much of the literature focuses on South in a separate analysis by the authors for malnutrition using Asia (e.g., Bicego, 1996; Adhikari, 2003; Raj, 2010; Raj et al., stunting as the main measure of interest. In principle, given that 2013; Raj and Boehmer, 2013; Prakash et al., 2011; Nasrullah et malnutrition is a key factor leading to premature death for al., 2014). The results suggest that children born of young children, one could argue that all correlates of under-five mothers are indeed at higher risk of under-five mortality. malnutrition should also be used as correlates of under-five mortality. The issue however is that the rate of under-five mortality Statistics comparing under-five mortality according to the age of in countries is much smaller than the rate of stunting. The models the mother may hint at the relationship between the two. But for used tend to perform less well when very few of the observations assessing marginal impacts, regression analysis is needed. Part take on a positive value for the dependent variable (i.e., dying of the literature relies on survival models, which provide before the age of five). In addition, when many more variables are information on how long children survive given their used, there is also a much higher risk of perfect correlation characteristics. The models are censored, in that if a child has (prediction) between some of the variables and the dependent survived beyond five years of age, s/he is considered as having variable, in which case the independent variable will be dropped avoided under-five mortality. One may also rely on simpler logit from the model as well as the observations for which the outcome or probit models to analyze under-five mortality. In this case, the was perfectly predicted. This calls for being somewhat focus is on whether the child has survived, or not, as opposed to parsimonious in the specifications. how long the child has survived. Given the focus in this brief on the contribution of early pregnancies and deliveries to under-five In addition to what is often done in the literature, this brief also mortality, results from the probit regressions will be presented, as assesses the potential reduction in under-five mortality that could they provide a simple way to provide those estimates. arise from eliminating early pregnancies and deliveries, or, said differently, the share of deaths for children under five that can be Different specifications are estimated to assess the robustness of attributed to early childbirth according to the results. Finally, in the results to changes in the econometric models. Overall, the term of interpretation, it is important to mention the risk of omitted main results are robust to different specifications. For the baseline variables bias, as noted in Box 3 of the brief. model, the independent variables are: (1) the age of the mother at the time of delivery by categories; (2) the child’s gender; (3) whether the child had siblings born at the same time (multiple This brief was produced by a World Bank team as part of the Economic birth); (4) the birth order of the child and the child’s birth weight by Impacts of Child Marriage study. The synthesis report under the study was categories; (5) the length of time between the child’s birth and a produced jointly with the International Center for Research on Women. previous birth for the mother; (6) whether the delivery took place The study benefitted from support from the Bill & Melinda Gates in a health facility; (7) the location of the child by region and by Foundation, the Children’s Investment Fund Foundation, and the Global urban-rural category; (8) the education of the mother; (9) whether Partnership for Education. Comments from colleagues and peer reviewers are gratefully acknowledged. The opinions expressed in this the household has access to an improved water source and brief are those of the authors only and need not reflect the views of the improved sanitation; (10) the wealth quintile of the household; World Bank, its Executive Directors, of the countries they represent. (11) whether the household practices polygyny; and finally (12) indicators of decision-making power for the mother in the household. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4