Knowledge Brief Health, Nutrition and Population Global Practice EARLY CHILDBIRTH AND UNDER-FIVE MALNUTRITION IN BURKINA FASO Adenike Onagoruwa and Quentin Wodon June 2017 Child Marriage Series with Education Global Practice KEY MESSAGES:  In Burkina Faso, more than three 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 does not lead to a statistically significant increase in the likelihood of stunting for children under- five, as compared to otherwise similar children born of older mothers. Nearly one-fifth of under-five deaths could be prevented Box 1: Brief and Series Primer with optimal feeding. Poor nutrition at a young age may also have irremediable consequences for brain How is early childbirth defined? Early childbirth is defined in development, cognitive skills, and productivity in adult life. this brief as a child being born of a mother younger than 18. Early 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 Poor nutrition weakens children’s immune systems, putting development outcomes. Demonstrating these impacts will assist them at a greater risk of falling sick from preventable governments and others to make the case for intervening to illnesses such as pneumonia and diarrhea. According to reduce the practice. Horton et al. (2008), nearly one-fifth of under-five deaths in the world could be prevented with optimal feeding. What are the topics discussed in the series? The series looks 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 adult life. Unfortunately, a large share of children in the practice are also discussed. developing world are malnourished. The question considered in this brief is whether early childbirth (defined What is the question asked in this brief? The question is: What as a child being born of a mother younger than 18), which is the impact at the margin of an early childbirth on the probability in many countries is the result of child marriage, contributes of malnutrition (stunting) for children under-five years of age? to under-five malnutrition in a significant way in Burkina How is the question answered? Econometric analysis of Faso. The brief is part of a series of similar standardized Demographic and Health Survey data is used to estimate the country-specific briefs on the same topic for a number of impact of an early childbirth on under-five malnutrition. countries. Page 1 HNPGP Knowledge Brief  Statistically, children from young mothers are seven 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 With the baseline specification, table 2 indicates that analysis is based on data from the 2010 Demographic and deliveries at a young age do not significantly increase the Health Survey for Burkina Faso. Estimates suggest that likelihood of stunting for the children in comparison to a 42.33 percent of children born of mothers younger than 18 delivery at 18 to 34 years of age (in Burkina Faso). are stunted. The proportion is still high, but seven points However, the difference in risk of stunting between mothers lower at 34.99 percent for children born of mothers 18 to ages 18-34 and mothers above 35 is statistically significant 34 years of age. The difference in stunting rate between at the one percent level. these two age groups is statistically significant. For children of mothers older than 35, the incidence of stunting was still In Burkina Faso, delivery at a young age does not increase lower at 29.56 percent. the likelihood of stunting for the child in comparison to a delivery at 18 to 34 years of age. Table 1: Incidence of Stunting by Age of the Mother Age of the mother Stunting (%) Mother younger than 18 42.33 Marginal effects do not change much when additional Mother in 18-34 age bracket 34.99 controls are added (extended model). There is thus some Mother older than 35 29.56 evidence that in the case of Burkina Faso, after controlling Source: Authors. for a wide range of other variables, early childbirth may not contribute directly (after controlling for other variables) to Box 2: Measures of Malnutrition stunting, but prudence remains needed when interpreting these results given the risk of omitted variable bias (see Three main measures of malnutrition are used in applied work. A box 3). child is considered underweight if s/he has a weight more than two standard deviations below the reference median weight for Table 2: Impact of Early Childbirth on Stunting the child’s age. A child is considered wasted if s/he has a weight Age at first marriage Baseline Extended to height ratio more than two standard deviations below the model model median weight for height for the reference population. A child is Mother younger than 18 0.0156 0.0182 considered stunted if s/he has a height more than two standard Mother in 18-34 age bracket Reference Reference deviations below the median reference height for that age. If a Mother older than 35 -0.0620*** -0.0624*** child on any of these measures is below three standard deviations of the norm, s/he is considered as severely underweight, wasted, Source: Authors. or stunted. Among the three measures, stunting and wasting tend Levels of statistical significance: *** 1%, ** 5%, * 10%. to be used the most. Stunting often results from persistent insufficient nutrient intake and infections. It may lead to delayed Box 3: Risk of Omitted Variable Bias motor development and poor cognitive skills that can affect school performance as well as productivity and earnings later in life. In many countries, although not in Burkina Faso, early childbirth Wasting tends to result more from acute food shortage or disease appears to be positively correlated with the risk of stunting after and may lead to death. For the purpose of this brief, given a controlling for other factors that may also contribute to stunting. separate brief of under-five mortality, stunting is the best measure This could indicate a causal effect. However, other variables to focus on. correlated with both early childbirth and stunting not included in the analysis could be at the source of the correlation between early childbirth and stunting. Because of the risk of omitted Controlling for other factors, early childbirth does not variable bias, the results cannot be considered as fully conclusive increase the likelihood of stunting substantially. regarding a causal impact of early childbirth on the risk of stunting. The difference in the likelihood of stunting between children A number of results from the regression analysis not shown of young and older mothers does not necessarily imply a in table 2 are worth mentioning. The impact of wealth on causal effect of the age at delivery, but it does suggest that the likelihood of stunting is statistically significant in the early childbirth may contribute to stunting. To check highest wealth quintile. Children in the highest quintile (the whether controlling for other factors early childbirth is richest 20% of households) have a likelihood of stunting indeed associated at the margin with higher under-five eleven percentage points lower than children in the poorest malnutrition, regression analysis is used (see the annex for 20% of households. A number of other effects are also details on the methodology). statistically significant, as discussed in the more detailed study on which the brief is based. But one effect deserves Page 2 discussion here: children from better educated mothers are likelihood that children who were born of mothers younger less likely to be stunted. than 18 would have been stunted if they had been born of older mothers. In other words, we are considering the direct This points to the possibility of indirect effects of early effects of the age of the mother on stunting, shifting in the childbirth on stunting. Because early childbirth may have data deliveries by young mothers to deliveries at a later an impact on other variables used as controls in the age, and observing the difference that this makes for regression, its overall effect on stunting, including indirect stunting rates nationally. In the case of Burkina Faso, effects through these other variables, may be larger than because the effect of early childbirth on stunting is not the direct effect. For example, for some girls having a baby statistically significant, direct effects are not (statistically at a young age, early childbirth may have reduced speaking) present. education attainment. Early deliveries, by increasing the number of household members may also contribute to Because only a small share of deliveries are by mothers lower standards of living. In Burkina Faso, as mentioned younger than 18, very few stunted children can be said to earlier, the regression results suggest that the level of be stunted directly due to early childbirth. welfare as measured through wealth quintiles have an effect on stunting. Conclusion As shown in table 3, the marginal impact of a mother having Early childbirth may contribute to the risk of malnutrition for a secondary education or better on the likelihood that her children, directly and indirectly. This brief has provided child will be stunted is statistically significant and large at estimates of the direct impact of early childbirth on stunting eleven to twelve percentage points depending on the model. This marginal effect is in comparison to mothers in Burkina Faso using the latest DHS survey. More than three in ten children under the age of five are stunted. with an education below the primary level. While the effect Controlling for socio-economic and other characteristics, of secondary education on stunting is large for women with being born of a mother younger than 18 does not have a a secondary education or better, the indirect effect of early statistically significant effect on the likelihood of stunting as childbirth on stunting through education is likely to be much smaller. This is because in Burkina Faso, only a small compared to otherwise similar children born of older share of girls with an early childbirth who have dropped out mothers. This suggests that few children are stunted directly because of an early childbirth, even though some school due to the pregnancy would have remained in may be indirectly through education. school long enough to complete secondary education if they had not become pregnant. Even if ten percent of the References girls who became pregnant (or married) had completed their secondary education without the pregnancy (or Fall, C. H., et al., 2015, Association between maternal age at marriage), the indirect effect of early childbirth on stunting childbirth and child and adult outcomes in the offspring: a through education would be one tenth of the coefficients in prospective study in five low-income and middle-income countries table 3. This is not negligible, but often much smaller than (COHORTS collaboration), Lancet Glob Health 3(7):e366-77. any observed direct effects when those are observed. Finlay. J. E., E. Özaltin, and D. Canning, 2011. The association Early childbirth may affect under-five malnutrition through of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low- and lower education attainment for mothers or lower socio- middle-income countries, BMJ 1:e000226. economic status. Horton, S., H. Alderman, and J. Rivera. 2008. “Copenhagen Table 3: Impact of the Mother’s Education on Stunting Consensus 2008 Challenge Paper: Hunger and Malnutrition.” Age at first marriage Baseline Extended http://www.copenhagenconsensus.com. model model No education or below primary Reference Reference Institut National de la Statistique et de la Démographie (INSD) et Primary education -0.0485** -0.0529** ICF International (2012). Enquête Démographique et de Santé et Secondary education or higher -0.120*** -0.114** à Indicateurs Multiples du Burkina Faso 2010. Calverton, Source: Authors. Maryland, USA : INSD et ICF International. Levels of statistical significance: *** 1%, ** 5%, * 10%. Simulations suggest that very few children under-five are stunted directly due to early childbirth. The last step in the analysis consists in assessing the potential impact of eliminating early childbirth on stunting. This can be done by predicting (i.e. simulating) the Page 3 HNPGP Knowledge Brief  Annex: Methodological Note In this brief, due to space constraints and because of the interest in the share of stunting that could be attributed to early childbirth, There is an existing literature on the relationships between early the focus is on reporting results from probit regressions. In those childbirth, child marriage, and the risks of under-five malnutrition regressions, the dependent variable is whether a child is stunted (e.g., Fall et al., 2015, and Finlay et al. 2011). This literature or not. suggests that children born of young mothers are at higher risk of malnutrition. How much higher in the case of Niger is the question Different specifications are estimated to assess the robustness of to be answered. To answer this question, this brief focuses on the results to the choice of models. Overall, the results are fairly stunting as the measure that tends to best capture persistent robust to different specifications. For the baseline model, the exposure to malnutrition with likely long term negative independent variables are the following: (1) the age of the mother consequences for children. at the time of delivery by categories; (2) the child’s age and gender; (3) whether the child had siblings born at the same time There is no doubt that children born to very young mothers are (multiple birth); (4) the birth order of the child and the child’s birth more likely to be malnourished than other children, but this might weight by categories; (5) the length of time between the child’s not specifically be due to the fact that the mothers are young. Girls birth and a previous birth for the mother; (6) whether the child has who have children before the age of 18 tend to be poorer. This received recommended immunizations; (7) whether the delivery implies that their children are at higher risk of inadequate took place in a health facility and was attended by skilled nutritional intake. Early pregnancies are more common in areas personnel; (8) the mother’s height and education level, as well as where access to healthcare is limited to prevent or treat whether she works and the type of work involved; (9) the father’s malnutrition. Young girls also often suffer from a lack of agency occupation and his level of education; (10) the location of the child and decision-making power in the household, which may reduce by region and by urban-rural category; (11) whether the their ability to seek care for their children when needed. Girls who household has access to an improved water source and improved give birth early are likely to have dropped out of school due to sanitation; (12) whether the household has more than two pregnancy or marriage, which may also affects the nutritional children under-five; and finally (13) the wealth quintile of the status of their children due to lack of education or knowledge on household. how to best take care of young children. In the extended model, additional controls are added: (14) These risk factors correlated with early childbirth do not whether the household practices polygyny; (15) whether the necessarily imply that early pregnancies by themselves contribute distance to health facility is a major problem for the household; in a direct way to child malnutrition. Controlling for other factors, (16) the age gap between the spouses; (17) indicators of it could be that early childbirth does not lead to a higher risk of decision-making power for the mother; (19) tolerance towards malnutrition for children. But it could also be that there is a direct wife beating; and (20) whether the mother is able to get causal link between early childbirth and child malnutrition, for permission to access healthcare. example if some young mothers giving birth are not yet be ready physiologically to give birth, which could in turn affect the health This brief was produced by a World Bank team as part of the Economic of their children. This brief estimates the direct impact of early Impacts of Child Marriage study. The synthesis report under the study was childbirth on under-five malnutrition. produced jointly with the International Center for Research on Women. The study benefitted from support from the Bill & Melinda Gates In addition, the brief provides an assessment of the extent to Foundation, the Children’s Investment Fund Foundation, and the Global which under-five malnutrition would be reduced if early Partnership for Education. Comments from colleagues and peer pregnancies/deliveries were eliminated. In order to measure the reviewers are gratefully acknowledged. The opinions expressed in this potential impact of early childbirth at the margin on stunting for 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