Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MALNUTRITION IN NEPAL Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In Nepal, four in ten children under the age of five are stunted; but for children born of mothers younger than 18, the risk of stunting is higher.  Controlling for socio-economic and other characteristics, being born of a mother younger than 18 increases the likelihood of stunting for children under-five by ten percentage points in the baseline model, as compared to otherwise similar children born of older mothers. Box 1: Brief and Series Primer Nearly one-fifth of under-five deaths could be prevented with optimal feeding. Poor nutrition at a young age may How is early childbirth defined? Early childbirth is defined in also have irremediable consequences for brain this brief as a child being born of a mother younger than 18. Early development, cognitive skills, and productivity in adult life. childbearing is often related to the practice of child marriage. Malnutrition has severe consequences for children. Why a series on child marriage? Child marriage has significant negative impacts – not only for girls, but also for a range of development outcomes. Demonstrating these impacts will assist Poor nutrition weakens children’s immune systems, putting governments and others to make the case for intervening to them at a greater risk of falling sick from preventable reduce the practice. illnesses such as pneumonia and diarrhea. According to Horton et al. (2008), nearly one-fifth of under-five deaths in What are the topics discussed in the series? The series looks the world could be prevented with optimal feeding. at the impacts of child marriage on health, population, education, Research also suggests that poor nutrition at a young age employment, agency, and violence, among other outcomes. The may have irremediable consequences for brain welfare, budget, and non-monetary costs of child marriage are development, cognitive skills, and ultimately productivity in estimated. Legal/institutional aspects and options to reduce the practice are also discussed. adult life. Unfortunately, a large share of children in the developing world are malnourished. The question What is the question asked in this brief? The question is: What considered in this brief is whether early childbirth (defined is the impact at the margin of an early childbirth on the probability as a child being born of a mother younger than 18), which of malnutrition (stunting) for children under-five years of age? in many countries is the result of child marriage, contributes to under-five malnutrition in a significant way in Nepal. The How is the question answered? Econometric analysis of brief is part of a series of similar standardized country- Demographic and Health Survey data is used to estimate the specific briefs on the same topic for a number of countries. impact of an early childbirth on under-five malnutrition. Page 1 HNPGP Knowledge Brief  Statistically, children from young mothers are ten Table 2 provides key results with baseline and extended percentage points more likely to be stunted than if the models. The interpretation of the coefficients is in terms of mother is between 18 and 34 years of age. marginal impacts in percentage terms. For example, a statistically significant coefficient of 0.05 for a mother The focus in this brief is on stunting as a measure of younger than 18 would indicate that children of very young persistent exposure to malnutrition with potentially severe mothers have a likelihood of stunting five percentage points long-term consequences throughout a person’s life (see higher than otherwise similar children of older mothers. box 2 on indicators used to measure malnutrition). The analysis is based on data from the 2011 Demographic and With the baseline specification, table 2 suggests that Health Survey for Nepal. Estimates suggest that 48.48 deliveries at a young age increase the likelihood of stunting percent of children born of mothers younger than 18 are for the children by 9.5 percentage points in comparison to stunted. The proportion is still high, but ten points lower at a delivery at 18 to 34 years of age (coefficient statistically 38.61 percent for children born of mothers 18 to 34 years significant at the ten percent level). The difference in risk of of age. The difference in stunting rate between these two stunting between mothers ages 18-34 and mothers above age groups is statistically significant. For children of 35 is not statistically significant. mothers older than 35, the incidence of stunting was higher at 51.04 percent. Deliveries at a young age may increase the likelihood of stunting for the children by 7.8 percentage points in Table 1: Incidence of Stunting by Age of the Mother comparison to a delivery at 18 to 34 years of age. Age of the mother Stunting (%) Mother younger than 18 48.48 Mother in 18-34 age bracket 38.61 Marginal effects do not change much when additional Mother older than 35 51.04 controls are added (extended model). There is thus some Source: Authors. evidence that after controlling for a wide range of other variables, early childbirth may contribute to stunting, but Box 2: Measures of Malnutrition prudence remains needed when interpreting these results given the risk of omitted variable bias (see box 3). Three main measures of malnutrition are used in applied work. A child is considered underweight if s/he has a weight more than Table 2: Impact of Early Childbirth on Stunting two standard deviations below the reference median weight for Age at first marriage Baseline Extended the child’s age. A child is considered wasted if s/he has a weight model model to height ratio more than two standard deviations below the Mother younger than 18 0.0951* 0.101** median weight for height for the reference population. A child is Mother in 18-34 age bracket Reference Reference considered stunted if s/he has a height more than two standard Mother older than 35 -0.0101 -0.0176 deviations below the median reference height for that age. If a Source: Authors. child on any of these measures is below three standard deviations Levels of statistical significance: *** 1%, ** 5%, * 10%. of the norm, s/he is considered as severely underweight, wasted, or stunted. Among the three measures, stunting and wasting tend to be used the most. Stunting often results from persistent Box 3: Risk of Omitted Variable Bias insufficient nutrient intake and infections. It may lead to delayed motor development and poor cognitive skills that can affect school Early childbirth appears to be positively correlated with the risk of performance as well as productivity and earnings later in life. stunting after controlling for other factors that may also contribute Wasting tends to result more from acute food shortage or disease to stunting. This could indicate a causal effect. However, other and may lead to death. For the purpose of this brief, given a variables correlated with both early childbirth and stunting not separate brief of under-five mortality, stunting is the best measure included in the analysis could be at the source of the correlation to focus on. between early childbirth and stunting. Because of the risk of omitted variable bias, the results cannot be considered as fully conclusive regarding a causal impact of early childbirth on the risk Controlling for other factors, early childbirth still of stunting. increases the likelihood of stunting substantially. A number of results from the regression analysis not shown The difference in the likelihood of stunting between children in table 2 are worth mentioning. The impact of wealth on of young and older mothers does not necessarily imply a the likelihood of stunting is statistically significant, with causal effect of the age at delivery, but it does suggest that children from wealthier households tending to be less early childbirth may contribute to stunting. To check stunted. For example, compared to children in the poorest whether controlling for other factors early childbirth is 20% of households, those from the second, third and fourth indeed associated at the margin with higher under-five quintiles have a likelihood of stunting ranging from 11-20 malnutrition, regression analysis is used (see the annex for percentage points lower. Children in the highest quintile details on the methodology). (the richest 20% of households) have a likelihood of stunting 18 percentage points lower. Page 2 As shown in table 3, the marginal impact of a mother having without early deliveries, the share of children stunted could a secondary education or better on the likelihood that her decrease by about 0.7 percentage points. This child will be stunted is not statistically significant, which is corresponds (roughly) to the product of the marginal effect somewhat surprising. of early deliveries on stunting (0.101 in table 2) times the share of children born of mothers younger than 18 (seven Note though more generally that the inclusion of education percent of children). Given the rate of stunting nationally, as a control points to the possibility of indirect effects of two in 100 stunted children could be considered as stunted early childbirth on stunting. Because early childbirth may due to the direct effect of early childbirth on the likelihood have an impact on other variables used as controls in the of stunting. This may appear low in comparison to the total regression, its overall effect on stunting, including indirect number of children who are stunted, but still represents a effects through these other variables, may be larger than large number of children. the direct effect documented in table 2. For example, for some girls having a baby at a young age, early childbirth Because only a small share of deliveries are by mothers could have reduced education attainment, which could lead younger than 18, only two in 100 stunted children can be to a higher risk of stunting (although not in Nepal according said to be stunted directly due to early childbirth. to the regression results). In addition, early deliveries, by increasing the number of household members may also Conclusion contribute to lower standards of living. In Nepal, as mentioned earlier, the regression results suggest that the Early childbirth contributes to the risk of malnutrition for level of welfare as measured through wealth quintiles have children, directly and indirectly. This brief has provided an effect on stunting. Still, in terms of magnitude, those indirect effects are likely to be small in comparison to the estimates of the direct impact of early childbirth on stunting in Nepal using the latest DHS survey. Four in ten children direct effects in table 2. under the age of five are stunted. For children born of mothers younger than 18, the risk of stunting is higher by Early childbirth may affect under-five malnutrition through ten percentage points. Controlling for socio-economic and lower education attainment for mothers or lower socio- other characteristics, being born of a mother younger than economic status, but these effects are likely to be smaller. 18 appears to increase the likelihood of stunting by ten percentage points versus children born of older mothers. Table 3: Impact of the Mother’s Education on Stunting Given the share of children born of mothers younger than Age at first marriage Baseline Extended 18, nationally for every 100 stunted children, at least two model model could be stunted directly because of early childbirth. This No education or below primary Reference Reference may appear low, but still represents a large number of Primary education 0.0250 0.0198 children. Secondary education or higher 0.0246 0.0233 Source: Authors. References Levels of statistical significance: *** 1%, ** 5%, * 10%. Fall, C. H., et al., 2015, Association between maternal age at Overall, the results suggest that as a first order childbirth and child and adult outcomes in the offspring: a approximation, one may rely on the estimated direct effects prospective study in five low-income and middle-income countries of early childbirth on stunting when simulating the impact (COHORTS collaboration), Lancet Glob Health 3(7):e366-77. of the elimination of early childbirth on malnutrition in the country. Doing so does likely entail underestimation of the Finlay. J. E., E. Özaltin, and D. Canning, 2011, The association overall effects, but probably not by a wide margin. of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low- and Simulations suggest that about two in 100 stunted middle-income countries, BMJ 1:e000226. children is stunted directly due to early childbirth. Horton, S., H. Alderman, and J. Rivera. 2008. “Copenhagen Consensus 2008 Challenge Paper: Hunger and Malnutrition.” The last step in the analysis consists in assessing the http://www.copenhagenconsensus.com. potential impact of eliminating early childbirth on stunting. This is done by predicting (i.e. simulating) the likelihood Ministry of Health and Population (MOHP) [Nepal], New ERA, and that children who were born of mothers younger than 18 ICF International Inc. 2012. Nepal Demographic and Health would have been stunted if they had been born of older Survey 2011. Kathmandu, Nepal: Ministry of Health and mothers. In other words, we are considering the direct Population, New ERA, and ICF International, Calverton, effects of the age of the mother on stunting, shifting in the Maryland. data deliveries by young mothers to deliveries at a later age, and observing the difference that this makes for stunting rates nationally. The simulations suggest that Page 3 HNPGP Knowledge Brief  Annex: Methodological Note In this brief, due to space constraints and because of the interest There is an existing literature on the relationships between early in the share of stunting that could be attributed to early childbirth, childbirth, child marriage, and the risks of under-five malnutrition the focus is on reporting results from probit regressions. In those (e.g., Fall et al., 2015, and Finlay et al. 2011). This literature regressions, the dependent variable is whether a child is stunted suggests that children born of young mothers are at higher risk of or not. malnutrition. How much higher in the case of Niger is the question to be answered. To answer this question, this brief focuses on Different specifications are estimated to assess the robustness of stunting as the measure that tends to best capture persistent the results to the choice of models. Overall, the results are fairly exposure to malnutrition with likely long term negative robust to different specifications. For the baseline model, the consequences for children. independent variables are the following: (1) the age of the mother at the time of delivery by categories; (2) the child’s age and There is no doubt that children born to very young mothers are gender; (3) whether the child had siblings born at the same time more likely to be malnourished than other children, but this might (multiple birth); (4) the birth order of the child and the child’s birth not specifically be due to the fact that the mothers are young. Girls weight by categories; (5) the length of time between the child’s who have children before the age of 18 tend to be poorer. This birth and a previous birth for the mother; (6) whether the child has implies that their children are at higher risk of inadequate received recommended immunizations; (7) whether the delivery nutritional intake. Early pregnancies are more common in areas took place in a health facility and was attended by skilled where access to healthcare is limited to prevent or treat personnel; (8) the mother’s height and education level, as well as malnutrition. Young girls also often suffer from a lack of agency whether she works and the type of work involved; (9) the father’s and decision-making power in the household, which may reduce occupation and his level of education; (10) the location of the child their ability to seek care for their children when needed. Girls who by region and by urban-rural category; (11) whether the give birth early are likely to have dropped out of school due to household has access to an improved water source and improved pregnancy or marriage, which may also affects the nutritional sanitation; (12) whether the household has more than two status of their children due to lack of education or knowledge on children under-five; and finally (13) the wealth quintile of the how to best take care of young children. household. These risk factors correlated with early childbirth do not In the extended model, additional controls are added: (14) necessarily imply that early pregnancies by themselves contribute whether the household practices polygyny; (15) whether the in a direct way to child malnutrition. Controlling for other factors, distance to health facility is a major problem for the household; it could be that early childbirth does not lead to a higher risk of (16) the age gap between the spouses; (17) indicators of malnutrition for children. But it could also be that there is a direct decision-making power for the mother; (19) tolerance towards causal link between early childbirth and child malnutrition, for wife beating; and (20) whether the mother is able to get example if some young mothers giving birth are not yet be ready permission to access healthcare. physiologically to give birth, which could in turn affect the health of their children. This brief estimates the direct impact of early This brief was produced by a World Bank team as part of the Economic childbirth on under-five malnutrition. Impacts of Child Marriage study. The synthesis report under the study was produced jointly with the International Center for Research on Women. In addition, the brief provides an assessment of the extent to The study benefitted from support from the Bill & Melinda Gates which under-five malnutrition would be reduced if early Foundation, the Children’s Investment Fund Foundation, and the Global pregnancies/deliveries were eliminated. In order to measure the Partnership for Education. Comments from colleagues and peer potential impact of early childbirth at the margin on stunting for reviewers are gratefully acknowledged. The opinions expressed in this brief are those of the authors only and need not reflect the views of the children under the age of five, regression analysis is used. In the World Bank, its Executive Directors, of the countries they represent. more detailed paper on which this brief is based, both tobit regressions (to measure the degree of stunting among children who are stunted) and probit regressions (to measure the likelihood of stunting) are provided. 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